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Admission Date: [**2127-10-16**] Discharge Date: [**2127-10-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Urosepsis.
Major Surgical or Invasive Procedure:
PICC line placement.
History of Present Illness:
Mr. [**Known lastname 18937**] is an 87 year old Spanish speaking male recently
admitted for elective right iliac aneurysm repair on [**2127-10-12**].
Pt had experienced witnessed LOC while ambulating. Of note, had
experienced similar episode syncope 3 weeks prior, found to be
bradychardic by PCP, [**Name10 (NameIs) 151**] atenolol stopped. On this occaision,
he complained of low back pain, came to ED,found on CT R common
iliac artery aneurysm with old contained rupture. Transfered
here to OR emergently for repair. Had aortic stent graft with
extension into R external iliac artery. Stable post op with dc
on [**2127-10-14**]. On [**2127-10-15**] pt developed fever to 104, burning
urination, lower abdominal pain, rigors and went to [**Hospital1 487**]
where he had blood/UCx and got levoquin. He syncopized there in
setting of valsalva (was on commode post valsalva complaining of
dizziness, with BP initially unobtainable but improved on lying
down. Given immediately recently post op from [**Hospital1 **] transferred
here for further care. At [**Hospital1 18**] ED got blood and UCx, CXR and
EKG. Zosyn but not Vanc given, sent to ICU as developed an O2
requirement of 4L and persistently hypotensive despite 3L
IV.Vitals at time of transfer were BP 150/110, HR 90, 94% RA,
afebrile, 20.
.
Blood and urine cultures pending after Abx at both [**Hospital1 487**] and
[**Hospital1 18**].
.
In the ICU, Pt became persistently hypotensive to the 80s.
Received total 5.5 L IVF, with improvement of systolic BPs from
80s systolic to 120's systolic by ICU day 1. Patient did not
require pressors. His uop was low/concentrated with stable cr.
He was febrile to 104.2, defervescing over his ICU course with
tylenol, IVF and ABX. wbc peaked to 12.9 o/n then declined. His
afib was well rate controlled in 70s. He was restarted on his
outpatient coumadin 3mg initially given subtherapeutic INR, then
increased to 5mg given his subtherapeutic INR of 1.5 in setting
of abx. He was eventually weaned from O2 and considered stable
for transfer to the floor.
Past Medical History:
1)Dementia
2)AFib
3)CVA x 3
4)HTN - Baseline BP 140s.
5)CAD
6)scars on abdomen suggest prior surgeries
7)DM- list on problem list from OSH, but pt and family deny
Social History:
Originally from [**Doctor Last Name 84730**] in [**2088**]. Lives with
daugher in [**Hospital1 487**], has 17 children -patriarch of community.
Former tobacco and alcohol, none currently. AOX3 Mild memory
loss-occaissionally forgets namesx2 years. Independent with
ADLs. Walks without a cane, but does have trouble with stairs
and occ getting out of a chair. Gets home VNA several times a
week for meds/blood draws. Quit smoking in [**2107**], used to drink
heavily, none >10 years.
Family History:
Non-contributory.
Physical Exam:
Vitals: T: 98.9 (104.2) BP: 87/52 P: 87 afib R: 11 O2:100% on 4L
General: Sleeping but easily arousable, answers simple questions
in spanish, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Minimal diffuse crackles
CV: irregularlly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Groin: well healed scars bilaterally, small hematoma on right,
no bruits
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes, warm at torso, thighs, cold hand/feet
Pertinent Results:
[**2127-10-16**] 02:46PM GLUCOSE-96 UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-22 ANION GAP-9
[**2127-10-16**] 02:46PM CALCIUM-7.9* PHOSPHATE-3.6# MAGNESIUM-2.5
[**2127-10-16**] 02:46PM WBC-11.9*# RBC-2.91* HGB-8.4* HCT-26.6*
MCV-92 MCH-28.8 MCHC-31.5 RDW-16.0*
[**2127-10-16**] 02:46PM PLT COUNT-153
[**2127-10-16**] 02:46PM PT-17.2* PTT-30.4 INR(PT)-1.5*
[**2127-10-16**] 12:07AM LACTATE-1.2
[**2127-10-16**] 12:00AM NEUTS-88.1* LYMPHS-7.6* MONOS-3.9 EOS-0.2
BASOS-0.2
[**2127-10-16**] 12:00AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2127-10-16**] 12:00AM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-MOD
[**2127-10-16**] 12:00AM URINE RBC-[**11-21**]* WBC->50 BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2127-10-16**] 12:00AM URINE WBCCLUMP-MOD
Cultures:
[**2127-10-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-10-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-10-18**] STOOL OVA + PARASITES-FINAL INPATIENT
[**2127-10-17**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE
TOXIN A & B TEST-FINAL INPATIENT
[**2127-10-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2127-10-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2127-10-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2127-10-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2127-10-16**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
EMERGENCY [**Hospital1 **]
Echo: [**2127-10-16**]:
The left atrium is dilated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The ascending aorta is moderately 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. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mildly dilated/hypokinetic RV with moderate to
severe tricuspid regurgitation. Normal regional and global LV
systolic function. Mild mitral regurgitation.
CXR: [**2127-10-16**]: No pulmonary edema or pneumonia seen.
2. Right upper lobe pleural thickening and linear opacities, of
uncertain
etiology, possibly atelectasis related to restrictive pleural
thickening or
bronchiectasis. PA and lateral views of the chest are
recommended for further
assessment.
Renal US [**2127-10-20**]: COMPARISON: CTA aorta/bifem of [**2127-10-12**].
FINDINGS: The right kidney measures 10.1 cm. The left kidney
measures 11.3
cm. There is no hydronephrosis, stones, or mass bilaterally. The
bladder is
moderately well distended and appears normal.
IMPRESSION: No hydronephrosis.
Brief Hospital Course:
Mr [**Known lastname 18937**] is an 87 yo M with h/o CAD, HTN, recent iliac artery
repair and readmission for UTI, admitted with hypotension
concerning for sepsis of uro- or surgical source.
# Sepsis: Pt was admitted to the ICU with fever to 104 and
hypotension from baseline 140s to SBP 80s-90s with MAPs in mid
60s. He responded to IVF without requiring pressors. He was
initially started on broad spectrum antibiotics with Levoflox,
Zosyn and Vancomycin. Cultures from [**Hospital 487**] Hospital and [**Hospital1 18**]
revealed ESBL positive E.coli. His antibiotics were narrowed to
zosyn however he spiked a fever on zosyn and was thus switched
to meropenem with clinical improvement. He had a new O2
requirement briefly due to volume overload, but was tapered to
room air by the time he reached the regular floor. His urine
output was good on the floor, his foley was discontinued, with
initial incontinence which subsequently resolved. He should
complete a 14-day course of meropenem to end on [**10-30**].
# Syncope: He experienced Last week episode thought to be due to
bradycardia and BB discontinued. However, symptoms on admission
resembeled orthostatic hypotension post valsalva in the setting
of sepsis. He was monitored on telemetry, was not found to be
orthostatic on exam, did not have any bradychardic or syncopal
episodes here. Plan for outpt holter monitoring to be
orchestrated by PCP by Dr [**Last Name (STitle) 29065**].
# Afib: He had previously been on atenolol as an outpatient
however he had been bradychardic with syncope, and his atenolol
had been discontinued. He was found to be in rapid afib, for
which he was started on low dose metoprolol, with good control
of his heart rate and he remained asymptomatic from his afib. He
was found initially to be subtherapeutic with an INR of 1.5 with
possible interference from antibiotics,
so his coumadin was increased from 3mg to 5 mg, and his INR
remained in the therapeutic range. At time of discharge his
coumadin dose is 4 mg; this dose should be continued until
INR/PTT levels are checked two days after discharge.
# CAD: He had a history of coronary artery disease. His EKG did
not reveal any changes, and his aspirin and simvastatin were
continued. He remained DNR/DNI through the course of his
hospitalization.
Medications on Admission:
Medications at home:
Atenolol 50mg daily held [**2-3**] bradychardia &syncope (dc'[**Initials (NamePattern4) **] [**9-22**])
Coumadin 3mg (decreased during last hospitalization [**Hospital1 487**]?
Aspirin 325mg daily
Aricept 5mg
Simvastatin 10qd
Tylenol prn pain
.
Medications on transfer:
1. Piperacillin-Tazobactam 4.5 g IV Q8H
2. Vancomycin 1000 mg IV Q 12H
3. Warfarin 5 mg PO DAILY16
4. Aspirin 325 mg PO DAILY
5. Simvastatin 10 mg PO DAILY
6. Donepezil 5 mg PO HS
7. Heparin 5000 UNIT SC TID
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. Ibuprofen Suspension 600 mg PO Q8H:PRN pain/fever
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
5. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
6. Sodium Chloride 0.9 % Injection
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for line flush.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] Care and Rehab
Discharge Diagnosis:
Primary:
Complicated Urinary Tract Infection.
Secondary:
Iliac artery aneurysm
Atrial Fibrillation
Coronary artery disease
Hypertension
Dementia
Discharge Condition:
Vital signs stable. Afebrile.
Discharge Instructions:
You were admitted to the hospital because you had a urinary
tract infection. You were treated with intravenous antibiotics
and improved a great deal. You will continue to receive
intravenous antibiotics to completely cure your infection.
.
We INCREASED your coumadin from 3 mg daily to 4 mg daily.
We ADDED irtepenem to treat the infection.
We ADDED metoprolol for blood pressure and heart rate control.
.
Please return to the hospital or see your doctor if you have
flank or abdominal pain, chest pain, problems with your
urination, diarrhea, constipation, shortness of breath, nausea,
vomiting, headache, fever, chills, sweats, muscle pain, joint
pain, weight loss, or any other symptoms that are concerning to
you.
Followup Instructions:
-Please schedule follow-up with your primary care physician in
[**Name9 (PRE) 487**] in [**1-3**] weeks. If you do not have a primary care
physician, [**Name10 (NameIs) **] schedule to see a physician at [**Hospital 3038**]: [**Telephone/Fax (1) 250**].
-[**Telephone/Fax (1) **] [**Telephone/Fax (1) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-11-17**] 10:30
-[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-11-17**]
11:10
|
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"0389",
"78552",
"5990",
"99592",
"42731",
"41401",
"V5861",
"2724",
"4019",
"V1582"
] |
Admission Date: [**2155-4-28**] Discharge Date: [**2155-5-1**]
Date of Birth: [**2087-11-9**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Past Medical History:
Emphysema
Asthma
History of Present Illness:
67 yo Haitian-Creole speaking male with COPD on 2L oxygen at
home, recently discharged from [**Hospital1 2177**] for COPD exacerbation and
treated for pneumonia presenting with shortness of breath. Pt
reports that he was recently hospitalized at [**Hospital3 9947**] from [**2155-4-25**] to [**2155-4-27**] for COPD exacerbation and was also
treated with antibiotics for pneumonia. He was discharged home
yesterday and was planning to fill his prescriptions today until
he became short of breath. He presented to the ED where he was
noted to be tachypneic (RR38) with oxygen saturation of low 80s.
He was placed on NRB and then bipap. He was given 125mg iv
solumedrol, 2g iv ceftriaxone, and 500mg iv azithromycin. He
was weaned to 4L oxygen by nasal cannula by time of transfer to
ICU. Vitals prior to transfer: 123/62 108 98%4L. Labs were
remarkable for lactate 2.8, trop <0.01, BNP 163.
Past Medical History:
Emphysema
Asthma
Social History:
Came to the US in [**2136**]. Lives alone. Does not work; on
disability. Reports that he quit smoking many years ago.
Denies alcohol or illicit drug use
Family History:
Denies family hx of cardiopulmonary disease or cancer
Physical Exam:
Admission physical exam
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD not appreciated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: faint wheezes diffusely, mildly tachypneic
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact
Discharge physical exam
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds bilaterally, no wheezes, no
crackles, rales or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended at baseline, bowel sounds
present, no rebound tenderness or guarding, no organomegaly,
Ext: Bilateral LE are Warm, well perfused, 2+ DP pulses
Pertinent Results:
Admission labs
[**2155-4-28**] 05:12PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2155-4-28**] 05:12PM LACTATE-2.7*
[**2155-4-28**] 04:47PM CK(CPK)-614*
[**2155-4-28**] 04:47PM CK-MB-21* MB INDX-3.4 cTropnT-<0.01
[**2155-4-28**] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2155-4-28**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2155-4-28**] 11:54AM TYPE-[**Last Name (un) **] PO2-82* PCO2-102* PH-7.23* TOTAL
CO2-45* BASE XS-10
[**2155-4-28**] 11:20AM GLUCOSE-156* UREA N-18 CREAT-1.0 SODIUM-145
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-36* ANION GAP-15
[**2155-4-28**] 11:20AM estGFR-Using this
[**2155-4-28**] 11:20AM WBC-10.3 RBC-4.48* HGB-12.2* HCT-40.3 MCV-90
MCH-27.2 MCHC-30.2* RDW-12.9
[**2155-4-28**] 11:20AM NEUTS-64.4 LYMPHS-24.9 MONOS-7.9 EOS-2.3
BASOS-0.5
Imaging:
IMPRESSION: Vague opacities obscuring the right and left heart
border which could represent pneumonia, although the possibility
of epicardial fat pad is also raised. Recommend followup to
resolution. Consider dedicated PA and lateral views for a more
complete assessment.
Micro:
[**2155-4-28**] 4:48 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2155-5-1**]**
MRSA SCREEN (Final [**2155-5-1**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS
[**2155-4-28**] 2:00 pm URINE
**FINAL REPORT [**2155-4-29**]**
URINE CULTURE (Final [**2155-4-29**]): NO GROWTH
Discharge labs
[**2155-4-29**] 12:39AM BLOOD WBC-6.7 RBC-4.37* Hgb-11.8* Hct-38.6*
MCV-88 MCH-27.0 MCHC-30.6* RDW-12.9 Plt Ct-144*
[**2155-4-30**] 06:05AM BLOOD Glucose-105* UreaN-18 Creat-1.0 Na-142
K-4.6 Cl-96 HCO3-40* AnGap-11
[**2155-4-29**] 12:39AM BLOOD LD(LDH)-268* CK(CPK)-576*
[**2155-4-29**] 12:39AM BLOOD CK-MB-16* MB Indx-2.8 cTropnT-<0.01
[**2155-4-29**] 12:39AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.9*
[**2155-4-29**] 12:50AM BLOOD Lactate-2.0
Brief Hospital Course:
67 year old Hatian-Creole speaking male with a history of COPD
who presented with shortness of breath likely a COPD
exacerbation.
# COPD Exacerbation: Patient presented with hypoxia and
shorntess of breath which required BiPap and an ICU admission.
He improved with BiPap and standing nebulizers and was
transferred to the floors on 2L of oxygen. He was placed on
standing albuterol and ipratroium nebulizers q6h with a q2h PRN
which he improved on. He was also placed on prednisone 60mg
daily. His symptoms improved however his oxygen requirement
fluctuated during his time on the general medical floors. On the
day of discharge he was comfortable on 2L but continued to have
a persistent cough which waxed and waned. Plan would be for a
prednisone taper of 60mg for 1 day (End [**5-2**]), 40mg for 3 days
([**Date range (1) **]), 20mg for 3 days ([**Date range (1) 61537**]) and 10mg for 3 days
([**Date range (1) 61876**]). He should conintue with albuterol nebs PRN and
spiriva daily. He was also placed on Levofloxacin as he was
having dyspnea and increased sputum production. He will continue
until [**5-2**] for a total of 5 days.
# Hyperglycemia: He has a history of glucose intolerance and
while on prednisone, his sugars did go up. He was started on an
inuslin sliding scale and his sugars improved. His insulin
sliding scale will need to be titrated based on his sugars and
prednisone taper.
# Cognitive impairment: Patient was noted to have poor insight
on his current condition. Upon further evaluation, it was found
out that he was living in squalor. Concern regarding patients
cognition was brought up during his hospitalization therefore
neurocognitive assessement is recommended.
# BPH: Patient had no symtoms during his admission therefore he
was continued on terazosin.
# GERD: He was stable in his home regimen therefore was
continued on omeprazole.
TRANISTIONAL ISSUES:
- Taper prednisone 60mg for 1 day (End [**5-2**]), 40mg for 3 days
([**Date range (1) **]), 20mg for 3 days ([**Date range (1) 61537**]) and 10mg for 3 days
([**Date range (1) 61876**]).
- Will need to titrate insulin based on blood glucose and
prednisone taper
Medications on Admission:
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
2. Tiotropium Bromide 1 CAP IH DAILY
3. Albuterol Inhaler 2 PUFF IH Q4H
4. Omeprazole 20 mg PO DAILY
5. Terazosin 5 mg PO HS
6. Acetaminophen 500 mg PO Q6H:PRN PRN
7. Azithromycin 500mcg for 3 days
8. Prednisone 20mg tabs (3tabs for one day, 2tabs for 3 days,
1tab for 3 days and half tab for 3 days)
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN PRN
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
3. Omeprazole 20 mg PO DAILY
4. Terazosin 5 mg PO HS
5. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB or wheeze
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
7. Guaifenesin [**5-1**] mL PO Q6H:PRN PRN
8. Insulin SC Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
9. Ipratropium Bromide Neb 1 NEB IH Q6H
10. Levofloxacin 750 mg PO Q24H Start: In am
End [**5-2**]
11. PredniSONE 60 mg PO DAILY Start: In am
prednisone 60mg for 1 day (End [**5-2**]), 40mg for 3 days
([**Date range (1) **]), 20mg for 3 days ([**Date range (1) 61537**]) and 10mg for 3 days
([**Date range (1) 61876**])
Tapered dose - DOWN
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
COPD exacerbation
Secondary:
Glucose intolerance
probable cognitive impairment
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 because you had a COPD
exacerbation. You have improved with antibiotics and albuterol,
ipratropium and systemic steroids. You are currently on 2Liters
of oxygen and at your baseline.
If you experience further shortness of breath or difficulty
breathing, please see your doctor.
Medications stopped
Azithromycin
Medications started
Prednisonse 60mg for 1 day (End [**5-2**]), 40mg for 3 days
([**Date range (1) **]), 20mg for 3 days ([**Date range (1) 61537**]) and 10mg for 3 days
([**Date range (1) 61876**])
Tapered dose - DOWN
Levofloxacin 750mg daily until [**5-2**]
Insulin Sliding Scale (see sheet)
Guaifenesin [**5-1**] mL every 6 hours as needed for cough
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Hospital 112345**]
[**Hospital1 **]
[**Location (un) 686**], [**Numeric Identifier 12201**]
[**Telephone/Fax (1) 12016**]
Friday [**5-9**] at 11AM
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"486",
"51881",
"2762",
"V5867",
"53081",
"V1582"
] |
Admission Date: [**2194-12-6**] Discharge Date: [**2194-12-26**]
Date of Birth: [**2139-7-9**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: The patient is status post left
upper wedge resection and chest wall resection for Pancoast
tumor and status post chemotherapy and radiation therapy.
the patient had intermittent left shoulder pain and weight
loss preoperatively. Postoperatively, the patient did not
keep multiple appointments. On [**12-3**], he presented to an
outside hospital with cough, disorientation. A workup
revealed a pneumonia empyema. The patient was then
transferred to the [**Hospital1 **] Hospital after being
started on antibiotics and obtaining cultures at the outside
hospital, which were negative for any growth.
PAST MEDICAL HISTORY: Migraine headaches, hyperthyroidism,
vitamin B-12 deficiency, anemia, Pancoast tumor.
PAST SURGICAL HISTORY: Spine surgery, cholecystectomy.
MEDICATIONS: Oxycontin, Percocet, iron, [**Name (NI) 8863**], PTU.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature 98.7. Heart rate 68.
Blood pressure 106/63. Respiratory rate 20. O2 sat 95% 4
liters. Chest decreased breath sounds left side. Right side
with coarse breath sounds. Cor regular rate and rhythm.
Abdomen soft, nontender, nondistended. Extremities no edema.
LABORATORY ON ADMISSION: White blood cell count 6.9,
hematocrit 31.3, platelet 316, sodium 138, potassium 3.6,
chloride 98, bicarbonate 33, BUN 13, creatinine .3, glucose
82. A chest CT done on [**12-6**] revealed a 10.3 by 8.5 cm
loculated fluid collection at the left apex and a moderate
size left pleural effusion at the left lung base with
evidence of gas bubbles.
The patient was admitted to the hospital and had a
thoracocentesis performed, which revealed some cloudy
purulent fluid. The patient was admitted and started on
Ceftriaxone and Clindamycin. On [**12-8**] he had pigtail
drainage by interventional radiology of the left upper and
left lower lobe fluid collections. It was decided on [**12-9**] to take the patient to the Operating Room and a total
pulmonary decortication was done. Postoperatively with two
chest tubes and two Malecot tubes were placed. The patient
was transferred to the Intensive Care Unit intubated. The
patient was in the Intensive Care Unit for essentially
aggressive pulmonary toilet. On [**12-11**] the patient self
extubated, however, he tolerated it well and was not
reintubated. On [**12-14**], tube feeds were started for
approximately three days, however, the patient removed the
tubes on several occasions and further attempts were aborted.
On [**12-15**], Levaquin was started and Ceftriaxone and
Clindamycin were discontinued.
The patient was stable on transfer to the floor on [**12-16**]. Multiple chest x-rays were reviewed on the floor over
the next several days, which revealed left apical
pneumothorax and left basilar hydropneumothorax, which was
stable. On [**12-21**] a chest CT was performed, which
revealed significant improvement of the left apical
pneumothorax and also significant improvement of the left
basilar hydropneumothorax. The patient had interventional
radiology drain the left basilar pneumothorax. Several 100
cc of fluid were obtained. The Malecot tubes were
discontinued on [**12-23**]. On [**12-24**] a pain consult was
obtained and his pain medications were optimized. On [**12-26**] chest tubes were removed after obtaining a chest x-ray,
which revealed significant improvement of his disease.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS: Levaquin 500 mg q.d. for 28 days, iron sulfate
325 mg t.i.d., MS Contin 60 mg b.i.d., Ritalin 2.5 mg b.i.d.
at 6:00 a.m. and 12:00 p.m., sodium chloride 1 gram po
b.i.d., MSIR 10 to 20 mg q 2 hours prn, [**Month (only) 8863**] XL 100 mg q
day, multi vitamin, Colace 100 b.i.d., Boost one can t.i.d.
with meals, Zantac 150 mg b.i.d., PTU 100 mg po t.i.d.,
Celexa 200 mg q.h.s., heparin 5000 units b.i.d.
DISCHARGE STATUS: Rehabilitation facility. The patient will
follow up with Dr. [**Last Name (STitle) 175**] in two weeks and primary care
physician in two weeks.
DISCHARGE DIAGNOSIS:
Empyema status post open lung decortication.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2194-12-26**] 09:22
T: [**2194-12-26**] 10:54
JOB#: [**Job Number 35732**]
|
[
"486"
] |
Admission Date: [**2137-6-16**] Discharge Date: [**2137-6-21**]
Date of Birth: [**2053-6-7**] Sex: F
Service: MEDICINE
Allergies:
Cymbalta / Penicillins / Keflex / Coumadin
Attending:[**First Name3 (LF) 1845**]
Chief Complaint:
Asymtomatic Hypotension and Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 84 y/o F with CAD s/p BMS, sCHF w/EF 30%,
PAFib, DM2, PAD, HTN, HL, h/o DVT/PE with recent admission for
CHF exacerbation coming with asymptomatic hypotension and
tachycardia. She was in her prior state of health until ~3 days
ago where she was diagnosed with a UTI and prescribed
ciprofloxacin. She decided to take only 1 dose. Then, during the
last day she has noticed increase fatigue. She denies any
nausea, vomitting, chills, fever, diarrhea, changes in her
medications. Her son took her BP and found her 70/50 and HR
100-150's, so held her metoprolol. He called Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who
recommended for the patient to be evaluated in the ER. Family
called EMS who found her sats in the mid 80s on room air and
hypotensive up to 80/40 with an ECG showeing AFib with RVR at
140s. Pt received diltiazem by EMS (unknown dose).
In the [**Hospital1 1388**] ER her initial VS were T 99.2 F, HR 119 BPM, BP
96/63 mmHg, RR 19 X', SpO2 ? and no pain. She was good apearing,
no crackles, wheezes or ronchi, but with a pressure ulcer in her
heel. Her initial ECG showed AFib with RVR at 140s and her labs
showed WBC 11.2, HCT 31.7 at her baseline, PLTs of 258, normal
coags, Trop-T: 0.12, CK: 42 MB: Notdone, Na:129, K:4.7, Cl:101,
TCO2:17, Glu:63, Lactate:1.8, BUN 46, creatinine 1.2 and a
negative UA. There was concern for MI, because the ER physicians
did not think that the renal function was elevated enough to
explain the elevation in the Trop T so she was started on a
heparin gtt. She was noted to have ECG ischemic changes. CXR was
concerning for LLL PNA, so pt received Vanc 1g/Levofloxacin
750(radiology read it as normal). PE-CT did not show infection
or clots. Blood pressure was fluctuating in the mid 80s and
responded to fluid, patient receiving aproximately 3 L NS. Pt
received her metoprolol 12.5 dose (home dose) and her AFib was
rate controlled. Pt received tylenol as well.
Past Medical History:
-CAD s/p BMS x 3 to RCA [**2136-6-22**]
-Chronic systolic heart failure with EF 30% 02/10
-Chronic diastolic CHF
-Atrial fibrillation with hx of RVR
-[**Month/Day/Year 2320**]
-PAD s/p R ant tib artery stent [**2136-7-5**]
-Normocytic anemia, Hct ~33% at baseline
-Post-partum DVT/PE [**2093**]
-HTN
-Hyperlipidemia
-Peripheral neuropathy
-OA
-s/p appendectomy
-s/p bilateral total hip replacement
-6/27/9 - 7/2/9 for right 1st toe ulcer w/maggot infection, with
amputation 6/28/9
Social History:
Married, 6 living children. Lives in [**Location 745**], lived with husband
until recent admission to rehab.
- Tobacco history: Never
- ETOH: None
- Illicit drugs: None
Has one son who lives out of state but is involved in her care.
Family History:
Father - Deceased, MI at 50
Mother - Deceased, MI at 65
3 brothers died of [**Name (NI) 5290**] in 60s and 70s.
Pt also reports significant FH of HTN
Physical Exam:
Admission Physical Exam:
VITAL SIGNS - Temp F, BP 117/64 mmHg, HR 83 BPM, RR X', O2-sat
98% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
not jaundiced (skin, mouth, conjuntiva)
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-5**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Discharge Physical Exam:
Gen - Alert, NAD
HEENT - NC/AT
CV - RRR; No m/r/g
Resp - CTA B
Abd - S/NT/ND; BS present
Pertinent Results:
---------------
Admission Labs:
---------------
[**2137-6-15**] 10:30PM BLOOD WBC-11.2* RBC-3.62* Hgb-10.4* Hct-31.7*
MCV-88 MCH-28.6 MCHC-32.6 RDW-20.2* Plt Ct-258
[**2137-6-15**] 10:30PM BLOOD PT-13.1 PTT-31.8 INR(PT)-1.1
[**2137-6-15**] 10:30PM BLOOD Fibrino-642*
[**2137-6-16**] 06:52AM BLOOD Glucose-159* UreaN-37* Creat-1.0 Na-129*
K-4.5 Cl-102 HCO3-17* AnGap-15
[**2137-6-15**] 10:30PM BLOOD Calcium-8.6 Phos-3.0 Mg-1.6
[**2137-6-16**] 06:52AM BLOOD calTIBC-168* VitB12-474 Folate-16.8
Ferritn-100 TRF-129*
[**2137-6-16**] 06:52AM BLOOD Iron-16*
[**2137-6-16**] 01:30PM BLOOD TSH-4.2
[**2137-6-16**] 01:30PM BLOOD T4-5.7
[**2137-6-15**] 10:38PM BLOOD Glucose-63* Lactate-1.8 Na-129* K-4.7
Cl-101 calHCO3-17*
---------------
Cardiac Enzymes:
---------------
[**2137-6-15**] 10:30PM BLOOD cTropnT-0.12*
[**2137-6-15**] 10:30PM BLOOD CK-MB-NotDone
[**2137-6-16**] 06:52AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2137-6-16**] 01:30PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2137-6-15**] 10:30PM BLOOD CK(CPK)-42
[**2137-6-16**] 06:52AM BLOOD CK(CPK)-47
[**2137-6-16**] 01:30PM BLOOD CK(CPK)-42
---------------
Urine Studies:
---------------
[**2137-6-19**] 12:03AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.021
[**2137-6-19**] 12:03AM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2137-6-19**] 12:03AM URINE RBC-[**4-5**]* WBC->50 Bacteri-MOD Yeast-MANY
Epi-0-2
[**2137-6-18**] 03:29AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2137-6-18**] 03:29AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2137-6-18**] 03:29AM URINE RBC-13* WBC-525* Bacteri-NONE Yeast-FEW
Epi-0
[**2137-6-15**] 11:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2137-6-15**] 11:50PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2137-6-15**] 11:50PM URINE RBC-0 WBC-[**4-5**] Bacteri-FEW Yeast-NONE
Epi-1
---------------
Other Labs:
---------------
[**2137-6-15**] 10:30PM BLOOD Lipase-25
[**2137-6-16**] 06:52AM BLOOD calTIBC-168* VitB12-474 Folate-16.8
Ferritn-100 TRF-129*
[**2137-6-16**] 01:30PM BLOOD TSH-4.2
[**2137-6-16**] 01:30PM BLOOD T4-5.7
[**2137-6-17**] 03:13AM BLOOD Cortsol-23.7*
[**2137-6-18**] 03:28AM BLOOD Vanco-25.2*
---------------
Discharge Labs:
---------------
[**2137-6-21**] 06:55AM BLOOD WBC-5.5 RBC-3.83* Hgb-10.5* Hct-34.1*
MCV-89 MCH-27.3 MCHC-30.7* RDW-19.9* Plt Ct-211
[**2137-6-21**] 06:55AM BLOOD Glucose-93 UreaN-52* Creat-2.3* Na-132*
K-3.9 Cl-104 HCO3-18* AnGap-14
[**2137-6-21**] 06:55AM BLOOD Calcium-7.6* Phos-3.8 Mg-2.2
---------------
Micro Data:
---------------
C.Diff +
VRE Screen +
Blood Cx PENDING at time of d/c with no growth to date
---------------
Imaging:
---------------
CTA chest ([**6-16**]):
No pulmonary embolism or dissection. no focal areas of
consolidation. Small hiatal hernia.
CXR ([**6-15**]):
The lungs are clear without consolidation or edema. There is
mild aortic tortuosity with calcified plaque seen at the arch.
The cardiac silhouette is borderline enlarged but stable. No
effusion or pneumothorax is seen. The visualized osseous
structures are diffusely osteopenic with no displaced fractures
evident.
IMPRESSION: No acute pulmonary process.
CXR ([**6-19**]):
New small bilateral right greater than left pleural effusion.
Brief Hospital Course:
Pt is 84-year-old woman with CAD s/p BMS, sCHF w/ EF 30%, PAFib,
DM2, PAD, HTN, HL, h/o DVT/PE with recent admission for CHF
exacerbation coming with asymptomatic hypotension and
tachycardia.
# Paroxysmal atrial fibrillation, question of sick sinus
syndrome - Patient with diarrhea at home and poor oral intake
after being discharged at rehab. She was feeling very tired and
with poor appetite. She probably became orthostatic and
hypotensive that caused someone to hold her metoprolol.
Afterwards patient went into PAF that responded to her home
medications. Her CHADS2 score is 4 and she is not anticoagulated
because in the past she has developed nausea and discomfort with
coumadin. She was briefly started on a heparin gtt out of
concern for ACS, but this was stopped as the suspicion for ACS
was low. During the admission, her metoprolol was held initially
for concern of hypotension. On the first hospital night, she was
noted to develop several [**6-6**] second sinus pauses on telemetry;
her heart rate was observed to fall to the 30s transiently
throughout the night. During these times, she was asymptomatic
with stable blood pressure. Her sinus pauses and bradycardia
were felt to be secondary to sick sinus syndrome. It is possible
that the combination of acute illness, excessive AV nodal
blockade (from metoprolol and diltiazem she had received in the
ED and en route to the hospital), and underlying conduction
disease, caused her heart rate to drop. Given the patient's
desires for less invasive interventions, we did not consult
cardiology. Her beta-blocker was held though the acute illness
and restarted after she was felt to be more stable clinically.
However, later in her hospital course, she was noted to have
some additional episodes of bradycardia to the 20's with
associated lightheadedness. Her metoprolol was therefore held.
# Leukocytosis/UTI - Patient with WBC of 11.2 at admission.
Patient with recent antibiotic use and subsequent diarrhea, poor
PO intake. She was treated with broad-spectrum antibiotics,
which included vancomycin (empiric cellulitis/foot ulcer
coverage), Flagyl (empiric C dif coverage), and meropenem
(empiric UTI coverage given history of resistant Klebsiella
UTIs). C.diff came back positive, and the patient was continued
on flagyl. Vancomycin was discontinued because it was felt that
her foot ulcers did not appear infected. She was presumed to
have a UTI her UA findings; however, her urine cultures only
grew out yeast. Given her history of resistant Klebsiella in her
urine in the past, she was treated with meropenem throughout her
hospitalization. This was changed to cefpodoxime prior to
discharge. She will continue a total course of 10 days of
antibiotics for her UTI.
# Diarrhea: Found to be positive for c.diff during her
admission. She was placed on flagyl, which she will continue for
14 days (10 days after she completes the cefpdoxime for her
UTI).
# Melena: Pt developed guaiac positive dark stools during her
hospital course. Hematocrit remained relatively stable. GI was
consulted and saw the patient. She declined any invasive
procedures for further evaluation, given her goals of care. Her
ASA and plavix were stopped. She did not have any further
episodes of melena. ASA and plavix can be restarted 7 days after
discahrge.
# Acute Renal Failure - Was initially thought to be related to
dehydration. However, creatinine was continuing to rise when the
patient was called out to the medical floor. FeNa was 1.17%. It
was felt that the patient's ARF was likely multifactorial,
related to dehydration, ATN in the setting of her initial
hypotension, as well as kidney injury from her CTA contrast. Pt
was given IV fluids and her creatinine improved. Creatinine
peaked at 3.2 and was improving at the time of discharge.
# Hyponatremia - Was thought to possibly be related to free
water administration, as pt had been getting D5W. Could also be
related to hypovelmia. Improved with NS boluses.
# CAD - We initially continued her home ASA, Plavix, and
Lipitor. Imdur was held given her hypotension at presentation.
ASA and Plavix were later held given her melena and can be
restarted 7 days after discharge.
# Pump - Patient with EF 30%, no signs of failure, clean lungs.
In the setting of her hypotension, Lasix, spironolactone and
metoprolol were held. these were not restarted at discharge;
further adjustments of these medications can be done by the
patient's outpatient providers.
# Diabetes mellitus - She was treated with humalog insulin
sliding scale. Glargine and glipizide were held due to
hypoglycemia. These can be restarted by the patient's outpatient
providers.
# PVD - We continued her home statin. ASA and plavix were held
after the patient developed melena. These can be restarted 7
days after discharge.
# Code - DNR/DNI (this was confirmed with patient and with her
son and health-care proxy).
Medications on Admission:
Atorvastatin 80 mg PO Daily
Plavix 75 mg PO Dialy
Lasix 20 mg PO Daily
Glipizide 5 mg PO BID
Lantus 20 U QHS
Imdur 30 mg PO Daily
Metoprolol 12.5 mg PO BID
Nitroglycerin 0.4 mg SL PRN
Silver sulfadiazine 1% in ankle
Spironolactone 25 mg PO Daily
Aspirin 325 mg PO Daily
Bacitracin-polymixin B
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
2. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual PRN as needed for chest pain: [**Month (only) 116**] repeat after 5
minutes if chest pain has not resolved. If pt continues to have
chest pain after 3 doses or 15 minutes, please contact covering
MD.
3. Insulin Lispro 100 unit/mL Solution Sig: As Directed Units
Subcutaneous As Directed: Please follow provided sliding scale.
4. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 14 days: To complete 10 days of treatment AFTER
cefpodoxime is finished. Last day of flagyl should be [**2137-7-5**].
6. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days: To complete a total of 10 days of
treatment, ending on [**2137-6-25**].
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. Anticoagulation
Patient's aspirin and plavix were held due to GI bleeding. These
medications should be restarted 7 days after discharge, on
[**2137-6-28**]. The patient's dosages were as follows:
Aspirin 325 mg daily
Plavix (Clopidogrel) 75 mg daily
10. Outpatient Lab Work
Patient should have a CBC and a Chem 10 (Na, K, Cl, HCO3, BUN,
Cr, Glucose, Ca, Mg, Phos) drawn on Monday [**2137-6-24**] and faxed to
her PCP. [**Name10 (NameIs) **] fax number is [**Telephone/Fax (1) 3382**] (Attn: Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis:
- Urosepsis
- Clostridium Difficile Colitis
- Atrial Fibrillation with Sick Sinus Syndrome
Secondary Diagnosis:
- Coronary Artery Disease
- Systolic Heart Failure
- Diabetes Mellitus
- Peripheral Artery Disease
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for low blood pressure and a
fast heart rate. You were felt to likely have a urinary tract
infection, and you were treated with antibiotics for this. You
were also found to have a bacterial infection in your colon, for
which you were placed on antibiotics. Your hospital course was
also complicated by fast and slow heart rates and some kidney
dysfunction. At the time of discharge, your kidney function was
improving and your heart rate was stable.
CHANGES TO YOUR MEDICATIONS:
- Hold plavix and aspirin. These medications should be restarted
7 days after discharge ([**2137-6-28**]).
- START Iron suppplementation
- START Pantoprazole, given your recent GI bleeding
- START Cefpodoxime 200 mg daily for 4 more days, to complete a
total course of 10 days of therapy (ending on [**2137-6-25**]).
- START Flagyl 500 mg every 8 hours for 14 more days, to
complete a total course of 10 days of Flagyl AFTER you complete
your other antibiotics. You last day of Flagyl will be [**2137-7-5**].
- Your lasix and spironolactone were stopped given your low
blood pressure and renal dysfunction. You should discuss with
your PCP when you will restart these medications.
- You lantus and glipizide were stopped because your blood
sugars were low. You should discuss with your PCP when to
restart these medications. You are being continued on sliding
scale insulin.
- You metoprolol was stopped given your slow heart rate.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
It was a pleasure taking part in your medical care.
Followup Instructions:
You have the following follow-up appointments scheduled:
Department: PODIATRY
When: FRIDAY [**2137-6-28**] at 3:50 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2137-7-12**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6310**], NP [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2137-7-16**] at 4:20 PM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"0389",
"5845",
"5990",
"2761",
"2762",
"99592",
"42731",
"41401",
"V4582",
"4019",
"2724",
"4280"
] |
Admission Date: [**2158-5-6**] Discharge Date: [**2158-5-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
- Right hip fracture
- transfer to MICU for hypotension, hypoxic resp failure, afib w
RVR
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central Venous Line placement
Bronchoscopy
History of Present Illness:
85yo M w/hx of Crohn's disease, CAD, COPD, CHF (EF 50%), afib,
recent PNA who initially presented to [**Hospital1 **] on [**5-6**] with right hip
fracture and likely bilateral PNA. He was started on
vanco/zosyn/flagyl for his PNA and preop managed for his right
hip fracture with intermittent pain meds. Patient had trigger
#1 on arrival to floor for Afib w RVR and hypoxia (80% RA).
Placed on 4L NC and given lopressor, morphine, IVF, dilt.
Trigger #2 at 2:30am for afib w RVR and altered ms. [**Name13 (STitle) **] was
given 500cc IVF and ABG 7.34/52/83 w lactate of 2.4. He had
poor resp effort and ms [**First Name (Titles) **] [**Last Name (Titles) **] to MICU.
.
Patient semi-emergently intubated on arrival to ICU. He was
given etomidate and succ and 8.0 ETT placed without issue.
Subsequently, patient became hypotensive requiring neo.
Semi-urgent right IJ catheter placed which was c/b site hematoma
and persistent bleeding around CVL. Stat VBG sent with SvO2 40.
CXR confirmed placement. Pt hemodynamically stabilized.
.
ROS unobtainable.
.
Past Medical History:
1. History of CAD, s/p PTCA (? details)
2. CHF, last echo in [**2147**] with EF 50-60%, depressed RV function
with moderately dilated RV cavity, mild to moderate MR, mod TR,
moderate PASP, signficant PR
3. Crohn's disease
4. COPD, no PFTs on file (diagnosis by CXR)
5. Vitamin B12 deficiency
6. Atrial fibrillation, previously anticoagulated (not
currently)
7. PVD, with arterial studies [**2154-6-12**] with moderate bilateral
tibial artery occlusive disease.
8. History of partial SBO, treated medically
9. History of gallstone pancreatitis
10. Dementia, likely vascular
Social History:
He lives at a rehab facility. No children, closest to his
sister. [**Name (NI) **] used to smoke cigars in the past, quit 30-40 years
ago. Past EtOH.
Family History:
Non-contributory
Physical Exam:
On presentation to the ICU:
VS: T98.0, BP120/70, HR150 (improved to 90 p dilt), RR 26 O2 86%
on RA (improved to 95% on 4L)
GENERAL: ill-appearing man, uncomfortable, moaning in pain,
unable to answer questions
HEENT: No scleral icterus. PERRLA/EOMI. MM dry. OP clear. Neck
Supple, No LAD.
CARDIAC: tachycardic, irregularly irregular. Normal S1, S2. No
m/r/g.
LUNGS: Coarse breath sounds throughout.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: 2+ peripheral edema to knees. Erythema of bilateral
lower extremities consistent with venous stasis, appears
chronic. Dopplerable pulses bilaterally. Extremities warm. RLE
externally rotated.
NEURO: A&O X 1, moving all extremities, unable to complete full
neuro exam due to mental status.
.
Pertinent Results:
[**2158-5-6**] 01:15PM WBC-8.2# RBC-3.65* HGB-11.4* HCT-34.6* MCV-95
MCH-31.4 MCHC-33.1 RDW-15.3
[**2158-5-6**] 01:15PM NEUTS-76.1* LYMPHS-16.8* MONOS-6.4 EOS-0.4
BASOS-0.3
[**2158-5-6**] 01:15PM PLT COUNT-101*
.
[**2158-5-6**] 01:15PM PT-18.1* PTT-30.5 INR(PT)-1.7*
.
[**2158-5-6**] 01:15PM GLUCOSE-154* UREA N-30* CREAT-0.8 SODIUM-134
POTASSIUM-3.4 CHLORIDE-94* TOTAL CO2-31 ANION GAP-12
.
[**2158-5-6**] 01:28PM LACTATE-2.1*
[**2158-5-7**] 02:46AM BLOOD Lactate-2.4*
[**2158-5-7**] 02:48AM BLOOD Lactate-1.9
[**2158-5-7**] 04:27AM BLOOD Lactate-2.4* K-4.6
[**2158-5-7**] 06:06AM BLOOD Lactate-3.8*
[**2158-5-7**] 08:37AM BLOOD Lactate-4.7*
[**2158-5-7**] 02:09PM BLOOD Lactate-5.5*
[**2158-5-7**] 03:36PM BLOOD Lactate-6.5*
[**2158-5-7**] 10:40PM BLOOD Lactate-5.5*
[**2158-5-8**] 05:37AM BLOOD Lactate-7.0*
.
CXR [**2158-5-6**]: dense nodular material at LL base stable in
appearance, increased opacification at bilateral lung bases may
represent atelectasis or consolidation. Mild increase opacity at
RL base adjacent to cardiac silloute.
.
Hip X-ray [**2158-5-6**]: Comminuted, intertrochanteric fx of R hip.
Femoral head in acetabulum with superiorly displaced femur.
.
EKG ON MICU ADMIT: Afib w RVR 120s, NA, NI, Q V1
.
CTA CHEST:
IMPRESSION:
1. Subsegmental right lower and upper lobe pulmonary emboli. No
evidence of
aortic dissection.
2. Bilateral left greater than right lower lobe pneumonias with
collapse of the left lower lobe and secretions within the left
lower lobe bronchi.
Small-to-moderate bilateral reactive effusions with bilateral
subpulmonic
components.
3. Markedly dilated right atrium with underlying right heart
dysfunction.
Dilated main pulmonary artery likely from pulmonary arterial
hypertension.
4. Extensive atherosclerotic disease involving the aorta and
coronary
circulation.
5. Cholelithiasis with no secondary findings of acute
cholecystitis. Trace
abdominal ascites.
.
ECHO:
The right atrium is markedly dilated. The left ventricular
cavity is unusually small. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded. Left
ventricular systolic function is hyperdynamic (EF>75%). The
right ventricular cavity is markedly dilated with depressed free
wall contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade. Echocardiographic signs of tamponade may be absent in
the presence of elevated right sided pressures.
IMPRESSION: Markedly dilated and hypokinetic right ventricle
with evidence of pressure/volume overload and at least moderate
pulmonary artery hypertension. Moderate tricuspid regurgitation.
The left ventricle is small (probably due to the effect of the
large RV), with hyperdynamic function and mild mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2154-8-28**],
the image quality is better on the current study. The RV may be
slightly more dilated. The degree of pulmonary hypertension is
similar.
Brief Hospital Course:
85yo M w/hx of CAD, systolic CHF, afib, recent PNA, and recent
right hip fracture presents to MICU with altered ms, afib with
RVR, and hypoxic respiratory failure. Now with tenuous
hemodynamics s/p intubation.
.
# Shock: Patient had systolic blood pressures in the 90s in
setting of afib w RVR then hypotensive s/p intubation.
Initially the cause of shock was unknown likely a combination of
cardiogenic, septic, and possibly obstructive shock. A CTA
showed small PE's and bilateral lower lobe pneumonias. He was
started on neosyneprhine which was changed to levaphed for
elevating lactate. He failed to wean from the vent and his
pressor requirement elevated to the point that he was on maximal
doses of Levaphed, Neosynephrine, and Vasopressin. He continued
to be hypotensive to 70s/40s with HR gradually rising to the
140s overnight. His family was updated on the gravity of his
situation and made the decision to focus on comfort. He was
made CMO, life support was withdrawn, and he passed quickly on
[**2158-5-8**].
.
# Hypoxic resp failure: Mr. [**Known lastname 5762**] was transfered to the ICU
after hypoxic event. He had evidence of bilat infiltrates on
CXR and recent PNA treated with levaquin. Reportedly flu
negative at rehab. He had a CTA chest which showed small PEs
and bilateral lower lobe PNAs. He was unable to wean from the
vent given his increasing pressor requirements.
.
# Cards rhythm: afib w RVR known in his past. Generally well
rate controlled. As above, his pressor requirement increased
and his HR remained elevated until the decision to withdraw life
support.
.
# Hip fracture: patient was admitted for hip fx s/p fall. He
was awaiting hip replacement when he decompensated and passed
away as described above.
Medications on Admission:
1. Oseltamivir 75mg PO qday
2. Levofloxacin 250mg PO qday
3. Calcium Carbonate 650mg PO BID
4. Cholecalciferon 1000mg PO qday
5. Furosemide 40mg PO BID
6. Senna 2 tabs PO qHS
7. Alendronate 70mg PO qSUN
8. ASA 81mg PO qday
9. Toprol XL 50mg PO qday
10. Albuterol/iptratropium nebs q6H secheduled and q4H PRN
11. APAP 650mg PO q4H PRN
.
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
Completed by:[**2158-5-10**]
|
[
"51881",
"486",
"5180",
"5849",
"41401",
"496",
"42731"
] |
Admission Date: [**2137-4-25**] Discharge Date: [**2137-5-4**]
Date of Birth: [**2087-10-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Scrotal Bleeding
Major Surgical or Invasive Procedure:
Paracentesis times 3
History of Present Illness:
49 yo man w h/o etoh cirrhosis, portal hypertension with
refractory ascites s/p recent TIPS placement who presents with
scrotal bleeding. He was discharged yesterday and got home to
find that he had urinary incontinence. Took off underwear and
"scraped" his scrotum. He then described a "squirt of blood"
shooting out of the base of his scrotum approximately 5 feet
away. It was a steady stream and soaked through his white
t-shirt (which he used to clean up the mess). Lasted
approximately 5m. Called his liver team who recommended eval.
ED: VSS. Morphine 10mg for abd pain. Underwent u/s guided para
which was neg for SBP.
Currently, he described constant dull aching abd pain since
discharge. Also describes scrotal discomfort. Reports that he
has had mild bloody discharge from a prior para site for several
days. Otherwise ROS neg for F/C/NS/bloody stools/melena/N/V.
Denies any current scrotal bleeding.
Past Medical History:
-EtOH cirrhosis, end-stage liver disease: EGD showing portal
hypertensive gastropathy, but no h/o acute GI bleeds but
continues blood loss from gastropathy; no h/o SBP; refractory
chylouse ascites s/p TIPS on [**2137-4-12**] without complication or
encepalopathy but hepatic encephalopathy in the past. non
compliance with fluid and salt restriction
- Hyponatremia
- Anemia
- H/o cellulitis
- broad base colon polyp, extending [**3-10**] of colonic
[**Last Name (LF) 74615**], [**First Name3 (LF) **] need to be removed to be enlisted on
transplant list. To be coordinated with Dr. [**Last Name (STitle) **]
Social History:
Lives at home with his mother who suffered from a large MI and
his brother who also has [**Name (NI) 13808**] secondary to EtOH cirrhosis.
Unemployed. Denies EtOH (quit months ago) or tobacco use
currently.
.
Family History:
Brother w substance abuse and ETOH cirrhosis, mother with CAD.
Physical Exam:
VS: 98.8 112/58 HR 82 98% RA
Gen: cachectic appearing, jaundiced, NAD. large edema
Neuro: Pos asterixis, alert to person, place, not month
([**Month (only) **])
HEENT: Scleral icteric, MMM
Cards: RRR II/VI systolic m and LUSB
Lungs: CTAB
Abd: protuberant. shifting dullness. ttp diffusely but no
rebound or guarding. no masses. two sites of drainage: right
lateral spot draining mild amounts of blood. right medial spot
draining chylous ascites fluid.
Scrotum: excoriations at base but no bleeding. unable to palpate
testes [**3-9**] edema
Ext: profound painful edema
rectal: light red OB pos. no melena
Pertinent Results:
[**2137-3-8**] EGD: Granularity and mosaic pattern in the fundus
compatible with portal hypertensive gastropathy
[**2137-3-8**] Colonoscopy: A single flat polyp was found in the
proximal ascending colon. The polyp covered one third of the
colon cicumference. Cold forceps biopsies were performed for
histology at the flat polyp in the proximal ascending colon.
Final Path colon bx: Adenoma
**FINAL REPORT [**2137-5-1**]**
Blood Culture, Routine (Final [**2137-5-1**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
Anaerobic Bottle Gram Stain (Final [**2137-4-29**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2137-4-29**] 10:30AM.
GRAM POSITIVE COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2137-4-29**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**5-2**]
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-20mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF 60%) There is no ventricular septal defect. The right
ventricular cavity is dilated with normal free wall
contractility. 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
structurally normal. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2137-2-12**], the tricuspid regurgitation is increased.
IMPRESSION: no obvious vegetations seen
---------------
3.27 lenis
FINDINGS: No DVT was demonstrated in either leg.
-------------------
[**5-1**]
IMPRESSION:
1. T12 compression fracture without evidence of retropulsion or
significant spinal canal stenosis. Hyperintensity signal is
identified in the intervertebral disc space at T11 and T12
without evidence of bone edema.
Posterior disc bulge is noted at T10/11 producing mild anterior
thecal sac deformity, without evidence of nerve root
compression.
This is a very limited examination secondary to motion artifact
even after the administration of multiple pain medications,
please consider obtaining a new study under conscious sedation
if clinically warranted.
Bilateral pleural effusion is noted
---------------
[**4-28**] u/s
IMPRESSION:
1. Markedly elevated flow velocities in the mid and distal TIPS,
concerning for intrastent stenosis.
2. Cirrhotic liver.
3. Large volume of ascites
Brief Hospital Course:
49 y/oM with [**Month/Year (2) 13808**]/Cirrhosis secondary to heavy alcohol use and
alcohol addiction, no history of viral hepatitis, portal
hypertension without varices but with hypertensive gastropathy
and significant refractory ascites s/p TIPS, renal impairment,
anemia, admitted with scrotal bleeding, diagnosed with SBP,
transiently in ICU for severe abdominal pain, found to have T12
compression fx, now re-transferred to medicine after
stabilization.
.
# SBP
Diagnosed per ultrasound guided paracentesis with increased
polys. Started on CTX and Vanco. Cont to have abd pain and
intermittent fever but with stable hemodynamics. Completed
course of cefepime, subsequent tap revealed adequate treatment.
Was discharged on prophylactic ciprofloxacin 250mg daily for
life.
.
# Fever/SCN Bacteremia
Staph coagulase negative, likely contaminant, treated with 7
days vancomycin as precaution given his cirrhosis,
immunosuppressed state. Repeat tap had 300 wbc and only 20%
polys. Surveillance cultures all no growth. TTE to workup IE was
negative as were LENI's which were checked given assymetric leg
swelling. Was ruled out for c.diff toxin given abx, negative
times 3. Review of MRI was negative for signs of abscess.
.
# Cirrhosis secondary to EtOH
Has had refractory ascites and also mild encephalopathy. No
history of bleeding though is anemic. Encephalopathy, Cont
lactulose, rifaxamin. Continued MVI and PPI
- Varices: No varices on EGD
- Ascites: therapeutic tap 2 days ago with 3L off, s/p TIPS
placed 3 weeks ago, placed back on lasix 20, aldactone 50 at
discharge
- SBP: completed course abx, cipro daily as ppx
- Coagulopathy- no h/o bleeding
- [**Name (NI) 74616**] unclear
- [**Name (NI) 55362**] on list
.
# T12 Compression fracture
[**Month (only) 116**] be contributing to abdominal pain. No evidence of falls.
Orthospine ordered MRI thoracic spin with STIR, possible
vertebroplasty, seen by Dr. [**Last Name (STitle) 548**], MRI c/w old fracture, no
surgical intervention, signed off, pain control.
.
# Scrotal Bleeding- resolved at discharge
Medications on Admission:
Lactulose 30 TID
MVI
Pantoprazole 40 q24
Folic acid daily
B12 100 daily
Rifax 600 [**Hospital1 **]
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every
eight (8) hours.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO twice a day.
6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**5-12**]
hours as needed for pain.
Disp:*20 Capsule(s)* Refills:*0*
11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Spontaneous bacterial peritonitis
T12 compression
Scrotal Bleeding
Abdominal Pain
Secondary Diagnosis:
ETOH Cirrhosis
Refractory Ascites
Discharge Condition:
Stable, ambulating well
Discharge Instructions:
You were admitted to the hospital with scrotal bleeding and were
found to have a bacterial infection in your abdomen for which
you completed antibiotics and will now need to take
Ciprofloxacin 250mg 1 tablet daily to prevent recurrence of this
infection. You also had bacteria in your blood which was treated
with antibiotics. You were found to have a T12 compression
fracture which was evaluated by surgery with an MRI, the
fracture did not require any surgical intervention. You had
fluid removed from your abdomen several times and you were
placed back on diuretics (water pills). You
Your new medication list will be printed for you before you
leave.
If you develop fevers, chills, severe abdominal pain or any
worrisome symptoms then call the transplant clinic or go to the
emergency room for evaluation.
Followup Instructions:
Dr. [**Last Name (STitle) 497**] ([**Telephone/Fax (1) 3618**] call his office on Monday to schedule
an appointment in [**3-11**] weeks, transplant coordinator aware
.
[**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 3183**] call on Monday to schedule an
appointment in the
|
[
"2761",
"2875"
] |
Admission Date: [**2186-10-28**] Discharge Date: [**2186-12-9**]
Date of Birth: [**2118-10-27**] Sex: M
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Biliary obstruction.
Coronary artery disease.
Congestive heart failure.
History of myocardial infarction.
Status post coronary artery bypass graft.
History of atrial fibrillation.
Chronic renal insufficiency.
Status post bilateral inguinal hernia repair.
Hypertension.
Status post insertion of pacemaker and implantable
cardioverter defibrillator.
DISCHARGE DIAGNOSIS: Toxic metabolic delirium.
Respiratory failure.
Bilateral pleural effusions.
Failure to wean from ventilation.
Adult respiratory distress syndrome.
Atrial fibrillation.
Ventricular tachycardia.
Congestive heart failure.
Hypertension.
Coronary artery disease/myocardial ischemia.
Liver failure.
Superior mesenteric artery thrombosis, status post
exploratory laparotomy with thrombectomy.
Diarrhea.
Volume overload.
Malnutrition.
Hypokalemia.
Hyponatremia.
Acute renal failure.
Anemia.
Pneumonia.
Bandemia.
Sepsis.
Staphylococcal bacteremia.
Adrenal insufficiency.
HISTORY OF HOSPITAL COURSE: Mr. [**Known lastname 59459**] was a 67 year old male
with an extensive past medical history as noted in the
admission diagnosis who was transferred to the [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2186-10-28**] with
questionable obstructive jaundice for which he was
transferred directly to the Medical Service to the Intensive
Care Unit. Upon workup for this obstructive jaundice,
Surgery was consulted and it was noted that the patient was
having a significant gastrointestinal bleed and was, in fact,
found on computerized tomography scan to have a superior
mesenteric artery thrombosis which was felt to be the cause
of his abdominal pain rather than biliary problem in origin.
He was taken urgently to the Operating Room on [**2186-10-29**], and at that time underwent an exploratory laparotomy
and a thrombectomy of a superior mesenteric artery
thrombosis. There was no necrotic bowel and no bowel was
resected. The patient had a long and protracted
postoperative course subsequent to that time which was 41
days in duration and is most easily explained by systems.
Neurologically, the patient's main issue was change in mental
status. This was felt to be secondary to his overall septic
state, his liver failure, resulting in a toxic metabolic
syndrome. There was no evidence of any sort of mass effect
or bleed or central nervous infection. Throughout the course
of his hospitalization his mental status continued to
deteriorate as he became more obtunded. He did become more
arousable in the final week of his hospitalization but never
truly reached an alert and oriented baseline.
Respiratory, as noted during the patient's postoperative
Intensive Care Unit course his respiratory status was
complicated by development of significant pleural effusions
and pulmonary edema which were secondary to pneumonias. The
patient suffered a volume overload. He developed an adult
respiratory distress syndrome type picture at the mid point
of his hospitalization and failed to wean from the ventilator
over the course of his hospitalization. During attempts to
wean the patient from the ventilator, he suffered from
several episodes of apnea for which no etiology was found.
In order to relieve his effusions, diuresis was attempted as
were thoracenteses but the effusions continued to recur,
compromising the patient's pulmonary function.
Cardiovascular, the patient had a history of atrial
fibrillation which significantly complicated his hospital
course, secondary to hypotension from that source, in
addition to his septic update. Eventually we were able to
reach rate-controlled state with his atrial fibrillation
using Digoxin as his blood pressure did not tolerate any sort
of calcium channel blockade or beta blockade. Towards the
end of his hospitalization the patient continued to
experience runs of nonsustained ventricular tachycardia. His
pacer was notably shut off on the day he was made Comfort-
Measures-Only. The patient came in with a baseline ejection
fraction of 20 percent which made managing his huge fluid
shifts extremely difficult. Although diuresis was attempted,
the patient continued to experience recurrent episodes of
fulminant congestive heart failure which complicated his
hepatic function secondary to severe venous congestion. All
attempts were made to augment his cardiac contractility with
the use of Digoxin, but in the end, this was not successful.
Gastrointestinal, as noted the patient came in an superior
mesenteric artery thrombosis which was treated with urgent
operation and there was no bowel resected. He was
anticoagulated postoperatively for this and his atrial
fibrillation and never again during his hospitalization
demonstrated any evidence of bowel ischemia.
Regarding his liver function, the patient's status continued
to deteriorate up until the mid point of his hospitalization
at which point his bilirubin reached above 40. On workup
this was found not to be secondary to hemolysis or an
obstructive process but in fact, after consultation with the
Hepatology Service, is most likely secondary to his sepsis,
his total parenteral nutrition and his severe congestive
heart failure resulting in venous congestion. We attempted
to reduce the venous congestion through continuous venovenous
hemodialysis in order to improve the patient's liver
function. Unfortunately after decreasing to total bilirubin
of 30 we did not really see any improvement, although we had
stopped his total parenteral nutrition and were treating his
sepsis as aggressively as possible. The patient's main fluid
issues were secondary to huge volume shifts. He was well
over 25 kg positive at times in terms of body weight
secondary to the huge volumes he required to maintain his
intravascular status during his septic state. These shifts
contributed to his pulmonary edema and his congestive heart
failure. We were aggressive in our measures to diurese him
with a variety of diuretics and as noted below we even
attempts continuous venovenous hemodialysis after
consultation with the Nephrology Service. The patient also
had significant electrolyte abnormalities secondary to
nasogastric suctioning, diarrhea and fluid shifts which were
aggressively corrected.
Renally the patient went into acute renal failure with
progressively worsening BUN and creatinine, reaching an
azotemia with a BUN in the mid 100s. The Nephrology Service
agreed that continuous venovenous hemodialysis was
appropriate to see if we could improve the patient's status.
This was attempted for one week and although it did clear his
azotemia, upon discontinuation of continuous venovenous
hemodialysis his renal function continued to return towards
his baseline.
Hematologically, as noted the patient was anticoagulated with
heparin and Coumadin for his thrombosis and atrial
fibrillation. He had no significant episodes of bleeding but
did require some blood transfusions for anemia which is felt
to be secondary to decreased production.
The patient had a number of infectious disease issues which
included pneumonia secondary to methicillin-resistant
Staphylococcus aureus and generalized sepsis which was also
Staphylococcal in etiology. There was a question of fungemia
secondary to [**Female First Name (un) 564**] growing on catheter tips and in his
sputum for which he was started on Caspofungin. The patient
was tired on a variety of broad-spectrum antibiotics and was
maintained during the final week and a half through his
hospitalization on Vancomycin, Zosyn, Metronidazole and
lastly we added Caspofungin for essentially total
antimicrobial coverage, although he failed to improve on
this.
By postoperative day Number 41, as the patient's mental
status had failed to significantly improve and the patient
remained in respiratory failure with failure to wean from
ventilation, even after undergoing tracheostomy, and as the
patient continued to require significant amounts of
vasopressor support from Levophed and Pitressin, along with
his hepatic and renal failure, it was felt that the patient
had multiorgan system failure which he would not recover from
and after extensive discussion with the family and Ethic
Services, it was felt the patient should be made Comfort-
Measures-Only.
On [**2186-12-8**], as noted above the patient was made
Comfort-Measures-Only at which time all medical and
ventilatory support was withdrawn. Discussion for autopsy
was offered to the patient's family and they elected only for
an isolated hepatic autopsy to determine the cause for the
patient's liver failure but did not otherwise consent to a
general autopsy.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**], M.D. [**MD Number(2) 12418**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2186-12-8**] 16:14:58
T: [**2186-12-8**] 16:58:04
Job#: [**Job Number 59460**]
|
[
"4280",
"5849",
"42731",
"99592"
] |
Admission Date: [**2193-6-11**] Discharge Date: [**2193-6-15**]
Service: VSU
CHIEF COMPLAINT: Ruptured pseudoaneurysm.
PHYSICAL EXAMINATION: General - well-appearing 81 year old
white male in no acute distress. Lungs - clear to
auscultation bilaterally. Heart - regular rate and rhythm.
Extremities - left groin pulsatile hematoma noted. Left and
right dorsalis pedis are palpable to touch. Abdomen - soft,
bowel sounds hyperactive and soft, nontender to palpation.
LABORATORY: CBC - white blood cell count 8.2, hemoglobin
8.8, hematocrit 27.3. Chemistry - sodium 134, potassium 4.0,
chloride 102, bicarb 26, urea 9, creatinine 0.7, glucose 111,
PT 13.1, PTT 32.3, INR 1.1. Ultrasound revealed a pulsatile
hematoma. The impression was partially thrombosed left groin
pseudoaneurysm with 6 mm neck and 2.3 cm round component
containing active color flow.
HOSPITAL COURSE: The patient is an 81 year old white male
who presented to the Emergency Department at [**Hospital1 **] Hospital on [**2193-6-11**] for evaluation of a
pulsatile mass in his left groin. The patient had undergone a
cardiac catheterization on [**2193-6-6**]. On physical
examination, the patient was noted to have a pulsatile
hematoma in the left groin. Ultrasound subsequently revealed
a pseudoaneurysm in the left groin. The patient subsequently
was taken to the Operating Room for repair of an acutely
expanding pseudoaneurysm. After the procedure, the patient
remained stable and continued to progress each day. On postop
day 3, it is of note that in the early morning, the patient
experienced tightness in his arms similar to a feeling that
he described as having when he suffered his first episode of
cardiac ischemia in early [**Month (only) **]. EKGs were obtained, cardiac
enzymes, chest x-ray and labs with CBC and blood gases. EKGs
showed no change from previous EKGs taken. Chest x-ray was
normal. Cardiac enzymes were normal. Blood gases were normal.
However, it was felt that because of the patient's recent
cardiac history, a Cardiology consult was needed and
subsequently obtained. Cardiology felt that although the
patient was stable and ready to go home from a surgical
standpoint, the patient should remain in the hospital
overnight and be observed. The patient therefore was
transferred to the Internal Medicine Service at [**Hospital1 346**] for observation and treatment
overnight. The remainder of the [**Hospital 228**] hospital course was
unremarkable and he was discharged on [**6-15**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES: Ruptured pseudoaneurysm.
CAD.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po qd.
2. Acetaminophen 325 mg two tablets po q4h as needed for
fever and pain.
3. Clopidogrel bisulfate 75 mg one tablet po qd.
4. Atorvastatin calcium 10 mg one tablet po qd.
5. Lisinopril 5 mg one tablet po qd.
6. Atenolol 25 mg one tablet po qd.
7. Isosorbide mononitrate 30 mg one tablet sustained release
24 hour po qd.
8. Multivitamin capsule one po qd.
9. Allopurinol 100 mg three tablets po qd.
10. Docusate sodium 100 mg capsule one po bid.
11. Nitroglycerin 0.3 mg one tablet sublingual times
three prn as needed.
12. Levofloxacin 500 mg one tablet po q24h times 14
days.
FOLLOW UP: The patient is to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] office within one week. JP drainage is to remain
in place and the patient has received instructions on how to
care for that drain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 16264**]
MEDQUIST36
D: [**2193-6-14**] 23:04:15
T: [**2193-6-15**] 08:47:07
Job#: [**Job Number 41042**]
|
[
"4019",
"2720",
"41401"
] |
Admission Date: [**2122-6-19**] Discharge Date: [**2122-6-24**]
Date of Birth: [**2044-4-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
fentanyl / midazolam
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
1. [**6-23**] - colonoscopy
2. [**6-23**] - upper GI endoscopy
History of Present Illness:
Mr. [**Known lastname 111746**] is a 78 year old gentleman with history significant
for hypertension who presented to [**Hospital6 33**] on [**6-16**]
with abdominal distension, some lower abdominal pain, and blood
per rectum. He says the blood has been alternately dark black
and bright red, but that the BRBPR has slowed significantly and
he has not had any bowel movements all day today. His abdominal
distension is much better and he is passing gas from below, but
his lower abdominal pain is unchanged. He had a CT scan at [**Hospital1 34**]
which revealed diverticular disease, gastrohepatic lymph nodes,
and subcentimeter hepatic
cysts, as well as gastric distension and moderate splenomegaly.
He then had an EGD which demonstrated a mass at the GE junction
that was actively bleeding. His hematocrit was 50 on
presentation, then drifted down to 27 last night. After a unit
of blood his repeat hematocrit was 26, at which point he
received
two more units of blood. His Hct is now 30.
Past Medical History:
hypertension
Social History:
SOCIAL HISTORY: Quit smoking 15 years ago. Drinks 2-3 beers/day
followed by [**1-23**] glasses of wine. No RDA. Used to work as a
salesman but now retired. Lives alone.
Cigarettes: [ ] never [x] ex-smoker [ ] current Pack-yrs:____
quit: __15 yrs ago____
ETOH: [ ] No [x] Yes drinks/day: __5-6___
Drugs:
Exposure: [x] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation: salesman (retired)
Marital Status: [ ] Married [x] Single
Lives: [x] Alone [ ] w/ family [ ] Other:
Other pertinent social history:
Travel history: none
Family History:
non-contributory
Physical Exam:
Temp: 98.6 HR: 111 BP: 166/54 RR: 31
O2
Sat: 97% on RA
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [x] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR [x] All findings normal, tachy
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] reducible
umbilical hernia
[ ] Abnormal findings:
GU [ ] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[x] Abnormal findings: Rectal: normal tone, dark stool in vault,
guaiac positive, enlarged firm prostate.
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [ ] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [x] Abnormal findings:
b/l buttock rash, chronic
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
[**2122-6-19**] 11:17PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2122-6-19**] 11:17PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2122-6-19**] 08:39PM WBC-15.0* RBC-3.51* HGB-10.0* HCT-30.9*
MCV-88 MCH-28.5 MCHC-32.3 RDW-16.5*
[**2122-6-19**] 08:39PM GLUCOSE-111* UREA N-52* CREAT-1.3*
SODIUM-150* POTASSIUM-4.4 CHLORIDE-117* TOTAL CO2-24 ANION
GAP-13
Brief Hospital Course:
Mr. [**Known lastname 111746**] presented to the ED on [**6-19**] at [**Hospital3 **] for BRBPR. Admission labs were notable for a Hct of
54.4 with WBC of 22.5. During his brief hospital course his Hct
continued to drop (to a low of 26) warranting a total of 3 PRBC
transfusions. The patient was evaluated by both the Oncology and
Gastroenterology teams and a upper endoscopy was performed on
hospital day 1 - notable for a large bleeding mass located in
the GE junction. Biopsies were performed and given the high
concern for malignancy the patient was prepared for transfer to
[**Hospital1 18**] SICU for further management.
Here, he was found to be hemodynamically stable. His
hematocrit dropped from 30.9 on [**6-19**] to 24.7 on [**6-21**], so he was
transfused a unit of pRBCs. His hematocrit stabilized and he
was transferred to the floor. On [**6-22**], he underwent a
colonoscopy to evaluate for a lower GI bleed given his initial
presentation. The colonoscopy showed dark melenic-appearing
stool in the whole colon and terminal ileum, non-bleeding
diverticulosis of the sigmoid colon, non-bleeding internal
hemorrhoids, and otherwise normal colonoscopy to cecum and
terminal ileum. He tolerated the procedure well. On [**6-23**], the
foley was discontinued, but the patient failed to void and
required reinsertion. Also, an endoscopic ultrasound was
attempted but failed due to patient agitation. The patient
apparently had an undocumented drug side effect of the
lorazepam, which resulted in two code purples being called.
Throughout the entire time, the patients vital signs were within
normal limits and stable, including oxygen saturation (once the
measurement was obtainable - originally the patient was refusing
pulse ox). The patient was discharged on [**6-24**] in stable
condition with a leg bag in place. His daughter declined our
offer to schedule him with a nearby urologist to follow up on
the leg bag because they live in [**Location (un) 5087**]. She was informed that
it is very important, therefore, that he follow up with his PCP
quickly to get a referral to a urologist in Hindham to manage
the leg bag. Mr. [**Known lastname 111746**] was discharged in stable condition.
Medications on Admission:
1. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 Tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
2. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 Capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. Ciprofloxacin HCl 250 mg PO Q12H UTI Duration: 5 Days
4. metoprolol
5. ASA 325mg
6. lisinopril
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 Tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
2. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 Capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. Ciprofloxacin HCl 250 mg PO Q12H UTI Duration: 5 Days
4. lisinopril
5. metoprolol
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
upper gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with bleeding from an
esophageal mass. You required blood transfusions to correct your
anemia. You are now ready for discharge.
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 5067**]/Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you
experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Provider: [**Name Initial (NameIs) 2963**] (ST-4) GI ROOMS Date/Time:[**2122-6-29**] 7:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2122-6-29**] 7:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2122-7-14**] 9:30
|
[
"5849",
"2851",
"2760",
"41401",
"4019",
"2724",
"V1582"
] |
Admission Date: [**2166-9-25**] Discharge Date: [**2166-10-14**]
Date of Birth: [**2084-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 4578**]
Chief Complaint:
Dense R hemiparesis with aphasia
Major Surgical or Invasive Procedure:
IA tPA and MERCI extraction R MCA clot
History of Present Illness:
Patient is a 82 yo RHM with hx of Afib on coumadin,
hyperlipidemia and HTN here from OSH with sudden dense R
hemiparesis with aphasia. Per admission note and OSH physician,
[**Name10 (NameIs) **] was attending a meeting or a show when he suddenly slumped to
his R with dense R hemiparesis around 1:30 pm yesterday. He was
nonverbal but awake. There is no hx of trauma or fall. EMS was
called who found him to be severely bradycardic as well with HR
down to 30's hence he received 2 doses of atropine en route to
OSH. At the OSH, he had stat CT of head and was intubated for
airway protection after much sedation including Versed. He was
then transferred to [**Hospital1 18**].
Here at [**Hospital1 18**] he was minimally responsive given sedation and
continued to be R hemiplegic - repeat imaging including CTA and
CTP showed distal R ICA and MCA occlusion with increased MTT and
decreased CBV over R hemisphere. He was urgently taked to the
cerebral angio suite where he received IA tPA plus MERCI
procedue which successfully removed the clot over superior
division of R
MCA but due to the tortuosity of the inferior division, only IA
tPA was give for the inferior division. He was taken admitted
to SICU where he remained hemodynamically stable overnight.
He is more alert this morning but remains intubated although
requiring minimal support.
Per son, patient lives alone and independently. He drives,
walks without assistance and pays own bills. No hx of recent
infection or illness per family but they do not live with him.
Past Medical History:
1. Afib on coumadin
2. Hyperlipidemia
3. RBBB
4. HTN
5. Urticaria
6. hx of hernia repair in [**2148**]
7. s/p lap cholecystectomy in [**2161**]
8. perforated appendicitis with abscess in [**2164**]
9. CKD (baseline ~1.4)
Social History:
Separated, has 4 grown children who live locally. No EtOH,
cigarettes or illicit drug hx. Was a draftsman (architect) then
worked for [**Location (un) **] until 12 yrs ago.
Family History:
NC
Physical Exam:
T 97.8 BP 114~148/56~72 HR 58~77 RR 20 O2Sat 95% on CPAP 5/5
Gen: Lying in bed, intubated but arousable.
CV: Irregularly irregular but no murmurs/gallops/rubs
appreciated lots of transmitted upper airway sounds
Lung: +breath sounds bilateally but frequent coughing with thick
secretions.
Abd: +BS, soft, nontender
Ext: 1+ symmetric dorsalis pedis; trace edema bilaterally.
Neurologic examination on admission:
MSE: Awake and oriented to self. Follows simple commands ("open
your eyes," "stick out your tongue") but not with motor
movements. Remains nonverbal.
Neuro exam at d/c: expressive aphasia, EOMI, CN II-XII intact,
UE & LE reflexes +2, motor strength intact as far as can be
assesed UE & LE [**5-5**], follow 95% commands.
Cranial Nerves:
Pupils are round and equally reactive to light (4->2mm) but no
blink to visual threat on R and L gaze preference although eyes
pass midline with oculocephalic maneuver. Face symmetric and
+cough.
Motor:
Normal to slight hypotonia. Little voluntary movement even in L
but >[**3-5**] in both UE and LE. R biceps [**3-5**] but rest difficult to
assess. No purposeful withdrawal movements either.
Sensation: Grimaces to noxious stimuli and more pin prick
sensation on L than R.
Reflexes:
2 and symmetric throughout. Toes upgoing bilaterally
Unable to test coordination or gait.
Pertinent Results:
TELEMETRY demonstrated: A fib with HR today ranging up to 170.
Currently in 130s.
.
2D-ECHOCARDIOGRAM
[**2166-10-2**]
The left atrium is normal in size. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF 60-70%).
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. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen.
Compared with the findings of the prior study (images reviewed)
of [**2166-9-26**], no major change.
.
Echo [**2166-9-26**]
Extremely poor image quality. Cardiac chamber dimensions and
contractile function grossly preserved.
.
If clinically indicated, a transesophageal echocardiogram is
recommended for adequate imaging of cardiac structure and
function.
.
OTHER TESTING:
CXR [**2166-10-3**]:
CHEST RADIOGRAPH
FINDINGS: As compared to the previous radiograph, the
nasogastric tube has been removed and replaced by Dobbhoff
catheter. The catheter could be advanced by 5 cm. The left-sided
central venous access line is in unchanged position. The size of
the heart is also unchanged, however a subtle left-sided partly
retrocardiac area of hypoventilation has newly appeared.
There is no evidence of other focal parenchymal opacities
suggestive of pneumonia, no evidence of pleural effusions.
.
CT brain perfusion [**2166-9-25**]:
IMPRESSION:
1. CT of the head demonstrating hyperdense left middle cerebral
and internal carotid arteries, consistent with thrombosis. No
evidence for hemorrhage, edema, or mass effect.
2. CT perfusion study demonstrating increased mean transit time
for preserved blood volume and flow in the entire left MCA
territory, consistent with reversible ischemia.
3. CTA demonstrating occlusion of the left internal carotid
artery distal to the carotid bifurcation. There is no flow in
the entire cervical and intracranial internal carotid artery on
the left or the left middle cerebral artery. The anterior
cerebral artery is reconstituted the flow from the anterior
communicating artery. The remainder of the CTA is unremarkable.
.
CTA head and neck [**2166-9-25**]:
IMPRESSION:
1. CT of the head demonstrating hyperdense left middle cerebral
and internal carotid arteries, consistent with thrombosis. No
evidence for hemorrhage, edema, or mass effect.
2. CT perfusion study demonstrating increased mean transit time
for preserved blood volume and flow in the entire left MCA
territory, consistent with reversible ischemia.
3. CTA demonstrating occlusion of the left internal carotid
artery distal to the carotid bifurcation. There is no flow in
the entire cervical and intracranial internal carotid artery on
the left or the left middle cerebral artery. The anterior
cerebral artery is reconstituted the flow from the anterior
communicating artery. The remainder of the CTA is unremarkable
.
[**2166-9-27**] CT head without contrast
IMPRESSION: Evidence for left middle cerebral artery territory
infarction is reidentified with patchy foci of hyperdense
attenuation suggestive of petechial hemorrhage. No significant
change compared to the study from a day prior.
.
[**2166-9-25**] 04:30PM BLOOD WBC-5.2 RBC-4.83 Hgb-15.6 Hct-46.6 MCV-97
MCH-32.3* MCHC-33.4 RDW-14.7 Plt Ct-127*
[**2166-10-8**] 06:40AM BLOOD WBC-4.7 RBC-3.32* Hgb-10.6* Hct-31.0*
MCV-93 MCH-31.8 MCHC-34.1 RDW-14.6 Plt Ct-240
[**2166-10-8**] 11:13PM BLOOD WBC-11.9*# RBC-3.47* Hgb-11.2* Hct-32.5*
MCV-94 MCH-32.2* MCHC-34.4 RDW-14.7 Plt Ct-253
[**2166-10-9**] 03:52AM BLOOD WBC-14.2* RBC-3.42* Hgb-11.0* Hct-32.0*
MCV-93 MCH-32.2* MCHC-34.5 RDW-14.6 Plt Ct-245
[**2166-10-9**] 03:52AM BLOOD Neuts-79* Bands-7* Lymphs-6* Monos-6
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2166-9-25**] 04:30PM BLOOD PT-23.1* PTT-35.2* INR(PT)-2.2*
[**2166-10-9**] 09:20AM BLOOD PT-47.1* INR(PT)-5.2*
[**2166-9-25**] 04:30PM BLOOD Glucose-94 UreaN-20 Creat-1.2 Na-137
K-4.6 Cl-106 HCO3-23 AnGap-13
[**2166-10-9**] 03:52AM BLOOD Glucose-121* UreaN-24* Creat-1.4* Na-135
K-4.0 Cl-104 HCO3-23 AnGap-12
[**2166-9-26**] 03:14AM BLOOD CK(CPK)-65
[**2166-9-26**] 01:24PM BLOOD CK(CPK)-603*
[**2166-9-27**] 02:28AM BLOOD CK(CPK)-799*
[**2166-10-4**] 07:20AM BLOOD CK(CPK)-187*
[**2166-10-5**] 05:14AM BLOOD ALT-43* AST-45* CK(CPK)-184* AlkPhos-63
Amylase-54 TotBili-0.8
[**2166-10-5**] 10:00AM BLOOD CK(CPK)-204*
[**2166-10-6**] 06:10AM BLOOD ALT-56* AST-58* AlkPhos-75 TotBili-1.0
[**2166-10-7**] 06:40AM BLOOD ALT-67* AST-64* AlkPhos-67
[**2166-10-8**] 06:40AM BLOOD ALT-71* AST-64* AlkPhos-66 TotBili-0.9
[**2166-10-13**] AST46 ALT33 LD251 Alk ph61 Tbili 0.7
[**2166-9-26**] 03:14AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2166-9-26**] 01:24PM BLOOD cTropnT-<0.01
[**2166-9-27**] 02:28AM BLOOD cTropnT-<0.01
[**2166-10-5**] 05:14AM BLOOD CK-MB-5 cTropnT-<0.01
[**2166-10-5**] 10:00AM BLOOD CK-MB-5 cTropnT-<0.01
[**2166-10-5**] 05:14AM BLOOD Lipase-40
[**2166-9-26**] 03:14AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.7 Cholest-104
[**2166-10-9**] 03:52AM BLOOD Calcium-8.8 Phos-2.3* Mg-1.7
[**2166-9-26**] 01:24PM BLOOD %HbA1c-5.8
[**2166-9-26**] 01:24PM BLOOD Triglyc-80 HDL-32 CHOL/HD-2.8 LDLcalc-42
[**2166-9-26**] 01:12PM BLOOD Digoxin-0.6*
.
Labs on day of d/c
N134 Cl101 BUN25 glc91 AGap=9
K5.0 HCO329 Creat1.3
Ca: 9.1 Mg: 2.0 P: 3.2
WBC94 H/H 4.9/33.8 plt312
Brief Hospital Course:
Patient is a 82 yo RHM with hx of paroxysmal Afib, HTN and
hyperlipidemia who had a witnessed dense R hemiparesis with
aphasia found to have clot in his R MCA who underwent IT tPA and
MERCI procedure which successfully removed his superior division
clot but not the inferior divison (supplying the R temporal
lobe) - only IA tPA.
.
Possibly emoblic stroke given the sudden nature of onset -
possible sources include cardiac or carotid. Patient does have
risk factors including age, HTN, hyperlipidemia and PAF although
he was anticoagulated and was therapeutic on admission.
.
He was admitted to Neuro ICU and was successfully extubated on
HD#2 - he continued to make improvements especially in motor
movements and although due to impaired comprehension, its
difficult to do formal strength testing, he appears to be full
strength throughout. His main deficits remain speech/language
given extensive L temporal lobe infarct. He has an expressive
aphasia but follows 90% of commands. He was initially started on
ASA only then on HD#5, restarted on Coumadin with ASA bridging
only given the extensive infarct to minimize risk of hemorrhagic
transformation. His coumadin was held during the second half of
his hospitalization as his INR was supratherapeutic. He was
instructed to restart his coumadin the day after discharge. Echo
was done twice - initial study was subpar but the 2nd study was
adequate to show preserved systolic functions and no thrombus.
.
He has known PAF but his rate was poorly controlled during this
admission. Cardiology was consulted and they recommended
streamlining his regimen including discontinuation of digoxin,
disopyramide, and metoprolol and changing to long acting
diltiazem. He was later continued on diltiazem and started on
amiodarone 200mg PO TID but he continued to have PAF at which
point he was started on an amiodarone drip. He converted to NSR
while on the amiodarone drip. After finishing 5hrs on drip of
1mg/min and then 18hrs at 0.5mg/min he was switched to
amiodarone 200mg TID. He went back into Afib on the Amiodarone
PO which was likely secondary to the stress of his UTI (see
below). On [**2166-10-13**] he converted back to NSR. He is being
discharged on amiodarone 200mg PO TID and after he has been
loaded for a total of 10g he will be switched to a maintenance
dose of 200mg daily (loading will be done on [**2166-10-22**]). His
LFTs (AST & ALT) increased from the 40s to the 70s likely due to
the amiodarone but trended back down. His statin was stopped in
the setting of his increased LFTs and he was restarted on the
statin when his LFTs fell. The patient's goal INR is 2.5-3 but
he was supratherapeutic for much of his hospitalization. The
patient's previous coumadin home regimen was 4mg (TTSS) and 2mg
(MWF) as he should be restarted on that the day after discharge.
.
Late in his admission he developed rigors and decreased UOP.
His foley was changed and his urine analysis showed evidence of
a UTI. His UTI was being treated with cipro but his culture came
back resistent to cipro and he was changed to nitrofurantoin. He
needs to finish his course of nitrofurantion and his last day of
a seven day course will be [**2166-10-17**]. He is being discharged
with a foley due to problems with urinary retention. He is set
up with urology follow up for urinary retention.
.
The patient was seen by speech and swallow and has the following
food restrictions.
-Dysphagia with following recs from swallowing exam: Diet:
ground consistency solids w/ thin liquids, Meds: whole in puree,
Seated upright during meals, and Needs full supervision for
feeding.
.
The patient is full code which was confirmed by the patient and
his son.
.
The patient will get Speech, PT, and OT at [**Hospital 38**] Rehab.
Medications on Admission:
1. Coumadin (4mg TTSS and 2mg MWF)
2. Digoxin 125mcg daily
3. Metoprolol 50 am /25 night
4. Lipitor 10 daily
5. Verapamil 40 TID
6. MVI
7. Disopyramide 150 [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. coumadin Resume when INR < 3 in order to maintain goal INR of
2.5-3. (previous regimen TTSS 4mg and MWF 2mg)
5. MVI daily
6. lab work [**2166-10-13**] AST, ALT, CBC, Chem 7 fax results to PCP
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29247**]
7. Outpatient Lab Work INR checks daily (goal 2.5-3)
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO three times a
day for 13 days: last dose evening of [**2166-10-22**].
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
START ON [**2166-10-23**] after finishing TID dosing.
10. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day): Until [**10-17**].
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary
Stroke of LMCA
Paroxysmal Atrial Fibrillation
Urinary tract infection
Urinary retention
Difficulty swallowing
Hyperlipidemia
Increased LFTs
.
Secondary
RBBB
HTN
Urticaria
hx of hernia repair in [**2148**]
s/p lap cholecystectomy in [**2161**]
perforated appendicitis with abscess in [**2164**]
CKD
Discharge Condition:
Stable. Expressive aphasia. Understands 80% of commands.
Treating UTI. NSR.
Discharge Instructions:
You were admitted with a R hemiparesis and aphasia and found to
have clot in your L MCA vessel. You underwent IT tPA and MERCI
procedure which was successfully removing his superior division
clot but not the inferior divison (supplying the R temporal
lobe). You understand about 80% of commands but have expressive
aphasia and a slight pronator drift. You were in paroxysmal
atrial fib and treated with oral and IV amiodarone. You will be
discharged on oral amiodarone. You also developed urinary
retention and will be discharged with a foley with urology
follow up. You had a urinary tract infection which was treated
with nitrofurantoin and will need to finish a 7 day course of
antibiotics. Once you finish this antibiotic course, you should
have your foley catheter removed, if possible. If the foley
catheter cannot be removed, your urinary retention should be
addressed at your urology appointment. You also had some
difficulty swallowing and should take the following precautions
when eating:
1. Diet: ground consistency solids w/ thin liquids
2. Meds: whole in puree
3. Seated upright during meals
4. Needs full supervision for feeding
5. Continue to monitor for aspiration
.
New medication:
Amiodarone 200mg PO TID until [**2166-10-22**] and then amiodarone 200mg
PO daily
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Nitrofurantoin 100 [**Hospital1 **] until [**10-17**]
.
Stopped medications:
Digoxin
Verapamil
Disopyramide
Coumadin is being held due to supratherapeutic INR, should be
resumed when INR < 3 for goal INR of 2.5-3.
.
Continue the following old medications:
MVI
.
Please return to the ED if you experience any palpitations,
chest pain, new weakness, numbness, difficulty seeing, or any
other new medical problem.
Followup Instructions:
Urology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] [**Hospital Ward Name 23**] center on [**2166-10-22**]
at 10 am.
Neurology: Dr. [**Last Name (STitle) 6938**] on Friday [**10-24**] 3:30 [**Hospital Ward Name 23**]
building.
Primary Care: Please Call Dr. [**Last Name (STitle) 29247**] for an appointment within 2
weeks. [**Telephone/Fax (1) 29248**]
.
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2166-10-31**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2166-11-21**] 1:20
Completed by:[**2166-10-22**]
|
[
"5990",
"42731",
"2724",
"40390",
"5859",
"V5861"
] |
Admission Date: [**2159-6-20**] Discharge Date: [**2159-7-21**]
Date of Birth: [**2090-12-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Altered mental status, respiratory failure.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 68 yo M with h/o COPD and HTN who initially presented
to the neurology service on [**6-20**] with AMS who is now being
transferred to the MICU for HTN urgency and hypoxia. The pt had
been in his USOH until he returned from [**Country 4754**] approximately
[**2-4**] wks ago and felt fatigued. He subsequently experienced
visual changes, emotional lability, and confusion. An outpt head
MRI/MRA revealed total stenosis of the [**Doctor First Name 3098**] but no ischemic
infarcts. He was then tx'd to [**Hospital1 18**] on [**6-20**] after presenting to
an OSH with slurred speech. Since being on the neurology
service, he has had a EEG negative for szs, rpt MRI/MRA head
without ischemia or temporal lobe enhancement, and LP that was
significant for lymphocytic pleocytosis (WBC 85, 95% lymphs).
Past Medical History:
COPD
Dyslipidemia
HTN
Deaf in L ear
Social History:
Married and lives with wife. [**Name (NI) 1403**] a writer. Recent travel to
[**Country 4754**] 2-3 weeks ago. + tobacco, no EtOH, no illicits.
Family History:
non-contributory
Physical Exam:
VS: 96.5 166/92 80 26 90% on NRB --> 96% BIPAP 10/5 FiO2 ...
GEN: elderly appearing man in NAD, awake, alert
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP
slightly dry and without lesions, JVP approxmiately 13 cm above
sternal notch
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: + accessory muscle use and abdominal breathing, improved
from initial evaluation, + diffuse rhonchi
ABD: Soft, NT, ND, no HSM
EXT: No c/c/e
SKIN: No rash
Pertinent Results:
IMAGING:
[**2159-7-4**] Evoked Potentials: BRAIN STEM AUDITORY EVOKED POTENTIAL
(08-044): After stimulation of either ear there were very poorly
formed (and likely unreliable) evoked potential peaks including
wave I and probably waves III and V, but the latencies were
extremely difficult to determine. They all appeared to occur
within normal limits.
The study is unreliable but suggests some brain stem activity.
A possible explanation is involvement of the VIIIth nerve
peripherally,
dampening and distorting subsequent peaks.
[**2159-7-1**] EEG: Probably abnormal EEG with no clear overriding
background
rhythm seen largely because of superimposed beta activity which
could be
medication effect. This tracing could be consistent with an
encephalopathic process but further repeat study, as clinically
indicated, would be of further diagnostic benefit. There was no
overt
epileptiform or subclinical electrographic seizure activity
seen.
[**2159-7-13**] EEG: IMPRESSION: This is an abnormal EEG due to the
presence of a slow and disorganized background consistent with a
moderate encephalopathy of toxic, metabolic, or anoxic etiology.
Note is made that with the observed movements, no epileptiform
activity occurred.
Brief Hospital Course:
OVERALL HOSPITAL COURSE SUMMARY:
Mr. [**Known lastname **] was transferred to the MICU due to respiratory
failure on the neurology floor from a combination of aspiration
PNA and hypertensive urgency leading to flash pulmonary edema.
In the MICU, his major problems were AMS, respiratory failure,
blood pressure lability, tremors. These were attributed to
likely encephalitis, possibly viral in etiology. He had an
extensive neurologic workup for causes of his encephalitis
(labs, imaging, EEG, etc) and all of these results were
negative. His family brought up the possibility of an anti-NMDA
receptor antibody mediated encephalitis as a possible cause, and
CSF was sent to UPenn for special analysis; the Anti-NMDA Ab was
negative. After this, his family made him DNR and as he showed
no improvement in the next several days he was eventually made
CMO and extubated on [**7-21**].
<br> HOSPITAL COURSE BY PROBLEM:
<br> Altered Mental Status: Patient's mental status rapidly
deteriorated in the MICU. During the first 2 days, he followed
commands, but became unresponsive thereafter. He did not open
his eyes, did not make purposeful movements, and did not
withdraw to pain. Work-up was significant for lymphocytosis on
CSF, two stable MRIs, 2 EEGs that showed no seizure activity,
and evoked potentials that showed some brainstem activity. A
full panel of encephalitis and prion disease labs were sent.
Labs were negative for Bartonella, Lyme, Erlichiosis, HSV as
well as WNV, EEE, CJD. Also, CSF was sent to UPenn for
evaluation for anti-NMDA antibody encephalities and this was
negative (testicular U/S performed for associated testicular
malignancy in the setting of anti-NMDA receptor encephalitis was
also negative and AFP which can be elevated in this setting was
also negative). Neuro also recommended against brain bx, as
there was no focal lesion. He was sedated on propofol and
fentanyl and propofol was weaned several times to see if his
mental status had changed but he did not exhibit signs of
improvement. Propofol was weaned on the day before he was
extubated and he still did not show signs of improvement in
mental status.
<br> Respiratory failure: Initially, patient's respiratory
failure was thought to be due to a combination of aspiration PNA
and flash pulmonary edema. With diuresis and broad spectum
coverage, his CXR improved and his leukocytosis and fevers
resolved. However, he was unweanable from the vent due to poor
mental status, blood pressure lability, and heavy sedation
requirements. It is thought that the underlying cause of Mr.
[**Known lastname 78543**] resp failure was neurologic dysfunction. Pt has a hx
of COPD, which was treated with standing albuterol and atrovent
nebs and a steroid taper, with minimal signs of improvement.
Patient's sputum did grow out Klebsiella on [**7-6**] and he was
initially treated with a course of vanc/cipro; cultures were
pan-sensitive and vanc was D/C. Because repeat sputum on [**7-10**]
grew out GNR he was also started on cefipime, but the cultures
only showed minimal growth of pan-sensitive Klebsiella and
cefipime was D/C on [**7-13**]. Cipro was continued for a total of 10
days. After the decision was made to extubate on [**7-21**], his PEEP
was weaned and he was kept sedated to a respiratory rate of
[**10-17**].
<br> Blood pressure lability: Pt presented to the MICU with
hypertensive urgency, which led to flash pulmonary edema. As his
mental status worsened, so did his hemodynamic instability. He
was consistently hypertensive to SBPs in the 190s and 200s when
sedation was weaned or when he was agitated. When comfortable
and on BP meds and full sedation, he dropped his SBPs into the
80s and 90s. Metoprolol was tried but this caused the patient to
drop his SBPs and was not continued.
He was maintained on low dose captopril to treat hypertension,
as well as using sedation (propofol) to maintain BPs at a normal
range. Propofol was weaned several times to see if there was
change in mental status, and most times it was weaned he became
more hypertensive.
<br> Tremors: Pt started tremoring ~5 days into his MICU stay.
It begain with tongue fasciculations, spread to his entire right
side, then progressed to a full-body tremor. 2 EEGs were
performed during a heavily symptomatic (tremor) period and was
read as no seizure activity, but did show disorganized
background activity c/w toxic/metabolic/anoxic encephalopathy.
Tremors are caused by many of the viral encephilitidies and this
was thought to be the most likely cause of his tremor.
<br> Hypernatremia: Patient was initially hypernatremic at
presentation. This was treated with free water boluses and
resolved.
<br> Hyponatremia: Patient was noted to be hyponatremic (129) on
[**7-13**] and free water boluses were D/C. He was hyponatremic (130)
on [**7-15**] but a repeat sodium was 140 and this was thought to be
due to lab error. Sodium was monitored and was within normal
limits after this time.
<br> R upper extremity edema: Patient was noted to have swelling
of R upper extremity greater than on the L on [**7-12**]. Patient had
PICC on R arm and swelling was thought to possibly be [**2-3**] clot
at PICC site. R extremity U/S normal and on [**7-13**] arms appeared
similar size. This was monitored through the rest of his
hospital course and remained normal.
<br> Leukocytosis: Increased WBC count initially; resolved.
CDiff negative X3. Likely this was due to initiating steroids,
as no source of infection was identified.
<br> COPD: Pt had mild/moderate ds at baseline [**2-3**] prolonged
smoking hx. Albuterol / atrovent were continued per PE tube.
Steroids were given as above.
<br> Hypercholesterolemia: home statin was continued.
<br> FEN: Patient was put on tube feeds and kept at goal.
Patient given Narcan PRN constipation.
<br> Access: R PICC was inserted on [**6-24**].
<br> PPx: heparin SC, pneumoboots, pantoprazole, bowel regimen.
<br> Code: FULL (at admission) --> DNR ([**7-18**]). Patient was kept
full code through numerous family meetings while the family
waited for full results to be available. The family was
especially interested in the results of the anti-NMDA receptor
antibody before making any decisions. After the NMDA receptor
antibody came back negative, the family changed his code status
to DNR.
Medications on Admission:
Docusate Sodium 100 mg PO BID
Insulin SC Sliding Scale
Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze, SOB
Acyclovir 750 mg IV Q8H
Ceftriaxone 2 gm IV q24h
Lisinopril 5 mg PO DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN hypoxia, wheeze
Metoprolol Tartrate 5 mg IV Q6H:PRN
Amlodipine 10 mg PO DAILY
Nicotine Patch 14 mg TD DAILY
Aspirin 325 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Atorvastatin 40 mg PO DAILY
Citalopram Hydrobromide 40 mg PO DAILY
Discharge Medications:
none, discharge to death
Discharge Disposition:
Expired
Discharge Diagnosis:
suspected viral encephalitis, tremors of unknown origin,
respiratory failure
Discharge Condition:
death
Discharge Instructions:
none, discharge to death
Followup Instructions:
none, discharge to death
Completed by:[**2159-7-22**]
|
[
"51881",
"5070",
"2760",
"2761",
"496",
"2720"
] |
Admission Date: [**2179-10-18**] Discharge Date: [**2179-10-29**]
Date of Birth: [**2121-1-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
acute onset back pain and syncope
Major Surgical or Invasive Procedure:
[**2179-10-18**] emergency repl. ascending aorta ( 28 mm Gelweave
graft)/ AVR ( 27 mm CE pericardial valve)
History of Present Illness:
58 yo man presented to OSH ER with one day history of acute
onset back pain and syncope with a witnessed collapse at work.
CTA showed acute Type A dissection at the level of the aortic
root to the left common iliac artery as well as moderate
hemopericardium. Hypotensive in ER.Transferred intubated and
sedated by [**Location (un) **] emergently to [**Hospital1 18**].
Past Medical History:
HTN
obesity
CRI
s/p pancreatitis
prostate CA
anemia
diverticulosis
CVA left caudate [**2170**]
adrenal hyperplasia s/p adrenalectomy [**2169**]
hypertriglyceridemia
pre-diabetic
Social History:
unknown
Family History:
unknown
Physical Exam:
Admission:Ht 68" Wt @100 kg
intubated, sedated
skin unremarkable
CTAB
RRR with murmur
obese abd, soft , NT, ND
cool extremities
no peripheral edema
unable to assess neuro status
PE on DISCHARGE:
VS:T 98.7/97.6, 143/90,P 89, 98% R/A O2SAT, 114KG
General: A&O x3,NAD
CVS:RRR
Lungs: (B)crackles
ABD: benign
EXTR: [**12-27**]+edema RUE, superficial thrombus of r cephalic, (B)LE
edema
Wound: sternal incision: C/D/I, stable
Neuro: continues to have rt sided weakness with lower extremity
weakness more pronounced than upper extremity. Facial droop
largely resolved. Passed swallow on [**10-28**]
Pertinent Results:
[**2179-10-18**] 07:49PM UREA N-29* CREAT-2.3* POTASSIUM-4.7
[**2179-10-18**] 07:49PM HCT-30.8*
[**2179-10-18**] 06:03PM WBC-7.0 HCT-28.1*
[**2179-10-18**] 05:35PM GLUCOSE-204* LACTATE-6.0*
[**2179-10-18**] 05:22PM ALT(SGPT)-23 AST(SGOT)-42* LD(LDH)-298* ALK
PHOS-35* TOT BILI-0.9
[**2179-10-18**] 05:08PM GLUCOSE-209* LACTATE-6.1* K+-4.7
[**2179-10-18**] 11:06AM GLUCOSE-115* NA+-137 K+-4.7
[**2179-10-18**] 10:59AM UREA N-28* CREAT-1.8* CHLORIDE-111* TOTAL
CO2-23
[**2179-10-18**] 10:59AM WBC-6.4 RBC-3.07* HGB-9.4* HCT-25.3* MCV-83
MCH-30.7 MCHC-37.3* RDW-14.6
[**2179-10-18**] 10:59AM PLT COUNT-126*
[**2179-10-18**] 10:59AM PT-15.0* PTT-45.5* INR(PT)-1.3*
[**2179-10-28**] 06:32AM BLOOD WBC-15.0* RBC-3.06* Hgb-9.4* Hct-27.9*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.8 Plt Ct-296
[**2179-10-28**] 06:32AM BLOOD Plt Ct-296
[**2179-10-27**] 04:50AM BLOOD PT-13.6* INR(PT)-1.2*
[**2179-10-28**] 06:32AM BLOOD Glucose-106* UreaN-57* Creat-2.1* Na-139
K-3.7 Cl-101 HCO3-31 AnGap-11
[**2179-10-23**] 02:56AM BLOOD ALT-8 AST-21 LD(LDH)-293* AlkPhos-65
Amylase-113* TotBili-0.7
MRI SCAN OF THE BRAIN WITH MR ANGIOGRAPHY OF THE HEAD
HISTORY: Status post aortic valve replacement following an
aortic dissection,
with a period of hypotension.
TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was
obtained, as
well as MR angiography of the circle of [**Location (un) 431**] and its
tributaries, utilizing a three-dimensional time-of-flight
imaging protocol, with multiplanar reconstructions.
COMPARISON STUDY ON PACS ARCHIVE: CT scan of the head from
[**2179-10-20**].
FINDINGS: There are numerous, largely subcentimeter foci of
elevated T2
signal scattered throughout the brain, including the centrum
semiovale
bilaterally. This region is more extensively involved on the
left side.
Additional foci of restricted diffusion are noted within the
right occipital lobe, left thalamic region anteriorly, the left
side of the pons (which was suspected on the prior CT scan) as
well as the inferolateral aspect of both cerebellar hemispheres.
As these abnormalities also manifest elevated T2 signal, they
are likely subacute infarctions. There are no areas of abnormal
susceptibility demonstrated.
There is no hydrocephalus or shift of normally midline
structures.
The principal vascular flow patterns are identified. There is
near-complete loss of aeration of the right maxillary sinus, and
to a moderate degree within the left maxillary sinus. Extensive
mucosal thickening and possibly fluid is noted within the
ethmoid sinuses, with moderate sphenoid sinus mucosal thickening
seen, and lastly minimal frontal sinus mucosal thickening. The
sinus abnormalities could represent the effects of intubation,
as well as an inflammatory process.
MR angiography of the circle of [**Location (un) 431**] and its tributaries shows
no overt sign of an area of hemodynamically significant
stenosis, or within the limitations of this technique, an
aneurysm.
CONCLUSION: Multiple small areas of subacute infarction. Given
the history
of protracted hypotension as well as recent aortic valve
surgery, both
hypotensive and embolic sources for the infarctions need to be
considered.
COMMENT: I discussed this case with Ms. [**Last Name (Titles) 38136**], the nurse
practitioner who requested this study, immediately after the
examination was completed, via telephone.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: FRI [**2179-10-22**] 8:09 AM
TEE
Conclusions
PRE-BYPASS:
1. The left atrium and right atrium are normal in cavity size.
No atrial septal defect is seen by 2D or color Doppler.
2. Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). 3. Right
ventricular chamber size and free wall motion are normal.
4. The aortic root is markedly dilated at the sinus level. The
ascending aorta is moderately dilated. The aortic arch is mildly
dilated. A mobile density is seen in the ascending aorta
consistent with an intimal flap/aortic dissection. A mobile
density is seen in the aortic arch consistent with an intimal
flap/aortic dissection. A mobile density is seen in the
descending aorta consistent with an intimal flap/aortic
dissection.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. Moderate to severe (3+) aortic regurgitation is
seen.
6. Mild (1+) mitral regurgitation is seen.
7. There is a small pericardial effusion.
POST-BYPASS:
1. An aortic valve tissue prosthesis is in good position with
good leaflet excursion. The mean gradient is appropriate. There
is a trace paravalvular leak that improved with protamine.
2. MR is now trace.
3. Right and left ventricular function is preserved.
4. The remainder of the study is unchanged.
Dr. [**Last Name (STitle) **] was notified in person of the results at the
time of the examination.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2179-10-19**] 09:40
Radiology Report CHEST (PA & LAT) Study Date of [**2179-10-28**] 3:01 PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2179-10-28**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 81544**]
Reason: eval pleural effusions
Final Report
CHEST PA AND LATERAL.
INDICATION: Status post aortic valve replacement, evaluate
chest.
FINDINGS: The patient's condition does not permit standard chest
technique
and the patient is examined in AP projection in semi-erect
position. A
lateral view was obtained with the patient barely sitting up.
Comparison is made with the next previous similar study of
[**9-27**],0 [**2178**]. Status post sternotomy is unchanged and the
position of the metallic components of a porcine aortic valve
prosthesis is a identified in unchanged position. Cardiac
enlargement persists and the left diaphragmatic contour and
lateral pleural sinuses are obliterated. Comparison with the
next preceding study suggests that the amount of effusion has
increased mildly. Size quantification, however, is difficult
considering patient's position and examination technique. Can,
however, identify pleural effusions in the posterior pleural
sinuses of the left side as seen on the lateral view. No
evidence of pneumothorax. The patient is extubated and the
previously identified NG tube has been removed. A left
subclavian approach central venous line persists and terminates
overlying the SVC at the level of the carina. No pneumothorax
has developed.
IMPRESSION: Persistent left-sided pleural effusion, possibly
increased
slightly. No pneumothorax, new infiltrates or other
complications.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2179-10-28**] 6:48 PM
[**Last Name (LF) **], [**First Name3 (LF) **] [**2179-10-28**]
RENAL SCAN Clip # [**Clip Number (Radiology) 81545**]
Reason: 58 YR OLD MAN WITH S/P ACUTE DISSECTION AND RENAL
FAILURE, EVAL FOR FLOW/SPLIT
Final Report
RADIOPHARMACEUTICAL DATA:
5.4 mCi Tc-[**Age over 90 **]m MAG3 ([**2179-10-28**]);
HISTORY: 58 y/o male s/p acute type A dissection extending to
common iliac
bifurcation and left common iliac artery. Involvement of renal
arteries is
unknown. Patient is presenting for evaluation of renal failure.
INTERPRETATION:
Flow and dynamic images were obtained after intravenous
administration of
tracer. Blood flow images show symmetric perfusion to both
kidneys. Renogram images show delayed excretion of tracer
bilaterally.
The differential function obtained by analysis of tracer
concentration in the parenchyma from 2 to 3 minutes post tracer
injection shows the left kidney to be performing 47 % of the
total renal function and the right kidney performing 53 %.
IMPRESSION: 1. Symmetric renal function. 2. Markedly delayed
tracer
excretion bilaterally. Findings consistent with poor parenchymal
function which
may reflect acute tubular necrosis in the setting of recent
hypotensive insult
or chronic medical renal disease. Repeat assessment could be
performed as
clinically indicated.
Findings discussed with Dr. [**Last Name (STitle) **] on the afternoon of
[**2179-10-28**] by Dr.
[**First Name (STitle) 7747**] over the telephone.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7747**], M.D.
Brief Hospital Course:
Admitted directly to the OR after [**Location (un) 7622**] from [**Hospital1 **]
emergency room .Was hypotensive on arrival to OR. Underwent
surgery with Dr. [**First Name (STitle) **], please see OR report for details. In
summary he had an ascending aorta replacement with an aortic
valve replacement. He tolerated the operation and was
transferred to the CVICU in fair conditiion following surgery.
Vascular surgery and general surgery both consulted for rising
lactate and abdominal distention. Renal service also consulted
for acute renal failure. He remained critically ill and very
volume overloaded and therefore remained intubated and sedated
for several days post-operatively. Drips titrated for BP and
glucose control. Neuro consult obtained for inability to respond
appropriately and right-sided weakness. CT obtained and then
subsequent MRI showed multiple areas of small infarcts. Tube
feedings started on POD #2. Pancultured for fever and Cipro
started for gram negative rods in sputum. OT eval done. He was
extubated POD #5. Patient had intermittant episodes of atrial
fibrillation and was started on amiodarone. He initially failed
a swallow evaluation however a repeat eval was done POD #7,
which he passed. Diet was advanced as tolerated. Coumadin was
discontinued with rhythm remaining in Sinus. Antihypertensives
optimized. POD#10 Renal ultrasound performed showed no eveidence
of hydronephrosis with symetric flow to both kidneys. Pt
continued to progress and on POD #11 he was ready for discharge
to rehab. All follow up appointments were advised.
Medications on Admission:
atenolol
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x 7days then 200mg QD.
6. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection QAC&HS.
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Atenolol 50 mg Tablet Sig: as directed Tablet PO twice a
day: 100mg QAM
50mg QPM.
14. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO every [**2-28**]
hours as needed.
17. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO PRN for
SBP>150.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) tx Inhalation Q4H (every 4 hours) as
needed.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Type A aortic dissection s/p AVR/replacement ascending aorta
CVA
postop A Fib
HTN
obesity
CRI
s/p pancreatitis
prostate CA
anemia
diverticulosis
CVA left caudate [**2170**]
adrenal hyperplasia s/p adrenalectomy [**2169**]
hypertriglyceridemia
pre-diabetic
Discharge Condition:
stable
Discharge Instructions:
no lotions, creams or powders on any incision
call for fever greater than 100, redness, or drainage
no driving for at least one month and until off all narcotics
no lifting greater than 10 pounds for 10 weeks
shower daily and pat incisions dry
Followup Instructions:
see PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**11-25**] weeks
See Dr. [**Last Name (STitle) **] ( for Dr. [**First Name (STitle) **] for postop visit in 3 weeks at
[**Hospital1 **]- call for appt. [**Telephone/Fax (1) 6256**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2179-10-29**]
|
[
"5845",
"2851",
"2762",
"4241",
"5859",
"2875",
"40390",
"42731"
] |
Admission Date: [**2156-12-13**] Discharge Date: [**2156-12-14**]
Date of Birth: [**2156-12-9**] Sex: F
Service: NEONATOLOGY
HISTORY: Four-day-old pre-term infant, readmitted for
management of hyperbilirubinemia.
Infant born at 36 2/7 weeks to a 24-year-old gravida I, para
0 now I woman. Reportedly benign antepartum. Admitted in
labor. Received intrapartum antibiotic prophylaxis three and
a half hours prior to delivery. No maternal fever. Rupture
of membranes eight hours prior to delivery. Benign CBC.
Negative blood culture. Bilirubin 11.3 on day of life two.
Blood type A positive/A positive/Coombs negative.
Discharged to home. Breast feeding exclusively. Seen in
follow up on [**12-13**]. Bilirubin was 22. Referred to
Neonatal Intensive Care Unit for management of
hyperbilirubinemia.
PHYSICAL EXAMINATION: On admission, birth weight was 2580
grams, weight on admission was 2330 grams, length 48 cm, head
circumference 32.5 cm. Physical examination remarkable for
alert, well-appearing, pre-term infant in no distress, with
soft anterior fontanel. Jaundice to torso, pink, normal
facies, wet mucous membranes, no grunting, flaring or
retracting, clear breath sounds. No murmur, present femoral
pulses. Flat, soft, nontender abdomen, without
hepatosplenomegaly, normal external genitalia, stable hips,
normal tone and activity.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant has remained in room air
throughout this hospitalization, with oxygen saturations
greater than 95% and respiratory rate 30 to 40. The infant
did not have any apnea or bradycardia this hospitalization.
2. Cardiovascular: The infant has remained hemodynamically
stable this hospitalization. No murmur. Heart rate 120 to
140.
3. Fluids, electrolytes and nutrition: The infant
exclusively breast feeding at the time of admission. The
infant received a normal saline bolus of 20 cc/kg on
admission, and was breast feeding and receiving
supplementation of Enfamil 20 calories/ounce once admitted to
the Neonatal Intensive Care Unit. The infant was discharged
from the Neonatal Intensive Care Unit to home breast feeding
and supplementing with Enfamil 20 calories/ounce ad lib by
mouth.
4. Gastrointestinal: Bilirubin on admission was 24.5/0.5.
The infant was started on triple phototherapy. The repeat
bilirubin on [**12-14**] was 13.2, then 12.9. The
phototherapy was discontinued at 6 P.M. on [**12-14**], and
the rebound bilirubin was 11.
5. Hematology: Patient blood type A positive, direct Coombs
negative. The hematocrit on admission was 48.8, and the
reticulocyte count was pending at the time of discharge.
6. Infectious Disease: No issues.
7. Neurology: No issues.
8. Sensory: No issues.
9. Psychosocial: Parents involved.
CONDITION AT DISCHARGE: Former 36 [**2-5**] week gestation female,
now five days old, stable in room air.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: [**Hospital **] Pediatrics, phone
number [**Telephone/Fax (1) 40204**].
CARE RECOMMENDATIONS:
1. Feedings at discharge: Breast feeding ad lib with
supplementation of Enfamil 20 calories/ounce by mouth.
2. Medications: None.
3. Car seat position screening was not performed at the time
of discharge.
4. State newborn screening status: Results are pending.
5. Immunizations: The infant did not receive any
immunizations during this hospitalization.
6. Follow-up appointments: Follow-up appointment with
[**Hospital **] Pediatrics in one to two days.
DISCHARGE DIAGNOSIS:
1. Premature female, 36 2/7 weeks
2. Non-hemolytic hyperbilirubinemia
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Last Name (NamePattern1) 43219**]
MEDQUIST36
D: [**2156-12-15**] 00:51
T: [**2156-12-15**] 00:57
JOB#: [**Job Number 47360**]
|
[
"7742"
] |
Admission Date: [**2131-6-10**] Discharge Date: [**2131-6-11**]
Date of Birth: [**2100-2-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Seizure
Reason for MICU admission: Hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History was obtained from ED and medical records as patient
arrived to somnolent to answer questions.
31 yo female with hx of seizure disorder, EtOH abuse and
medication non-compliance who presents to the ED after having a
seizure at work. Patient states she has been very stressed out
both at home and at work, states she has not been sleeping well.
She has been drinking a lot of water and alcohol lately, and
not eating very well. While at work she had a generalized tonic
clonic seizure of unknown duration with eyewitnesses. Her last
seizure prior to that was in [**Month (only) 116**], again patient attributes this
to increased stress and poor sleep.
.
In the ED, initial vs were: 98.2 110 166/100 18 99%. She was
noted to be hyponatremic and felt to be hypovolemic as well.
She was given 1.5 L of NS with correction of Na from 124 to 130.
Additionally she received 4 mg of lorazepam for witnessed
seizure with symptoms of eye deviation, body stiffening,
followed by post-ictal phase. Neurology saw her and feels her
current seizures are from the hyponatremia. They recommended
ICU admission for close monitoring during Na correction and she
was loaded with 1 gm of Keppra IV.
.
On the floor, Patient is noted to be somnolent with slow
responses to questions.
.
Review of sytems:
(+) Per HPI
(-) Unable to respond to ROS
.
Past Medical History:
- Migraines (triggers - menstrual cycle, stress, and sleep
deprivation)
- Seizures, in setting of being very stressed out at school,
sleep deprivation and she missed some doses
- EtOH abuse
- Anxiety
Social History:
Lives in [**Location **]. Works as waitress. Lives with partner,
feels safe at home. Lots of financial and family stress.
Tobacco - 1ppd x 5 years
EtOH - 4-6 beers per day
Drug use - denies
.
Family History:
Seizures - second degree relative
HTN - father
.
Physical Exam:
Upon arrival to the MICU:
Vitals: T: 98 BP: 144/84 P: 82 R: 18 O2: 98% on RA
General: Patient somnolent, but 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,
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: Patient somnolent, PERRL, reflexes sluggish, Gag not
vigoruous
.
Pertinent Results:
[**2131-6-10**] 03:25PM WBC-10.0 RBC-4.38 HGB-14.6 HCT-40.8 MCV-93
MCH-33.2* MCHC-35.7* RDW-12.6
[**2131-6-10**] 03:25PM NEUTS-87.4* LYMPHS-8.4* MONOS-3.7 EOS-0.3
BASOS-0.3
[**2131-6-10**] 03:25PM PLT COUNT-341
.
[**2131-6-10**] 03:25PM GLUCOSE-135* UREA N-8 CREAT-0.7 SODIUM-124*
POTASSIUM-4.7 CHLORIDE-88* TOTAL CO2-20* ANION GAP-21*
[**2131-6-10**] 03:25PM CALCIUM-9.6 PHOSPHATE-3.2 MAGNESIUM-2.1
.
[**2131-6-10**] 03:25PM OSMOLAL-261*
.
[**2131-6-10**] 11:30PM ALT(SGPT)-17 AST(SGOT)-22 LD(LDH)-153 ALK
PHOS-67 TOT BILI-0.6
.
Na Trend:
124
130
137
.
[**2131-6-10**] 11:30PM BLOOD TSH-3.0
.
[**2131-6-10**] 09:15PM BLOOD TRILEPTAL-PND
.
CT head: IMPRESSION: No acute intracranial process.
.
CXR: IMPRESSION: Lungs fully expanded and clear. Heart size top
normal. No
pleural abnormality or evidence of central adenopathy.
Brief Hospital Course:
30 F with seizure disorder, EtOH abuse who presents after a
seizure and found to have hyponatremia.
.
# Hyponatremia: Hypoosmotic. Likely [**1-1**] decreased po intake,
primary polydipsia on trileptal (can also be primary effect of
drug itself), with possible component from beer potomania (few
beers daily). Less likely [**1-1**] EtOH withdrawal. CXR and TSH nl.
Trileptal discontinued. Was intially given 1.5 L NS in ED with
rapid correction of Na to 130 and subsequently to 139 with no
further intervention. Ataxic gait in ED likely [**1-1**] lorazepam
effect rather than demyelination as neuro exam remained intact
and ambulating well on discharge.
.
# Seizures: One witnessed in the ED with gaze deviation. Has
underlying seizure d/o with this episode likely in the setting
of hyponatremia, likely medication
noncompliance, and alcohol use. Seen by Neuro who recommended
discontinuing Trileptal and loading with keppra, then
discharging on once daily dosing of Keppra XR 2000mg. Counseled
against EtOH abuse and instructed not to drive for 6 months. Pt
to follow up with Dr. [**Last Name (STitle) **] tomorrow ([**2131-6-12**]). If her
anxiety worsens while on Keppra, could consider transitioning to
long acting Lamictal as an outpatient.
*Trileptal level pending on discharge.*
.
# EtOH Abuse: Patient states she has been drinking more often
due to stress in her life, at least 2-4 beers daily. Last drink
PM of [**2131-6-9**]. Did not appear to be in EtOH withdrawal. Did
receive banana bag. Counseled against EtOH use and discharged on
daily MVI.
.
# Anion gap acidosis: Likely related to ketosis given ketonuria.
Improved in AM after hydration and reinitiation of po diet.
.
# Anxiety: Patient initially refusing admission to MICU due to
"personal problems". [**Name2 (NI) **] staff noted her to be very anxious and
received ativan there. Discharged on home clonazepam 0.5mg TID
PRN.
.
FEN: No IVF, regular diet
Prophylaxis: Subcutaneous heparin
Access: peripherals
Code: Full (discussed with patient)
Communication: Patient, Mother [**Telephone/Fax (1) 31070**]
Medications on Admission:
- Clonazepam 0.5mg [**Hospital1 **] prn
- Oxcarbazepine 600mg [**Hospital1 **], has taken irregularly.
Discharge Medications:
1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Keppra XR 500 mg Tablet Sustained Release 24 hr Sig: Four (4)
Tablet Sustained Release 24 hr PO once a day.
Disp:*120 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hyponatremia, possibly secondary to primary polydypsia
Seizure disorder
Discharge Condition:
good, hemodynamically stable, no neural deficits.
Discharge Instructions:
You were admitted for seizure and found to have a low sodium
level. This is thought to be due to multiple factors including
possible side effect of trileptal, increased water intake with
decreased food intake, or possibly increase intake of beer,
which has no sodium. The lower sodium puts you at risk for more
frequent seizures. Your sodium corrected rapidly without any
neurologic problems. [**Name (NI) **] were given Keppra to prevent seizures
in the future.
.
Due to the fact that you had a seizure, you may NOT drive for 6
months. Please see your neurologist tomorrow as described below.
.
Medication changes:
- Please STOP taking trileptal
- Please take 1 tab of Keppra 500 mg tonight ([**2131-6-11**]), then
start Keppra XR
- Please take Keppra XR as prescribed.
- Please take a multivitamin daily
- Please take your other medications as prescribed.
.
seizures, confusion, dizzyness, fevers, chills, nausea,
vomiting, diarrhea, or other concerns.
Followup Instructions:
You have the following scheduled appointment with your
Date/Time:[**2131-6-12**] 2:30
Completed by:[**2131-6-12**]
|
[
"2762",
"2761"
] |
Admission Date: [**2166-3-20**] Discharge Date: [**2166-4-11**]
Date of Birth: [**2096-8-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Brain Mass
Major Surgical or Invasive Procedure:
[**2166-3-20**]: left post. fossa craniotomy/cranioplasty
[**2166-3-22**]:Left posterior fossa exploration for hemorrhage/EVD
[**2166-3-27**]: Replacement EVD drain at bedside
[**2166-3-30**]: PEG placed
History of Present Illness:
69-year-old right-handed woman, with left facial spasms since
[**2163**], who is here in the Brain [**Hospital 341**] Clinic for an evalaution of
her enlarging left cerebellopontine angle meningioma. This
hemi-facial spasm developed slowly over time. There is no pain.
She has vertex headache, mild nasuea but no vomiting, and mild
vertiginous sensation. She has lost hearing in the left ear. She
has numbness on the left side of her face. She had a
gadolinium-enhanced head MRI on [**2164-2-17**] at [**Hospital 3278**] Medical Center
that showed a left cerebellopontine angle mass abutting the
exiting zone of the left 7th and 8th nerves. After that MRI, she
went back to [**Country 651**] and she came back to [**Location (un) 86**] in the fall of
[**2165**]. Her head MRI was repeated on [**2165-11-5**] and it showed slight
enlargement. She does not have imbalance, seizure, loss of
consciousness, or fall. She was electively admitted for a
craniotomy.
Past Medical History:
Hypertension and hypercholesterolemia.
Social History:
She does not smoke cigarettes or drink alcohol
Family History:
Her parents died of old age. She has 5 siblings and they are all
healthy. She has 2 children and they are all healthy.
Physical Exam:
ADMISSION EXAM:
Physical Examination: Temperature is 98.0 F. Her blood pressure
is 140/72. Heart rate is 64. Respiratory rate is 20. Her skin
has full turgor. HEENT examination is unremarkable. Neck is
supple. Cardiac examination reveals regular rate and rhythms.
Her lungs are clear. Her abdomen is soft with good bowel sounds.
Her extremities do not show clubbing, cyanosis, or edema.
Neurological Examination: Her Karnofsky Performance Score is 70.
She is awake, alert, and oriented times 3. There is no
right-left confusion or finger agnosia. Her language is fluent
in Chinese (there is an interpreter present) with good
comprehension, naming, and repetition. Her recent recall is
good. Cranial Nerve Examination: Her pupils are equal and
reactive to light, 4 mm to 2 mm bilaterally. Extraocular
movements are full. Visual fields are full to confrontation.
Funduscopic examination reveals sharp disks margins bilaterally.
Her face is symmetric, but she has intermittent left hemi-facial
spasms. Facial sensation is intact on the right but decreased at
V1 and V2 and partially in V3. Her hearing is intact on the
right but lost completely on the left (Rinnie test shows loss of
neurosensory hearing). Her tongue is midline. Palate goes up in
the midline. Sternocleidomastoids and upper trapezius are
strong. Motor Examination: She does not have a drift. Her muscle
strengths are [**5-28**] at all muscle groups. Her muscle tone is
normal. Her reflexes are 2+ and symmetric bilaterally. Her ankle
jerks are absent. Her toes are downgoing. Sensory
examination is intact to touch and proprioception. Coordination
examination does not reveal dysmetria. Her gait is normal. She
can do tandem. She does not have a Romberg.
ON DISCHARGE:
PERRLA, Follows simple commands with son's translation. Moves
all extremities purposefully. All surgical incision clean, dry,
intact. No sutures/staples intact.
Pertinent Results:
MR HEAD [**2166-3-20**]
IMPRESSION: Large left-sided CP angle mass essentially unchanged
from the
prior study.
CT HEAD [**2166-3-20**]:
There is no evidence of immediate post-surgical intracranial
hemorrhage. Patient is status post left occipital craniotomy
with a regional osseous defect and overlying metallic mesh. Soft
tissue in the posterior left occiput overlying this region
demonstrates edema and subcutaneous emphysema, as expected
post-surgically. Post-surgical pneumocephalus is also identified
within the left occipital region as well as within the
suprasellar cistern, in the left temporal, left frontal, and
right frontal regions. Left CP angle mass resection bed
demonstrates a small amount of low density fluid layering along
the left posterior fossa, with mild deviation of the posterior
fossa contents to the right. Mild effacement of the
quadrigeminal plate cistern and fourth ventricle are present on
the left, but decreased as compared to prior mass effect exerted
by the meningioma pre- surgically. Supratentorial cerebral
parenchyma appears normal without evidence of hemorrhage, mass
effect, or midline shift. Paranasal sinuses and mastoid air
cells are aerated. No osseous defect in addition to surgical
defect as described.
IMPRESSION: No evidence of acute post-surgical intracranial
hemorrhage. Post- surgical changes as described.
MR HEAD [**2166-3-21**]
FINDINGS:
The patient is status post left suboccipital craniotomy for
resection of left CP angle meningioma. There is a postoperative
collection in the left lateral posterior fossa extending into
the CP angle cistern with mass effect on the brainstem and
cerebellum as well as shift of midline to the right. There is
mass effect on the fourth ventricle. Ventricular size is stable.
There is dural enhancement in the operative bed, which is felt
to be post-surgical. There is also mild leptomeningeal
enhancement within the cerebellar folia, which is again
post-surgical. A minimal amount of enhancement is noted along
the inferior most aspect of the left petrous ridge, image 22
series 9, which could represent venous sinus, but recommend
attention on followup imaging. There is tonsillar herniation,
which is unchanged compared to the preoperative study. There is
question of the neural hypointensity within the spinal cord on
the T1-weighted images. This appears to be new compared to the
prior MRI. Recommend dedicated MRI of the cervical spine for
further evaluation.
IMPRESSION:
Post-surgical changes status post resection of left CP angle
mass. No large area of residual neoplasm is seen. Question of
linear hypointensity in the cervical cord. Recommend dedicated
cervical spine MRI for further evaluation. No evidence for acute
ischemia.
CT HEAD [**2166-3-22**]
FINDINGS: There is interval placement of an intraventricular
drain with right transfrontal approach and the tip terminating
near the foramen of [**Last Name (un) 2044**]. Small amount of intraventricular
hemorrhage layering in the dependent portions of the bilateral
frontal [**Doctor Last Name 534**] and occipital horns, and tracking inferiorly to the
third ventricle and fourth ventricles. There is no significant
interval worsening of hydrocephalus. There is unchanged
tonsillar and ascending transtentorial herniation. Small amount
of air is noted in the anti-dependent position of the right
frontal [**Doctor Last Name 534**] and also the bifrontal extra-axial space. A pocket
of air in the left posterior fossa anti-dependent position, with
the previously noted moderate extra-axial hemorrhage now
replaced by low-density fluid. The craniotomy flap is again
noted in the left occiput. There is no shift of normally midline
structures. Scattered opacification is noted in the ethmoid
sinuses.
IMPRESSION:
1. Interval placement of the intraventricular drainage catheter
via right
transfrontal approach with the tip terminating near the foramen
of [**Last Name (un) 2044**].
2. No interval worsening hydrocephalus. No midline shift. Small
intraventricular hemorrhage in all ventricles, unchanged.
3. Interval removal of the extra-axial hemorrhage at left CP
angle.Hypodensity in the left brachium pontis likely secondary
to post
surgical changes although ischemia is not entirely excluded.
4. Expected post-procedural pneumocephalus.
CT HEAD [**2166-3-22**]
As compared to most recent prior study, craniotomy and
post-surgical changes in the left posterior fossa, with mildly
decreased air and fluid collection with stable small amount of
hemorrhage and maybe hyperdense post-surgical material.
Intraventricular hemorrhage extending from the lateral
ventricles into the third and fourth ventricles with subsequent
hydrocephalus is again noted. There has been interval decrease
in size of right lateral ventricle and third ventricle. The left
lateral ventricle is grossly stable. Tonsillar herniation and
obliteration of the basal cisterns persists. The suprasellar
cistern is patent. Mildly hyperdense material in the left
frontal lobe (2A:22) may represent small amount of subarachnoid
Hemorrhage. No new areas of hemorrhage are seen. Small amount of
air in the frontal [**Doctor Last Name 534**] of the right lateral ventricle is
grossly stable. There is a right transfrontal ventricular
drainage shunt with the tip approximately at the foramen of
[**Last Name (un) 2044**], unchanged in position. Atherosclerotic calcifications of
the intracranial carotid arteries and vertebral arteries are
noted. Imaged mastoid air cells and paranasal sinuses are
grossly unremarkable.
IMPRESSION:
1. Interval decrease in the size of right lateral and the third
ventricle
status post right transfrontal intraventricular drain placement.
No change in the size of the left lateral ventricle, with
persistent intraventricular hemorrhage.
2. Slightly improved post-surgical changes in the left posterior
fossa,
status post recent evacuation of left subdural hemorrhage.
3. Degree of upward transtentorial and tonsillar herniation
unchanged.
4. No new hemorrhage.
NCHCT [**3-27**]:
IMPRESSION:
1. Stable appearance of right frontal approach ventriculostomy
without
evidence of hydrocephalus. A focus of hyperattenuation adjacent
to the
catheter tip is unchanged, likely sequela of catheter passage.
2. Stable left posterior fossa post-surgical changes with
persistent crowding of foramen magnum and mild low lying
tonsils. No new intracranial hemorrhage.
NCHCT [**3-27**]:
IMPRESSION: Moderate degree of new intracranial hemorrhage
tracking along the catheter tract after catheter removal, with
extension into the ventricular system, distending the occipital
[**Doctor Last Name 534**] of the right lateral ventricle, and tracking into the third
and fourth ventricles.
NCHCT [**3-28**]:
Stable appearance of hemorrhagic tract of prior catheter with
extension
into lateral ventricles and third and fourth ventricles. No new
hemorrhage. No significant mass effect, edema, midline shift, or
herniation
LENIS [**4-1**]:
IMPRESSION: No evidence of deep vein thrombosis in either leg.
MRI HEAD [**4-2**]:
FINDINGS: When compared to the most recent head CT, there has
been no
significant change in the volume of intracranial hemorrhage,
with the majority of residual hemorrhage remaining within the
occipital horns bilaterally. There are persistent blood products
along the course of the right frontal ventriculostomy catheter
tract. Within the dorsal pons, left middle cerebellar peduncle
and anterior left cerebellar hemisphere, there is a focal region
of hemorrhage with associated abnormal slow diffusion, with
corresponding FLAIR signal abnormality. Postoperative changes
are present following prior left occipital craniotomy with
prominence of the extra-axial space overlying the left
cerebellar hemisphere and blood products layering posteriorly
within the resection cavity as well as along the surface of the
brain. The ventricles are mildly prominent and unchanged in
size.
IMPRESSION:
1. No significant interval change in the volume of intracranial
hemorrhage, with the majority of blood layering within the
occipital horns bilaterally, as well as along the resection
cavity.
2. Abnormal slow diffusion centered within the left middle
cerebellar
peduncle is associated with small hemorrhage, and it is unclear
to what extent the abnormal diffusion is related to the blood
products and/or underlying true ischemia.
ECHO [**4-4**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion
CT TORSO [**4-4**]:
1. No source for fevers localized.
2. Extensive pneumoperitoneum, fairly out of proportion to
expected
postoperative amount status post PEG.
3. Cholelithiasis without secondary signs of cholecystitis.
4. Extensive fluid-filled loops of small and large bowel.
5. 2.5 x 1.8 cm thyroid nodule seen within the right lobe for
which, if no
previous evaluation has been performed elsewhere, a thyroid
ultrasound is
recommended on nonurgent basis.
CT HEAD [**4-6**]:
Perhaps minimal increase in size of the frontal horns of the
lateral ventricles. Other numerous abnormalities appear
relatively stable in extent, compared to the CT scan of the head
two days ago. The left middle
cerebellar peduncular lesion could represent an area of
infarction that
appears to have developed following the prior MR study of
[**2166-3-21**]
Labs on Discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2166-4-10**] 05:35AM 15.8* 3.44*# 10.8 33.1 96 31.5 32.8
17.9* 451*
[**2166-4-9**] 05:50AM 9.4 2.67* 8.4* 25.3* 95 31.6 33.3
17.8* 357
[**2166-4-8**] 05:30AM 13.2* 2.81* 9.1* 26.9* 96 32.3* 33.8
16.9* 403
[**2166-4-7**] 04:58AM 9.4 2.49* 8.0* 23.5* 94 32.2* 34.2
16.2* 412
Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2166-4-10**] 05:35AM 127*1 13 0.4 143 3.9 104 28 15
[**2166-4-9**] 05:50AM 120*1 13 0.3* 138 3.6 103 31 8
[**2166-4-8**] 03:35PM 141
[**2166-4-8**] 05:30AM 123*1 15 0.4 135 3.8 101
Brief Hospital Course:
Ms [**Known lastname **] [**Last Name (Titles) 1834**] a left sided craniotomy without complications.
She was observed for 2 days in the ICU where she remained
neurologically at baseline with left facial and left hearing
loss. Her blood pressure was maintained less than 140, she was
started on steroid [**Last Name (LF) 15123**], [**First Name3 (LF) **] MRI was done on post op day 1 which
showed good resection of the tumor. She had decreased mental
status on postop day number two. She was scanned and noted to
have bleeding into the resection cavity wiht effacement of the
basilar cysterns. She was taken back emergently for evacuation
of the clot and placement of an EVD. She was kept intubated for
approximately two days post-operatively due to a poor gag
reflex. On [**3-25**], she was extubated, and EVD was clamped at 20cm.
Her mental status was stable, and on [**3-26**] at 1500 a NCHCT was
done to evaluate her clamping trial. Head CT showed stable
ventricular size and a stable neurologic examination and in the
afternoon of [**3-27**], her EVD drain was removed. Late in the
evening, she was found with a GCS 3, reintubated, and sent for
an emergent head CT. This revealed extension of intraventricular
hemorrage and blood along the EVD track. Given her deterioration
and CT scan, the EVD was replaced. After the drain was replaced,
her examination markedly improved. The EVD was maintained at 5cm
and open. TPA 1mg [**Hospital1 **] was given over three days to ensure
ongoing patency of the tubing, as well as to facilitate thrombus
degredation.
Percutaneous gastrostomy tube was placed on [**2166-3-30**]. The patients
sputum grew out
G+ rods, G- rods, G+ cocci and she was started on Zosyn in
addition to the Vanco that she was already on for the EVD. On
[**3-31**] the patient was extubated and her neuro exam remained
stable.
She was found to be severly hyponatremic on [**4-1**], with a Na level
of 125 and serum osm of 274. 3% HTS @ 30cc/hr was started, with
close monitoring of her labs. It rectified to 133 on [**4-2**].
However, on [**4-4**], after the HTS was discontinued, her NA again
dropped to 128 and it was restarted in conjunction with sodium
tablets. Her SQH was stopped on [**4-3**] and EVD drain was removed
in the morning of [**4-4**]. Head CT was performed afterward;
revealing stable intracranial hemorrhage-without new bleeding.
She was also again febrile on [**4-4**] to 103, and she was
recultured. CT torso, LENIS, and CSF were performed/sent.
Infectious disease was also consulted to guide antibiotic
coverage, and identfication of febrile source was her sputum
(Gram - rods). She was place on Ceftriaxone and Flagyl, and
later changed to meropenum.
She was transferred out of the ICU on [**4-6**] to the step down
unit. Her sodium count remained from 135-145 with Na Tabs Q6.
Her neurological exam improved slightly, as she was more alert,
attentive, and followed simple commands.
On [**4-10**], she had a video assisted swallow evaluation. She was
deemed not appropriate to be able to take PO nutrition as yet.
She also had routine LENIS done of her lower extremities. Her
left tibial vein displayed some "venous slowing" that was
concerning for early DVT development. Given this, she was
started on ASA.
She was screened for rehab on [**4-9**], and was transferred via
ambulance to [**Hospital **] Rehab on [**2166-4-11**].
Medications on Admission:
carbemezepine (for facial spasms), amlodipine, simvastatin,
calcium, vit D
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 0.5 Tablet
PO BID (2 times a day).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: [**1-25**] PO BID (2 times a
day) as needed for prn constipation.
5. Oxycodone 5 mg/5 mL Solution Sig: [**1-25**] PO Q4H (every 4 hours)
as needed for pain.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Sodium Chloride 1 gram Tablet Sig: Six (6) Tablet PO TID (3
times a day) as needed for hyponatremia: Hold for Na > 145.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Prochlorperazine 10 mg IV Q6H:PRN n+v
15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q4H (every 4 hours) as needed for NAUSEA.
16. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 8 doses.
17. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP > 160.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Meningioma
Respiratory failure
Intraventricular hemorrhage
Failure to Thrive
Pneumonia(HAP)
Hyponatremia
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**4-28**]
3pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your acute hospitalization
****You should have a repeat of your Lower Extremities Ultra
Sound on [**2166-4-17**]
Completed by:[**2166-4-11**]
|
[
"51881",
"486",
"2720",
"4019"
] |
Admission Date: [**2131-5-29**] Discharge Date: [**2131-6-5**]
Date of Birth: [**2054-4-10**] Sex: M
Service: SURGERY
Allergies:
Optiray 300 / Iodine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Thoracic Aortic Anuerysm
Major Surgical or Invasive Procedure:
Stent graft repair of the descending thoracic aortic aneurysm
with 2 [**Doctor Last Name 4726**] TAG endoprostheses: The first one is reference
number [**Serial Number 24968**], lot or batch code number [**Serial Number 24969**]. The second one
is catalog number [**Serial Number 24970**], lot or batch code number [**Serial Number 24971**].
Left carotid subclavian bypass graft with 8-mm [**Doctor Last Name 4726**]-Tex graft.
History of Present Illness:
This 77-year-old gentleman is undergoing endovascular repair of
a descending thoracic aortic aneurysm. It will be necessary to
cover the left subclavian artery with a device in order to
obtain adequate proximal seal and he has
previously had an infrarenal aortic aneurysm repair and a
lowered thoracoabdominal aneurysm repair. He is undergoing
carotid subclavian bypass to decrease the chances of paraplegia
with the other procedure.
Past Medical History:
CAD,
HTN,
MI,
Bladder CA,
GERD
PSH:
s/p CCY,
cataract,
CABG, AAA repair '[**15**],
prostatectomy,
hernia
Social History:
Pos hx smoking / quit [**2104**]
Pos alcohol 2 per day
Family History:
Non contributary
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
Wet Read Audit # 1 PXDb SUN [**2131-6-3**] 9:05 PM
New LLL opacity, could be a combination of effusion, atelectasis
and
pneumonia. Clear right lung. Stable post surgical changes,
Intervale
extubation and removal of the NG tube
[**2131-6-4**] 06:05AM BLOOD
WBC-7.4 RBC-3.15* Hgb-9.2* Hct-27.7* MCV-88 MCH-29.3 MCHC-33.4
RDW-14.4 Plt Ct-181
[**2131-6-3**] 04:00AM BLOOD
PT-12.7 PTT-34.4 INR(PT)-1.1
[**2131-6-4**] 06:05AM BLOOD
Glucose-98 UreaN-25* Creat-1.7* Na-141 K-4.6 Cl-109* HCO3-24
AnGap-13
[**2131-6-4**] 06:05AM BLOOD
Calcium-8.3* Phos-2.1* Mg-2.0
[**2131-6-3**] 06:17PM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
URINE RBC-0-2 WBC-[**4-5**] Bacteri-FEW Yeast-NONE Epi-0-2 TransE-0-2
Brief Hospital Course:
Mr. [**Known lastname **],[**Known firstname 24972**] was admitted on [**5-29**] with TAA. He agreed to
have an elective surgery. Pre-operatively, she/he was consented.
A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all
other preperations were made.
This is joint operation with Dr [**Last Name (STitle) 914**] for Cardiac Surgery.
It was decided that she would undergo a TAG with left subclavian
to carotid artery BPG. Pt with Lumbar drain.
He was admitted the night before because of his CRF with a
baseline creatinine of 1.7. On DC his creatinine is 1.6, He was
prehydrated with PO mucomyst and IV Sodium Bicarbonate.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, he was transferred to the CVICU for further
stabilization and monitoring.
POD # 1
He was immediatly extubated. He did recieve post operative PO
Mucomyst and IV Sodium Bicarbonante. HCT on arrival stable.
Creatinine was stable. His neo was weaned. Pt kept bedrest.
POD # 2
Lumbar drain removed, remained neurologically intact. SBP
remained high treated with IV hydralazine. Foley remained in
place with good urine output. 02 weaned to 2L. Treated with
humulog SSI. Good pain control. Encouraged IS support.
Transfered to the VICU.
While in the VICU he recieved monitered care. When stable he was
delined. His diet was advanced. A PT consult was obtained.
POD # 3
PT consulted. Cleared PT for home without serivices. Pt went
into rapid Afib to 130's. Hemodynamically stable without
sequele. Lopressor did not work, Started on Dilt drip. Pt r/o
for MI.
POD # 4
Converted to NSR, Dilt drip weaned. Recieved Lasix for fluid
overload. Had good responce with adaquate uop.
He was stabalized from the acute setting of post operative care,
he was transfered to floor status
POD # 5
febrile, pan cultured. CXR shows LLL PNA, cx'x negative. PO
levoquin started. Creat stable. Pt stable for DC
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home in stable
condition.
To note his coumadin was started on DC. His PCP to [**Name9 (PRE) **] INR
in the usual manner.
Medications on Admission:
ASA 81, lipitor 20, Coreg 3.125, coumadin 2.5 6d/wk, 3 1d/wk,
diovan 80, MVI
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Carvedilol 3.125 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. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for fever: prn.
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed: prn.
Disp:*30 Tablet(s)* Refills:*0*
9. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-2**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*1 Polyvinyl Alcohol-Povidone (Ophthalmic) 1.4-0.6 %*
Refills:*0*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain for 10 days: prn.
Disp:*30 Tablet(s)* Refills:*0*
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM: Have your INR checked in the usual manner. Goal INR is
[**3-6**].
Discharge Disposition:
Home
Discharge Diagnosis:
Descending thoracic aortic aneurysm
Pneumonia LLL
Afib
PMH: CAD, HTN, MI, Bladder ca, GERD
.
PSH: Thoracoabdominal AAA repair c supraceliac clamp [**2127-11-26**],
s/p CCY, cataract, CABG, AAA repair '[**15**], prostatectomy, hernia
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Thoraic Aortic Aneurysm (TAA) Discharge
Instructions, with Subclavian Artery to Carotid BPG
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? 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 to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**3-6**]
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
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and 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:
?????? 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
?????? Call and schedule an appointment to be seen in [**5-7**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower and or upper 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 or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2131-7-2**] 1:20
Call Dr[**Name (NI) 9379**] office ([**Telephone/Fax (1) 1504**]. Schedule an appointment
for 4 weeks. You may need a CTA. This is a CAT Scan with
contrast. Let the receptionist know that you had a TAG (thoracic
aortic graft stent placement). Also let the receptionist know
that you have renal failure. You may need to be hydrated with a
special medication before you get the CAT Scan. His office will
arrange the follow-up and the CAT scan if you need.
Completed by:[**2131-6-5**]
|
[
"9971",
"42731",
"53081",
"412",
"40390",
"5859",
"V4581",
"V5861"
] |
Admission Date: [**2154-10-30**] Discharge Date: [**2154-11-5**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
GI BLEED
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57M with CAD s/p MI with LV hypokinesis, afib, CHF EF 30%, DM2,
HTN, ESRD on HD (last done on Saturday [**2154-10-26**]) who reported
weakness and fatigue at dialysis. Hct at that time was 12.
Patient has also had one week of intermittet melena with 2-3
stools ranging from black/tarry to BRB, associated with fatgue,
lightheadedness, DOE. Patient denies any fevers, chills, recent
EtOH use, ASA use, NSAID use, recent travel, uncooked foods.
Patient also denies any hematemesis, hemoptysis, dysphagia,
abdominal pain, abdominal cramping, tenesmus. Patient's GI bleed
is also temporally associated with chest pain, reported as a
[**5-23**] squeezing pain radiating to the L arm. CK: 133 MB: 6
Trop-T: 0.18. Baseline Tn is 0.16.
.
Patient did not go to dialysis as [**Month/Year (2) 1988**] on [**2154-10-29**] and also
has stopped taking all medications since [**2154-10-26**]. Patient
[**Year (2 digits) 18038**] crack cocaine on day PTA.
.
Multiple previous workups have included at least six
endoscopies, three colonoscopies, one enteroscopy, and a capsule
camera study, and all have been negative, except for small AVM's
in the duodenum
seen and cauterized on one study and minor jejunal erosions
noted
on the capsule camera study.
.
Most recent EGD was [**2154-8-29**] and was normal and last colonoscopy
was on [**2153-6-1**] that showed blood throughout the entire colon and
TI abd bleeding source was not identified.
.
In ED patient was hemodynamically stable with Hct of 12. GI and
Renal made aware. Patient did have some chest pain in the ED
with EKG was unchanged and initial enzymes were negative.
Past Medical History:
1. Type II diabetes mellitus
2. CAD s/p MI, MIBI in [**11-18**] showed reversible defects
inferior/latateral
3. CHF with EF 20-30% and severe global hypokinesis
4. Hypertension
5. Dyslipidemia
6. Atrial fibrillation
7. Hisrory of gastrointestinal bleed: Duodenal, jejunal, and
gastric AVMs, s/p thermal therapy; sigmoid diverticuli
8. Chronic pancreatitis
9. Hepatitis C
10. GERD
11. CRF, baseline 3.9-5.3
12. Gout, s/p arthroscopy with medial meniscectomy [**5-/2149**]
13. Depression, s/p multiple hospitalizations due to SI
14. Polysubstance abuse: crack cocaine, EtOH, tobacco
15. Erectile dysfunction, s/p inflatable penile prosthesis
[**5-/2148**]
Social History:
Smokes 3 cigs/day. Hx of alcohol abuse, with DTs and
detoxification. Active crack cocaine use.
Family History:
Father with alcoholism, cousin with [**Name2 (NI) 14165**] cell. Mother with
renal failure, d. 58. Twin brother and son with kidney disease.
Physical Exam:
Vitals - T 97.6 BP 131/77 HR 84 RR21 99%4L
GENERAL: laying in bed, NAD
SKIN: [**Last Name (un) **] extremities, warm and well perfused, no excoriations,
no rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pale conjunctiva,
MMM, no LAD, no JVD
CARDIAC: RRR, nl S1, S2
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, +hepatomegaly 7cm below costal margin
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 1+ DP pulses bilaterally
Pertinent Results:
[**2154-10-30**] 07:25PM CK(CPK)-104
[**2154-10-30**] 07:25PM CK-MB-6 cTropnT-0.18*
[**2154-10-30**] 07:25PM HCT-20.2*
[**2154-10-30**] 04:36PM GLUCOSE-317* UREA N-57* CREAT-5.8* SODIUM-136
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
[**2154-10-30**] 04:36PM CALCIUM-9.1 PHOSPHATE-5.0* MAGNESIUM-2.3
[**2154-10-30**] 04:36PM WBC-5.8 RBC-2.05* HGB-5.1* HCT-16.5* MCV-80*
MCH-24.7* MCHC-30.7* RDW-17.9*
[**2154-10-30**] 04:36PM NEUTS-76.7* BANDS-0 LYMPHS-15.0* MONOS-6.1
EOS-1.5 BASOS-0.6
[**2154-10-30**] 04:36PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ SCHISTOCY-1+
[**2154-10-30**] 04:36PM PLT COUNT-289
[**2154-10-30**] 04:36PM PT-13.4* PTT-26.6 INR(PT)-1.2*
[**2154-10-30**] 01:16PM WBC-6.4 RBC-1.87*# HGB-4.6*# HCT-14.9*#
MCV-80* MCH-24.5* MCHC-30.8* RDW-17.1*
[**2154-10-30**] 01:16PM NEUTS-82.7* BANDS-0 LYMPHS-11.1* MONOS-4.8
EOS-1.0 BASOS-0.4
[**2154-10-30**] 01:16PM PLT COUNT-372
[**2154-10-30**] 12:20PM GLUCOSE-276* UREA N-58* CREAT-5.7*#
SODIUM-137 POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-24 ANION GAP-20
[**2154-10-30**] 12:20PM CK(CPK)-133
[**2154-10-30**] 12:20PM cTropnT-0.18*
[**2154-10-30**] 12:20PM CK-MB-6
[**2154-10-30**] 12:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-10-30**] 12:20PM PT-13.0 PTT-25.6 INR(PT)-1.1
CHEST (PORTABLE AP) [**2154-10-30**] 12:24 PM
CHEST (PORTABLE AP)
Reason: eval for ptx, chf
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with chest pain at site of HD catheter
REASON FOR THIS EXAMINATION:
eval for ptx, chf
HISTORY: 57-year-old male with chest pain at the site of
hemodialysis catheter.
COMPARISON: Radiographs [**2154-10-9**].
SINGLE PORTABLE VIEW OF THE CHEST: A left subclavian large-bore
dual-lumen catheter reaches the high atrium. Cardiomegaly,
interstitial edema, and bilateral pleural effusions (right
greater than left), have not changed significantly since the
prior exam. The bony thorax is normal.
IMPRESSION: Overall no change since [**2154-10-9**]. Please
note that radiographic examination cannot address the site of
catheter insertion.
AV FITULOGRAM SCH [**2154-11-4**] 7:43 AM
AV FITULOGRAM SCH
Reason: Please eval fistula
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
57 yo male with CAD, HTN, ESRD on HD. ? high pressures within
fistula per renal team.
REASON FOR THIS EXAMINATION:
Please eval fistula
INDICATION OF EXAM: This is a left AV fistulogram for a
59-year-old male with end-stage renal disease. High pressures
during dialysis.
RADIOLOGISTS: The procedure was performed by Drs. [**Last Name (STitle) 15785**] and
[**Name5 (PTitle) **], the attending radiologist, who was present and
supervising throughout the procedure.
PROCEDURE AND FINDINGS: After informed consent was obtained from
the patient explaining the risks and benefits of the procedure,
the patient was placed supine on the angiographic table, and the
left arm was prepped and draped in the standard sterile fashion.
Using palpatory technique and after injection of 1 cc of 1%
lidocaine, the AV fistula was accessed with a 21 gauge needle
pointing towards the venous outflow. A 0.018 guide wire was
placed. The needle was then exchanged for a 4.5 French
micropuncture sheath. The inner dilator and the wire were
removed, and hand injection of contrast demonstrates good
positioning of the micropuncture sheath within the left cephalic
vein. Serial venograms were performed at the level of the arm,
shoulder and chest, for possible venous outflow stenosis.
Diagnostic venograms demonstrate two areas of narrowing, one
within the fistula in the proximal cephalic vein, and proximal
to the level of the junction of the cephalic vein with the
axillary vein. Collateral formation/flow was identified. Based
on these diagnostic findings, it was decided that the patient
would benefit from balloon dilation of these lesions. The
micropuncture sheath was then exchanged for a 6 French vascular
sheath over a 0.035 [**Last Name (un) 7648**] wire. A roadmap venogram was
obtained, and a 6 mm balloon was advanced over the wire up to
the level of the narrowings, and several balloon dilations were
performed at dilations up to 15 ATM. A second area of narrowing
was dilated with a 7 mm balloon up to 10 ATM. The balloon was
removed. Followup venogram demonstrated partial angiographic
improvement of venous outflow after dilation.
Films were also obtained for evaluation of the arterial
anastomosis without any significant stenosis seen. The patient
tolerated the procedure well.
IMPRESSION:
1. Left AV fistulogram demonstrates two areas of venous
narrowing at the level of the proximal cephalic vein near the
fistula and near the junction of the cephalic vein with the
axillary vein.
2. Partial angiographic improvement after angioplasty with 7 and
6 mm balloons.
US EXTREMITY NONVASCULAR RIGHT [**2154-11-4**] 12:12 PM
US EXTREMITY NONVASCULAR RIGHT
Reason: R/O DVT, SWELLING
[**Hospital 93**] MEDICAL CONDITION:
58 year old man with right arm swelling
REASON FOR THIS EXAMINATION:
please rule out upper extremity DVT
INDICATION: Right upper extremity swelling.
COMPARISONS: None.
FINDINGS: [**Doctor Last Name **] scale, color and spectral Doppler ultrasound
images of right upper extremity veins were obtained.
Flow and compressibility is demonstrated within both internal
jugular veins.
Additionally, the right axillary, subclavian, brachial, basilic
and cephalic veins are patent and compressible. The right
axillary, subclavian, brachial, and basilic veins demonstrate
normal respiratory phasicity and response to distal
augmentation.
IMPRESSION: 1) No evidence of right upper extremity deep vein
thrombosis.
Brief Hospital Course:
#GI BLEED: Patient was intially admitted to the ICU for
management of his GI Bleed. His Hct was intially 15 but after 7
Units of prbcs, patients HCt had improved to 30 and remained
stable. Patient was seen by GI who felt that given the patients
extensive history of GI bleeds and multitude of studies that
have been done, there was no acute need for intervention. The
previous workups have included at least six endoscopies, three
colonoscopies, one enteroscopy, and a capsule camera study, and
all have been negative, except for small AVM's in the duodenum
seen and cauterized on one study and minor jejunal erosions
noted on the capsule camera study. Patients Hct was stable
once transferred to the floor. He was started on a PPI. Patient
was stable upon discharge.
.
#ESRD on HD: Patient with last HD on saturday prior to
admission. He received HD on first 2 days of admission given
extensive volume overload and then resumed on his regular
outpatient schedule. An AV fistulogram was done which showed
stenosis at the venous anastomosis and angioplasty was done x4
with partial resolution. Renal was aware of the results. He
remained in the hospital an additional day in order to make sure
the AV Fistula was functioning well.
.
#CAD: s/p MI - Pt has ruled out x3. ASA was initially held given
GI bleed but resumed on hospital day #4. Patient was continued
on his statin and labetolol. He remained chest pain free during
remaining stay. Of note, his Amlodipine, Isosorbide and
Lisinopril were held during hospitalization given his normal BP
and use of cocaine prior to admission. He was restarted on his
Lisinopril on the day of discharge given his slightly elevated
BP. His Amlodipine and Isosorbide were held upon discharge.
.
#DM: Patient continued his home insulin regimen.
.
#Depression/Delirium/Substance Abuse-The patient has a long
history of cocaine abuse. He had positive cocaine urine tox
screen while in the hospital. He admits to cocaine use on the
days prior to admission. In addition, the patient has a known
history of depression. He has poor follow up, however, with the
outpatient appointments made for him on prior hospitalizations.
Patient was seen by psychiatry during his stay for agitation and
delirium which occured during his initial ICU stay. It was felt
that the patients delirium was secondary to not being dialyzed
for over a week. THe patient received Seroquel for his
agitation. He also had a 1:1 sitter while in the ICU. The
patients mental status improved after he received dialysis. The
sitter was removed. The patient remained depressed but had no
suicidal ideation. He was evaluted by social work to make
further recommendations regarding his follow up. He will be
attending a partial hospitalization program at [**Hospital1 **] on Mondays,
Wednesdays, and Fridays the day after admission.
.
Medications on Admission:
Aspirin 325 mg Tablet
Amlodipine 5 mg Tablet
Atorvastatin 20 mg
Ferrous Sulfate 325 *
Pantoprazole 40 mg
Thiamine HCl 100 mg
Folic Acid 1 mg
Lisinopril 40 mg
Sevelamer 800 mg Tablet tid with meals
Labetalol 100 mg Tablet [**Hospital1 **]
Isosorbide Mononitrate 30 mg daily
NPH Insulin 30 qam / 20 units qpm
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
30Units qam Subcutaneous once a day: Please return to your home
regimen.
5. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
20 Units qPM Subcutaneous at bedtime: Please resume your [**Last Name (un) **]
regimen.
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
7. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
GI Bleed
Discharge Condition:
Improved
Discharge Instructions:
You were admitted to the hospital for bloody stools and fatigue.
You had what is called a GI Bleed. You were admitted to the
intensive care unit for monitoring and treatment. You received
7 units of blood to improve your blood levels. In addition, you
had some blood tests to rule out any evidence of ischemia to
your heart. These were all negative.
In addition, you had a AV Fistulogram to evaluate the AV fistula
in your left arm. The vessels were re-opened by what is called
angioplasty.
It is crucially important to your health that you stop using
cocaine, as this can damage your already compromised heart
function.
Your next dialysis session is on Thursday and you will continue
to follow a Tuesday, Thursday, Saturday dialysis schedule.
We stopped 2 medications that you had previously been taking for
blood pressure. You will not take your Isosorbide Mononitrate
or your Amlodipine.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
You should return to the ED with fatigue, dizziness, black or
bloody stools, recurrent chest pain, shortness of breath,
fevers, chills, nausea, vomiting, or for any other problems that
concern you.
You will need to follow up with your PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] as below.
Followup Instructions:
You will be attending a partial hospitalization program at [**Hospital1 **]
on Mondays, Wednesdays, and Fridays starting tomorrow. You have
been given information about this program by the social worker.
You also should keep the following appointments:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2154-11-13**]
12:10
Dialysis Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON
BILLING Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2154-12-4**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2155-1-3**] 8:20
|
[
"40391",
"4280",
"42731"
] |
Admission Date: [**2108-1-2**] Discharge Date: [**2108-1-9**]
Date of Birth: [**2032-11-19**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
hypotension, nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 y.o. Hispanic F with h/o colon Ca s/p resection, CHF (EF 25%)
who presents with severe weakness and vomiting x 24 hours.
Patient reports poor appetite x 5 days. She reports decreased
intake, while taking her medications including her lasix and her
zestril. Patient notes onset of lightheadedness, and nausea
since AM of [**1-1**]. Patient had 2 episodes of vomiting, small
amount of emesis, nonbloody. She also reports decreased urine
output, but no change in color. No dysuria/hematuria. Patient
denied any f/c, no neck stiffness, no sore throat, no dysphagia,
but reports metalic taste in her mouth. No chest pain, no sob,
no cough, no orthopnea, no PND, no LE swelling. No abdominal
pain. She denies any change in her osteomy output or
consistency. No recent antibiotics. No myalgias /arthralgias.
.
ED VS: were 96.4 HR 66 BP 64/p RR 12 Sating 100%% on RA - 2L; BP
improved to 500 cc NS to 93/p; UO was 60 cc in ED; She received
a total of 2800 cc. Patient was found to be in ARF with K of 8.0
(slightly hemolyzed), no peaked T waves, she was given 1 mp Ca
Gluconate, 10 units of IV insulin/1 amp D50 with repeat K of
6.8. She was also started on Heparin gtt and received ASA 325
for presumed NSTEMI.
Past Medical History:
- subtotal colectomy and ileostomy on [**2107-7-2**] for pneumotosis, R
sided colono dilation with ileocecal valve incompetence, and
adenocarcinoma in the sigmoid, perforation in the ileum, also
with ileal attachment to the invasive adenoCa, LN were negative.
- baseline Blood pressure 90/60, even as low as SBP of 80
- severe ischemic CHF - EF 20-25% with global HK - NYHA Class 2
---- full mile in warm weather, a block in cold weather
- CAD
- baseline Cr 0.8 -> 1.3 in [**12-2**]
Social History:
No tobacco/EtOH/DOA, lives w/ family at home.
Family History:
+ for Ca, no h/o CHF, HTN, MI or SCD
Physical Exam:
T: 96.6 BP: 113/40 P: 100 RR: 17 O2 sats: 100 2L UO: 225
Gen: NAD, speaking in full word sentences
HEENT: NCAT, PERRL, EOMI, anicteric
Neck: flat JVP
CV: RRR 2/6 SEM @ apex; no pericardial rub appreciated, nl S1,
S2
Resp: CTAB/l, no w/r/r, no crackles
Abd: decreased BS, RLQ ostomy, no surrounding erythema,
nontender, soft, no guarding, no rebound
Back: no CVA tenderness
Ext: no edema, no cyanosis, + 1 DP b/l
Neuro: no focal deficits
Pertinent Results:
CXR: clear
.
EKG: NSR @ 73; negative axis; incomplete LBBB, STD of 0.5 mm in
II, III, aVF with inverted TWaves and in V4-V6; there was
mentioning of T wave flatening on [**2107-8-3**] cardiology note -
although not present when compared to prior EKG of [**7-2**]
.
Echo [**12-2**]: EF 20-25; + 1 MR; mild pHTN.
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is mildly dilated with severe global
left ventricular hypokinesis (LVEF = 20-25 %). Systolic function
of apical segments is relatively preserved. No left ventricular
thrombus is seen. Tissue Doppler suggests and incresaed LVEDP
(>18mmHg). Right ventricular chamber size is normal with mild
free wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
Compared with the prior study (images reviewed) of [**2107-7-1**],
left ventricular cavity size is smaller and the severity of
mitral regurgitation is reduced. The heart rate is also much
lower.
.
MIBI [**8-2**]:
.
IMPRESSION:
1. Partially reversible, large, severe perfusion defect
involving the LAD territory.
2. Fixed, medium sized, severe perfusion defect involving the
PDA territory.
3. Increased left ventricular cavity size. Severe systolic
dysfunction with severe hypokinesis of the mid anteroseptal,
distal anterior, distal septal, distal inferior and apical walls
as well as the mid and basal inferior and inferolateral walls.
.
HCT stable in mid 20's during hospitalization. On discharge CBC
was WBC 5.4, HCT 26.1, Hgb 8.7, Plt 308
.
Cr was 9 on admission with baseline of 0.8. This trended down to
1.1 on the day of discharge.
On discharge sodium 141, K 4.8, Cl 111, HCO3 26, BUN 10, Cr 1.1
Glucose 74
.
Other lab values of interest during hospitalization:
[**2108-1-3**] 06:16AM BLOOD LD(LDH)-138 Amylase-155*
[**2108-1-3**] 06:16AM BLOOD Lipase-168*
[**2108-1-1**] 10:45PM BLOOD Lipase-422*
[**2108-1-2**] 02:42AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2108-1-1**] 10:45PM BLOOD cTropnT-0.06*
[**2108-1-8**] 06:05AM BLOOD Mg-1.7
[**2108-1-5**] 07:10AM BLOOD Mg-1.4*
[**2108-1-3**] 06:16AM BLOOD Calcium-8.3* Phos-5.3* Mg-1.2* Iron-101
[**2108-1-1**] 10:45PM BLOOD Albumin-4.1 Calcium-9.7 Phos-12.3*#
Mg-2.1
[**2108-1-3**] 06:16AM BLOOD calTIBC-306 Hapto-241* Ferritn-226*
TRF-235
[**2108-1-2**] 02:42AM BLOOD Triglyc-54 HDL-59 CHOL/HD-2.7 LDLcalc-89
[**2108-1-3**] 11:48AM BLOOD TSH-1.0
Brief Hospital Course:
75 year old female with CAD, CHF EF 25%, subtotal colectomy who
presented with ARF
.
# ARF:
Likely prerenal, creatinine was up to 9 on admission and patient
required MICU admission for hypotension and hyperkalemia. She
was stabilized quickly with IV fluids. Creatinue trended down
gradually with IV fluids over the course of several days and was
1.1 at discharge. Renal US was unremarkable for structural renal
disease. Her ACEI was held given the renal failure and
hypotension. Her lasix was also held given the dehydration.
.
# Diarrhea:
The diarrhea is likely the cause of the patient's presenting
hypovolemia. She did have watery, profuse output from her stoma.
The cause is unclear though viral gastroenteritis is likely.
Stool studies for c diff and bacterial diarrhea were negative.
She did require IV fluid repletion to balance her stool output.
At discharge her stoma output was more formed.
.
# elevated troponin:
There was a mild troponin elevation to 0.06 with negative CK and
MB in setting of hypotension and ARF. There were lateral ECG
changes. She had a positive stress in [**8-2**] for which
intervention has been considered though not yet pursued. She was
continued on aspirin, BB, statin.
.
# Pancreatitis
This was likely secondary to acute illness. The pancreatic
enzymes trended down. She has no abdominal pain.
.
# systolic CHF with EF 25%:
She remained hypovolemic during the admission. Lasix was held
and she was given IV fluids. Beta-blocker was continued but the
dose was lowered given her hypotension. Her lisinopril was held
given the ARF and hypotension.
.
# Access - 2 PIV
.
# PPx - Heparin SC; H2Blocker
.
# FEN - cardiac diet
.
# Code - FULL
.
# Communication - Discussed with son [**Name (NI) **] [**Telephone/Fax (1) 73900**]; Also
spoke to PCP office, Dr. [**Last Name (STitle) 31**] and faxed this report to
[**Telephone/Fax (1) 73901**].
.
.
TO DO FOR PCP:
[**Name10 (NameIs) 357**] check blood pressure, weight and creatinine, BUN and
potassium.
If patient blood pressure above systolic of 100, please increase
carvedilol to 3.125mg [**Hospital1 **].
If patient weight increases by more than 2 pounds or she is
clinically fluid overloaded, please restart lasix for fluid
overload. (weight was 45.3 kg (99.7 pounds).
If the patient blood pressure is above systolic of 120, please
restart lisinopril (but please check Cr and Potassium as well-
Cr was 1.1 on discharge with baseline at 0.8).
Medications on Admission:
Carvedilol 25 mg [**Hospital1 **]
Lisinopril 5 mg Daily
Lasix 40 mg daily
ASA 325 Daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Carvedilol 3.125 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
acute renal failure
diarrhea- viral gastroenteritis
hypotension
hypovolemic shock
Secondary Diagnosis:
chronic systolic CHF with EF 25%
CAD
Discharge Condition:
stable
Discharge Instructions:
You came to the hospital with low blood pressure and kidney
failure. You were found to have diarrhea. This was monitored in
the hospital until it resolved. Your kidney function is almost
back to baseline.
Please note the following medication changes (and please see the
medication sheet for details):
1. Your carvedilol dose has been lowered. Please discuss with
your doctor when to increase it.
2. Your lisinopril and lasix (furosemide) was stopped. You
should discuss restarting this when you see your primary care
physician for repeat labs
3. Prilosec is a new medication that was started to protect your
stomach since you are taking aspirin
You should take your weight daily. If you gain more than 3
pounds, please call your doctor. Please monitor your fluid
intake and limit it to 1.5L/day (unless you are having extensive
diarrhea. If you have extensive diarrhea, please call your
doctor.). Please limit your salt intake to 2g per day.
If you have further diarrhea, fevers, chills, dizziness,
light-headedness, or any other concerning symptoms, please call
your doctor or go to the emergency room.
Followup Instructions:
Dr. [**Last Name (STitle) 31**], PCP, [**Name10 (NameIs) **] up appointment on Thursday [**2108-1-12**] at 2pm. Please call to reschedule at [**Telephone/Fax (1) 2115**].
Please call Dr.[**Name (NI) 3536**] office to make sure that you have
appropriate follow-up. I called and left a message with the
office that you would need follow up in the next week or two.
You are currently scheduled for an appointment in [**Month (only) **].
Provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2108-6-18**]
9:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2108-1-9**]
|
[
"5849",
"41071",
"4280",
"2767"
] |
Admission Date: [**2121-12-24**] Discharge Date: [**2121-12-31**]
Date of Birth: [**2076-7-19**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
facial pain and numbness
Major Surgical or Invasive Procedure:
[**2121-12-24**]: Right sided microvascular decompression
[**2121-12-26**]: Right frontal EVD placement
History of Present Illness:
Pt reports right sided facial pain, began approx. 13 years
ago. Pain subsided for several years, and returned 3 years ago.
Pain has been progressively worsening last 2-3 weeks, affecting
pts sleep. Pt reports pain [**6-17**] currently in V2, V3
distribution.
Occasionally pain extends to V1 and in eyes. Pt reports
intermittent facial itching, denies numbness. Reports bilateral
eye redness, lacrimation & rhinnorhea x2-3 weeks. Denies hx of
herpetic lesion or head trauma.
Past Medical History:
Diabetes, hypercholesterolemia, hypertension
Social History:
Lives with wife, works [**Name2 (NI) 84406**] as construction
laborer. Smokes few cigarettes/day, no ETOH abuse.
Family History:
NC
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**4-9**] bilaterally, conjunctiva injected bilaterally
EOMs: Full
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension.
Cranial Nerves:
I: Not tested
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 without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice & finger rub bilaterally.
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.
Pertinent Results:
[**2121-12-24**] CT head Post-Op
Right suboccipital craniectomy and post-surgical changes as
above with small amount of hemorrhage and scattered
pneumocephalus. Extensive intracranial pneumocephalus, without
significant mass effect or hemorrhage. Followup as clinically
indicated.
[**2121-12-25**] MRI Brain
IMPRESSION: Status post decompression of right trigeminal nerve.
Abnormal
FLAIR signal intensity in the right cerebellar hemisphere
suggestive of
likely postoperative edema with mass effect on the fourth
ventricle with
dilatation of bilateral lateral and third ventricles suggestive
of acute
hydrocephalus.
[**2121-12-26**] CT head:
IMPRESSION:
1. Right cerebellar edema, with obstructive hydrocephalus and
mild upward
transtentorial herniation.
2. Postsurgical changes in the right suboccipital region and
right cerebello-pontine angle region.
[**2121-12-27**] CTP:
IMPRESSION: CT head shows placement of the right-sided
ventricular drain with persistent dilatation of the temporal
horns. Right-sided cerebellar
hemispheric swelling is identified with upward transtentorial
herniation and obliteration of the quadrigeminal plate and
indentation on the posterior aspect of the mid brain and pons.
These may have slightly increased since the previous CT of
[**2121-12-26**]. CT perfusion shows no perfusion abnormalities in the
cerebellar hemispheres.
[**12-30**] CT head:
IMPRESSION:
1. Right cerebellar edema with decreased mass effect on the
right portion of the fourth ventricle. There is resultant
decrease in the obstructive
hydrocephalus since most recent examination with bifrontal
ventricular
diameter of 23 mm (previously 28 mm) and right third ventricle
diameter of 7 mm (previously 8 mm). There is also decrease in
temporal [**Doctor Last Name 534**] dilation.
2. Surgical changes in the right suboccipital region with
persistent
lenticular collection of fluid and air with hyperdense component
suggesting either hemorrhage or post-surgical changes which are
stable to slightly increased from [**2121-12-26**] but
unchanged from [**2121-12-27**].
NOTE ON ATTENDING REVIEW:
While there is some improvement in the mass effect on the 4th
ventricle, there is a hypodense area in the right cerebellar
hemisphere that is more well defined compared to the prior study
and may relate to vasogenic edema
with/without associated ischemic changes. MR can be considered
for better
assessment and to exclude ischemia/infarction/inflammatory
changes.
Slightly dense focus adjacent to/within the 3rd ventricle- se 2,
im11, may
relate to Basilar artery or blood products. Attention on
followup.
[**12-31**] CT Head- stable ventricles. final read pending
Brief Hospital Course:
Patient presented electively on [**12-24**] for a right sided
microvascular decompression for trigeminal neuralgia. he
tolerated the procedure well, was extubated in the OR and
transferred to the ICU post-operatively for monitoring and
management. On [**12-25**] he was neurologically intact with
improvement of his trigeminal neuralgia symptoms and only
complaints of mild incisional discomfort. He was written to
transfer out of the ICU and was ntoed to have tachycardia and
was given fluid boluses and placed on standing beta blockers for
this. On [**12-26**] he was out of ebd to chair in teh ICU and was
ambulatory. His MRI was reviewed and showed right cerebellar
edema and his steropid doisng was changed to 4mg TID for 1 week
followed by a every other day taper to off. He remained
neurologically stable and recieved a bed on the floor. On the
floor there was a noted neuro change and a Head CT showed acute
hydrocephalus and early herniation. He was taken to the OR
emergently for placement of a R frontal EVD and then transferred
to the ICU.
On [**12-27**] his exam reamained stable. A CTP was ordered which
showed no change to the enlargement of the ventricles so the EVD
was dropped to 10. There was symmetric perfusion to bil
cerebellum with no abnormalities.
On [**12-28**] the patient was neurologically stable so he was
transferred to the step down unit. He c/o dizziness so he was
given a IVF bolus since he was negative 3+L over his hospital
course.
On [**12-29**] his EVD was raised to 15. In the AM of [**12-30**] a CT was
obtained to evaluate the baseline ventricular size, then the EVD
was raised to 25. He ambulated during the day without
difficulty. He tolerated the EVD at 25 during the day on [**12-30**]
with a CT scan of the head planned for [**12-31**]. Overnight on [**12-30**]
into [**12-31**] he had no drainage from his EVD with no episodes of
increased ICP or complaints. He had a head CT on [**12-31**] which
showed stable ventricle size. His EVD was removed at that time.
He remained neurologically stable and was cleared for discharge
home at this time.
Medications on Admission:
Oxcarbazepine, oxycodone
Discharge Medications:
1. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 10
days: 4mg TID until [**1-2**] then 3mg TID x2day,2mg TID x2day,1mg
TID x2 day,1mg daily x2 then d/c.
Disp:*qs Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Trigeminal neuralgia
Cerebral edema
Hydrocephalus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair 3 days after the sutures were placed
([**1-3**]).
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
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, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**6-14**] days(from [**12-31**]) for removal
of your suture and a wound check. This appointment can be made
with the Nurse Practitioner. Please make this appointment by
calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP. [**Name10 (NameIs) **]
you go to your PCP, [**Name10 (NameIs) **] is only one suture that needs to be
removed (top of head), the others are dissolvable.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2121-12-31**]
|
[
"25000",
"4019",
"2720"
] |
Admission Date: [**2180-6-21**] Discharge Date: [**2180-6-25**]
Date of Birth: [**2128-5-10**] Sex: M
Service: .
CHIEF COMPLAINT: Increasing dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 42744**] is a 52 year old
gentleman with a history of adult onset diabetes mellitus,
hypertension, hyperlipidemia and ongoing tobacco abuse, who
noted increasing dyspnea on exertion for the past week.
Starting at noon on [**6-21**], he noted a constant substernal
chest pain for approximately ten hours. He presented at
[**Hospital6 3105**] when his pain persisted despite
aspirin and Nitroglycerin. He was transferred to [**Hospital1 346**] after elevated cardiac enzymes were
noted.
PAST MEDICAL HISTORY:
1. Adult onset diabetes mellitus.
2. Hypertension.
3. Hyperlipidemia.
SOCIAL HISTORY: One to two pack per day smoker with
occasional ethanol use.
FAMILY HISTORY: Family history is negative for coronary
artery disease.
MEDICATIONS:
1. Metformin.
2. Glipizide.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: Negative for cerebrovascular accident or
transient ischemic attack. Negative for melena. All other
review of systems are negative.
PHYSICAL EXAMINATION: Vital signs were pulse 68, blood
pressure 110/70; respirations 18; O2 saturation 95% on room
air. The patient is afebrile. He is a pleasant gentleman in
no apparent distress. His heart is regular rate and rhythm.
Normal S1, S2. His lungs are clear to auscultation
bilaterally. His abdomen is soft, nontender, nondistended,
with normoactive bowel sounds. Extremities are without
cyanosis, clubbing or edema.
LABORATORY: EKG examination was remarkable for normal sinus
rhythm, Q waves in II, III and AVF.
Mr. [**Known lastname 42744**] was subsequently taken for cardiac catheterization
which revealed 80% mid - left anterior descending stenosis,
80% major diagonal stenosis, subtotal left circumflex with
99% major obtuse marginal stenosis, 90% proximal right
coronary artery stenosis and 80% distal right coronary artery
stenosis. His left ventricular ejection fraction was 45%.
Mr. [**Known lastname 42744**] was then subsequently evaluated for cardiac
surgery.
HOSPITAL COURSE: Mr. [**Known lastname 42744**] was taken to the Operating Room
on [**2180-6-21**], for a coronary artery bypass graft times
five. Grafts included left internal mammary artery to
diagonal 1 and left anterior descending; saphenous vein graft
to obtuse marginal 1; saphenous vein graft to patent ductus
arteriosus and P2. His procedure was performed without
complication and Mr. [**Known lastname 42744**] was subsequently transferred to
the Cardiac Intensive Care Unit.
He was extubated on postoperative day one, weaned off drips
and hemodynamically monitored. He was fluid resuscitated and
his chest tube was discontinued on postoperative day one. By
postoperative day two, Mr. [**Known lastname 42744**] was recovering well and
felt stable to be transferred to the floor.
Mr. [**Known lastname 42744**] did well upon transfer to the floor. He was
ambulating well and tolerating a good p.o. diet. His pain
was well controlled on oral pain medications.
On postoperative day four, Mr. [**Known lastname 42744**] completed a Level V
Physical Therapy evaluation and was felt to be stable to be
discharged home.
PHYSICAL EXAMINATION: Upon discharge, temperature 99.0 F.;
pulse 103; blood pressure 114/61; respirations 22; O2
saturation 91% on room air. Examination of his heart was
regular rate and rhythm. Lungs were clear to auscultation
bilaterally. Abdomen was soft, nontender, nondistended,with
normoactive bowel sounds. His extremities were remarkable
for trace edema in the bilateral lower extremities. His
incision was clean, dry and intact.
DISCHARGE MEDICATIONS:
1. Glipizide XL 10 mg p.o. q. day.
2. Metformin 500 mg p.o. twice a day.
3. Enteric-coated aspirin 325 mg p.o. q. day.
4. Docusate 100 mg p.o. twice a day while taking Percocet.
5. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. twice a day times 14 days.
6. Furosemide 20 mg p.o. twice a day times 14 days.
7. Metoprolol 50 mg p.o. twice a day.
8. Percocet one to two tablets q. four to six hours p.r.n.
as needed for pain.
9. Calcium carbonate 1000 mg three times a day for one week.
DISCHARGE INSTRUCTIONS:
1. Mr. [**Known lastname 42744**] is to follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks.
2. He is to follow-up with Dr. [**Last Name (STitle) 41033**] in three to four
weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Mr. [**Known lastname 42744**] is to be discharged home.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft times five.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 11235**]
MEDQUIST36
D: [**2180-6-25**] 17:38
T: [**2180-6-25**] 21:29
JOB#: [**Job Number 42710**]
|
[
"41401",
"4019",
"25000",
"2720",
"3051"
] |
Admission Date: [**2176-7-23**] Discharge Date: [**2176-7-30**]
Date of Birth: [**2131-11-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2176-7-29**] emergent subtotal colectomy, small bowel resection, tube
thoracostomy
History of Present Illness:
44M with h/o CLL on rituxan tx presented to [**Hospital 8641**] Hospital in
NH on [**2176-7-8**] with abdominal pain. Free air was noted on upright
CXR. Patient went emergently to the OR, where a perforated
anterior gastric ulcer was discovered and contained with [**Location (un) **]
patch. On [**7-18**], he returned to the OR for fascial dehiscence,
and was found to be obstructed. He underwent LOA with placement
of retention sutures. On [**7-19**], his total bilirubin began to
rise, reaching a max of 8.6 on [**7-23**]. A CT thorax did not reveal
any abdominal pathology. He was transferred to [**Hospital1 18**] for
suspicion of cholangitis and possible ERCP. On admission, he
was on TPN and Zosyn (day 15).
Past Medical History:
-CLL on rituxan
-GERD
-cholelithiasis s/p cholecystectomy
-perforated anterior gastric ulcer s/p exploratory laparotomy &
[**Location (un) **] patch, s/p re-exploration & LOA
Social History:
Married.
Occasional EtOH.
Family History:
Unremarkable.
Physical Exam:
On admission:
101.7 137 121/64 29 92%2L
Gen: cachectic
Neuro: A&Ox3, appropriate/attentive, motor tone/power WNL
HEENT: PERRL, icteric sclera, nasal mucosa WNL
Lymph: enlarged cervical, supraclavicular, axillary LN b/l
CVS: sinus, clear S1S2, no m/g
Pulm: symmetry/expansion/effort/palpation WNL, dullness to
percussion at L base, absent breath sounds at L base, no
wheezes/crackles/pleural rubs/egophony
Abd: tense, distended, tender, no bowel sounds, +guarding, no
rebound, incision with retention sutures
Ext: trace edema b/l, no clubbing/cyanosis
Skin: warm, jaundiced
Pertinent Results:
On admission:
[**2176-7-23**] 03:23PM BLOOD WBC-12.2* RBC-3.62* Hgb-10.5* Hct-31.7*
MCV-88 MCH-29.1 MCHC-33.2 RDW-17.8* Plt Ct-108*
[**2176-7-23**] 03:23PM BLOOD Neuts-63.5 Bands-2.1 Lymphs-31.3
Monos-2.1 Eos-0 Baso-0 Atyps-1.0*
[**2176-7-23**] 03:23PM BLOOD PT-12.7 PTT-23.0 INR(PT)-1.1
[**2176-7-23**] 03:23PM BLOOD Glucose-124* UreaN-16 Creat-0.6 Na-133
K-4.1 Cl-102 HCO3-24 AnGap-11
[**2176-7-23**] 03:23PM BLOOD ALT-50* AST-31 LD(LDH)-161 AlkPhos-132*
Amylase-32 TotBili-7.8* DirBili-7.1* IndBili-0.7
[**2176-7-23**] 03:23PM BLOOD Lipase-13
[**2176-7-23**] 03:23PM BLOOD Albumin-1.8* Calcium-7.1* Phos-2.9 Mg-2.2
[**2176-7-23**] 06:00PM BLOOD Lactate-1.3
CT abd/pelvis ([**2176-7-24**]): 1. Distal small bowel obstruction. 2.
Large amount of ascites, some of which is loculated, and
minimal free intraperitoneal air. These findings may be
related to previous laparotomy. 3. Cholelithiasis. 4.
Innumerable enlarged lymph nodes in the chest, abdomen and
pelvis, compatible with known diagnosis of CLL. 5. Diffuse
anasarca.
RUQ U/S ([**2176-7-24**]): Limited evaluation of gallbladder due to
multiple air containing stones as viewed on CT causing diffuse
posterior shadowing. No definite evidence of air within the
wall itself.
Gallbladder scan ([**2176-7-25**]): The above findings are consistent
with severe liver dysfunction without evidence of common bile
duct obstruction. Please note the gallbladder and cystic duct
cannot be adequately assessed in the setting of liver
dysfunction.
MRCP ([**2176-7-26**]): Intra- and extra-hepatic bile ducts appear
unremarkable. There is no evidence of choledocholithiasis. 2.
Gastric wall thickening and hyperenhancement likely representing
post-operative changes and possible ongoing ulcer disease. 3.
Pleural effusion and moderate ascites.
[**2176-7-27**] 02:15AM BLOOD Lipase-10
[**2176-7-28**] 03:44PM BLOOD ALT-35 AST-16 AlkPhos-90 TotBili-12.6*
UGI/SBFT ([**2176-7-28**]): No evidence of extraluminal extravasation
of contrast on this study limited by patient intolerance of
prone positioning. 2. Free passage of contrast through the
stomach into the duodenum. 3. Thickened folds of the gastric
body and limited gastric distensibility.
RUE U/S ([**2176-7-28**]): 1. Nonocclusive thrombus present within the
right basilic vein. 2. Right internal jugular vein not directly
identified. Followup study may be performed is there is clinical
concern for venous occlusion. 3. Cervical lymphadenopathy.
Pathology ([**2176-7-29**]):
I. Ileocolectomy (A-L): 1. Pseudomembranous colitis, diffuse,
extending to distal resection margins. 2. Malignant lymphoma
involving ileum and mesenteric lymph nodes. The case will be
reviewed by hematopathology with their report in an addendum. 3.
Organizing peritoneal hemorrhage.
II. Left colon (M-R): 1. Diffuse pseudomembrane colitis,
extending to both margins. 2. Hemorrhage and fibrotic serosa
and mesocolic fat. 3. No tumor.
III. Sigmoid colon (S-U): 1. Mild pseudomembranous colitis,
extending to the margins. 2. Fibrosis and hemorrhage of serosa
and mesocolic fat. 3. No tumor.
IV. Small intestine, partial resection (V-Y): 1. Unremarkable
small intestinal mucosa. 2. Hemorrhage and fibrosis of
peritoneum. 3. No tumor.
CT head ([**2176-7-29**]): 1. No intracranial hemorrhage, mass effect,
or abnormal enhancement. 2. Mucosal thickening in multiple
paranasal sinuses with features as described above.
CT chest/abd/pelvis ([**2176-7-29**]); 1. Bilateral airspace
consolidation with moderate pleural effusion and atelectasis,
suggestive of ARDS. 2. Massive mediastinal, hilar, axillary,
mesenteric, and retroperitoneal
lymphadenopathy due to chronic leukemia. 3. Two loculated
fluid collections versus abscesses, one at the left flank and
one anterior to the rectum, which may be communicating. 4.
Marked wall thickening throughout the colon, suggestive of
pancolitis. Edema in the peritoneal fat and small amount of
ascites. 5. Gallstones.
On day of expiration:
[**2176-7-30**] 03:00AM BLOOD WBC-56.6* RBC-3.99* Hgb-12.5* Hct-37.0*
MCV-93 MCH-31.4 MCHC-33.8 RDW-15.5 Plt Ct-57*
[**2176-7-30**] 03:00AM BLOOD PT-15.6* PTT-37.3* INR(PT)-1.4*
[**2176-7-30**] 03:00AM BLOOD Fibrino-318
[**2176-7-30**] 03:00AM BLOOD Glucose-113* UreaN-26* Creat-0.8 Na-145
K-5.8* Cl-119* HCO3-23 AnGap-9
[**2176-7-30**] 03:00AM BLOOD Calcium-6.7* Phos-5.5* Mg-1.9
[**2176-7-30**] 07:44AM BLOOD Type-ART pO2-42* pCO2-78* pH-7.06*
calTCO2-24 Base XS--11
[**2176-7-30**] 06:34AM BLOOD Lactate-3.6*
[**2176-7-30**] 06:34AM BLOOD O2 Sat-74
Brief Hospital Course:
Patient was admitted to the [**Hospital Unit Name 153**] and started on vanc/[**Last Name (un) 2830**]. He
was made NPO with IVF. A fever (Tmax 101.4) work-up was
initiated. A CXR demonstrated a LLL infiltrate. All urine and
blood cultures drawn throughout this hospital stay were
ultimately negative. Surgery was consulted. An NGT was placed
with immediate bilious output and symptomatic relief. Patient
was transferred to SICU on HD 2. He continued to be febrile
(Tmax 101.2) and tachycardic. A CT demonstrated distal SBO and
cholelithiasis. He was not a candidate for ERCP given his
recently laparotomies x 2 and perforated ulcer repair. Flagyl
was added. On HD 3, he continued tachycardic, but his
temperature decreased slightly; Tmax was 100.4. HIDA and MRCP
were performed without evidence for CBD obstruction. TPN was
started. On HD 4, Tmax was 101.7 and he remained tachycardic.
Diuresis was begun with IV Lasix. On HD 5, Tmax was 101.5. He
was still tachycardic. All antibiotics were d/c'd and the
patient was transferred to the floor. On HD 6, Tmax decreased
to 100, but he was still tachycardic. He was transferred back
to the SICU for progressive dyspnea (RR in mid 30s) and labored
breathing, ABG 7.53/34/50/29/5. Lasix gtt was started. He
failed to improve clinically despite non-rebreather FM and
BiPAP; he was later intubated. An UGI with SBFT failed to
demonstrate a leak. His NGT was d/c'd. On HD 7, he continued
to be febrile and tachycardic. He required increasing amounts
of pressors to maintain his BP. Lasix was d/c'd. Vanc/Zosyn
were started empirically. NGT was replaced. CVL was replaced.
He underwent CT torso which demonstrated pancolitis, ARDS, and
large L pleural effusion. As his WBC rose to 57 and he had
new-onset diarrhea, it was felt to be indicative of fulminant
C.diff colitis. He underwent subtotal colectomy emergently. A
small bowel resection and tube thoracostomy were also performed.
Overnight, he became hypotensive, hypoxemic, and acidemic. He
continued to require 3 pressors. The following day, he
continued to be unstable, requiring massive fluid intake to
maintain his pressures (despite multiple pressors). A family
meeting was held in the afternoon. The patient was made CMO.
All pressors were d/c'd. He expired at 13:35.
Medications on Admission:
Zosyn, Protonix, Zofran, morphine PCA
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
C. difficile pancolitis, septic shock, hyperbilirubinemia,
partial SBO, ARDS
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
Completed by:[**2176-11-25**]
|
[
"51881",
"99592",
"4280",
"5119"
] |
Admission Date: [**2141-7-15**] Discharge Date: [**2141-7-18**]
Date of Birth: [**2068-3-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Mobitz [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] AV block w/ LBBB
Major Surgical or Invasive Procedure:
Placment of temporary pacemaker
Placement of permanent pacemaker
History of Present Illness:
73 yo woman with hx of HTN, ? afib (never on anticoagulation)
and ? CVA was transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital after being
found to have Mobitz type II AV block w/ LBBB. She presented to
the OSH this am c/o of dizziness since midnight, however says
she actually noted feeling "woozy" with standing for about 1
week. She tolerated this until MN last night when she got out
of bed to use the bathroom and noted she was very dizzy. Denied
any SOB, CP, N/V; She did have some diarrhea yesterday, but
denied any fever or chills, and no urinary symptoms.
.
The pt presented to OSH where she was found to be in 3rd degree
AV block on ECG. She had transcut pacer pads placed, received
ASA 325mg x 1 and was medflighted to [**Hospital1 18**].
.
Here her ECG demonstrated Morbitz type II with LBBB. She had a
temporary wire placed at bedside in R IJ position w/o any
complications
Past Medical History:
HTN
Social History:
Married. 2 sons, 4 [**Name2 (NI) 69484**] a day for 40 years quit. Takes 2
drinks with dinner. No IVDU. Lives in [**Location 69485**].
Family History:
no CAD, CVA, DM, or thyroid disease
Physical Exam:
Admission:
VS: 98.6, 80 V paced, 150/50, 100% on 2L
Gen: NAD
HEENT: no JVD, MMM
CVS: ireg HR, nl s1 and s2, no m/g/r
lungs: CTABL
ABD: soft, NT/ND
Ext: no edema, 2+ DP
Pertinent Results:
Admission Labs:
.
[**2141-7-16**] 05:56AM BLOOD WBC-14.6* RBC-4.39 Hgb-14.0 Hct-40.5
MCV-92 MCH-31.9 MCHC-34.5 RDW-13.4 Plt Ct-258
[**2141-7-16**] 05:56AM BLOOD Plt Ct-258
[**2141-7-16**] 05:56AM BLOOD Glucose-138* UreaN-12 Creat-0.6 Na-140
K-3.7 Cl-103 HCO3-28 AnGap-13
[**2141-7-16**] 05:56AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
.
Radiology:
CXR ([**2141-7-15**]): There is a right IJ line with tip projecting over
the right ventricle. The lungs are clear without infiltrate or
effusion. There is no pneumothorax.
CXR ([**2141-7-18**]): Standard position of right pacemaker leads with no
evidence of discontinuation. No pneumothorax. Left small pleural
effusion grossly unchanged. No evidence of congestive heart
failure.
.
Other Labs:
[**2141-7-16**] 09:29AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2141-7-16**] 09:29AM URINE Blood-LGE Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2141-7-16**] 09:29AM URINE Mucous-RARE
Urine cx ([**2141-7-16**])- 4000/ml Gram negative rods (discussed with
microbiology lab corresponding to 4000 colonies which was
insignificant)
Lyme serology ([**2141-7-17**]) - pending
Discharge Labs:
.
[**2141-7-18**] 06:20AM BLOOD WBC-11.3* RBC-3.74* Hgb-12.7 Hct-34.6*
MCV-93 MCH-34.0* MCHC-36.7* RDW-13.3 Plt Ct-194
[**2141-7-18**] 06:20AM BLOOD Plt Ct-194
Brief Hospital Course:
The patient is a 73 yo F w/ ? h/o afib, ? h/o CVA, HTN p/w
Mobitz [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] AV block w/ LBBB. Her hospital course for this
admission is as follows:
.
1. Morbitz type II AV block : temporary pacer placed when
patient first presented with Morbitz type II block as bridge to
permanent pacemaker. Held BB for pre-permanent pacer placment;
permanent pacer placement on [**2141-7-17**]. Metoprol was restarted
initially at 25mg PO bid, titrated up to 50mg PO bid (her home
dose); Lyme titer was drawn to search for potential causes of
her AV block which was still pending at the time of discharge.
Will follow up with her Lyme titer after discharge
.
2. HTN: Initially, we held BB as we don't want to supress any
escape foci shd her temp wire fail prior to her permanent
pacemaker placement, but continued outpt amlodipine 10mg PO
qday. Once her permanent pacer was placed on [**2141-7-17**], we
restarted her metoprolol, and continued her amlodipine.
.
3. ? Afib: pt does not have any recollection of this. not on
aspirin or coumadin. She was told to follow up with her PCP for
follow up.
.
4. ? h/o CVA; pt doesn't have any recollection of this. Will
follow up with her PCP within [**Name Initial (PRE) **] week for further workup with
imaging. patient remained alert and oriented throughout her stay
with normal neuro exam.
.
5. ? urine cx - her initial UA showed 32 RBC, 0 WBC, occ
bacteria from her cath, and subsequent urine cx grew 4000
colonies/ml of gram negative rods. Patient remained afebrile
throughout her stay, and had no urinary symptoms. Discussed
with the microbiology lab (insignificant growth most likely from
contamination of cath) and infectious disease fellow on call
([**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **]). Recommended no treatment if patient have no
symptoms and afebrile.
.
6. PPX: colace
.
7. Code: Full
Medications on Admission:
Metoprolol 50mg PO bid
Amlodipine 10qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP<100.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP<100 and HR<60.
4. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day for 5 doses: Please take one dose tonight and four
doses tomorrow.
Disp:*5 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Morbitz type II AV block
Secondary Diagnosis
HTN
Discharge Condition:
stable in good condition, no fever, chest pain, SOB, Nausea or
vomiting.
Discharge Instructions:
If you experience chest pain, shortness of breath or fevers, or
any other serious medical conditions, please return to the
emergency room immediately
.
You should follow a cardiac healthy diet.
.
Please take all your medications as prescribed
.
Please follow up with your appointments
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24913**] [**Telephone/Fax (1) 32949**] next
Monday [**2141-7-24**] 11:30am, in adddition to the following
appointments
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2141-7-24**]
3:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2141-7-19**]
|
[
"4019",
"42731",
"V1582"
] |
Admission Date: [**2178-7-13**] Discharge Date: [**2178-7-16**]
Date of Birth: [**2113-11-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bee Pollens
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
decreased exercise tolerance
Major Surgical or Invasive Procedure:
Minimally invasive mitral valve repair w/annuloplasty band
History of Present Illness:
64 y/o male w/known MVP, decreasing exercise tolerance, followed
by echo. Recently with severe MR, decreased LVEF.
Past Medical History:
MI
MR/MVP
hepercholesterolemia
HTN
BPH
s/p tonsillectomy
s/p repair of deviated septum
Social History:
married
never smoked
2 glasses wine/day
no drug abuse history
Family History:
mother died of MI at age 55
father died of MI age 62
Physical Exam:
unremarkable pre-op
Pertinent Results:
[**2178-7-16**] 07:20AM BLOOD WBC-8.1 RBC-2.91* Hgb-9.1* Hct-26.6*
MCV-92 MCH-31.3 MCHC-34.2 RDW-14.1 Plt Ct-113*
[**2178-7-16**] 07:20AM BLOOD Plt Ct-113*
[**2178-7-15**] 06:40AM BLOOD Glucose-114* UreaN-22* Creat-0.8 Na-136
K-4.4 Cl-105 HCO3-27 AnGap-8
Brief Hospital Course:
Mr. [**Known lastname 2137**] was admitted to the pre-op holding area on [**2178-7-13**]
and taken to the operating room where he underwent a minimally
invasive mitral valve repair w/annuloplasty band.
Post-operatively he was taken to the cardiac surgery recovery
unit. He was weaned from mechanical ventilation and extubated
the evening of surgery. He was transferred to the telemetry
floor on POD # 1. His chest tubes were removed without issue.
He worked with physical therapy to improve his strength and
mobility. He has remained hemodynamically stable and was
discharged home on postoperative day three. He will follow-up
with Dr. [**Last Name (STitle) 1290**], his cardiologist and his primary care
physician as an outpatient.
Medications on Admission:
ASA 81'
Lipitor 80'
Lisinopril 40'
Terazosin 5'
Proscar 5'
Zetia 10'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 weeks: then Q 6 hours prn pain.
Disp:*90 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
MR s/p min inv MV Repair(#34 annuloplasty band
PMH: MR, ^chol, HTN, BPH
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
take all medications as prescribed
call for any fever, redness or drainage from wounds
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (Prefixes) **] in 4 weeks
with Dr. [**First Name (STitle) **] in [**12-26**] weeks
with Dr. [**Last Name (STitle) **] in [**12-26**] weeks
Completed by:[**2178-7-31**]
|
[
"4240",
"4019",
"2724",
"412",
"2859"
] |
Unit No: [**Numeric Identifier 60746**]
Admission Date: [**2190-5-21**]
Discharge Date: [**2190-5-29**]
Date of Birth: [**2190-5-21**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 174**] is the 38 and
[**2-12**] week gestational infant, admitted with respiratory
distress.
MATERNAL HISTORY: Mother is a 31 year-old, Gravida II, para
I to II woman. Past medical history is notable for
adenocarcinoma (in-situ). Prenatal screens were as follows:
A positive, antibody negative, Hepatitis B surface antigen
negative. RPR nonreactive. Rubella immune. GBS unknown.
ANTENATAL HISTORY: Estimated date of delivery was [**2190-5-26**]
for an estimated gestational age of 38 and 1/7 weeks.
Pregnancy was uncomplicated. It was a repeat Cesarean
section under general anesthesia. Rupture of membranes was
at the time of delivery which yielded clear amniotic fluid.
There was no intrapartum fever or other clinical evidence of
chorioamnionitis.
NEONATAL COURSE: Neonatal Intensive Care Unit team was not
initially in attendance at delivery. Infant was bulb
suctioned and [**Last Name (un) **] suctioned. Neonatal Intensive Care Unit
was called for grunting respirations. Apgars were 8 at one
minute and 9 at five minutes.
PHYSICAL EXAM: Physical examination on admission revealed a
birth weight of 4060 grams. Head circumference 37 cm. Length
53.3 cm. Infant was on CPAP with saturations of 95% in 30%
FI02. Heart rate of 124. Respiratory rate of 60's to 80's.
Temperature 96.8. Blood pressure 56/36 with a mean blood
pressure of 52. Anterior fontanel was open and soft. Infant
was non dysmorphic appearing. Palate was intact with a
normal neck and mouth. Normocephalic. CPAP in place.
Chest with mild intercostal retractions, good breath sounds
bilaterally and scattered, coarse crackles. Cardiac
examination revealed a well perfused infant with normal S1
and S2, no murmur. Normal femoral pulses. Abdominal
examination: Soft, nontender with the liver felt 1.5 cm
below the right costal margin. No splenomegaly. No masses.
Active bowel sounds with a patent anus. Genitourinary
examination revealed normal female genitalia. Neurologic
examination revealed an alert, active infant, responsive to
stimulation with normal tone. Moving all extremities
symmetrically. A normal suck, root and gag. Symmetrical
grasp reflexes. Skin examination was normal as well as
normal spine, limbs, hips and clavicles.
HOSPITAL COURSE:
1. Respiratory: Chest x-ray was obtained on admission which
demonstrated bilateral interstitial opacities. Infant was
initially placed on CPAP. Follow up chest x-ray on day
of life number two revealed continued bilateral opacities,
more consistent with neonatal pneumonia. Infant continued
on CPAP until day of life number four when she was
transitioned to nasal cannula. She slowly weaned on her
nasal cannula until day of life number seven when she was
successfully weaned to room air and maintained saturations
greater than 95%.
2. Cardiovascular: The patient was without a murmur. She
was hemodynamically stable throughout her admission.
3. FEN: The patient was initially started on intravenous
fluids secondary to tachypnea and respiratory distress, at
60 cc per kg per day. On day of life number three, she
was allowed to begin feeding either formula or breast milk
and she is currently feeding Similac 20 calories per ounce
in an ad lib fashion. Weight at the time of discharge is
3820 grams.
4. Gastrointestinal: Patient had a bilirubin on day of life
number 5 of 17. At this point, double phototherapy was
started. Bilirubin on day of life six was 11.8.
Phototherapy was discontinued on day of life seven and
rebound bilirubin [**Location (un) 1131**] was 6.6.
5. Infectious disease: The patient was initially started on
Ampicillin and Gentamycin, given respiratory distress.
CBC was obtained which was benign and blood cultures were
obtained which remained negative. Due to continued
presence of bilateral interstitial infiltrates as well as
continued respiratory distress, the patient was treated
with Ampicillin and Gentamycin for seven days for
presumed pneumonia. A lumbar puncture was obtained on day
of life number five which was reassuring.
6. Sensory: A hearing screen was performed prior to discharge
and was passed.
CONDITION ON DISCHARGE: Good.
DISCHARGE CONDITION: Home.
PRIMARY CARE PEDIATRICIAN: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 60747**], MD, telephone
number [**Telephone/Fax (1) 47504**].
CARE RECOMMENDATIONS:
Feeds: The patient may bottle or breast feed ad lib on
demand.
MEDICATIONS: None.
State screening test was sent on [**2190-5-24**] and results are
pending.
Car seat screening performed due to respiratory illness,
infant passed.
IMMUNIZATIONS: The patient received the first hepatitis B
vaccine on [**2190-5-29**].
DISCHARGE DIAGNOSES:
1. Presumed pneumonia versus prolonged TTN.
2. Hyperbilirubinemia, resolved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 58729**]
MEDQUIST36
D: [**2190-5-28**] 16:10:22
T: [**2190-5-28**] 16:52:42
Job#: [**Job Number 60748**]
|
[
"486",
"V290",
"V053"
] |
Admission Date: [**2109-10-30**] Discharge Date: [**2109-11-20**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Patient is an 85-year-old male
with a history of hypertension and heart murmur, who had a
near syncopal episode while at the grocery store. He was
brought to [**Hospital6 33**] and ruled out for MI. He had
an echocardiogram which showed severe aortic stenosis and an
EF of 55-60%. He was then transferred to [**Hospital1 346**] and underwent cardiac
catheterization on [**10-30**], which showed an A-V
gradient of 63 mm Hg and aortic valve area of 0.35 cm
squared, right coronary artery was 60% stenosed proximally,
left main to be normal, left anterior descending artery with
60% stenosis in the mid vessel and left circumflex normal.
Patient was then referred for coronary artery bypass
grafting.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Non-Hodgkin's lymphoma which was "low grade" and he is
status post chemotherapy.
3. Spinal stenosis.
4. Degenerative joint disease.
5. Rheumatic fever.
6. Macrocytic anemia.
7. Asbestus exposure.
8. Status post prostate shaving.
9. Mastoiditis as a child.
SOCIAL HISTORY: He is a widower and lives alone. He is a
remote pipe and cigar smoker. He drinks alcohol rarely.
ALLERGIES: Has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Tylenol.
2. Procardia.
REVIEW OF SYSTEMS: On admission, he had no recent visual
changes, no dysphagia, occasional shortness of breath with
walking. He has no palpitations, no chest pain. He does
occasionally experience heartburn and takes Tums with good
relief. He has no melena and no hematochezia. He does have
nocturia x1. He has no weakness. Does occasionally
experience numbness in his left leg with prolonged sitting
secondary to his spinal stenosis. He has no history of CVA
nor TIA and no history of vein stripping.
PHYSICAL EXAMINATION: On physical exam, he is a pleasant,
elderly male in no apparent distress. His vital signs showed
his heart rate to be 77, blood pressure 132/71, respirations
20, and O2 saturation 97% on 1 liter nasal cannula. His
HEENT shows PERRLA. EOMI. Oropharynx is clear with some
missing teeth. His neck is supple with no JVD, no bruits,
and carotid pulses are 1+ bilaterally. His lungs are clear
to auscultation bilaterally. His heart is regular, rate, and
rhythm with a 4/6 systolic ejection murmur. His abdomen has
positive bowel sounds, soft, nontender, nondistended.
Extremities show no clubbing, cyanosis, or edema. DP and PT
pulses are by Doppler bilaterally, and his radial artery
pulses are 2+ bilaterally. His neurologic examination shows
him to be alert and oriented times three and to be grossly
intact. The skin shows no rashes and no abrasions.
LABORATORIES: White count of 7.2, hematocrit of 30.6,
platelet count of 181,000. Sodium 139, potassium 4.2,
chloride 107, CO2 26, BUN 26, creatinine 0.9, and glucose of
115. PT was 12.8, INR of 1.1, PTT 34.4. His LFTs were all
within normal limits.
Patient was accepted as a surgical candidate and it was
requested that he undergo a carotid ultrasound prior to
surgery.
HOSPITAL COURSE: On [**2109-10-31**], patient underwent
carotid ultrasound which showed bilateral internal carotid
stenoses of less than 40%. He had no events prior to going
to the operating room and on [**2109-11-1**], he was taken
to the operating room for an aortic valve replacement with a
#21 mm CE pericardial valve and coronary artery bypass
grafting x1 of the left internal mammary artery to the left
anterior descending artery. The surgery was performed under
general endotracheal anesthesia by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] with Dr.
[**Last Name (STitle) 100894**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96760**], NP as an assistant.
During the postoperative night, the patient was weaned off
his propofol and attempted to extubate, but was not able to
extubate, and was resedated on propofol. On the following
morning, the propofol was weaned again, but the patient was
too sedated to be weaned from the vent.
On postoperative day #2, he was noted to have decreasing
cardiac index over the course of the day, and a cardiac
echocardiogram was ordered. This revealed global hypokinesis
with an EF of about 40%. He was also seen by Neurology team
for assessment of possible stroke. He was noted to have left
hemiplegia after being in AFib. He did receive CT of the
head which showed evidence of right MCA stroke, but no bleed.
It was recommended at that time that his systolic blood
pressure be kept in the 140s-160s, and that he be
Heparinized.
For his atrial fibrillation, he was given beta blocker and
started on amiodarone drip. He was cardioverted to sinus
rhythm with 200 joule shock because the AFib was concurrent
with the increasing cardiac index and he did return to sinus
rhythm.
By postoperative day #4, he was off his propofol, having some
agitation, and minimally moving to commands. He was weaned
to CPAP and started to be exercised. He continued on CPAP
for the following day and was extubated on postoperative day
#5.
Through postoperative days #6 and seven, he continued to be
in and out of AFib. He was on his Lopressor increased to 50
b.i.d. and was converted to amiodarone p.o. while on the
amiodarone drip.
By postoperative day #8, he was transferred to the Surgical
floor. He began working with Physical Therapy more
aggressively and on postoperative day #9, he was noted to
have UTI and was started on Levaquin. He continued on the
Heparin at this time, and was started on low dose Coumadin
for further anticoagulation. Overnight period of
postoperative day #9, he became more confused. He did
receive minimal doses of Haldol for agitation. His confusion
seemed to clear during the daytime and gradually improved
until discharge.
He was noted on postoperative day #12 to have left sided
effusion by chest x-ray. This was evaluated again by CT
scan, and it was felt that it could be tapped. He eventually
on postoperative day #14 went for ultrasound guided
thoracentesis on the left side. They were able to take off
approximately 800 to 1000 cc from the left and 500 cc from
the right. His followup chest x-ray showed no signs of
pneumothorax.
He was then felt to be ready for discharge to rehab, but
overnight period of postoperative day #17, he was noted to
have a heart rate in the 30s-40s. He had his amiodarone and
Lopressor D/C'd and his heart rate remained in the 40s to low
50s. It was also determined since he had fallen at one point
while trying to get out of bed on his own, that he was at
fall risk and his Heparin and Coumadin treatment were
discontinued.
On postoperative day #19, it is felt that he is ready for
discharge to rehab. His discharge examination shows him to
be alert. He is moving all extremities to command. His
lungs are clear at the apices, but decreased breath sounds at
the bases. Heart is regular, rate, and rhythm. Abdomen is
soft, good bowel sounds, soft, nontender, nondistended.
Extremities show no clubbing, cyanosis, or edema. His
sternal wound is stable and his incisions are clean, dry, and
intact.
Laboratories on discharge include a white count of 9.7,
hematocrit of 30.7%, platelet count of 266,000. Sodium was
134, potassium 4.7, chloride 101, CO2 27, BUN 21, creatinine
1.3, and a glucose of 92.
His chest x-ray did show small bilateral pleural effusions.
DISCHARGE MEDICATIONS:
1. Captopril 50 mg p.o. t.i.d.
2. Colace 100 mg p.o. b.i.d.
3. Ranitidine 150 mg p.o. b.i.d.
4. Enteric coated aspirin 325 mg p.o. q.d.
5. Levofloxacin 250 mg p.o. q.d. x5 days.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement with a #21
pericardial valve and coronary artery bypass graft x1 with a
left internal mammary artery to the left anterior descending
artery on [**11-1**].
2. Postoperative atrial fibrillation with eventual sinus
bradycardia secondary to amiodarone and Lopressor.
3. Status post bilateral pleural effusions, which underwent
thoracentesis for approximately [**Telephone/Fax (1) 20571**] on the left and 500
on the right.
DISPOSITION: He will be discharged to rehab on [**2109-11-20**].
FOLLOW-UP INSTRUCTIONS: Should follow up with his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**1-14**] weeks after discharge from
rehab, and he should follow up with Dr. [**Last Name (STitle) **] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 31272**]
MEDQUIST36
D: [**2109-11-20**] 10:24
T: [**2109-11-20**] 10:36
JOB#: [**Job Number 100895**]
|
[
"4241",
"5990",
"9971",
"42731",
"5119",
"41401",
"4019"
] |
Admission Date: [**2144-9-18**] Discharge Date: [**2144-9-23**]
Date of Birth: [**2089-3-16**] Sex: M
Service: CSURG
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
This is a 55 yo male patient who reports 6 months of throt
tightness with exertion, resolving with continued exercise.
Major Surgical or Invasive Procedure:
CABG x 3.
History of Present Illness:
This is a 55 yo male patient who reports 6 months of throt
tightness with exertion, resolving with continued exercise.
Stress testing on [**2144-9-1**]: partially reversible anterior wall
defect, reversible inferoapical defect, EF 59%. Cath [**2144-9-11**]:
LMCA 70%, LAD 90%, RCA 50%, PDA 70%
Past Medical History:
DM 1
Hyperlipidemia
Arthroscopic left knee surgery
Correction of stabismus
Social History:
Married, lives in [**Location 31086**], NH with wife. [**Name (NI) **] has two grown
sons. [**Name (NI) **] works full time as a carpenter. Denies history of
cigarette smoking.
Family History:
Mother MI in 60s.
Sister MI in 40s.
Physical Exam:
On presentation:
Ht: 6'0" Wt: 200# VS: 70 NSR BP 133/76 RR 18 SpO2 RA 99%.
General: Laying flat in bed in NAD. Neuro: A+O x 3.
Appropriate. Resp: CTA. CV: RRR. S1 S2. No M/R/G. GI: soft,
flat, NT, ND, + BS. Extremities: Warm, well perfused. No
edema, no varicosities.
Pertinent Results:
[**2144-9-21**] 06:15AM BLOOD WBC-7.5 RBC-3.30* Hgb-10.9* Hct-30.4*
MCV-92 MCH-33.0* MCHC-35.7* RDW-12.6 Plt Ct-154
[**2144-9-21**] 06:15AM BLOOD Plt Ct-154
[**2144-9-20**] 02:18AM BLOOD PT-14.4* PTT-30.4 INR(PT)-1.3
[**2144-9-22**] 06:05AM BLOOD Glucose-200* UreaN-14 Creat-0.7 Na-135
K-4.0 Cl-98 HCO3-32* AnGap-9
Brief Hospital Course:
Mr. [**Known lastname 3175**] was admitted on the morning of his operative day. He
underwent a CABG x 3 with Dr. [**Last Name (STitle) **] with LIMA to the LAD, SVG
to the Ramus, and a SVG to the PDA. His total cardio-pulmonary
bypass time was 66 minutes and his cross clamp time was 53
minutes. His OR course was uneventful and he was transferred to
the ICU on insulin, propofol, and neosyneprine drips. He was
extubated on the evening of his operative day and his IV drip
medications were weaned as tollerated.
His chest tubes were removed on POD 2 and his cardiac pacing
wires were removed on POD 3. The remainder of his
post-operative course was uneventful.
Because Mr. [**Known lastname 3175**] is a known type 1 diabetic he was sustained
on an insulin drip initially. The [**Last Name (un) 387**] service was consulted
on his second post-operative day at which time his insulin drip
was stopped and he was changed over to his insulin pump per the
recommendation of the [**Last Name (un) **] physicians in conjunction with the
patient.
The physical therapy team assessed Mr. [**Known lastname 3175**] initially on [**9-21**]
and on [**9-22**] found that he had met the proposed goals and is
safe for discharge home from their prospective.
Medications on Admission:
Wellbutrin XL 300 mg daily
Altace 10 mg daily
pravachol 20 mg daily
aspirin 81 mg daily
MVI
Glucosamine
insulin pump: basal rate of 0.8 units from 12 AM to 3 am; 0.9
units from 3 am to 8 am; 0.5 units from 8 am to 6 am, 0.4 units
from 6 pm to 12 am.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD ().
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
6. Bupropion HCl 100 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO QAM (once a day (in the morning)).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] HOME HEALTH
Discharge Diagnosis:
Coronary artery disease.
IDDM.
^chol.
Discharge Condition:
Good.
Overall PE unremarkable. Sternal and leg incisions without
drainage or s/s of infection.
Discharge Instructions:
No heavy lifting > 10 pounds.
No driving for 4 weeks.
Follow medications on discharge instructions.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**3-3**] weeks.
Follow-up with Dr. [**Last Name (STitle) 31087**] in 4 weeks.
Follow-up with Dr. [**Last Name (STitle) 11493**] in [**1-1**] weeks.
Completed by:[**2144-9-23**]
|
[
"41401",
"2724"
] |
Admission Date: [**2114-7-1**] Discharge Date: [**2114-7-11**]
Date of Birth: [**2114-7-1**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**Known lastname 11468**] was born at 30 weeks gestation
by cesarean section for bleeding. The mother is a
23-year-old gravida V, para I now II woman (TAB x 2, SAB x
1). The prenatal screens are blood type O positive, antibody
negative, rubella immune, RPR nonreactive, hepatitis surface
antigen negative, and group B strep unknown.
The mother's past obstetrical history is remarkable for a
current six-year-old child who was delivered at 32 weeks
gestation with diagnosis of gastroschisis. The child is well
at this time. This pregnancy was complicated by a rib
fracture in [**2114-1-26**] (the mother was attacked while
riding a bus). The pregnancy was also complicated by
pyelonephritis on [**2114-6-11**], treated with intravenous
antibiotics, and a chlamydia infection on [**2114-6-12**], treated
with azathiamycin. The mother was admitted to [**Hospital3 1280**]
Hospital on [**2114-6-28**] with bleeding, treated with magnesium
sulfate. She developed toxicity and was discontinued. She
had pre-term labor, and a known low-lying placenta. She was
transferred to [**Hospital1 69**], where
the bleeding progressed, and so she was delivered by cesarean
section. The infant emerged with good cry and respiratory
effort. Apgars were 8 at one minute and 8 at five minutes.
Birth weight was 1405 grams (60th percentile), birth length
36.5 cm (20th percentile), and birth head circumference 27 cm
(25th percentile).
PHYSICAL EXAMINATION: Revealed a pink, appropriate for
gestational age, pre-term infant. Anterior fontanel open and
flat, positive bilateral red reflex, intact palate.
Grunting, flaring and retracting, with decreased air movement
to the bases. Normal S1, S2 heart sounds, no murmur.
Mucous membranes pink, well perfused. Normal male pre-term
genitalia, stable hip examination, and age-appropriate tone
and reflexes.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant was intubated soon after
admission, received one dose of surfactant, weaned to
continuous positive airway pressure on day of life one, and
then to room air by day of life two, where he has remained.
He has had approximately one episode of apnea and bradycardia
in each 24 hours. He has not required any methylxanthine
treatment.
2. Cardiovascular: He received a fluid bolus for
hypotension at the time of admission, and has remained
normotensive since that time. He has a normal S1, S2 heart
sound, no murmur. He is pink and well perfused.
3. Fluids, electrolytes and nutrition: Enteral feeds were
begun on day of life number one, and advanced without
difficulty to full volume feedings by day of life number six.
He is currently feeding preemie Enfamil 24 calories/ounce,
total fluids 150 cc/kg/day by gavage feeding. Feedings are
given over one hour's time. The last set of electrolytes was
done on [**2114-7-8**]. Sodium was 134, potassium 5.9, chloride 99,
and bicarbonate 21.
His measurements at the time of discharge are weight 1370
grams, length 39 cm, and head circumference 27 cm.
4. Gastrointestinal: The infant was treated with
phototherapy for physiologic hyperbilirubinemia from day of
life number two until day of life number four. His peak
bilirubin occurred on day of life number two, and was total
7.0, and direct 0.4. His last bilirubin on [**2114-7-8**] was total
5.6, and direct 0.4.
5. Hematology: The infant's hematocrit at the time of
admission was 47.4, and platelets were 302,000. The infant's
blood type is O positive, direct Coombs negative. The infant
has received no blood products during this Newborn Intensive
Care Unit admission.
6. Infectious Disease: The infant was started on ampicillin
and gentamicin at the time of admission for sepsis risk
factors. The antibiotics were discontinued after 48 hours
when the blood cultures were negative and the infant was
clinically well. He has remained off antibiotics since that
time.
7. Neurology: A head ultrasound has not been done yet, and
is recommended during the next week of life.
8. Audiology: Hearing screening has not yet been done, and
is recommended prior to discharge.
9. Ophthalmology: The patient is due for his first
examination at four weeks of age.
10. Psychosocial. The mother has been involved in the
infant's care during his Newborn Intensive Care Unit stay.
CONDITION AT DISCHARGE: Good
DISCHARGE STATUS: The infant is being transferred to [**Hospital3 6454**] Hospital Level II Nursery for continuing care.
NAME OF PRIMARY PEDIATRICIAN: The family has not yet
identified a primary pediatric care provider.
CARE RECOMMENDATIONS:
1. Feedings: Preemie Enfamil 24 calories/ounce, total
fluids 150 cc/kg/day every four hours
2. Medications: Fer-in-[**Male First Name (un) **] 0.12 cc by mouth once daily to
provide 2 mg/kg/day of elemental iron, vitamin E 500 IU by
mouth once daily
3. The infant has not yet had a car seat position screening
test.
4. State screen test was sent on [**2114-7-6**].
5. The infant has not yet received any immunizations.
DISCHARGE DIAGNOSIS:
1. Prematurity, 30 weeks
2. Sepsis ruled out
3. Status post respiratory distress syndrome
4. Status post physiologic hyperbilirubinemia
5. Apnea of prematurity
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2114-7-11**] 03:18
T: [**2114-7-11**] 03:54
JOB#: [**Job Number **]
1
1
1
DR
|
[
"V290"
] |
Admission Date: [**2192-6-9**] Discharge Date: [**2192-6-15**]
Date of Birth: [**2145-8-19**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Codeine / Colchicine Derivatives / Erythromycin Base
/ Celexa
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with stent to OM1.
History of Present Illness:
46 y.o. female with HTN, DM, hypercholesteremia, ESRD s/p
transplant x 3, RSD and depression who presents with diffuse
chest pain. Yesterday morning patient noted bilateral arm pain,
achy in nature, and some tightness in her neck with some DOE. BP
was elevated to 225/115 and she took diovan x 1 that she takes
only on a prn basis. Shortly thereafter she developed [**9-23**] chest
pain located on right, center, and left side, radiating to back,
and arm pain worsened. Called PCP who instructed her to take
cardizem x 1, which she did, but pressure remained elevated to
SBP 210. She was nauseated last night and vomitted x 3, non
bloody, and L arm pain worsened (more than right). Presented to
ED for evalation of symptoms.
.
In ED patient was given 3 nitro with some relief, 4 mg morphine
x 2. Also given ASA, anzemet, ativan 3 mg x 1, and home meds of
prednisone and cardizem. Currently the patient states pain [**5-23**],
and has been ongoing since episode started yesterday,
exacerbated by deep inspiration. Leaning forward does not make
pain worse. No SOB. In ED EKG with NSR, no ST changes, old Q
waves, T wave flattening in lateral precordial leads more
prominent, initial set of CE's negative with trop 0.02. CXR nml
and without mediastinal widening. MRI performed to r/o
dissection (can not get CTA d/t renal function), and this was
negative although initial read noted that EKG gating was
suboptimal, however further review of MRA with radiology
confirmed very low suspicion of dissection.
.
On ROS, denies lightheadedness, dizziness, palpatations,
orthopnea, PND. Normally without SOB or DOE. Noted diarrhea x 1
wk, nonbloody, and stomach distension x 3 wks, nonpainful. No
URI sxs such as cough, nasal congestion, sore throat. No
dysuria, urgency, hestancy. Motor strength intact.
Past Medical History:
# s/p cadaveric kidney transplant x3, most recent in [**2177**]. Renal
failure d/t chronic pylenephritis.
# Familial glomerulonephritis, chronic pyelonephritis.
# Type II DM, diet controlled
# s/p cholecystectomy
# R eye cataract s/p surgery (related to chronic steroids)
# Depression
# HTN
# Hyperlipidemia
# RSD - Reflex sympathetic dystophy, on chronic pain meds
Social History:
Denies tobacco, EtOH, or illicit drug use. Previously
worked in banking; not currently working.
Family History:
Mother, brother - glomerulonephritis
Physical Exam:
Vitals: 98.6, 55-65, 165/97 (130-170/80's), 16, 100% RA
Gen: pleasant young woman, lying in bed, no acute distress, but
still with ongoing pain
HEENT: anicteric, OP clear
Lungs: clear, symmetrical BS, no wheezes or crackles
CV: I/VI SEM M at LUSB, no s3, no rubs, some reproducible pain
over sternum, however not fully
Abd: soft, ND, NT, no HSM
Groin: kidney graft non-tender
Extr: no edema, good distal pulses
Pertinent Results:
[**2192-6-9**] 02:50AM BLOOD WBC-8.3 RBC-4.50 Hgb-13.7 Hct-38.1 MCV-85
MCH-30.4 MCHC-35.9* RDW-13.5 Plt Ct-153
[**2192-6-9**] 02:50AM BLOOD PT-12.2 PTT-26.2 INR(PT)-1.0
[**2192-6-9**] 02:50AM BLOOD Glucose-199* UreaN-36* Creat-2.4* Na-140
K-3.8 Cl-108 HCO3-19* AnGap-17
[**2192-6-9**] 02:50AM BLOOD ALT-25 AST-28 CK(CPK)-68 AlkPhos-114
TotBili-0.2
[**2192-6-9**] 10:15AM BLOOD CK(CPK)-113
.
DISCHARGE LABS:
[**2192-6-15**] 04:02AM BLOOD WBC-4.9 RBC-3.66* Hgb-11.0* Hct-31.4*
MCV-86 MCH-30.1 MCHC-35.1* RDW-13.8 Plt Ct-94*
[**2192-6-15**] 04:02AM BLOOD Plt Ct-94*
[**2192-6-15**] 04:02AM BLOOD Glucose-99 UreaN-34* Creat-2.7* Na-141
K-3.8 Cl-110* HCO3-18* AnGap-17
[**2192-6-15**] 04:02AM BLOOD Ret Aut-1.0*
[**2192-6-14**] 05:35AM BLOOD ALT-85* AST-96* LD(LDH)-262* AlkPhos-114
TotBili-0.2
[**2192-6-15**] 04:02AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.4
[**2192-6-15**] 04:02AM BLOOD Cyclspr-LESS THAN 25
[**2192-6-14**] 05:35AM BLOOD Cyclspr-LESS THAN 25 rapmycn-6.2
[**2192-6-11**] 05:20AM BLOOD Cyclspr-77* rapmycn-4.1*
[**2192-6-10**] 04:02PM BLOOD Cyclspr-60*
[**2192-6-14**] 02:49PM BLOOD PTH-170*
.
Creatinine:
[**2192-6-15**] 04:02AM BLOOD Glucose-99 UreaN-34* Creat-2.7* Na-141
K-3.8 Cl-110* HCO3-18* AnGap-17
[**2192-6-14**] 10:20AM BLOOD K-4.6
[**2192-6-14**] 05:35AM BLOOD Glucose-108* UreaN-30* Creat-2.3* Na-140
K-6.3* Cl-112* HCO3-19* AnGap-15
[**2192-6-13**] 11:41PM BLOOD Glucose-202* UreaN-33* Creat-2.3* Na-139
K-3.7 Cl-109* HCO3-19* AnGap-15
[**2192-6-13**] 04:50AM BLOOD Glucose-90 UreaN-37* Creat-2.5* Na-144
K-4.0 Cl-114* HCO3-18* AnGap-16
[**2192-6-12**] 05:30AM BLOOD Glucose-125* UreaN-36* Creat-2.5* Na-141
K-4.0 Cl-109* HCO3-20* AnGap-16
[**2192-6-11**] 05:20AM BLOOD UreaN-40* Creat-2.7* K-4.0
[**2192-6-10**] 09:25AM BLOOD Glucose-88 UreaN-33* Creat-2.5* Na-142
K-3.8 Cl-111* HCO3-23 AnGap-12
[**2192-6-9**] 02:50AM BLOOD Glucose-199* UreaN-36* Creat-2.4* Na-140
K-3.8 Cl-108 HCO3-19* AnGap-17
.
Cardiac Enzymes:
[**2192-6-13**] 11:41PM BLOOD CK-MB-NotDone cTropnT-0.72*
[**2192-6-11**] 05:20PM BLOOD CK-MB-NotDone cTropnT-0.45*
[**2192-6-11**] 05:20AM BLOOD CK-MB-8 cTropnT-0.45*
[**2192-6-10**] 05:20PM BLOOD CK-MB-16* MB Indx-9.7* cTropnT-0.54*
[**2192-6-10**] 09:25AM BLOOD CK-MB-12* MB Indx-8.8*
[**2192-6-9**] 09:17PM BLOOD CK-MB-17* MB Indx-10.5* cTropnT-0.49*
[**2192-6-9**] 03:55PM BLOOD CK-MB-17* MB Indx-11.6* cTropnT-0.02*
[**2192-6-9**] 10:15AM BLOOD CK-MB-12* MB Indx-10.6* cTropnT-0.25*
[**2192-6-9**] 02:50AM BLOOD cTropnT-0.02*
[**2192-6-9**] 02:50AM BLOOD CK-MB-NotDone
Brief Hospital Course:
46 yo F hx renal trasnplant, DM, hypercholesterolemia p/w
episodes of acute onset substernal chest pain radiating to back
in setting of hypertension.
.
CP/NSTEMI - initial presentation of chest pain was very
concerning for dissection and held off initially on heparin or
plavix. Once MRA results were reviewed with radiology and
comfortable enough to r/o dissection started heparin drip and
loaded with plavix to rule for ACS in setting of elevated
cardiac enzymes, non-specific ECG changes. Elevated MB is
especially concerning, and acute elevation in troponin
concerning despite chronic renal failure. Cont ASA, high dose
statin, nitro drip. No integrillin given the hx of renal
transplant. Patient was admitted to r/o MI and potentially for
cath.
.
Cardiac enzymes peaked (precath) on [**6-10**] with CK 76 CK-MB Trop
0.54. She underwent a MIBI on [**6-12**] which was normal, however,
patient has continued to have intermittent chest pain. As her
chest pain persisted she underwent cardiac cath on [**6-13**]. Cath
report --> R heart cath --> RA 5, RV 30/2, PA 28, 8, PCW 10, CO
5.15, CI 3.33. R dominant system with LAD - distal focal 80%
stenosis, RCA - distal 70% lesion, LCX - stent to OM1. During
the procedure predilation of the OM resulted in dissection to
the superior vessel. Vessel was stented with normal flow;
superior branch had retrograde flow with noted adventitial
hematoma.
.
Transferred to CCU for monitoring. Patient had N/V following
cath, however, this resolved within hours. Initially transferred
to CCU on nitro gtt, she was weaned off within a few hours. She
was chest pain free during her CCu stay. ECHO on [**6-14**] - EF > 65%,
nl chamber size, no significant valavular disease, small
pericaridal effusion (unchanged from prior). Continued on ASA,
statin, and beta blocker. Needs Plavix x 12 months. Per Dr.
[**First Name (STitle) **], patient should have other lesion(s) addressed in [**4-19**]
weeks. Pt. transferred to floor, remained CP free, discharged
home.
.
s/p renal trasplant - Continued on outpatient immunosupression
regimen of prednisone, cyclosporine, rapamune. Cr has ranged
between 2.3-2.7. Received hydration prior to cath. CSA level
noted to be low on [**6-15**] so cyclosporine dose was increased 75 mg
[**Hospital1 **]. Also dilitiazem, which can affect levels of cyclosporine
was dicontinued in favor of titrating up beta blockade. Plans
made for f/u of Cr as outpt. on Saturday c renal team aware.
.
Hypertension - Diltiazem discontinued. Blood pressure being
controled with metoprolol, although SBPs have been labile. [**Month (only) 116**]
need ongoing titration in out-patient setting. Unclear if renal
function can tolerate ace inhibitor.
.
Depression - cont topamax, depression
.
FULL code
Medications on Admission:
Prednisone 2 mg PO QDS
Cyclosporin 50 mg PO BID
Cardizem 120 mg PO QD
Rapaimmune 3mg PO QD
Lipitor 10 mg PO QD
Protonix 40 mg PO QD
Topamax 100mg QAM, 50 mg QPM
Effexor 37.5 mg PO QD
Fentanyl patch 25 mg Q3days
Diovan prn
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
3. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*90 Tablet(s)* Refills:*2*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Epoetin Alfa 2,000 unit/mL Solution Sig: 0.5 mL Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*100 mL* Refills:*2*
8. Cyclosporine 25 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
Disp:*360 Capsule(s)* Refills:*2*
9. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
11. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
12. Venlafaxine 37.5 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for muscle spasm.
15. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
16. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*60 Tablet, Sublingual(s)* Refills:*1*
17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for indigestion.
18. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
NSTEMI
renal insufficiency seconday to familial glomerulonephritis -
s/p renal transplant
DM - diet controlled
hypertension
hyperlipidemia
depression
Reflex sympathetic dystrophy
Discharge Condition:
Good, chest pain free.
Discharge Instructions:
Please take all of your medications as prescribed. Note we have
adjusted your dose of cyclosporin.
*
Please call your doctor or return to the emergency room if you
develop shortness of breath, chest pain, nausea/vomiting, you
cannot eat drink or take your medications, or you develop any
other symptoms that are concerning to you.
Followup Instructions:
Please report to [**Hospital Ward Name 1826**] 7 to have your blood laboratories
monitored by the renal service.
Please follow up with your nephrologist, Dr [**Last Name (STitle) **].
Please contact Dr. [**First Name (STitle) **] of Cardiology during next week. He
will like perform repeat cardiac catheterization in [**4-19**] weeks
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in one-two weeks.
Please request that your LFT's be monitored on this visit.
*
You will also need to follow-up with cardiology and discuss
further interventions as you have two other blockages in your
coronary arteries.
*
Please follow-up with Dr. [**Last Name (STitle) **] in one-two weeks.
.
You have the following appointments:
Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], NP Date/Time:[**2192-6-20**] 9:10
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2192-8-21**] 10:30
|
[
"41071",
"41401",
"2720",
"25000",
"4019"
] |
Admission Date: [**2122-2-21**] Discharge Date: [**2122-2-28**]
Date of Birth: [**2052-10-30**] Sex: M
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypoxia and dyspnea
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
69 M h/o COPD, dCHF, on coumadin for h/o afib (per wife, though
pt not taking it now) presenting for respiratory distress. Per
wife, pt with 2d increasing SOB, non-productive cough, "in bed
all day", multiple other family members sick with "flu."
.
Pt presented to the ED with VS: 97.4 153 134/89 34 83% RA,
improved to 96% with NRB, though RR 40s, so pt started on CPAP,
with sats 93%, SBP 130s->94, so put back on 4L, with sats 91%.
pulmonary exam sounded tight, +wheezing, sinus tach on EKG, CXR
showed no CHF, ?PNA in RLL. given solumedrol 125, nebs,
levo/vanco for broad coverage.
.
Pt also with L>R edema, and bilateral LE redness concerning for
cellulitis, had similar sx [**10-30**], LENIs negative. unable to lie
flat for CTA.
ROS negative for F/C/N/V/D, CP, dysuria, constipation. +sick
contacts, fatigue.
Past Medical History:
- COPD (no available PFTs) - on 2L O2 at home, keeps a nebulizer
at home and in his taxi
- HTN
- dCHF (TTE [**10-30**] EF>55%, RV free wall HK, mod aortic dilation)
- h/o ?afib.
Social History:
TOB up to [**2-24**] ppd x 50 years, now <1 ppd. Denies etoh/illicts.
Married. 8 children. Taxi driver.
Family History:
non-contributory
Physical Exam:
VS: 95.5 145 125/78 39 89%4L
GEN: ill appearing, pale, blue ears, speaks in [**12-24**] word
sentences, using accessory muscles.
HEENT: No JVD.
CV: regular, tachy, nl s1, s2, no appreciable m/r/g.
PULM: poor airmovement throughout, bilateral +wheeze.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL. B LE [**12-24**]+ EDEMA, L>R,
+erythema, ?chronic venous changes vs cellulitis.
NEURO: alert & oriented x 3.
.
Pertinent Results:
[**2122-2-20**] 11:15PM BLOOD WBC-8.1 RBC-4.41* Hgb-14.0 Hct-42.9
MCV-97 MCH-31.7 MCHC-32.6 RDW-14.5 Plt Ct-171
[**2122-2-27**] 03:27AM BLOOD WBC-7.2 RBC-4.40* Hgb-13.7* Hct-42.3
MCV-96 MCH-31.2 MCHC-32.5 RDW-14.6 Plt Ct-148*
[**2122-2-20**] 11:15PM BLOOD Neuts-83.6* Lymphs-9.2* Monos-6.4 Eos-0.7
Baso-0.1
[**2122-2-20**] 11:15PM BLOOD PT-11.7 PTT-26.7 INR(PT)-1.0
[**2122-2-27**] 03:27AM BLOOD PT-11.8 PTT-27.0 INR(PT)-1.0
[**2122-2-20**] 11:15PM BLOOD Glucose-126* UreaN-16 Creat-0.9 Na-145
K-3.5 Cl-97 HCO3-45* AnGap-7*
[**2122-2-27**] 03:27AM BLOOD Glucose-78 UreaN-30* Creat-0.8 Na-139
K-4.5 Cl-91* HCO3-46* AnGap-7*
[**2122-2-20**] 11:15PM BLOOD CK-MB-7 cTropnT-0.03* proBNP-5511*
[**2122-2-22**] 04:00AM BLOOD CK-MB-4 cTropnT-<0.01
[**2122-2-20**] 11:15PM BLOOD Calcium-9.2 Phos-5.0* Mg-2.3
[**2122-2-21**] 12:13AM BLOOD Type-ART pO2-121* pCO2-93* pH-7.29*
calTCO2-47* Base XS-14 Intubat-NOT INTUBA
[**2122-2-26**] 11:35PM BLOOD Type-ART Temp-36.4 O2 Flow-3 pO2-51*
pCO2-91* pH-7.35 calTCO2-52* Base XS-19 Intubat-NOT INTUBA
[**2122-2-20**] 11:27PM BLOOD Lactate-1.6
[**2122-2-21**] 03:29AM BLOOD Lactate-1.0
[**2122-2-21**] 05:26AM BLOOD Lactate-0.7
FINDINGS: A single portable image of the chest was obtained and
compared to the prior examination dated [**2122-2-20**]. In the
interim, an endotracheal tube has been placed that terminates
approximately 9 cm above the carina. The image is slightly
underpenetrated. There is a new left pleural effusion. In
addition, suggestion of a new left retrocardiac opacity is
noted, likely secondary to the underlying effusion and
atelectasis, difficult to exclude pneumonia. The right
hemithorax is relatively clear.
IMPRESSION:
1. Endotracheal tube not in ideal position, consider right
repositioning.
2. New left retrocardiac opacity, likely secondary to a
small-to-moderate size effusion and atelectasis, difficult to
exclude pneumonia.
EKG:
The rhythm is probably sinus tachycardia. Right bundle-branch
block. Left
anterior fascicular block. Compared to the previous tracing of
[**2121-11-3**]
there has been a marked increase in rate. Otherwise, no
diagnostic interim
change.
Brief Hospital Course:
# hypoxia: Patient intially on 4L NC mainting oxygen
saturations of 90%. Over the course of the first few hours of
his admission, he showed worsening respiratory distress, with
increasing work of breathing. Patinet was intially started on
BIPAP for non-invasive ventillatory support. The etiology of
his hypoxia/dyspnea was believed to be most likely secondary to
a COPD flare. He demonstrated wheezes on chest exam with poor
pair movement consistent with an obstructive etiology. Patient
with negative LENIS, and given such a low suspicison of PE, CTA
was not pursued. He had negative cardiac enzymes x 3, and no
evidence of fluid overload on CXR. Patient was intubated on the
second day of admission due to increasing hypercapnea and
increased work of breathing that was not believed to be
sustainable. The patient showed improved ABG on ventilator,
with a blood gas that was believed to be consistent with his
baseline of CO2 retention. The patient remained intubated for 6
days. During the ce course, he was continued on steroids,
freqent nebulizer treatments, and started on levoquin for
empiric atypical coverage. Invectious etiology, and more
specifically viral cause, was believed to be the inciting factor
to his COPD exacerbation. CXR showed no frank infiltrates,
sputum Cx showed no growth, and the patient was DFA negative.
Patient began to show evidence of fluid overload on exam and
CXR, and was diuresed with resolution. The patient showed
improvement on physical exam and ease of oxygentation, and was
ultimatly extubated. Following extubation the patient showed
worsened wheezes and the need for continued BIPAP. When the
possibility of re-intubation was addressed, the patient refused.
Prednisone was continued with plans for a slow taper. He is
being discharged to hospice with BIPAP. on CPAP. Patient
hyperventilating w/ anxiety.
#Anxiety: Patient notably anxious following extubation, with
hypertension, tachycarida, and hyperventilation. These symptoms
were somewhat improved on anxietylitics and plan is to discharge
patient on morphine and ativan.
#cardiac: Again, given shortness of breath and LE edema, some
concern of MI at time of admission. The patient had cardiac
enzymes negative x three. He was intially started on ASA, which
was proptly discontinued.
#Diastolic HF: Patient has previously carried the diagnosis.
Had LE edema on admission, but not signs of fluid overload on
CXR. During the admission, patient showed worsened evidence of
fluid overlaod, and was successfully diruesed. The patient will
be discharged on a maintence dose of lasix that may require
further adjustment.
# HTN: The patient has a history of hypertension. He was
continued on his home lisinopril/HCTZ, and BP was well
controlled.
#LE edema/erythema: On admission, the patient was noted to have
left lower extremity erythema. Unclear if cellulites vs.
changes from venoustasis. The patient had no elevation of WBC
or LE edema. He was started on vanc because of concern of it
looking worsened in intesnity. With blood cultures negative and
low probablity concern of MRSA, the patient was continued on
levoquin feeling that it would offer adquate coverage. The
patient showed marked improvement with antibiotics and diuresis.
#Leg Mass: Patient with fungating black mass on right ankle.
Some concern of melanoma, and dermatology was consulted. The
differential diagnosis for these lesions includes
lymphangiectasia, angiokeratoma, pyogenic granuloma, venous [**Doctor Last Name **]
or an atypical kaposi's sarcoma. Bx is needed to rule out KS.
The
clinical presentation is not consistent with melanoma.
Recommened shave biopsy as an outpatient.
#Disposition: The patient requested to not be intubated, and
given the progressed nature of his end stage COPD, the decision
was made with the patient and his family to be discharged to
hospice.
Medications on Admission:
-ipratropium Bromide 0.02 % IH Q6HR
-albuterol Sulfate 0.083 % IH Q6HR
-lisinopril 10 mg po qdaily
-hctz 12.5 mg po qdaily (zestoretic)
-prednisone 30mg po qdaily
-bactrim 400-80 mg po qdaily
-CALCIUM 500+D 500 po qdaily
-chantix
---
lasix (dose [**Last Name (un) 5487**] per wife, not recorded on pharmacy list)
coumadin (not taking)
Discharge Medications:
1. BIPAP [**Last Name (un) **]: 4 liters bleed in qHS and PRN comfort: 15 cm
H2O IPAP/5 cm H2O EPAP.
Disp:*1 BIPAP machine* Refills:*0*
2. Home oxygen [**Last Name (un) **]: Four (4) liters continuous.
Disp:*1 home oxygen delivery system* Refills:*0*
3. Albuterol 90 mcg/Actuation Aerosol [**Last Name (un) **]: One (1) nebulizer
Inhalation q2-4 hours as needed for shortness of breath or
wheezing.
Disp:*1 box* Refills:*2*
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (un) **]: One (1)
nebulizer Inhalation every six (6) hours.
Disp:*120 aerosol* Refills:*2*
5. Roxanol Concentrate 20 mg/mL Solution [**Last Name (un) **]: [**12-24**] mL PO q2 hour
as needed for shortness of breath or wheezing.
Disp:*30 mL* Refills:*0*
6. Lorazepam 2 mg/mL Concentrate [**Month/Day (2) **]: One (1) mL PO q 4-6 hours
as needed for anxiety or shortness of breath.
Disp:*30 mL* Refills:*0*
7. Prednisone 20 mg Tablet [**Month/Day (2) **]: 3 tabs daily x 5 days; 2 tabs
daily x 5 days Tablets PO once a day for 10 days: Then resume
home dose of 30 mg daily.
Disp:*25 Tablet(s)* Refills:*0*
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: [**12-24**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
9. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*1*
13. Lisinopril 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Hospice Care
Discharge Diagnosis:
COPD exacerbation
Hypertension
AVNRT
Viral Pneumonia
Cellulitis
Acute on chronic diastolic heart failure
Discharge Condition:
Stable on 3L O2
Discharge Instructions:
You are being discharged from the hospital after admission for
respiratory distress. This was believed to be due to a flare of
you underlying, end-stage COPD. In order to help you breath,
you required intubation. You were successfully extubated, but
still had significant difficulty breathing. After length
discussion about goals of care, you decided to pursue comfort
measures only, and are now discharged how with hospice care.
Followup Instructions:
Additional Care provided through hospice services. Contact your
PCP to apprise him of your change in care goals.
|
[
"51881",
"4280",
"42789",
"V5861",
"42731",
"4019"
] |
Admission Date: Discharge Date: [**2184-5-28**]
Date of Birth: [**2135-3-30**] Sex: M
Service:
ADDENDUM:
HOSPITAL COURSE: The patient was taken to the cardiac
catheterization laboratory on [**2184-5-19**] which showed a normal
left ventricular ejection fraction with normal left
ventricular systolic function, 50% left main stenosis with
distal eccentric plaque, subtotal in-stent restenosis in an
ostial proximal portion of the left circumflex stent. In
addition, there was a jailed ramus, high marginal with
subtotal ostial proximal narrowing. The patient was referred
for evaluation by Cardiac Surgery.
The patient was taken to the Operating Room with Dr.
[**Last Name (STitle) 70**] on [**2184-5-20**] for a CABG times three, LIMA to LAD,
free RIMA to OM3, sequential graft to the ramus. Please see
the operative note for further details. The patient was
transferred to the Intensive Care Unit in stable condition.
The patient was weaned and extubated from mechanical
ventilation on the first postoperative night.
After the patient was extubated, the patient began
complaining of jaw pain which had previously been his anginal
equivalent. Multiple EKGs were performed, none of which
showed any ischemic changes. The patient was placed on a
nitroglycerin drip without any change in the jaw pain.
On the morning of postoperative day number one, it was
decided to have the patient return to the catheterization
laboratory to evaluate his graft in light of the continued
jaw pain. In the Cardiac Catheterization Lab, it was shown
that there was a lesion at the touchdown of the free RIMA
graft with the OM1 with a 99% occlusion. It was decided by
Dr. [**Last Name (STitle) 70**] to have the patient return to the Operating
Room for revision of this graft.
On postoperative day number one, the patient was taken back
to the Operating Room for a reduced CABG times one, at which
point a saphenous vein graft was placed as a Y graft from the
ramus to the free RIMA. The patient also tolerated the
procedure well, required dobutamine immediately
postoperatively for maintenance of cardiac output and was
transferred to the Intensive Care Unit in stable condition.
Please see the second operative note for further details.
The patient had elevated chest tube output on postoperative
day number one after his reoperation and required several
transfusions of platelets and packed red blood cells. The
patient remained intubated on mechanical ventilation with
significant hypoxia and a chest x-ray that showed pulmonary
edema. The patient began aggressive diuresis in attempts to
wean him from mechanical ventilation. The patient was able
to wean off the dobutamine on [**2184-5-22**] with adequate cardiac
output.
On postoperative day number two, the patient continued to be
intubated on mechanical ventilation with hypoxia. The
patient remained sedated on propofol for his comfort and
aggressive diuresis continued. By postoperative day number
three, the patient's hypoxia was improving and the amount of
support that the patient was receiving from mechanical
ventilation was weaned down. The patient was extubated from
mechanical ventilation on postoperative day number three
which he tolerated well. The patient continued to have
aggressive diuresis.
He began ambulating with Physical Therapy on postoperative
day number four. On postoperative day number five, the
patient was transferred from the Intensive Care Unit to the
regular floor. The patient continued to ambulate with
Physical Therapy. The patient's oxygen requirement decreased
dramatically as the patient was able to tolerate diuresis.
By postoperative day number six, the patient had completed a
level V with physical therapy, was able to walk 500 feet and
climb one flight of stairs without difficulty. The patient
had remained hemodynamically stable without any further
complaints of chest or jaw pain. The patient had been in
stable rhythm with adequate blood pressure. The patient's
epicardial pacing wires had been discontinued without
difficulty and by postoperative day number seven, the patient
was cleared for discharge to home.
PHYSICAL EXAMINATION ON DISCHARGE: T maximum 98, pulse 74,
sinus rhythm, blood pressure 108/60, respiratory rate 14,
room air oxygen saturation 94%. Neurologically, the patient
was awake, alert, and oriented times three, anxious to leave
the hospital. Cardiovascular: Regular rate and rhythm, no
rub, no murmur. Respiratory: Breath sounds were clear
bilaterally. GI: Positive bowel sounds, soft, nontender,
nondistended, tolerating a regular diet. The sternal
incision was clean and dry without erythema. The vein
harvest site was clean and dry without erythema.
LABORATORY/RADIOLOGIC DATA: White blood cell count 9.6,
hematocrit 30.2, platelet count 486,000. Sodium 138,
potassium 4.9, chloride 104, bicarbonate 24, BUN 13,
creatinine 0.7, glucose 98.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Zantac 150 mg p.o. b.i.d.
3. Percocet 5/325 mg one to two tablets p.o. q. six hours
p.r.n.
4. Aspirin 81 mg p.o. q.d.
5. Imdur 30 mg p.o. q.d.
6. Verapamil 20 mg p.o. q. eight hours.
7. Lopid 600 mg p.o. b.i.d.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post CABG with reoperation for postoperative
anastomotic lesion.
3. Hypercholesterolemia.
4. Remote 45 pack year smoker.
5. History of nephrolithiasis.
FOLLOW-UP: The patient is to follow-up with Dr.
.................... for Cardiology in two weeks. The
patient is to follow-up with his primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 17029**], in two weeks. The patient is to follow-up with
Dr. [**Last Name (STitle) 70**] in five to six weeks. The patient is to return
to [**Hospital Ward Name 121**] II in two weeks for a wound check.
DISPOSITION: The patient is to be discharged to home in
stable condition.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 43187**]
MEDQUIST36
D: [**2184-5-28**] 05:05
T: [**2184-5-28**] 18:57
JOB#: [**Job Number 43188**]
|
[
"41401",
"V4582",
"2720",
"412"
] |
Admission Date: [**2182-5-20**] Discharge Date: [**2182-5-31**]
Date of Birth: [**2115-6-19**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Amiodarone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
dyspnea, hypoxia
Major Surgical or Invasive Procedure:
arterial line placement
PICC line placement
History of Present Illness:
Ms. [**Known lastname 11372**] is a 66 yo female with PMH of CAD, dCHF and chronic
dyspnea with minimal exertion, afib s/p AVJ ablation and pacer,
COPD, moderate to severe pulm HTN thought secondary to elevated
left atrial pressures and not intrinsic lung disease, possible
lupus pneumonitis vs cryptogenic organizing pneumonia (based on
pulmonologist note), and DM who is transferred from [**Hospital 11373**] for management of respiratory distress and hypoxia.
.
She presented to [**Location (un) **] on [**5-15**] two days after sudden shortness
of breath and DOE which she experienced while folding clothes.
She normally uses prn home oxygen, but had used it at all times
in the 2 days prior to presentation. She also had a HA, dysuria,
right LE edema. She denied CP, palpitations, LH, wheezing, upper
respiratory symptoms, hemoptysis. She reportedly appeared volume
overloaded on CXR. She was given a diagnosis of bronchitis. An
LE ultrasound in their ED was negative for ED and she was sent
home on inhalers. She had a chinese food meal that night. She
represented to their ED the next day after she awoke and felt
worse. The CXR at that point was oncerning for pna. A BNP was
483, later up to 1050. She was given 40mg of IV lasix and
admitted. She developed worsening SOB during her stay. A CT scan
was read as consistent with pneumonitis and on [**5-16**], she was
started on IV solumedrol. On [**5-18**], she received another 60mg IV
lasix. Other complications during her stay included ARF with Cr
up to 1.9, felt likely prerenal, and hyponatremia to 124 thought
[**1-29**] hypovolemia.
.
On [**5-19**], she had an episode of respiratory distress requiring
transfer to the ICU. At that time, notes report that she was
still felt to be fluid overloaded. She was on 2L of O2 upon
admission with sats in the low 90s. Starting on [**5-18**], she
consitently required 5-7L to sat around 90%.
.
Her pulmonologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], saw her at [**Location (un) **], was
concerned about inflammatory pneumonitis and initiated the
steroids. He feels that this is probably vascular pneumonitis
and less likely hypersensitivity pneumonitis. He reports that
she has had a negative [**Doctor First Name **], normal ANCA, ACE level borderline at
73, and negative hypersensitivity pneumointis panel. Her ESR has
been persistantly elevated.
.
She was given 2g CTX and 750mg of levofloxacin prior to
transfer.
.
7.47/31/61 on 6L [**5-18**]
7.49/22/59 on 6L
.
CK 37, trop 0.04 on [**5-18**]
.
An ECHO during her stay showed distal septal and apical
hypokinesis with EF of 40-50% and [**12-29**]+ MR, moderate to sever TR,
pulm HTN with pulm systolic pressure estimated at 50-60, and
right-sided pressure and volume overload.
.
.
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] (cardiology) recently prescribed Revatio on
[**2182-4-22**] to trial for her dCHF. She started in on [**2182-4-26**].
.
On the floor, she is tachypneic and fatigued appearing.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: MIDCAB with a LIMA to LAD which failed on the first day
and she had a median sternotomy the next day with a redo LIMA to
LAD with vein patch arterioplasty according to notes. LIMA to
the LAD, SVG to DIAG and SVG to LCX in [**2167**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Diabetes
- Dyslipidemia
- Hypertension
- ? pneumonitis from vasculitis or hypersensitivity
- COPD
- moderate-to-severe pulmonary hypertension
- dCHF with a normal left ventricular ejection fraction of
approximately 60%, followed by Dr. [**First Name (STitle) 437**]
- paroxysmal Afib status post permanent pacemaker implantation
in [**2181-10-28**] and AVJ ablation in [**2181-11-27**].
- paroxysmal Afib with multiple cardioversions on amiodarone,
then subsequent lung toxicity to Amiodarone
- anxiety
- depression
- sleep apnea
- GERD
- Right groin infection s/p cath requiring surgical debridement
Social History:
Lives at home with her husband.
- Tobacco: 25 pack yrs, quit 25 years ago
- Alcohol: denies
- Illicits: denies
Family History:
Her daughter died from complications related to sarcoidosis
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
Vitals: 95.9 104/73 70 29 95%on 6L NC
General: Alert, oriented, tachypneic though no use of accessory
muscles
HEENT: Sclera anicteric, MMD, oropharynx clear
Neck: supple, triphasic JVP 12cm, no LAD
Lungs: bilateral basilar rales, bronchial breath sounds in left
base.
CV: Regular rate and rhythm, normal S1 + S2, SEM, rubs, gallops.
+ RV heave.
Abdomen: soft, non-tender, non-distended, bowel sounds
hypoactive, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2182-5-20**] 12:52PM BLOOD WBC-12.7* RBC-4.33 Hgb-10.6* Hct-33.1*
MCV-77* MCH-24.4* MCHC-31.9 RDW-18.6* Plt Ct-301
[**2182-5-21**] 05:49AM BLOOD WBC-12.3* RBC-4.43 Hgb-10.8* Hct-33.7*
MCV-76* MCH-24.4* MCHC-32.1 RDW-18.6* Plt Ct-285
[**2182-5-21**] 03:40PM BLOOD WBC-10.7 RBC-4.13* Hgb-10.7* Hct-31.1*
MCV-75* MCH-25.9* MCHC-34.3 RDW-18.7* Plt Ct-220
[**2182-5-20**] 12:52PM BLOOD PT-37.4* PTT-34.0 INR(PT)-3.9*
[**2182-5-21**] 05:49AM BLOOD PT-59.1* PTT-35.1* INR(PT)-6.7*
[**2182-5-21**] 03:40PM BLOOD PT-31.1* PTT-33.8 INR(PT)-3.1*
[**2182-5-20**] 12:52PM BLOOD Glucose-275* UreaN-70* Creat-2.0* Na-120*
K-5.1 Cl-83* HCO3-22 AnGap-20
[**2182-5-21**] 03:40PM BLOOD Glucose-223* UreaN-82* Creat-2.1* Na-126*
K-4.8 Cl-87* HCO3-24 AnGap-20
[**2182-5-20**] 12:52PM BLOOD Albumin-3.5 Calcium-9.7 Phos-4.4 Mg-2.7*
[**2182-5-21**] 05:49AM BLOOD Calcium-9.7 Phos-5.2* Mg-3.0*
[**2182-5-21**] 03:40PM BLOOD Calcium-9.6 Phos-4.4 Mg-2.9*
[**2182-5-20**] 12:52PM BLOOD ALT-107* AST-96* LD(LDH)-507* AlkPhos-93
TotBili-1.5
[**2182-5-20**] 12:52PM BLOOD proBNP-[**Numeric Identifier 11374**]*
[**2182-5-20**] 12:52PM BLOOD CRP-178.0*
[**2182-5-20**] 12:52PM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2182-5-20**] 12:52PM BLOOD C3-129 C4-35
.
[**5-21**] ECHO
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is mild global left ventricular
hypokinesis (LVEF = XX %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. [In the
setting of at least moderate to severe tricuspid regurgitation,
the estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2181-5-3**], the
right ventricle is probably more dilated and hypokinetic than on
prior. As a result, the left ventricle is now more compressed in
the pericardial sac. LV systolic function is not as vigorous -
particularly in the septum (the septal hypokinesis is also
partly due to RV pressure/volume overload. The degree of mitral
regurgitaiton has increased (may have been UNDERestimated on
prior). Degree of tricuspid regurgitation has also increased
slightly.
.
[**5-21**] CXR
IMPRESSION: Worsening bilateral airspace opacities consistent
with worsening alveolar pulmonary edema.
.
[**5-20**] CXR
IMPRESSION: The differential diagnosis is broad and includes an
infectious
process, likely viral or atypical pneumonia
Brief Hospital Course:
Ms [**Known lastname 11372**] was initially admitted to the MICU for shortness of
breath likely due to diastolic heart failure exacerbation.
Associated with her diastolic failure, she had acute renal
failure, and congestive hepatopathy along with hyponatremia. An
echo on [**2182-5-21**] revealed a large and dilated RV compressing the
LV in the pericardial sac. For diuresis, a lasix drip was
started to goal negative of 2 L daily; she was continued on [**First Name8 (NamePattern2) **]
[**Last Name (un) **] and beta-blockade. Repeat echo following diuresis showed
marked reduction of mitral regurgitation however had continued
intra and interventricular dysynchrony. We attempted to upgrade
to a [**Hospital1 **]-ventricular pacer but the LV lead slipped out of
position overnight. She will return on Monday [**6-3**] for
reposition of the lead.
.
Her acute renal failure improved with diuresis. Her
hyponatremia also improved, which was thought to be secondary to
hypervolemic hyponatremia. Transaminitis improved. She was
maintained on coumadin for paroxysmal atrial fibrillation
although her INR was supratherapeutic on admission. She was
initially reversed with Vitamin K and FFP and her coumadin was
restarted with goal of [**1-30**] INR. She was rate-controlled on
metoprolol. In addition to her shortness of breath secondary to
congestion, we felt she could have an element of pneumonitis:
inflammatory markers were elevated, however [**Doctor First Name **], ANCA,
complements were negative. Anti-GBM were pending at time of
discharge. Following diuresis with IV lasix, she was switched
to PO torsemide. Her coumadin was held around time of pacer
revision and she was put on full dose aspirin for clot
prevention.
Medications on Admission:
Home Meds:
calcium carbonate 1 tab daily
colchicine 0.6 mg qday
nexium 40
lasix 40 [**Hospital1 **]
amaryl 4mg qday
synthroid 37.5mcg qday
lopressor 75mg [**Hospital1 **]
pravachol 80mg qday
zoloft 25mg qday
sildenafil 20mg tid
spironolactone 25mg qday
calan SR 120mg qday
coumadin 5mg alt with 7mg
ambien 10mg qhs
Discharge Medications:
1. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Amaryl 4 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lantus 100 unit/mL Solution Sig: Thirty Six (36) units
Subcutaneous at bedtime.
8. Levothyroxine 25 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
10. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
12. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Acute on Chronic Diastolic congestive Heart Failure
Atrial Fibrillation on Coumadin
Pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for fluid overload and we gave you extra
medicine to get rid of the fluid. WE tried to revise your
pacemaker so that there is a lead in the left side. When we
checked the x-ray this morning, we found the lead was not in the
right place and we want you to come in on Monday to try it
again. We made the following changes to your medicines:
1. discontinue lasix (furosemide), Calen SR, coumadin and
spironolactone. You will resume the coumadin after the pacer
revision on Monday.
2. Start Torsemide instead of the Lasix. Take once daily
3. Start Cephlexin four times a day for one week. This is to
prevent an infection at the pacer site.
4. Start Losartan to help your heart work better and control
your blood pressure
5. Start aspirin while you are off the coumadin. This will
prevent blood clots.
.
Your white blood cell count is high and we sent a urine culture
today to make sure you don't have an infection. We will call you
at home if the culture is positive.
.
Weigh yourself daily and report any weight gain of more than 3
pounds in 1 day or 6 pounds in 3 days to Dr. [**First Name (STitle) 437**].
.
Pacemaker revision on Monday [**6-3**]:
Please come to the holding area at 9am on [**Hospital Ward Name **] [**Location (un) **]. Hold
your amaryl on Sunday night and in the morning on Monday. You
can take your regular dose of Lantus (Glargine) the night
before. Nothing to eat or drink after midnight on Monday
morning. You can take the Lantus as usual. You will be staying
overnight after the revision is done.
Followup Instructions:
Cardiology:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2182-6-10**] 3:30
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2182-7-31**] 11:00
.
Dr [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] Phone: [**Telephone/Fax (1) 250**] Date/time: Monday [**6-10**] at
1:30pm.
.
Primary Care:
[**Last Name (LF) 11375**],[**First Name3 (LF) **] R. Phone: [**Telephone/Fax (1) 11376**]
Date/time: Please keep any previously scheduled appts.
Completed by:[**2182-5-31**]
|
[
"51881",
"486",
"5849",
"5990",
"2761",
"4280",
"V4581",
"496",
"5859",
"V5861",
"25000",
"2724",
"4240"
] |
Admission Date: [**2113-9-30**] Discharge Date: [**2113-10-3**]
Date of Birth: [**2034-11-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
78 yo M with h/o CIDP, HTN, depression p/w one day of altered
mental status. Per the pt's daughters he was in his usual state
of health last night. He was interactive, conversing with them,
functioning at his baseline. However, this morning the pt was
found to be behaving oddly. He was found to be sitting on his
bed. His speech was garbled and nonsensical. He collapsed, but
his daughter slid him down to the floor without him hitting his
head. He was incontinent of urine and was moving his hands as if
trying to perform some function but no overt T-C movements were
noted. EMS was called.
.
The pt was transferred to [**Hospital1 **] [**Location (un) 620**]. There he was found to be
afebrile, have SBPs in the 140s-150s, and an irregular HR in the
110s-120s. He was given lopressor 5 mg X2 with control of his
HR. Because of increasing agitation he was given ativan 1mg x 3
and 2mg x 1 and haldol 5mg x 2. CT head there was negative. LP
demonstrated with WBC 0 and RBC 5, protein 61 and glucose 55. Pt
was given acyclovir 800 mg IV X1 and then transferred to [**Hospital1 18**].
.
In the ED here pt was found to have temp to 101, 215/108, HR
149, rr 18, sat 98%. Pt given lopressor 5mg IV X2 with better
rate control. Given ativan 2 mg IV X1 for agitation. CTX 2 gm IV
X1. ASA 325 mg.
Neuro evaluated pt and were concerned about sz vs.
stroke--recommended MRI/A head/neck for further eval as well as
EEG.
.
Pt transferred to MICU for further management and observation.
Past Medical History:
CIDP, diagnosed 9 years ago. At baseline, he has mostly sensory
loss with imbalance. He has been using a wheelchair but is able
to walk on occasion. He is treated with IVIG weekly, the last
treatment on Thurs.
h/o stroke, no more known
HTN
s/p cholecystectomy, appendectomy
diverticulitis
depression
pancreatitis
irritable bowel syndrome
Social History:
wife died 3 weeks ago. Has six children (five duaghters, one
son) all very involved in care. No h/o TOB or illicits, social
ETOH in past. Lives alone.
Family History:
no known h/o neurologic d/o's
Physical Exam:
Temp 98.2
BP 180/90
Pulse 123
Resp 17
O2 sat 97% 2L
Gen - lying in bed, non-responsive to questions
HEENT - PER sluggishly RL, fundi normal, anicteric, mucous
membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - rhonchorous @ R base
CV - irreg irreg, no murmurs appreciated
Abd - Soft, nontender to deep palp, nondistended, with
normoactive bowel sounds
Extr - No edema. 2+ DP pulses bilaterally
Neuro - non-responsive, moving all four ext, withdraws to
painful stimulit, unable to elicit DTRs, Babinskis [**Name2 (NI) 11849**] b/l
Pertinent Results:
Labwork on admission:
[**2113-9-30**] 06:11PM WBC-8.8 RBC-3.91*# HGB-12.9*# HCT-37.4*#
MCV-96 MCH-33.0* MCHC-34.4 RDW-14.3
[**2113-9-30**] 06:11PM PLT COUNT-218
[**2113-9-30**] 06:11PM NEUTS-80.5* LYMPHS-11.0* MONOS-7.6 EOS-0.2
BASOS-0.6
[**2113-9-30**] 06:11PM PT-12.8 PTT-22.6 INR(PT)-1.1
[**2113-9-30**] 06:11PM GLUCOSE-124* UREA N-17 CREAT-1.1 SODIUM-140
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-16
[**2113-9-30**] 06:11PM ALT(SGPT)-41* AST(SGOT)-61* LD(LDH)-303*
CK(CPK)-384* ALK PHOS-94 AMYLASE-83 TOT BILI-0.7
[**2113-9-30**] 06:11PM LIPASE-31
[**2113-9-30**] 06:11PM cTropnT-0.13*
[**2113-9-30**] 06:11PM CK-MB-4
[**2113-9-30**] 06:11PM TSH-1.6
[**2113-9-30**] 06:11PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2113-9-30**] 08:11PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-RARE
EPI-<1
[**2113-9-30**] 08:11PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2113-9-30**] 08:11PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2113-9-30**] 10:36PM LACTATE-3.3*
[**2113-9-30**] 11:35PM TYPE-ART PO2-80* PCO2-34* PH-7.43 TOTAL
CO2-23 BASE XS-0
.
CHEST (PORTABLE AP) [**2113-10-1**] 12:15 AM
IMPRESSION: Nodular opacities in both lungs and prominent right
hilar region. No old films available for comparison. It would be
helpful to have a CT scan to further evaluate these findings,
old films and more history cannot be obtained. These findings
were called to the house staff at the time of dictating this
report.
.
ECG Study Date of [**2113-9-30**] 5:57:34 PM
Atrial fibrillation with rapid ventricular response
Inferior/lateral ST-T changes are nonspecific
.
MR HEAD W/O CONTRAST [**2113-10-1**] 5:53 PM
Preliminary Report
Acute large posterior left MCA distribution infarct. Limited
study.
Brief Hospital Course:
Impression: Mr. [**Known lastname 11850**] is a 78 yo M with a history of CIDP, HTN,
depression presenting with one day of altered mental status
found to have a large stroke seen on MRI.
.
Hospital Course:
.
Mental status changes: On admission the acuity of the onset of
symptoms was concerning for CVA vs. seizure vs. toxic-metabolic
insult. Neurology was consulted as above and recommended loading
the patient with dilantin with a subsequent standing dose. They
further recommended an EEG and MRI/A of the patient's head and
neck. An EEG and the MR imaging were performed. At present the
EEG [**Location (un) 1131**] is pending. However, the MRI demonstrated a large
left sided stroke in the region of the left PCA circulation Per
neurology the patient's prognosis is poor. A family meeting was
held with the patient's children and social work involved. The
decision was made to change the goals of care to comfort
measures only. The patient's children felt that this decision
would be in line with the patient's wishes if he were able to
speak for himself. The patient is to be transferred to a skilled
nursing facility with hospice care. While he remained at [**Hospital1 18**]
he received continued care to control pain, agitation and
respiratory discomfort.
.
Episodes of apnea: On admission the patient had multiple
episodes of apnea in ICU, though was able to maintain his oxygen
saturations. Serial ABGs demonstrated adequate
oxygenation/ventilation. Supplemental oxygen was removed once
the patient was made CMO.
.
atrial fibrillation: The pt has no known history of atrial
fibrillation. Initially the patient's heart rate was controlled
with lopressor IV as needed. He was also loaded with digoxin on
the night of admission and placed on a standing dose. This
medicaiton was withdrawn once goals of care were changed as
above.
.
Elevated troponin: On admission this was felt to likely be
demand ischemia in the setting of RVR. There was no evidence of
ischemia on EKG. Cardiac enzymes were cycled and were trending
down.
.
HTN: On admission the pt's blood pressurew was permissively
allowed to be 160-180 given concern for CVA. His home toprol was
held on admission.
.
FEN: The patient was made NPO on admission.
.
ppx: The patient was placed on pneumoboots and a ppi on
admission.
.
Code status: The patient's code status was DNR/DNI as discussed
with his family on the night of admission. He was later made CMO
on hospital day number three as above.
Medications on Admission:
ativan
benadryl
ambien
promethazine
hyosciamine
ASA 81 mg
toprol 50 mg daily
colace
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed for fever or pain.
2. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal ONCE (Once) for 1 doses.
4. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO q1-2
hours prn as needed for pain: sublingual.
5. Lorazepam 2 mg/mL Concentrate Sig: 0.5-2 mg PO every four (4)
hours as needed for anxiety/agitation: sublingual.
6. Levsin 0.125 mg/5 mL Elixir Sig: 0.125-0.25 PO every four
(4) hours as needed for secretions: sublingual.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Primary: intracerebral stroke
Seconday:
chronic inflammatory demyelinating polyneuropathy
hypertension
depression
Discharge Condition:
Mr. [**Known lastname 11850**] has been made comfort measures only.
Discharge Instructions:
Mr. [**Known lastname 11850**] is being transferred to a skilled nursing facility to
attend to his needs and his comfort.
Followup Instructions:
Mr. [**Known lastname 11850**] will be followed by the healthcare providers at his
skilled nursing facility.
Completed by:[**2113-10-3**]
|
[
"42731",
"5070",
"4019",
"311",
"2859"
] |
Admission Date: [**2194-3-24**] Discharge Date: [**2194-4-5**]
Date of Birth: [**2121-9-24**] Sex: F
Service: CARDIAC SURGERY
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 72 year old female who
is status post mitral valve replacement in [**2190-10-8**],
with a #31 millimeter Carbomedics mechanical valve with a
complaint of one month history of shortness of breath with
exertion. The patient also is status post several severe
bouts of pneumonia, after which the patient was found to have
lymphoma, for which she underwent right lung resection in
[**2193-1-6**]. The patient reports being in her usual state
of health from a cardiac standpoint since her heart surgery
in the [**2190**], until one month ago when she began experiencing
shortness of breath on exertion and a feeling of chest pain
only when she was under stressful situation. The patient saw
her cardiologist who sent her for a transesophageal
echocardiogram which revealed a perivalvular leak. The
patient now presents for cardiac catheterization, which
showed normal coronaries and moderate mitral regurgitation,
ejection fraction of 55%. The patient is to be evaluated for
redo mitral valve repair by Dr. [**Last Name (Prefixes) **].
PAST MEDICAL HISTORY:
1. Mitral regurgitation, status post mitral valve
replacement in [**2190-10-8**].
2. Atrial fibrillation.
3. Congestive heart failure.
4. Hepatitis, question possibly due to transfusion during
hysterectomy.
5. Hypertension.
6. Status post hysterectomy.
7. Status post cholecystectomy.
8. Status post right lung resection for lymphoma in [**2193-1-6**].
9. Irritable bowel syndrome.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.125 mg p.o. once daily.
2. Toprol XL 25 mg p.o. once daily.
3. [**Doctor First Name **] 60 mg p.o. twice a day.
4. Coumadin 2.5 mg p.o. once daily.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with husband in [**Name (NI) 5110**],
[**State 350**]. The patient is not employed, housewife, and
grandmother. The patient stopped smoking approximately
twenty-six years ago and smoked one pack per week for
twenty-six years. She drinks approximately three to four
glasses per week.
PHYSICAL EXAMINATION: Blood pressure was 120/50, heart rate
67, and in atrial fibrillation. Generally, the patient is in
no acute distress. The pupils are equal, round, and reactive
to light and accommodation. Extraocular movements are
intact. Normal buccal mucosa. No dentures. Normal
dentition. Neck is supple with no jugular venous distention,
no thyromegaly. No carotid bruits. Lungs are clear to
auscultation bilaterally. No wheezing or rhonchi. Sternum
is stable. Cardiovascular - irregularly irregular rate with
S1 and S2 and II to III/VI murmur left sternal border fourth
intercostal space. Positive mechanical valve click. The
abdomen is soft, nontender, nondistended, no guarding, no
rebound, no rigidity. Extremities are warm with no edema, no
cyanosis or clubbing, positive varicosities. Pulse are 2+
posterior tibial and dorsalis pedis bilaterally. Neurologic
examination is grossly intact. No motor or sensory defects.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Surgery service. The patient was put on Heparin and stopped
her Coumadin. The patient's INR was 1.0. Partial
thromboplastin time was 30.0 on hospital day number two and
was increased to be therapeutic partial thromboplastin time
on hospital day number three. The patient was on Heparin
drip at 700, remained afebrile and still in atrial
fibrillation. Normal white blood cell count of 5.9,
hematocrit 35.7, creatinine 0.5. The patient was preopped
for the surgery.
On hospital day number three, the patient underwent mitral
redo sternotomy perivalvular leak repair for mitral
perivalvular leak, status post mitral valve replacement. The
patient had a mean arterial pressure of 88, central venous
pressure was 7, PAD was 11, [**Doctor First Name 1052**] was 16, and atrial
fibrillation rate of 98 and was on Epinephrine 0.03
mcg/kg/minute and Nitroglycerin 1.4 mg/kg/minute and Propofol
titrated when she was transferred to the CSRU.
On postoperative day number one, the patient was extubated.
The patient received a bolus of lactated ringer's for low
urine output. The patient had Nitroglycerin drip of 0.6,
remained afebrile and continued to be in atrial fibrillation.
The patient was net positive five liters, white blood cell
count 12.9, hematocrit 27.3, creatinine 0.5. The patient was
started on Lopressor 25 mg twice a day and Lasix 20 mg twice
a day and chest tubes were removed and the patient was
transferred to the floor.
On postoperative day number two, the patient remained
afebrile, pulse 105, atrial fibrillation, and blood pressure
150s over 60s. She was taking good p.o. and making good
urine. White blood cell count was 12.9. The patient was
started on Heparin and started on Coumadin at 2 mg and
Lopressor was increased to 50 mg twice a day.
On postoperative day number three, the patient continued on
the Heparin drip and was afebrile, continued to be in atrial
fibrillation, was taking good p.o. and making good urine.
White blood cell count was 13.8, creatinine 0.6.
On postoperative day number four, the patient continued to be
on Heparin drip, had low grade temperature of 100.4, still in
atrial fibrillation, making good urine. The patient's INR
was 1.2.
On postoperative day number five, the patient continued on
Heparin drip, was in atrial fibrillation, up to 120s to 140s,
however, blood pressure was 122/80, making good urine, taking
good p.o., and INR was 1.2. The patient was on 3 mg of
Coumadin.
On postoperative day number six, the patient was continued on
Heparin drip, remained afebrile, atrial fibrillation, taking
good p.o. and making good urine. The patient's INR was
continued to be 1.2 and Heparin was titrated to partial
thromboplastin time between 62 and 80. The patient remained
afebrile with stable vital signs. The patient was making
good urine and taking good p.o. INR was 1.7.
On postoperative day number eight, the patient remained
afebrile, in atrial fibrillation, taking good p.o. and making
good urine and INR was 2.4.
On postoperative day number nine, the patient's INR was 2.5
and the patient was discharged home to be followed being in
therapeutic range.
FINAL DIAGNOSES:
1. History of mitral regurgitation, status post mitral valve
replacement in [**2190-10-8**].
2. Atrial fibrillation.
3. Congestive heart failure.
4. Hepatitis.
5. Hypertension.
6. Status post hysterectomy.
7. Status post cholecystectomy.
8. Status post right lung resection for lymphoma.
9. Irritable bowel syndrome.
10. Perivalvular leak, status post mitral valve repair.
MEDICATIONS ON DISCHARGE:
1. Percocet 5 one to two tablets q4hours p.r.n. pain.
2. Aspirin 325 mg p.o. once daily.
3. Colace 100 mg p.o. twice a day.
4. Metoprolol 50 mg p.o. twice a day.
5. Coumadin 2.5 mg p.o. q.h.s. for tonight and tomorrow.
Please have INR checked on Monday morning and adjust the
Coumadin dose based on the result.
6. Fexofenadine 60 mg p.o. twice a day.
7. Digoxin 0.125 mg p.o. once daily.
8. Lasix 20 mg p.o. twice a day for seven days.
9. Potassium Chloride 20 mEq p.o. twice a day for seven
days.
FO[**Last Name (STitle) **]P: Please follow-up with Dr. [**Last Name (Prefixes) **] in four
weeks. Please call for follow-up appointment. Please
follow-up with Dr. [**Last Name (STitle) **] in one to two weeks and please
have INR checked on Monday, to have Coumadin dose adjusted by
Dr. [**Last Name (STitle) **] on Monday.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Home with VNA services.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3118**]
MEDQUIST36
D: [**2194-4-5**] 13:25
T: [**2194-4-5**] 13:46
JOB#: [**Job Number 32706**]
|
[
"42731",
"4280",
"4019",
"V5861"
] |
Admission Date: [**2173-8-30**] Discharge Date: [**2173-9-2**]
Date of Birth: [**2094-4-11**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Falls, Hypoxia in ER
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
This is a 79 y.o. male with history of smoking, CAD, HTN, DM2,
obesity, who was initially sent from home by VNA due to multiple
falls (s/p rib fxs/humeral fx) and lethargy. He was recently
discharged from the emergency department after a right humeral
fracture (an oblique fracture through the proximal/mid shaft of
the humerus, + lateral displacement of the distal bony
fragment). In the emergency department, patient was noted to
have decreased oxygen saturations to low 80s, although he denied
any symptoms with this. The hypoxia would intermittently
correct with supplemental O2 up to 6 liters, but then
subsequently recur. Patient denies any symptoms such as
exertional dyspnea (walks with walker), orthopnea, PND, or
worsening of lower extremity edema. He does endorse decreased
sleep latency, falling asleep in less than 5 minutes, and also
questionable daytime hypersomnolence, but denies morning
headaches. Of note, patient received prescription for Vicodin
upon discharge from ED on [**2173-8-28**].
.
In the ED on this vist, patient received 80mg furosemide, 2
tablets percocet, nebulizers and 60mg prednisone in addition to
supplemental O2. His O2 Saturation was 92% after this. ABG
showed compensated hypercarbia, 7.39/57/87.
.
Review of Systems:
.
POS: low grade T 100, [**Name6 (MD) 96748**] to md 80's when talking,
increased lasix requirement over past week w/ increase in periph
edema
NEG: CP/SOB/other pain
Past Medical History:
1. CAD w/ h/o STEMI [**2171-11-16**] s/p RCA stent (cypher stent x 2 to
RCA w/ TIMI III flow)
2. CHF (diastolic dysfunction) - ECHO '[**69**]: EF > 60%, LA mod
dilated, mild symm LVH w/ normal cavity size, 1+ MR, aortic
valve leaflets mildly thickened
3. NIDDM (>15 years)
4. HTN
5. Osteopenia
6. Hyperlipidemia
7. ? TIA like sx [**2168**] (numb around the mouth, relieved w/ [**Year (4 digits) **])
8. h/o pyonidal cyst
9. gout (last flare 1 1/2 years ago)
10. carpal tunnel syndrome
11. CRI (Cr 1.3 since STEMI [**2171-11-16**], previously 0.9)
12. s/p thyroidectomy
13. s/p appy
14. s/p TKR
15. Anemia
16. L-sided stroke several years ago
17. BPH
18. Erectile dysfunction
19. Right humeral fracture ([**2173-8-28**])
Social History:
He was most recently D/C'd to [**Hospital1 5595**] MACU on [**11-2**] for further
care. Prior to that, he was at home with his wife. Further
history limited. Quit smoking 39 years ago but 100 pack-year
history.
Family History:
Mother: heart problems; father: arthritis, brother died at 19 of
Hodgkins disease
Physical Exam:
PE: VS: T 99.3, HR: 109; BP 152/53; RR 20; O2 sat: 98% on 4L NC
[**Month/Year (2) 4459**]:NCAT; Neg lesions nares, oral pharnyx, auditory intackt,
Supple range of neck motion. Negative lymphadenopathy,
supraclavicular nodes
LUNGS: CTA bilaterally
CARDIAC: RRR witout murmurs, rubs, gallops
ABDOMEN: Soft, Non tender to palpation, non-distended, positive
Bowel Sounds
EXT: 2+ Lower extremity edema
NEURO: Alert and Oriented X 3, nonfocal, sleepy
SKIN: ecchymoses on Left shoulder
Pertinent Results:
[**2173-8-30**] 06:15PM PT-13.2* PTT-36.7* INR(PT)-1.1
[**2173-8-30**] 06:15PM PLT SMR-NORMAL PLT COUNT-170
[**2173-8-30**] 06:15PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-2+ POLYCHROM-1+ OVALOCYT-1+
STIPPLED-OCCASIONAL
[**2173-8-30**] 06:15PM NEUTS-65.7 BANDS-0 LYMPHS-20.9 MONOS-3.7
EOS-9.0* BASOS-0.7
[**2173-8-30**] 06:15PM WBC-9.3 RBC-2.91* HGB-7.8* HCT-23.9* MCV-82
MCH-26.9* MCHC-32.8 RDW-18.7*
[**2173-8-30**] 06:15PM CK-MB-NotDone cTropnT-0.04* proBNP-680
[**2173-8-30**] 06:15PM CK(CPK)-88
[**2173-8-30**] 06:15PM estGFR-Using this
[**2173-8-30**] 06:15PM GLUCOSE-195* UREA N-38* CREAT-1.7* SODIUM-133
POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-31 ANION GAP-15
[**2173-8-30**] 07:24PM TYPE-ART PO2-87 PCO2-57* PH-7.39 TOTAL
CO2-36* BASE XS-7
.
[**2173-8-30**]
CHEST, PA AND LATERAL: The cardiac and mediastinal contours are
stable. There is slight unfolding of the aorta. No focal
pulmonary opacities are identified to indicate pneumonia.
Flowing syndesmophytes are again seen involving the thoracic
spine. IMPRESSION: No acute cardiopulmonary disease.
.
.
[**2173-8-30**]
CT HEAD WITHOUT IV CONTRAST: Focal areas of hypoattenuation
involving the
left posterior temporal lobe and left central sulcus consistent
with
encephalomalacia from prior infarctions appears stable. No new
areas of
hypoattenuation are identified and the [**Doctor Last Name 352**]-white matter
differentiation
appears intact. There is no evidence of intracranial hemorrhage.
There is no evidence of hydrocephalus or shift of normally
midline structures. Partially aerosolized secretions within both
maxillary antra appear similar when compared to the previous
exam with mild mucosal thickening within the ethmoid air cells.
IMPRESSION: 1. Stable encephalomalacia of the left posterior
temporal lobe and left central sulcus, indicating areas of
previous infarction. No definite evidenceof new infarction
identified.
2. No intracranial hemorrhage or edema.
.
Brief Hospital Course:
.
79 yo man with history of coronary artery disease, hypertension,
diabetes mellitus, obesity, presumpted obstructive sleep apnea
and poor compliance with medical follow-up, with recent
mechanical falls here with dizziness, hypoxia, and lethargy.
.
1. Hypoxia: Though patient appears to have long standing
pulmonary disease, oxygen requirement on transfer appeared to be
new. Patient has improved significantly and appears to be at
baseline. Chest x-ray from [**8-30**] had increased diffuse opacities
along bases consistent with physical exam findings of crackles
upon arrival to floor. Would suspect patient had component of
atelectasis in addition to central hypoventilation. Would also
suspect patient has baseline hypercarbia and oxygen
supplementation with agressive goals resulted in further
decreased respiratory drive. We titrated oxygen supplementation
and started ipratropium inhaler. He was transfused 1 unit of
PRBC and improved very well, likely due to improved oxygen
delivery and improvement of pre-existing pulmonary
vasoconstriction. Patient has continued to refuse non-invasive
positive pressure devices and is aware of importance of being
evaluated for obstructive sleep apnea but declines any workup.
.
2. Multiple falls: Patient initially provided hisotry of
dizziness and weakness which were difficult to confirm during
admission. It appears he has been having disequilibrium and
would benefit from physical therapy. With recent falls and
prior stroke however, these were concerning for new
cerebrovascular events. Physical exam however remained non-focal
and patient was receiving [**Hospital **] medical therapy for
secondary prevention. Head CT was negative, and MRI head could
not be performed secondary to anxiety and positional arm pain.
We continued aspirin, statin and [**Hospital 4532**]. Patient will require
continuing physical therapy after discharge, will defer decision
to pursue MRI to primary care physician.
.
3. Coronary artery disease/Congestive Heart Failure: Stable
during admission, with low suspicition for pulmonary edema. We
continued home meds of lasix, [**Hospital **], [**Hospital 4532**], metop, lipitor. We
held imdur however due to concerns of orthostatic hypotension
and will defer decision to restart it to primary care physician.
.
4. Diabetes Mellitus type 2: Patient was kept on insulin sliding
scale and was discharged back on oupatient hypoglycemic regimen.
.
5. Chronic Renal Insufficiency: Patient presented with baseline
creatinine and continued to be at baseline during admission.
.
6. Anemia - {atient was found to be anemic at admission. Because
of hypoxia and concern for obstructive sleep apnea causing
pulmonary vasoconstriction, patient was trasfused 1 unit of PRBC
with good post trasfusion response. Workup revealed normal TSH,
folate and B12 with inappropriately normal reticulocyte count in
setting of normal colonoscopy and EGD last year. Will defer
further workup to primary care team.
.
7. Leukocytosis: Most likely secondary to prednisone, was
resolving and patient had no signs of infection.
.
8. Gout: We continued outpatient regimen of allopurinol,
colchicine.
.
9. BPH: We continued Terazosin per outpatient regimen
.
10. FEN: Patient tolerated a diabetic, low sodium diet without
difficulty.
.
11. Prophylaxis: heparin sq, PPI, bowel regimen.
.
12. Code status: Patient remained FULL CODE, confirmed directly
with patient.
.
Medications on Admission:
Lasix 60 daily
Metoprolol 12.5 mg [**Hospital1 **]
Clopidogrel 75mg daily
Isosorbide 60 mg daily
Terazosin 10mg daily
Lipitor 80mg daily
[**Hospital1 **] 325 mg daily
Prilosec 20mg daily
Potassium 20 mEq [**Hospital1 **]
Glipzide 5 mg [**Hospital1 **]
Metformin 500mg daily
Allopurinol 150mg daily
Colchicine 0.6mg daily
Vicodin 1 tab TID for pain PRN
Senakot 1 qd
Colace 100mg [**Hospital1 **].
Iron
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
18. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
19. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
PRIMARY:
1. HYPOXIA
2. ANEMIA
3. RIGHT HUMERAL FRACTURE
4. HYPERTENSION
5. DIABETES MELLITUS
SECONDARY
1. HISTORY OF STROKE
Discharge Condition:
Stable, saturating greater than 94% on room air.
Discharge Instructions:
You were admitted to the hospital because you began feeling
sleepy and tired, and were found to have low levels of oxygen in
your blood. You were taken to the intensive care unit where you
were closely monitored and multiple tests were performed. We
believe this was caused by your underlying lung disease and the
effects of the pain medicines you were given for the arm pain.
We have changed your medicine to another type, gave you blood to
correct your anemia and you recovered very well. You will still
need to work with the physical therapist for some time.
Please take all medications as directed and keep all doctors
[**Name5 (PTitle) 4314**]. If you develop severe pain, constant somnolence,
confusion, difficulty breathing, chest pain, shortness of breath
or feel ill, please call your primary care physician or come
into the emergency room for evaluation.
Followup Instructions:
Please schedule an appointment with your primary care physician,
[**Name10 (NameIs) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 8417**] within 2 weeks of returning
home.
Your doctor will also visit you at the rehab facility.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
|
[
"32723",
"496",
"4280",
"5859",
"25000",
"40390",
"41401",
"V4582",
"2724",
"412"
] |
Admission Date: [**2135-6-2**] Discharge Date: [**2135-6-6**]
Date of Birth: [**2093-10-29**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7733**]
Chief Complaint:
Right hand injury
Major Surgical or Invasive Procedure:
1. Revascularization, right ulnar artery (microvascular).
2. Primary group fascicular repair, right ulnar nerve
(microvascular).
3. Primary repair of flexor digitorum profundus tendons and
muscles, right index, long, ring and fifth fingers.
4. Primary repair of flexor digitorum profundus tendons,
right long, ring and fifth fingers.
5. Closure, complex, laceration right forearm, distal third.
History of Present Illness:
41 yo R hand dominant male who stumbled at work and fell onto
outstretched hand but fell onto steel pipe. It immediately
started bleeding and was taken to [**Hospital6 **]. Xray
taken/given tetnaus and ancef. Had artery ligated. No foreign
object seein in wound at OSH. Transfered here for further
evaluation and treatment.
Past Medical History:
Hypercholesterolemia
MVC [**2132**], compound fx with bilateral lower extremity , sacral
fx, fx of C1, C5, C7,
subdural hematoma
Deep venous thromboiss tx w/ coumadin x 6 months and IVC filter
now removed
Social History:
HVAC technician
Physical Exam:
MIld distress
Right arm splinted and wrapped in volar splint
able to flex/extend right hand
No obvious laceration to hadn but only partially exposed in cast
numbness in 4th and 5th digit further exam revealed
1. Deep laceration distal right forearm.
2. Lacerated right ulnar nerve.
3. Lacerated right ulnar artery.
4. Lacerated superficial flexor tendons to right index, long,
ring and fifth fingers.
5. Lacerated, incomplete, deep flexor tendons to right long,
ring and fifth fingers.
Full ROM and normal exam of Left hand
Brief Hospital Course:
The patient had an urgent operative repair on [**2135-6-2**]. he
tolerated the procedure well (see full op report for details).
He was given ancef, aspirin and had strict elevation. His hand
was in a splint, and had residual diminished sensation at the
fingertips post operatively. The patient remained stable and
was observed until POD 4, when he was ready for discharge to
home.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) for 2 months.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p ulnar [**Last Name (un) **] and nerve repair, FCU, FDP/FDP x 4 repair [**2135-6-2**]
ulnar artery injury
ulnar nerve injury
Flexor tendon injury
history of hypercholesterolemia
history of Deep venous thrombosis
Discharge Condition:
Good
Discharge Instructions:
Please call if you have redness or drainage from your wound.
Please call if you have numbness or loss of sensation in your
right hand.
take your medications as prescribed
elevate arm at all times
Do not get splint/dressing wet
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 5385**] in 1 week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]
|
[
"2720"
] |
Admission Date: [**2104-6-2**] Discharge Date: [**2104-6-7**]
Date of Birth: [**2048-5-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
pollen
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increasing exertional dyspnea and fatigue
Major Surgical or Invasive Procedure:
[**2104-6-2**] aortic valve replacement ([**First Name8 (NamePattern2) 11688**] [**Male First Name (un) 923**] regent
mechanical)
History of Present Illness:
This 55 year old gentleman with a history of a patent ductus
arteriosus repair as a child and a known bicuspid aortic valve
which has been followed by serial echocardiograms over the past
decade. Serial echocardiograms have shown a progressive decrease
in his aortic valve area and now a slightly depressed left
ventricular function. He is symptomatic with dyspnea and chest
heaviness with exertion as well as a generalized fatigue. Given
the progression of his disease and early decline in LV function,
he has been referred for surgical management.
Past Medical History:
aortic valve stensosis/insufficiency
Hypertension
Hyperlipidemia
Gout
Anemia
insulin dependent diabetes mellitus
Chronic kidney disease (Creat 1.4)
Diabetic neuropathy
gastroesophageal reflux
s/p Patent Ductus Arteriosus Repair as child 8 y/o([**2056**])
s/p Cataract surgery
s/p Tonsillectomy
Social History:
Lives with: Wife in [**Name2 (NI) 3494**]
Occupation: Cook at [**University/College **] Univ. dining services
Tobacco: 40 pack year history quit [**2088-2-1**]
ETOH: [**2-4**] drinks per day
Family History:
Mother died of MI at 84. Sister with MI at 58.
Physical Exam:
Pulse: 84 SR Resp: 18 O2 sat: 100%
B/P Right: 177/66 Left: 170/65
Height: 70" Weight:182lb BSA: 2.01m2
General: WDWN in NAD
Skin: Warm, Dry, intact. Well healed Left thoracotomy
HEENT: PERRLA, EOMI, sclera anicteric.
Teeth in poor repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]; well healed left thoracotomy
extending very close to the sternum.
Heart: RRR, III/VI systolic ejection murmur;
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: none.
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit Bilat: Transmitted soft sound likely from the
heart murmur vs bruit
Pertinent Results:
[**2104-6-2**] Intraop TEE:
PRE-CPB: The left atrium is moderately dilated. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is mildly
depressed (LVEF=40-45 %). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. No thoracic aortic dissection is seen. The aortic valve
is bicuspid with a horizontal commisure. The aortic valve
leaflets are moderately thickened. There is critical aortic
valve stenosis (valve area <0.8cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. Trivial mitral
regurgitation is seen.
POST-CPB:
There is a mechanical valve in the aortic position. The valve is
well-seated with normally mobile leaflets. There is no evidence
of paravalvular leaks. The peak gradient across the aortic valve
is 14mmHg, the mean gradient is 7mmHg with CO of 5L/min. The LV
systolic function remains mildly impaired, unchanged from
pre-op, estimated EF=40-45%. There is no evidence of aortic
dissection.
.
[**2104-6-7**] 11:00AM BLOOD Hct-25.4*
[**2104-6-7**] 05:45AM BLOOD WBC-5.9 RBC-2.66* Hgb-8.7* Hct-23.8*
MCV-90 MCH-32.9* MCHC-36.8* RDW-13.5 Plt Ct-262
[**2104-6-6**] 04:45AM BLOOD PT-29.1* PTT-34.1 INR(PT)-2.8*
[**2104-6-6**] 01:15PM BLOOD PT-34.5* INR(PT)-3.4*
[**2104-6-7**] 05:45AM BLOOD PT-32.2* INR(PT)-3.2*
[**2104-6-6**] 04:45AM BLOOD UreaN-34* Creat-1.6* Na-138 K-4.3 Cl-102
[**2104-6-6**] 04:45AM BLOOD Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 90057**] was admitted and underwent mechanical aortic valve
replacement by Dr. [**Last Name (STitle) **](see operative report for further
details). He received Cefazolin for perioperative antibiotics.
Following the operation, he was brought to the intensive care
unit for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without complication. On
post operative day one he was started on beta blockers, lasix
for gentle diuresis and transferred to the floor. Warfarin was
initiated and dosed for a goal INR between 2.5 - 3.0. He
remained in a normal sinus rhythm without atrial or ventricular
arrhythmias. Beta blockade was advanced as tolerated and his
preoperative Labetolol was resumed. Chest tubes and pacing wires
removed per protocol.Over several days, he continued to make
clinical improvements with diuresis and was cleared for
discharge to home on postoperative day # 5.
At discharge, his INR was 3.2. Prior to discharge, arrangements
were made with the [**First Name9 (NamePattern2) 2287**] [**Hospital 1468**] [**Hospital3 **] to
monitor Warfarin as an outpatient.First INR check tomorrow [**6-8**].
Medications on Admission:
ALLOPURINOL 100 mg daily
AMLODIPINE 5 mg daily
ATORVASTATIN 80 mg daily
COLCHICINE 0.6 mg daily
ENALAPRIL MALEATE 5 mg daily
FUROSEMIDE 40 mg daily
LABETALOL 300 mg qpm and 150 mg qam
LORAZEPAM 0.5 mg prn
OMEPRAZOLE 20 mg daily
ASPIRIN 81 mg daily
ERGOCALCIFEROL 1,000 unit Capsule daily
NPH INSULIN 100 unit/mL Suspension per sliding (3-7 units before
dinner)
OMEGA-3 FATTY ACIDS 1,000 mg daily
VITAMIN E 400 unit daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily)
for 1 days: 4 mg dose today [**6-7**] only; then all further daily
dosing per coumadin clinic provider at [**Name9 (PRE) 2274**]/[**Name9 (PRE) 2287**]; target INR
2.5-3.0 for mechanical aortic valve.
Disp:*100 Tablet(s)* Refills:*1*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. labetalol 100 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)): 150 mg every morning.
Disp:*100 Tablet(s)* Refills:*1*
12. labetalol 200 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)): 300 mg every evening.
Disp:*100 Tablet(s)* Refills:*1*
13. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 1 weeks.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
16. NPH insulin /humulin N Sig: 3-7 units sliding scale
Injection every evening before dinner.
Disp:*20 100u/ml solutions* Refills:*1*
17. Outpatient Lab Work
please draw BUN/creatinine in one week with results to PCP
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Living
Discharge Diagnosis:
aortic valve stenosis/insufficiency
s/p aortic valve replacement (MECHANICAL)
Hypertension
Hyperlipidemia
Gout
Anemia
Insulin dependent diabetes mellitus
Chronic kidney disease
Diabetic neuropathy
Gastroesophageal reflux disease
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**6-26**] at 1:15pm
Cardiologist: Dr [**Last Name (STitle) 25982**] on [**7-2**] at 2:20pm
Please call to schedule appointments with:
Primary Care Dr [**Last Name (STitle) 64786**] in [**5-6**] weeks ([**Telephone/Fax (1) 83559**])
**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 valve
Goal INR 2.5-3.0
First draw Sunday [**6-8**]
Results to [**First Name9 (NamePattern2) 2287**] [**Location (un) 1468**] coumadin clinic phone [**Telephone/Fax (1) 31020**]
Completed by:[**2104-6-7**]
|
[
"5859",
"40390",
"53081"
] |
Admission Date: [**2119-2-9**] Discharge Date: [**2119-2-11**]
Date of Birth: [**2056-4-29**] Sex: F
Service: MEDICINE
Allergies:
Oxaliplatin
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 year old female with chief complaint of SOB. She has
metastatic [**First Name3 (LF) 499**] cancer to the lungs, with near occlusion of
RUL, also with hx sarcoid. She has had progressive dyspnea since
[**Month (only) **]/[**Month (only) 1096**], attributed to worsening disease. She has been
off chemotherapy since [**Month (only) **], and is essentially receiving
symptom control at this point with no further plans for chemo.
She has been on multiple medications to control her worsening
SOB, including steroids, multiple inhalers, and opioids. On
Prednisone which she tapered from 15 to 10 mg daily on Monday.
She called her oncologist today with gradually worsening dyspnea
for the past two days. Notes significant breathlessness when
getting from bed to commode, as well as breathlessness with
speech. Baseline nonproductive cough; no recent change. No noted
wheezing. No chest pain. No fever though does note sweats. No GI
or urinary symptoms. No recent sinus symptoms. No sick contacts.
Using 5LPM O2 in daytime and 3.5L at night. Baseline sats in low
90s on 5L with drops to 70s-80s with minimal exertion. Also of
note, patient and husband discussing hospice care and has
appointment for official enrollment in hospice tomorrow.
.
In the ED, initial vs were: T99.3 105 141/87 20 100% on NRB.
Patient was given solumedrol 125 mg x1, ipratropium/albuterol
nebs, and levofloxacin 750 mg. ABG was drawn on ventimask with
7.46/48/68, so placed back onto NRB and plan for MICU admission.
Her oncologist also saw her in the ED where it was discussed
that she is full code and would be intubatable to allow time for
treatments to potentially work, but if not able to be
successfully liberated from ventilator would want tube removed
(no trach).
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, headache, sinus tenderness, rhinorrhea
or congestion. Denied chest pain or tightness, palpitations.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Past Medical History:
# colorectal cancer metastatic to lung
# Sarcoidosis: lungs, liver, skin
# HTN
# Hypercholesterolemia
.
Oncologic history:
Ms. [**Known lastname 4469**] is a 61-year-old woman with a history of stage II
[**Known lastname 499**] cancer S/P lower anterior resection of the sigmoid and
rectum with a primary anastomosis in [**10/2113**] who did not receive
any adjuvant chemotherapy and was diagnosed with metastatic
cancer to the lungs in [**4-20**]. She underwent resection of left
upper lobe lesion in [**5-21**] which showed adenocarcinoma extending
to the resection margin consistent with known colonic primary.
All lymph nodes tested from left and right were negative. A left
chest Port was placed at the time of the mediastinoscopy and
biopsy/resection. She was started on FOLFOX/Avastin/Erbitux
(protocol 05-449) on [**2115-7-16**] and did very well but came off
protocol on [**2116-3-9**] for stable disease and to get a break from
chemotherapy. In [**2116-4-14**], a follow-up CT torso revealed
progression of R cavitary lesion, new L pulmonary nodule and
increased in mediastinal LAD. CT torso [**11-21**] revealed
progressive lung nodules and increased LAD. FOLFOX/Avastin
chemotherapy was started on [**2117-1-26**]. She had 2 doses held for
neutropenia, and then had an allergic reaction to oxaliplatin on
[**2117-2-23**]. She started FOLFIRI/Avastin on [**2117-3-9**]. Regimen was
dose-reduced starting C2 for mucositis. Scans in [**5-23**] showed
progression of disease with CEA trending up. Erbitux was added
[**5-23**], and Avastin was stopped after C4. Due to mucositis,
5FU/leucovorin was stopped [**2117-7-6**] (last dose 7/8). Most
recently on Irinotecan with Cetuximab.
Social History:
She does not smoke or drink. She is happily married.
Family History:
Mother had sarcoidosis. However, she indicates that there had
been some murmurs in her family that her mother had actually
been adopted. She reports maternal grandfather with [**Name2 (NI) 499**] cancer
in his late 70s; however, again as mentioned above, it is not
clear to the patient that this was her biologic grandfather.
Physical Exam:
99.3 101 113/62 high 20s RR, 100% on NRB
General: Alert, oriented, tachypneic.
HEENT: Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear
without evidence of thrush or lesions.
Neck: supple, JVD not appreciated, no LAD.
Lungs: Marked inspiratory and expiratory crackles, occasional
rhonchi at bases, some decrease at apices, prolonged expiratory
phase.
CV: Regular rate and rhythm, normal S1 + S2, [**1-21**] SM at LUSB.
Abdomen: Audible bowel sounds, soft, non-tender, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: warm, well perfused, 2+ pulses, 1+ pitting edema,
significant venous stasis and sarcoid changes of anterior shins.
Neuro: CN II-XII intact, strength 5/5 in UEs and LEs.
Pertinent Results:
[**2119-2-9**] 10:44AM BLOOD WBC-12.4* RBC-3.38* Hgb-9.4* Hct-29.3*
MCV-87 MCH-27.7 MCHC-32.0 RDW-14.3 Plt Ct-314
[**2119-2-10**] 04:31AM BLOOD WBC-9.3 RBC-3.15* Hgb-8.9* Hct-27.2*
MCV-86 MCH-28.1 MCHC-32.6 RDW-13.7 Plt Ct-236
[**2119-2-11**] 05:08AM BLOOD WBC-12.6* RBC-3.16* Hgb-8.8* Hct-27.1*
MCV-86 MCH-27.8 MCHC-32.4 RDW-13.9 Plt Ct-300
[**2119-2-9**] 10:44AM BLOOD Neuts-88.4* Lymphs-6.4* Monos-3.5 Eos-1.5
Baso-0.2
[**2119-2-9**] 10:44AM BLOOD PT-12.0 PTT-24.2 INR(PT)-1.0
[**2119-2-9**] 10:44AM BLOOD Glucose-152* UreaN-14 Creat-0.7 Na-134
K-4.0 Cl-93* HCO3-29 AnGap-16
[**2119-2-10**] 04:31AM BLOOD Glucose-156* UreaN-18 Creat-0.6 Na-132*
K-5.1 Cl-92* HCO3-32 AnGap-13
[**2119-2-10**] 01:47PM BLOOD Glucose-158* UreaN-25* Creat-0.7 Na-130*
K-4.5 Cl-89* HCO3-31 AnGap-15
[**2119-2-11**] 05:08AM BLOOD Glucose-115* UreaN-27* Creat-0.9 Na-134
K-4.3 Cl-94* HCO3-35* AnGap-9
[**2119-2-9**] 10:44AM BLOOD ALT-9 AST-12 LD(LDH)-301* AlkPhos-166*
TotBili-0.4
[**2119-2-9**] 10:44AM BLOOD proBNP-371*
[**2119-2-9**] 10:44AM BLOOD Albumin-3.3* Calcium-9.1 Phos-3.1 Mg-1.5*
[**2119-2-11**] 05:08AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1
[**2119-2-9**] 01:21PM BLOOD Type-ART pO2-68* pCO2-48* pH-7.46*
calTCO2-35* Base XS-8
[**2119-2-9**] 10:45AM BLOOD Lactate-1.5
Urine culture negative. Blood cultures NGTD. Urine legionella
antigen negative.
CXR
IMPRESSION: Overall mild increase in opactiy with more confluent
opacity seen in bilateral lower lobes, may represent progression
of diffuse pulmonary metastases, although infectious process can
not be excluded. Complete right upper lobe opacification and
left lower lobe confluent opacities. Given this background,
acute infection cannot be excluded
Brief Hospital Course:
62F with metastatic [**Month/Day/Year 499**] cancer and sarcoidosis with very
extensive pulmonary mets, initiating hospice care, now admitted
to MICU with respiratory distress and hypoxemia requiring NRB.
While she understands the terminal nature of her disease, she
expressed desire to evaluate this acute decompensation for any
possible reversible causes and treat if possible. The
decompensation occured in the setting of tapering steroids. Her
steroids were increased, she was treated for CAP with
levofloxacin and will complete a 5 day course and her nebulized
medication regimen was optimized for symptomatic control.
Medications on Admission:
- Home oxygen
- Prednisone 10 mg daily (tapering as above)
- Lasix 20 mg daily
- BUDESONIDE - 0.5 mg/2 mL nebs [**Hospital1 **]
- Serevent 50 mcg [**Hospital1 **]
- Albuterol nebs/MDIs prn (using neb [**Hospital1 **])
- Bactrim DS three times weekly.
- ATORVASTATIN 10 mg once a day - NOT TAKING
- BENZONATATE 100 mg Capsule - 3 Capsule(s) three times a day
- fentanyl patch 37.5 mcg/hr Q72hrs.
- FLUTICASONE - 50 mcg [**12-17**] sprays(s) intranasally once daily
- FOLIC ACID 1 mg daily - NOT TAKING
- MORPHINE 10 mg/5 mL - 2.5 mL(s) nebulized [**Hospital1 **]
- OXYCODONE - 5 mg/5 mL Solution - 2.5-10 mg by mouth q2h as
needed
for cough, shortness of breath - NOT TAKING
- PANTOPRAZOLE - 40 mg twice a day - NOT TAKING
- POTASSIUM CHLORIDE - 10 mEq Capsule, daily but taking QOD or
so
- ZOLPIDEM - 10 mg Tablet at bedtime
- colace 2 tabs daily
- POLYETHYLENE GLYCOL 3350 PRN
- SENNA 2 tabs daily
Discharge Medications:
1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
2. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q2H (every 2
hours) as needed for wheeze or shortness of breath.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
Disp:*120 vials* Refills:*2*
5. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal
Q72H (every 72 hours).
Disp:*10 patch* Refills:*2*
7. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal
every seventy-two (72) hours.
Disp:*10 patches* Refills:*2*
8. Morphine 10 mg/mL Syringe Sig: Five (5) mg Injection Q2H
(every 2 hours) as needed for shortness of breath or wheezing:
mix with 3ml of NS for inhalation with albuterol neb.
9. Benzonatate 100 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day) as needed for cough.
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
11. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day:
continue on this dose until instructed to taper.
Disp:*180 Tablet(s)* Refills:*2*
12. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One
(1) inhalation Inhalation twice a day.
15. Serevent Diskus 50 mcg/Dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
18. Polyethylene Glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO once a day as needed for constipation.
19. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
20. Bedside Commode
please provide with one bedside commode
dx - metastatic [**Hospital1 499**] ca
[**29**]. Morphine Concentrate 20 mg/mL Solution Sig: [**5-4**] ml PO Q2H
as needed for pain: place sublingually.
Disp:*60 ml* Refills:*2*
22. Actiq 800 mcg Lozenge on a Handle Sig: One (1) lozenge
Buccal q2H as needed for pain: swab buccal mucosa until you
acheive pain relief.
Disp:*60 lozenges* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice of [**Location (un) 86**] and Greater [**Hospital1 1474**]
Discharge Diagnosis:
Priamry: metastatic [**Hospital1 499**] cancer involving the lung,
sarcoidosis, community acquired pneumonia, hypoxic respiratory
failure
Secondary: hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted and treated for increasing oxygen needs and
shortness of breath with a 5 day course of levofloxacin for a
possible pneumonia and an increase in your prednisone regimen to
60mg daily. Please complete the course antibiotics as prescribed
and continue on your steroids at a higher dose and consult your
oncologist regarding further tapering of the dose. Please
contact your hospice provider for any difficulty controlling
your shortness of breath, coughing, or pain or any other concern
you have.
Follow up as need with your oncology team.
Followup Instructions:
You have the following appointments scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2119-2-14**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2119-2-14**] 9:30
Provider: [**First Name4 (NamePattern1) 4617**] [**Last Name (NamePattern1) 4618**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2119-2-14**] 10:30
|
[
"486",
"51881",
"2761"
] |
Admission Date: [**2190-11-17**] Discharge Date: [**2190-11-22**]
Service: MEDICINE
Allergies:
Penicillins / Demerol / Heparin Agents
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Failure to thrive at rehab
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 y/o female with a progressive upper cervical myelopathy who
is s/p cervical spine surgery [**2190-10-13**], trach/peg placement
[**2190-11-2**], who presented from [**Hospital6 23973**] ([**Location (un) 1110**]) with
failure to thrive. Per daughter, she has had no progression at
rehab. She has been immobile. Her daughter wanted her
re-evaluated and transferred to another rehab facility. The
patient is unable to give any history as she is non verbal from
this presumed mass. In ED, T101.6, P 106,BP 108/49, RR 16, 96%
on trach mask 35% O2. Over the course of the evening she had
sveral episodes of desats to the 80's requiring frequent
suctioning productive of mucous plugs. During one suctioning of
a large mucous plug she became hypotensive with an SBP in the
70's. She was started on normal saline and dopamine and her SBP
increased to 80'-100s. In the ED she was given a total of 5 L of
NS, vancomycin 1 gram, ceftriaxone 2 grams (given before LP
sent), tylenol, ativan.
She was admitted to the MICU with hypotension, fevers, change in
mental status and concern for sepsis. She was placed on the MUST
protocol. She received IVF per the protocol to maintain a CVP
greater than 8. She was placed on vancomycin, levaquin, and
flagyl. Her LP did not indicate infection. She only required
dopamine for a few hours, and was weaned off. On [**2190-11-18**] she
was transferred to the floor as she was hemodynamically stable.
Her neurological history is as follows: She originally
presented in [**2186**] with cervical spondylosis, which was treated
symptomatically for 3 years. In [**2190-1-10**], she presented to
[**Hospital 7817**] Clinic c/o tingling in her hands. At that time
she declined MRI [**1-11**] claustrophobia and was managed
symptomatically with physical therapy. In [**2190-5-11**], she
returned to their clinic with a significant deterioration. She
was quadriparetic and had developed urinary incontinence. MRI
revealed C1-2 subluxation with a large degenerative pannus (as
is seen in rheumatoid arthritis) around the odontoid process,
compressing the cervical medullary junction, as well as C3-C4
stenosis.
She underwent neurosurgery on [**2190-10-13**], where she had a transoral
resection of the odontoid/pannus as well as a posterior
occipital cervical decompression. This was complicated by a
prolonged intubation and failure to wean. She was extubated on
[**10-19**] but required reintubation on [**10-27**]. At that point she had
a trach and a peg placed. Per the d/c summary, post-op the pt
was able to open her eyes, grip with her hands, move all
extremities spontaneous (although decreased in the RUE as she
was preop) but could not follow commands. She was discharged to
rehab at this point.
Past Medical History:
1. s/p C-spine operation (as above) for subluxation with pannus
around odontoid
2. Tracheostomy [**2190-11-2**]
3. PEG placement [**2190-11-1**]
4. HIT, diagnosed [**10-14**]
5. IVC filter placement [**2190-10-28**]
6. Bipolar d/o, on lithium
7. c-section x3
Social History:
Came from rehab, married, husband is also sick at times per
daughters, has 2 daughters and 1 son, children very involved.
Communication: Husband/daughter at ([**Telephone/Fax (1) 23974**]
Son at ([**Telephone/Fax (1) 23975**]
Family History:
Parents with CAD
Physical Exam:
T: 98.4 BP: 120/60 P: 75 R: 20 O2 sat 98% on 40% trach mask
Gen: elderly female in cervical collar, tracks with eyes,
following some commands, answers yes/no questions, mouthing
words
HEENT: Trach in place, PERRL, anicteric, MMM
CV: RRR, nl S1, S2, II/VI SEM at LSB.
Lungs: coarse breath sounds throughout but less rhonchorous than
on admission
Abd: +PEG, site drsg c/d/i, NT, +BS, approx 5 cm ventral hernia
easily reducible
Ext: no edema
Neuro: RUE dense paresis, otherwise moves BLE and LUE slightly
against gravity, nonresponsive to questions, withdraws to pain.
increased tone in RUE.
Pertinent Results:
[**2190-11-16**] 07:40PM BLOOD WBC-12.7* RBC-3.08* Hgb-9.7* Hct-29.1*
MCV-95 MCH-31.4 MCHC-33.3 RDW-14.3 Plt Ct-291
[**2190-11-17**] 08:00PM BLOOD Hct-24.3*
[**2190-11-18**] 06:09AM BLOOD WBC-9.4 RBC-3.20* Hgb-9.9* Hct-29.8*
MCV-93 MCH-30.9 MCHC-33.1 RDW-15.7* Plt Ct-295
[**2190-11-16**] 07:40PM BLOOD Neuts-85.4* Lymphs-10.9* Monos-3.1
Eos-0.4 Baso-0.3
[**2190-11-18**] 06:09AM BLOOD PT-12.9 PTT-23.6 INR(PT)-1.1
[**2190-11-18**] 06:09AM BLOOD Glucose-88 UreaN-13 Creat-0.4 Na-145
K-3.7 Cl-113* HCO3-24 AnGap-12
[**2190-11-17**] 10:30AM BLOOD ALT-36 AST-22 LD(LDH)-232 AlkPhos-107
TotBili-0.4
[**2190-11-18**] 06:09AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.3
[**2190-11-17**] 10:30AM BLOOD Albumin-2.3* Calcium-7.8* Phos-2.8 Mg-1.9
[**2190-11-17**] 10:30AM BLOOD VitB12-599
[**2190-11-17**] 10:30AM BLOOD TSH-4.8*
[**2190-11-17**] 08:00PM BLOOD Free T4-1.0
[**2190-11-17**] 10:30AM BLOOD Cortsol-21.9*
[**2190-11-18**] 06:09AM BLOOD Vanco-21.4*
[**2190-11-16**] 07:46PM BLOOD Lactate-1.2
[**2190-11-17**] 10:31AM BLOOD Lactate-0.6
D/c labs:
[**2190-11-22**] 10:32AM BLOOD WBC-10.2 RBC-3.33* Hgb-10.7* Hct-31.1*
MCV-94 MCH-32.1* MCHC-34.2 RDW-15.8* Plt Ct-382
[**2190-11-22**] 10:32AM BLOOD Glucose-128* UreaN-18 Creat-0.4 Na-145
K-3.5 Cl-113* HCO3-28 AnGap-8
[**2190-11-22**] 10:32AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.2
LP results:
Tube 1: (CSF) WBC-49 RBC-[**Numeric Identifier 16351**]* Polys-98 Lymphs-1 Monos-1
Tube 4: (CSF) WBC-0 RBC-68* Polys-64 Lymphs-36 Monos-0
(CSF) TotProt-36 Glucose-62
Gram stain neg for polys or bacteria
UA lg blood, neg nit/leuk, [**10-30**] RBCs, 3-5 WBCs, few bact, urine
cx no growth (final)
Sputum cx with 4+ oropharyngeal flora
EKG [**11-17**]: Sinus rhythm, Nonspecific inferolateral T wave
flattening
CXR [**11-17**]: Bibasilar patchy and linear opacities with slight
worsening at left lung base. This may be due to atelectasis or
aspiration. Infectious pneumonia in left lower lobe is not
excluded.
Brief Hospital Course:
1. Hypotension: This had resolved by the time she arrived on
the floor, and at that point she actually became hypertensive.
Her antihypertensives were restarted. Her original hypotension
was felt to be secondary to sepsis given her fever and
infiltrate on CXR. Her cortisol was normal and so it was not
likely due to adrenal insufficiency.
2. Fever: This was likely due to an aspiration pneumonia. Her
urine, CSF, and blood cultures all remained negative. She was
originally treated with vanc/levo/flagyl, but the vanc was
discontinued on HD3 as she appeared to have an aspiration
pneumonia. She will be treated with Levaquin and Flagyl for a
total 14 day course, last day [**2190-11-30**].
3. Altered mental status: Her AMS resolved while in the ICU.
Her TSH was mildly elevated (not a helpful test in the acutely
ill) with a normal T4. Her LFTs, B12, and LP were wnl. Her
lithium was continued and her Ativan was restarted on a lower
dose, prn basis. Neurosurgery followed her while she was an
inpatient and did not feel she had any acute issues related to
her recent surgery.
4. FEN: On HD3, she appeared to develop abdominal pain, with
abdominal tenderness on exam which was not present 2 minutes
later while the patient was asleep. She was having bowel
movements and had normoactive bowel sounds. Her ventral hernia
was nontender and easily reducible. Because of this, her tube
feeds were held. They were restarted later and she tolerated
this well. She was placed on aspiration precautions. On HD3,
respiratory therapy gave her a pessy-muir valve, which she
tolerated for only a few minutes at a time.
5. RUE edema: Initially on exam she had some RUE edema, which
was concerning as she had a R subclavian central line in place.
An u/s was done, which ruled out DVT.
6. Guaiac pos stool: She was guaiac pos. in the ICU. Her Hct
actually increased from 29 to 31 when she reached the floor. It
was felt this may be due to her PEG tube, and her hematocrit
remained stable.
7. Ppx: She was on lansoprazole, pneumoboots (no heparin as has
HIT)/IVC filter while an inpatient.
Medications on Admission:
Metoprolol 50 mg daily
Hydralazine 10 mg Q 6 hours
Levaquin 500 mg daily
Colace
Bisacodyl
Prevacid 30 mg daily
Estrogen 0.3
Lithium carbonate 300 mg daily
Ativan 0.5 mg Q 4-6 hours PRN
Tylenol PRN
Isosource
Medications on transfer:
Metoprolol 12.5 mg [**Hospital1 **]
Metronidazole 500 mg GT tid
Levofloxacin 250 mg GT daily
Lithium 300 mg daily
Vancomycin 1 g IV daily
Lansoprazole 30 mg daily
Bisacodyl
Colace
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. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
4. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO QD
().
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days: Last dose [**2190-11-30**].
Disp:*9 Tablet(s)* Refills:*0*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days: Last dose [**2190-11-30**].
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100 or pulse <60.
8. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours): Hold for SBP <100.
10. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID
(2 times a day).
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Aspiration Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Please call your PCP or return to the ED if you experience
fevers, lightheadedness, chest pain, shortness of breath,
increased secretions from your trach, greenish secretions from
your trach, abdominal pain, nausea, vomiting, diarrhea, or
swelling in your legs.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12005**] Where: LM [**Hospital Unit Name 12006**] Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2190-12-7**] 10:00
Please f/u with your PCP [**Last Name (NamePattern4) **] 1 week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"0389",
"5070"
] |
Admission Date: [**2195-10-24**] Discharge Date: [**2195-11-4**]
Date of Birth: [**2121-10-27**] Sex: M
Service: CCU
HISTORY OF THE PRESENT ILLNESS: This is a 73-year-old man
with history of diabetes mellitus, hypertension,
hypercholesterolemia, and known two-vessel coronary artery
disease. The patient is admitted to [**Hospital1 190**] for non ST elevation myocardial infarction.
He was recently admitted to [**Hospital 1121**] Hospital for
treatment of ureteral obstruction due to prostate cancer. He
underwent uneventful reimplantation of ureters after failed
ureteral stents, one day prior to admission. He also had a
bilateral orchiectomy one day prior to admission. He had an
uneventful postoperative period until 5 AM with chest pain,
shortness of breath, and anterior and lateral ST depressions
2 mm to 3 mm in size. He was noted clinically and
radiographically to be in volume overload. He was
unsuccessfully diuresed with Lasix. He was subsequently
transferred to [**Hospital1 69**] for
further management.
At [**Hospital1 69**] the patient presented
with acute shortness of breath, pink frothy secretions from
the mouth. He was intubated immediately for impending
respiratory failure. Chest x-ray revealed diffuse pulmonary
edema. The patient subsequently ruled in for non ST
elevation MI with CK over 1100. Significant findings at
catheterization included elevated left ventricular and
diastolic pressure of 28, 90% proximal LAD lesion, 70% mid
left circumflex lesion and no significant right coronary
artery disease. The patient had his LAD lesion stented. The
patient was also noted to have significant aortic stenosis
with a valve area of approximately 0.8 cm squared and
gradient of 39 mm.
He was admitted to the CCU for further management.
PAST MEDICAL HISTORY:
1. Coronary artery disease, aortic stenosis, diabetes
mellitus type 2 for 20 years, hypercholesterolemia status
post right hip replacement [**2179**], revision in [**2187**],
cholecystectomy, prostate cancer, status post prostatectomy,
XRT, and ureteral stents, hypertension, COPD, chronic renal
insufficiency with baseline creatinine around 2.0.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Allopurinol 150 mg q.d.
2. Captopril 50 mg b.i.d.
3. Insulin 70/30, 20 units b.i.d.
4. Metformin 150 mg b.i.d.
5. Folate 1 mg q.d.
6. Triamterene/HCTZ 25/37.5.
7. Lipitor 20 mg q.d.
8. Atenolol 25 mg q.d.
9. Norvasc 2.5 mg q.d.
SOCIAL HISTORY: The patient is married and lives in a house
with his wife. [**Name (NI) **] quit smoking in [**2154**] and he does not drink
alcohol.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: Temperature 100.6, heart rate 81, blood pressure
114/56, oxygen saturation 100% on assist-controlled
ventilation. Volume: 750. Rate: 12. FIO2 0.8. PEEP
12.5. GENERAL: Intubated man in no distress. HEENT: Moist
oral mucosa, no JVD, brisk carotid upstroke. Carotid murmurs
bilaterally. LUNGS: Crackles 75% of the way up bilaterally.
HEART: Regular rate and rhythm, 2/6 systolic ejection murmur
at the right upper sternal border and [**2-11**] holosystolic murmur
at the apex, radiating to the axilla. ABDOMEN: Right
nephrostomy tube, suprapubic tube clear, soft, nontender,
nondistended, normoactive bowel sounds. EXTREMITIES: No
edema; 2+ dorsalis pedis pulses. Right femoral sheath in
place. NEUROLOGICAL: The patient was sedated, moving four
extremities spontaneously.
LABORATORY DATA: Laboratory data revealed the following:
Peak CK 1158, peak MB 36, peak troponin I greater than 58.
White blood count 12.0, hematocrit 30.8, platelet count
137,000, sodium 137, potassium 4.6, chloride 105, total CO2
18, BUN 62, creatinine 3.2, glucose 269, INR 1.1, PTT 30.1.
Liver function tests were within normal limits.
EKG: Normal sinus rhythm at 71. Right axis deviation. New
ST depression V3 through V6. Right bundle branch block.
Chest x-ray: Pulmonary edema bilaterally.
HOSPITAL COURSE: By system.
CARDIOVASCULAR: Coronaries. After the LAD stent, the
patient was continued on aspirin, Plavix, and Lipitor for
treatment of coronary artery disease. He did not have
further chest pain or shortness of breath throughout the
admission.
PUMP: The patient presented in heart failure. Swan-Ganz
catheter was placed. He responded well to Lasix diuresis
with decreased wedge pressure and increased cardiac index.
Echocardiogram on [**10-26**], revealed mildly decreased
left ventricular systolic function with left ventricular
ejection fraction approximately 45% to 50% and inferior wall
hypokinesis. The patient was restarted on Metoprolol and
Hydralazine when the blood pressure could tolerate it. These
medications were titrated up to their maximum doses after the
patient became hypertensive post extubation on [**10-28**].
By the time of discharge, the patient's blood pressures had
decreased to be in the range of systolics of 100 to 130 and
diastolics 50 to 70.
BOWELS: The patient was noted to have severe aortic
stenosis. The echocardiogram on [**10-26**] revealed aortic
valve area of approximately 0.6 cm squared and a mean aortic
valve gradient of 60 mmHg. During the course of his
afterload reduction, the patient's mean arterial pressures
were monitored and maintained over 60 mmHg.
Prior to discharge, he was evaluated by the cardiothoracic
surgery service for future aortic valve replacement. This is
planned for six to eight weeks post discharge.
RHYTHM: The patient remained in normal sinus rhythm
throughout admission. The patient had occasional PVCs and
short runs of NSVT within 72 hours post catheterization.
PULMONARY: The patient was maintained on a ventilator for
the first several days of stay in the ICU. The oxygenation
improved with diuresis and the ventilator was weaned and
discontinued on [**10-28**]. The patient had interstitial
markings on the chest x-ray. The patient received a BAL
after he spiked a temperature. The BAL was consistent with
possible pneumonia. The patient was treated for the
pneumonia with a course of Ceftazidime and Vancomycin, which
was changed to IV Levofloxacin and the cultures did not grow
organisms. Post extubation, the patient had good oxygen
saturation and at the time of discharge, the patient was
doing well on room air.
RENAL: The patient was noted, prior to admission, to have
baseline renal insufficiency and baseline creatinine of
approximately 2.0. After the catheterization, the patient's
creatinine increased to a level over 3.5. He was noted by
urine electrolytes to be prerenal. He also had casts in his
urine suggestive of ATN. This was felt to be possibly
secondary to a die load or to the hypotension that the
patient had experienced. Renal ultrasound was obtained to
rule out obstruction in the ureters and bladder. The
ultrasound revealed no obstruction. He was noted to drain
preferentially out of his right nephrostomy tube, but that he
did drain out of the suprapubic tube as well. On the days,
prior to discharge, the patient's creatinine remained in the
range between 2.5 and 3. He was seen by the renal
consultation service and a workup for cause of acute renal
insufficiency on top of the chronic renal insufficiency was
in progress at the time of discharge.
INFECTIOUS DISEASE: The patient was noted to have "MRSE"
urinary tract infection at the outside hospital prior to
admission. He had been started on Vancomycin and a ten-day
course of this was completed at [**Hospital1 188**]. The patient also completed a course of
Ceftazidime/Levofloxacin for possible ventilator-associated
pneumonia as above.
NUTRITION: While the patient was intubated, he received
orogastric tube feedings. Post extubation, the patient
initially was not capable of swallowing and the tube feeds
were continued. When the patient's swallowing function
improved, he was advanced on a diet and at the time of
discharge, the patient was tolerating full solids.
HEMATOLOGY: The patient was transfused two units of red
cells for hematocrit that reached nadir of 22.6 on [**10-27**]. The hematocrit increased to over 30 and remained over
30 throughout the remainder of his admission. He was noted
to have guaiac-negative stools.
ENDOCRINE: The patient was initially maintained on an
insulin drip for blood sugar control in the CCU. Post
extubation, the patient was placed on NPH and regular insulin
sliding scales. The NPH insulin was titrated up to doses of
50 units q.a.m. and 25 units q.p.m. for improved sugar
control.
PROPHYLAXIS: The patient received a proton pump inhibitor
and subcutaneous heparin for prophylaxis throughout the stay
in the hospital. At the time of discharge, the patient was
ambulating well. The patient was not discharged on
subcutaneous heparin.
NEUROLOGICAL: The patient was noted to be delirious for
approximately 48 hours after extubation. He received several
doses of Zyprexa with reduced agitation. After this period
of time, the patient's mental status cleared and he became
oriented to his location and situation.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post LAD stent, post non
ST elevation MI.
2. Hypertension.
4. Diabetes mellitus type 2.
5. Prostate cancer status post ureteral reimplantation and
suprapubic tube placement.
6. Chronic renal insufficiency.
7. Anemia.
CONDITION ON DISCHARGE: Fair.
DISCHARGE MEDICATIONS:
1. Metoprolol 100 mg PO t.i.d.
2. Imdur 30 mg PO q.d.
3. Aspirin 325 mg PO q.d.
4. Lipitor 10 mg q.d.
5. Plavix 75 mg PO q.d. until [**2195-11-29**].
6. Insulin NPH 25 units q.a.m.; 25 units q.p.m.
7. Folic acid 1 mg PO q.d.
8. Tylenol p.r.n.
DISCHARGE STATUS: The patient is discharged to a
rehabilitation facility to be determined. The patient is to
followup with Dr. [**Last Name (STitle) 120**], two weeks post discharge. The
patient is to have a possible AVR six to eight weeks post
discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 5596**]
MEDQUIST36
D: [**2195-11-4**] 12:07
T: [**2195-11-4**] 12:08
JOB#: [**Job Number 25058**]
|
[
"51881",
"486",
"4280",
"4241",
"496",
"5990",
"41401",
"2720"
] |
Admission Date: [**2161-6-7**] Discharge Date: [**2161-6-10**]
Date of Birth: [**2078-11-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy [**2161-6-9**]
History of Present Illness:
Ms. [**Known lastname 13144**] is an 82 yo F w/h/o stroke, CAD w/ stents, and
diverticulosis, who presented for BRBPR. She was in her USOH
until this afternoon at 12:30 pm when she developed painless,
BRBPR of uncertain volume. She denied abd pain, N/V, F/C,
cramping, diarrhea/constipation and CP/SOB. She went to the
[**Location (un) 620**] ED where Hct was 35.2; she received 1L NC and nexium 20
mg IV x 1. She was then then was transferred to [**Hospital1 18**] for
further care (specifically for angiography back-up
capabilities).
.
Of note, she has had one prior episode of painless BRBPR in
[**4-/2161**] for which she presented to [**Location (un) 620**] and had a colonoscoy.
No source was identified: she was given supportive care with
some RBC transfusions (though unclear how many; sounds like one)
and she was discharged to a rehab facility. She also had a
single polyp identified on colonoscopy which was not removed at
the time.
.
In the [**Hospital1 18**] ED, VS were HR 104, BP 84/60, RR 22, 100% 2L NC.
She was given 2 units RBC and 1 L NS for resuscitation. NG
lavage was negative. The ED team spoke with GI who suggested a
RBC scan if she opens up again; she has not been seen yet by GI.
She has not had any more episodes since the ambulance ride from
[**Location (un) 620**]; Hct was 35.2 on d/c from [**Location (un) 620**] and then 30.8 on
arrival here. Baseline Hct is uncertain.
Past Medical History:
tobacco
multiple falls (4 in last year), with broken vertebra 1y PTA
Diveritculosis
CAD-- s/p AMI, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] [**2156**]
Stroke
Anemia
COPD
HTN
Arhtritis
Social History:
Significant tobacco use, unquantified
No etoh
No drugs
She is currently living at home and gets home VNA and PT. She
has five children; she was a homemaker.
Family History:
Noncontributory
Physical Exam:
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1060**] [**Last Name (NamePattern1) **]
VS: Tcurrent 35.8 HR 89, BP 135/43, RR 18 , 93% 2L NC
General Appearance: NAD, elderly, pale,
Eyes / Conjunctiva: Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Cardiovascular: normal S1/S2, no murmur
Peripheral Vascular: 2+ radial, 2+ pedal pulses, warm, dry
Respiratory / Chest: symmetric expansion, crackles at bases
Abdominal: Soft, Non-tender, Bowel sounds present, Not Distended
Musculoskeletal: Muscle wasting
Skin: scattered ecchymoses
Neurologic: attentive, oriented x 3; no focal deficits
Pertinent Results:
[**2161-6-7**]
6:12p
138 99 27 AGap=13
------------<159
3.9 30 0.5
estGFR: >75
CK: 35
Trop-T: <0.01
ALT: 16 AP: 81 Tbili: 0.2 Alb:
AST: 22 LDH: Dbili: TProt:
CBC: 9.8
12.0>-----<282
30.8
N:64.6 L:30.0 M:4.3 E:0.8 Bas:0.2
Lactate 2.3
[**2161-6-9**] Colonoscopy) Diverticulosis of sigmoid and descending
colon, otherwise nml colonoscopy.
Brief Hospital Course:
82 yo F with diverticulosis, COPD, CAD on plavix/ASA at the time
of admission presented with painless BRBPR.
.
#. LGIB: Most likely diverticular given painless nature and
prior history. She had no further episodes since the early
evening after arriving at [**Hospital1 18**]. In the ED, 2 units pRBC and 1L
NS were administered and patient was transferred to the [**Hospital Unit Name 153**].
On arriving at the [**Name (NI) 153**] pt was hemodynamically stable. The
decision was made to hold home antihypertensives and asa, plavix
therapy. Pts hct was monitored overnight with no need for
additional transfusions. In the morning GI was consulted.
Colonoscopy was scheduled for the following morning which
revealed diverticulosis of sigmoid and descending colon,
otherwise normal, no evidence of active bleeding.
Given history of two significant GI bleeds in the past month,
patient's aspirin and plavix were held. Of note, pt has hx of
drug-eluting coronary stents placed in [**2156**], anterior MI and
CVA. She has strong indications for those meds, but given
recent life-threatening GI bleed and from discussion with pt,
her greatest current concern is recurrent GI bleed and she
agrees with plan to hold ASA and plavix. At PCP f/u,
re-evaluation rsik/benefit for aspirin and plavix should be
made.
# CAD: Pt denies and chest pain or cardiac symptoms. CE were
negative.
#. HTN: Pt was hypotensive on admission. Blood pressure
normalized. Restarted home emds after colonoscopy.
.
#. COPD: Patient with history of COPD on supplemental oxygen at
home. Pt breathing with pursed lips on admission. No home meds
for COPD. CTA b/l on admission. Pt treated with
atrovent/albuterol nebs. Pt given rx for advair and combivent
on d/c. Outpt pulm f/u.
Medications on Admission:
Home medications:
Plavix 75 mg, ASA 352 mg
Prevacid 30 mg QD
Iron sulfate 325 mg QD
Diltiazem 30 mg QD
HCTZ uncertain dose
Vit D
Discharge Medications:
1. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
3. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO once a day:
Continue home med dose and frequency.
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day: Continue home dose.
5. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. holding meds Sig: One (1) once a day: HOLDING PT'S plavix
and ASA given recent significant GI bleed. At f/u PCP visit,
[**Name9 (PRE) 48258**] whether to restart.
8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Disp:*1 inhaler* Refills:*3*
9. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary: Lower GI Bleed, anemia
Secondary: COPD, Hypertension
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return if having blood in one's stool, chest pain, dizziness,
shortness of breath, significant weakness.
DO NOT TAKE YOUR ASPIRIN OR PLAVIX FOR NOW. HOWEVER, YOU NEED TO
FOLLOW-UP WITH YOUR PCP [**Last Name (NamePattern4) **] 2 WEEKS TO REEVALUATE WHETHER YOU
SHOULD RESTART ONE OR BOTH OF THOSE MEDS AT THAT TIME.
Followup Instructions:
Patient to f/u with PCP [**Last Name (NamePattern4) **] 2 weeks.
|
[
"2851",
"41401",
"V4582",
"496"
] |
Admission Date: [**2120-6-27**] Discharge Date: [**2120-6-29**]
Date of Birth: [**2077-6-11**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Clonidine Overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 33469**] is a 43 y/o M with a h/o bipolar and multiple
hospitalizations for suicidal ideation/suicide attempts who
presents after being found down by EMS today outside the [**Location (un) 86**]
Public Library. He was discharged from [**Hospital 1680**] Hospital after a
psychiatric stay the morning of the overdose. He admits to
taking 50, 0.1mg between noon and 6pm and then taking 10 more
of the 0.1mg pills at approximately 8pm, along with two shots of
liquor sometime throughout the day, he admits that this was a
suicide attempt. He was found with a bottle of ibuprofen,
carbamazepine and clonidine.
.
In the ED, initial vs were: HR 64, BP 152/110, RR 12, 97% on RA
and was complaining of a dry throat. He was initially naloxone
2mg x 1 for his bradycardia, toxicology was consulted who
recommended using naloxone and pressors if needed should he
become hypotensive, repeat electrolyte checks in case he had
other co-ingestions, along with an ICU admission for monitoring
should he have late hypotension and bradycardia. In the ER his
labs were notable for an alcohol level of 20 otherwise negative
serum tox, glucose of 109, negative urine tox screen and a U/A
with 8 WBC's, small leuks and trace protein. His EKG was sinus
bradycardia at 57bpm. His VS on transfer were: 72, 183/132, 16,
100% on 2LNC.
.
In the ICU initial VS were: 57, 151/101, 15, 99% on RA. He is
currently complaining of wanting to have his oxygen off,
otherwise when asked about his suicide attempt, he admits that
it was a suicide attempt but does not want to discuss many
details. Currently feels well, denies any CP, SOB, nausea has
resolved, no abdominal pain. 10 ROS is otherwise negative.
Past Medical History:
Bipolar disorder with multiple admissions to psychiatric
facilities for suicide attempts
Splenectomy status post motorcycle accident; pt states that he
is up to date on immunizations
Social History:
Homeless, admits to alcohol use when suicidal, denies other
current coingestions. No cigarettes or IVDU.
Family History:
No neoplasm.
Physical Exam:
Physical Exam:
Vitals: T: 36.1 BP: 130/85 P: 57 R: 19 O2: 100% 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
Rectal: No prostatitis
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2120-6-27**] 10:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2120-6-27**] 08:45PM ASA-NEG ETHANOL-20* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2120-6-27**] 10:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2120-6-27**] 10:05PM URINE RBC-1 WBC-8* BACTERIA-NONE YEAST-NONE
EPI-0
[**2120-6-27**] 10:05PM URINE HYALINE-4*
[**2120-6-27**] 10:05PM URINE MUCOUS-MOD
[**2120-6-27**] 08:45PM GLUCOSE-123* UREA N-17 CREAT-1.1 SODIUM-140
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
[**2120-6-27**] 08:50PM GLUCOSE-109* K+-4.3
[**2120-6-27**] 08:45PM WBC-8.6 RBC-4.49* HGB-14.4 HCT-42.3 MCV-94
MCH-32.0 MCHC-34.0 RDW-14.8
[**2120-6-27**] 08:45PM NEUTS-57.5 LYMPHS-31.1 MONOS-7.5 EOS-2.2
BASOS-1.6
[**2120-6-27**] 08:45PM PLT COUNT-269
.
Microbiology:
urine culture ([**6-28**]):negative
.
Imaging:
CXR ([**6-28**]): IMPRESSION:
Multiple prior healed rib fractures are seen on the left side. A
small focal
opacity in the left lung base near costophrenic angle may be
either
intraparenchymal or could be due to a callus formation from old
rib fractures.
Repeat PA and lateral radiograph may be performed for further
differentiation.
Otherwise, lungs are clear without effusion/pneumothorax. Heart
size is top
normal. Mediastinal and hilar contours are normal
.
EKG: sinus bradycardia at 57 bpm
Brief Hospital Course:
Mr. [**Known lastname 33469**] is a 43 y/o M with a h/o bipolar d/o who presents
after a suicide attempt from a clonidine overdose.
.
#) Clonidine Overdose: The patient reported on presentation to
the ED that he took 60 pills of clonidine 0.1mg in a suicide
attempt; he is no longer suicidal. The toxicology team was
consulted and recommended treating hypotension with naloxone and
use pressors as necessary. Initial effects of clonidine
overdose can include hypertension, especially in patients who
also receive naloxone. Later effects include hypotension,
bradycardia, CNS depression, respiratory depression and miosis.
The patient received a dose of naloxone in the ED, but needed no
further therapy once transferred to the ICU. He was monitored
in the ICU for a day with no sign of paroxysmal hypertension or
hypotension. He was not bradycardic and had no sign of
respiratory depression. There were no EKG changes. A chest
X-ray to check for aspiration was negative. After observation
during the day, he was transferred to the medical floor for
further therapy.
.
#) Bipolar Disorder/Suicide Attempt: The patient has had
multiple hospitalizations and suicide attempts in the past, and
currently admits to being very depressed. On admission he was
unable to articulate many details about his care or medications,
but during the first day became more alert and was able to
discuss his mood with the psychiatry team. Given his recent
history of relapse and serious suicide attempt, it was
determined he required admission to a locked psychiatric unit.
He was placed on 1:1 observation during his stay for safety and
a section 12 was filed. The patient signed a release for
records from his [**Hospital1 1680**] hospitalization; these records are
pending. He was continued on Tegretol for his bipolar disorder.
.
#) Pyuria: On admission the patient was found to have signs of
infection on urinalysis. Rectal exam revealed no clinical
evidence for prostatitis. Antibiotics were held in the absence
of symptoms or positive cultures. Final culture was negative.
#) TMJ - chronic jaw pain; continued on ibuprofen.
#)ID - patient had a positive MRSA screen and was placed on
contact precautions.
# FEN: regular diet
# Prophylaxis: Subcutaneous heparin; 1:1 sitter for safety
# Access: peripherals
# Communication: Patient
# Code: Full
# Disposition: Psych bed
Medications on Admission:
Tegretol 400mg [**Hospital1 **]
clonidine 0.1mg TID
ibuprofen 600mg TID prn pain
Discharge Medications:
1. carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
3. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)) as needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
Suicide attempt with clonidine ingestion
Discharge Condition:
Stable for transfer to psych facility
Discharge Instructions:
Continue to take your medications as directed by the
psychiatrists
Please notify your doctors if [**Name5 (PTitle) **] develop any change to your
usual headache, or any dizziness, lightheadedness, or pain
Followup Instructions:
As per the psychiatry team
|
[
"42789"
] |
Admission Date: [**2111-8-19**] Discharge Date: [**2111-8-26**]
Date of Birth: [**2049-9-30**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5368**]
Chief Complaint:
CC: nausea, vomiting x 2 days
Major Surgical or Invasive Procedure:
AV fistula
tunneled central line
History of Present Illness:
HPI: 61 year old female with history of IDDM with frequent
episodes of DKA last admitted [**2111-8-6**] for DKA, nephropathy, CAD
with CABG '[**03**], poorly controlled HTN, CHF with EF 40%, PVD s/p L
CEA, pancreatitis p/w nausea and vomiting since yesterday. In
the ED, BP 230/100 91% BG=900. Gap closed to 12 within 6 hours
with insulin gtt, ivf. Head CT negative for acute hemorrhage or
edema.
Past Medical History:
PAST MEDICAL HISTORY:
1. Insulin-dependent diabetes mellitus for 25 years. Diagnosed
in [**2085**] @ age 36.
-last Hemoglobin A1C 8.3 in [**5-31**]
-h/o of diabetic ketoacidosis
-nephropathy: baseline 2.8-3.2 in recent months. Recent
-neuropathy: Gastroparesis, peripheral neuropathy
2. Coronary artery disease
-5 vessel coronary artery bypass graft in [**2103**] at [**Hospital1 756**] and
Women??????s.
-cardiac catheterization in [**2109**] revealed patent grafts.
-Echo [**2111-2-20**] revealed LVEF 40%, 1+MR
[**Name13 (STitle) 35744**] MIBI [**2111-3-27**] revealed no reversible perfusion
defect. Mild global hypokinesis, LVEF 39%.
3. Congestive heart failure with an ejection fraction of 40%.
4. Hypertension.
5. Hypercholesterolemia, no longer on a statin secondary to LFT
abnormalities.
6. History of fibroids.
7. History of peripheral vascular disease, status post left
carotid endarterectomy.
8. osteoporosis
9. pubic ramus fracture in 12/[**2108**].
10. History of Methicillin resistant Staphylococcus aureus
urinary tract infection in [**2111-1-26**].
11. Status post cholecystectomy.
12. ? right lower lobe pulmonary mass seen on [**12-31**] chest CT.
13. History of pleural effusions, which were tapped in [**Month (only) 956**]
[**2110**], with negative cytologies.
14. dizziness
15. folliculitis
16. pancreatitis
17. pneumonias
Social History:
>100 pack-year smoking history and she continues to smoke.
Occasional alcohol.
Divorced with 2 children.
She lives with her mother, who is in her 80s, who is the
patient's primary caregiver.
Family History:
Father died of myocardial infarction at the age of 65.
Her mother had a heart attack and had cardiac surgery in [**2101**].
She has a history of hypertension. No history of cancer, strokes
or liver or kidney disease.
Physical Exam:
VITALS:
GEN: NAD, AOx3, thin
HEENT: PER, minimally reactive to light, MMM
CV: S1S2, ectopic beats
RESP: lower [**11-28**] CTA B/L
ABD: +BS, soft, NT, ND
EXT: L arm with 3 small bandages, C/D/I, no induration, edema
vendoynes in place
NEURO: CN 2-12 in tact
Pertinent Results:
[**2111-8-19**] 06:30AM WBC-12.2* RBC-3.99* HGB-12.7 HCT-39.4 MCV-99*
MCH-31.8 MCHC-32.2 RDW-13.3
[**2111-8-19**] 06:30AM NEUTS-91* BANDS-0 LYMPHS-6* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2111-8-19**] 06:30AM GLUCOSE-953* UREA N-63* CREAT-4.2*
SODIUM-131* POTASSIUM-5.5* CHLORIDE-85* TOTAL CO2-23 ANION
GAP-29*
[**2111-8-19**] 08:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2111-8-19**] 08:40AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2111-8-19**] 08:40AM CK-MB-NotDone cTropnT-0.15*
[**2111-8-19**] 08:40AM CK(CPK)-37 AMYLASE-50
[**2111-8-19**] 08:40AM LIPASE-38
Brief Hospital Course:
Hospital course, briefly, by system:
1. DM/Chronic [**Month/Day/Year **] failure:
Pt was admitted in DKA to the [**Hospital Unit Name 153**]. Her DKA was managed with
insulin and IVF. Her [**Hospital Unit Name **] function was noted to be declining
so she underwent AV fistula formation and received a central
line to begin dialysis during this admission rather than later
next month as was originally planned.
The patient's anion gap closed with insulin and IVF and she was
called out of the [**Hospital Unit Name 153**] on HD#3. The patient underwent three
successful rounds of hemodialysis during this admission, and was
set up to undergo outpatient hemodialysis on a
Tuesday/Thursday/Saturday schedule at the dialysis unit in
[**Location (un) 1468**]. Once the patient was transferred to the floor, she
continued to have elevated blood sugars >400 in the evening, so
her basal glargine was increased to 10 units at bedtime. [**Last Name (un) **]
followed the patient while she was inhouse.
2. CAD
Pt's EKG upon presentation demonstrated chronic t-wave inversion
and her cardiac enzymes were cycled to rule her out for MI. Of
note, the patient did report one episode of chest pain during
admission that resolved promptly with nitroglycerin sl. Her EKG
demonstrated no changes during this episode. The patient was
continued on a beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], statin, and ACE inhibitor in
house.
3. UTI
UA was suggestive of a UTI so the patient was given a 3-day
course of levofloxacin.
4. HTN
Pt was continued on amlodipine, lisinopril, and metoprolol for
control of her blood pressure. Upon discharge, the patient's
blood pressure ranged from 110-160/40-80s.
5. Hypercholesterolemia
The patient was continued on atorvastatin 10 mg qday for
cholesterol management.
On hospital day #8, the patient was cleared by PT and discharged
to home in stable condition.
Medications on Admission:
- [**First Name3 (LF) **] 325 mg qday
- multivitamin
- Vit D3 400 units qday
- albuterol MDI prn
- Toprol XL 150 mg qday
- isosorbide mononitrate 60 qday
- hydralazine 25 mg qid
- reglan 10 mg qidachs
- FeSO4 325 mg qday
- protonix 40 mg qday
- lantus 8 units qhs
- lasix 40 mg qday
- SS humalog
- colace 100 mg [**Hospital1 **]
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
6. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO QD (once a day).
Disp:*30 Cap(s)* Refills:*2*
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 6 days.
Disp:*3 Tablet(s)* Refills:*0*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
11. Metoclopramide HCl 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
14. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection four times a day: [**First Name8 (NamePattern2) **] [**Last Name (un) **] sliding scale.
15. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
1. DKA
2. s/p AV fistula
3. End-stage [**Location (un) **] disease; successful initiation of
hemodialysis
Discharge Condition:
good
Discharge Instructions:
1. Please call your doctor if you experience nausea, vomiting,
lightheadedness, chest pain, difficulty breathing, fevers,
chills, or any other symptoms of concern.
2. Please check your blood sugars four times per day. Call your
primary care physician if blood sugars > 400.
3. Please resume all of your preadmission medications.
4. Make sure your hematocrit is check at dialysis on Thursday
[**8-27**]. If < 30, you may benefit from 1u of blood given your
history of coronary artery disease.
5. Your phosphate level has been low in the hospital. Talk
with your physician at dialysis about decreasing your phosphate
binder.
Followup Instructions:
1. You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Last Name (un) **]
Center) today ([**2111-8-26**]) at 3pm.
2. You have a dialysis slot on Thursday, [**2111-8-27**], at 6:30 am at
the [**Location (un) 1468**] dialysis unit ([**Street Address(2) 35749**]; ([**Telephone/Fax (1) 12905**]).
3. Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] to schedule an
appointment within the next two weeks.
4. Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office ([**Telephone/Fax (1) 3618**] to
schedule a follow-up appointment within the next two weeks
(transplant surgery). It is important that you see Dr. [**First Name (STitle) **]
to evaluate your left arm!
4. You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital 4054**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2112-2-8**] 10:30
|
[
"5849",
"40391",
"4280",
"496"
] |
Admission Date: [**2118-2-7**] Discharge Date: [**2118-2-11**]
Date of Birth: [**2045-10-10**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 72-year-old female
patient without a history of coronary artery disease. She
reports a 10-year history of anginal-like symptoms with a
negative stress test in [**2102**]. Over the past four month she
reports progressive angina with pain and pressure radiating
to her left arm, shoulder, neck, left jaw, and cheek. Only
with exertion and resolving with rest and/or sublingual
nitroglycerin. A stress test in [**2117-11-24**] showed
posterolateral ischemia and an ejection fraction of 72
percent. At this time, she was referred for cardiac
catheterization.
Cardiac catheterization on [**2118-1-31**] revealed an
ejection fraction of 66 percent, LAD stenosis of 70 percent,
left circumflex stenosis of 70 percent, and OM1 stenosis of
80 percent. At this time, she was referred for coronary
artery bypass grafting by Dr. [**First Name (STitle) **] [**Name (STitle) **].
PAST MEDICAL HISTORY: Hypertension, elevated lipids,
cerebrovascular accident in [**2109**], osteoarthritis, bursitis of
the hips, renal calculi, and status post lithotripsy in [**2116**].
PAST SURGICAL HISTORY: Right carpal tunnel release and left
thumb joint replacement in [**2110**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Lipitor 80 mg once daily, aspirin
325 mg once daily, tramadol 50 mg at bedtime as needed,
lisinopril/hydrochlorothiazide combination 10/12.5 mg once
daily, ibuprofen once daily, and Zyrtec as needed.
SOCIAL HISTORY: She lives in [**Location 9188**] with her husband.
Retired but volunteers often. She drives. She uses a cane
when she is tired. She has a history of tobacco use; having
quit one week prior to initial visit on [**1-31**] with less
than a 50-pack-year history. She denies any alcohol use.
PHYSICAL EXAMINATION ON PRESENTATION: Height was 5 feet 2
inches tall and weight was 148 pounds. The heart rate was 83
in sinus rhythm, the blood pressure was 108/69, the
respiratory rate was 21, and oxygen saturation was 100
percent on room air. In general, the patient was lying flat
in bed in no acute distress. Neurologically, alert and
oriented times three, appropriate, and moved all extremities.
Positive carotid bruits bilaterally. Respiratory examination
revealed clear to auscultation bilaterally. Cardiovascular
examination revealed a regular rate and rhythm. S1 and S2.
A positive [**1-30**] blowing systolic murmur. Gastrointestinal
examination revealed soft, round, nontender, and nondistended
with positive bowel sounds. The extremities were warm and
well perfused. No edema or varicosities with good dorsalis
pedis and posterior tibial pulses bilaterally.
LABORATORY DATA ON PRESENTATION: White blood cell count was
6.7, hematocrit was 29.9, and platelets were 233. PT was
13.5, PTT was 29.3, and INR was 1.9. Sodium was 139,
potassium was 3.2, chloride was 104, bicarbonate was 29,
blood urea nitrogen was 28, creatinine was 0.7, and glucose
was 215. ALT was 16, AST was 14, alkaline phosphatase was
58, amylase was 82, total bilirubin was 0.3, and albumin was
3.9.
RADIOLOGIC STUDIES: Carotid ultrasounds from [**2117-11-9**] showed a left stenosis of 41 to 59 percent; no
hemodynamically significant.
SUMMARY OF HOSPITAL COURSE: The patient was admitted on her
operative day ([**2118-2-7**]) and proceeded to the
Operating Room with Dr. [**First Name (STitle) **] [**Name (STitle) **]. She underwent an off-
pump coronary artery bypass grafting times three with a LIMA
to the LAD, a saphenous vein graft to the OM, and a saphenous
vein graft to the LPDA. Her Operating Room course was
uneventful. Please see the Operative Note for full details.
She was transferred to the Cardiac Surgery Recovery Room with
a mean arterial pressure of 66, central venous pressure of 9,
on Neo-Synephrine and propofol drips. On the evening of her
operative day, weaning of her endotracheal tube was
unsuccessful with poor atrial blood gas improving when
returned to synchronized intermittent mandatory ventilation.
She was extubated successfully on the morning of operative
day one. On the same day she was started on Lopressor for
beta blockade. Her Neo-Synephrine was weaned off, and her
chest tubes were discontinued. She was found to be stable
for transfer to the inpatient floor for ongoing recovery and
rehabilitation.
On postoperative day two, she continued uneventfully with
discontinuation of her cardiac pacing wires, increase of her
beta blockade for a slightly elevated heart rate and blood
pressure. On the same day, she was evaluated by Physical
Therapy and it was thought that she will likely need
rehabilitation prior to discharge home.
On postoperative day three, she continued again uneventfully.
A normal sinus rhythm with stable vital signs and ambulation
with nursing. It was decided that the patient should be
screened for rehabilitation for discharge to rehabilitation
on [**2118-2-11**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass grafting times three.
3. Hypertension.
4. Elevated lipids.
MEDICATIONS ON DISCHARGE:
1. Lipitor 40 mg p.o. once daily.
2. Colace 100 mg p.o. twice daily.
3. Lasix 20 mg p.o. twice daily.
4. Potassium chloride 20 mEq p.o. twice daily.
5. Dilaudid 2 mg to 4 mg p.o. q.4-6h. as needed (for pain).
6. Lopressor 25 mg p.o. twice daily.
7. Aspirin 81 mg once daily.
DISCHARGE FOLLOW-UP PLANS:
1. The patient is to make an appointment to see Dr. [**First Name (STitle) **]
[**Name (STitle) **] in approximately four weeks.
2. The patient is also to make an appointment to see Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] in two to four weeks' time.
3. She should make an appointment with her primary
cardiologist in one to two weeks' time.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) 5898**]
MEDQUIST36
D: [**2118-2-10**] 15:55:41
T: [**2118-2-10**] 19:24:56
Job#: [**Job Number **]
|
[
"41401",
"4019",
"2724"
] |
Admission Date: [**2111-2-24**] Discharge Date: [**2111-3-5**]
Date of Birth: [**2057-4-5**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 3444**] is a 53-year-old
female with a multitude of medical problems who was admitted
on [**2111-2-24**] to [**Hospital1 69**]
with MRSA and VRE bacteremia. Patient was just recently
discharged from [**Hospital1 69**] at the
pneumonia and pleural effusion as well as mental status
changes. Upon her discharge to [**Location 6065**], she was noted to have
urinary tract infection with Klebsiella for which she
received a full course of antibiotics namely amikacin
and Cipro which ended on [**2111-2-18**]. Her repeat
urine cultures grew Klebsiella, Staph, and Enterococcus. Her
blood cultures drawn revealed MRSA and VRE for which the
Center.
Upon arrival at [**Hospital1 69**], she
began her treatment with Vancomycin for MRSA bacteremia.
Initially, she was started on linazolid for VRE, however,
following ID evaluation, that was thought to be
colonization. No other cultures drawn at [**Hospital1 346**] confirmed VRE. The patient
underwent an echocardiogram which revealed an ejection
fraction of 75% and no vegetations, as well as spine films to
evaluate for osteomyelitis which were negative.
On [**2111-3-3**], the patient was noted to have increased
oxygen requirement as well as shortness of breath and mental
status changes. To maintain her saturations of 90%, she
required a nonrebreather mask and due to the mental status
changes was evaluated for Medical Intensive Care Unit
admission.
At the time of being evaluated by the MICU team, the patient
was confused and was not able to provide any history. She
was using accessory muscles of ventilation and was pulling
off her nonrebreather mask. An arterial blood gas was drawn
which revealed a pH of 7.37, pCO2 of 24, and pO2 of 60.
Patient was changed to BiPAP mask and transferred to Medical
Intensive Care Unit.
SOCIAL HISTORY: Patient is a Jehovahs Witness. She had a 35
pack year smoking history, quit in [**2094**]. She denied any
alcohol. Healthcare proxy was [**Name (NI) 449**] [**Name (NI) **], [**Telephone/Fax (1) 99170**].
FAMILY HISTORY: Noncontributory.
PAST MEDICAL HISTORY:
1. Congestive obstructive pulmonary disease with 35 pack year
smoking history on 2 liters home O2, no CO2 retention per
prior blood gases.
2. Obstructive-sleep apnea on CPAP - patient is poorly
compliant.
3. Diabetes mellitus type 2.
4. Adrenal insufficiency secondary to steroid use on chronic
steroids.
5. AVM malformation of the gut status post gastrointestinal
bleeding.
6. History of HIT-antibody positivity.
7. History of liver failure of unknown etiology. Full workup
was undertaken on prior admissions and was negative. Two
leading etiologies are alcohol and NASH.
8. Status post cholecystectomy.
9. Status post total abdominal hysterectomy.
10. Status post left total knee replacement.
PHYSICAL EXAMINATION ON ADMISSION TO MICU: Temperature is
98.6 rectally, blood pressure 105/70, respiratory rate 20,
heart rate 88, O2 saturation 99% on BiPAP mask [**10-18**] with 60%
FIO2. Generally, the patient was an elderly female with
moderate respiratory distress using her accessory muscles of
ventilation. She was somnolent and not oriented. HEENT:
She had scleral icterus. Pupils are equal and reactive to
light. Extraocular movements are intact. Oropharynx was
clear. Could not assess jugular venous pressure due to the
body habitus. Heart was regular, rate, and rhythm, no
murmurs, rubs, or gallops were appreciated. Lungs were with
decreased breath sounds on the left base. Abdomen was soft,
obese. Could not assess for ascites or hepatosplenomegaly.
Extremities were edematous with 3+ pitting edema. There is
no cyanosis noted.
LABORATORY FINDINGS ON ADMISSION TO MICU: White count 20.9
which is up from 14, hematocrit 27.8, platelet count 118, MCV
107. Sodium 143, potassium 4.1, chloride 115, bicarbonate
15, BUN 17, creatinine 2.0, glucose 81. Calcium was 8.5,
phosphorus 5.3, magnesium 1.8. Her INR was 2.5, PTT was
43.6. Vancomycin level was 20.2. Her last LFTs done on
[**2111-2-25**] showed an ALT and AST of 41 and 46,
alkaline phosphatase of 152, T bilirubin of 6.6. Her
arterial blood gas drawn on BiPAP of [**10-18**] at 60% of FIO2
showed a pH of 7.27, pCO2 of 30, pO2 of 92. Blood cultures
drawn on 14th and [**3-3**] no growth to date. Blood
cultures drawn on [**2-25**] had 2/4 bottles growing VRE
linazolid sensitive. The [**3-17**] blood cultures drawn on [**2-24**] showed MRSA. Her urine cultures have been negative
throughout the whole hospitalization with exception of culture
drawn on [**2-28**], which revealed more than 100,000 of
yeast.
CHEST X-RAY: On [**2111-3-2**] showed a PICC line in the
brachiocephalic vein, increased left pleural effusion,
continuous left lower lobe collapsed consolidation.
Echocardiogram performed on [**2111-3-2**] showed
hyperdynamic left ventricle with an ejection fraction of 75%,
moderate pulmonary hypertension.
HOSPITAL COURSE: In summary, the patient is a 53-year-old
female with liver failure of unknown etiology as well as
renal failure with MRSA bacteremia. Admitted to MICU for
acute respiratory decompensation.
During this hospitalization, the patient's issues included:
1. MRSA bacteremia. The patient was continued on Vancomycin.
For the presumed left lower lobe pneumonia, she was started
on levofloxacin and Flagyl. Linezolid was d/c'd as per ID
recommendations.
2. Hypoxia. The patient had enlarged AA gradient that was
most likely due to combination of her pulmonary hypertension,
pneumonia, and congestive obstructive pulmonary disease. She
was not able to tolerate BiPAP due to the mental status
changes and required intubation on [**2111-3-3**].
3. Acute renal failure. The patient was thought to be
prerenal, however, throughout her MICU stay, she was
aggressively hydrated with normal saline and Lactated ringers
with improvement in her creatinine and minimal urine output.
4. Liver failure. Patient's INR remained elevated. Her
albumin was 2.0. She was presumed to be encephalopathic and
an OG tube was placed for lactulose delivery.
5. Patient has a history of HIT antibody positivity. She did
not receive any Heparin during this hospitalization.
6. Adrenal insufficiency. The patient was continued on high
dose hydrocortisone for possible congestive obstructive
pulmonary disease exacerbation as well as for adrenal
insufficiency.
7. Diabetes. The patient was maintained on sliding scale and
her glucose was monitored.
8. Access. PICC line and A-line which was placed on [**2111-3-3**].
Upon extensive discussion with the family, with the light of
the patient becoming hypotensive, a decision was made to
concentrate on patient's comfort. Patient's severe acidosis
continued to progress and she passed away on [**2111-3-5**] at 1:28 pm. Family was at the bedside. Request for
autopsy was denied.
IMMEDIATE CAUSE OF DEATH:
1. Hypertension.
2. Acidosis.
CHIEF CAUSE OF DEATH: Liver, kidney, and pulmonary failure.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2111-3-5**] 14:43
T: [**2111-3-6**] 05:29
JOB#: [**Job Number **]
|
[
"486",
"5845",
"2762",
"51881"
] |
Admission Date: [**2113-11-18**] Discharge Date: [**2113-11-28**]
Date of Birth: [**2030-9-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
Pacemaker implant
History of Present Illness:
This is an 83 yo male with a history of CAD, CHF, CKD, and a.fib
who presents with sympomatic bradycardia. The symptoms
apparently began this morning when his caregivers noted that he
was "not himself". He noted that he felt dizzy standing up in
the morning to shave and had multiple presyncopal episodes
throughout the day. He does note some mild DOE starting today
but denies any chest discomfort. Prior to today he was in his
USOH, fully functional. Later that day, his grandaughter found
him at home, diaphoretic, nauseous, and with decreased
responsiveness. He was sitting in a chair and was thought to
maybe pass out at one point, when his eyes rolled back in his
head. 911 was then called.
EMS responded to the scene and found his heart rate to be in the
20s with a BP of 80s/P. He was given bicarb and atropine by EMS
with no effect. They tried to externally pace him but could not
capture.
On arrival to the ED, initial vitals were 97.5, 36, 112/43,
satting 99% on 4L. His FS was noted to be greater than assay. At
this time he was much more responsive and with stable BP. He
received 10units IV insulin and 2L NS.
Past Medical History:
-CABG: [**2104**]- LIMA to the diagonal branch, solitary saphenous
graft to LPDA. Followed by Dr. [**Last Name (STitle) **] at NEBH.
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**2109-9-2**] at NEBH after + thallium stress with ischemia at low
workload
RCA- 100% occluded at mid portion, high grade ostial disease
Saphenous graft to PDA- patent
LIMA to diagonal [**Last Name (un) **]- widely patent but anastomosed into
disease diagonal branch with backflow to LAD
LCx- 100% occluded
-CHF- echo in [**2109**]- EF 45%
-Paroxysmal A.fib
-PVD
-Chronic renal insufficiency (Cr 1.7-1.9 in [**2113**])
-Anemia NOS (Baseline 30-31)
-DM
-HTN
-HL
-Legally blind/diabetic retinopathy
-History of tachy-brady syndrome. He has had runs of
Mobitz II block, which have been felt to be asymptomatic. There
has been no evidence of prolonged block on multiple monitoring.
Social History:
Mr. [**Known lastname **] continues to live with his wife and has four hours of
shared personal care assistance in thehome, which is typically
devoted to his wife's personal care.
-Tobacco history:Quit smoking > 40 years ago.
-ETOH: None
-Illicit drugs: None
Family History:
CAD in several brothers
Physical Exam:
On Admission:
VS: T=98.3 BP=139/63 HR=36 RR=16 O2 sat=100% 2L
GENERAL: WDWN in NAD. Oriented x2.5. 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 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Brady, 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/e. No femoral bruits. 1+ LE edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2113-11-28**] 07:10AM BLOOD WBC-4.1 RBC-2.95* Hgb-9.9* Hct-27.9*
MCV-95 MCH-33.4* MCHC-35.3* RDW-16.1* Plt Ct-171
[**2113-11-23**] 07:04AM BLOOD WBC-5.0 RBC-2.57* Hgb-8.6* Hct-24.2*
MCV-94 MCH-33.6* MCHC-35.6* RDW-14.5 Plt Ct-120*
[**2113-11-20**] 03:32AM BLOOD Neuts-81.9* Lymphs-10.7* Monos-6.4
Eos-0.7 Baso-0.3
[**2113-11-28**] 07:10AM BLOOD PT-15.0* PTT-30.8 INR(PT)-1.3*
[**2113-11-23**] 01:25PM BLOOD PT-28.0* PTT-36.3* INR(PT)-2.8*
[**2113-11-28**] 07:10AM BLOOD Glucose-103 UreaN-15 Creat-1.3* Na-141
K-3.9 Cl-109* HCO3-23 AnGap-13
[**2113-11-19**] 04:03AM BLOOD LD(LDH)-221 CK(CPK)-94 TotBili-0.4
DirBili-0.2 IndBili-0.2
[**2113-11-20**] 03:32AM BLOOD CK-MB-6 cTropnT-0.16*
[**2113-11-28**] 07:10AM BLOOD Mg-2.0
[**2113-11-19**] 04:03AM BLOOD Hapto-104
[**2113-11-19**] 04:05PM BLOOD TSH-2.0
[**2113-11-18**] 07:24PM BLOOD Lactate-2.3* K-5.3
ECHO [**11-20**]
Suboptimal image quality. Normal left ventricular cavity size
with regional systolic dysfunction most c/w multivessel CAD.
Mild mitral regurgitation.
Brief Hospital Course:
This is an 83 year old male with extensive CAD, CHF, CKD, and
a.fib presents with new onset bradycardia and hyperglycemia.
.
# Bradycardia: Unclear precipitant but his baseline EKG showed
RBBB and LAFB so any further conduction system degeneration
would likely result in complete heart block, likely infranodal,
which is more likely given his lack of response to atropine. No
signs of acute ischemia and cardiac enzymes were cycled to
confirm. According to his family, SOB is pt's anginal
equivalent.
Pt initially had temporary pacer wire placed after INR reversed
with FFP. Permanent pacemaker was placed the next morning, which
pt tolerated well and had no furthur arrhythmias. There was no
indication for ICD and warfarin was restarted prior to DC.
# GI bleed: On [**11-23**] pt passed some guaiac positive dark stool
with question of flecks of blood, in the setting of dropped
hematocrit to 24.2 Pt remained hemodynamically stable and was
transfused one unit of pRBCs. He was held over the weekend for
lowering of INR and prep for EGD and colonoscopy given unstable
hematocrit and anticoagulation. Monday with INR of 1.7, pt was
taken for EGD which showed gastritis and duodenitis with
biopsies taken, and also a colonoscopy with multiple polyps but
polypectomy not done and pt recommended to have repeat scope
with lower INR and better prep. Pt's hematocrit remained stable
and he did not have any more guaiac positive stools. On
discharge hematocrit was 27.9.
#Hyperglycemia: Cause was unclear as there was no signs of
infection on U/A or CXR and no localizing signs. [**Month (only) 116**] be a sign
of coronary ischemia. Patient denied missing medications and has
been well controlled on them prior. Pt was initially on insulin
drip for several hours and then was well controlled on insulin
sliding scale.
# Dementia and mental status changes: Pt showed signs of
delirium, with visual and auditory hallucinations in the ICU.
History of dementia with ongoing workup exacerbated by blindness
and ICU delirium. Recent MRI ([**9-11**]) showed microvascular
ischemia. No evidence of infection by fever or WBC, and neuro
exam was unchanged throughout. Pt responded well to Haldol 2mg
as needed at night. Delirium resolved once pt was transferred to
the floor.
# Acute on chronic renal failure: On presentation, Cr was
elevated to 2.5 from basline 1.7-1.9, thought to be secondary to
poor forward flow in setting of bradycardia. Renal function was
monitored and improved with pacing of heart rate. ACEi was
initially held and restarted prior to discharge.
# Hyponatremia: Pt with sodium 131 on admission likely due to
hyperglycemia, and resolved with control of BS.
# HTN: Initially home PO regimen was held due to
hypotension/bradycardia and restarted. Pt discharged on
beta-blocker, ACEi and lasix.
# CAD: On presentation troponins were slightly elevated, thought
to be secondary to renal failure. Pt was medically managed with
ASA, statin, ACEi, beta blocker once appropriate with blood
pressure and renal function.
# CHF: Restarted on home doses of ACEi, lasix and BB once
tolerated by blood pressure and renal function.
# PVD: Stable. Pt continued on Cilostazol
# Hyperlipidemia: Continued on statin
# Atrial fibrillation: Initially did not require rate control
due to presumed AV disease and heart block. Pt's coumadin was
held briefly for PPM placement, bridged with heparin and
coumadin restarted.
# Iron Def. Anemia: Stable at baseline, continue iron.
Medications on Admission:
ATORVASTATIN 10 mg daily
CILOSTAZOL 100 mg twice a day
FUROSEMIDE 80 mg daily
LISINOPRIL - 5 mg daily
METOPROLOL SUCCINATE 100mg PO daily
WARFARIN 5 mg daily
ASPIRIN - 81 mg daily
FERROUS SULFATE - 325 mg daily
Glipizide ER 10mg qAM 5mg qPM
MVI
Discharge Medications:
1. Outpatient Lab Work
Please check Chem 7, INR, hct on [**2113-12-1**] and call results to
Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 719**].
2. Cilostazol 100 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. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Glucotrol XL 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: Two (2)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
Disp:*60 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
8. Glucotrol XL 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO at bedtime.
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 5 days.
Disp:*1 bottle* Refills:*0*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. 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*
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Bradycardia
Dementia with transient Delerium
Acute on Chronic Renal Failure
Hypertension
Acute on Chronic Congestive Heart Failure
Peripheral Vascular Disease
Acute Blood Loss Anemia
Discharge Condition:
stable
Discharge Instructions:
You had a slow heart rate and a pacemaker was placed to keep
your heart rate in a normal range. Your kidney function worsened
but is now improving. Please get your labs drawn on Friday
[**12-1**] and have the results called to Dr. [**Last Name (STitle) **].
You had a colonoscopy that showed multiple benign looking
polyps. The colonoscopy will need to be repeated with a better
bowel prep and a INR of < 1.4 to remove these polyps. the
endoscopy of your stomach showed gastritis and you have been
started on pantoprazole to take twice daily to treat this.
New Medicines:
1. Glucatrol for your diabetes which is a long acting form of
Glipizide
2. Miconazole for the rash
3. Metoprolol was decreased
4. Furosemide and Lisinopril was unchanged
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Cardiology:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 7960**] Date/Time:
[**12-11**] at 11:30am.
[**Hospital **] clinic:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2113-11-30**]
11:00
.
Primary Care:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 13171**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2113-12-5**] 9:30
.
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2114-1-22**] 2:00
Completed by:[**2113-12-1**]
|
[
"42789",
"5849",
"2851",
"2761",
"41401",
"40390",
"5859",
"42731",
"4280"
] |
Admission Date: [**2170-12-28**] Discharge Date: [**2171-1-8**]
Date of Birth: [**2100-9-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2170-12-31**] Cardiac cath
[**2171-1-2**] Coronary artery bypass grafting x3, left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft to diagonal branch and the marginal branch
History of Present Illness:
The patient is a 70 year old female with history of DM,
hypertension, and recurrent pulmonary emboli who had an abnormal
stress test at [**Hospital3 **] and was transferred to [**Hospital1 18**] for
catheterization. The patient reports having intermittent chest
pain for the past 4 years. During stress testing, she developed
DOE and ST depressions in the inferior leads. Cardiac cath on
[**1-1**] at [**Hospital1 18**] revealed LM disease. She was referred for
revascularization. She is currently denies chest pain.
Past Medical History:
Diabetes Mellitus
Hypertension
Hyperlipidemia
Morbid obesity
Recurrent pulmonary emboli
Breast cancer s/p L mastectomy, XRT, and hormone therapy
Melanoma -- upper left arm, s/p resection
s/p L mastectomy 5 years ago
s/p melanoma resection 5 years ago
Umbilical hernia repair 10 years ago
Spinal Cyst removal
Social History:
Race: Caucasian
Last Dental Exam:: Upper dentures, has not seen a dentist in
several years
Lives with:Lives with husband, daughter, and daughter's
boyfriend.
Occupation:
[**Name2 (NI) 1139**]: Quit 6 years ago. Smoked 1-1.5 PPD previously.
ETOH: None
Family History:
Mother, Maternal grandmother, Brother -- DM and CAD
Father -- CAD
Siblings -- Sister with Parkinsons (deceased), sister with lung
disease (deceased), sister with DM (deceased)
Physical Exam:
Physical Exam
Pulse: Resp: 16 O2 sat: 99% RA
B/P Right: 114/60 Left:
Height:5'6" Weight: 110.4 kg
General:
Skin: Dry [x] intact [x] LE with chronic venous stasis changes
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] Distant breath sounds,
bibasilar crackles
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Obese, well healed umbilical scar
Extremities: Warm [], well-perfused [] Edema 2+ L>R
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2171-1-8**] 04:42AM BLOOD WBC-8.4 RBC-3.03* Hgb-9.2* Hct-27.3*
MCV-90 MCH-30.4 MCHC-33.8 RDW-17.1* Plt Ct-326
[**2170-12-29**] 08:05AM BLOOD WBC-8.1 RBC-4.03* Hgb-12.5 Hct-36.5
MCV-91 MCH-31.1 MCHC-34.3 RDW-15.4 Plt Ct-317
[**2171-1-8**] 04:42AM BLOOD PT-23.0* INR(PT)-2.2*
[**2170-12-29**] 08:05AM BLOOD PT-23.7* PTT-25.5 INR(PT)-2.2*
[**2171-1-8**] 04:42AM BLOOD UreaN-32* Creat-0.9 Na-136 K-4.4 Cl-100
[**2170-12-29**] 08:05AM BLOOD Glucose-126* UreaN-36* Creat-1.1 Na-139
K-4.4 Cl-101 HCO3-25 AnGap-17
[**2170-12-31**] 09:25PM BLOOD ALT-21 AST-23 LD(LDH)-180 AlkPhos-74
TotBili-0.4
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 89624**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 89625**] (Complete) Done
[**2171-1-2**] at 2:19:51 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: [**2100-9-21**]
Age (years): 70 F Hgt (in): 66
BP (mm Hg): 110/70 Wgt (lb): 250
HR (bpm): 72 BSA (m2): 2.20 m2
Indication: CABG
ICD-9 Codes: 786.05
Test Information
Date/Time: [**2171-1-2**] at 14:19 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
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 #: 2011AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: *3.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.0 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. No ASD by 2D or
color Doppler.
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: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Focal calcifications in aortic arch. Normal descending
aorta diameter. Focal calcifications in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace 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.
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. 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%).
Right ventricular chamber size and free wall motion are normal.
T
he ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. T
he aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**Known firstname **] [**Known lastname **].
Post_Bypass:
Normal biventricular systolic function.
Remaining findings are the same as prebypass.
Intact throacic aorta.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2171-1-8**] 09:25
?????? [**2162**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2170-12-28**] for further
management of her chest pain and abnormal stress test. Her
coumadin was stopped and she was placed on lovonox as a bridge
for cardiac catheterization. On [**2170-12-31**] Mrs. [**Known lastname **] underwent a
cardiac catheterization which revealed severe left main and
multivessel coronary disease. Given the severity of her disease,
the cardiac surgical service was consulted for surgical
revascularization. She was worked-up in the usual preoperative
manner including a carotid duplex ultrasound which showed [**Doctor Last Name 37282**]
then 40% stenosis of her bilateral internal carotid arteries.
She was noted to have a urinary tract infection for which she
was treated with ciprofloxacin. On [**2171-1-2**], Mrs. [**Known lastname **] was taken
to the operating room where she underwent coronary artery bypass
grafting to three vessels (Left internal mammary artery grafted
to left anterior descending artery. Saphenous vein grafted to
Diagnal/Obtuse Marginal). Please see operative note for details.
Cardiopulmonary Bypass time= 62 minutes. Cross Clamp time= 51
minutes. Postoperatively she was taken to the intensive care
unit for monitoring. Over the next 24 hours, she awoke
neurologically intact and was extubated. Beta blockade, aspirin
and a statin were resumed. Her coumadin was also resumed given
her history of pulmonary embolism. Her diabetes medications were
resumed and titrated based on her blood sugars. All lines and
drains were discontinued in a timely fashion. She was
transferred to the step down unit for further recovery. Physical
therapy was consulted for evaluation of her strength and
mobility. She was gently diuresed towards her preoperative
weight. Ms. [**Known lastname **] continued to make steady progress and was
discharged to LifeCare Center of [**Hospital3 7571**]rehabilitation
on postoperative day #6. All follow up appointments were
advised. Her coumadin will be managed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42967**]
once she has been discharged from rehabilitation. Her lisinopril
can be resumed as an outpatient as her blood pressure
tolerates.
Medications on Admission:
Medications at home:
Atenolol 25 mg PO daily
Amlodipine 10 mg PO daily
HCTZ 25 mg PO daily
Lisinopril 40 mg PO daily
Simvastatin 10 mg PO daily
Warfarin 2.5 mg PO daily - last dose Friday [**12-28**] - followed by
PCP
[**Name Initial (PRE) 89626**] 1000 mg PO BID
Lantus 50 units QHS
Humalog sliding scale TID
Multivitamin 1 tab PO daily
Calcium 500 mg PO daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. warfarin 1 mg Tablet Sig: As instructed for Goal INR 2.0-2.5
Tablets PO Once Daily at 4 PM: Please adjust dose as needed for
goal INR 2.0-2.5. Discharge dose is 2.5mg daily.
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14
days.
9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 14
days.
10. Insulin Sliding Scale and Fixed Doses
Please see attached sheet
11. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO
twice a day.
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
14. insulin glargine 100 unit/mL Cartridge Sig: One (1)
Subcutaneous Q AM: 40 units Q AM.
15. insulin glargine 100 unit/mL Cartridge Sig: One (1)
Subcutaneous Q PM: 30 units Q PM.
16. warfarin 1 mg Tablet Sig: [**Name8 (MD) **] MD Tablet PO DAILY (Daily):
INR 2-2.5 for history of recurrent PE.
17. warfarin 1 mg Tablet Sig: 0.5 Tablet PO once for 1 doses.
18. insulin lispro 100 unit/mL Cartridge Sig: One (1)
Subcutaneous ACHS: per Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
lifecare center of [**Hospital3 **]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
Diabetes Mellitus
Hypertension
Hyperlipidemia
Morbid obesity
Recurrent pulmonary emboli
Breast cancer s/p L mastectomy, XRT, and hormone therapy
Melanoma -- upper left arm, s/p resection
s/p L mastectomy 5 years ago
s/p melanoma resection 5 years ago
Umbilical hernia repair 10 years ago
Spinal Cyst removal
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2171-1-31**] 1:00
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-22**] weeks. A message has
been left at his office to call you to schedule an appointment.
if you do not hear from him, please call to schedule. ([**Telephone/Fax (1) 72829**]
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42967**] in [**3-26**] weeks [**Telephone/Fax (1) 22235**]
**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: history of recurrent PE
Goal INR: >2
First draw: daily->1st draw [**2171-1-9**]
Results to phone fax
Completed by:[**2171-1-8**]
|
[
"41401",
"5990",
"4019",
"2724",
"4240",
"V5861"
] |
Admission Date: [**2161-8-11**] Discharge Date: [**2161-8-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
left arm pain and atrial flutter
Major Surgical or Invasive Procedure:
[**2161-8-11**] Left brachial thromboembolectomy
[**2161-8-11**] Right PICC placement
[**2161-8-12**] Left forearm fasciotomy
History of Present Illness:
[**Age over 90 **] y/o lady with h/o aflutter presented to OSH with cold left
arm. She was found to be aflutter with RVR and was started on
dilt drip and heparin drip. She was transfered to [**Hospital1 18**] for
surgical eval. Patient underwent left brachial thrombectomy by
vascular surgery. During surgery her HR was in 60-70s per
Anesthesia however rebounded to 120s in PACU. She was given 15
mg IV dilt bolus and was started on a dilt drip in PACU. She was
transferd to the floor for further managment.
.
On arrival to the floor patient was found to be unresponsive to
verbal stimuli. She will occasionally open her eyes. She did not
have a gag reflex and had diffuse rhonchi. She was triggered.
She received 10 of IV morphine (total) and some dilaudid in
PACU. ABG was 7.24/58/236 c/w respiratory acidosis. She received
narcan IV 0.5 mg once and her mental status and gag reflex
improved. She was complaining of left upper extremity pain.
.
Patient was recently seen at OSH with a possible eye infection
and might have left AMA. The records are not available
currently. Patient has memory confusion problems at baseline,
however could ambulate and dress herself at home.
.
Patient is a poor historian and unable to give a good history.
Past Medical History:
CAD
H/o aflutter (per son, at least once ten years ago and another
episode in setting of ?eye infection)
Depression
Dementia
Trigeminal Neuralgia
Left eye infection
?S/p left eye surgery
Social History:
Lives with son and daughter-in-law. Unattended during day when
family at work although a family member will usually check in at
lunchtime. H/o smoking, quit in her 60s. No EtOH or drug use.
Family History:
N/C
Physical Exam:
On discharge:
VS: BP 148/64 HR 84 RR 16 O2 sat 95% RA
GENERAL: in NAD, difficult to understand speech, A and O x 1
HEENT: MMM, oropharynx clear
NECK: supple, no JVD
CARDIAC: S1S2 RRR
LUNGS: CTA bilaterally
ABDOMEN: Soft, NTND.
EXTREMITIES: LUE swollen, radial pulse 2+ on left, dressed with
erythema/ecchyosis over anterior aspect of LUE; 2+ pulses
throughout
NEURO: CN II-XII intact, moves all four extremites spontaneously
Pertinent Results:
[**2161-8-19**] WBC-10.2 RBC-2.85* Hgb-8.9* Hct-26.4* MCV-93 MCH-31.3
MCHC-33.7 RDW-16.7* Plt Ct-309
[**2161-8-19**] Plt Ct-309
[**2161-8-19**] PT-24.7* PTT-31.2 INR(PT)-2.4*
[**2161-8-19**] Glucose-138* UreaN-86* Creat-3.3* Na-140 K-3.7 Cl-101
HCO3-25 AnGap-18
[**2161-8-12**] CK(CPK)-[**Numeric Identifier 83288**]*
[**2161-8-17**] CK(CPK)-1874*
[**2161-8-19**] Calcium-9.8 Phos-3.6 Mg-2.3 Iron-PND
TTE - Mild calcific aortic stenosis. Normal global biventricular
systolic function. Mild pulmonary hypertension.
Brief Hospital Course:
[**Age over 90 **] yo woman with history of dementia, coronary artery disease,
paroxysmal atrial flutter who was transferred to [**Hospital1 18**] for left
upper extremity thrombectomy and atrial flutter with rapid
ventricular response complicated by worsening renal failure,
rhabdomyolysis status post left upper extremity fasciotomy.
# Left brachial thrombus complicated by compartment syndrome,
Rhabdomyolysis
- The patient was found to have cool, pulseless left arm
extremity and taken to the operating room by Vascular Surgery on
[**2161-8-11**] for left brachial thromboembolectomy. The patient
developed decreasing arm sensation and strength over [**2161-8-12**] with
development of compartment syndrome, likely due to reperfusion
injury, and was taken to the operating room by Plastics for
fasciotomy. Following the fasciotomy, the patient was followed
by plastics for wound management, and received heparin for
anti-coagulation. The patient was transitioned to oral
anti-coagulation, and INR at discharge was 2.4 on warfarin 2 mg
daily. The patient will be followed by the hand clinic at
rehab.
# Atrial flutter
- The patient has a histroy of atrial flutter and was found to
be in rapid ventricular response prior to transfer to [**Hospital1 18**] and
was started on a diltiazem drip. The rate improved in the
operating room on sedation; following transfer to the cardiac
unit post-operatively, the patient again had rapid ventricular
response. The patient was transitioned back to home metoprolol
as rate controlled off diltiazem drip. The patient's home
digoxin was discontinued as digoxin level rose to 2.8 in setting
of acute renal failure, and decreased to 2.4 after
discontinuation of digoxin. Of note, digoxin reportedly was
started only 1 month ago and may have been supratherapeutic as
patient had described vision changes although dig level only 0.7
on admit. The patient's rate remained well controlled following
transfer to the general medical floor on home metoprolol
regimen.
# Acute renal failure
- The patient's baseline was unknown but was 1.2 on admission.
The creatinine continued to rise with declining urine output
progressing to anuria in setting of difficulty obtaining
intravenous access and rhabdomyolysis from the compartment
syndrome. The urine sediment consistent with ATN. Duloxetine,
gabapentin, and digoxin was discontinued, and not restarted at
time of discharge. Given rising creatinine despite initiation
of aggressive intravenous fluids once PICC was placed,
hemodialysis was considered and family amenable. However, the
patient was responsive to diuresis with diuril and high dose
lasix with improvement in urine output that was greater than 100
cc/hour. Following transfer from the ICU, intravenous fluids
and diuresis was discontinued, the patient was started on a
dysphagia diet, the creatinine continued to improve with
adequate urine output. Creatinine at time of discharge was 3.3
and down-trending from a peak of 4.8.
# Rhabdomyolysis
- The patient reportedly was found in bed with left arm pain per
her son although circumstances leading up to this unclear.
Creatinine kinase was 1405 on admission but increased rapidly as
initially unable to obtain vascular access. Interventional
radiology-guided PICC was placed successfully, and the patient
was hydrated aggressively first with normal saline, then
switched to normal bicarbonate. Peak creatinine kinase was
[**Numeric Identifier 83288**] on evening of [**2161-8-12**] and was downtrending at 1874 on
[**2161-8-17**].
# Hypocalcemia
- Patient had low calcium levels in the setting of
rhabdomyolysis, and calcium was repleted throughout the hospital
course.
# CAD Native Vessel
- The patient has an unspecified history of coronary artery
disease per her son. It was felt that the elevated cardiac
enzymes were difficult to interpret in the setting of worsening
renal failure, and acute coronary syndrome was considered
unlikely. The patient may have had some demand ischemia in the
setting of atrial flutter with rapid ventricular response.
Cardiac markers were decreasing during hospitalization,
metoprolol, aspirin, and heparin/coumadin were given, and
transthoracic echo showed no wall motion abnormalities with
preserved biventricular systolic function, with an estimated
ejection fraction of 55%.
# Delerium, Dementia - Senile
- The patientt has dementia at baseline, and there were no acute
findings on CT head. The patient was thought to be somnolent in
setting of OR sedation with some improvement after receving
Narcan. Again noted to be somnolent after second OR procedure
although improved back to baseline without Narcan and with
continued improvement of above medical problems. The TSH was
normal.
# Conjunctivitis
- The patient had a purported eye infection and was continued on
the antibiotic ointment used prior to transfer.
# Mild Malnutrition
- Following nasogastric tube removal, a speech and swallow
evaluation 2 days prior to discharge cleared the patient for a
dysphagia diet with close one to one supervision. The patient
was taking PO at discharge.
Medications on Admission:
Aspirin 325 mg daily
Metoprolol 50 mg [**Hospital1 **]
Digoxin 0.125 mg daily
Cymbalta 40 mg daily
Gabapentin 300 mg [**Hospital1 **]
Erythromycin eye ointment
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
Sea View Retreat
Discharge Diagnosis:
Primary Diagnoses:
left brachial thrombus s/p thrombectomy
compartment syndrome s/p fasciotomy
a. flutter with RVR
rhabdomyolysis
acute renal failure
Secondary Diagnoses:
CAD
H/o aflutter (per son, at least once ten years ago and another
episode in setting of ?eye infection)
Depression
Dementia
Trigeminal Neuralgia
Left eye infection
Discharge Condition:
stable and improved
Discharge Instructions:
You were admitted to the hospital for left arm pain. A blood
clot was found in your arm, and you had surgery to remove the
clot. During the recovery process, your arm developed high
pressures, and you had to have surgery to release that pressure.
At this time, your kidney function declined, and you needed IV
fluids and medication. You stayed in the ICU for a short amount
of time, and then you were transferred to the general medicine
floor. There, you continued to improve, and you were discharged
on [**2161-8-19**] to an extended care facility for continued care.
You will follow up with the hand clinic, see appointment below.
Dr. [**Last Name (STitle) 8448**], your regular doctor, will see you in the rehab
center.
Please have the staff at the rehab center call Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8448**] at [**Telephone/Fax (1) 83289**] to set up an appointment.
You were discharged on a new medication, coumadin, and your
cymbalta and neurontin were discontinued when you left the
hospital.
Please call or have your caretakers call if you develop left arm
pain/numbness/weakness or your arm becomes cold, fevers or
chills, or any other concerning medical symptoms.
Followup Instructions:
Please have the staff at the rehab center call Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8448**] at [**Telephone/Fax (1) 83289**] to set up an appointment.
Dr.[**Name (NI) 27488**] appointment:
Specialty: Plastic Surgery Clinic
Date and time: [**8-28**] at 1pm
Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 4652**]
Special instructions if applicable:
|
[
"5845",
"2762",
"41401",
"311",
"V1582"
] |
Admission Date: [**2126-4-30**] Discharge Date: [**2126-5-5**]
Service: ACOVE
CHIEF COMPLAINT: Melena.
HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
woman without a history of GI bleed who presents with new
onset melena at approximately 3:00 a.m. on the day of
presentation. She denied nausea or vomiting but states that
she has had crampy abdominal pain. She has been taking Vioxx
50 mg p.o. q.d. episodically over the last few weeks for
right shoulder pain. She denied dizziness or
lightheadedness. No chest pain or shortness of breath. She
came to [**Hospital1 18**] ED where NG lavage in the Emergency Room
reportedly was negative. No signs of orthostatic changes in
blood pressure were noted. She was then admitted to the
Medicine ICU for further evaluation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hiatal hernia.
3. Meniere's disease.
4. DJD.
5. Diverticulitis.
6. Chronic renal insufficiency with a baseline creatinine of
2.2.
7. Osteoporosis.
8. GERD.
9. Glaucoma.
10. Hyperlipidemia.
11. Status post bilateral total hip replacement.
ADMISSION MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Lasix, dose unknown.
3. Metoprolol 50 mg p.o. b.i.d.
4. Vioxx 50 mg p.o. q.d., although the patient states that
she has only taken a few pills.
SOCIAL HISTORY: No tobacco or alcohol use. She was never
married and lives alone. She is independent in all
activities of daily living. The patient walks with a walker
and cane while at home.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood
pressure 187/90, heart rate 64, respiratory rate 18, oxygen
saturation 100% on 2 liters nasal cannula. General: The
patient is pleasant and conversant. She was in no apparent
distress. She was well nourished and well developed. HEENT:
The head was normocephalic, atraumatic. The extraocular
muscles were intact. The pupils were equal, round, and
reactive. The oropharynx was dry. The sclerae were
anicteric and were not pale. Neck: Supple, no
lymphadenopathy. Lungs: Clear to auscultation bilaterally.
Cardiovascular: Regular rate, no murmurs, rubs, or gallops
noted. Abdomen: Soft, nontender, nondistended, normoactive
bowel sounds. Extremities: No clubbing, cyanosis or edema.
Neurologic: She was alert and oriented times three. Cranial
nerves II through XII were intact. Motor strength was
4+-[**6-17**], symmetrical lower extremities.
LABORATORY VALUES ON PRESENTATION: White blood cell count
9.7, hematocrit 40.5, MCV 93, platelets 189,000. PT 12.7,
PTT 27.1, INR 1.1. Sodium 139, potassium 3.4, chloride 99,
bicarbonate 26, BUN 60, creatinine 3.2, glucose 112, ALT 9,
AST 14, LDH 201, alkaline phosphatase 105, amylase 107, total
bilirubin 0.6, lipase 48, calcium 10.3, albumin 4.3. H.
pylori antibody test negative.
IMPRESSION: The patient is a [**Age over 90 **]-year-old female with
multiple medical problems and no history of gastrointestinal
bleed who presents with new onset melena starting on the date
of admission.
HOSPITAL COURSE: 1. GASTROINTESTINAL: Mrs. [**Known lastname 25345**] was
admitted to the Intensive Care Unit for emergent endoscopy.
The initial EGD showed a single ulcer in the prepyloric
region with clotted blood adherent to the ulcer; 4 cc of
1:10,000 epinephrine was injected at the ulcer site with good
hemostasis. She was monitored overnight in the Intensive
Care Unit with hemodynamic stability and stable crit between
36-40. She was then transferred to the ACOVE Service for
further observation.
On the day after transfer, hospital day number three, she was
noted to have a drop in her hematocrit from 37 to 31 and a
repeat endoscopy was performed which showed a visible vessel
in the prepyloric region suggestive of recent bleeding.
Again, 1-2 cc of 1:10,000 epinephrine was injected for
hemostasis. BICAP electrocautery was applied as well. Her
hematocrit was followed q. six hours thereafter and found to
remain stable in the 30-32 range. She continued to have
melena throughout the hospitalization.
She was started on Protonix 40 mg p.o. b.i.d. and instructed
to avoid all NSAIDs, [**Doctor Last Name **]-2 inhibitors, or aspirin. An H.
pylori antibody was sent and found to be negative.
2. CARDIOVASCULAR: Once hemodynamic stability was proven,
she was restarted on her Lopressor 25 mg p.o. b.i.d. with
moderate control of blood pressure. She had no episodes of
hypotension. Her Lasix was not restarted at this time
secondary to evidence of dehydration.
3. RENAL: Ms. [**Known lastname 25345**] has evidence of chronic renal
insufficiency with a baseline creatinine of 2.2. On
admission, her creatinine was mildly elevated to 3.2 which
responded to intravenous fluids. It was likely that she was
dehydrated secondary to blood loss. Her creatinine remained
stable around baseline for the remainder of the
hospitalization.
4. FLUIDS, ELECTROLYTES, AND NUTRITION: Following second
endoscopy, a clear liquid diet was initiated and was advanced
as tolerated. She had no difficulties.
5. DISPOSITION: Physical Therapy evaluated the patient
while hospitalized and found some evidence of deconditioning
and unsteadiness. She was determined safe to be discharged
to home with home PT and home safety evaluation.
6. HEMATOLOGY: Acute blood loss from GI bleeding as
described above. She required no transfusions during this
hospitalization.
7. PAIN CONTROL DUE TO OSTEOARTHRITIS AND DEGENERATIVE JOINT
DISEASE: She was taking NSAIDs medication namely Vioxx while
at home. She was instructed to continue taking Tylenol only
for pain relief. She is to follow-up with Dr. [**Last Name (STitle) 16258**] for
further decisions concerning pain medication.
DISCHARGE CONDITION: Stable and improved.
DISCHARGE DIAGNOSIS:
1. Gastrointestinal bleed secondary to prepyloric ulcers
thought secondary to NSAID use.
2. Deconditioning.
3. Hypertension.
4. Degenerative joint disease.
5. Acute on chronic renal insufficiency, resolved.
6. History of gastroesophageal reflux disease.
7. History of hyperlipidemia.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. b.i.d.
2. Lopressor 50 mg p.o. b.i.d.
3. Tylenol 500 mg q. six hours p.r.n.
4. Lasix at unknown dose.
DISCHARGE DISPOSITION: Ms. [**Known lastname 25345**] is to be discharged
home with follow-up with home physical therapy and safety
evaluation. She is to follow-up with Dr. [**Last Name (STitle) 16258**] in one week.
Additionally, she is to follow-up with [**First Name8 (NamePattern2) 1586**] [**Doctor Last Name **] in GI for
repeat endoscopy in four to six weeks.
[**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17144**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2126-5-3**] 06:39
T: [**2126-5-4**] 19:00
JOB#: [**Job Number 25346**]
|
[
"53081",
"4019",
"2724"
] |
Admission Date: [**2128-1-3**] Discharge Date: [**2128-1-27**]
Date of Birth: [**2081-11-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
46 M w/ h/o metastatic colorectal CA with widespread mets
including spinal mets w/ h/o radiographic cord compression at T5
p/w sensation/sensory changes below the nipple line
corresponding to the T5 level, and progressive lower extremity
weakness.
Major Surgical or Invasive Procedure:
1. Transpedicular decompression, T5 and L1.
2. Multiple thoracic laminotomies.
3. Fusion of T1 to L3.
4. Segmental instrumentation T1 to L3.
5. Autograft.
6. Epidural catheter placed.
History of Present Illness:
46 M with h/o metastatic colorectal CA and prior radiation to
the spine who has sudden onset of sensation changes from the
nipple level down and loss of ability to ambulate after a fall.
Prior to this the patient was ambulating with a cane and
assistance.
Pt was admitted to [**Hospital6 204**] and spine MRI was
performed, whose images we have reviewed. There is a dominant
lesion at approximately T5 in the right posterior/lateral
pedicle and invading into the spinal cord. There are areas of
metastatic disease throughout the spine.
Per patient report, he and neurosurgery were hesitant to operate
because of his low platelet count previously. Patient was
transferred to [**Hospital1 18**] for further management. Of note, the
patient had already received ~4000cGy to the T5 spine and his
cervical, lumbar, and S1 levels. He received cyperknife to L1
level late [**7-14**].
Past Medical History:
--Metastatic Colon CA with extensive bony metastases to his
spine, ribs, left humerus, right humerus (dx [**2123**]).
--- s/p XRT
--- s/p stereotactic cingulotomy.
--- s/p Cyberknife treatment(at [**Hospital1 18**]) at L1
--- s/p Avastin and 5-fluorouracil treatment. Followed by
Radiation Oncology at [**Hospital6 204**](Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **]
-- Falls
-- s/p humeral fracture (bilat) s/p ORIF
-- Thrombocytopenia (platelet count on admit [**12-31**] to LGH 12)
-- Ulcerative colitis
Social History:
Married w/ 3 children, former home constructor, no tob, rare
ETOH. His children are 18,11,7. He has a great support system
at home.
Family History:
GM with breast CA
GF with skin CA
Physical Exam:
On arrival to [**Hospital1 18**]
97.5 110/70 70 20 97% RA
patient lying in bed in NAD
OP clear without evidence of bleeding or oral lesions
neck supple
Regular nl S1 S2 no MRG
CTA bilaterally
soft NT/ND +BS colostomy site c/d/i
no HSM
+staples along left humerus with bruising down left arm to
hands, no swelling, staple site c/d/i
Upper extremity strength 5/5 bilaterally
LE weak bilaterally
Decreased sensation to light touch below the nipple level
Pertinent Results:
Imaging:
[**2128-1-20**] RUQ U/S - Limited study. Multiple likely metastatic
lesions in the liver. No biliary ductal dilation. Gallbladder
suboptimally visualized, but no evidence to suggest
cholecystitis.
[**2128-1-20**] CT Head - Probable metastatic lesions bilaterally in the
deep frontal white matter. See prior MRI with gadolinium for
better assessment. Multiple lytic and sclerotic lesions
involving the skull, skull base, and cervical spine, highly
suspicious for metastases.
[**2128-1-20**] CXR - Lungs clear. Heart size normal. There is no
pleural effusion. Expansile left lower posterior rib and
pleural thickening around healed left lateral rib fracture are
unchanged. Spinal stabilization rods in place.
[**2128-1-20**] MRI - Skull base metastatic foci, including a locale
adjacent to the right trigeminal ganglion. Status-post
cingulotomies, but no evidence for brain parenchymal metastases
Cultures:
[**2128-1-19**] Blood - pending
[**2128-1-19**] Urine - contaminated
[**2128-1-19**] Blood - pending
[**2128-1-17**] Blood - no growth
[**2128-1-17**] Urine - enterococcus
[**2128-1-19**] Blood - NGTD
[**2128-1-19**] Urine - NGTD
Brief Hospital Course:
At [**Hospital6 204**], lumbar CT scan showed diffuse
osteopenia and lesions at L4-5 with compression fracture at L1
and fracture at L5. He reportedly had a T5 cord compression of
which no reports were sent. Neurosurgery (OSH) felt he was not a
good operative candidate secondary to his thrombocytopenia, he
was transferred here for possible gamma knife treatment.
Patient's platelet count was 12 on admission -->6 units of
platelets. He has been febrile intermittently and neutropenic.
He was started on tequin 400 mg IV qd for his bandemia. He
continued steroids. He has required 11 units of packed red blood
cells. and multiple units of platelets: good response in plt
count (max 140), but not sustained.
He received decadron 6mg IV q 6 hours for cord compression.
Patient was taken to the OR on [**2128-1-4**] for. Multiple thoracic
laminotomies, fusion of T1 to L3, segmental instrumentation T1
to L3, autograft, epidural catheter placement.
Patient received ancef x 48 hours peri-operatively and
Prednisone 10 q 8. Pain service was consulted for epidural
management.His postoperative exam on transfer to the ICU was as
follows:
IP Q HS TA [**Last Name (un) 938**] GS
R 4 4+ 4+ 5 5 4+
L 4 4+ 4+ 5 5 4+
SILT L2-S1 bilaterally. The epidural was d/c'd on [**1-5**].
By POD #3, patient continued to improve, was out of bed sitting
in a chair and pain [**Last Name (un) 19692**] well controlled with a PCA. On POD #4
patient was fit with a TLSO brace and continued to make progress
slowly with physical therapy. On [**2128-1-9**] his drains were
discontinued. On [**2128-1-10**] patient was transfused 2 units of
PRBC for hematocrit = 22 and symptomatic with tachycardia. On
[**2128-1-11**] he was transfused 6 pack of platelets for plt=25.
He recovered well until [**1-11**] when he developed SOB/CP/EKG
changes and was transferred to the ICU. Trop x 3 was negative
and CTA was negative. He was noted to have an epidrual hematoma
and underwent I and D on [**1-12**] (POD 3). The hemovac drain was
d/c'd [**1-14**] and he has had no further bleeding episodes.
The patient was transferred to the medical service on [**2128-1-16**].
From a cord compression standpoint, he remained stable s/p
laminectomy and epidural hematoma evacuation. His bilateral
asymetrical LE motor deficits improved slowly with physical
therapy. PT worked with the patient almost daily until
discharge to a rehab facility. He was originally on a PCA for
pain control. We were able to successfully switch the patient
to a fentanyl patch with liquid oxycodone for breakthrough pain.
The patient continued to complain of trigeminal neuralgia that
had been worsening over the past month. A CT head was ordered
to evaluate for any signs of metastatic disease. It showed
numerous skull mets, but no parychemal involvement. There were
skull mets close to the trigeminal nucleus but it remained
unclear if this was the cause of his pain. Radiation Oncology
felt there was no need for treatment at this time. The patient
also had new findings of horners syndrome. A neurooncology
consult was called. They requested MRI imaging of the orbits
and an LP to look for spread of the cancer to the CSF. The MRI
of the orbits was unremarkable. Because the patient is not
currently a candidate for chemotherapy (low counts, advanced
disease), he opted against the LP because it would not change
our current management. He was started on neurontin for the
trigeminal neuralgia but it was discontinued because it was not
providing relief.
Further, during his stay on the medical service, the patient
continued to spike low grade fevers. He was treated with vanco
and switched to levo when sensitives showed pansensitive
enterococcus UTI. He was treated with a full 10 day course. He
continued to spike fevers which were eventually attributed to
hematoma breakdown (he had numerous large hematoma throughout
his body). All cultures (other than the Urine showing
enterococcus) remained negative to date. We decided to not
empirically treat unless he spiked greater than 101. During the
time on the medicine service he was only neutropenic for 24
hours.
Because of the UTI, we removed the patients foley and gave him
several voiding trials. He continued to retain ([**2-12**] effects of
the cord compression) and he was discharged with a foley in
place.
Throughout his hospital course the patient was thrombocytopenic.
He had the extensive hematoma formation at his surgical site
with a platelet count of 24. Because of this, it was decided
that the transfusion threshold would be to keep plts >50. His
thrombocytoenia was likely multifactorial with a significant
contribution from marrow suppression from XRT and chemotherapy.
Other contributors include prolonged illness and drug effect.
Every 2-3 days his platelets would drift to <50 and require
transfusion. He will need continual platelet tranfusions at
rehab and at home (will be under bridge to hospice) to keep
plts>50.
The patient also was anemia which again was thought to be
multi-factorial from: 1) bone marrow suppression from XRT and
chemotherapy (note retic=0.6) 2) anemia of chronic disease (note
alb=2.8) 3) peri-operative blood loss 4) marrow infiltration by
cancer (significant bony destruction on imaging, although no
nucleated RBCs on smear). His threshold for transfusion was to
keep hct>28. He required much less frequent PRBC transfusion
than platelets. He required only 1 unit PRBC during his week on
the medical service. His hct will need to be checked every few
days after discharge and transfused for hct<28. There was
concern that the patient might have been hemolyzing because his
labs showed an elevated LDH, low haptoglobin, and increased
bilirubin. His hct remained relatively stable and his LDH
slowly trended down. The LDH was attributed to hematoma
breakdown (hematomas on left arm and right flank). Because the
patients TBil continued to rise, a RUQ U/S was obtained and
showed multiple liver mets. The primary oncologist confirmed
that these lesions were new. He showed no signs of biliary
obstruction. The patient will follow up after discharge with
his primary oncologist at [**Hospital3 **] for further treatment.
Because of the new metastatic disease that was identified in the
skull and liver, we consulted [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] to discuss hospice
care. The patient was made aware that his disease had
progressed and there may not be any further treatement
available. He understood and continued to want aggressive
management. He expressed his desire to get stronger at rehab
and get home to his family. He remained full code throughout
his hospital admission. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] contact[**Name (NI) **] the patients [**Name (NI) 269**]
service at home and his nurse is a hospice nurse. The patient
will leave rehab with bridge to hospice so that he can continue
transfusion and other treatment options.
Medications on Admission:
Dilaudid
Oxycodone 30mg PO q4Hr
Bowel regimen PRN
Prednisone 4mg PO daily
Zofran PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q3H (every 3
hours) as needed for pain.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q3H (every 3
hours) as needed for pain.
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
8. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane QID (4 times a day).
11. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) Patch 72HR
Transdermal Q72H (every 72 hours).
12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea
13. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] OF [**Hospital1 **]
Discharge Diagnosis:
# Metastatic colon cancer to the spine and paraparesis.
# Cord Compression s/p laminectomy ([**1-3**])
# Epidural Hematoma s/p evacuation ([**1-11**])
# Colorectal Cancer with known bony mets and new Liver and skull
Mets
# Horner's syndrome: (patient defers LP to look for malignant
etiology as not currently a chemo candidate)
# Pancytopenia: ([**2-12**] large doses of chemo + XRT)
# Neutropenia
# Intra-hepatic cholestasis: [**2-12**] liver mets
# Trigeminal Neuropathy: skull bony mets may be etiologic
# Urinary retention
# Pain Syndrome
# HTN
# Enterococcus UTI
# Hyponatremia
Discharge Condition:
stable, progressing with physical therapy
Discharge Instructions:
**[**Name8 (MD) 138**] M.D. for redness or drainage from wound, breakdown of
wound, fever, severe headache, change in neurological status,
dizziness, weakness, sensory changes, questions or concerns.
**Please take all medications as prescribed.
Followup Instructions:
**Follow-up with Dr. [**Last Name (STitle) 363**] in the orthopaedic spine surgery
clinic within 1 week of leaving rehab. Please call clinic to
schedule [**Telephone/Fax (1) 1228**]. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 66052**]
Call to schedule appointment
**Please followup with Dr.[**Last Name (STitle) 26683**] within 1-2 weeks of leaving
rehab.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
"5990",
"2761"
] |
Admission Date: [**2121-8-28**] Discharge Date: [**2121-9-10**]
Date of Birth: [**2056-5-14**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
CC: weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 65 yr old female with hx of type I DM, hyperthyroidism, PVD
who presents with weakness, difficulty controlling blood sugars.
Pt states that her symptoms started on [**8-17**] when she noted
severe fatigue. Since that time, her appetite has decreased but
her fingersticks have been elevated, requiring higher doses of
humalog. For example, this am, she required 45units (15U x 3)
of Humalog for glucose>200 despite eating almost nothing. Pt
also complains of dizziness, esp when standing, nausea and some
mild lower abd cramping. No fevers, chills, night sweats,
diarrhea, dysuria. Pt notes that her freq of urination has
decreased and her po intake of fluids has also decreased as it
causes nausea.
Past Medical History:
PMH:
1. Recurrent UTIs for which she takes prophylactic Bactrim.
2. type 1 diabetes. She was diagnosed 50 years ago. Her
diabetologist is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Last Name (un) **] Center. Recent
HbA1c 9.0
3. hypothyroidism.
4. Peripheral vascular disease, status post left lower extremity
bypass.
5. High cholesterol
6. Aortic stenosis
7. Osteopenia
8. hx of tick bite last year (treated empirically)
Social History:
no tobacco, no alcohol, lives alone (husband passed away sev
months ago)
Family History:
DM; mother died of CHF, father died of lung dz
Physical Exam:
temp 98.6, BP 167/70 (lying) --> 166/80 (sitting), HR 100, R
12, O2 100% RA
Gen: NAD, pleasant
HEENT: PERRL, EOMI, MM dry
Neck: jug veins flat
CV: RRR, [**4-6**] harsh systolic murmur at RUSB, radiating to
carotids
Chest: clear
Abd: +BS, soft, NTND
Ext: no edema, 1+ DP on left, nonpalp on right; sensation intact
Skin: tan but not hyperpigmented in creases; several areas of
circular, blocthy erythema onn back, upper chest, legs, arms
Neuro: CN 2-12 intact
Pertinent Results:
[**2121-8-28**] 11:59PM GLUCOSE-254* NA+-127*
[**2121-8-28**] 11:55PM CK(CPK)-51
[**2121-8-28**] 11:55PM CK-MB-NotDone cTropnT-<0.01
[**2121-8-28**] 11:55PM WBC-12.4* RBC-3.95* HGB-11.5* HCT-32.5*
MCV-82 MCH-29.1 MCHC-35.4* RDW-12.0
[**2121-8-28**] 11:55PM PLT COUNT-314
[**2121-8-28**] 07:40PM URINE HOURS-RANDOM UREA N-191 CREAT-35
SODIUM-27 POTASSIUM-19 TOT PROT-6 PROT/CREA-0.2
[**2121-8-28**] 07:40PM URINE HOURS-RANDOM
[**2121-8-28**] 07:40PM URINE OSMOLAL-173
[**2121-8-28**] 07:40PM URINE GR HOLD-HOLD
[**2121-8-28**] 07:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2121-8-28**] 07:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
[**2121-8-28**] 05:35PM GLUCOSE-155* UREA N-12 CREAT-0.9 SODIUM-125*
POTASSIUM-4.8 CHLORIDE-87* TOTAL CO2-24 ANION GAP-19
[**2121-8-28**] 05:35PM CK(CPK)-67
[**2121-8-28**] 05:35PM CK-MB-NotDone cTropnT-<0.01
[**2121-8-28**] 05:35PM TSH-4.4*
[**2121-8-28**] 05:35PM CORTISOL-28.8*
[**2121-8-28**] 05:35PM WBC-13.1*# RBC-4.55 HGB-13.3 HCT-38.6 MCV-85
MCH-29.2 MCHC-34.4 RDW-12.3
[**2121-8-28**] 05:35PM NEUTS-86.4* BANDS-0 LYMPHS-9.6* MONOS-2.9
EOS-0.8 BASOS-0.3
[**2121-8-28**] 05:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2121-8-28**] 05:35PM PLT SMR-NORMAL PLT COUNT-358#
Brief Hospital Course:
65F with hx of DM type I, PVD, hypothyroidism who presents with
weakness, dizziness, nausea and difficulty controlling blood
sugars found to be hyponatremic. Trasfered back to the floor
from MICU after desenstization for ceftriaxone to treat Lyme
disease.
.
1. Hyponatremia: In setting of weakness, anorexia, nausea,
dizziness (esp on standing), inital concern for adrenal
insufficiency however, pt with elevated BP and leukocytosis,
both not typically seen with adrenal insufficiency. Pt appears
hypovolemic on exam, UNa>20 indicating renal losses but FeNa <1%
indicating kidneys avid for Na. Ddx includes renal losses (salt
wasting nephropathy, adrenal insuff) vs extra-renal losses
(inadequate intake). Sodium continued to decrease on [**2121-8-30**].
[**Month (only) 116**] be c/w siadh, ivf stopped and pt placed on fluid
restriction. renal consulted on [**2121-8-30**] and recommended
hypertonic saline at 20 cc/hr, for total 400 cc (started at 9pm
on [**2121-8-30**]) and continued checking of sodium q6h. Given possible
SIADH, patient had MRI [**2121-8-31**] 12:30am. MRI of head no lesion.
Na Tread
123->125->124->123->123->122->125->126->126->124
>127->126->128-> 130->134->131
Upon discharge Hyponatremia believed to be secondary to SIADH,
secondary to Lyme disease.
.
2. Weakness, dizziness: Nonspecific complaints and without
evidence of infection on exam, unclear what the significance is.
As above, may be [**3-5**] adrenal insufficiency. [**Month (only) 116**] also be due to
volume depletion. No evidence of neurologic deficits to
indicate CNS process. Cardiac enzymes neg x 1 and no changes on
EKG to indicate cardiac source. Upon discharge weakness was
believed to be seconadary to Lyme disease
.
3. Worsening Hyperglycemia: Pt requiring increasing doses of
insulin for decrased po intake indicating worsening insulin
resistance or decreased insulin secretion. Also pt notes
increased ketones in urine. Relatively acute in nature (over
past 1.5 weeks). Etiologies of worsening hyperglycemia include
infection, stress. No evidence of infection on UA and no signs
or sx on H&P to indicate clear source of infection or
pancreatitis. CXR- benign. Question of infiltrative disease
causing beta cell destruction. Continued [**Last Name (un) **] consultation
with recommended changes in insulin regimen.
.
4. Leukocytosis with left shift: No source of infection,
Bimanual exam no evidence of PID. UA neg, urine cx pending, CXR
no evidence of pulmonary infection. Blood cultures to be sent
[**2121-8-29**]. LP to be done [**8-30**] w/20 WBCs, lymphocytic [**Last Name (un) 11840**], gram
stain pending. Discussed w/ID, will send csf for lyme,
enterovirus, but no abx for now. [**8-31**] ID formally consulted
recc sending Erhlichia antibody, peripheral blood smears for
Babesia,added testing for HSV to CSF fluid collection. MRI of
lumbar spine showed no abscess. Suspected lyme disease. EKG
showed no AV block, so does not suggestive of cardic involvment.
Patient started on Doxycycline 200 po qd [**2121-9-2**]
IgM was positive for Lyme, IgG negative. Enterovirus negative.
Positive IgM LYME on [**2121-9-5**].On [**2121-9-6**] patient noted to have left
sided Bell's Palsy. Patient under desensitization with
Cetriaxone on Sunday in MICU without complications. On [**2121-9-7**]
patient noted to have left sided Bell's Palsy.
CSF POSITIVE FOR LYME DISEASE
Patient was will continue on Ceftriaxone (Day 4/21 days)
.
5. Skin rash: Pt had recently received morphine for back pain
and then noted circular patches of erythema soon after.
However, given hx of tick bite (given empiric tx) last year,
slight concern for lyme disease, although pt received adequate
treatment. Patient given benedryl.
.
6.Mitral Regurg, new from last Cardiology visit
TEE [**2121-9-2**] showed no significant change from previous echo
.
7. Hypothyroidism: TSH slightly changed than baseline. Increased
levoxyl.
.
8.Back pain
MRI of lumbar spine showed: Mild degenerative changes at several
levels, most pronounced (but still mild) at the L5-S1 level,
with a disc bulge touching both S1 nerve roots. Patient recieved
Tylenol, Percocet and Ultram for pain control.
Patient will recieve Flexeril upon discharge.
.
9.Support
Social Work was consulted b/c pt husband passed away in past
year and patient need help with paperwork.
.
10.FEN: Patient was maintained on DM diet with fluid
restrictions during hospitalization. Due to lack of peripheral
access a PICC line was placed on [**2121-9-2**]
Upon discharge patient will be maintained on fluid restrictions.
.
11.Calf pain on [**2121-9-8**]: Patient was recieving SubQ heparin
during hospitalization.
The SubQ hep was stopped on[**2121-9-7**] on b/c PTT was 92 but patient
had pneumoboots. On [**2121-9-8**] am patient complained of calf pain
L>R. Negative [**Last Name (un) 5813**] sign. Bilateral doppler showed
12. Physical Therapy-required to increase mobility
Medications on Admission:
Meds:
* AZITHROMYCIN 500MG--Take one pill one hour prior to dental
procedures
* BACTRIM SS qd
* CALCIUM 500/VITAMIN D tid
* HUMALOG sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **]
* LANTUS 17U qhs
* LEVOXYL 50MCG qd
* LIPITOR 20 mg qd (stopped 2 days ago)
Discharge Medications:
1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4-6H (every 4 to 6
hours) as needed.
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-2**]
Drops Ophthalmic PRN (as needed).
7. Ceftriaxone Sodium 1 g Recon Soln Sig: One (1) Intravenous
every twelve
(12) hours for 17 days.
8. Flexeril 5 mg qhs prn for 10 days
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 11057**] Nursing & Rehabilitation Center - [**Location (un) 3320**]
Discharge Diagnosis:
SIADH secondary to Lyme infection with CNS involvement
Discharge Condition:
Stable (as of [**9-8**] NEEDS TO UPDATED)
Discharge Instructions:
Please call primary care physician or come to emergency room if
have increasing weakness, increased blurry vision or difficulty
closing eyes, fever, or any other concerning symptoms.
Please call primary care physician or come to emergency room if
have increasing weakness, increased blurry vision or difficulty
closing eyes, fever, or any other concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2322**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2121-10-21**]
11:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2122-4-21**] 11:30
Completed by:[**2121-9-10**]
|
[
"4241",
"2720",
"2449"
] |
Admission Date: [**2120-11-10**] Discharge Date: [**2120-11-17**]
Date of Birth: [**2053-7-24**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Thoracic Aortic Ulcer, acute renal failure (bilateral stenosis)
Major Surgical or Invasive Procedure:
Angiogram with angioplasty/stenting of renal arteries [**2120-11-15**]
History of Present Illness:
68 y/o F with a past medical history of hypertension,
non-alcoholic pancreatitis presented to an OSH on [**11-9**] with
sudden-onset [**7-16**] back pain radiating to the epigastrum. CT
scan done showed a probable type B aortic dissection. She was
transferred to the Vascular service at [**Hospital1 18**] for further care.
On arrival, BPs were 200/100 and patient was placed on an
esmolol drip. CT scan done here showed intra-aortic intramural
hematomas, penetrating ulcer in aortic arch, and significant
right renal artery stenosis/thrombosis. Decision was made to
medically manage the aortic hematomas with blood pressure
control. Creatinine on arrival was 1.2. Patient became oligutic
during the day on [**11-10**], and creatinine increased to 2.0 this
morning.
Vascular surgery, cardiac surgery and nephrology consulted for
management of her overall care.
Past Medical History:
HTN, non-EtOH pancreatitis [**2-/2120**]
Social History:
Patient reports smoking 1ppd, denies alcohol or IV drug use.
She lives with her husband and is currently retired.
Family History:
NC
Physical Exam:
PHYSICAL EXAM Temp 98.7F HR 94 BP 111/80 RR 17 O2 Sat 96%
4L
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, No masses or nodules, No right
carotid bruit, No left carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound,
No hepatosplenomegally, No hernia, No AAA.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P. Brachial: P.
LUE Radial: P. Brachial: P.
RLE Femoral: P. Popiteal: P. DP: P. PT: P.
LLE Femoral: P. Popiteal: P. DP: P. PT: P.
Pertinent Results:
[**2120-11-10**] 03:00AM BLOOD WBC-11.4* RBC-4.03* Hgb-12.1 Hct-34.7*
MCV-86 MCH-30.0 MCHC-34.8 RDW-13.9 Plt Ct-176
[**2120-11-15**] 02:50AM BLOOD WBC-10.9 RBC-3.55* Hgb-10.5* Hct-30.6*
MCV-86 MCH-29.6 MCHC-34.4 RDW-14.0 Plt Ct-242
[**2120-11-16**] 05:00AM BLOOD WBC-11.7* RBC-3.74* Hgb-11.2* Hct-32.0*
MCV-86 MCH-29.9 MCHC-34.9 RDW-14.0 Plt Ct-275
[**2120-11-15**] 02:50AM BLOOD PT-12.0 PTT-28.5 INR(PT)-1.0
[**2120-11-10**] 03:00AM BLOOD Glucose-222* UreaN-22* Creat-1.2* Na-141
K-4.2 Cl-104 HCO3-25 AnGap-16
[**2120-11-11**] 01:46AM BLOOD Glucose-129* UreaN-28* Creat-2.0* Na-138
K-4.2 Cl-104 HCO3-23 AnGap-15
[**2120-11-13**] 03:58AM BLOOD Glucose-103* UreaN-19 Creat-1.3* Na-137
K-3.5 Cl-101 HCO3-26 AnGap-14
[**2120-11-15**] 02:50AM BLOOD Glucose-98 UreaN-26* Creat-1.7* Na-135
K-3.8 Cl-97 HCO3-30 AnGap-12
[**2120-11-17**] 04:30AM BLOOD Glucose-95 UreaN-26* Creat-1.5* Na-132*
K-3.7 Cl-93* HCO3-27 AnGap-16
[**2120-11-10**] 03:00AM BLOOD cTropnT-<0.01
[**2120-11-11**] 11:09PM BLOOD CK-MB-5 cTropnT-<0.01
CT
1. High density within the wall of the aorta, on correlation
with the recent CT, imaging features are suggestive of an
intramural hematoma.
2. Delayed excretion of contrast from the left kidney consistent
with renal dysfunction.
US
1. The right kidney is noted to be smaller than the left kidney.
2. No hydronephrosis and no perinephric fluid collection
identified.
3. Very low velocity of flow identified within the right kidney
as compared to the left kidney. Limited Doppler study.
MRI
1. Penetrating ulcer within the arch of the aorta with an
associated
intramural hematoma, which arises below the level of the left
subclavian
artery (type B). Follow up MR imaging in [**1-10**] weeks to further
assess changes in the hematoma is advised.
2. Tight stenosis of the right renal artery and a small right
kidney is
present.
3. Mild stenosis of the left (lower) renal artery.
US
No evidence of acute deep venous thrombosis in both lower
extremities.
RUS
1. The right kidney is noted to be smaller than the left kidney.
2. No hydronephrosis and no perinephric fluid collection
identified.
3. Very low velocity of flow identified within the right kidney
as compared
to the left kidney. Limited Doppler study.
Brief Hospital Course:
Patient was admitted to the cardiac surgery service on [**2120-11-10**]
for careful observation and monitoring for concerns of expanding
intramural hematoma. She was observed at the CVICU for strict
monitoring of blood pressure (SBP< 140). For her worsening renal
failure (given rising Cr and oliguria), renal consulted and
likely etiology contrast nephropathy with chronic renal
stenosis. She was taken to the operating room on [**2120-11-15**] for
angiogram, renal artery stenting and angioplasty. She had a
normal postoperative course and will be discharged [**2120-11-17**].
Her hospital stay can be summarized by the following review of
systems -
Neuro: Pt pain controlled with iv and oral narcotics. She will
be discharged on oxycodone and nicotine patch.
Pulm: Pt with h/o COPD and exhibited some hypoxia during
hospital course - unclear etiology but responded with nebulizer
treatments. She is otherwise asymptomatic and stable, normal
mentation. She continues to be on room air on discharge, SaO2>
93% on room air.
Cardio: BP control critical in setting of intramural hematoma
and bilateral renal artery stenosis. She was on multiple
anti-hypertensive (5) and even esmolol with nicardipine gtt.
After procedure, she was no longer on any drips and BP
controlled on amlodipine, metoprolol, and dyazide on discharge.
Angiogram showed normal aorta despite findings on MRI. She will
be discharged on ASA325 and to follow up with cardiac surgery
clinic in 4 weeks; will obtain MRA of torso in 3 weeks to be
follow up in clinc. Her hypertensive regimen was changed and PCP
will be notified.
GI: Tolerating regular diet. On ranitidine for H2B prophylaxis.
Renal: Acute/chronic RF with Cr 1.2 at baseline. With acute
renal failure, Cr did rise to 2.0 w/ oliguria. Now s/p bilateral
renal artery stenosis angioplasty with stenting. After her
procedure, Cr did decrease to 1.5 on discharge. She continues to
make > 1.5L/24 hrs of urine. She will be discharged and follow
up with nephrology outpatient for close monitoring, labs,
ultrasound. Her home lisinopril will be held given renal
failure.
Heme: to be discharged on ASA. She was maintained on SQH as
inpatient. LENI did not show any DVT's for concerns that PE was
causing her respiratory hypoxia. However, she was weaned to room
air on discharge with no other symptoms.
Medications on Admission:
atenolol 100', lisinopril 5', ASA 325'
Discharge Medications:
1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/headache.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
9. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every four
(4) hours.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Penetrating ulcer in aortic arch and intramural hematoma
Bilateral renal artery stenosis, acute/chronic renal failure
HTN
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, 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 to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-10**]
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
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and 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:
?????? 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
?????? Call and schedule an appointment to be seen in [**2-8**] weeks for
post procedure check and ultrasound
What to report to office:
?????? 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
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
It is crucial that you continue to check your blood pressures
twice daily. You will be discharged on new anti-hypertensives
and any concerns of light headedness or low blood pressure (<
90) will warrant an emergency department visit or phone [**Name6 (MD) 138**] to
M.D.
Do not continue lisinopril for concerns of worsening renal
failure in the acute setting.
Please continue diabetic and low sodium diet for optimal blood
pressure control
Followup Instructions:
Follow up with PCP [**Last Name (NamePattern4) **] 1 week
Follow up with Nephrology, pls call to make an appointment -
[**Telephone/Fax (1) 9420**]
Follow up with cardiac surgery in 4 weeks, pls call to make an
appointment - [**Telephone/Fax (1) 170**]
(will need MR angiogram of torso - to be obtained and to bring
CD to clinic appointment)
Follow up with Dr. [**Last Name (STitle) **] in [**2-8**] weeks, pls call to make
an appointment - [**Telephone/Fax (1) 1237**]
Completed by:[**2120-11-18**]
|
[
"5849",
"40390",
"5859",
"496",
"3051"
] |
Admission Date: [**2174-5-9**] Discharge Date: [**2174-5-13**]
Date of Birth: [**2106-3-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 4 (LIMA-LAD, SVG-PDA, SVG-RI, SVG-OM)
[**2174-5-9**]
History of Present Illness:
This 68 year old gentleman has a
history of exertional angina and dyspnea for the past 2 months.
It occurs with activity such as playing tennis and with walking
or climbing stairs. He denies any symptoms at rest. He denies
any PND, orthopnea, edema. He denies any lightheadedness or
claudication.
He was referred for stress testing to further evaluate on
[**2174-4-12**]. He exercised for 7 minutes and 20 seconds and stopped
due to fatigue. EKG with 1mm upsloping St segment depressions in
II, III, F and V4-V6. No chest pain.
He underwent cardiac cath on [**2174-4-25**].
Past Medical History:
Coronary Artery Disease, s/p CABG
PMH:
hyperlipidemia
GERD
Past Surgical History:
right rotator cuff surgery
s/p bilateral knee arthroscopy
s/p appendectomy
s/p tonsillectomy
s/p left and right inguinal hernia repair
Social History:
Lives with: alone
Contact: [**Name (NI) **], [**Name (NI) **] Phone # wk: [**Telephone/Fax (1) 110476**]
Occupation: Owns trucking company
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:
ETOH: < 1 drink/week [] [**2-8**] drinks/week [] >8 drinks/week [x]
Drinks 30 beers/week
Illicit drug use
Family History:
Premature coronary artery disease
Father MI < 55 [x] MI at age 41 Brother with stents in his 50s
Physical Exam:
Pulse: 67 Resp: 16 O2 sat: 100% RA
B/P Right: 155/84 Left: 156/76
Height: 6' Weight: 215 lbs.
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] __none___
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: cath site, 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2174-5-9**] Intra-op TEE
Conclusions
Pre Bypass: The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
Post Bypass: Patient is A paced on phenylepherine infusion.
Preserved biventricular funciton. LVEF 55%. Aortic countours
intact. Remaining exam is unchanged. All findings discussed
witih surgeons at the time of the exam.
.
[**2174-5-13**] 05:05AM BLOOD WBC-10.6 RBC-3.37* Hgb-10.4* Hct-32.3*
MCV-96 MCH-30.9 MCHC-32.3 RDW-12.4 Plt Ct-216
[**2174-5-12**] 04:32AM BLOOD WBC-12.8* RBC-3.13* Hgb-9.8* Hct-29.2*
MCV-93 MCH-31.5 MCHC-33.7 RDW-12.1 Plt Ct-173
[**2174-5-13**] 05:05AM BLOOD Glucose-111* UreaN-18 Creat-0.9 Na-139
K-4.0 Cl-103 HCO3-28 AnGap-12
[**2174-5-12**] 04:32AM BLOOD Glucose-126* UreaN-17 Creat-0.9 Na-137
K-3.7 Cl-99 HCO3-30 AnGap-12
[**2174-5-13**] 05:05AM BLOOD Mg-2.0
[**2174-5-12**] 04:32AM BLOOD Mg-1.9
Brief Hospital Course:
The patient was brought to the Operating Room on [**2174-5-9**] where
the patient underwent CABG x 4 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 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 home in good
condition with appropriate follow up instructions.
Medications on Admission:
ATORVASTATIN 20 mg Tablet - 1 Tablet by mouth daily
OMEPRAZOLE 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule by
mouth daily
Medications - OTC
ASPIRIN 81 mg Tablet, Chewable - 1 Tablet by mouth daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D (D3)] - Dosage
uncertain
NAPROXEN SODIUM 220 mg Capsule - 2 Capsule(s) by mouth daily
VITAMIN E 400 unit Capsule - 1 Capsule by mouth daily
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily until further instructed.
Disp:*120 Tablet(s)* Refills:*2*
7. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Packet(s)* Refills:*0*
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
PMH:
hyperlipidemia
GERD
Past Surgical History:
right rotator cuff surgery
s/p bilateral knee arthroscopy
s/p appendectomy
s/p tonsillectomy
s/p left and right inguinal hernia repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
1+ 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**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] [**2174-5-19**] at
10:00a
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2174-6-15**] at 1:00p
Cardiologist Dr. [**Last Name (STitle) 10543**] [**2174-6-2**] at 11:15a
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**Known firstname **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 18325**] in [**4-7**] 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:[**2174-5-13**]
|
[
"41401",
"9971",
"42731",
"2724",
"53081"
] |
Admission Date: [**2145-4-28**] Discharge Date: [**2145-5-4**]
Date of Birth: [**2082-10-3**] Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Amoxicillin
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
SOB, chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
62 yo F with metastatic breast cancer, on Xeloda and Herceptin
since [**2138**] (herceptin alone since [**2135**]), presents with 1 week of
CP and SOB. She describes a nonpleuritic chest tightness only
with exertion and also LE edema. She returned recently from a
trip to [**Male First Name (un) 1056**], and went to see her PCP. [**Name10 (NameIs) **] ordered by
her PCP showed bilateral pleural effusions for which she was
sent to the ED. CTA showed bilateral pleural effusions,
moderate pericardial effusion worse than before, but no PE or
aortic dissection. She had a viral cold recently.
.
In [**2132**], around the same time that she was diagnosed with breast
cancer, she was also found to have pleural and pericardial
effusions, preceded by a viral prodrome. She had a thoracentesis
that did not reveal malignant cells. She had several follow up
echos showing resolving pericardial effusion. It was concluded
that this was a viral related serositis and not due to
metastatic breast cancer. Her last echo was in 3/98.
.
On this admission, another TTE was obtained which showed
echocardiographic evidence for cardiac tamponade. She had a CT
chest 2 weeks ago for cancer staging purposes which showed a
small pericardial effusion. She underwent pericardiocentesis
and was then transferred to the CCU for further management
.
Currently, patient feels some soreness in her chest where the
pericardiocentesis was performed. Otherwise, she feels her
breathing is improved, but not yet back to her baseline. No
chest pain, abdominal pain, palpitation, lightheadedness.
.
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 exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of
palpitations, syncope or presyncope.
Past Medical History:
Breast cancer - diagnosed [**2132**], s/p R mastectomy, on herceptin
since [**2135**] and xeloda since [**2138**]
Hypothyroidism
h/o one past episode of pericardial effusion in [**2132**]
Social History:
She is divorced and is a ticketing officer with american
airlines. No kids. She smokes approximately half a pack a day
and has for ten years. She drinks alcohol socially.
Family History:
Two maternal aunts who developed breast cancer, one in her 50's
and one in her late 60's. There is no other breast or ovarian
cancer in her family. Her father died of lymphoma
Physical Exam:
On trasnfer to CCU
VS: 145/70, 98, 26, 93% 2L
Pulsus: 18 mmHg
GEN: Pleasant, well appearing woman in NAD, mildly dyspneic
HEENT: PERRLA, EOMI, MMM, OP clear, no LAD, JVP low
LUNGS: bibasilar crackles with pleural effusion R>L
CVS: S1S2, RRR, no m/r/g
ABD: soft, ND, NT, +BS, no ascites
EXT: 1+ bilateral pedal edema to ankles, 2+ peripheral pulses
NEURO: CN II-XII grossly intact, no focal deficits
Pertinent Results:
Cardiac Cath Study Date of [**2145-4-29**]
COMMENTS:
1- Emergent pericardiocentesis was performed via subxyphoid
access in
the usual fashion.
2- Pericardial space easily accessed and more than 600 cc of
bloody
fluid
3- Pericardial drain left in place
4- No complications
FINAL DIAGNOSIS:
1. Pericardial tamponade
2. Successful emergent pericardiocentesis and removal of >600 cc
of
bloody fluid
3. Pericardial drain left in place
4. Postprocedure bedside echocardiography showed resolution of
pericardial effusion and well expanded RA and RV without
tamponade
physiology
5. Patient was transferred to the CCU for observation
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2145-4-28**]
7:35 PM
IMPRESSION:
1. No pulmonary embolus or acute aortic syndrome.
2. Large (new) pericardial effusion, raising concern for
tamponade.
Correlation with echocardiography is recommended.
3. Enlargement of bilateral pleural effusions, moderate on the
right and
small on the left, with associated compressive atelectasis.
4. Stable adenopathy compared to [**2145-4-7**].
.
TTE (Complete) Done [**2145-4-29**] at 8:59:16 AM
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 10-20mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The 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. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is a large pericardial
effusion. The effusion appears circumferential. There is brief
right atrial diastolic collapse. There is right ventricular
diastolic collapse, consistent with impaired fillling/tamponade
physiology. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, consistent with
impaired ventricular filling.
IMPRESSION: Normal biventricular systolic function. There is
echocardiographic evidence for cardiac tamponade.
.
Portable TTE (Focused views) Done [**2145-4-29**] at 4:44:04 PM
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
is no pericardial effusion. A catheter is seen in the
pericardial space.
Compared with the prior study (images reviewed) of [**2145-4-29**],
the pericardial fluid has been removed. The right ventricle is
larger without evidence of tamponade physiology.
.
Portable TTE (Focused views) Done [**2145-4-30**] at 12:00:00 PM
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
Trivial mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling. The echo findings
are suggestive but not diagnostic of pericardial constriction.
IMPRESSION: No significant residual pericardial effusion. Study
consistent with effusive-constrictive physiology following
drainage of pericardial effusion.
.
CBC
[**2145-5-2**] 05:47AM BLOOD WBC-4.9 RBC-3.95* Hgb-12.4 Hct-38.5
MCV-97 MCH-31.5 MCHC-32.3 RDW-16.9* Plt Ct-274
[**2145-5-1**] 04:29AM BLOOD WBC-5.2 RBC-3.97* Hgb-12.6 Hct-38.1
MCV-96 MCH-31.8 MCHC-33.1 RDW-16.4* Plt Ct-275
[**2145-4-30**] 03:02AM BLOOD WBC-5.0 RBC-3.76* Hgb-12.1 Hct-37.0
MCV-98 MCH-32.1* MCHC-32.6 RDW-17.3* Plt Ct-249
[**2145-4-29**] 08:05AM BLOOD WBC-3.5* RBC-3.28* Hgb-10.4* Hct-32.3*
MCV-99* MCH-31.9 MCHC-32.3 RDW-16.3* Plt Ct-207
[**2145-4-28**] 05:30PM BLOOD WBC-4.2 RBC-3.39* Hgb-11.0* Hct-33.8*
MCV-100* MCH-32.5* MCHC-32.6 RDW-17.8* Plt Ct-229
.
Chemistry
[**2145-5-2**] 05:47AM BLOOD Glucose-124* UreaN-11 Creat-0.7 Na-142
K-3.9 Cl-106 HCO3-26 AnGap-14
[**2145-5-1**] 04:29AM BLOOD Glucose-115* UreaN-13 Creat-0.7 Na-141
K-3.6 Cl-104 HCO3-29 AnGap-12
[**2145-4-30**] 03:02AM BLOOD Glucose-112* UreaN-10 Creat-0.6 Na-142
K-3.9 Cl-106 HCO3-26 AnGap-14
[**2145-4-29**] 08:05AM BLOOD Glucose-125* UreaN-12 Creat-0.7 Na-142
K-4.3 Cl-109* HCO3-27 AnGap-10
[**2145-4-28**] 05:30PM BLOOD Glucose-107* UreaN-14 Creat-0.7 Na-142
K-4.3 Cl-107 HCO3-24 AnGap-15
[**2145-5-2**] 05:47AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
[**2145-5-1**] 04:29AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1
[**2145-4-30**] 03:02AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
[**2145-4-29**] 08:05AM BLOOD Albumin-3.9 Calcium-8.6 Phos-3.7 Mg-2.1
.
LFT
[**2145-5-1**] 04:29AM BLOOD ALT-29 AST-35 LD(LDH)-197 AlkPhos-133*
TotBili-1.8*
[**2145-4-30**] 03:02AM BLOOD ALT-44* AST-53* AlkPhos-140* TotBili-1.8*
DirBili-0.4* IndBili-1.4
[**2145-4-29**] 08:05AM BLOOD ALT-43* AST-49* LD(LDH)-224 AlkPhos-119*
TotBili-1.6*
.
Pericardial fluid
- Cytology - pending
- WBC 1150, Hct 17, Polys 3%, Lymphs 3%, Monos 0%, Mesothe 1%,
Macro 53%, Other 40%
- TotProt 5.2, Glucose 93, LD(LDH) 274, Amylase 36, Albumin 3.3
.
[**2145-4-29**] 4:25 pm FLUID,OTHER PERICARDIAL.
GRAM STAIN (Final [**2145-4-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2145-5-2**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2145-4-30**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
62 F with metastatic breast cancer with acute onset bilateral
pleural effusion and worsening pericardial effusion found to
have tamponade physiology.
.
#. PUMP/Tamponade - patient has a history of one other episode
of pericardial effusion in [**2132**], likely of viral etiology, which
resolved on its own. Two weeks ago on CT chest for staging
purposes, she was found to have a small pericardial effusion and
no pleural effusion. On admission, she had no clinical evidence
of tamponade, however TTE showed significant pericardial
effusion with tamponade physiology. She had a viral cold
recently, and the rapid onset symptoms could again suggest a
viral serositis, however would not explain the presence of blood
in pericardial fluid. She has no signs of infection: no white
count or fever. Malignant effusion remains high on the
differential; her breast cancer has been stable for years,
however the presence of blood and 40% other cells in pericardial
fluid raises this suspicion. Herceptin has a <1% occurrence of
pericardial effusion, unlikely to be the culprit as she has been
on it stabily since [**2135**]. Patient does not appear uremic on
labs nor does she have a history of collagen vascular disease.
Has not had radiation to her chest. Unlikely due to MI, as
symptoms were gradual in onset, and she is CE negative x1.
.
Patient is now s/p pericardiocentesis and hemodynamically
stable. The drain was removed after several days after it
stopped draining. Pulsus was checked 3-4 times a day with
improvement following pericardiocentesis and is currently [**3-9**]. A
repeat echo done on [**2145-5-4**] showed no recurrent fluid. She was
set up with repeat echo in about 4 weeks with follow up with Dr [**Doctor Last Name 11723**] scheduled. Cytology was pending at the time of
discharge.
.
Currently while patient is stable, there are no plans for
pericardial window, however if effusion reaccumulates, a
pericardial window would be indicated.
.
Pleural effusions: Pt with bilateral pleural effusions that
appear new since early [**Month (only) 116**]. High suspicion for malignancy. As
the pt was satting well on room air and asymptomatic, there was
no plan for thoracocentesis at the time of discharge.
#. BREAST CANCER - chemotherapy was held during this admission
per oncology recommendations. Patient will continue to follow
up with her primary oncologist. Cytology from effusions was
pending at time of discharge.
Medications on Admission:
Herceptin 6mg/kg - IV infusion, every 3 weeks
Capecitabine [Xeloda] 500 mg - 2 tabs in the AM, 3 tabs in the
PM - 2 weeks on, 1 week off.
Fluticasone 50 mcg 2 sprays each nostril daily
Ibuprofen 600 mg TID prn pain
Levothyroxine 75 mcg daily
Lorazepam 1 mg qhs
Zolpidem 10 mg qhs prn insomnia
Discharge Medications:
1. Herceptin 440 mg Recon Soln Sig: One (1) Intravenous q3
weeks: 6 mg/kg .
2. Xeloda 500 mg Tablet Sig: ASDIR Tablet PO ASDIR: 2 tabs in
the AM, 3 tabs in the PM - 2 weeks on, 1 week off.
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] PRN () as needed for nasal congestion.
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
(1) Pericardial Effusion
(2) Pleural effusions
(3) Breast cancer history
Discharge Condition:
Stable for home; ambulating on room air, mild shortness of
breath on activity.
Discharge Instructions:
Dear Ms [**Last Name (Titles) 5025**],
You were admitted because you had worsening shortness of breath.
This occurred because we found you had accumulated fluid around
your heart and lungs. Fluid around the heart is a serious
condition and can cause your blood pressure to fall, so to treat
this, we drained this fluid to relieve the pressure on your
heart. We don't know for sure yet why you have fluid in these
areas, but it can happen because of your breast cancer history.
We are waiting on results from the fluid we removed to determine
whether cancer is the cause. You will need close follow up with
cardiology and they will follow up on this result.
.
We did not make any changes in your medications during this
hospitalization.
.
Please call your doctor immediately or return to the emergency
department if you start to feel increasingly short of breath,
dizzy or lightheaded, or have any other concerning symptoms.
.
You have follow up appointments scheduled with cardiology as
below. The echocardiogram will be done on the same day; you
should receive a call about this. Please call [**Telephone/Fax (1) 62**] if
you have not heard from them over the next week to confirm these
appointments.
Followup Instructions:
Your cardiology appointment with Dr[**Doctor Last Name 3733**] is on [**6-18**]
at 320 PM. Please call [**Telephone/Fax (1) 62**] if you have not heard from
them over the next week to confirm these appointments.
.
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2145-5-5**]
12:15
Provider: [**First Name8 (NamePattern2) 2191**] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2145-5-5**]
2:00
Provider: [**Name10 (NameIs) 17246**] [**Name11 (NameIs) **], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2145-5-25**] 12:00
|
[
"5119",
"5180",
"2449",
"3051"
] |
Admission Date: [**2171-4-20**] Discharge Date: [**2171-4-24**]
Date of Birth: [**2114-11-25**] Sex: F
Service: CCU
CHIEF COMPLAINT: Inferior myocardial infarction.
HISTORY OF PRESENT ILLNESS: This is a 56 year-old female
with a history of type 2 diabetes insulin requiring and
chronic obstructive pulmonary disease who presents with jaw
pain, dyspnea, and diaphoresis. The patient was recently
discharged from an outside hospital on [**2171-4-12**] after being
treated for a chronic obstructive pulmonary disease
exacerbation. On the evening prior to admission the patient
was feeling unwell and contact[**Name (NI) **] her primary care physician
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 807**] who recommended that the patient take
[**Location (un) 2452**] juice for presumed hypoglycemia. This a.m. the
patient went to the primary care physician's office and
complained of jaw pain, dyspnea at rest and diaphoresis. She
was immediately sent to [**Hospital6 **] for evaluation.
An ECG on arrival there demonstrated Q waves in 2, 3 and F
with [**Street Address(2) 4793**] elevations inferiorly and 1 mm down sloping ST
segments with T wave inversions in V2 to V5. A CK was drawn,
which was 400 with an MB of 50 and troponin was 30. The
patient was diagnosed with an inferior myocardial infarction
and started on intravenous nitroglycerin, Aggrastat, heparin,
Lopressor, morphine sulfate, Solu-Medrol and nebulizers and
transferred to [**Hospital1 69**] was
arranged. A chest x-ray obtained at [**Hospital6 **] was
consistent with hyperinflated lungs and moderate congestive
heart failure. The patient developed prior to transfer
worsening dyspnea and became hypertensive to 230/140 with
worsened hypoxia. The patient was then intubated after
additional morphine, Fentanyl, Lopressor, nitroglycerin and
Lasix were administered. The patient became hypotensive to
an SBP of 65 and she required Dopamine for approximately
thirty minutes. The Dopamine was discontinued and the
patient was transferred to the Coronary Care Unit. Her post
intubation arterial blood gas was 7.13, 76 and 424 on unknown
settings.
On arrival to the Coronary Care Unit the patient was
complaining of nausea, diaphoresis and dyspnea. She was
hemodynamically stable and treated with intravenous Ativan.
Within 20 minutes the patient stabilized on the vent. ecg
demonstrated persistent elevations inferiorly with down
sloping ST depressions from V2 to V5. She was taken to the
catheterization laboratory where her right heart
catheterization revealed the following, a PA diastolic of 32
with a wedge of 31 and a mixed venous O2 sat of 66%. Her
left heart catheterization revealed the following, left main
showed no obstruction, left anterior descending coronary
artery showed a 50% D1, left circumflex shoed a 90% lesion
with an ulcer that was stented and an right coronary artery
that showed a 90% lesion and distal 50% lesion. She received
a stent to the mid right coronary artery lesion and
percutaneous transluminal coronary angioplasty to the distal
right coronary artery lesion. Her post catheterization
electrocardiogram was notable for Q waves in 2, 3 and F and
persistent down sloping ST depressions in V2 to V5. She was
transferred to the Coronary Care Unit in stable condition for
further management.
PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary
disease. No home O2 use. No intubations for chronic
obstructive pulmonary disease exacerbations in the past. 2.
Type 2 diabetes insulin requiring exacerbated on Prednisone.
3. Depression. 4. Status post cholecystectomy.
SOCIAL HISTORY: There is a greater then fifty pack year
history of tobacco use. The patient continues to smoke.
There is occasional alcohol use, but no elicit drug use.
FAMILY HISTORY: Noncontributory.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: 1. Zyflow. 2. Uniphyl. 3.
Combivent. 4. Serevent. 5. Prednisone. 6. Mavik. 7.
Prozac. 8. Amaryl. 9. Insulin 70/30 sliding scale.
ADMISSION PHYSICAL EXAMINATION: Vital signs temperature
97.7. Pulse 70. Blood pressure 120/70. Respiratory rate
16. O2 sat 100%. Vent settings IMV 12 by 800 with no
spontaneous respirations. 40% FIO2 and PEEP of 7.5.
Arterial blood gas is 7.4, 42, and 133. In general, this is
an intubated and sedated female. HEENT examination revealed
normocephalic, atraumatic. Pupils are equal, round and
reactive to light. Extraocular movements intact. The
trachea is midline. The trachea venous pressure is estimated
to be 12 cm of water. The neck is supple with a full range
of motion. Cardiovascular normal rhythm, regular rate. No
murmurs or rubs. Positive S4. Pulmonary clear to
auscultation bilaterally on anterior examination alone.
Abdomen soft, nontender, nondistended. Normoactive bowel
sounds. No hepatosplenomegaly. Extremities warm, left
bilateral lower extremities with 1+ edema. Pulses are 2+.
Groin reveals a small palpable 1 by 1 cm hematoma lateral to
cannulation site with no overlying bruit.
LABORATORY DATA: White blood cell count 20, hematocrit 40,
platelets 224, coags 15, 65 and 1.6. SMA 7 140, 4.3, 104,
23, 50, 1.0 and 279. CK of 2252, MB is 219 and a troponin
greater then 50.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit for post inferior myocardial infarction.
Management, she was extubated within the first day after the
procedure. She diuresed well to moderate doses of Lasix.
Her peak CK was 2789 and was noted to be trending down. She
was chest pain free for the remainder of her admission.
In regard to the groin hematoma, no bruit developed and the
size of the hematoma remained stable. The patient's
hematocrit remained roughly 37. The patient's white count
also declined as she was stabilized.
In regard to the patient's oxygenation and ventilation she
was noted to have bibasilar rales by hospital day three, but
an oxygen saturation of 96% on room air. Her chronic
obstructive pulmonary disease regimen while in house included
Prednisone 60 mg po q day, Albuterol and Atrovent MDI and
long acting beta agonist was also added to the regimen. She
also was maintained on the montelukast she takes at home.
The patient did have some coffee ground emesis in the setting
of anticoagulation with Aggrastat, chronic steroid use and
the acute stress of the myocardial infarction, this was all
noted to resolve after the 2B3A inhibitor was discontinued
and the patient was maintained on proton pump inhibitor.
On hospital day number three the patient developed paroxysmal
atrial flutter with variable block with a rate as high as the
140s. She was hemodynamically stable and spontaneously
converted after receiving Diltiazem for rate control.
On the following day a transthoracic echocardiogram was
obtained, which revealed an EF of 30 to 35% with an E to A
ratio of 2.4 and an estimated PA systolic pressure of 21 mm.
Her left atrium was noted to be mildly dilated at 5.6 cm.
There was also mild left ventricular dilatation noted and
multiple regions of resting wall motion abnormalities
including inferolateral akinesis and inferoseptal
hypokinesis, 2+ MR was also noted on the echocardiogram. No
spontaneous echocardiogram contrast was observed. In light
of the patient's multiple risk factors for the development of
cerebrovascular accident, the decision was made to
anticoagulate. The patient was started on Lovenox and
Coumadin while in house, which she will continue on the
outside. EP consultation was also obtained. The final
recommendations of which are pending.
I communicated with the patient's primary care physician
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 807**] regarding this hospitalization and in
particular the diagnosis of depressed EF and paroxysmal
atrial flutter necessitating anticoagulation. He agreed with
the management and planned on seeing the patient in one
week's time after discharge from the hospital.
On [**2171-4-24**], after physical therapy had seen the patient she
is felt to be stable for discharge. The results of pulmonary
function tests are pending at the present time. These were
obtained on the day of discharge.
DISCHARGE DIAGNOSES:
1. Inferior myocardial infarction, peak CK 2800.
2. Depressed EF with multiple resting wall motion
abnormalities.
3. Paroxysmal atrial flutter.
4. Severe chronic obstructive pulmonary disease.
5. Type 2 diabetes insulin requiring.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q day, Plavix 75 mg
po q.d. times thirty days, Zestril 10 mg po q.d., Diltiazem
30 mg po q.i.d., Prednisone 60 mg po q.d. taper as per
outpatient physician. [**Name Initial (NameIs) 6196**] 40 mg po q.d., Lasix 40 mg po
q.d., Lovenox 80 mg subQ b.i.d., Coumadin 5 mg po q.h.s.,
montelukast 10 mg po q.d., Combivent MDI two puffs q.i.d.,
Amaryl 2 mg po q.d.
DISCHARGE CARE: The patient will receive home VNA to help
with her Lovenox injections and encouragement of medication
compliance.
DISCHARGE FOLLOW UP: The patient will follow up with her
primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 807**]. Telephone number
[**Telephone/Fax (1) 823**] in one week's time for an INR check and
alterations in the medication regimen, in particular Coumadin
and Prednisone and possibly Diltiazem.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-463
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2171-4-23**] 16:43
T: [**2171-4-24**] 13:21
JOB#: [**Job Number 37915**]
|
[
"41401",
"9971",
"42731",
"496",
"25000"
] |
Admission Date: [**2145-10-26**] Discharge Date:10/ [**9-/2145**]
Date of Birth: [**2145-10-26**] Sex: F
Service: NB
This is an interim summary covering from birth thru [**2145-11-12**].
DISCHARGE DIAGNOSES:
1. Premature female infant - 34 and [**4-11**] week gestation.
2. Infant of a type 1 diabetic.
3. Hypoglycemia.
4. Hyperbilirubinemia.
HISTORY OF PRESENT ILLNESS: [**Known lastname 15406**] if the former 34 and
[**5-12**] week female admitted for issues of hypoglycemia and
prematurity. The infant was born to a 36-year-old gravida 3,
para 0, B positive female whose prenatal screens were
noncontributory. Her past medical history is significant for
type 1 diabetes insulin dependent for 10 years. Her recent
hemoglobin A1C was 6.6. Mother was also on labetalol for
gestational hypertension. She had a normal level 2
ultrasound and triple screen, and she declined an
amniocentesis. She had one termination of pregnancy in [**2141**]
and a spontaneous abortion in [**2144**].
Mother was brought to Labor and Delivery on the day of
delivery because of nonreassuring fetal heart rate tracing
with variable decelerations and reversed diastolic flow.
Labor and Delivery monitoring showed occasional small
variable decelerations. The infant was delivered by cesarean
section with Apgar scores of 7 and 8.
The infant was admitted to the Neonatal Intensive Care Unit
at [**Hospital3 **] Hospital. Upon admission, she had dextrose
stick of 8. An IV was started. A complete blood count and
blood cultures were sent.
HOSPITAL COURSE BY PROBLEMS:
1. RESPIRATORY: There were no respiratory issues. No
evidence of apnea or bradycardia of prematurity.
2. CARDIAC: There were no cardiac issues.
3. HYPOGLYCEMIA: The infant was initially started on D-10-W
and was advanced to D-12.5. She remained on D-12.5 with 2
of sodium over the next few days, and the IV was finally
discontinued on [**10-31**] with a good result. Her oral
PG volume was decreased from 160 to 150, and three
dextrose sticks prior to feeds on the reduced volume were
above 60.
4. FEEDING AND NUTRITION: The infant was advanced on oral
feeding and increased to 160 cc/kilogram per day, and as
soon as sugars were normalized she was decreased to 140
cc/kilogram per day of mom's milk 24 or Neosure 24
calories per ounce. At the time of discharge, she weighed
2 kilograms and was feeding ad lib amounts of Neo Sure or
mom's milk. She was breast feeding at least twice per
day. However mom has been producing small volumes of milk
5. INFECTIOUS DISEASE: The infant had an initial complete
blood count that was benign. Therefore, no antibiotics
were initiated. Blood culture was negative at 48 hours.
6. HEMATOLOGIC: Mom was B positive. The infant's initial
hematocrit was 55. The infant had a total bilirubin of
16. She had been under phototherapy from [**10-27**]
through [**11-1**] with a rebound bili of 8.2 that
increased to 10.2 and then down to 9.5 with a final
bilirubin level on [**11-7**] of 5.9.
7. SCREENS: Hearing screen to be performed prior to
discharge.
8. IMMUNIZATIONS: Hepatitis B immunization given on [**11-4**].
9. Dermatologic: Infant has flat hemangioma on abdomen that is
darkening with extension which is tail like in form.
Parents are aware.
DISCHARGE FOLLOWUP: Upon discharge, the infant will be
followed up within five days at [**Hospital1 **] by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Visiting nurse to come to home day post discharge.
[**Last Name (LF) **], [**Name8 (MD) **] MD [**MD Number(1) 38370**]
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2145-11-1**] 09:06:16
T: [**2145-11-1**] 09:59:39
Job#: [**Job Number 56891**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2187-7-10**] Discharge Date: [**2187-7-13**]
Date of Birth: [**2137-3-14**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Abdominal wall bleeding s/p pericentesis of abdominal ascites
Major Surgical or Invasive Procedure:
Paracentesis [**2187-7-10**]
History of Present Illness:
50 yo male with history of cirrhosis secondary to Hepatitis C
and ETOH abuse presented for routine paracentesis for diuretic
resistant abdominal ascites. Pt has no history of variceal
bleeds, hepatic encephalopathy, or jaundice. The patient had
never been treated for his Hepatitis.
Past Medical History:
CAD with stent
Anemia
ETOH abuse
Hepatitis C
Liver cirrhosis/End stage liver disease
Social History:
Currently unemployed
Lives with wife, a healthcare proxy
Lives in [**Location 21318**]
Has not used drugs x 15 years
No ETOH since [**6-14**]
[**1-12**] pack of cigarrettes/day
Family History:
non-contributory
Physical Exam:
T 99.5 BP 108/64 72 14 96% RA
General: awake, somewhat frail, pleasant
HEENT: Dry mucous membranes, mildly icteric sclera, mildly dark
pink mucous, membranes in the mouth/tongue, OP clear
Lungs: minimal crackles in left base
CVS: RRR
Abdomen: distended, nontender with + BS, flat and tympanic
abdominal sounds (fluid, gas?) 5x5 umbilical hernia,
retractable,
LE: +1 PE wih minimal venous stasis, +2 DP, no lesions,
Pertinent Results:
[**2187-7-12**] 06:15AM BLOOD WBC-6.6 RBC-3.34* Hgb-10.5* Hct-30.6*
MCV-91 MCH-31.4 MCHC-34.4 RDW-15.8* Plt Ct-82*
[**2187-7-11**] 03:35PM BLOOD WBC-6.2 RBC-3.26* Hgb-10.2* Hct-29.4*
MCV-90 MCH-31.4 MCHC-34.8 RDW-16.4* Plt Ct-72*
[**2187-7-11**] 05:43AM BLOOD WBC-5.9 RBC-3.14* Hgb-9.6* Hct-28.6*
MCV-91 MCH-30.5 MCHC-33.6 RDW-16.3* Plt Ct-94*
[**2187-7-10**] 09:01PM BLOOD Hct-27.9*
[**2187-7-10**] 02:25PM BLOOD Hct-25.8*
[**2187-7-10**] 10:55AM BLOOD WBC-7.8 RBC-2.64* Hgb-8.6* Hct-24.3*
MCV-92 MCH-32.7* MCHC-35.5* RDW-15.9* Plt Ct-94*
[**2187-7-10**] 10:00AM BLOOD WBC-8.1 RBC-2.66* Hgb-8.5* Hct-24.4*
MCV-92 MCH-31.8 MCHC-34.6 RDW-15.9* Plt Ct-106*
[**2187-7-10**] 08:10AM BLOOD WBC-9.1 RBC-3.43* Hgb-11.0* Hct-31.8*
MCV-93 MCH-32.2* MCHC-34.7 RDW-15.9* Plt Ct-114*
[**2187-7-10**] 08:10AM BLOOD Neuts-67.3 Lymphs-16.6* Monos-12.0*
Eos-3.5 Baso-0.6
[**2187-7-12**] 06:15AM BLOOD Plt Ct-82*
[**2187-7-12**] 06:15AM BLOOD PT-16.3* PTT-39.6* INR(PT)-1.8
[**2187-7-11**] 03:35PM BLOOD Plt Ct-72*
[**2187-7-11**] 03:35PM BLOOD PT-15.3* PTT-37.1* INR(PT)-1.5
[**2187-7-11**] 05:43AM BLOOD Plt Ct-94*
[**2187-7-11**] 05:43AM BLOOD PT-14.9* PTT-37.0* INR(PT)-1.5
[**2187-7-10**] 09:39PM BLOOD PT-15.1* PTT-38.9* INR(PT)-1.5
[**2187-7-10**] 02:25PM BLOOD PT-15.7* PTT-42.4* INR(PT)-1.6
[**2187-7-10**] 10:55AM BLOOD Plt Ct-94*
[**2187-7-10**] 10:00AM BLOOD Plt Ct-106*
[**2187-7-10**] 08:10AM BLOOD Plt Ct-114*
[**2187-7-10**] 08:10AM BLOOD PT-16.7* INR(PT)-1.9
[**2187-7-11**] 05:43AM BLOOD Glucose-116* UreaN-23* Creat-1.1 Na-132*
K-4.6 Cl-99 HCO3-24 AnGap-14
[**2187-7-10**] 09:01PM BLOOD Glucose-140* UreaN-27* Creat-1.4* Na-129*
K-5.2* Cl-98 HCO3-23 AnGap-13
[**2187-7-10**] 08:10AM BLOOD Glucose-115* UreaN-34* Creat-2.0*#
Na-127* K-5.5* Cl-95* HCO3-24 AnGap-14
[**2187-7-10**] 08:10AM BLOOD ALT-20 AST-43* AlkPhos-77 TotBili-4.7*
[**2187-7-11**] 05:43AM BLOOD Calcium-8.8
[**2187-7-10**] 09:01PM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1
[**2187-7-10**] 02:25PM BLOOD Calcium-8.7
[**2187-7-10**] 08:10AM BLOOD Albumin-2.8* Calcium-8.9 Phos-4.3
[**2187-7-13**] 09:25AM BLOOD WBC-7.5 RBC-3.56* Hgb-11.0* Hct-32.7*
MCV-92 MCH-31.0 MCHC-33.8 RDW-15.8* Plt Ct-85*
Brief Hospital Course:
Pt is a 50 yo man with cirrhosis secondary to HCV and ETOH abuse
and baseline anemia who had an abdominal bleed after a routine
pericentesis to remove ascitic fluid, s/p transfusions, now
stable.
1.Abdominal bleed: most likely secondary to hitting a vessel
during pericentesis. Pt has been transfused multiple times and
given fluids in an effort to address his falling
hematocrit/bleed. Now that pt is stable, will start to
diurese/remove fluid that has accumulated in his abdomen. Pt
notes that abdominal size is close to, but not as large as his
abdomen prior to getting his pericentesis. Pt seen by Liver and
received another paracentesis for abdominal ascites on [**7-12**]
without complications. Pt is to be dc'd with follow up with Dr.
[**Last Name (STitle) 497**] on [**7-19**].
2.Anemia: pt transfused with FFP, currently 28.6 Hesitant to
transfuse now due to increasing accumulation of fluid in the
abdomen and the sequelae of SOB and discomfort. Will follow and
check crit in AM- Vitals stable, if crit decreased, will
transfuse. Currently stable.
3.FEN: Pt to get meal tonight. DC NPO. Cont bowel regimen. No
protonix due to low platelets.
4.Cirrhosis: continue lactulose.
5.Pain/Headache. Cont. oxycodone for pain until follow up.
6.Cough: Pt with productive cough, yellowish grey sputum.
Possible etiologies are URI considering slightly elevated
temperature, Chronic bronchitis exacerbation considering pt??????s
smoking history. Pt??????s CXR negative for consolidation. Will
monitor for fevers, worsening cough. Cont. guanefesin-codeine
for cough and cipro 500 mg qd x 7 days and follow up with Dr.
[**Last Name (STitle) 497**] if cough persists.
Medications on Admission:
Medications on admission
Oxycodone 5 mg po BID
Lasix 20 mg qd
Spironolactone 100 mg qd
nadolol 20 mg qd
Caltrate 600 mg [**Hospital1 **]
Mycelex 1 x 5/day lactulose 30 mg TID
Discharge Medications:
1. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
4. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed.
Disp:*1 ML(s)* Refills:*0*
5. Phytonadione 5 mg Tablet Sig: 1-2 Tablets PO QD (once a day)
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
6. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for headache.
Disp:*25 Tablet(s)* Refills:*0*
7. Ciprofloxacin HCl 500 mg Tablet Sig: One (1) Tablet PO QD
(once a day) as needed for cough for 7 days.
Disp:*6 Tablet(s)* Refills:*0*
8. Aldactone 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. ESLD
2. Abdominal bleed after therapeutic paracentesis on [**2187-7-7**]
3. Anemia
4. bronchitis
Discharge Condition:
Fever to 100.5 on day of discharge, no localizing symptoms,
tolerating pos, ambulating
Discharge Instructions:
1. Please follow up at the [**Date Range **] unit on [**7-29**] for your next
paracentesis.
2. Take all your medications, including the antibiotics for the
cough
3. If you experience fevers, chills, increasingly severe cough,
nausea, vomiting, or a tender abdomen that causes you pain, come
to the emergency department at once.
4. Take oxycodone for your headaches, 5-10 mg (1-2 tablets) by
mouth every 6 hours.
5. Take the cough syrup, but if you continue to cough by your
appointment with Dr. [**Last Name (STitle) 497**], be sure to be examined and worked up
for something more serious.
6. You need to stay on a strict 1.5 L diet. If you have
questions, talk to Dr. [**Last Name (STitle) 497**] at your appointment.
Followup Instructions:
1 follow up:
Provider: [**Name10 (NameIs) 454**],TEN DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8
Date/Time:[**2187-7-19**] 11:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"2761",
"2859"
] |
Admission Date: [**2150-4-3**] Discharge Date: [**2150-4-6**]
Date of Birth: [**2093-10-8**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This 56-year-old gentleman has a
history of numbness in the substernal area and weak knees
while treadmill exercising in [**2149-11-18**]. He had
electrocardiogram changes. The next day he had a positive
thallium exercise tolerance test which sent him forward for
cardiac catheterization. He received two stents to his left
anterior descending artery.
He has had growing fatigue on exertion and document
restenosis of his left anterior descending artery stent.
Cardiac catheterization on [**3-22**] showed left anterior
descending artery and a left main disease with a question of
circumflex lesion. Reports were available per Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 15933**] office. He was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**].
PAST MEDICAL HISTORY: (Past medical history as follows)
1. Hypertension.
2. Diverticulitis.
3. Hypercholesterolemia.
4. Status post two stents to left anterior descending
artery.
PAST SURGICAL HISTORY:
1. Appendectomy.
2. Vasectomy.
3. Tonsillectomy.
4. Hydrocelectomy.
MEDICATIONS ON ADMISSION: Medications prior to admission
were as followed; Cozaar 25 mg p.o. q.d., Toprol-XL 25 mg
p.o. q.d., vitamin C p.o. q.d., and folic acid p.o. q.d.,
Lescol-XL 80 mg p.o. q.d. He had been on aspirin daily
which was discontinued by his primary physician on [**3-28**].
ALLERGIES: He was allergic to CODEINE which gave him
nightmares.
PERTINENT LABORATORY DATA ON PRESENTATION: Preoperative
laboratory work showed a white blood cell count of 9.6,
hematocrit of 44, and a platelet count of 256,000. PT
of 13.7, PTT of 27.9, with an INR of 1.3. Preoperative
chemistries showed a sodium of 139, potassium of 4.3,
chloride of 100, bicarbonate of 25, blood urea nitrogen
of 17, creatinine of 1, with a blood glucose of 83.
RADIOLOGY/IMAGING: A preoperative chest x-ray showed no
acute cardiopulmonary disease, and a question of a small left
pleural effusion.
A preoperative electrocardiogram showed sinus bradycardia at
51 with no acute ischemic changes.
HOSPITAL COURSE: On [**4-3**], the patient underwent coronary
artery bypass graft times three; off pump. He had a left
internal mammary artery to the left anterior descending
artery and a left radial artery sequentially to diagonal and
the obtuse marginal by Dr. [**Last Name (STitle) 1537**]. He was transferred to
Cardiothoracic Intensive Care Unit in stable condition on a
nitroglycerin drip at 0.5 mcg/kg per minute and a propofol
drip at 20 mcg/kg per minute.
On postoperative day one, he was hemodynamically stable. He
had been extubated and was oxygenating well. His
postoperative hematocrit was 33 with a potassium of 4.9. He
remained on a nitroglycerin drip at 0.25 for his radial
artery coverage. His blood pressure was 113/56, and he was
in sinus rhythm at 72. He was neurologically intact.
He was transferred from the Cardiothoracic Intensive Care
Unit to [**Hospital Ward Name 121**] Six. He was seen by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (his
cardiologist).
On postoperative day one, his Swan-Ganz catheter and cordis
were discontinued. His atrial line was discontinued. He was
out of bed to the chair. He started his p.o. Lasix with
potassium chloride and started his Plavix for off-pump
coverage. He was seen by Physical Therapy on the floor and
began ambulating.
On postoperative day two, he was stable overnight. He
hemodynamically stable with a temperature maximum of 99.3,
saturating 96% on 2 liters. His chest tubes put out 110 in a
prior 8-hour period and later that day were discontinued.
His incisions were clean, dry, and intact. His lungs were
clear. His heart was regular in rate and rhythm. His
abdominal examination was benign. His Foley catheter was
removed, and he continued to ambulate.
On postoperative day three, he continued to be stable. He
was alert and oriented times three. His incision were clean,
dry, and intact. His pacing wires were removed. His lungs
were clear. He remained in sinus rhythm in the 70s with a
blood pressure of 114/72. He was seen by Case Management and
received his request for [**Hospital6 407**] services,
and he was discharged from the hospital in stable condition
on [**4-3**] on the following medications.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. q.d. (times one week).
2. Potassium chloride 20 mEq p.o. q.d. (times one week).
3. Colace 100 mg p.o. b.i.d.
4. Zantac 150 mg p.o. b.i.d.
5. Enteric-coated aspirin 325 mg p.o. q.d.
6. Plavix 75 mg p.o. q.d.
7. Imdur 60 mg p.o. q.d.
8. Lopressor 25 mg p.o. b.i.d.
9. Percocet one to two tablets p.o. p.r.n. q.4-6h.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft times three; off
pump.
2. Hypertension.
3. Diverticulitis.
4. Hypercholesterolemia.
5. Status post two stents to left anterior descending
artery.
DISCHARGE INSTRUCTIONS: He was discharged with the
instructions to follow up with his primary care physician
(Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5448**]) in two weeks and to see Dr. [**Last Name (STitle) 1537**] in the
office for his postoperative check in four weeks.
DISCHARGE STATUS: He was discharged to home with [**Hospital6 3429**] services on [**4-3**].
CONDITION AT DISCHARGE: In stable condition.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2150-5-18**] 13:03
T: [**2150-5-19**] 13:10
JOB#: [**Job Number 15934**]
|
[
"2720",
"4019"
] |
Admission Date: [**2146-10-3**] Discharge Date: [**2146-10-7**]
Date of Birth: [**2079-6-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2042**]
Chief Complaint:
melena, hypotension
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD) [**10-4**]
History of Present Illness:
Mr. [**Known lastname 57230**] is a 67 yo M with history of multiple myeloma,
paroxysmal atrial fibrillation, and prior known duodenal ulcer
who presented to an outside hospital with one day history of
melena and hypotension to SBP in the 80s at home. He had
chemotherapy with valcade and dexamethasone at [**Hospital3 328**] three
days prior to admission.
At OSH, he was guaiac positive, and his hct was found to be 22
down from a baseline in the mid 30s per his wife. [**Name (NI) **] was
transfused two units of packed red cells and a Cordis was
placed. Patient also complained of chest pain on presentation
and had dynamic ST depressions in the lateral leads. He was
given nitro and blood with resolution of his symptoms. Patient
was transferred to [**Hospital1 18**] for further management.
In the [**Hospital1 18**] ED, initial vs were: 97.0, 99, 128/89, 20, 100% 10L
NRB. Patient was given a IV bolus and started on a PPI drip. He
had a negative NG lavage but was again guaiac positive. Repeat
labs here showed hematocrit of 24.8 (he did not bump his
hematocrit after the two units given at the OSH). EKG here
showed atrial fibrillation without any ST changes. GI was
consulted, and he was admitted to the ICU for further
management. On transfer, vitals were 107, 122/76, 14, 99% 2L
NC.
In the MICU, the patient received a total of 4 units which he
tolerated well without complaints. His chest pain completely
went away when he received blood products. Patient had 18 hours
of diarrhea after taking his chemo on Friday but did not notice
any blood at that time. He did have three hours of melena on
Saturday night but has had no further BMs since. No abdominal
pain, nausea, vomiting, constipation. No change in PO intake,
difficulty breathing or dyspnea on exertion.
Past Medical History:
Multiple myeloma on chemo
Paroxysmal Afib
CAD s/p PTCA in [**2115**]
HTN
h/o gastric ulcer
TIAs
Hypercholesterolemia
PFO with ASD on echo with right to left & left to right shunts
Presumed diagnosis of amyloid angiopathy
h/o ICH while on warfarin (no longer anticoagulated)
Social History:
He is married and his wife is his HCP. [**Name (NI) **] denies smoking, EtOH
or drugs.
Family History:
Uncle: Died of MI in 70's
Father: Leukemia, MI at age 65 also AML
Uncle: Died of MI in 40's
Physical Exam:
On transfer in the [**Hospital1 18**] ER
Temp:97.0 HR:99 BP:128/89 Resp:20 O(2)Sat:100 normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic; pale conjunctiva
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: tachy Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Pertinent Results:
ADMISSION LABS:
[**2146-10-3**] 06:25AM BLOOD WBC-15.0*# RBC-2.87*# Hgb-8.8*#
Hct-24.8*# MCV-87 MCH-30.8 MCHC-35.5* RDW-16.5* Plt Ct-214
[**2146-10-3**] 06:25AM BLOOD Neuts-85.7* Lymphs-10.0* Monos-4.0
Eos-0.1 Baso-0.1
[**2146-10-4**] 04:09AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Spheroc-2+ Ovalocy-1+
Schisto-OCCASIONAL
[**2146-10-3**] 06:25AM BLOOD PT-12.3 PTT-19.4* INR(PT)-1.0
[**2146-10-3**] 06:25AM BLOOD Glucose-128* UreaN-72* Creat-1.6* Na-139
K-3.9 Cl-105 HCO3-25 AnGap-13
[**2146-10-3**] 01:46PM BLOOD Calcium-7.9* Phos-2.8 Mg-2.5
[**2146-10-3**] 01:46PM BLOOD ALT-19 AST-15 CK(CPK)-63 AlkPhos-66
TotBili-1.3
[**2146-10-3**] 06:25AM BLOOD cTropnT-0.02*
[**2146-10-3**] 01:46PM BLOOD CK-MB-4 cTropnT-0.05*
[**2146-10-3**] 03:20PM BLOOD CK-MB-4 cTropnT-0.05*
[**2146-10-3**] 08:42PM BLOOD CK-MB-3 cTropnT-0.06*
[**2146-10-4**] 04:09AM BLOOD CK-MB-3 cTropnT-0.05*
[**2146-10-4**] 08:08PM BLOOD CK-MB-3 cTropnT-0.04*
.
ECG Study Date of [**2146-10-3**] 6:22:00 AM
Atrial fibrillation with rapid ventricular response. Diffuse
non-specific ST-T wave flattening. Compared to the previous
tracing of [**2142-9-29**] the lateral ischemic appearing T wave
abnormalities are no longer recorded. However,
pseudonormalization cannot be excluded, given the rapid rate.
Atrial fibrillation has appeared. Followup and clinical
correlation are suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
105 0 84 362/440 0 -3 134
.
EGD [**2146-10-4**]
Normal esophagus. Edematous, erythematous antral fold noted
consistent with inflammation and possibly underlying ulcer. A
single non-bleeding 2 mm ulcer was found in the stomach body.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Mr. [**Known lastname 57230**] is a 67 yo male with history of paroxysmal atrial
fibrillation, coronary artery disease, hypertension and
multiple myeloma s/p recent chemo. He has a known duodenal ulcer
and presented with melena and hypotension (SBP 80's) to an
outside hospital. There he was found to have a hematocrit of 22
down from his baseline in the mid 30's. He also complained of
chest pain with lateral ST depressions noted on EKG that
resolved when he received nitroglycerin and 2 units PRBCs.
.
ICU COURSE: He was transferred to [**Hospital1 18**]. On initial evaluation
in the emergency room he had a hematocrit of 24 despite the 2
units PRBCs from the outside hospital and was noted to be in
atrial fibrillation with a ventricular rate greater than 100. He
was started on a PPI drip and admitted to the ICU for further
management. While in the ICU, his atrial fibrillation was
controlled with metoprolol IV and reinstitution of his sotalol.
The patient had one further episode of chest tightness that
resolved with nitrates as he received an additional 4 units of
PRBC's with his hematocrit stabalizing in the low 30's. He was
ruled out for an MI and remained stable from a cardiac
standpoint after that single episode. He had no further melena
or guaiac positive stools in the ICU and underwent EGD on
[**2146-10-4**] with the results as noted above. On [**Hospital 57232**] transfer to
the hospital floor on [**2146-10-5**], he had a transient episode of
hypotension with a pressure of 85/58 when he was transferring
from the stretcher to the bed, which was attributed to the
patient having restarted his home dose of labetalol on the
evening of transfer. His labetalol was subsequently held (until
the day of discharge) and his blood pressure stabalized.
.
# GI bleed: EGD: edematous, erythematous antral fold noted c/w
inflammation and possibly underlying ulcer; single non-bleeding
2 mm ulcer was found in the stomach body. The patient was
treated with a total of 6 units of PRBCs with stabalization of
his hematocrit. His intravenous pantoprozole was changed to po
and the patient's diet was advanced. On the 4th and 5th hospital
days following transfer from the ICU, the patient had an episode
of black tarry stool on each day. In consultation with the GI
service, these episodes were felt to be due to old blood from
his initital upper GI bleed. His hematocrit and blood pressure
remained stable over the course of these two days with no
further evidence of new bleeding.
.
# Chest pain: The patient's episode of chest tightness was felt
to be demand ischemia related to GI bleed superimposed on atrial
fibrillation and rapid ventricular response. Pain improved with
SL nitroglycerin and blood transfusions. His troponins remained
flat and he ruled out for an MI. He has been continued on his
statin. The [**Hospital 228**] hospital course was reviewed with the
patient's primary cardiologist and the patient will follow up
with him on [**10-12**].
.
# Atrial fibrillation: The patient has paroxysmal atrial
fibrillation treated with sotalol and labetalol. His rapid
ventricular response at the outside hospital appeared related to
hypovolemia and ischemia from his GI bleed. His rate has been
controlled with single doses of metoprolol IV when in the ICU
and reinstitution of his sotalol. He converted to NSR by
hospital day 4. On the last hospital day, he has been restarted
on a lower dose of his labetalol (in addition to sotalol) to
prevent further rapid ventricular response, but his dose is
limited by his earlier hypotensive episodes. The patient is
anticoagulated with low dose aspirin and aggrenox, but these
were held during his GI bleed. He received a single dose of each
on the 4th hospital day just prior to having two further guaiac
positive, melenic stools. Although, the stools are thought to be
from old blood and the patient's hematocrit has remained stable,
his anticoagulation was discontinued. This has been discussed
with his primary cardiologist by phone, and the patient will see
him in follow up on [**10-11**] to address restarting low dose
aspirin and aggrenox.
.
# Multiple myeloma: Last chemo [**9-30**] with velcade and decadron
at [**Hospital3 328**]. The patient was continued on bactrim and
acyclovir prophylaxis and he will follow up with Dr. [**Last Name (STitle) 57233**] at
the [**Company 2860**] on [**10-10**] where he will be evaluated and the decision
whether or not to proceed with chemotherapy will be made.
.
# Hypertension: He takes numerous antihypertensives at home
including amlodipine, tekturna, labetalol, clondine and
losartan. These had been held in the setting of his hypotension
and GI bleeding and only clonidine and labetalol have been
reinstituted at the time of discharge. He will follow up with
his cardiologist on [**10-12**] and his PCP on [**10-13**] to
reinstitute these medications as tolerated.
Medications on Admission:
Aggrenox 200 mg-25 mg [**Hospital1 **]
amlodipine-atorvastatin 10 mg-80 mg daily
aliskiren 300 mg daily
Sotalol AF 120 mg daily
labetalol 400 mg [**Hospital1 **]
clonidine 0.1 mg [**Hospital1 **]
furosemide 80/40 mg daily
Aspirin Low-Strength 81 mg Chewable daily (takes [**12-27**])
losartan 100 mg daily
folic acid 1 mg daily
Vitamin D 50,000 unit qweek
nitroglycerin 0.4 mg Sublingual PRN
multivitamin 1 daily
amlodipine besylate 5mg daily
dexamethasone -- Unknown Strength
Revlimid -- Unknown Strength
Valcade Unknown sig
Bactrim -- Unknown Strength qMonday Wednesday Friday
acyclovir unknown daily
Discharge Medications:
1. sotalol 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Omeprazole 40 mg Tablet, Sig: One (1) Tablet, PO Q12H (every
12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): do not take if your pulse is less than 50 beats per
minute.
Disp:*60 Tablet(s)* Refills:*2*
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. Vitamin D 50,000 unit Capsule Oral
10. multivitamin Oral
11. take your chemotherapy medicines as directed by your
oncologist
these include revlimid, dexamethasone, and velcade
Discharge Disposition:
Home
Discharge Diagnosis:
Upper Gastrointestinal Bleed from Gastric Ulcers
Atrial Fibrillation
Coronary artery disease
Hypercholesterolemia
Multiple myeloma
TIAs
S/P intracranial hemorrhage on warfarin for afib
presumed amyloid angiopathy
patent foranen ovale with ASD on echo with righ to left and left
to right shunts
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a bleeding ulcer that required intensive
care because your blood pressure was low. You were treated with
blood transfusions and a new medicine to decrease your stomach
acid production. Your anemia and low blood pressure caused you
to have chest pain from your heart disease and caused your heart
to beat fast from your atrial fibrillation (afib). The blood
transfusions and heart medicine helped to stop the chest pain.
There are no signs that you had a heart attack. In the setting
of your bleeding, your blood thinners for your afib and heart
disease were stopped. You will work with your cardiologist to
decide the right time to restart your blood thinners. Because
your blood pressure has been low, we have stopped most of your
high blood pressure medicines. Do NOT take your losarten,
amlodipine, tekturna (also called aliskiren), or lasix until
advised to restart these medications by your doctors. Do NOT
take your aggrenox or low dose aspirin. You should avoid taking
any aspirin, ibuprofen or drugs containing aspirin or NSAIDs
(motrin or aleve)unless you have asked one of your doctors. You
were taking caduet - a combination blood pressure and statin,
but you will take only atorvastatin now.
Followup Instructions:
Hematology Oncology
Name: Dr. [**Last Name (STitle) 57233**]
When: Monday [**2146-10-10**] at 1pm
Cardiology
Name: Dr. [**Last Name (STitle) 57206**]
When: Wednesday [**2146-10-12**] at 1PM
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Thursday [**2146-10-13**] at 12 PM
Address: 199 ROUTE 101 [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 57234**]
Phone: [**Telephone/Fax (1) 57235**]
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2146-10-19**] at 3:30 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"2851",
"42731",
"40390",
"2720",
"41401",
"V4582"
] |
Admission Date: [**2160-11-28**] Discharge Date: [**2160-12-7**]
Date of Birth: [**2101-6-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Ileo-right colectomy.
3. Ileostomy/Hartmann procedure.
4. Liver biopsy.
History of Present Illness:
59M recently diagnosed with sclerosing cecal adenocarcinoma on
routine colonoscopy at [**Hospital1 1774**] presented with acute onset
abdominal pain/vomiting to [**Hospital6 5016**]. KUB positive
for free air. Patient transferred to [**Hospital1 18**].
Past Medical History:
Path at [**Hospital1 1774**]: mod differentiated sclerosing adenocarcinoma
Social History:
Pt is married with children and one grandchild. Pt is an avid
swimmer. He denies all tobacco, ethanol, and recreational drug
use.
Family History:
Non-contributory
Physical Exam:
On discharge:
98.7 87 118/64 18 94%RA
Gen: NAD
CVS: RRR, nl S1S2
Pulm: CTA b/l
Abd: soft, NT, ND, +BS, wound healing well s erythema/drainage,
ostomy pink & viable with brown stool & gas in bag
Ext: 2+ pitting edema b/l LE, warm & well perfused
Pertinent Results:
On admission:
[**2160-11-27**] 10:50PM BLOOD WBC-1.5* RBC-5.10 Hgb-14.3 Hct-42.6
MCV-84 MCH-28.1 MCHC-33.6 RDW-16.6* Plt Ct-480*
[**2160-11-27**] 10:50PM BLOOD PT-16.1* PTT-29.1 INR(PT)-1.5*
[**2160-11-27**] 10:50PM BLOOD Gran Ct-1100*
[**2160-11-27**] 10:50PM BLOOD Glucose-168* UreaN-19 Creat-1.1 Na-139
K-3.7 Cl-102 HCO3-25 AnGap-16
.
On discharge:
[**2160-11-28**] 04:08AM BLOOD calTIBC-173* VitB12-174* Ferritn-20*
TRF-133*
[**2160-11-29**] 02:12AM BLOOD ALT-20 AST-40 LD(LDH)-192 AlkPhos-33*
Amylase-42 TotBili-0.8
[**2160-11-29**] 02:12AM BLOOD Lipase-10
[**2160-12-1**] 04:03AM BLOOD Glucose-59* UreaN-10 Creat-0.8 Na-137
K-3.6 Cl-105 HCO3-28 AnGap-8
[**2160-12-1**] 04:03AM BLOOD Calcium-7.7* Phos-1.9* Mg-1.8
[**2160-12-2**] 06:30AM BLOOD CEA-4.6*
[**2160-12-2**] 04:53PM BLOOD PT-16.3* PTT-29.4 INR(PT)-1.5*
[**2160-12-2**] 04:53PM BLOOD Folate-7.6
[**2160-12-3**] 06:40AM BLOOD WBC-10.2 RBC-3.14* Hgb-8.8* Hct-26.4*
MCV-84 MCH-28.1 MCHC-33.4 RDW-16.9* Plt Ct-318
.
Pathology:
1. Right colon and terminal ileum, hemi-colectomy (A-S):
A. Adenocarcinoma, see synoptic report.
B. Evidence of perforation with surgical repair; acute
serositis and granulation tissue with pigmented and polarizable
material.
2. Liver biopsy (T):
Metastatic adenocarcinoma consistent with colonic primary.
Colon and Rectum: Resection Synopsis
MACROSCOPIC
Specimen Type: Colonic resection. Location: Right colon
(hemicolectomy).
Specimen Size
Greatest dimension: 31.5 cm.
Tumor Site: Cecum.
Tumor configuration: Exophytic.
Tumor Size
Greatest dimension: 5 cm. Additional dimensions: 3 cm x
0.8 cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: Low-grade (well or moderately
differentiated).
EXTENT OF INVASION
Primary Tumor: pT3: Tumor invades through the muscularis
propria into the subserosa or the nonperitonealized pericolic or
perirectal soft tissues.
Regional Lymph Nodes: pN2: Metastasis in 4 or more lymph
nodes.
Lymph Nodes
Number examined: 18.
Number involved: 7.
Distant metastasis: pM1: Distant metastasis: Liver.
Margins (See comment.)
Proximal margin:
Uninvolved by invasive carcinoma. Distance of tumor
from closest margin: 110 mm.
Distal margin:
Uninvolved by invasive carcinoma. Distance of tumor
from closest margin: 135 mm.
Circumferential (radial) margin:
Uninvolved by invasive carcinoma. Distance of tumor
from closest margin: 45 mm.
Lymphatic Small Vessel Invasion: Present.
Venous (large vessel) invasion: Absent.
Additional Pathologic Findings: Adenomas (0.7 cm, 0.6 cm,
distant from margin).
Comments: Tumor directly extends to peritoneal surface and is
present associated with granulation tissue on the serosa.
.
[**12-5**] CT ABDOMEN:
IMPRESSION:
1. Status post ileal/right colectomy and ileostomy/Hartmann
pouch. Again seen is bowel wall thickening in particularly
involving the ileum, which may be related to anasarca and large
amount of intraabdominal fluid.
2. The small bowel is mildly dilated, likely representative of
ileus. No
evidence of bowel obstruction.
3. Multiple low-density lesions within the liver, which is
concerning for
metastases.
4. Moderate-sized bilateral pleural effusion and adjacent
atelectasis.
Indeterminate nodular opacities in the lungs, which may
represent atelctasis however cannot exclude metastatic lesion.
Recommend reevaluation with CT chest with better inspiratory
effort after resolution of pleural effusions.
5. Large amount of intraabdominal fluid , which limits
evaluation for omental lesions. No intraabdominal abscess is
identified.
.
[**12-5**] LENIS
No evidence of DVT.
.
CT torso:
1. Status post ileal/right colectomy and ileostomy/Hartmann
pouch. There is bowel wall thickening, in particular involving
the ileum, which may be related to anasarca/large amount of
intrabdominal fluid.
2. Multiple incompletely characterized low-density lesions
within the liver for which metastatic lesion cannot be excluded.
Geometric wedge-shaped defect is seen within the right posterior
lobe of the liver consistent with biopsy.
3. Moderate-sized bilateral pleural effusion and adjacent
atelectasis.
Indeterminate nodular opacity in the right lower lobe, which may
be related to atelectasis/inflammatory process. Recommend
reevaluation after resolution of atelectasis and effusion.
4. Large amount of intrabdominal fluid which limits evaluation
for omental lesions.
Brief Hospital Course:
Pt transferred from OSH with perforated viscus and taken to the
OR emergently. Pt had colonoscopy on [**11-4**] for unexplained
weight loss/ This study demonstrated polps and adenocarcinoma
of the cecum. On the day of admission, pt presented to [**Hospital 40796**] with marked RUQ abdominal pain and vomiting. He
received a CT scan demonstrating free air.
.
Neuro: In the immediate post-operative period, the patient was
receiving propofol 50 for sedation. The patient's pupils were
equal and reactive and his EOMI. By the following day, the
patient was extubated and was AxOx3 and was being given dilaudid
IV for pain control. He was converted to PO pain medication on
POD 4 and has tolerated it well with eventually transitioning to
PO tylenol at the time of discharge.
.
CVS: During patient's stay in ICU, he became intermittently
hypotensive. This required intermittent levophed and
vasopressin for support. In addition, pt received more than 20
liters of fluid resusciation in the first 24 hours after
arrival. On POD# 1, levophed was weaned off and vasopressin was
weaned to halve its previous dose. Pt never required lasix for
this robust fluid resuscitation. He has since had excellent
urine output, and was hep locked on POD 3, taking a regular
diet.
.
Pulm: Initially, pt was transferred to SICU on AC with FIO2 of
60% rate of 18, peep of 5 without pressure support. Pt was soon
extubated and maintained on a face tent with high sats until
being transferred to the floor. At the time of discharge the
pt's breath sounds were clear with Sats greater than 95 percent
on room air only. Sats have been stable during ambulation.
.
GI: Surgery demonstrated gross fecal contamination and a 3 cm
perforation in the cecum. Pathology obtained from outside
hospital was consistent with moderately differentiated
sclerosing adenocarcinoma. During surgery, liver biopsy was
sent. Pt was also seen by our oncology service to discuss
outpatient management of disease. Pt also received stool
softeners with his narcotics.
.
Renal: Pt with stable BUN and creatinine throughout stay. Pt
with consistent and strong urinary output.
.
ID: Pt begun on cipro, flagyl, vanco at OSH and continued during
hospital admission. All antibiotics were stopped prior to
discharge following a nine day course beginning with IV
medication and concluding on PO's.
.
Heme: Pt with stable crit throughout surgery and postop period.
However, pt's INR at admission was noted to be 1.5 and
increased to 2.5 directly post-op. The last INR for this
patient was 1.5 on [**12-2**].
.
Endo: Pt maintained on ISS with QID finger-sticks throughout his
hospitalization.
.
FEN: Electrolytes were repleted as necessary.
.
Medications on Admission:
Aspirin
Saw [**Location (un) **]
Discharge Medications:
1. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
1 months: To prevent constipation while taking narcotics for
pain relief.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Perforated Cecal Adenocarcinoma
Discharge Condition:
Afebrile, vital signs stable, tolerating regular diet,
functioning ostomy, ambulating, pain well controlled on PO
medication. VNA services arranged for wound care.
Discharge Instructions:
Please call your doctor or return to the ER for 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.
* Your skin, or the whites of your eyes become yellow.
* 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.
* 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.
Followup Instructions:
The following appointments have been made for you for follow-up
care.
.
Hematology Oncology
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3150**] Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2160-12-26**] 11:00
.
GI Hematology Oncology:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2160-12-26**]
11:00
.
Please call Dr. [**Last Name (STitle) **], Trauma Surgery, at ([**Telephone/Fax (1) 22750**] to
schedule an appointment within 1-2 weeks.
.
Please call Dr. [**Last Name (STitle) **], Hepatobiliary Surgery, at ([**Telephone/Fax (1) 3618**]
to schedule an appointment within 1-2 weeks.
|
[
"0389",
"2762"
] |
Admission Date: [**2170-4-9**] Discharge Date: [**2170-4-15**]
Date of Birth: [**2109-1-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Arterial Line in RIGHT RADIAL
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
s/p failed gallstones removal c/b gallbladder perforation
Major Surgical or Invasive Procedure:
IR guided attempted removal of gallstones and fragmented
cholecystostomy tube (failed attempt), complicated by
perforation of the gallbladder.
History of Present Illness:
Mr. [**Known lastname 92497**] is a 61 y/o male with h/o HTN, COPD, chronic renal
disease on HD, s/p AAA repair and cholecystitis who was admitted
to the MICU after a failed attempt to remove stones/biliary
dilation and removal of previous catheter fragment that was
complicated by gallbladder/cystic duct perforation. The patient
presented with acute cholecystitis on [**2169-10-17**] and
underwent percutaneous cholecystostomy; at that time as based on
his comorbidities he was not felt to be a good surgical
candidate. Since then he has undergone ERCP x 2 with
sphincterotomy as well as failed laparoscopic cholecystectomy
because of adhesions on [**2170-2-8**]. His cholecystostomy
tube came out accidentally and a new percutaneous tube was
replaced on [**2170-3-9**]. Unfortunately this
cholecystostomy tube was severed by VNA, leaving him with a
cathetar fragment at his ostomy site.
.
Of note, all of his prior care has been at [**Hospital1 498**]. He was
referred to IR (Dr. [**Last Name (STitle) 4686**] for a cholangiogram via his
existing cholecystostomy tube +/- stone extraction, catheter
fragment removal and sphincteroplasty. The procedure performed
yesterday was unsuccessful in removing the gallbladder stones or
the catheter fragment, and was also complicated by
gallbaldder/cystic duct perforation. Pt was hemodynamically
stable, complaining only of RUQ pain ([**5-8**]).
.
This morning pt had episodes of hypotension with SBP's to the
70's prior to dialysis. Pt was mentating well, Tmax of 100.1.
Pt not currently complaining of abdominal pain. Pt was
transferred to the MICU because of concern for sepsis following
perforation.
Past Medical History:
-Hypertension
-COPD on home oxygen (2L)
-Chronic renal disease on HD (T,Th,Sat schedule. Last HD on
Saturday [**2170-4-7**])
-Open AAA repair in [**2164**] c/b abdominal wall hernia repaired with
mesh.
-Thoracic aortic aneurysm, s/p endograft repair
-S/p LUE AVF
-Cholelithiasis
-Sleep apnea
-Hypercholesterolemia
-CVA -recent (diagnosed via MRI)
-Arthritis
Social History:
- Tobacco: 2-3packs/day x 40 years
- Alcohol: very heavy drinker x 15 years
- Illicits: none
Family History:
- No family history of gallstones
- Kidney stones: brothers
Physical Exam:
Vitals: T:97.5 BP:90/50 P:79 R:12 O2:99% 2L
General: Alert, interactive, oriented, no acute distress
HEENT: Sclera anicteric, mucus membranes [**Doctor Last Name **], oropharynx
clear, EOMI
Neck: Supple
CV: Regular rate and rhythm, normal S1 + S2, GII systolic and
diastolic murmer at RUSB, GII holosystolic and diastolic murmer
at LSB, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, non-tender, mild distension, ostomy site clean
with bandage in place and cholecystostomy drain with
serosanguinous drainage in bag, +BS
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
MICU Admission Exam:
Vitals: T: 99.5 BP: 83/48 P: 85 R:9 18 O2: 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild tenderness to palpation in the RUQ,
non-distended, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission Labs:
[**2170-4-9**] 09:40PM BLOOD WBC-11.1* RBC-3.57* Hgb-9.7* Hct-29.4*
MCV-82 MCH-27.1 MCHC-32.9 RDW-16.0* Plt Ct-309
[**2170-4-10**] 10:40AM BLOOD Neuts-79* Bands-0 Lymphs-9* Monos-10
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2170-4-10**] 10:40AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2170-4-9**] 09:40PM BLOOD Glucose-102* UreaN-29* Creat-4.6* Na-138
K-4.0 Cl-102 HCO3-23 AnGap-17
[**2170-4-10**] 05:35AM BLOOD Calcium-8.2* Phos-6.2* Mg-2.1
[**2170-4-10**] 05:35AM BLOOD ALT-5 AST-10 LD(LDH)-158 AlkPhos-65
TotBili-0.2
[**2170-4-9**] 09:40PM BLOOD PT-12.5 PTT-34.0 INR(PT)-1.2*
[**2170-4-11**] 03:24AM BLOOD Cortsol-8.7
[**2170-4-11**] 03:24AM BLOOD Vanco-18.6
Micro:
[**4-11**] BCx pending
[**4-10**] BCx negative
[**4-10**] UCx negative
[**2170-4-11**] 9:58 am BILE BILE.
**FINAL REPORT [**2170-4-15**]**
GRAM STAIN (Final [**2170-4-11**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2170-4-15**]):
ENTEROCOCCUS SP.. RARE GROWTH.
ENTEROCOCCUS SP.. RARE GROWTH. SECOND MORPHOLOGY.
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S 0.5 S
PENICILLIN G---------- 4 S 2 S
VANCOMYCIN------------ 1 S <=1 S
ANAEROBIC CULTURE (Final [**2170-4-15**]): NO ANAEROBES ISOLATED.
Imaging:
CT Abd/Pelvis ([**2170-4-10**]):
1. Phlegmonous change within the gallbladder fossa with one
intact pigtail
catheter in place. There is also a fragment present laterally
within No
drainable collection identified. Adjacent inflammatory fat
stranding and
pericholecystic fluid.
2. Moderate duodenal diverticulum.
3. Simple cysts within both kidneys.
4. Multiple stable subcentimeter hepatic hypodensities which are
too small to characterize.
4. Intrahepatic ductal dilation with enhancement of the
intrahepatic duct
suggestive of cholangitis.
5. Stable aneurysmal aorta and right common iliac artery.
6. Sigmoid and ascending colon diverticulosis, without evidence
of acute
diverticulitis.
.
TTE ([**2170-4-11**]):
The left atrium is mildly dilated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
RUE Ultrasound ([**2170-4-12**]): No evidence of deep venous thrombosis
in the right upper extremity.
.
CXR ([**2170-4-15**]):
Normal size of the cardiac silhouette. No lung parenchymal
disease.
Brief Hospital Course:
61yoM with h/o HTN, COPD, chronic renal disease on HD, s/p AAA
repair and cholecystitis who was admitted after failed attempts
by IR to remove stones and previous catheter fragment,
complicated by gallbladder/cystic duct perforation and sepsis.
.
# Hypotension/Perforated Gallbladder/Common Bile Duct: The
patient was admitted on [**4-9**] following a failed IR attempt to
remove gallstones and a cholecystostomy catheter fragment, which
was complicated by gallbladder/cystic duct perforation with
contrast seen extravasating from the gallbladder. Post
procedure BPs were in the 90s from a baseline of 120-140
systolic, attributed to sedation with slow clearance in the
setting of liver failure. He was covered with Ceftriaxone and
Flagyl. However, he then became hypotensive with SBP 70's-80's
the following morning on [**4-10**] with low grade fever and
increasing white count, and he was broadened to Vanc/[**Last Name (un) **] for
concern for early peritonitis and sepsis. Blood pressures did
not respond to several boluses of IVF and he was transferred to
the MICU, where he received 8L NS. His blood pressures
stablilized and white count down-trended, fever resolved on
Vanc/[**Last Name (un) **]. CT was concerning for cholangitis, but LFTs did not
show a cholestatic picture. ERCP was consulted and did not have
plans to intervene unless the patient developed a cholestatic
hepatitis. Surgery was consulted and is planning to perform an
open cholecystectomy when he becomes medically stable. GB was
determined to be adequately decompressed with his
cholecystostomy tube at this time, and LFTs were WNL. He was
discharged with a plan to continue Vancomycin/Meropenem for a 2
week course. Bile culture grew enterococcus sensitive to
Vancomycin. The patient was given Acetaminophen and Oxycodone
was increased for pain control. Gemfibrozil was discontinued,
as this can precipitate gallstone formation. The day of
discharge, there was question of whether the patient's insurance
would cover his Vancomycin and Meropenem as an outpatient, but
the patient refused to remain in-house to wait for confirmation
of insurance approval. He will follow-up with his PCP as an
outpatient regarding this, as he was refusing to remain in-house
for this issue, despite knowing the risks of leaving. The day
after discharge, on [**4-16**], the patient was called and he
confirmed that the VNA just finished giving him the IV
antibiotics and confirmed that his insurance would cover enough
antibiotics for 10 days, for a full course.
.
# Anemia: The patient had hct 29 on initial presentation that
slowly down-trended to 24 post-op. Likely dilutional in the
setting of missing HD due to hypotension vs slow blood loss from
ostomy vs anemia of ESRD without EPO repletion given recent
initiation of HD. He was transfused 2 units PRBC in the MICU
with subsequent increased and stable HCTs. He will receive EPO
with HD per renal.
.
# R Hand Ischemia: While in the MICU, the patient developed
cyanosis of the right hand, which was attributed to A-line
insertion in the setting of visualized small caliber vessel.
Perfusion returned s/p removal of the line. Surgery/Hand
consulted, felt there were no concerning findings. [**Doctor Last Name **]??????s test
normal.
.
# HD dependent ESRD: The patient was initially on a T/Th/Sat
hemodialysis schedule but while in the MICU, his schedule was
switched to M/W/F. He received an extra dose of HD in-house
after being called out to the floor, as he initially missed HD
while in the MICU for sepsis. Continued sodium bicarb 650 mg
tid, sevelamer 1600 mg tid with meals. Renal was following
in-house.
.
# Hypertension: Patient was recently hypotensive in the setting
of sepsis, and his home lisinopril and metoprolol were held
until follow-up with his PCP.
.
# COPD on home oxygen (2L): Patient is currently asymptomatic,
with no shortness of breath or wheezing. The patient is on 2L
at home chronically but has been non-compliant with his oxygen
use at home. He was intermittently on 2L NC in-house. His home
regimen of tiotropium and albuterol were continued in-house.
.
#Hypercholesterolemia: Pt currently on Simvastatin 40mg daily,
continued in-house.
.
#CVA: Recent (diagnosed via MRI). Continued home aspirin 81mg
daily.
.
.
# Code: Full code
Transitions of Care:
- Vancomycin, to be continued until [**2170-4-23**] - needs confirmation
that insurance will cover outpatient medication
- Meropenem to be continued until [**2170-4-23**] - needs confirmation
that insurance will cover outpatient medication
- f/u BP; re-start Lisinopril and Metoprolol as BP tolerated
- Tamsulosin was STOPPED for hypotension; follow up PCP or
nephrologist prior to re-starting this medication
- Furosemide was STOPPED for hypotension; follow up with
nephrologist prior to re-initiation
- Percocet was INCREASED in frequency temporarily for pain
control post-procedure
- Gemfibrozil was STOPPED, as this can cause gallstones
- Genasyme was HELD; follow up with nephrologist or PCP before
[**Name9 (PRE) 18290**]
Medications on Admission:
-Aspirin 81mg daily
-Flovent (1puff twice daily)
-Furosemide 40mg [**Hospital1 **]
-Genasyme
-Lisinopril 20mg QD
-Metoprolol 100mg [**Hospital1 **]
-Gabapentin 100mg tab x 2 tabs TID
-Ursodiol 300mg [**Hospital1 **]
-Sevelemer 800mg TID
-Meclizine 12.5mg [**Hospital1 **]
-Darbepoetin injections on Thursday
-Oxycodone/Acetaminophen PRN
-Simvastatin 40mg dialy
-Spiriva daily
-Budesonide 2 puffs twice daily
-Gemfibrizol 600mg [**Hospital1 **]
-Tamsulosin
-Sodium bicarbonate 325mg x 2 tabs three times daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. fluticasone 110 mcg/actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO three times
a day.
4. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. darbepoetin alfa in polysorbat Injection
8. oxycodone-acetaminophen 2.5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain for 7 days: You should
not drive or do anything that requires alertness while taking
this medication. You should AVOID drinking alcohol while taking
this medication. .
Disp:*20 Tablet(s)* Refills:*0*
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. budesonide 90 mcg/actuation Aerosol Powdr Breath Activated
Sig: Two (2) puffs Inhalation twice a day.
12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
13. sodium bicarbonate 325 mg Tablet Sig: Two (2) Tablet PO
three times a day.
14. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Recon
Soln Intravenous Q24H (every 24 hours) for 10 days: Last dose on
[**2170-4-24**].
Disp:*5000 mg Recon Soln(s)* Refills:*0*
15. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000)
mg Intravenous HD PROTOCOL (HD Protochol) for 10 days: Last dose
on [**2170-4-24**].
Disp:*5000 mg* Refills:*0*
16. Normal Saline Flush 0.9 % Syringe Sig: One (1) injection
Injection twice a day: 10 cc of normal saline flush- before and
after MEROPENEM INFUSION.
Disp:*20 INJECTIONS* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Acclaim
Discharge Diagnosis:
Perforated gallbladder/common bile duct
Sepsis
Acute on chronic renal failure
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 while you were at [**Hospital1 18**].
You came to the hospital to have Interventional Radiology remove
stones and a catheter fragment from your gallbladder.
Unfortunately the procedure was very difficult and it was not
possible to remove the stones nor the catheter fragment. During
the procedure your gallbladder was perforated and you had to be
admitted to the hospital for observation. While you were in the
hospital, your blood pressure dropped most likely due to your
body reacting to a bacteria in the blood. Your antibiotics were
switched and you were in the intensive care unit until your
blood pressure stabilized. You will be discharged on a course
of antibiotics to be taken at home.
You will have the VNA who will be doing the antibiotic infusion
daily. The infusion company called [**Location (un) 511**] Home therapy will
be calling you tomorrow in the morning to set up the delivery
time of your antibiotic. However, we were not able to get it
approved by your insurance today given it is [**Last Name (LF) 1017**], [**First Name3 (LF) **] we do
not know the cost of your copay. We have recommended that you
stay inpatient until this is cleared tomorrow morning, but you
have refused. IT IS EXTREMELY IMPORTANT THAT YOU GET THE
ANTIBIOTIC- MEROPENEM TOMORROW IN THE AFTERNOON. IF YOU HAVE ANY
PROBLEMS PLEASE CALL OUR FLOOR AT [**Telephone/Fax (1) 3633**].
While in the hospital, your kidney function was found to be
abnormal, likely due to ****dehydration**** and your kidney
function improved after receiving intravenous fluids. Please
call your dialysis unit on Monday morning at 06:00 AM to make
sure if you will need to go on Monday or back to your regular
schedule Tues/Thurs/Sat schedule.
The following changes were made to your home medications:
- Vancomycin was STARTED, to be continued until [**2170-4-23**]
- Meropenem was STARTED, to be continued until [**2170-4-23**]
- Nephrocaps was STARTED
- Sevelamer was INCREASED
- Percocet was INCREASED in frequency temporarily
- Gemfibrozil was STOPPED, as this can cause gallstones
- Tamsulosin was STOPPED; please follow up with your kidney
specialist or your primary care physician before [**Name9 (PRE) 18290**]
this medication
- Furosemide was STOPPED; please follow up with your kidney
specialist or your primary care physician before [**Name9 (PRE) 18290**]
this medication
- Genasyme was HELD; please follow up with your kidney
specialist or your primary care physician before [**Name9 (PRE) 18290**]
this medication
-Lisinopril was STOPPED; please follow up with your kidney
specialist or your primary care physician before [**Name9 (PRE) 18290**]
this medication
-Metoprolol was STOPPED; please follow up with your kidney
specialist or your primary care physician before [**Name9 (PRE) 18290**]
this medication
Followup Instructions:
Department: HEMODIALYSIS
Please call your dialysis unit on Monday morning at 06:00 AM to
make sure if you will need to go on Monday or back to your
regular schedule.
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 92498**], and arrange to follow up with him within 5 days of
discharge from the hospital.
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the surgery department at [**Hospital1 18**]
at ([**Telephone/Fax (1) 16915**] and arrange to follow up with him within [**3-2**]
weeks after discharge to discuss removing your gallbladder.
|
[
"40391",
"5849",
"496",
"32723",
"2720",
"25000",
"V5867",
"3051"
] |
Admission Date: [**2157-8-19**] Discharge Date: [**2157-10-24**]
Date of Birth: [**2096-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8810**]
Chief Complaint:
Disseminated fusarium, VRE bacteremia
Major Surgical or Invasive Procedure:
Bone marrow biopsy [**2157-9-2**]
Bone marrow biopsy [**2157-9-17**]
Bone marrow biopsy [**2157-10-18**]
Skin biopsy [**2157-8-20**]
History of Present Illness:
The patient is a 61yo M with a PMH of biphenotypic leukemia on
outpatient treatment with Ambisome and voriconazole for
disseminated fusarium [**Month/Day/Year 2**] and recent admission to the [**Hospital Unit Name 153**]
on [**7-27**] for fever and abdominal pain, now being admitted for a
new lesion on congenital oral mass concerning for persistent and
worsening fungal [**Month/Day (4) 2**]. Patient had been going to outpatient
clinic daily for IV infusion of Ambisome. Today patient noted a
sore on the congenital mass on the roof of his mouth that has
been persistent for the past 4-5days. Lesion on roof of mouth,
under dentures, [**2156-1-22**] pain improved without dentures in place.
Has not taken pain medication for it, does not believe it is
worsening. Denies fevers/chills, night sweats. Max temperature
in the last 5 days, per patient, has been 99.0F. No CP, SOB,
trouble breathing, wheezing, HA, nausea. BMs unchanged. Patient
was admitted from clinic for work up of this oral lesion.
.
Also, of note patient developed painless nonpruritic
erythematous blanching patches on his shins bilaterally within
the last day.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies recent weight loss or gain (currently 155, has ranged
from 145-155, though was 185 in [**Month (only) 116**]). Denies sinus tenderness,
rhinorrhea or congestion. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Biphenotypic Leukemia - Initially prsented with "autoimmune
pancytopenia" treated with steroids and IVIG. In [**3-/2157**] his
cytopenias worsened and he was noted to have about 90% blasts
and he was transferred to [**Hospital1 18**]. Preliminary bone marrow biopsy
was suspicious for a biphenotypic leukemia and therapy was
initiated with hyperCVAD. His day 14 marrow showed persistent
disease and his regimen was changed to 7+3. Day 14 and two
subsequent marrows all continued to show persistent involvement
with leukemia. Further chemotherapy was held as he was found to
have disseminated fusarium [**Hospital1 2**] in the setting of prolonged
neutropenia. He was ultimately discharged on G-CSF and daily
Ambisome infusions. He was admitted to the [**Hospital Unit Name 153**] on [**2157-7-27**] for
neutropenic fever and abdominal pain of unknown etiology. While
hospitalized he was treated with a 10-day course of decitabine
without complications.
.
OTHER PMH:
Disseminated Fusarium ([**5-14**]):treated with Ambisome and
Voriconazole
H/O Hepatitis B (on Lamivudine)
S/P appendectomy
S/P umbilical hernia repair
Social History:
Currently on disability. Wife is a retired physician. [**Name Initial (NameIs) **]
from [**Country 5976**]. Nonsmoker, no EtOH, no IVDU.
Family History:
One brother died of ALL. Denies DM, CAD, Strokes, other CAs
Physical Exam:
Admission Exam:
VS: T 98.5, BP 120/76, HR 69, RR 16, SpO2 100%RA
Gen: pleasant elderly male in NAD. Oriented x3. Mood, affect
appropriate.
[**Country 4459**]: NCAT. Sclera anicteric. PERRL, [**Country 3899**]. MMM, OP with
petechiae on posterior palate and 1X0.5cm submucosal
hardened/firm lesion on anterior roof of mouth with 2mm ulcer
over center. Missing teeth.
Neck: Supple, No cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G.
Chest: CTAB without crackles, wheezes or rhonchi. No use of
accessory muscles
Abd: Normal bowel sounds. Soft, NT, mildly distended. +
splenomegaly.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, PT 2+.
Skin: Petechiae on lower abdomen around waist line, diffusely on
legs and feet. 1-4cm erythematous, blanching patches on anterior
shins with superficial ulcerations bilaterally.
Neuro: A&O x3.
Discharge Exam:
Pertinent Results:
Admission Labs:
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] WBC-0.3* RBC-2.98* Hgb-9.0* Hct-24.8*
MCV-83 MCH-30.0 MCHC-36.2* RDW-14.7 Plt Ct-10*
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] Neuts-0* Bands-0 Lymphs-67* Monos-0 Eos-0
Baso-0 Atyps-5* Metas-0 Myelos-0 Blasts-28*
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] Hypochr-1+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-1+
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] Plt Smr-RARE Plt Ct-10*
[**2157-8-20**] 12:10AM [**Month/Day/Year 3143**] PT-15.2* PTT-31.7 INR(PT)-1.3*
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] UreaN-25* Creat-1.1 Na-142 K-3.4 Cl-108
HCO3-25 AnGap-12
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] ALT-33 AST-24 LD(LDH)-148 AlkPhos-218*
TotBili-0.6
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] Calcium-8.5 Phos-3.8 Mg-1.7
Cultures:
[**2157-8-21**] [**Month/Day/Year **] culture: VRE
[**8-26**] [**Month/Day (4) **] culture X2 negative
[**8-30**] [**Month/Year (2) **] culture X2 negative
Imaging:
[**2157-8-21**] MRI soft tissue head: No evidence of enhancing soft
tissues or fluid collection identified in the neck. There is
minimal soft-tissue thickening in the partially visualized
maxillary sinuses. The patient previously had maxillary sinus
disease on prior sinus CT. if further evaluation of sinuses is
clinically indicated, consider a repeat sinus CT.
[**2157-8-30**] Echo: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a small to moderate sized pericardial effusion. There
is right ventricular diastolic collapse, consistent with
impaired fillling/tamponade physiology. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20342**] was
notified by telephone on [**2157-8-30**] at 4:35 pm.
Compared with the prior study (images reviewed) of [**2157-8-1**],
the pericardial effusion is now larger and there is now right
ventricular diastolic collapse. Left ventricular systolic
function appears slightly more vigorous.
[**2157-9-2**] Echo: Overall left ventricular systolic function is
mildly depressed (LVEF= 50 %) with inferior hypokinesis. Right
ventricular chamber size and free wall motion are normal. There
is a small to moderate sized pericardial effusion. The effusion
appears circumferential. No right ventricular diastolic collapse
is seen. There is brief right atrial diastolic collapse
suggestive of elevated intrapericardial pressure without overt
tamponade. Compared with the prior study (images reviewed) of
[**2157-8-30**], no change.
[**2157-9-4**] RUQ US: 1. No biliary obstruction or other explanation
for abnormal LFTs. 2. Trace perihepatic ascites. 3. Right
pleural effusion.
4. Moderate pericardial effusion.
[**2157-9-4**] CXR: AP chest compared to [**6-27**] through [**7-30**]:
Moderate-to-severe enlargement of the cardiac silhouette which
enlarged
between [**6-13**] and [**7-27**] is unchanged subsequently.
Mediastinal and
pulmonary vascular engorgement are essentially unchanged since
[**Month (only) **], and edema is minimal, if any, difficult to
distinguish from relatively symmetric infrahilar opacification
which could also be due to mild-to-moderate atelectasis. There
is no pulmonary edema or consolidation in the upper lungs.
[**2157-9-9**] Echo: Normal LV size with low-normal systolic function.
Normal right ventricular chamber size and systolic function.
Moderate sized circumferential pericardial effusion with
evidence of early hemodynamic effect in inversion of the right
atrium, consistent with increased intrapericardial pressure. No
definitive signs of pericardial tamponade. In the setting of
elevated right sided pressures, echocardiographic evidence of
tamponade may be absent. Mild-moderate mitral regurgitation and
mild-moderate tricuspid regurgitation.
Compared with the findings of the prior study (images reviewed)
of [**2157-9-2**], the effusion is slightly larger and there is
slightly more pronounced diastolic inversion of the right
atrium.
[**2157-9-9**] CXR: In comparison with study of [**9-4**], there is
continued substantial enlargement of the cardiac silhouette with
less prominent vascular congestion that may reflect the PA
rather than supine AP technique. Opacification at the left base
in the retrocardiac region could merely reflect atelectasis,
though in the appropriate clinical setting supervening pneumonia
would have to be seriously considered. There is left and
possibly also right pleural effusion. Scattered streaks of
atelectasis are seen especially at the left base.
Pathology:
[**2157-8-20**] left shin biopsy: The sections shows patchy superficial
and mid-dermal hemorrhage. No primary vasculitis/microthrombotic
vasculitis are seen. There is no evidence of malignancy in this
specimen. Hemosiderin-laden macrophages are present in the
superficial dermis, compatible with relative chronicity of this
hemorrhagic episode. The PAS, GMS, and tissue Gram stains are
negative for microorganisms. Overall, the findings in this
biopsy are non-specific and are suggestive of purpura (e.g.
secondary to trauma, etc.). Culture growing enterococcus
[**2157-9-2**] Bone marrow biopsy: Immunophenotypic findings
consistent with involvement by persistent involvement by
patient's known acute leukemia.
As reported previously, the blasts express myeloid markers
(CD117, CD13) along with B-marker CD19, as well as CD7.
PERSISTENT ACUTE LEUKEMIA WITH MIXED LINEAGE PHENOTYPE (see
note).
Note: Blasts comprise 81% of aspirate differential and a
majority of the core cellularity (overall cellularity 90-100%).
Compared to the previous biopsy (S11-36436R, M11-540 dated
[**2157-7-21**]), the current marrow shows a significant increase in both
overall cellularity and blast count.
Brief Hospital Course:
Mr. [**Known lastname 1005**] is a 61 yo M with refractory biphenotypic leukemia
and history of disseminated fusarium [**Known lastname 2**], on Ambisome and
voriconazole in the setting of prolonged neutropenia from
induction chemotherapy. He was recently transferred to the CCU
for pericardio-centisis on [**2157-9-14**] and pericardial drain
(pulled [**9-16**]).
.
# BIPHENOTYPIC LEUKEMIA: Initial therapy was included hyperCVAD.
His day 14 marrow showed persistent disease and his regimen was
changed to 7+3. Two subsequent marrows all continued to show
persistent involvement with leukemia. Further chemotherapy was
held as he was found to have disseminated fusarium [**Month/Year (2) 2**] in
the setting of prolonged neutropenia. He then received 10 days
of decitabine (C1D41, [**2157-9-10**]). Continued home neupogen to
stimulate WBC in setting of fusarium [**Month/Day/Year 2**]. Patient remained
persistently neutropenic. [**9-2**] BM biopsy showed extensive
disease. The patient then received MEC (C1D1 [**2157-9-24**]). Following
this the patient was noted to have persistence of blasts in
periphery and continued to be pancytopenic. BM on day 21
([**2157-10-18**]) showed >80% blasts. He was discharged with plan to
discuss possible outpatient chemotherapy trials with primary
oncologist Dr. [**Last Name (STitle) **]. Patient was maintained on the following
ppx regimen: bactrim (switched from atovaquone [**10-17**]) and
atovaquone.
.
# FEBRILE NEUTROPENIA, BACTEREMIA: pt with low-grade fevers on
admission. Derm biopsy of left shin showed chronic changes, and
culture grew out enterococcus (likely seeded from [**Last Name (LF) **], [**First Name3 (LF) **]
derm). [**First Name3 (LF) **] culture from [**8-21**] grew VRE. No new murmurs.
[**2157-8-30**] echo showed no signs of endocarditis. Patient was
started on daptomycin for VRE. Repeat [**Month/Day/Year **] culture on [**10-11**] negative. Patient's legs stable without tenderness. Biopsy
site of left shin healing well, still with erythema. Bilateral
changes appear chronic. He spiked a fever in the CCU on [**9-14**]
after placement of pericardial drain ([**Last Name 788**] problem #4), at which
point empiric vancomycin and cefepime were started. Per ID recs,
daptomycin was discontinued. Negative infectious workup,
including UCx, BCx, pericardial fluid cx, and Quantiferon gold.
On [**10-11**], antibiotics were tapered to PO Levofloxacin. He was
discharged on Levoquin for ppx as outpatient, given his chronic
neutropenia.
.
# DISSEMINATED FUSARIUM [**Month/Year (2) **]: occurred in the setting of
neutropenia after induction chemotherapy. Voriconazole held
during chemo on [**11-8**]. Fusarium sensitivities are >4 for
Ambisome, >16 for Vori. On [**10-19**], Ambisome discontinued with
goal of pt returning home shortly not on ambisome infusions.
Patient was discharged on voriconazole. Most recent beta glucan
and galactomannan are negative.
.
# AFIB WITH RVR: On [**9-20**], pt developed new onset Afib with RVR
to the 140s in the setting of low potassium (has chronically low
potassium [**12-22**] ambisome). CXR WNL, electrolytes repleted, trops
neg X2. Managed initially with diltiazem, then switched to
metoprolol and diltiazem per cardiology recs, ultimately
titrated up to metoprolol 37.5mg PO q6 hours and diltiazem 60mg
PO q6 hours. HR in low 100s after that, pt asymptomatic. Pt not
anticoagulated as he is thrombocytopenic.
.
# PERICARDIAL EFFUSION: pt with evidence of cardiac tamponade in
early [**Month (only) **], found on hospitalization to have worsening
pericardial effusion and RV collapse. Repeat echo [**9-2**] showed
persistent effusion without signs of tamponade. Repeat [**9-9**]
echo unchanged, with elevated pulmonary artery pressures
(therefore, RV pressures are likely high, even if no RV
collapse/frank tamponade). On [**9-14**] pt had pericardiocentesis
with placement of pericardial drain, in the setting of starting
anthracycline with potential for cardiotoxicity and worsening
EF. He tolerated the procedure well, with inital output around
500-700 cc and he was transferred to the CCU. While in the CCU
the patient's pericardial drain output eventually started
decreasing and it was pulled. Pulsus remained normal throughout.
Analysis of fluid revealed transudate with reactive inflammatory
cells; cx (including mycobacteria and fungi) and cytology were
negative. However, this was still felt to be most likely
malignant effusion. Repeat TTE on [**2157-9-27**] showed persistence of
small effusion.
.
# PLEURAL EFFUSIONS: pt developed significant BL pleural
effusions of unknown etiology, most likely cardiac given pulm
vascular congestion. While pt had no respiratory compromise and
maintained normal O2 saturations, there was concern for eventual
compromise of lung expansion given severity of effusion. BL
chest tubes placed on [**9-22**], with drainage of about 2L on each
side. Pleural fluid analysis showed transudate with reactive
inflammatory cells; bacterial/mycobacterial/fungal cultures and
cytology negative. Removed R chest tube [**9-22**], unclamped and
removed L chest tube on [**9-23**]. On [**10-7**], left pleural effusion
showed interval worsening. On [**10-18**], CXR showed slightly
improved R atalectasis, stable L pleural effusion. Pt
intermittently clinically volume overloaded during
hospitalization, likely [**12-22**] his cardiopulmonary issues as well
as fluid overload from chemo. He received IV lasix and PO
spironolactone, transitioning to PO lasix and then ultimately
discharged on only spironolactone 20mg PO daily.
.
# RV STRAIN ON TTE: After the pericardial drain was place and
then later pulled, echocardiogram showed new significant RV
strain and volume overload. PE was high on DDx. Negative LENIs
and VQ scan (performed in lieu of CTA [**12-22**] rising creatinine and
thrombocytopenia).
.
# ACUTE RENAL FAILURE: While in the CCU, the patient developed
acute renal failure, with creatinine trending up to 2.1 in the
context of spiking a fever. Found to be prerenal in etiology as
well as from ATN, improved somewhat with IV fluids. Meds renally
dosed, nephrotoxins avoided.
.
# ANEMIA/THROMBOCYTOPENIA: [**12-22**] leukemia, as well as autoimmune
destruction and splenic sequestration (pt with massive
splenomegaly). Patient requiring frequent (q1-2 days) [**Month/Day (2) **] and
platelet transfusions. Goal HCT>25, platelets>20 (or >20 if
having nosebleed).
.
# HEPATITIS B: patient with positive surface and core antibodies
in [**3-30**]. Patient is maintained on Lamivudine. Pt with mildly
elevated LFTs during hospitalization, which improved after
Bactrim was discontinued. Bactrim then restarted without issues.
.
# MECHANICAL FALL: pt had mechanical fall while walking from the
bathroom on the evening of [**2157-9-26**] with minor head trauma and no
other injuries. Given his thrombocytopenia, received immediate
transfusion 2 units platelets. STAT head CT showed no acute
hemorrhage, edema, mass effect or skull fracture but was notable
for left frontal subgaleal hematoma. Serial neurologic exams
WNL. Follow up head CT one week later revealed resolving left
frontal subgaleal hematoma. Pt suffered no consequent
disabilities as a result of this incident.
.
# ORAL LESION: located under patient's dentures. It is unclear
how long it has been present for, but seems to be chronic mass
(possibly congenital) that is newly irritated X4-5days by
dentures. MR showed no evidence of enhancing soft tissues or
fluid collection. Mass does not appear infected and was only
monitored on admission.
.
# MOOD INSTABILITY: Patient has a history of mood instability,
managed on olanzapine. This was continued during
hospitalization.
Medications on Admission:
acyclovir
ambisome
folic acid
lamivudine
levofloxacin
olanzapine
oxycodone
potassium chloride
bactrim
voriconazole
magnesium oxide-Mg AA chelate
Centrum
Omega 3- fish oil
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12
hours).
Disp:*90 Tablet(s)* Refills:*2*
3. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
4. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
7. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
8. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
Disp:*120 Tablet(s)* Refills:*2*
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*12 Tablet(s)* Refills:*2*
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for nausea/anxiety/insomnia.
Disp:*120 Tablet(s)* Refills:*0*
13. ipratropium bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagonsis: disseminiated fusarium, VRE bacteremia
Secondary Diagnosis: Biphenotypic Leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 1005**],
It was a pleasure taking care of you in the hospital. You were
admitted because your doctors suspected your [**Name5 (PTitle) 2**] was
worsening. Your treatment for the fungal [**Name5 (PTitle) 2**] was
continued. You were found to have a bacteria (called
Enterococcus) growing in your [**Name5 (PTitle) **] and on skin biopsy and so
you were treated with an antibiotic called daptomycin. You got
several imaging studies of your heart because we were worried
about the fluid around it. You were given small doses of lasix
to manage the extra fluid in your body and to help you breathe
more easily. You also had irregular and rapid heart beat
(atrial fibrillation) which we treated with diltiazem and
metoprolol. Finally, you had a repeat bone marrow biopsy that
showed persistent leukemia. After discussion with your family
and Dr. [**Last Name (STitle) **], it was decided that you would be discharged home
with outpatient followup to determine how to proceed with your
care.
Please attend the follow-up appointments with Dr. [**Last Name (STitle) **] and
nursing listed below.
We made the following changes to your medications:
1. STARTED diltiazem 60mg by mouth every 6 hours
2. STARTED metoprolol succinate 150mg by mouth once daily
3. STARTED spironolactone 25mg by mouth daily
4. STARTED bactrim DS (double strength) on Mondays, Wednesdays
and Fridays
5. STARTED ipratropium nebulizer 1 treatment every 4 hours as
needed for wheezing/shortness of breath
6. INCREASED voriconazole to 300mg by mouth twice daily (from
300mg by mouth once daily)
Followup Instructions:
Department: BMT CHAIRS & ROOMS
When: TUESDAY [**2157-10-25**] at 12:00 PM
Department: HEMATOLOGY/BMT
When: TUESDAY [**2157-10-25**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2157-10-25**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"5845",
"486",
"5119",
"5180",
"2760",
"2762",
"42731"
] |
Admission Date: [**2170-11-19**] Discharge Date: [**2170-12-1**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
fevers, chills, cholangitis and gallstone pancreatitis
Major Surgical or Invasive Procedure:
[**11-19**]: ERCP with sphincterotomy and stent placement in common
[**Last Name (un) **] duct.
History of Present Illness:
The patient is a [**Age over 90 **]y man who presented to an outside hospital in
new onset rapid a-fib, ruled out for MI. While in house he
developed RUQ pain, fever, elevated LFTs and pancreatic enzymes,
as well as GNR bacteremia that was cultured as e coli for which
he was started on zosyn. A central line was placed for volume
resuscitation and monitoring purposes. He also began to develop
acute renal failure. He was transferred to [**Hospital1 18**] for management.
On admsission he denied nausea, vomiting, diarrhea, SOB, CP.
Past Medical History:
PMH:
Hypertension
Macular degeneration
Restless leg syndrome
Cataracts
Osteoarthritis
PSH:
Appendectomy [**2092**], T&A [**2092**], spinal stenosis surgery [**2165**],
laminectomy, RLL lung resection for benign lesion [**2169**].
Social History:
Lives in an [**Hospital3 **] facility call [**Location (un) **]
former pipe smoker
rare EtOH use.
Family History:
non-contributory
Physical Exam:
97.4, 110 a-fib, 177/84, 32, 93% 5L nc
A&O x 3
Mild icterus
CV:irregular, tachycardic, S1, S2
Pulm: tachypnic, CTA B
Abd: soft, non-distended, tenderness and guarding RUQ,
hypoactive bowel sounds
Extremities: no edema
Pertinent Results:
CHEST (PORTABLE AP) [**2170-11-19**] 3:41 PM
Probable bilateral pleural effusions with basilar atelectatic
change. Left subclavian catheter extends to the mid portion of
the SVC.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2170-11-19**] 4:03 PM
IMPRESSION:
1. Mild intrahepatic duct dilation. No gallstones. The common
bile duct was not evaluated. The liver parenchyma is grossly
unremarkable. The gallbladder wall is somewhat distended with a
wall measuring 3 mm.
Transthoracic echo [**11-21**]
IMPRESSION: Mild hypokinesis of the basal to mid inferior wall.
The right ventricular function is not well seen.
ERCP [**11-19**]:
Bulging of the major papilla was noted
Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique.
Cholangiogram showed a dilated CBD with a diameter of 1.5 cm
with small filling defects suggestive of sludge
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Sludge and pus were extracted successfully using a 12 mm
balloon.
A 7 cm by 10 fr Cotton [**Doctor Last Name **] biliary stent was placed
successfully in the common bile duct
Admission labs
[**2170-11-19**] 02:24PM GLUCOSE-80 UREA N-35* CREAT-1.1 SODIUM-141
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-17* ANION GAP-20
[**2170-11-19**] 02:24PM ALT(SGPT)-394* AST(SGOT)-483* LD(LDH)-383*
ALK PHOS-377* AMYLASE-1072* TOT BILI-4.1*
[**2170-11-19**] 02:24PM LIPASE-612*
[**2170-11-19**] 02:24PM ALBUMIN-2.8* CALCIUM-7.6* PHOSPHATE-3.4
MAGNESIUM-3.0*
[**2170-11-19**] 02:24PM WBC-23.8* RBC-3.38* HGB-11.2* HCT-34.5*
MCV-102* MCH-33.0* MCHC-32.3 RDW-12.4
[**2170-11-19**] 02:24PM PT-15.7* PTT-32.3 INR(PT)-1.4*
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**11-19**] from [**Hospital3 628**]
for management of acute cholagnitis and gallstone pancreatitis.
He was admitted directly to the [**Hospital Ward Name 516**] ICU and taken from
there to endoscopy for ERCP. During ERCP, a sphincterotomy was
performed and a dilated common bile duct was found.Sludge and
pus were extracted successfully using a 12 mm balloon. A biliary
stent was placed successfully in the common bile.
Cholangitis/Gallstone pancreatitis:The patient was admitted with
a temperature of 97.4, a WBC count of 23.8, and alk phos 377,
amylase 1072, lipase 612 and total bili 4.1. He was taken for
ERCP on the day of admission. During ERCP, a sphincterotomy was
performed and a dilated common bile duct was found.Sludge and
pus were extracted successfully using a 12 mm balloon. A biliary
stent was placed successfully in the common bile. Following the
procedure the patient's liver enzymes fell to alk phos 135,
amylase 394, lipase 247 and total bili 0.6.
Cardiac/atrial fibrillation: Patient was admitted w/ rapid
a-fib. Heparin drip was started and then discontinued. Patient
was changed from a amiodarone drip to PO amiodarone for which he
was discharged on a taper regimen.
Respiratory: During the early part of his course the patient
was tachypnic to the low 30s respriatory rate. He was diuresed
with IV and then PO lasix with increasing daily urine out-puts
and improved respiratiory status. His O2 requirement which
required intermittent facemask and high flow nasal cannula was
titrated down to 2L nasal cannula at time of discharge.
Pre-renal acute renal failure: Patient responeded well to fluid
resuscitation and creatinine stayed between 0.9 and 1.2. IV and
then PO lasix was titrated to effect and balanced with
respiratory function. Pt was d/c'd with no diuretic.
ID: The patient was placed on zosyn on admission for the
cholangitis and as prophylaxis following ERCP. He remained on
this until being transitioned to PO bactrim which he was
discharged on.
Neuro/Pain Control:patient's pain was well controlled during
admission.
GI/Nutrition: The patient was kept NPO with intermittent sips of
clears liquids until [**11-21**] when he was advanced to clear liquids
ad lib. The following day, [**11-22**], he was advanced to a regular
diet which he tolerated. He did require encouragement to take in
adequate POs.
Dispo: The patient was discharged to the [**Location (un) 86**] Center facility
for rehabilitation.
Medications on Admission:
neurontin 400mg QHS
aspirin daily
tylenol PRN
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours).
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for RLS.
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): take 400mg (2 tabs) twice a day until [**2170-12-2**]. Then take
400mg once a day for 1 month. Then take 200mg (1 tab) once a
day for 2 weeks.
Disp:*100 Tablet(s)* Refills:*0*
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb treatment Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
7. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center for Rehab
Discharge Diagnosis:
Cholangitis
Gram Negative Rod sepsis
Gallstone pancreatitis
Atrial Fibrillation
Acute renal failure
Discharge Condition:
Good. tolerating regular diet. Pain well controlled. Vital
signs stable
Discharge Instructions:
* The amiodarone dose you are taking for you heart will be
tapered. You will be on 400mg twice a day until [**2170-12-2**], then
400mg once a day for 1 month, then 200mg once a day for 2
weeks, then stop. Your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7842**], [**First Name3 (LF) **]
coordinate this with you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
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 skin, or the whites of your eyes become yellow.
* Your pain is getting worse or is changing location or moving
to your chest or back.
* 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.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 75436**] office at your eariliest convenience to
schedule a follow-up appointment for 2-3 weeks from now. The
number is ([**Telephone/Fax (1) 6347**].
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7842**]
(Phone:[**Telephone/Fax (1) 8506**], . You will need lab tests as an
out-patient while you are on amiodarone. You will need LFTs,
TFTs, a chest X-ray and an EKG. Your PCP will arrange for this.
|
[
"5849",
"99592",
"42731"
] |
Admission Date: [**2133-7-17**] Discharge Date: [**2133-7-21**]
Date of Birth: [**2080-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x3 (left internal mammary artery >
left anterior descending, saphenous vein graft > diagonal,
saphenous vein graft > obtuse marginal) [**2133-7-17**]
History of Present Illness:
52 yo male with angina for 6 weeks and a + ETT. Referred for
cardiac cath which revealed LM dz. Referred for CABG with Dr.
[**Last Name (STitle) **].
Past Medical History:
HTN
elev. lipids
hemachromatosis (monthly phlebotomy since [**1-16**])
PSH: hemorrhoidectomy
Social History:
technical writer
lives with wife
never used tobacco
rare ETOH
Family History:
no premature CAD
father with cerebral hemorrhafge at age 64
Physical Exam:
5'[**35**]" 200#
HR 51 RR 14 right 130/76 left 140/79
NAD, lying flat after cath
skin/HEENt unremarkable
neck supple, no carotid bruits appreciated
CTAB
RRR no murmur
soft, NT, ND, + BS, benign
extrems warm, well-perfused, no edema
no varicosities
unable to assess gait
neuro grossly intact
2+ bil. fems/DP/PT/radials
Pertinent Results:
[**2133-7-20**] 05:33AM BLOOD WBC-8.8 RBC-4.02* Hgb-11.8* Hct-34.5*
MCV-86 MCH-29.4 MCHC-34.3 RDW-13.3 Plt Ct-199
[**2133-7-20**] 05:33AM BLOOD Plt Ct-199
[**2133-7-20**] 05:33AM BLOOD Glucose-108* UreaN-13 Creat-0.8 Na-138
K-3.7 Cl-102 HCO3-26 AnGap-14
RADIOLOGY Final Report
CHEST (PA & LAT) [**2133-7-20**] 8:25 AM
CHEST (PA & LAT)
Reason: evaluate apical ptx
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate apical ptx
INDICATION: Status post CABG, evaluate apical pneumothorax.
FINDINGS: Two views of the chest are compared to [**2133-7-19**],
and no clear pneumothorax is identified. There are bibasilar
pleural effusions and atelectasis, unchanged. Postoperative
appearance of the mediastinum is stable. The patient is status
post recent CABG.
IMPRESSION: No pneumothorax identified.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: MON [**2133-7-20**] 12:04 PM
Brief Hospital Course:
Admitted [**7-17**] and underwent CABG x 3 with Dr. [**Last Name (STitle) **]. Tranferred
to the CVICU in stable condition on titrated phenylephrine and
propofol drips. Extubated later that afternoon and transferred
to the floor on POD #1. Chest tubes removed on POD #2. One
atrial wire broke at skin level during removal and is retained.
Other 3 wires removed on POD #3. Gently diuresed toward his
preop weight. Brief outburst of afib. Beta blockade
titrated.Cleared for discharge to home with services on POD #4.
Pt. is to make all postop appts. as per discharge instructions.
Medications on Admission:
plavix 75 mg daily
atenolol 50 mg daily
ASA 324 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for pain: no more than 4000mg total of
acetaminophen in 24 hours - please note that each percocet
tablet contains 325mg of acetaminophen .
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG x3
Hypertension
Dyslipidemia
Hemachromatosis
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name8 (NamePattern2) 7346**] [**Last Name (NamePattern1) **] in 1 week ([**Telephone/Fax (1) 8506**]) please call for
appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-15**] weeks - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2133-7-21**]
|
[
"41401",
"9971",
"4019",
"2724",
"42731"
] |
Admission Date: [**2176-1-12**] Discharge Date: [**2176-1-19**]
Date of Birth: [**2122-9-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
left foot redness/swelling
Major Surgical or Invasive Procedure:
Left foot debridement, right PICC line placement
History of Present Illness:
53 year old male w/ CAD s/p MI [**2171**], poorly controlled
type I DM and prior DKA presented to ED [**2176-1-12**] with left foot
pain/swelling. He was last hospitalized [**6-6**] with left foot
infection s/p debridement by podiatry and in mild DKA. Patient
had noted increased swelling/warmth of left foot over the last
month 2 months. Over the 5 days prior to admission, he noted
increased pain, associated with fevers, chills, generalized
fatigue, and anorexia. Pt does not check fingersticks. He
reports polyuria and N/V x 1 day. In the ED, his T 102.6, bp
183/70, HR 103, 987%RA. Blood cultures and urine cultures were
sent and the patient received vancomycin, levo, and flagyl.
Given that his blood sugar was >600 with a gap of 14, he
received Humalog 12 u and was started on an insulin drip.
Despite this, his blood sugars were persistently in the mid 400s
although AG closed to 10.
ROS: Denies URI/cough. CP, SOB, abdominal pain, dysuria, BRBPR
Past Medical History:
1) Type I DM: poorly controlled, history of prior DKA
2) CAD s/p MI [**2171**]
3) HTN
4) GERD
5) h/o MRSA (left foot wound)
Social History:
Works in sales. Denies ethanol, tobacco, or other drug use.
Lives with an aunt in [**Name (NI) 583**]
Family History:
Noncontributory
Physical Exam:
Tc 102.6, HR 88, bp 119/65, resp 18, 98% RA
Gen: well appearing middle-aged male in NAD
HEENT: PERRL, EOMI, anicteric, OMMM, OP clear
Neck: supp[le, no LAD, no JVD
Cardiac: RRR, no M/R/G
Pulm: CTA bilaterally
Abd: NABS, soft, NT/ND
Ext: Left foot and left lower extremity with erythema/edema,
mildly tender to palpation with fluctuance.
Neuro: CN II-XII grossly intact and symmetric bilaterally,
A&OX3, decreased sensation to light touch in lower extremities
to mid calves bilaterally
Pertinent Results:
At Time of Admission
wbc 10.6 (86% PMN, 5% bands, 5 lymph, 3 mono), HCT 39.6
Na 134, K 4.0, Cl 99, HCO3 25, BUN 18, Cr 1.1 AG 10, glucose 397
CK 73, TnT <0.01
U/A: 1000 glc, 150 ketones, small blood [**4-7**] rbc, 0 wbc 0 epi
serum tox (-)
[**1-12**] foot x-ray: extensive deformity, of lateral foot c/w DM
arthropathy. No fracture or evidence of osteomyelitis
[**1-12**] EKG NSR @ 97, LAD, LVH, IVCD, no ST/TW changes from [**6-6**]
[**3-/2171**] ETT MIBI: fixed moderate inferolateral perfusion defect
with apical hypokinesis
Brief Hospital Course:
1) DKA: This was likely precipitated by re-infection of left
foot. Although patient's initial anion gap closed while in the
emergency room, given persistant hyperglycemia >400 despite
insulin drip, he was admitted to the ICU. He was transitioned to
a subcutaneous NPH/Humalog regimen and transferred to the floor.
His hemoglobin A1C on [**1-12**] was 9.1, consistent with his known
poor glycemic control. The [**Last Name (un) **] service was consulted for
assistance with management of blood sugars and his standing
humalog and NPH as well as his Humalog sliding scale titrated
up. He will require close diabetes follow-up as an outpatient
and follow-up with his former [**Last Name (un) **] physician ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**]) was
arranged.
2) Left foot abscess/cellulitis: Initially covered with
vancomycin, levofloxacin, and Flagyl given history of MRSA,
which was changed to vancomycin and Unasyn. Blood cultures from
[**1-12**] remained negative at time of discharge. A swab culture of
his left foot wound from [**2176-1-12**] grew >3 colony types; Heavy
beta strep group B, sparse MRSA, and sparse diphtheroids. He
underwent debridement of the area by podiatry (including bone)
on [**2176-1-15**]. Follow-up foot X-ray showed findings consistent
with debridement of fifth metatarsal. There was a lucency deep
to the deepest area of debridement, however the Podiatry service
was confident that they had removed all of the infected
material. The pathology was pending at time of discharge,
however, tissue cultures grew sparse group B beta strep and
sparse gram positive organism (being further identified),
indicating contiguous polymicrobial osteomyelitis. He will
continue on 4 weeks of antibiotics from day of debridement (to
complete [**2176-2-12**]). He will remain non-weight bearing with dry
dressing changes QD. On [**2176-1-18**], increased erythema was noted
over dorsolateral foot, concerning for cellulitis. This was
improving at discharge, but will need to be closely followed as
an outpatient to ensure resolution.
3) CAD: No evidence of ischemia on admission EKG; one set of CE
(-). Pt continued on ASA and beta blocker. Given lipid panel
from [**6-7**] (LDL 54, HDL 46, total chol 135), a statin was not
initiated. His lipid panel will need to be followed closely as
an outpatient to ensure optimal control. In order to optimize
blood pressure control, low dose ACEI (lisinopril 10 mg PO
daily) was initiated, which can be titrated up as an outpatient.
4) Prophylaxis: Given his relative immobility, the patient
received Heparin SC TID throughout hospital stay.
Medications on Admission:
1) NPH 70 units SC QAM, 40 units SCqPM
2) Humalog 15 units SC QAM, 15 units SC qPM
3) Metoprolol 25 mg PO BID
4) ASA 325 mg PO daily
5) Tums prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold sbp <100, HR <55. Tablet(s)
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
4. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) Injection TID (3 times a day).
6. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifty
(50) units Subcutaneous qAM: and 40 u qhs .
8. Humalog 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous qAM (with breakfast): and 15 units qPM (with
dinner).
9. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous qAC and qhs: see attached sliding scale.
10. Ampicillin-Sulbactam Sodium [**3-5**] g Recon Soln Sig: Three (3)
grams Injection Q8H (every 8 hours): through [**2175-2-11**] (total 28
day course).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Vancomycin HCl 500 mg Recon Soln Sig: 1250 (1250) mg
Intravenous Q12H (every 12 hours): through [**2176-2-12**] (total 28
days of therapy).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Primary: osteomyelitis
Secondary: cellulitis, diabetic ketoacidosis, type II diabetes,
coronary artery disease, hypertension
Discharge Condition:
Good
Discharge Instructions:
Please take all of your medications as prescribed. You will be
on the antibiotics Unasyn and Vancomycin for 4 weeks (completing
the course on [**2176-2-12**]). You have been started on lisinopril for
your high blood pressure.
Please follow-up as indicated a below. It is very important in
order to ensure healing that your diabetes be well-controlled;
this requires close physician [**Last Name (NamePattern4) 702**].
Followup Instructions:
1) Primary Care
-- Dr [**Last Name (STitle) 1256**] (in place of Dr. [**Last Name (STitle) 2539**] secondary to availability of
appointments [**Telephone/Fax (1) 3070**]) [**2176-2-7**] 10 a.m.
2) [**Last Name (un) **]: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**] ([**Telephone/Fax (1) 2378**])
on [**2176-2-6**] at 8 a.m.
3) Podiatry:
DR. [**First Name8 (NamePattern2) 23305**] [**Name (STitle) **] Where: CC-2 PODIATRY UNIT Phone: [**Telephone/Fax (1) 25274**]
Date/Time:[**2176-1-22**] 2:30 p.m.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2176-5-8**]
|
[
"412",
"4019",
"2859"
] |
Admission Date: [**2183-9-22**] Discharge Date: [**2183-10-1**]
Date of Birth: [**2138-5-31**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain
Gallstone Pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 45 year old male transferred to [**Hospital1 18**] with a diagnosis
of acute pancreatits, felt to be gallstone etiology. He was
admitted to an outside hospital on [**2183-9-20**] complaining of 2
days of back pain and multiple hours of severe abdominal pain
which had awoken him from sleep. His pain at the time was
associated with nausea and vomiting, but no fever, chills,
diarrhea, melena. At the time of his initial evaluation, his
ALT/AST were 88/78, amylase/lipase were 3821/>3000 respectively.
Abdominal CT scan demonstrated an edematous pancrease
surrounding fat stranding and gallstones. His most recent LFT's
([**9-22**]) were normal and his A/L decreased to 729 and 2384. His
admission WBC was 20.6 and is currently 15.1. Follow-up CT scan
done earlier today demostrates interval worsening of the
peripancreatic inflammation and edema and formation of new
ascities.
Past Medical History:
Hypertriglyceridemia, hypothyroidism
PSH: vasectomy, anal fistulotomy
Social History:
Occasional ETOH
Denies tobacco
Physical Exam:
PE: 100.9, 116, 178/86, 16, 96% RA
Gen: Alert + O x 3, in apparent discomfort, but not toxic or ill
appearing.
CV: Regular rhythn, tachycardia
Chest: lungs clear bilat.
Abd: firm, distended and tympanitic, tender on palpation in the
mid-epigastric without rebound or guarding
Ext: No peripheral edema
Pertinent Results:
[**2183-9-22**] 09:48PM BLOOD WBC-14.0* RBC-4.17* Hgb-12.4* Hct-35.8*
MCV-86 MCH-29.8 MCHC-34.6 RDW-13.8 Plt Ct-286
[**2183-9-23**] 04:41AM BLOOD WBC-13.1* RBC-3.86* Hgb-11.4* Hct-33.7*
MCV-87 MCH-29.7 MCHC-33.9 RDW-13.9 Plt Ct-247
[**2183-9-23**] 04:41AM BLOOD PT-14.7* PTT-34.3 INR(PT)-1.3*
[**2183-9-23**] 04:41AM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-135 K-4.2
Cl-100 HCO3-27 AnGap-12
[**2183-9-22**] 09:48PM BLOOD ALT-19 AST-18 AlkPhos-49 Amylase-290*
TotBili-0.5
[**2183-9-23**] 04:41AM BLOOD ALT-17 AST-15 AlkPhos-47 Amylase-208*
TotBili-0.4
[**2183-9-22**] 09:48PM BLOOD Lipase-150*
[**2183-9-23**] 04:41AM BLOOD Lipase-99*
[**2183-9-23**] 04:41AM BLOOD Albumin-2.6* Calcium-7.8* Phos-2.0*
Mg-1.8
.
[**2183-9-26**] 07:31AM BLOOD WBC-17.6* RBC-3.89* Hgb-11.4* Hct-33.9*
MCV-87 MCH-29.2 MCHC-33.5 RDW-13.7 Plt Ct-367
[**2183-9-29**] 06:28AM BLOOD WBC-27.6* RBC-4.24* Hgb-12.2* Hct-37.0*
MCV-88 MCH-28.8 MCHC-32.9 RDW-13.7 Plt Ct-506*
[**2183-9-29**] 06:28AM BLOOD Glucose-115* UreaN-10 Creat-0.9 Na-135
K-4.6 Cl-94* HCO3-29 AnGap-17
[**2183-9-29**] 06:28AM BLOOD ALT-35 AST-30 AlkPhos-93 Amylase-44
TotBili-0.7
[**2183-9-25**] 05:26AM BLOOD ALT-14 AST-12 AlkPhos-62 Amylase-46
TotBili-0.4
[**2183-9-29**] 06:28AM BLOOD Lipase-29
[**2183-9-26**] 07:31AM BLOOD Lipase-17
[**2183-9-29**] 06:28AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.8*
.
ABDOMEN U.S. (COMPLETE STUDY) [**2183-9-23**] 3:23 PM
IMPRESSION:
1. Diffusely increased liver echogenicity consistent with fatty
infiltration. Other forms of liver disease and more severe forms
of liver disease including significant fibrosis or cirrhosis
cannot be excluded on this study. Suspicion for this is
increased given the presence of splenomegaly.
2. Splenomegaly (14 cm).
3. Heterogeneous echogenicity of the pancreas and (tail not
seen), which may be consistent with pancreatitis. No evidence of
peripancreatic fluid or pseudocyst.
4. Cholelithiasis.
5. Small right pleural effusion.
.
CT PELVIS W/CONTRAST [**2183-9-27**] 2:38 PM
IMPRESSIONS:
1. Severe pancreatitis, with necrosis of the pancreatic body,
but no evidence of associated vascular complication or discrete
collection to suggest pseudocyst.
2. Cholelithiasis.
3. Small simple left pleural effusion. Trace pericardial fluid.
4. Diffuse fatty infiltration of the liver.
.
Brief Hospital Course:
This is a 45 year old male with gallstone pancreatit1s
trasferred to [**Hospital1 18**] for care. He was admitted to the ICU for one
night of close monitoring and then moved to the [**Hospital1 **].
Pain: He was ordered for a Dilaudid PCA. He was using this
appropriately. Once tolerating clears, he was switched to PO
meds.
Pancreatitis: He was NPO/IVF. He was resuscitated with
aggressive IVF. We obtained a US on HD 2. This showed diffusely
increased liver echogenicity consistent with fatty infiltration.
Other forms of liver disease and more severe forms of liver
disease including significant fibrosis or cirrhosis cannot be
excluded on this study. Suspicion for this is increased given
the presence of splenomegaly (14 cm). Heterogeneous echogenicity
of the pancreas and (tail not seen), which may be consistent
with pancreatitis. No evidence of peripancreatic fluid or
pseudocyst. Cholelithiasis. Small right pleural effusion.
The ERCP team evaluated the patient and felt he did not need a
ERCP at this time due to his Amylase and Lipase trending down.
He went for repeat CT on [**2183-9-27**] and this showed Severe
pancreatitis, with necrosis of the pancreatic body, but no
evidence of associated vascular complication or discrete
collection to suggest pseudocyst. Cholelithiasis. Clincally he
look good and he was not complaining of pain. We were able to
advance his diet from clears to a low fat diet on [**2183-9-29**].
Leukocytosis: His WBC was 27.6K on [**9-29**]. A repeat WBC was 20.
He was assymptomatic.
FEN: He was started on clears and we slowly advanced his diet
along. He was still quite distended on HD 4 and was reporting
+flatus. He had a bowel movement prior to discharge.
Hypertension: He was hypertensive to the SBP 160's. He was
treated with Lopressor and Hydralizine.
Medications on Admission:
Gemfibrozil, levothyroxine
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone Pancreatitis
Leukocytosis
Discharge Condition:
Good
Tolerating a diet
Pain well controlled
Discharge Instructions:
Please call your doctor or return to the ER for 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.
* Your skin, or the whites of your eyes become yellow.
* 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.
* 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 amubulate several times per day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks on Monday [**2183-10-13**].
Call [**Telephone/Fax (1) 2835**] to schedule an appointment.
Completed by:[**2183-10-1**]
|
[
"2449"
] |
Admission Date: [**2159-2-9**] Discharge Date: [**2159-2-17**]
Date of Birth: [**2135-1-19**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p rollover MVC with prolonged extrication
Major Surgical or Invasive Procedure:
[**2159-2-11**]: I&D Right thumb, ORIF left tibia, and ORIF left ulna
History of Present Illness:
Mr. [**Known lastname 84125**] presented to the [**Hospital1 18**] on [**2159-2-9**] via [**Location (un) **]
transfer after being a driver of a rollover MVC, car vs. tree
with prolonged extrication. Patient complained of left arm and
leg pain
Past Medical History:
denies medical problems
hx substance abuse
Social History:
polysubstance abuse (tob/opiates/amphetamines)
Lives with girlfriend
Does not work
Lives on [**Location (un) 470**] no elevator
Family History:
n/a
Physical Exam:
Upon admission
Alert
Cardiac: Regular rate
Abdomen: Soft non-tender
Extremities:
C-collar in place
LUE: forearm, abrasion/swelling, +TTP skin intact, SILT, 2+
radial pulse
RUE: thumb, laceration with subcutaneous tissue exposed
LLE: Knee and calf, +swelling/TTP, +pulses, skin intact, SILT,
[**6-6**] AT/[**Last Name (un) 938**]/GS
Pertinent Results:
[**2159-2-9**] 09:49PM GLUCOSE-122* LACTATE-1.5
[**2159-2-9**] 09:49PM freeCa-1.10*
[**2159-2-9**] 05:35AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-POS mthdone-NEG
[**2159-2-9**] 05:35AM PT-13.4 PTT-24.0 INR(PT)-1.1
[**2159-2-9**] 05:35AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2159-2-9**] 05:35AM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG
[**2159-2-9**] 05:35AM URINE RBC-[**4-6**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2159-2-9**] 05:28AM GLUCOSE-181* LACTATE-3.5* NA+-140 K+-3.5
CL--107 TCO2-22
[**2159-2-9**] 05:20AM UREA N-18 CREAT-0.9
[**2159-2-9**] 05:20AM LIPASE-50
[**2159-2-9**] 05:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2159-2-9**] 05:20AM WBC-19.3* RBC-4.75 HGB-13.7* HCT-38.3*
MCV-81* MCH-28.7 MCHC-35.7* RDW-13.8
[**2159-2-9**] 05:20AM PLT COUNT-249
CT C spine: no fracture or dislocation. normal spine.
CT head: no acute abnormality
CT C/A/P
1. Minimally displaced manubrial fracture.
2. Multiple pulmonary contusions, most prominent in the right
middle lobe. In the right lower lobe, at the level of T6, is a
cyst which could represent a lung laceration.
3. Stranding of the fat on the left lateral abdominal wall,
incompletely
visualized. Recommend clinical evaluation for possible injury to
the soft
tissues at the site.
4. No evidence for traumatic injury to the aorta, or solid
intra- abdominal organs.
L Tib/Fib:
1. Comminuted fracture at the lateral aspect of the lateral
plateau.
2. Non-displaced fracture through the lateral tibial plateau.
3. Lipohemarthrosis within the knee joint.
4. Possible tiny medial tibial plateau fracture.
L forearm:
There is fracture of the ulnar shaft. The fracture
fragments are transfixed in good anatomic alignment by a slotted
plate and six screws. Cortical margins appear otherwise intact.
Brief Hospital Course:
Mr. [**Known lastname 84125**] presented to the [**Hospital1 18**] on [**2159-2-9**] via [**Hospital **]
transfer from the scene. He was evaluated by the orthopaedic
and trauma surgery services and found to have Right sided
anterior pulmonary contusions, a left proximal tibia shaft
fracture with lateral tibial plateau fracture, a left fibula
shaft fracture, a left ulnar shaft fracture, and a right thumb
palmar laceration which was superficial. He was admitted to the
trauma service initially, consented, and prepped for surgery.
Later that day he was taken to the operating room. When he was
intubated he had immediate desaturation, the ETT was exchanged
over a bougie and saturation improved. Chest x-ray revealed a
RUL collapse. Surgery was canceled and he was transferred to
the T/SICU for further monitoring. On [**2159-2-11**] he was taken to
the operating room and underwent an ORIF of his left tibia,
ulnar, and an I&D of his right thumb laceration. He tolerated
the procedure well and was transferred back to the T/SICU. He
was transfused with 2 units of packed red blood cells due to
acute blood loss anemia with improvement but required 2 units
again on [**2159-2-14**]. He had sputum samples taken in the ICU which
revealed strep pneumo so he was started on ceftriaxone. This
was changed to levofloxacin for discharge. His pulmonary
symptoms had improved at the time of discharge and he was
afebrile after [**2-15**]. On the floor he was seen by physical and
occupational therapy to improve his strength, mobility, and
function. He was also seen by chronic pain service to help with
his pain control. He was discharged in stable condition.
Medications on Admission:
denies
Discharge Medications:
1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg syringe
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*28 syringe* Refills:*0*
2. Wheelchair with elevating and removalbe leg rests
Disp # 1
Diagnosis: Left Tibial Fracture
3. 3 & 1 Commode
Disp # 1
Diagnosis: Left tibial fracture
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
6. Baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours.
9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p rollover MVC
Left tibia fracture
Left ulna fracture
Right thumb laceration
Acute blood loss anemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
Continue to be non-weight bearing on your left leg and left arm,
you may use your platform crutch to ambulate
Please take your lovenox injections as instructed for a total of
4 weeks after surgery
Please take all your medication as prescribed
If you have any chest pain, shortness of breath, increased
redness around the wound, drainage from the wound, or swelling
of the leg or arm, or if you have a temperature greater than
101.5 please call the office or come to the emergency department
You have been prescribed a narcotic pain medication. Please
take only as directed and do not drive or operate any machinery
while taking this medication. There is a 72 hour (Monday
through Friday, 9am to 4pm) response time for prescription refil
requests. There will be no prescription refils on Saturdays,
Sundays, or holidays. Please plan accordingly.
Physical Therapy:
TDWB on left leg
NWB left arm - may use forearm crutch to ambulate
Treatments Frequency:
Wound care: daily dressing changes to leg wound
Wound eval left arm and leg
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Completed by:[**2159-2-17**]
|
[
"5180",
"2851",
"32723"
] |
Admission Date: [**2106-8-18**] Discharge Date: [**2106-8-24**]
Date of Birth: [**2029-9-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain and dyspnea, referred from PCP office to emergency
room
Major Surgical or Invasive Procedure:
[**2106-8-18**] - Cardiac Catheterization with placement of an
Intra-Aortic Balloon Pump.
[**2106-8-18**] - CABGx4 (Left internal mammary artery->Left anterior
descending artery, Saphenous Vein Graft(SVG)->Diagonal Artery,
SVG->First Obtuse marginal artery, SVG->Second Obtuse marginal
artery).
History of Present Illness:
Seen by PCP in office, noted to be hypertensive and dyspnic. EKG
done that had new ST depressions. Referred to emergency room and
then to Cath lab, found to have left main disease. Intra-aortic
balloon pump placed in cath lab and then brought emergently to
operating room.
Past Medical History:
1) CAD: s/p inferior infarction with catheterization documented
right coronary artery occlusion and moderate LAD and diagonal
branch disease in [**2098-6-1**]
2) CHF: [**8-6**]: EF 50% with akinesis of the base of the inferior
wall.
3) Crohn's Disease dx 20 years ago without medical management
4) Hypertension
5) Hyperlipidemia
6) Glucose intolerance
7) Moderate MR, AR [**8-6**]: [**12-4**]+ aortic and [**12-4**]+ mitral
regurgitation
osteoarthritis
Social History:
Patient currently lives alone. Leads active lifestyle, able to
walk and carry on daily activities. Non-smoker.
Family History:
non contributory
Physical Exam:
VS T 98.1 HR 84 BP 97/59 RR 18 O2sat 97%-RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of *** 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.
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:
[**2106-8-18**] 12:50PM PLT COUNT-279
[**2106-8-18**] 12:50PM WBC-12.5* RBC-3.62* HGB-10.5* HCT-33.3*
MCV-92 MCH-29.1 MCHC-31.7 RDW-14.6
[**2106-8-18**] 12:50PM CK-MB-31* MB INDX-9.1*
[**2106-8-18**] 12:50PM cTropnT-0.76*
[**2106-8-18**] 12:50PM GLUCOSE-204* UREA N-28* CREAT-1.1 SODIUM-138
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18
[**2106-8-18**] 04:45PM PT-12.3 PTT-22.0 INR(PT)-1.0
[**2106-8-18**] 04:45PM WBC-15.5* RBC-3.62* HGB-11.0* HCT-32.8*
MCV-91 MCH-30.5 MCHC-33.6 RDW-14.6
[**2106-8-18**] 04:45PM ALT(SGPT)-34 AST(SGOT)-70* ALK PHOS-74
AMYLASE-61 TOT BILI-0.7
[**2106-8-18**] 04:45PM GLUCOSE-170* UREA N-25* CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-20* ANION GAP-21*
[**2106-8-23**] 06:05AM BLOOD WBC-8.5 RBC-3.91* Hgb-11.3* Hct-34.1*
MCV-87 MCH-28.8 MCHC-33.0 RDW-15.3 Plt Ct-286#
[**2106-8-23**] 06:05AM BLOOD Plt Ct-286#
[**2106-8-23**] 06:05AM BLOOD Glucose-129* UreaN-17 Creat-0.7 Na-141
K-4.5 Cl-102 HCO3-32 AnGap-12
Final Report
PA AND LATERAL CHEST ON [**2106-8-23**]
IMPRESSION: PA and lateral chest compared to [**8-21**],
preoperative chest radiograph:
Small bilateral pleural effusion is new. Severe cardiomegaly is
unchanged. Atelectasis in the left mid lung is changed in
distribution but not in overall severity. No pulmonary edema or
pneumonia. No pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Conclusions
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. There is severe regional left ventricular
systolic dysfunction with severe anterior, inferior mid to
apical hypokinesis.. The remaining left ventricular segments are
hypokinetic. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is moderate thickening of the mitral valve chordae. Mild to
moderate ([**12-4**]+) mitral regurgitation is seen. There is no
pericardial effusion.
IABP in good position.
POST CPB:
1. Mildly improved global and focal LV systolic function.
2. Preserved RV systolci function.
3. Mitral regurgitation is mild to moderate.
4. With improved cardiac output the [**First Name9 (NamePattern2) 19367**] [**Location (un) 109**] measured to
be 1.7 cm2
5. Persistent wall motion abnormalities (Inferior/anteroseptal
severe hypokinesis)
5. Persistent wall motion abnormalities.
Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
Brief Hospital Course:
Admitted for cardiac cath from ER [**8-18**] with NSTEMI. IABP placed
in the cath lab due to extensive coronary disease. Taken
emergently from cath lab to OR for surgery with Dr. [**First Name (STitle) **] that
evening. Transferred to the CVICU in fair condition on titrated
epinephrine, phenylephrine, and propofol drips. IABP removed and
extubated POD #1.Transferred to the floor on POD #2 Her activity
level was gradually advanced. Chest tubes and pacing wires
removed per protocol. Beta blockade titrated and gently diuresed
toward pre-op weight. Made excellent progress and cleared for
discharge to home on POD #6. Pt. is to make all follow-up appts.
as per discharge instructions.
Medications on Admission:
ASA 325', lopressor 50", univasc 15, norvasc 5', glyburide
[**9-6**]', metformin 500", HCTZ 25', asacol 2400", boniva 150qmo,
lipitor 40'
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*200 Tablet(s)* Refills:*0*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
Disp:*270 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily):
total dose 150 mg daily .
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days: for left leg .
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p CABG with preoperative IABP
Non ST elevation myocardial infarction
Acute on chronic systolic heart failure
crohns
colonic polyps
hyperlipidemia
Hypertension
Diabetes mellitus type 2
aortic regurgitation
mitral regurgitation
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. In the event that you have drainage
from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns. [**Telephone/Fax (1) 1504**]
8) Call with any questions or concerns. [**Telephone/Fax (1) 1504**]
Followup Instructions:
Wound Check Friday [**8-27**] with NP/PA on [**Hospital Ward Name **] 6 [**Telephone/Fax (1) 3071**]
Please follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
please follow-up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-5**] weeks.
[**Telephone/Fax (1) 62**]
Please follow-up with Dr [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 3329**]
Please call all providers for appointments
Scheduled appointments:
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2107-2-1**] 11:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6925**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2107-2-2**]
11:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2106-8-24**]
|
[
"41071",
"41401",
"4280",
"4019"
] |
Admission Date: [**2166-7-26**] Discharge Date: [**2166-9-1**]
Date of Birth: [**2097-1-4**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
EtOH withdrawal, C-spine fractures
Major Surgical or Invasive Procedure:
posterior cervical fusion; [**2166-7-27**]
PEG/trach [**2166-8-12**]
History of Present Illness:
69 yo male with a history of EtOH abuse and neck arthritis who
was transferred from [**Hospital3 **] for cervical spine fractures
s/p two falls over past 2 days. Pt reported falling forward onto
his forehead on 2 days ago and falling backward onto his neck in
his bathtub yesterday with loss consciousness both times but did
not seek medical attention. This AM, he presented to the [**Hospital 28941**] ED for neck pain and was found to have odontoid and C4
fractures; he was transferred here for further management.
.
In the ED, initial vs were: T 97.7, HR 106, BP 143/94, O2sat 96%
on RA. Pt alert and oriented with intact neurologic exam. Mildly
wheezy so given albuterol and ipratropium nebs x 2. Patient was
given morphine 2mg x 1 and 4mg x 2 for pain control. Seen by
Ortho-Spine who thought his C-spine fracture may have been acute
on chronic per review of OSH CT C-spine; recommended CT T- and
L- spine with plan for surgery. In the meantime, pt reported
feeling anxious and was given lorazepam 2mg IV per request.
There was subsequently concern for EtOH withdrawal given
restlessness, tachycardia to 107, and SBP 180s-200s. Pt admitted
to drinking 1 quart of vodka nightly. Given valium 10mg IV x 2.
Started on banana bag. Serum and urine tox screens pending.
Admitted to MICU for EtOH withdrawal. On transfer, VS: T 97.9,
HR 101, BP 153/48, RR 16, O2sat 100% NRB.
.
On the floor, pt denies hallucinations or anxiety. No neck or
back pain. Per his sister, his last known drink was Thursday
night. No h/o EtOH withdrawal in past ("never off alcohol long
enough"), seizure disorder, psych disorder. No h/o CAD or CVA.
No h/o neck fracture.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills. Denies headache, sinus. Denied cough,
shortness of breath. Denied chest pain. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. Denied arthralgias or
myalgias.
Past Medical History:
- EtOH abuse
- Tobacco abuse
- Neck arthritis
Social History:
Lives alone, never married, no children. Close relationship with
sister/HCP who lives nearby. Retired engineer for FAA. Drinks 1
quart vodka nightly. 1 ppd cigarettes x 60 years. No known h/o
illicit drug use per family.
Family History:
Father d. 58 of colorectal cancer. Mother d. 74 of COPD, CHF,
smoker. 2 healthy sisters. [**Name (NI) **] brother d. 26 of brain
aneurysm.
Physical Exam:
T 97, HR 95, BP 166/108, RR 20, O2sat 97% on 70% FM
General: Alert, oriented to "hospital in CT" but not cooperative
with most questioning; agitated and frequently trying to get up
but in no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear, abrasion over
left forehead.
Neck: [**Location (un) 2848**] J-collar in place.
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi.
CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, abrasion over right knee.
Pertinent Results:
[**2166-7-26**] 08:06AM BLOOD WBC-9.8 RBC-4.56* Hgb-16.1 Hct-47.4
MCV-104* MCH-35.3* MCHC-34.0 RDW-13.0 Plt Ct-173
[**2166-7-26**] 08:06AM BLOOD Neuts-71.4* Lymphs-20.5 Monos-7.0 Eos-0.8
Baso-0.3
[**2166-7-26**] 08:06AM BLOOD PT-13.0 PTT-27.2 INR(PT)-1.1
[**2166-7-26**] 08:06AM BLOOD Glucose-119* UreaN-15 Creat-0.6 Na-142
K-3.8 Cl-104 HCO3-25 AnGap-17
[**2166-7-26**] 08:06AM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.8 Mg-1.4*
[**2166-7-26**] 08:06AM BLOOD ALT-65* AST-100* AlkPhos-77 Amylase-17
TotBili-1.5 Lipase-15
.
[**2166-7-26**] 08:06AM BLOOD CK(CPK)-[**2089**]* CK-MB-9 cTropnT-<0.01
[**2166-7-26**] 03:06PM BLOOD CK(CPK)-1715* CK-MB-9 cTropnT-<0.01
.
[**2166-7-26**] 08:06AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2166-7-26**] 12:20PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
OSH [**2166-7-26**] CT head: No acute intracranial pathological
process.
.
OSH [**2166-7-26**] CT c-spine:
1. Transverse, type 2 odontoid fracture, with posterior
displacement of the C1/odontoid complex and the body of C2 at
approximately 7 mm. While the fracture line appears somewhat
corticated, making this of uncertain chronicity in the lack of
prior comparisons, prevertebral soft tissue swelling suggests an
element of acute injury.
2. Obliquely oriented fracture through the body of C4, with
extension into
the left lamina. There is also fracture of anterior bridging
osteophytic complex at C3-C4 level. There is exaggerated
lordotic curvature and distraction of fracture line, and some
retropulsion of the superior fracture fragment into the canal.
There is again prevertebral soft tissue swelling at this level.
3. Diffuse degenerative change, with profuse anterior bridging
osteophytes
and disc osteophyte complexes causing mild-to-moderate canal
stenosis. This does predispose patient to cord injury, and MRI
of the cervical spine is recommended to exclude ligamentous
involvement and cord contusion.
Addendum: Upon re-examination of the axial sections, the
epidural hemorrhage may be longitudinally more extensive than
localized at C3/4, and likely involves more cephalad segments.
However, it is still likely a relatively thin rind in shape. MR
scanning would be helpful in more detailed imaging of the cord
and dural margins.
MICRO:
[**7-28**]: MRSA neg
[**7-28**]: R BAL 4+ GNR, OP flora
[**7-28**]: L BAL 1+ GNR, OP flora
[**8-4**] MRSA - Neg
[**8-9**] Sputum: contaminated
[**8-10**]: BAL: GPC, GNR, PMN
[**8-10**]: blood Neg
[**8-10**]: urine enterococcus
[**8-11**]: MRSA neg
[**8-13**]: catheter tip neg
[**8-13**] blood cx: neg
[**8-14**] Ucx: neg
[**8-14**] Sputum: GPC
[**8-17**] sputum: GPC,yeast
[**8-17**] Bcx: p
[**8-17**] Ucx: p
[**8-18**] Cdiff neg
[**8-19**]: Cdiff neg
[**8-19**] Ucx neg
[**8-19**] sputum Cx P
[**8-19**] BAL GPC in clusters
[**8-20**] Cdiff neg
[**8-21**]: BAL GPC oropharyngeal flora, yeast
[**8-24**]: BCx neg , Ucx neg
[**8-29**]: blood - P
[**8-29**]: sputum - cancelled
.
IMAGING:.
[**7-25**]: Transverse, type 2 odontoid fracture, with posterior
displacement of the C1/odontoid complex and the body of C2 at
approximately 7 mm. Uncertain chronicity. Obliquely oriented
fracture through the body of C4, with extension into the left
lamina. There is also fracture of anterior bridging osteophytic
complex at C3-C4 level. There is exaggerated lordotic curvature
and distraction of fracture line, and some retropulsion of the
superior fracture
fragment into the canal.
[**7-29**]: CXR bibasilar atelectasis and bilar pleural effusion
[**7-30**]: CXR collapse RML, RLL
[**8-1**] (x2): CXR atelectasis in RLL, retrocardiac, no signs of new
PNA, ? small R pleural effusion
[**8-3**]: MRI: No acute infarct seen. Post-traumatic changes seen in
the
cervical spine on the sagittal images
[**8-4**]: Right lower lobe is still collapsed. Right upper lobe and
left lung are clear. Heart size normal.
[**8-13**] RUE US: near occlusive clot in right subclavian, axillary,
and brachial veins
[**8-14**]: Left subclavian tip is in lower SVC. Tracheostomy tip is
in standard position. Right PICC line is not visualized.
Bibasilar opacities due to small bilateral pleural effusions and
atelectasis are greater on the right side and unchanged. There
is no pneumothorax.
[**8-17**] CXR: S/p trach. interval improved aeration in the R lower
lung but there still continues to be right lower lobe volume
loss. There are small b pleural effusions.
[**8-18**] CXR: p
[**8-18**] CT abd/pelvis: Moderate amount of complex fluid (ie
hemorrage) within the intraperitoneal compartment, with the
largest collections located in the deep pelvis, paracolic
gutters, perihepatic in [**Location (un) 6813**] pouch, and along the anterior
peritoneal surface. No definite etiology/origin of bleeding
source is identified on this non-contrast- enhanced study. A
contrast-enhanced CT abdomen and pelvis is recommended for
further evaluation of etiology of intraabdominal hemorrhage as
discussed with the primary team at the time of dictation. 2.
Near complete right lower lobe collapse presumed secondary to
aspiration given intraluminal material within the right lower
lobe bronchus. Opacification in the left lower lobe may also
reflect aspiration/atelectasis versus pneumonia. 3.
Mild-to-moderate left anterior descending coronary artery
calcifications
[**8-21**] CXR: Improving left lower lobe aeration compared to one day
prior.
Brief Hospital Course:
[**7-27**]: intubated (fiberoptic) for resp depression, hypoxemia after
receiving 80mg valium for EtOH withdrawal. OR for spinal fusion.
Tachy O/N. UOP decreasing. FENA 0. Bolus 1L.
[**7-28**]: Bronch w/ mucus plugs bilaterally. clonidine. weaned to
cpap.
[**7-29**]: on SCH. on zosyn (GNR) for pna. titrating down sedation,
planning for extubation [**7-30**], lasix drip started, goal 1.5 L net
negative
[**7-30**]: dc lasix, switched diamox for met alkalosis. CXR showing
collapse RML and RLL. Bronch and suction. Extubated. Still
obtunded. 3L neg by afternoon, dc diamox. s/s in AM. New CXR
still w/ RLL collapse Started CPAP o/n but did not tol bc
secretions. [**Name (NI) **] Chest PT/ suctioning q hr. NC. added
azithromycin.
[**7-31**]: left UE wkness identified when midaz stopped, CT head neg;
Again started CPAP o/n but did not tol bc secretions, [**Name (NI) **] Chest
PT/ suctioning q hr.
[**8-1**]: Hard to arouse, but responded well to flumazenil,
depressed MS thought to be due to ativan; obstructed while in
CT, lying flat, thought to be due to [**Month (only) **] MS, flumazenil given
again with good effect, sats brought back up
[**8-2**]: stupor t/o day. Normal SaO2. Deterioration in mental
status. Flumazenil with little effect. ABG 7.19 pCO2 78 pO2 103
HCO3 31. Intubated w/ fiberoptic. Ammonia 66 (? toxic enceph).
MRI head ordered. OGT placed. Tubefeeds started. Started
cimetidine
[**8-3**]: Bronch w/ mucus plugging in RLL. aline and iv's replaced,
propofol for MRI. cosyntropin test.
[**8-4**]: pt more alert, did well on [**5-27**] but not following commands
[**8-5**]: Extubated again. Improved mental status early in the day
and then agitated and confused. Haldol given. Did not tolerate
dobhoff placement. Failed S&S. PICC line placed.
[**8-6**]: Agitated o/n. Attempted dobhoff in room and IR, not able
due to agitation. Haldol given. Picc placed.
[**8-8**]: olanzipine dose increased , HD stable, respiratory status
much improved, taking PO meds
[**8-9**]: Cont TPN and ground diet. Afebrile. Transient desats to
80'w. Still producing lots of thick sputum. Not as agitated,
olanzipine appears to help
[**8-10**]: Intubated (7.29/60/54/30). BAL showing mucus plugs to L
lung OG, aline placed. Trach/peg [**8-11**]. Fever 101.4, pan
cultured. Foley changed.
[**8-11**]: bedside trach unsucessful, pt will go to OR for open
trach, attempt to place dobhoff while pt under sedation for
trach w/ muscle relaxant unsucessful
[**8-12**]: s/p trach, PEG
[**8-13**]: PICC line d/c'd after US revealed right arm DVT. Lovenox
started. Left SC placed. Cultured for temp 101.5. Lasix given
for diuresis. Sputum cx GS for GPC prs/clusters
[**8-14**]: metoprolol dose increased, on trach mask during day, CPAP
at night, early AM of [**8-14**]
[**8-15**]: continued bleed to LSC bleed. Lovenox dose decreased.
Ortho debrided spine wound. To stay on trach collar.
[**8-16**]: wound care c/s, decreased UO, Fena 0.1, bolused 1L, CPAP
at night, back on AC. Tmax 100.5. Sister wants to make him [**Name (NI) 3225**].
[**8-17**]: Bolused + Hespan for low UOP. Febrile to 101.5, cx sent.
Hypernatremic. Hct 18, transfused 2 units.
[**8-18**]: bleed from ?source, f/u CT, levox held, desat sounded
roncherous/wet on exam, lasix given, fever spike 101, getting
hypernatremic so free water flushes upped to 200q4hrs
[**8-19**]: bronch w/ mucus plug in LLL, unasyn switched to vanco,
Fena 0.18, lasix given for low UOP, hypernatremia resolving,
free water flushes decreased 100 q6, tightened RISS, Fena
decreased 0.09, bolused w/ hespan, fever spike 100.7
[**8-20**]: bronch - persistent RLL collapse and Left lingular
plugging
[**8-21**]: bronch plugging and collapse of all major airways, BAL
sent, hep SC started, vanco dose upped as vanc level was low,
decreased metoptolol dose to 75mg PO TID as he had been having
doses held
[**8-26**]: trach changed with improvement in cuff pressures from
50->30.
[**Date range (1) 83327**]: no changes in condition awaiting rehab
Medications on Admission:
see above
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed for wheezing.
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
7. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever >101 or pain.
9. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q8H (every 8 hours) as needed for secretions.
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
14. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral IV - Inspect site every shift
19. Ondansetron 4 mg IV Q8H:PRN nausea
20. Haloperidol 2.5-5 mg IV Q8H:PRN agitation
21. Morphine Sulfate 2-4 mg IV Q2H:PRN btp only
22. Metoprolol Tartrate 5 mg IV Q4H:PRN tachycardia
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
cervical fracture
Discharge Condition:
stable
Discharge Instructions:
69M w/ odontoid fracture, C3-C4 fx dislocation from trauma fall
s/p C4 ORIF, C2-C7 spinal fusion, trach, PEG now w/ RUE DVT,
pneumonia Hct drop. wound dehiscence on occiput is stable
.
Neuro: 1) c-spine fractures: s/p fusion; collar for until follow
up with Dr. [**Last Name (STitle) 1352**] in two weeks (week of [**2166-9-15**]). for pain:
oxycodone; for sedation PRN haldol/zyprexa
.
CVS: lopressor 75 TID for HTN
.
Pulmonary: fully on trach mask for 48hr at time of discharge; to
start symbicort at rehab (per SICu attending)
GI: no acute issues;
FEN: TF at 50cc/hr goal around the clock; no boluses; nutren
pulmonary full strength with beneprotein 25g/day
.
Renal: No issues.
.
Heme: Lovenox 120mg [**Hospital1 **] started [**8-28**] for 3 weeks (ending
[**2166-9-18**]); will need repeat ultrasound in [**1-24**] months to evaluate
clot
Endo: RISS.
.
ID: No active issues; has had low grade fever periodically;
work up for fever; off vanco and all other meds for two weeks;
had vent associated PNA but now adequately treated
TLD: foley, piv, PEG , trach
Wounds: cervical spine -- improving last 2 weeks; collagenase
and dry sterile dressing daily;
Code: DNR per family
Physical Therapy:
activity as tolerated; collar at all times until follow up with
spine surgeon Dr. [**Last Name (STitle) **]
Treatment Frequency:
trach/peg care
cervical wound -- daily dressing change; collagenase and dry
sterile dressing change
Followup Instructions:
[**Doctor Last Name 1352**] [**Telephone/Fax (1) 1228**] during the week of [**2166-9-15**]
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 83328**]; in [**1-24**] weeks
|
[
"5990",
"2760",
"2851",
"32723"
] |
Admission Date: [**2144-6-4**] Discharge Date: [**2144-6-15**]
Date of Birth: [**2087-9-3**] Sex: F
Service: NEUROLOGY
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
weak dizzy poor balance and MRI findings.
Transfer from outside hospital.
Major Surgical or Invasive Procedure:
neurosurgical biopsy
History of Present Illness:
Ms [**Known lastname 69633**] is a 56 year-old left-handed woman with a PMH
of mitral valve prolapse, migraines, parotid gland tumor s/p
excission 30 years ago, and sciatica who presents from an
outside
hospital after presenting with poor balance and lesions found on
MRI. She initially presented to [**Hospital6 **] on
[**2144-5-31**]
after finding herself weak, poor balance, and 'dizzy.' She
reports that for the past month or so she had been dropping
things intermittently from her right hand. She had thought that
this might be a pinched nerve and did not pursue it. In the
past
few weeks, she had also felt mildly unsteady, tipping over when
she walked. She did not note any leg weakness. Last week, she
developed a severe migraine, typical of migraine headaches she
has had in the past. However, with the headache she noted that
her right arm was weaker than usual. The headache cleared as
her
migraines generally would, but her arm remained weaker and she
felt more unsteady. This progressed over the last several days
prior to her coming to [**Hospital3 **] on [**5-31**].
In the Emergency Room at [**Hospital3 **], she was noted to have
right arm weakness. A noncontrast head CT showed evidence of a
left frontal mass. MRI with and without gadolinium showed 3
ring
enhancing lesions in the left frontal lobe with no edema or
midline shift. These were initially felt to be likely
metastatic
lesions.
Neurosurgery was consulted by phone and recommended admission to
the Intensive Care Unit. Subsequently, the official [**Location (un) 1131**] on
the MRI indicated that the lesions appeared more consistent with
tumefactive multiple sclerosis, as a number of apparent
demyelinating lesions were seen in the periventricular and
subcortical white matter.
She has had migraines for many years, with fairly intense
headaches that occur without visual or neurologic aura. These
have been fairly infrequent. She had generally treated them
with
Excedrin migraine, and had never been prescribed triptans or
medications for migraine prophylaxis.
In addition to migraines, she has a history of lower grade
muscle
contraction-type headaches for many years. These have occurred
intermittently and she has generally not treated them, noting
that many people in her family have headaches.
In retrospect, however, she believes that she had had more of
these headaches in the past several months. She has had no
fevers. There has been no change in appetite or weight. She
has
had no nausea. Before the past few weeks, there has been no
focal weakness. She denies any prior history of transient
weakness or visual loss, sensory loss or other symptoms to
suggest attacks of demyelinating disease. She has had no recent
travel. There have been no rashes, shortness of breath or chest
pain.
While inpatient she had an MR spect which demonstrated an area
of
elevated choline /creatinine ratio of 2.6; elevated ratio of
greater than 1.5 has been reported in tumors. Differential
including metastatic disease versus tumafective MS;
A lumbar puncture was done which was reportedly negative for any
infection. She was started on solumedrol 1 gram daily in the
hospital for the past 2 days. Neurosurgery saw the patient and
thought a brain biopsy would be quite a high risk and could
cause
further motor deficits. She was also found to have intermittent
left bundle branch block found on her EKG. The patient was
recommended to have a lexiscan myoview done as an outpatient.
Echo done demonstrated an EF of 60% and trace TR and PI.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. (gets
occasional hot flashes) Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
-Long-standing migraine without aura.
-Right-sided sciatica.
-Mitral valve prolapse.
-Parotid gland tumor excised 30 years ago.
Social History:
She lives alone. She does not smoke or use
alcohol or drugs. Johovah's witness. Worked in office and home
cleaning
Family History:
Significant for headaches in multiple family
members. [**Name (NI) **] mother had breast cancer and father has a history
of coronary disease and diabetes.
Physical [**Name (NI) **]:
Vitals: T: 99.6 P:86 R: 18 BP: 139/80 SaO2:98% Ht5'2
Weight:143 lbs
General: Awake, cooperative, NAD.
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, 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 [**4-9**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
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.
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: Bradykinetic in left upper and lower
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, pinprick, vibratory sense,
proprioception throughout. 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
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. There was slowed
movements on FNF but no overt dysmetria.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
[**2144-6-9**] 02:03AM BLOOD WBC-14.5* RBC-5.05 Hgb-15.0 Hct-42.4
MCV-84 MCH-29.6 MCHC-35.3* RDW-13.5 Plt Ct-451*
[**2144-6-8**] 05:45AM BLOOD WBC-11.5* RBC-4.61 Hgb-14.0 Hct-39.2
MCV-85 MCH-30.4 MCHC-35.8* RDW-13.1 Plt Ct-406
[**2144-6-9**] 02:03AM BLOOD Plt Ct-451*
[**2144-6-8**] 05:45AM BLOOD Plt Ct-406
[**2144-6-9**] 02:03AM BLOOD Glucose-167* UreaN-27* Creat-0.9 Na-140
K-4.6 Cl-101 HCO3-27 AnGap-17
[**2144-6-8**] 05:45AM BLOOD Glucose-86 UreaN-31* Creat-0.7 Na-139
K-4.2 Cl-102 HCO3-27 AnGap-14
[**2144-6-5**] 05:45AM BLOOD ALT-15 AST-17 LD(LDH)-136 CK(CPK)-94
AlkPhos-69 TotBili-0.3
[**2144-6-9**] 02:03AM BLOOD Calcium-9.4 Phos-6.0*# Mg-2.5
Brief Hospital Course:
Upon admission, she was consulted by neurosurgery who performed
a biopsy on [**6-8**] which path report has results as final and is
GBM Stage IV. Following the biopsy, she was watched in the ICU
for one day without any difficulties. However, following the
biopsy, Ms. [**Known lastname 69634**] [**Last Name (Titles) **] changed and she has a significant
right sided paresis.
Neuro-oncologist Dr. [**Last Name (STitle) **] was consulted and was notified of
results by email. She has follow up arranged with him in clinic
to decide on treatment options.
Ms. [**Known lastname 69633**] is single but has support from her parents as well
as elders within her Jehova witness community.
Medications on Admission:
Lopressor, glucosamine, Excedrin p.r.n.
Discharge Medications:
1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO BID (2 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*15 Tablet Extended Release 24 hr(s)* Refills:*2*
8. Miralax 17 gram Powder in Packet Sig: One (1) PO at bedtime.
Disp:*30 * Refills:*2*
9. Senna Laxative 8.6 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Glioblastoma Multiforme
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital because of gradual onset of
right sided weakness. An MRI at the outside hospital showed a
suspicious mass in your left prefrontal region which is
responsible from the strength in your right arm and leg.
Unfortunately, a brain biopsy confirmed that you have grade IV
glioblastoma multiforme. You are currently on steriods to help
reduce the swelling postoperatively.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2144-6-29**] 10:00
|
[
"4240"
] |
Admission Date: [**2145-3-12**] Discharge Date: [**2145-3-22**]
Date of Birth: [**2080-10-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ciprofloxacin Hcl
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest tightness
Major Surgical or Invasive Procedure:
CABGx4(LIMA-LAD, SVG-OM1, SVG-Diag, SVG-PDA)[**3-15**]
History of Present Illness:
64yoM with 3 week history of chest tightness. Positive ETT at
cardiologists office. Followed by cardiac cath at [**Hospital1 **]
which showed multivessel disease then referred to cardiac
surgery
Past Medical History:
DM
^chol
HTN
sleep apnea
excision of precancerous lesion(nose)
Social History:
Lives with wife
[**Name (NI) 1403**] as machinist
Remote tobacco- quit 15 years ago
Remote ETOH- quit 5 years ago
Family History:
non contributory
Physical Exam:
Admission:
VS T 98 HR 71 BP 142/62 RR 18 O2sat..
Ht 5'[**47**]" Wt 205lbs
Gen NAD
Skin unremarkable
Neuro grossly intact
HEENT unremarkable, neck supple
Pulm CTA-bilat
CV RRR
Abdm soft, NT/ND/+BS
Ext warm, well perfused w/bilat varicosities
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77495**]Portable TTE
(Focused views) Done [**2145-3-18**] at 2:45:57 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2080-10-21**]
Age (years): 64 M Hgt (in): 71
BP (mm Hg): 127/48 Wgt (lb): 205
HR (bpm): 68 BSA (m2): 2.13 m2
Indication: Focused study to evaluate for pericardial effusion
ICD-9 Codes: 423.9
Test Information
Date/Time: [**2145-3-18**] at 14:45 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**]
[**Last Name (NamePattern1) 4135**], RDCS
Doppler: Limited Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2008W006-1:34 Machine: Vivid [**7-18**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
TR Gradient (+ RA = PASP): *34 mm Hg <= 25 mm Hg
Findings
LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall
motion abnormality cannot be fully excluded. Overall normal LVEF
(>55%).
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of tamponade.
Conclusions
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is mild pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2145-3-18**] 15:34
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2145-3-17**] 12:36 PM
CHEST (PORTABLE AP)
Reason: eval ptx s/p CT d/c
[**Hospital 93**] MEDICAL CONDITION:
64 year old man s/p CABG
REASON FOR THIS EXAMINATION:
eval ptx s/p CT d/c
HISTORY: Chest tube removal, to assess for pneumothorax.
FINDINGS: In comparison with study of [**3-15**], all of the tubes
have been removed. No evidence of pneumothorax or acute
pneumonia.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
[**2145-3-21**] 09:12AM BLOOD WBC-8.8# RBC-2.93* Hgb-9.3* Hct-26.6*
MCV-91 MCH-31.8 MCHC-35.1* RDW-14.5 Plt Ct-195
[**2145-3-19**] 04:10AM BLOOD PT-11.6 PTT-31.1 INR(PT)-1.0
[**2145-3-21**] 09:12AM BLOOD Glucose-224* UreaN-35* Creat-1.1 Na-136
K-4.5 Cl-99 HCO3-25 AnGap-17
Brief Hospital Course:
Mr [**Known lastname 7739**] was transferred from [**Hospital1 **] MC for coronary bypass
grafting after cardiac catheterization which showed multivessel
coronary disease with normal EF and valve function. He was
brought to the operating room on [**3-15**] where he had coronary
bypass x4, please see OR report for details. In summary had
CABGx4 with LIMA-LAD, SVG-Diag, SVG-OM1, SVG-PDA his bypass time
was 86 minutes with a crossclamp of 68 minutes. He tolerated the
operation well and was transferred to the cardiac surgery ICU in
stable condition. He did well in the immediate post-op period
but because he was a difficult intubation he remained sedated
and ventilated until the morning of POD1 at which point he was
extubated without difficulty. Later on POD1 he was transferred
to the step down floor for continued post-op care. On POD2 he
was noted to be oliguric with a rise in creatine and drop in
hematocrit. He was transferred back to the ICU for monitoring,
with tranfusion oliguria resolved and creatinine corrected. He
was monitored in ICU for additional 24 hours then transferred
back to step down floor. Over the next several days he advanced
his activity and endurance.
He was discharged to home in stable condition on POD#8.
Medications on Admission:
Lisinopril 10'
Pravachol 40'
ASA 81'
Actos 30'
Glyburide 10"
Metformin 1000"
Gemfibrozil 600"
B12
Garlic
Flax seed oil
Cod liver oil
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): 20mg [**Hospital1 **] x 7days then
20mg QD x 10days.
Disp:*24 Tablet(s)* Refills:*0*
3. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours): 20mEq [**Hospital1 **] x 7days then
20mEq QD x 10days.
Disp:*24 Packet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x 7days then
200mg QD.
Disp:*37 Tablet(s)* Refills:*1*
11. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Metformin 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:
Americare at Home Inc
Discharge Diagnosis:
s/p CABGx4(LIMA-LAD, SVG-Diag, SVG-OM1, SVG-PDA)[**3-15**]
PMH: CAD, DM, ^chol, HTN, OSA
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
wound clinic in 2 weeks
Dr [**Last Name (STitle) **] in [**2-14**] weeks
Dr [**First Name (STitle) 1075**] in 4 weeks
Dr [**Last Name (STitle) **] in 4 weeks
Vascular surgeon( referal per Drs [**Name5 (PTitle) **]/Love)
Patient to call for all appointments
Completed by:[**2145-3-22**]
|
[
"41401",
"5849",
"42731",
"2859",
"4019",
"2720",
"32723",
"V1582",
"V5867"
] |
Admission Date: [**2163-1-21**] Discharge Date: [**2163-1-23**]
Date of Birth: [**2090-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
Fluid overload
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Pt is a 73 yo female w/ pmhx DM, HTN, PVD, afib, hyperlipidemia,
ESRD on HD who presents today with acute shortness of breath. Pt
was last dialyzed on wednesday and she reports that was given
back all of the fluid that was taken off. Per dialysis nurse she
is actually below her dry weight. Last night she reports waking
up feeling palpatations and sob when laying on her side, no LE
edema although she has b/l BKAs. At that point had no
diaphoresis, cp, nausea or vomiting. Patient reports eating
cheese and crackers and having chinese for dinner last night. No
changes to her medications that she knows of. Pt denies URI
symptoms, fever, chills, cough, cp, abd pain, nausea, vomiting,
diarrhea. She occasionally has constipation.
.
EMS had a difficult time getting an O2 sat and placed her on
cpap and brought her to the ED whree she was weaned to 4 liters
nasal cannula. She received 1 sl nitro. On exam in ED, she was
noted to have crackles on lung exam and she received Asa 325 mg
x 1, 100 IV lasix and she put out 400 cc which per patient made
her feel better. Renal was consulted and recommended emergent
dialysis in the ICU. She was also placed on nitro gtt because
her initial blood pressure in ED was 210/104 and pressures is
now down to 150/80s. EKG showed st elevation V1-V4 c/w prior ekg
and recent prior cath 8 days ago was negative.
.
Of note, she had a recent admission to [**Doctor Last Name 1263**] with acute dyspnea
and fluid overload and was dialyzed emergently there. She was
then transferred from osh with elevated troponins and negative
stress test to [**Hospital1 18**]. Pt had coronary catheterization which
showed patent arteries at [**Hospital1 **] last week. She was thought to have
elevated troponins in setting of renal failure and demand
ischemia with aflutter. She underwent caval-isthmus atrial
flutter ablation which was unsuccessful and she was put on
coumadin and rate controlled.
.
In the ICU, patient's initial vs were: T 97.4, HR 81, BP 124/62,
R 23, O2 sat 100% on 4 l nc. She felt much better after the
lasix given in the ED. Denied dizziness, cp, palp, sob, abd
pain, nausea, etc.
Past Medical History:
-Hypertension
-Diabetes
-Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
-GERD
-Hypercholesterolemia
-ESRD on hemodialysis M,W,F. Right IJ Permanent Catheter in
place. Receives dialysis at [**Location (un) **] hemodialysis center in
[**Location (un) **].
-Paroxysmal atrial flutter, refused anticoagulation
-Peptic ulcer disease
-Hypertrophic Obstructive Cardiomyopathy.
-Mild mitral stenosis (MVA 1.5-2.0 cm2)
-Secondary Hyperparathyroidism
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
Social History:
Social history is significant for the presence of current
tobacco use, [**12-22**] PPD x 50 years. There is no history of alcohol
abuse. Lives in [**Hospital3 **] facility and uses a mobile
wheelchair.
Family History:
Her father died in his 90's and mother at the age of 102.
Patient unable to specify cause of death. She has one living
sister at the age of 75 and 6 sisters and one brother who passed
away. Her family history is significant for coronary artery
disease, cancer, and diabetes.
Physical Exam:
VS: Temp: 97.4 BP: 124 /62 HR: 81 RR: 23 O2sat 100% on 4 l nc
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: mild bibasilar crackles
CV: RR, S1 and S2 wnl, 2/6 sem at lusb and harsher hsm at apex
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: b/l bka, warm, no rashes
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
RECTAL: deferred
Pertinent Results:
Admission Labs:
[**2163-1-21**] WBC-18.8* RBC-3.99* Hgb-12.4 Hct-39.5 MCV-99* MCH-31.1
MCHC-31.4 RDW-19.8* Plt Ct-366 Neuts-83.4* Lymphs-12.9*
Monos-2.6 Eos-0.9 Baso-0.2
[**2163-1-21**] PT-40.7* PTT-43.9* INR(PT)-4.4*
[**2163-1-21**] Fibrino-506*
[**2163-1-21**] Glucose-119* UreaN-35* Creat-6.8* Na-139 K-5.0 Cl-101
HCO3-25 AnGap-18 Calcium-8.9 Phos-5.7*# Mg-2.3
[**2163-1-21**] CK(CPK)-48 Amylase-108*
[**2163-1-21**] CK-MB-4 proBNP-9533* cTropnT-0.12*
[**2163-1-21**]
AP PORTABLE CHEST: Dual-lumen catheter via right internal
jugular approach terminates near the cavoatrial junction. Heart
size is normal. Aorta is tortuous. The interstitial markings are
prominent and multiple peripheral septal lines are noted. Both
costophrenic sulci are blunted. There is no pneumothorax or
focal airspace consolidation. The bones are somewhat
demineralized.
IMPRESSION: Interstitial edema and small bilateral pleural
effusions.
[**2163-1-21**] EKG:
Sinus rhythm. Left atrial abnormality. Q waves in leads V1-V2
with poor
R wave progression. Suggest old anteroseptal myocardial
infarction.
Borderline left ventricular hypertrophy. ST-T wave
abnormalities, most likely related to secondary repolarization
abnormalities from left ventricular hypertrophy. Compared to the
previous tracing of [**2163-1-11**] there is no significant diagnostic
change.
Brief Hospital Course:
Patient is a 73 yo female with pmhx afib s/p failed ablation on
coumadin, htn, hyperlipidemia, DM and ESRD on HD who presented
with acute dyspnea and pulmonary edema, treated in the MICU with
urgent dialysis, called out to the floor on HD#2 euvolemic.
#. Dyspnea - Resolved quickly with hemodialysis, likely
secondary to volume overload from being underdialyzed and
dietary non-complaince. No evidence of PNA on admission CXR,
with resolved leukocytosis and afebrile. Anticoagulated so PE is
unlikely.
She was discharged to continue her dialysis on regular M/W/F
schedule. Patient was educated about a low salt, heart healthy
diet.
#. HTN- Patient hypertensive to 200s when she came to ED and was
started on nitro gtt. On admission to MICU, SBP 120s and
nitroglycerin gtt was quickly weaned off. This episode is likely
secondary to fluid overload and sob [**1-22**] fluid overload. Patient
was normotensive on transfer to the floor and remained
normotensive on the day of discahrge. She was discharged on her
home regimen with the uptitration of her beta blocker to
continue dialysis regimen as above.
#. ESRD- On dialysis M/W/F. Per report, patient was under
dialyzed on wednesday, two days prior to admission, because she
was under her dry weight. She received HD on the evening of
admission emergently and was sent home to continue HD on M/W/F
when she was euvolemic. The renal followed during her stay and
we continued sevelemer and nephrocaps. On the day of discharge,
patient was mildly hyperkalemic and received kayxalate prior to
discharge with plan for HD on the morning following discharge.
#. Leukocytosis- Patient's [**Known lastname **] count 18.8 on admission with no
localizing signs of infection or fever. [**Month (only) 116**] be stress related.
Resolved on transfer to the floor. Urine culture negative on
admission. Blood cultures x2 with no growth to date still
pending at time of discharge.
#. PAF- S/P failed ablation last admission on warfarin. INR
supratherapeutic on admission at 4.4. Her warfarin was held as
INR was supratherapeutic and resumed on discharge once INR fell
into therapeutic range. She was continued on metoprolol with
uptitration to 100mg [**Hospital1 **] and diltiazem at home dose for rate
control. Telemetry showed continued paroxysmal atrial
fibrillation during her stay.
#. Hyperlipidemia- Continued simvastatin 80 mg qd.
#. PVD- continued aspirin.
#. DM - Most recent A1c in [**11-27**] was 6.9. She was maintained on
NPH 16 units qam as per home regimen. QACHS finger sticks with
sliding scale coverage and diabetic diet were provided during
her stay.
#. Glaucoma- continued home meds.
#. GERD/PUD - continued ranitidine per home regimen.
# F/E/N: HD, Replete lytes PRN. diabetic/renal/cardiac diet
# PPx: Bowel regimen, H2 blocker, supratherapeutic INR
# Access: PIV, dialysis line
# Dispo: to home with HR and BP controlled and patient euvolemic
on exam.
# Code Status: Full
Medications on Admission:
from discharge summary on [**2163-1-13**]- pt reports no changes
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
2. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Diltiazem HCl 120 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily): Right eye.
11. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): Left eye.
12. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily): Left eye.
13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): Left eye.
14. Vigamox 0.5 % Drops Sig: One (1) drop Ophthalmic TID (3
times a day): Left eye.
15. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
16. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Sixteen
(16) units Subcutaneous once a day.
17. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days. (finished course)
Disp:*5 Tablet(s)* Refills:*0*
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Sixteen
(16) units/ml Subcutaneous once a day.
12. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
15. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Outpatient Lab Work
please check INR on [**1-25**] and fax results to [**Company 109100**] Anticoagulation
Management Service (ACMS)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Pulmonary Edema from volume overload
end-stage renal disease on hemodialysis
hypertensive urgency
atrial fibrillation
insulin dependent diabetes mellitus
Discharge Condition:
hemodynamically stable, saturating well on room air with no
signs of volume overload on exam.
Discharge Instructions:
You have been treated for your SOB with dialysis. Please adhere
to a low salt diet and take your medications as prescribed.
Your metoprolol was increased to 100mg twice daily from 75mg
during your stay.
During your stay, your coumadin was held because your INR was
elevated. Please resume your 5mg daily dose and have your INR
checked on [**1-25**] by the VNA. Your result should be faxed to [**Company 109100**]
Anticoagulation Management Service (ACMS).
Please resume your Monday, Wednesday, Friday dialysis schedule.
Please call your primary care provider or return to the
emergency department if you have any chest pain, shortness of
breath, fevers >100.8 or any other concerning symptoms.
Followup Instructions:
Please resume dialysis on [**2163-1-24**] and have your INR checked this
week by the VNA.
You have the following appointments scheduled:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT CENTER - NON BILLING
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2163-1-27**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2163-2-1**] 12:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2163-2-16**]
10:40
|
[
"4280",
"40391",
"25000",
"53081",
"2720",
"42731",
"2724",
"3051",
"V5861"
] |
Admission Date: [**2114-8-21**] Discharge Date: [**2114-8-31**]
Service:
HISTORY OF PRESENT ILLNESS: This is a 72 -year-old male who
presented to the Emergency Department with slurred speech.
health, he did have one glass of liquor prior to onset of
slurred speech. At 10:30 AM, the patient was well, wife took
his blood pressure which was elevated to 170 systolic. At
noon she noted her husband had slurred speech, was drowsy and
tilting his head toward the left. She was able to get him
changed, washed up, and brought into the Emergency
Department. He denied any headaches, visual changes,
difficulty swallowing.
PAST MEDICAL HISTORY:
1. Hypertension.
2. CVA twenty years ago with no residual changes.
3. Ethanol abuse.
4. Atrial fibrillation.
5. Esophageal varices.
ADMITTING MEDICATIONS: Allopurinol 300 mg po q day,
multivitamins, folic acid, thiamine, hydrochlorothiazide 25
mg po q day, Aldomet 250 mg po bid, Cozaar 50 mg po q day,
aspirin 81 mg po q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a retired police worker,
married and lives with his wife. History of ethanol abuse.
FAMILY HISTORY: Diabetes.
PHYSICAL EXAMINATION: Vital signs: afebrile, blood pressure
170/90, heart rate 80, respiratory rate 16, saturation 95% on
room air. In general, lying in bed in no apparent distress.
Head, eyes, ears, nose, and throat: neck supple, no bruits,
pupils are equal, round, and reactive to light. Chest: a few
crackles at base. Cardiovascular: Irregularly irregular
rhythm. Abdomen: protuberant, positive bowel sounds,
nontender. Extremities: no edema. Neurologic: the patient
was drowsy, preferred to lie with his eyes closed, alert and
oriented times three, decreased attention, comprehends
language, but positive dysarthria. No finger agnosia. He
had a left sided facial droop and tongue deviation to the
right. Musculoskeletal: overall tone and bulk okay, strength
5/5 throughout, except left triceps and left deltoid, and
positive left pronator drift. Reflexes symmetric
bilaterally.
HOSPITAL COURSE:
1. Neurologic: The patient was initially on the Neurology
Service. Head CT scan showed a right medial thalamic,
subacute, small lacunar infarct. MRA showed mild stenosis on
the left vertebral and mid basilar system. Etiology was
thought to be either cardiac embolus or arterial embolus.
The patient was initially managed conservatively with aspirin
and Aggrenox. The patient's neurological deficits improved
slowly throughout the course of his stay in the hospital.
2. Cardiovascular: The patient was hypertensive with
systolic blood pressure up to 200 during his initial
presentation in the hospital. His blood pressure remained
elevated despite being on a Nipride drip and multiple other
anti-hypertensives, including hydralazine,
hydrochlorothiazide, and Aldomet. Additionally, the patient
was found to be bradycardic to the 30s. Despite these
cardiovascular abnormalities, the patient was completely
asymptomatic. He was seen by Electrophysiology who
recommended putting a pacer in and a pacer was placed
subsequently. He was eventually weaned off the Nipride drip
and his blood pressure slowly decreased on oral medications.
The patient was seen by the Renal Service and a gadolinium
MRI showed equal sized kidneys with no hydronephrosis or
renal artery stenosis.
DISCHARGE DIAGNOSES:
1. Status post right thalamic, subacute lacunar infarct.
2. Status post pacer placement.
DISCHARGE MEDICATIONS: Hydralazine 100 mg po qid, Norvasc 10
mg po q day, Lasix 20 mg po q day, clonidine 0.3 mg tid,
Aldomet 1.0 gm [**Hospital1 **], aspirin, thiamine, multivitamin, folate,
Cozaar 50 mg po q day, Zantac, Serax, Albuterol metered dose
inhaler, and Tylenol prn.
DISCHARGE CONDITION: Stable.
DISPOSITION: Discharged to home with [**Hospital6 1587**] services.
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2114-11-28**] 11:06
T: [**2114-11-28**] 11:03
JOB#: [**Job Number **]
|
[
"42731",
"40390"
] |
Admission Date: [**2100-8-10**] Discharge Date: [**2100-8-21**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Fever, mental status change
Major Surgical or Invasive Procedure:
Angiogram of Left lower extremity with successful angioplasty of
distal bypass graft.
History of Present Illness:
86yo M with MMP including ESRD on HD, CAD (known reversible
defect that pt has refused intervention for), severe PVD with
h/o OM of L heel who was sent from [**Location (un) 1036**] NH to [**Hospital1 **]-[**Last Name (un) 4068**]
for fevers and lethargy. At OSH found to have T 103, WBC 38, bld
cxs drawn and pt was transferred to [**Hospital1 18**]. In [**Name (NI) **] pt had LP
which was negative, CXR showed R pleural effusion (unchanged
from prior studies), Head CT neg for acute bleed. Pt was
transferred to MICU where he got HD. He was continued on Vanc
and Ctx was added. The next day blood cultures from [**Hospital1 **]-[**Last Name (un) 4068**]
grew Proteus Mirabilis sensitive to amp, levoflox. He was
transferred to floor.
Past Medical History:
CAD s/p recent admission in [**4-27**] where he had NSTEMI and found
to have reversible defect on MIBI but refused intervention
s/p CABG, S/p PCIs
CHF
CMML x2 years with chronic thrombocytopenia and anemia
Ischemic colitis,
ESRD on HD with r av fistula,
PVD s/p L bypass
OM s/p debridement [**5-28**] (MRSA rx with vanco)-> followed by
Podiatry Dr. [**Last Name (STitle) **]
R pleural effusion (exudative but cytology negative for
malignancy)
HTN
Aspiration PNA
Social History:
no current etoh/tob/drug use.
Family History:
NC
Physical Exam:
T 97.8 BP 118/70 P72 R18 96%RA
Thin elderly man in NAD
grey sclera with arcus senilis, semi-dry MM with white patches
on tongue
RRR 2/6 SM at LUSB
decreased BS on R with dullness to percussion [**12-25**] way up on R
soft, slight epigastric tenderness, soft superficial masses on
abdomen, diminished BS
stable R 2nd digit foot ulcer without signs of infection
L heel with increased tenderness and erythema surrounding ulcer
which probed to bone.
Pertinent Results:
Hematologic:
[**2100-8-10**] 04:50PM WBC-36.9* RBC-3.10* HGB-9.5* HCT-27.9* MCV-90
MCH-30.6 MCHC-34.0 RDW-20.3*
[**2100-8-10**] 04:50PM BLOOD Neuts-74* Bands-0 Lymphs-12* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-4*
[**2100-8-18**] 09:24AM BLOOD WBC-57.7* RBC-2.90* Hgb-9.1* Hct-25.9*
MCV-89 MCH-31.4 MCHC-35.2* RDW-17.3* Plt Ct-102*#
[**2100-8-19**] 09:15AM BLOOD Neuts-61 Bands-2 Lymphs-4* Monos-17*
Eos-0 Baso-1 Atyps-0 Metas-2* Myelos-13* NRBC-1*
[**2100-8-20**] 05:56AM BLOOD WBC-57.6* RBC-3.27* Hgb-10.3* Hct-28.9*
MCV-88 MCH-31.5 MCHC-35.6* RDW-16.8* Plt Ct-78*
Chemistry:
[**2100-8-10**] 04:50PM BLOOD Glucose-100 UreaN-82* Creat-5.6*# Na-135
K-6.3* Cl-90* HCO3-27 AnGap-24*
[**2100-8-20**] 05:56AM BLOOD Glucose-65* UreaN-39* Creat-2.8*# Na-143
K-3.5 Cl-95* HCO3-34* AnGap-18
[**2100-8-10**] 04:50PM BLOOD Calcium-10.2 Phos-4.2 Mg-1.7
[**2100-8-20**] 05:56AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.6
Coags:
[**2100-8-10**] 04:50PM BLOOD PT-14.2* PTT-32.9 INR(PT)-1.3
[**2100-8-20**] 05:56AM BLOOD PT-13.9* PTT-34.1 INR(PT)-1.2
Cardiac:
[**2100-8-10**] 04:50PM BLOOD CK-MB-NotDone cTropnT-0.29*
[**2100-8-11**] 04:14AM BLOOD CK-MB-NotDone cTropnT-0.28*
Misc:
[**2100-8-13**] 09:00AM BLOOD VitB12-1406* Folate-GREATER TH
[**2100-8-13**] 09:00AM BLOOD TSH-4.7*
Brief Hospital Course:
1. Proteus [**Name (NI) 11646**] Pt was continued on ceftriaxone for
proteus bacteremia. He defervesced after first day. His
cultures from L heel ulcer also grew dense proteus so this was
felt to be the source. The patient will be continued on IV 1g
QD ceftriaxone for 4 weeks from [**2100-8-13**] and Vancomycin 750mg QHD
for 2more weeks (given history of MRSA OM) for osteomyelitis but
duration will be determined by outpatient Podiatry Dr. [**Last Name (STitle) **]
and will depend on how wound is heeling.
2. PVD- The worsening of his heel ulcer over the prior 2 weeks
was found to be secondary to decreased flow in his L bypass
graft. Vascular was consulted and arteriogram was performed on
[**8-17**] by Dr. [**Last Name (STitle) **] and angioplasty was successfully performed
on distal graft. Given the improvement in his distal blood flow
it was felt that the L heel osteomyelitis might respond to
conservative treatment with abx and wound care. The patient is
to follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] to assess
progression of wound and vascular status.
3. Rectus sheath hematoma- During hospital course pt developed
rectus sheath hematoma at sight of heparin injections. ASA
which had briefly been started was d/c'd for good along with hep
sq inj. Pt's Hct drifted down to 25 so he required several
blood transfusions to aim for Hct >30. Given his
thrombocytopenia (plts as low as 30) he was transfused several
bags of plts to keep count >100. The hematoma stabilized so pt
was felt stable for d/c with plans to recheck Hct and plts at HD
and transfuse to keep Hct>30 and Plts>50.
4. [**Name (NI) 5964**] Pt was continued on HD MWF. All medications were
renally dosed. He was continued on Epo at HD.
5. [**Name (NI) 298**] Pt was admitted with mental status change that
improved with treatment of infection. He had a MRI of his head
which revealed diffuse microvascular dz but no acute CVA.
Currently holding antiplatelet agents given low plt count.
Patient with 90% stenosis of R carotid artery, however refusing
surgical intervention.
6. Pain - The patient has some pain from the ulcer, as well as
from the rectus sheath hematoma. We have started oxycodone 2.5
mg QID, as well as PRN, which is keeping his pain
well-controlled. He may be switched to longer acting meds once
at rehab. We found that a dose of 5 mg of oxycodone q 6 hours
caused confusion.
7. Code status- Code status was discussed with patient and
family. He again affirmed that he was DNR/DNI. Given his poor
prognosis, goals of care were discussed and patient and family
agreed to current treatment plan which included antibiotics and
transfusions as necessary but avoiding major surgical
interventions. Things should be discussed with patient and
family as they arise on a situational basis.
Medications on Admission:
Metoprolol 75 mg PO TID
Ambien 5 mg PO qhs
Isosorbide dinitrate 30 mg xr
losartan 50 mg PO qd
famotidine 20 mg PO qd
Lipitor 20 mg PO qd
Sevelamer 800mg PO TID
MVI qd
Folic acid 1 mg PO qd
Gabapentin 100 mg PO qhs
Albuterol nebs q 6 hours
sertraline 50 mg PO qd
Colace 100mg PO BID
Collagenase ointment qd
Percocet 5-325 mg 1-2 tabs PO q4-6 hours
Tylenol 325 mg PO q4-6 hours
Heparin SQ TID
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection at HD.
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. Lidocaine 5 % Adhesive Patch, Medicated Sig: One (1) Adhesive
Patch, Medicated Topical Q12HR ().
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
11. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
12. Phytonadione 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
13. Oxycodone HCl 5 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day).
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
15. Oxycodone HCl 5 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day) as needed for breakthrough pain.
16. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1)
gram Intravenous Q24H (every 24 hours) for 4 weeks.
17. Vancomycin HCl 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous Q hemodialysis for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
L heel ulcer infected with proteus, MRSA
Proteus bacteremia
PVD
Right Rectus sheath hematoma
Discharge Condition:
Good, stable.
Discharge Instructions:
Take all medications as directed.
Continue wound care.
Return to the hospital if his hct is unable to be stablized with
ocasional transfusion.
Followup Instructions:
1) Call Dr. [**Last Name (STitle) **] (vascular) to schedule f/u appt in [**12-25**]
weeks. [**Telephone/Fax (1) 1784**].
2) Call Dr. [**Last Name (STitle) **] (podiatry) to schedule f/u appt in [**12-25**]
weeks. [**Telephone/Fax (1) 543**].
3) Provider: [**Name10 (NameIs) 454**],ONE DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8
Date/Time:[**2100-9-13**] 7:00
4) Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Where: [**Hospital 273**] RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2100-9-13**] 8:30
5) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
Date/Time:[**2100-9-27**] 3:00
|
[
"2767",
"496",
"4280"
] |
Admission Date: [**2164-7-5**] Discharge Date: [**2164-7-11**]
Date of Birth: [**2110-9-19**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 51 year old male
patient who noticed to have chest pressure a few hours prior
to admission. He presented to an outside hospital Emergency
Department about 3:00 in the afternoon and was found to have
elevated ST segments. He was started on Integrilin at that
time and was transferred to [**Hospital1 188**] for emergency cardiac catheterization. This revealed
left main and severe three vessel coronary artery disease
with a left ventricular ejection fraction of greater than 55
percent and was referred for emergency coronary artery bypass
grafting.
PAST MEDICAL HISTORY: Significant for nephrolithiasis status
post stone extraction as well as ankle surgery.
PREOPERATIVE MEDICATIONS: Accupril, Metoprolol 100 mg po
bid, Lipitor 20 mg po q d, Vitamin E, and Aspirin daily.
ALLERGIES: The patient states no known drug allergies
although he does note an upset stomach with erythromycin.
PHYSICAL EXAMINATION: Upon admission to the hospital was
unremarkable as were his laboratory values with the exception
of elevated CPKs and Troponins.
HOSPITAL COURSE: The patient was taken emergently to the
Operating Room due to his findings in catheterization
laboratory of a 95 percent left main coronary artery
stenosis, as well as a 90 percent to 95 percent left anterior
descending coronary artery lesion. 80 percent proximal left
circumflex and an occluded right coronary artery. The
patient was taken to the Operating Room with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] where he underwent coronary artery bypass graft
times three. The patient had an intraaortic balloon pump
placed preoperatively due to his anatomy. Postoperatively he
was transported from the Operating Room to Cardiac Surgery
Recovery Unit in good condition on Propofol and Phenylephrine
drips.
On postoperative day #1, he was weaned from mechanical
ventilation, successfully extubated. He remains on Neo-
Synephrine for the next day or so due to some hypotension,
his cardiac function remained good with a cardiac index of
greater than 3. His intraaortic balloon pump was weaned and
subsequently discontinued on postoperative day #1. The
patient did require some intravenous fluid boluses for
hypotension.
On postoperative day #2, the patient had some atrial
fibrillation and was placed on Amiodarone because of this.
He was also begun on Lopressor at that time and begun with
diuresis.
The following day the patient had converted back to normal
sinus rhythm. Had remained hemodynamically stable. Had his
Neo-Synephrine drip weaned to off and was tolerating beta
blocker and diuresis.
Postoperative day #3, he was transferred from the intensive
care unit to the telemetry floor. His Metoprolol had been
increased. His [**Location (un) 1661**]-[**Location (un) 1662**] drain in his leg had been
removed and he had begun ambulation and cardiac
rehabilitation. The patient subsequently on the telemetry
floor had another episode of atrial fibrillation that was
short lived on [**2164-7-10**], early in the morning that was
self limiting. His Lopressor was increased and he has not
had any further episodes of atrial fibrillation. He remains
on Amiodarone and Metoprolol for this.
PHYSICAL EXAMINATION: Today, [**2164-7-11**], is as follows:
The patient is afebrile. He is in normal sinus rhythm with a
rate in the mid 70's. His blood pressure is 120/74. Room
air oxygen saturation is 96 percent. Neurologically he is
grossly intact with no apparent deficits. His pulmonary
examination - his lungs are clear to auscultation
bilaterally. Coronary examination is regular rate and
rhythm. His abdomen is soft, nontender, nondistended. His
extremities are warm without edema. His sternal incision as
well as his right leg incisions are all clean and dry with no
erythema, no drainage. The Steri-strips are intact.
DISCHARGE MEDICATIONS: Lopressor 100 mg po bid, Lasix 20 mg
po bid times seven days, Potassium Chloride 20 mEq po bid
times seven days, Zantac 150 mg po bid, Aspirin 325 mg po q
d, Plavix 75 mg po q d times three months. Lipitor 20 mg po
q d, Percocet 5/325 po q four hours prn pain. The patient is
also to continue on Amiodarone 400 mg po tid times one week,
then decrease to 400 mg po bid times one week, then decrease
400 mg po q d times one week, and then decrease to 200 mg po
q d for the remaining week. This is the tentative plan for
Amiodarone loading unless it is altered or until it is
discontinued by the patient's primary cardiologist, Dr.
[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. The patient is also going home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts cardiac monitor for his Amiodarone loading and this
will be transmitted to the electrophysiology service here at
[**Hospital1 69**].
CONDITION ON DISCHARGE: Good.
The patient is to follow up with is primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 5661**] in one to two weeks. He is to follow up with his
primary cardiologist, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] also in one to two
weeks and to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in
approximately five to six weeks.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post emergent coronary
artery bypass graft.
2. Postoperative atrial fibrillation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 5664**]
MEDQUIST36
D: [**2164-7-11**] 12:35:25
T: [**2164-7-11**] 14:43:03
Job#: [**Job Number 5665**]
|
[
"41401",
"41071",
"9971",
"42731",
"4019",
"2724"
] |
Admission Date: [**2173-9-13**] Discharge Date: [**2173-9-17**]
Date of Birth: [**2103-10-30**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4181**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
1. Emergent cricothyrotomy with subsequent closure.
2. Tracheotomy with a #7 Portex tracheotomy tube.
History of Present Illness:
69-year-old patient with a history of T1, N0, squamous cell
carcinoma of the left true vocal cord, who presented to the ED
with respiratory distress. Patient is currently under the care
of
Dr. [**First Name (STitle) 3311**] at [**Hospital1 112**] and has been treated with external beam
irradiation ending in [**Month (only) 216**]. Recently, he has apparently been
treated for fungal mucusitis.
In the ED, the patient was stridorous and was treated with
heliox. Accessory muscle use were required for breathing. With
treatment, the patient significantly improved. After a
conversation with Drs. [**First Name (STitle) 3311**] and [**Name5 (PTitle) **], the decision was
made to go to OR for a tracheotomy to secure the airway.
The plan was to bring the patient to the OR for this reason.
Past Medical History:
1. Squamous cell carcinoma as stated in history of present
illness.
2. Benign prostate hypertrophy.
3. Diabetes mellitus.
4. Gallbladder removal.
5. coronary artery disease
6. perirectal abscess in [**2156**]
7. osteoarthritis,
Social History:
Mr. [**Known lastname 4182**] [**Last Name (Titles) 4183**] from [**Country 532**] in [**2155**]. He
worked as a construction engineer. He is married and lives with
his wife [**Street Address(1) 4184**]. They have one daughter who lives in
the area. The patient smoked one pack per day of unfiltered
cigarettes for 50 years.
Family History:
NC
Physical Exam:
Breathing well on heliox
No neck adenopathy, no neck masses
EOMI
Fiberoptic exam:
No supraglottic edema, left true cords minimally mobile,
exudates
over cords c/w possible fungal infection. Posterior glottic gap
4-5 mm.
Face symmetric
Pertinent Results:
[**2173-9-13**] 10:12PM CK-MB-7 cTropnT-<0.01
[**2173-9-13**] 02:00PM TYPE-[**Last Name (un) **] PH-7.44 COMMENTS-GREEN TOP
[**2173-9-13**] 02:00PM freeCa-1.07*
[**2173-9-13**] 01:53PM GLUCOSE-239* UREA N-17 CREAT-0.9 SODIUM-136
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-30 ANION GAP-11
[**2173-9-13**] 01:53PM CK-MB-11* cTropnT-<0.01
[**2173-9-13**] 01:53PM CALCIUM-8.6 PHOSPHATE-2.3* MAGNESIUM-1.8
[**2173-9-13**] 01:53PM WBC-9.1 RBC-4.07* HGB-12.3* HCT-35.7* MCV-88
MCH-30.1 MCHC-34.4 RDW-13.0
[**2173-9-13**] 01:53PM PLT COUNT-279
[**2173-9-13**] 10:04AM GLUCOSE-204* UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-33* ANION GAP-12
[**2173-9-13**] 10:04AM estGFR-Using this
[**2173-9-13**] 10:04AM CALCIUM-9.5 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2173-9-13**] 10:04AM WBC-10.8# RBC-4.47* HGB-13.6* HCT-39.6*
MCV-89 MCH-30.4 MCHC-34.3 RDW-12.9
[**2173-9-13**] 10:04AM NEUTS-76.1* LYMPHS-16.9* MONOS-6.0 EOS-0.3
BASOS-0.6
[**2173-9-13**] 10:04AM PLT COUNT-277
[**2173-9-13**] 10:04AM PT-13.7* PTT-33.3 INR(PT)-1.2*
CXR [**2173-9-13**]: Tracheostomy tube is in standard position with no
evidence of pneumothorax or pneumomediastinum. Patchy and linear
opacities in the
retrocardiac regions bilaterally likely reflect atelectasis but
aspiration is an additional consideration. Mild gastric
distension has developed.
ECG [**2173-9-13**]: Sinus tachycardia. Wandering atrial pacemaker.
Biatrial abnormality. Compared to the previous tracing of
[**2165-8-22**] there is biatrial abnormality and the rate has
increased. Otherwise, no diagnostic interim change.
SPECIMEN SUBMITTED: Tracheal window.
Procedure date Tissue received Report Date Diagnosed
by
[**2173-9-13**] [**2173-9-13**] [**2173-9-16**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dwc??????
Previous biopsies: [**-4/4013**] GASTRIC BX'S, 2.
[**Numeric Identifier 4185**] GI BX'S/bq/bb.
[**-1/3924**] GALLBLADDER, OMENTUM, SEROSA
DIAGNOSIS:
Tracheal window:
- Dense fibroconnective tissue and ossified cartilage; no
malignancy identified.
- Benign thyroid tissue.
Clinical: Airway obstruction.
Gross: The specimen is received fresh labeled with the patient's
name, "[**Known lastname 4182**], [**Known firstname 4186**]" and the medical record number and
"tracheal window." It consists of two fragments of pink-tan soft
tissue measuring 1.1 x 0.6 x 0.2 cm in aggregate. The specimen
is entirely submitted in cassette A.
Brief Hospital Course:
[**9-14**] pt transferred to floor from ICU
[**9-15**] pt had speech and swallow consult which showed he can have
meds, thin liquids and soft solids PO, pt encouraged to self
suction, spoke to daughter who would like pt to go to rehab
[**9-16**] pt had trach cuff taken down, and PT consult as well as
rehab screen to [**Hospital1 **], PT sts he is completely independent
and speech and swallow states he is low aspiration risk with
cuff down.
[**2173-9-17**] video swallow study showed that patient is without
aspiration risk with cuff deflated for thin liquids and soft
solids, rejected by rehab, being screened for [**Hospital1 4187**]
Medications on Admission:
Diflucan
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Fluconazole in Saline(Iso-osm) Intravenous
4. Hydromorphone (PF) 1 mg/mL Syringe Sig: One (1) Injection
Q3H (every 3 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
difficult intubation, tracheostomy
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications. Such medications include but are not
limited to narcotics and benzodiazepines. Use caution when
combining the above especially when adding other central nervous
system depressants and this may cause respiratory depression.
If being discharged on antibiotics, the entire course must be
finished as directed.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**9-2**] pounds for 6 weeks. You may
resume moderate exercise at your discretion.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Diet: soft solids and thin liquids
Followup Instructions:
Dr. [**First Name (STitle) 3311**], appointment already made, daughter aware of place
and time, necessary documents for preop were faxed to Dr [**Last Name (STitle) 4188**]
office with patients consent
Completed by:[**2173-9-17**]
|
[
"25000",
"41401"
] |
Admission Date: [**2181-4-16**] Discharge Date: [**2181-4-17**]
Date of Birth: [**2137-4-19**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4181**]
Chief Complaint:
Left vocal cord paralysis
Major Surgical or Invasive Procedure:
Laryngoplasty, left vocal cord medialization
History of Present Illness:
Mr. [**Name13 (STitle) 2637**] is a 43 year old male who resides at a rehab
facility after a boating accident in [**7-30**]. This accident was
complicated by a CVA resulting in dysphagia and left vocal cord
paralysis confirmed by videostroboscopy. For the full list of
injuries suffered from this accident please see the PMH section.
As a result of the vocal cord paralysis he has a had
significant decrease in the quality of his voice. He presents
today for laryngoplasty and left vocal cord medialization.
.
He was transferred to the ICU for 24hrs following surgery to
monitor for potential complications.
Past Medical History:
Boating accident [**7-30**] complicated by:
-Vfib arrest
-traumatic brain injury c/b intracranial hemorrhage (s/p
craniotomy)
-R cerebellar contusion
-?CVA; L vocal cord paralysis
-difficulty swallowing
-secretions (spits out q5-10min)
-persistent right sided weakness
-nasal bone fractures (closed reduction with external and
internal fixation)
-IVC filter placement for R cephalic vein thrombosis
-chronic nutrition solely via PEG
-episodic vertigo (presumed BPPV)
Ruptured appy at age 14 (c/b peritonitis)
Social History:
Primary language [**Name (NI) 8003**]
Married, wife lives in [**Name (NI) **] [**Country **]
Has close friend [**Name (NI) **] who lives in [**Name (NI) 86**]
Family History:
Noncontributory
Physical Exam:
AVSS
Gen: NAD
Neuro: AA&O x 3, hoarse, faint voice
CV: RRR
Pulm: CTA b/l
Abd: soft, NT, ND, G-tube in place
Ext: no peripheral edema
Pertinent Results:
[**2181-4-16**] 10:50AM GLUCOSE-98 UREA N-15 CREAT-0.6 SODIUM-141
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-30 ANION GAP-11
[**2181-4-16**] 10:50AM CALCIUM-9.2 PHOSPHATE-3.5# MAGNESIUM-2.1
[**2181-4-16**] 10:50AM WBC-5.1 RBC-4.26* HGB-13.3* HCT-36.8* MCV-86
MCH-31.3 MCHC-36.3* RDW-13.3
[**2181-4-16**] 10:50AM PLT COUNT-220
Brief Hospital Course:
Mr [**Known lastname 1005**] was admitted on [**4-16**] after his procedure which he
tolerated well. For details of the procedure please see the
operative report. At the end of the surgery his left vocal cord
was noted to be located in the midline but not past. He was
admitted to the ICU postoperatively for continue oxygen
saturation monitoring. His previous medications and
tubefeedings were continued. All NSAIDS were stopped and
pneumoboots were placed for DVT prophylaxis. He was given
tylenol and roxicet per his g-tube for pain. He did well
overnight with an oxygen saturation of 92-96% on room air
without evidence of stridor or wheezing. His 02 sat would
increase with deep breathing and IS. There was no evidence of
laryngeal edema. Mr [**Known lastname 1005**] was discharged back to his rehab
facility on postoperative day #1. He will be discharged on 5
days of keflex, a 6 day steroid taper with a medrol dosepack,
and should f/u with Dr. [**Last Name (STitle) **] as scheduled in 1 week.
Medications on Admission:
1. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: Two (2) drops NU
Nasal every four (4) hours as needed for dryness.
2. Artificial Tears Drops [**Last Name (STitle) **]: 1-2 Drops Ophthalmic PRN (as
needed).
3. Ondansetron HCl 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea: per G-tube.
4. Scopolamine Base 1.5 mg Patch 72 hr [**Last Name (STitle) **]: One (1) patch
patch Transdermal Q72H (every 72 hours).
5. Prevacid 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet
PO once a day: per G-tube.
6. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID
(2 times a day): hold for SBP < 90, HR < 60
per G-tube.
7. Trazodone 50 mg Tablet [**Last Name (STitle) **]: [**12-26**] Tablet PO HS (at bedtime):
per G-tube.
8. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: Ten (10) mL PO BID (2
times a day).
9. Dulcolax 10 mg Suppository [**Month/Day (2) **]: Ten (10) mg Rectal once a day
as needed for constipation.
10. Visine eye drops 1 drop OU q8hours prn for dryness
11. Milk of Magnesia suspension 30mL via g-tube daily prn for
consitipation
12. Lidoderm 5% patch topically to lower back daily, on at 9am,
off at 9pm
13. Dimenhydrinate 50mg qHS per g-tube
Discharge Medications:
1. Sodium Chloride 0.65 % Aerosol, Spray [**Month/Day (2) **]: Two (2) drops NU
Nasal every four (4) hours as needed for dryness.
2. Artificial Tears Drops [**Month/Day (2) **]: 1-2 Drops Ophthalmic PRN (as
needed).
3. Ondansetron HCl 4 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea: per G-tube.
4. Scopolamine Base 1.5 mg Patch 72 hr [**Month/Day (2) **]: One (1) patch
patch Transdermal Q72H (every 72 hours).
5. Prevacid 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet
PO once a day: per G-tube.
6. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID
(2 times a day): hold for SBP < 90, HR < 60
per G-tube.
7. Trazodone 50 mg Tablet [**Last Name (STitle) **]: [**12-26**] Tablet PO HS (at bedtime):
per G-tube.
8. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: Ten (10) mL PO BID (2
times a day).
9. Dulcolax 10 mg Suppository [**Month/Day (2) **]: Ten (10) mg Rectal once a day
as needed for constipation.
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month/Day (2) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
11. Dimenhydrinate 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO at
bedtime: via g-tube, hold for sedation.
12. Visine 0.05 % Drops [**Month/Day (2) **]: One (1) drop Ophthalmic every eight
(8) hours as needed for dryness or burning.
13. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day (2) **]:
One (1) patch Topical once a day: apply to lower back at 9am and
remove at 9pm.
14. Keflex 500 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO four times a
day for 5 days.
15. Medrol (Pak) 4 mg Tablets, Dose Pack [**Month/Day (2) **]: per instructions
Tablets, Dose Pack PO per instructions for 6 days: 1st day: 2
tablets before breakfast, 1 tablet after lunch and after supper,
and 2 tablets at bedtime.
2nd day: 1 tablet before breakfast. 1 tablet after lunch and
after supper, and 2 tablets at bedtime.
3rd day: 1 tablet before breakfast, after lunch, after supper
and at bedtime.
4th day: 1 tablet before breakfast, after lunch and at bedtime.
5th day: 1 tablet before breakfast and at bedtime.
6th day: 1 tablet before breakfast.
.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**]
Discharge Diagnosis:
Left vocal cord paralysis
Hypertension
Discharge Condition:
Good
Discharge Instructions:
Call your doctor [**First Name (Titles) **] [**Last Name (Titles) 7186**] of breath, chest pain, worsening
hoarseness of voice, hemoptysis, redness/discharge from
incision.
Continue all medications as you previously were except for
ibuprofen. No NSAIDS for 4 weeks. Complete course of medrol
dosepack and keflex.
Voice rest for 3 days.
Continue tube feedings as you previously were.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2181-4-25**] 2:45
Provider: [**Name10 (NameIs) 326**] UPPER GI (WEST) RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2181-5-8**] 10:00
Provider: [**Name10 (NameIs) **],DYS DYSPHAGIA AND MOTILITY UNIT
Date/Time:[**2181-5-8**] 10:00
|
[
"42731",
"4019"
] |
Admission Date: [**2154-6-18**] Discharge Date: [**2154-7-3**]
Date of Birth: [**2084-5-9**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Antihistamines
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Planned admission for ERCP to dilate post-stent stenosis of CBD
Major Surgical or Invasive Procedure:
ERCP
Biliary drain procedure by IR X 3
History of Present Illness:
70 year old female with a history of metastatic colon ca to
liver and lungs, admitted following ERCP to dilate post-stent
stenosis of CBD. Briefly Ms [**Name13 (STitle) 98372**] was diagnosed with
metastatic Colon cancer in [**2148**] and treated with resection and
5FU / Leucovorin. Unfortunately she had a recurrence in [**2152**]
with mets to liver and lungs. She has had multiple biliary
stents placed in the past for obstructive disease. Recently her
bilirubin has been elevated and she has undergone several ERCP's
with Dr [**Last Name (STitle) **] who was unable to remove all of the sludge
distal to the stents. Her chemotherapy regimen has been held for
the past several weeks due to the elevated bili and it was
recommended that she have the percutaneous biliary procedure
which was performed on [**6-6**]. She was then re-admitted on [**6-12**]
at which time IR replaced her percutaneous biliary drain.
.
According to the preliminary procedure documentation:
1. Previously placed metal stent was seen in the major papilla
with distal occlusion.
2. Cannulation of the biliary duct was performed with a balloon
catheter using a free-hand technique.
3. Cholangiogram showed partial stent occlusion with a normal
right hepatic system. The left hepatic system was dilated with
the external biliary drain in place.
4. Biliary Sludge was extracted from the biliary stent with a
balloon catheter.
.
ROS: Feels sleepy after procedure but otherwise well. No
f/c/n/v/SOB since recent discharge. Last BM today.
.
Past Medical History:
CVA on plavix, with residual deficit of dysarthria
Hypothyroidism
Pre-Diabetes
HTN
Patent foramen ovale
.
Onc Hx: Metastatic colon cancer; stage C when diagnosed in
[**8-/2148**] and treated with resection and 6 cycles of adjuvant 5-FU
and leucovorin. Recurrence in [**2152-12-14**] with liver and lung
metastasis. Had biliary stenting in [**12-18**]. Has been treated with
FOLFOX/Avastin since 1/[**2153**].
.
s/p chole
s/p hernia repair
Social History:
Patient lives at home with her husband. Now retired, but used to
work as a real estate and lead inspector for 20 years.
Prior history of smoking (roughly 10 ppy); quit 30 years ago. No
alchol use or illicit drugs.
Family History:
No FH of cancer
Physical Exam:
VS: Tc 98.7, BP 175/83, HR 57, RR 18, 97% on RA
GENERAL: obese woman, in NAD, resting comfortably in bed
HEENT: icteric sclerae; PERRLA
RESP: CTAB
CV: s1, S2, RRR, [**2-19**] sys murmur RUSB
ABD: hypoactive BS. obese. soft, nd, no HSM, no rebound.
Percutaneous drain in place with no evidence of erythema,
bleeding or drainage at site. Mildly TTP around perc drin site
EXT: Trace LE edema; no cyanosis or clubbing
Pertinent Results:
[**2154-6-17**] 10:00AM BLOOD WBC-7.4# RBC-3.56* Hgb-12.0 Hct-36.5
MCV-103* MCH-33.6* MCHC-32.8 RDW-14.1 Plt Ct-170
[**2154-7-3**] 12:00AM BLOOD WBC-8.3 RBC-3.02* Hgb-10.3* Hct-30.6*
MCV-101* MCH-34.2* MCHC-33.7 RDW-14.0 Plt Ct-226
[**2154-6-21**] 05:17PM BLOOD Neuts-73.5* Lymphs-19.8 Monos-5.3 Eos-1.0
Baso-0.4
[**2154-6-18**] 11:30AM BLOOD PT-15.6* INR(PT)-1.4*
[**2154-6-27**] 12:15AM BLOOD PT-18.3* PTT-42.8* INR(PT)-1.7*
[**2154-6-17**] 10:00AM BLOOD UreaN-6 Creat-0.6 Na-139 K-3.6 Cl-102
HCO3-25 AnGap-16
[**2154-7-3**] 12:00AM BLOOD Glucose-117* UreaN-6 Creat-0.5 Na-132*
K-3.8 Cl-97 HCO3-28 AnGap-11
[**2154-6-17**] 10:00AM BLOOD ALT-41* AST-79* LD(LDH)-149 AlkPhos-637*
TotBili-5.4* DirBili-3.6* IndBili-1.8
[**2154-6-21**] 05:00AM BLOOD ALT-34 AST-72* AlkPhos-496* TotBili-12.1*
DirBili-8.9* IndBili-3.2
[**2154-6-25**] 12:00AM BLOOD ALT-35 AST-77* AlkPhos-442* TotBili-10.2*
[**2154-7-3**] 12:00AM BLOOD ALT-24 AST-68* AlkPhos-435* TotBili-7.9*
[**2154-6-17**] 10:00AM BLOOD GGT-286*
[**2154-6-17**] 10:00AM BLOOD TotProt-7.0 Albumin-2.7* Globuln-4.3*
[**2154-7-3**] 12:00AM BLOOD Albumin-2.1* Calcium-7.9* Phos-3.0 Mg-2.2
[**2154-7-1**] 12:15AM BLOOD Osmolal-267*
[**2154-6-28**] 12:15AM BLOOD TSH-3.2
[**2154-6-25**] 12:00AM BLOOD CEA-4.2*
.
[**6-18**] ERCP
Procedures: Biliary Sludge was extracted from the biliary stent
with a balloon catheter.
Impression: 1. Previously placed metal stent was seen in the
major papilla with distal occlusion.
2. Cannulation of the biliary duct was performed with a balloon
catheter using a free-hand technique.
3. Cholangiogram showed partial stent occlusion with a normal
right hepatic system. The left hepatic system was dilated with
the external biliary drain in place.
4. Biliary Sludge was extracted from the biliary stent with a
balloon catheter.
.
[**6-19**] Tube cholangeogram
IMPRESSION: Successful placement of a 8.5-French right biliary
drainage tube, placed through the stent within the common bile
duct into the duodenum for internal drainage.
Successful replacement of pre-existing left biliary drainage
tube with a 6F nephrostomy catherter for external drainage.
.
[**6-21**] CXR
There is a large mass (4.7 x 5.7 cm) at the left lung apex.
Allowing for low inspiratory volumes, no CHF, focal infiltrate
or effusion is identified. The patient's numerous pulmonary
nodules are faintly visible. Drains noted over the upper
abdomen. No acute pneumonic infiltrate identified. Tip of right-
sided Port- A-Cath type catheter overlies the SVC/RA junction.
.
[**6-21**] EGD:
Impression: The esophagus was normal.
The stomach was normal with no blood within.
The ampullary area was examined using a duodenoscope. There was
a small mount of ooze around the previously placed metal stent.
The IR placed biliary stent could be seen within the metal
stent. There was no blood draining from the stent. The ooze was
flushed several times and seemed to be originating from the
periampullary area secondary to trauma from IR stent insertion
+/- metal stent change of position. The oozing had stopped by
the end of the procedure.
.
[**6-21**] GI Bleeding study:
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for 90 minuteswere obtained. A left
lateral view of the pelvis was also obtained.
Dynamic blood pool images show increased uptake throughout
possibly small bowel seen only in the delayed images (60-90).
The precise cause of the increased uptake or the location cannot
be determined.
IMPRESSION:
Increased uptake possibly in the small bowel seen only in the
delayed images (60-90min) likely representing slow upper GI
bleeding.
.
[**6-25**] CT Abd/Pelvis:
CT ABDOMEN WITH IV CONTRAST: There are multiple lung nodules at
the lung bases. The largest is located within the left lower
lobe and measures 2.9 x 2.1 cm and previously measured 2.7 x 2.0
cm. A right upper lobe nodule has increased in size and now
measures 0.6 x 0.6 cm (series 4, image 1). The patient is status
post PTC and two catheters are seen within the liver entering
via frontal and right lateral approaches. There is a small
amount of perihepatic and perisplenic ascites. A common bile
duct stent is unchanged in appearance. The subcapsular mass in
the lateral right lobe which previously measured 2.1 x 2.2 cm is
now ill- defined, perhaps secondary to phase of contrast
administration, but measures approximately 2.2 x 1.2 cm. There
remains mild intrahepatic biliary dilatation, which has
decreased and an expected small amount of pneumobilia. There is
evidence of tumor extension up the porta hepatis encircling the
left portal vein, decreased compared to the prior study. Lymph
nodes within the porta hepatis, some with mucinous calcification
are unchanged.
A cystic lesion in an enlarged spleen is stable. Cysts in the
right kidney are also unchanged. The pancreas, right adrenal
gland, left kidney, and stomach are unremarkable. A new 1.6 x
1.0 cm left adrenal nodule likely represents metastasis. Small
retroperitoneal lymph nodes do not meet criteria for pathologic
enlargement. There is a small ventral hernia containing
unremarkable appearing mesentery.
CT PELVIS WITH IV CONTRAST: The rectum, bladder, and uterus are
unremarkable. There is mild sigmoid diverticulosis. There are no
enlarged lymph nodes and no free fluid within the pelvis.
BONE WINDOWS: No suspicious lytic or sclerotic foci.
IMPRESSION:
1. Interval progression of disease. New left adrenal lesion
suspicious for metastasis. Enlargement of right upper lobe
pulmonary nodule. The right lateral hepatic lesion is more
ill-defined but has likely mildly decreased in size as has tumor
extending up the porta hepatis.
.
[**6-26**] Cholangiogram:
IMPRESSION:
1. Bilateral cholangiograms performed demonstrate decompressed
system and right-sided biliary catheter retracted into the liver
parenchyma. The left- sided biliary catheter presents in good
position and drainage of the left- sided biliary ducts.
2. Successful exchange for right-sided biliary catheter for a 10
French biliary catheter, the pigtail was coiled in the duodenum.
.
[**6-30**] CXR
IMPRESSION:
1. Smaller apparent size of left apical mass, which may related
to technique. If detailed comparison for interval change is
desired, then PA and lateral radiographs could be helpful.
2. Bibasilar opacities, probably atelectasis
Brief Hospital Course:
A/P: 70 F metastatic colon ca admitted for for ERCP to dilate
post-stent stenosis of CBD.
# Hyperbilirubinemia: It was never completely clear why we were
unable to get her bilirubuin down further than we did. The CT
scan did not show progression of disease. ? [**2-15**] paraneoplastic
syndrome. However, after multiple ERCP/IR procedures (detailed
below), her bilirubin started to trend down by discharge.
- On [**6-18**], she underwent successful ERCP during which they
dilated the distal CBD stent stenosis. She was started on
Levofloxacin after this procedure.
- On [**6-19**], IR placed a drain to her R biliary system that was
also internalized to her duodenum. They also replaced her L-
biliary drain (this could not be internalized).
- On [**6-21**], she had a lg amt of marroon blood per rectum. A
bleeding scan suggested an upper-GI bleed. She was transferred
to the [**Hospital Unit Name 153**] and an EGD was performed which showed a slow bleed
from around the site of entry of the CBD into the duodenum,
thought to be secondary to prior procedures. The bleeding had
stopped by the end of th EGD. Her hct was stable and she did
not require any transfusions during her hospital course.
- On [**6-21**], the same day that she was transferred to the [**Hospital Unit Name 153**], she
spiked a fever to 101. CXR did not show a PNA and UA did not
show a UTI. Vanc/Zosyn were started with concern for biliary
source with possible catheter-site infection. On approximately
[**6-27**], Vancomycin was stopped and she was switched to unasyn,
based on sensitivities (her biliary fluid grew out enterococcus
and K. pneumoniae.) On [**6-30**], cipro was added based on new
sensitivity data for the K. pneumoniae and the fact that she
spiked a low-grade fever. She remained afebrile for the
remainder of her hospital course. On discharge, she was sent
out on augmentin and cipro to be taken ongoing.
- On [**6-26**], IR performed another cholangiogram as her bilirubin
was persistently elevated and her drains seemed only to be
intermittently draining. They increased her R drain to a 10 F
and showed that the L drain was working.
- Prior to d/c we also consulted Hepato-biliary surgery. They
stated that they could offer her a surgical procedure to attempt
to provide better drainage but based on the fact that here bili
began to trend down and her drains seemed to be working, she
decided to defer surgery for now. She will have a f/u
appointment w/ Dr. [**Last Name (STitle) **] as an outpatient.
- She is at very high risk for infection given her 2 biliary
drains.
.
# Hpothyroidism: cont armour
.
# HTN: atenolol held during her gi-bleed and for approx 6 days
after and re-started at a lower dose prior to d/c
- d/c of quinipril as did not seem to need it
.
# Metastatic colon cancer: tx per Dr. [**Last Name (STitle) 2036**] (Dr. [**Last Name (STitle) **] covering
initially and Dr. [**Last Name (STitle) **] took over her care prior to D/c)
- her colon cancer does not appear to be very agressive but she
likely cannot receive any further chemotherapy [**2-15**]
hyperbilirubinemia
- [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] will continue to follow her bilirubin/CBC as
an outpatient.
.
Medications on Admission:
Plavix 75 mg once daily (held X 14 days), quinapril 60 mg daily,
Protonix 40 mg b.i.d., atenolol 50 mg once daily, citalopram 60
mg once daily, Armour 120 mg daily. Oxycodone 5 mg prn.
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Thyroid 120 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed: titrate to [**2-16**] BM per day.
Disp:*1000 ML(s)* Refills:*1*
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever: not to exceed 2gm daily .
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
11. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Total Bilirubin to be drawn every Monday, Wednesday and Friday.
Please fax results to [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **], NP at ([**Telephone/Fax (1) 98373**].
13. Outpatient Lab Work
AST/ALT/Alk Phos/Albumin/CBC to be drawn every Monday. Please
fax results to [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **], NP at ([**Telephone/Fax (1) 98373**].
14. Daily Heparin port-a-cath flushes per [**Location (un) 511**] therapy
protocol
Disp: 2 week supply
Refills: 4
15. Daily Normal Saline Flushes Per [**Location (un) 511**] Therapy Protocol
Disp: 2 week supply
Refills: 4
16. Weekly 20 gauge [**3-17**] inch [**Doctor Last Name **] needles for weekly needle
changes
Disp: 2 week supply
Refills: 4
17. VAD Kits
Disp: 2 week supply
Refills: 4
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Health Services
Discharge Diagnosis:
Metastatic colon cancer
Hypertension
Hypothyroidism
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted for ERCP and IR biliary drain revision.
Please continue the antibiotics as instructed. We also
decreased your blood pressure medications as you did not need as
much as you were receiving.
.
Please seek medical attention immediately if you develop fever,
chills, nausea, vomiting, increased abdominal pain or any other
concerning symptoms.
Followup Instructions:
[**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] will call you regarding your lab results and to
schedule follow-up w/ Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 2036**].
.
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Hepato-biliary surgeon) office
to obtain the date and time of your appointment w/ him. Tel.
([**Telephone/Fax (1) 3618**].
.
Please make a follow-up appointment w/ Dr. [**Last Name (STitle) 2204**] within the
next 2 weeks. Tel [**Telephone/Fax (1) 2205**].
.
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2156-1-20**] 4:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2156-1-20**] 4:00
|
[
"2449",
"4019"
] |
Admission Date: [**2105-9-26**] Discharge Date: [**2105-9-29**]
Date of Birth: [**2055-5-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 50 y/o male with PMHx EtOH abuse with withdrawal
symptoms and DTs, depression, HTN who presents to the ED with
suicidal ideations after an episode of binge drinking, called
EMS on self with SI. Did not actually harm himself. Was
recently admitted to dual diagnosis center for ~1 week starting
on [**9-16**], after discharge began drinking 1 pint of vodka nightly
and reports he drank [**1-3**] gallon of vodka today.
.
In the ED, initial vs were: Temp:99.3 HR:124 BP:135/88 Resp:16
Sat:95
Patient received thiamine, folate, multivitamin, 2L fluid and
was started on CIWA scale with valium and received a total of
80mg PO with 2mg Ativan due to withdrawal symptoms - agitation,
tachycardia, and tremulousness that resolved with treatment.
Psych was consulted and did not feel that a section 12 was
necessary at this time.
.
Of note, patient does admit to an admission at [**Hospital1 2025**] where he
experienced seizures and self reports a diagnosis of delirium
tremens.
.
On the floor, the patient feels shaky, anxious and tremulous.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
(from OMR, confirmed with patient)
PAST MEDICAL HISTORY:
- PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 49342**] at [**Hospital **] Medical Associates in [**Location (un) 5110**], MA
- s/p R nephectomy in [**2096**] [**2-3**] renal mass, HTN, dyslipidemia
PAST PSYCHIATRIC HISTORY: (from OMR, confirmed with patient)
- Unclear psychiatric diagnosis separate from his alcoholism.
Historical diagnosis of MDD, anxiety, bipolar disorder.
- Multiple past dual diagnosis hospitalizations, two at [**Hospital1 1680**]
JP
in the past month.
- Medication trials include prozac, seroquel and benzos.
- Pt reports one prior SA/SBI by stabbing himself once in [**2099**]
in
the RLQ, sought medical treatment at [**Hospital1 2025**]. Patient has scar on
RLQ, but appears to be surgical incision, possibly from
nephrectomy.
Social History:
- Tobacco: 1 pack/week
- Alcohol: 1 qt of vodka daily, reportedly [**1-3**] gallon today;
multiple in/outpatient detoxes; self-reported h/o withdrawal
seizure at [**Hospital1 2025**] ([**2100**]), self-reported DT's (tremors and VHs, no
ICU stays), and blackouts. Longest period of sobriety for three
months ending a couple months ago (similar to past evaluations,
patient vague about time frame.)
- Illicits: denies IVDU, remote h/o benzo and cocaine abuse
Family History:
Father died of MI at age 70.
Physical Exam:
Vitals: T: 98.0 BP: 142/794 P:70 R: 16 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, 2x2 erythematous scaly patch on right thigh since last
hospitalization
Skin: Diffuse erythematous macules on back and chest, some
excoriated, blanching. Erythematous face.
Neuro: AAOx3, 5/5 strength all extremities, +tremor, no
nystagmus
Pertinent Results:
Labs on Admission:
[**2105-9-26**] 02:55PM BLOOD WBC-7.8 RBC-4.60 Hgb-14.8 Hct-42.5 MCV-92
MCH-32.3* MCHC-35.0 RDW-14.4 Plt Ct-313
[**2105-9-26**] 02:55PM BLOOD Neuts-59.3 Lymphs-31.9 Monos-5.6 Eos-1.2
Baso-2.0
[**2105-9-26**] 02:55PM BLOOD Glucose-147* UreaN-15 Creat-1.1 Na-144
K-3.8 Cl-102 HCO3-23 AnGap-23*
[**2105-9-26**] 02:55PM BLOOD ALT-52* AST-60* LD(LDH)-197 AlkPhos-105
TotBili-0.5
[**2105-9-26**] 02:55PM BLOOD Albumin-4.3 Calcium-9.2 Phos-1.3*# Mg-1.9
[**2105-9-26**] 02:55PM BLOOD ASA-NEG Ethanol-277* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
.
Labs on Discharge:
[**2105-9-29**] 08:50AM BLOOD WBC-4.9 RBC-4.34* Hgb-13.6* Hct-40.7
MCV-94 MCH-31.3 MCHC-33.4 RDW-14.0 Plt Ct-209
[**2105-9-29**] 08:50AM BLOOD Glucose-94 UreaN-9 Creat-1.0 Na-140 K-4.5
Cl-104 HCO3-28 AnGap-13
[**2105-9-29**] 08:50AM BLOOD UricAcd-4.8
Brief Hospital Course:
In the MICU [**Date range (3) 49343**]:
50 y/o male with known history of EtOH withdrawal and DTs who
presents after SI while intoxicated, now with EtOH withdrawal
symptoms. In the [**Name (NI) **], Pt received diazepam 80mg PO with lorazepam
2mg and a banana bag and another 20mg of diazepam with 1mg
lorazepam overnight in the CCU. He felt better the following
morning and was transferred to the medical floor. Psych did not
recommend section 12. Pt also had an anion gap acidosis - (Gap
of 19 on admission) that had closed by morning.
.
Called out to the medical floor, [**9-27**] - [**9-29**]:
.
# ETOH withdrawal, dependence - On folate, thiamine, CIWA.
Continued to receive Valium through day 2 on medical floor for
CIWA > 10. When patient's symptoms of withdrawal had resolved,
he was discharged home with instructions for close follow-up.
.
# gout - Patient developed pain in right toe on the medical
floor. Presentation consistent with acute gout. Started on
naproxen and colchicine with significant improvement.
.
# depression with suicidality - Suicidal ideation resolved by
the time of discharge. Patient was seen by psych who recommended
dual diagnosis, however the patient refused.
.
# hepatitis, NOS - Mild elevation in ALT, AST. Most likely fatty
liver vs. alcohol induced.
.
# follow-up: Consider HIV testing and would vaccinate for HAV
and HBV.
Medications on Admission:
Zoloft
Trazodone
Norvasc
"Cholesterol medication"
Discharge Medications:
1. Outpatient Meds
Patient does not know doses of home medications. Please continue
taking trazodone and amlodipine as you have been directed.
2. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) for 5 days: Please take for five days following discarge.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital with alcohol intoxication and
withdrawal. You were given medication for your symptoms of
withdrawal. By the time of discharge, your symptoms had
resolved. Please do not drink alcohol.
.
You were also treated for pain that you experienced in your toe.
We believe this was related to a condition called gout. Please
take the Naprosyn (naproxen) 500 mg every twelve hours for the
next five days for this pain in your toe.
Followup Instructions:
Please follow-up at the following time/place:
.
Department: [**Hospital3 249**]
When: FRIDAY [**2105-10-16**] at 2:45 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
******PLEASE NOTE: YOU HAVE A MANAGED CARE INSURANCE PLAN AND
YOU MUST CALL YOUR INSURANCE TO TELL THEM WHO YOUR PRIMARY CARE
DOCTOR IS. DR [**Last Name (STitle) **] WORKS CLOSELY WITH DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
PLEASE LIST DR [**First Name (STitle) **] AS YOUR PCP WITH YOUR INS. QUESTIONS
PLEASE CALL NUMBER ABOVE.
|
[
"311",
"4019"
] |
Admission Date: [**2182-11-6**] Discharge Date: [**2182-12-6**]
Service:
HISTORY OF PRESENT ILLNESS: Patient is an 84-year-old male
with past medical history of diverticulosis, anemia, silent
MI with ejection fraction of 25%, prostate cancer,
gastrointestinal bleed, polymazic rheumatica and infrarenal
abdominal aortic aneurysm of 7.3 cm. Patient had an elective
abdominal aortic aneurysm repair on the [**8-30**]. It
was an endovascular repair for a 7.5 infrarenal abdominal
aortic aneurysm. The procedure was complicated by a type I
endoleak. The patient returned for an open repair on the
[**9-5**] then admitted to the SICU. With difficulty
weaning the patient postoperatively, he remained on a
ventilator until [**11-13**].
The patient required diuresis in order to be weaned from the
ventilator. He also was treated with Kefzol for 11 days due
to bilateral drainage from groin incisions. He also had
received Ceftriaxone to cover for a possible pneumonia. The
patient had episodes of paroxysmal atrial fibrillation
postoperatively with a heart rate in the 150s and drop in his
blood pressure. EP was consulted. The patient was treated
initially with beta blocker and Amiodarone with
anticoagulation. The patient converted back into normal
sinus rhythm, though he did have episodes of bradyarrhythmia
down to the 30s. EP felt the patient had Tachy-Brady
syndrome and recommended against continuing further beta
blocker.
It was felt that the patient had infiltrates and pneumonia
possibly secondary to aspiration that was contributing to his
paroxysmal atrial fibrillation. The pneumonia was treated
for 14 days of Ceftriaxone. The patient went into normal
sinus rhythm and remained there for the rest of his hospital
stay.
After extubation on the 30th, the patient remained having
some respiratory difficulty requiring Bi-PAP for CO2
retention. He had problems with thick tenacious secretions
with waxing mental status. He was eventually weaned from the
Bi-PAP to nasal cannula and transferred to the floor on the
[**10-22**]. He was saturating in the 90s on nasal
cannula.
On the [**10-26**], the patient had a swallowing study
which showed aspiration. The patient became tachypneic and
had an ABG of 7.22, 63, 111. He was transferred back to the
MICU secondary to hypercarbia, respiratory distress and
change in mental status. He was stabilized on Bi-PAP. He
remained stable until the [**10-28**] where he had
decreased mental status and an ABG showing 7.12, 94, 163 on
Bi-PAP. The patient was having thick tenacious tan
secretions which altered his respiratory status. He was
transferred from the MICU on the 14th for stabilization and
management of his respiratory failure.
PAST MEDICAL HISTORY:
1. Myocardial infarction. He had a V-fib arrest on a tennis
court approximately 30 years ago. Ejection fraction is
approximately 25% on echo in [**2182-10-15**]. He had a
Persantin thallium test on [**2182-10-23**] which showed a fixed
inferior defect with an ejection fraction, once again, of
25%.
2. The patient has prostate cancer thought possibly to be
metastatic. He is currently taking Lupron injections. His
last injection was 22.5 mg IM on the [**11-4**]. Infrarenal abdominal aortic aneurysm of 7.3 cm.
4. Also a 5.6 cm ascending aortic aneurysm.
5. Anemia with a ferratin greater than detectable levels
indicating chronic disease.
6. PMR on chronic Prednisone 5 mg q.d.
7. Vertebral compression fractures.
8. GI bleed. He required transfusion two years.
Colonoscopy showed diverticulosis as the most likely
etiology.
9. Hernia repair approximately 40 years ago.
ALLERGIES:
1. Norvasc.
2. Celebrex.
OUTPATIENT MEDICATIONS:
1. Prednisone 5 mg q.d.
2. Losartan 50 mg q.d.
3. Toprol 75 mg q.d.
SOCIAL HISTORY: Patient is married. His sons and wife are
also involved in his care. He smoked for approximately 10
years and quit about 35 years ago. Prior to admission the
patient used a walker for ambulation.
PHYSICAL EXAMINATION: Vitals, 98.8 F temperature, pulse 83,
blood pressure 153/66, respiratory rate 17, SVO2 100% on AC
of 550 with tidal volume 410 to 720, respiratory rate of 12
to 19 with PEEP of 5 and fio2 of 100%. Patient was a thin
elderly man intubated. Pupils were constricted. Sclerae
nonicteric. Dry blood in creases of mouth with dry mucous
membranes. No jugular venous distention. Coarse breath
sounds. Bilateral diffuse rales. Regular rate and rhythm,
S1, S2. There is a II/VI systolic ejection murmur right
sternal border greater than left. Midline abdominal scar
with staples. Soft with normoactive bowel sounds. No
tenderness, no rebound, no distention. Extremities: No
cyanosis, clubbing or edema. The patient does have a
slightly bulging area from his right groin. Neuro: He was
non-responsive when he was admitted due to sedation and
intubation.
LABORATORIES ON ADMISSION TO MICU: Sodium 143, potassium
4.3, chloride 107, bicarbonate 27, BUN 46, creatinine 0.6.
CKs were flat at 28, 32, 20. White count 12.9, hematocrit
33.2, platelets 235 at the time of admission.
Last ABG at the time of admission to the MICU of 7.36, 69,
94% and free calcium 7.24.
MICU COURSE: Patient is an 84-year-old male status post
abdominal aortic aneurysm repair complicated by endoleak,
hypotension converted to open repair, prolonged weaning from
vent most likely secondary to volume overload with extended
intubation followed by possible probable aspiration in
context of a swallowing study and respiratory distress
secondary to that aspiration and mucous plugging.
1. RESPIRATORY FAILURE: Patient was initially AC intubated.
He eventually underwent trach placement on the [**10-29**]. The patient also had chest VT and frequent
suctioning to help with mucous plugging. The patient
initially had difficulty weaning off AC on the trach tube.
We tried to wean him to pressor support and then to trach
mask. The patient had stridorous noises coming from the
trach tube without a leak, pain as well as respiratory
distress every time he was taken off of the ventilator onto
the trach mask.
The patient was rebronched on the 19th. It was discovered
that his trach tube was too large and the posterior aspect of
the trach tube was being occluded by the posterior wall of
the trachea as well as resulting in a small ulceration in the
posterior wall of the trachea. The trach tube was changed to
an appropriate sized trach tube with the help of
Interventional Pulmonology.
After being changed, the patient was able to be weaned from
AC to pressor support and then to a trach mask, 50% trach
mask on the day of discharge, the [**11-5**]. His last
ABG on 50% trach mask on the 21st was 7.36, pO2 of 123 and
CO2 of 49. The patient has not had any problems with mucous
plugging over 36 hours. He definitely requires significant
pulmonary toilet and having the patient out of bed in a chair
will in addition improve his mucous plugging pulmonary status
as well as hydration and intact via his J tube.
2. CARDIAC: Patient for blood pressure control was
continued on Losartan and was started on a low dose of
Hydrochlorothiazide 12.5 mg. His beta blocker was held
secondary to problems with bradyarrhythmia. The patient was
continued on his aspirin. The patient has had systolic blood
pressures in the 130s except when he becomes agitated. His
blood pressure does rise into the 190s region. Usually
treating the source of the agitation, for example pain, with
Morphine results in decrease of the patient's blood pressure
and pulse. The patient also has received at times 2.5 IV
Lopressor very slowly times one with results of decreasing of
his blood pressure and his heart rate.
3. RHYTHM: Patient had paroxysmal atrial fibrillation
thought to be secondary to pneumonia that developed during
his hospital to the floor perioperatively. The patient
remained in normal sinus rhythm throughout his stay in the
MICU becoming tachycardic and hypertensive secondary to
agitation. This resolved by treating the source of the
agitation as well as with p.r.n. once every other day or so
2.5 mg of Lopressor IV.
The patient was seen by Electrophysiology and felt to have
Tachy-Brady syndrome secondary to his bradying down following
beta blocker, significant doses of Toprol like 75 mg q. day.
The patient brady down to the 30s. He had initially been
treated as per early stay with Amiodarone for his atrial
fibrillation. The patient remains in normal sinus rhythm.
The patient's family declined permanent pacemaker placement.
It is possible that the patient may benefit from a low dose
of a beta blocker like 12.5 Toprol as his respiratory status
and functionality continues to improve.
4. NEUROLOGY: Agitation. The patient has had some
agitation, usually 10 PM on the last three to five days prior
to discharge from the MICU. Often this was relieved with
pain control. The patient is able to communicate pain or
hunger despite being trached. His agitation, though, has
gotten better with the removal of tubes like his NG tube and
we will remove his A-line today which should further help
him. He had initially been managed with benzodiazepine, but
this is felt that it may have worsened his mental status.
The patient was started on a form of Zyprexa. He was started
at 5 and titrated up to 10 mg q. day as well as Trazodone 25
mg q.h.s. It is felt to be best given at approximately 8 PM
as the patient tends to sundown at about 10 PM.
On the night before discharge, the patient did not require
any additional medications for agitation except for the
Zyprexa and Trazodone. He did receive 0.5 mg of subcutaneous
Morphine for relief of pain secondary to his J tube placement
and this satisfied his agitation resolving his pain. We
recommended trying to avoid treating the patient with
benzodiazepine where possible.
5. HEMATOCRIT: Patient had chronic anemia seeming to be
secondary to chronic disease. He has received transfusions
through his hospital course. His hematocrit was 29.5 the day
prior to discharge and 27.9 on the day of discharge, but his
hemoglobin only went down from 9.9 to 9.2. It is felt that
if the hematocrit was to drop any further, we would recommend
transfusing the patient one unit with an approximate goal of
28 to 30 with his hematocrit as well as maybe possibly
following the patient's B12 and folate and possibly starting
supplementation if necessary.
6. NUTRITION: The patient received a J tube which was
placed on the [**11-3**] without complication via
Interventional Radiology. The patient began tube feeds with
Ultracal 10 cc per hour on the [**11-4**]. This was
titrated up 10 cc an hour per six hours. He currently, at
the time of this dictation, was tolerating 40 cc per hour
while finishing without complications without changes in
abdominal pain, or any signs of not tolerating the tube
feeds. He also was receiving his last bag of TPN. When the
patient reaches his goal of 60 cc per hour, his TPN bag will
be stopped and he will receive approximately 250 cc b.i.d. of
free water boluses to meet his water necessity in addition to
his 60 cc an hour of the tube feeds of the Ultracal.
7. ENDOCRINE: Patient was initially switched from his
Prednisone to Hydrocortisone 10 q. 12 hours status post
placement of the NG tube. When the patient was taking p.o.
This was switched over back to is 5 mg q.d. The patient was
covered on a sliding scale regular insulin with fingersticks.
Steroids is his most likely etiology of his
hypercholesterolemia.
Tight control was the goal for his blood sugars with sliding
scales being instituted over 150. The patient generally had
good control of blood sugar with a max of 148 on the 22nd,
max of 133 on the 21st, max of 132 on the 20th, max of 152 on
the 19th. The patient's requirement may go down as he is
being switched back from the Hydrocortisone to the
Prednisone.
8. PROPHYLAXIS: Patient was placed initially on IV Protonix
40 mg q.d. which changed to Lansoprazole 30 mg elixir per J
tube. He is also placed on subcutaneous heparin 500 q.
b.i.d. and pneumo-boots as the patient was sitting up in [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 3788**] chair the day before discharge and as he becomes more
functional and able to ambulate, this requirement may not be
necessary.
Nutrition as previously stated, patient is on Ultracal with a
goal of 60 cc per hour. He is currently at 40 cc per hour
tolerating with no problems. [**Name (NI) **] may be finishing his last
back of TPN. The patient also will be receiving three water
boluses 250 b.i.d.
9. CODE STATUS: Patient is full code as per family.
10. COMMUNICATION: [**Name (NI) **] wife and sons were involved in
the patient's care and were consulted regarding any major
issues and this should be continued. The patient's
oncologist, Dr. [**Last Name (STitle) **] was also contact[**Name (NI) **] and secondary to
his instructions, an injection of Lupron 20 2.5 mg was
injected for his prostate cancer. The patient's further
Lupron injections, Dr. [**Last Name (STitle) **] should be consulted regarding
these approximately every three to four weeks.
DISPOSITION: Patient has improved with showing signs of
decreased agitation, decreased evidence of respiratory
failure, stability with his heart rate and cardiac rhythm,
tolerating tube feeds. It is felt as the patient's gains
strength with nutrition and Physical Therapy, his pulmonary
toilet issues will improve as well.
CONTACT INFORMATION: His wife, [**Name (NI) **] at phone #
[**Telephone/Fax (1) 110288**]. The patient is to be transferred to a
long-term care facility on the [**11-5**] as per
attending, case management and family.
[**Last Name (LF) **],[**Name8 (MD) **] M.D. [**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2182-12-6**] 12:12
T: [**2182-12-6**] 12:12
JOB#: [**Job Number **]
|
[
"42731",
"5070",
"4280"
] |
Admission Date: [**2178-3-21**] Discharge Date: [**2178-3-29**]
Service: MEDICINE
Allergies:
Codeine / Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
s/p Coronary cath [**3-23**] with POBA to SVG-PDA
History of Present Illness:
[**Age over 90 **] yo M with PMH CAD s/p CABG [**2153**] with SVG to RPDA, SVG to LAD,
SVG to diagonal, s/p PCI to SVG-Diag 100% occluded, DES to
SVG-LAD graft in [**4-29**], DESx2 to SVG-RPDA in [**9-30**], BMS to SVG-RCA
in [**10-1**], DES to SVG to LAD [**2175**] and DES x2 to proximal and mid
SVG to LAD in [**1-4**], and DESx2 to proximal and ostial [**Date Range **] in
[**2-5**]; right renal artery stenosis s/p stenting [**3-31**], [**Month/Year (2) 2091**], DMII,
HLD, HTN, ???GI bleed, small AAA presenting to OSH with chest
pain. Pt described the quality of the same as the same as that
which occurred prior to his previous stent placements - it was a
pressure, located in the center of his chest, nonradiating,
accompanied by intermittent SOB, "feeling hot," and
palpitations. It was also accompanied by dizziness and weakness
which was new for him. It was also more severe than any other
pain he has ever had, nearly bringing him to tears. No nausea,
vomiting, or diaphoresis. It lasted 30 minutes and was relieved
after taking 5 tabs of nitro. He was watching television when
the pain began. He states that he has had the pain 6 times over
the past week; all episodes occurred in the evening when he was
either lying in bed or just getting into bed. The pain has not
occurred during the day or with exertion. He denies h/o reflux
symptoms. States he eats dinner around 6pm. No fevers, chills,
abdominal pain, muscle aches, joint pains. Admits to SOB when
lying down and has become SOB at night before. Admits to cough
productive of white phlegm for about 1 week now. Also has a
runny nose. Sister has been sick but otherwise no sick contacts.
[**Name (NI) **] been constipated the past few days. Has been undergoing
treatment for diverticulitis with flagyl since hospitalization
at [**Hospital3 **] on [**2178-3-14**]. Does not like flagyl and says it
gives him an acid taste in his mouth. Last dose [**2178-3-24**]. Has
been taking of his medications as prescribed daily.
.
At OSH, initial VS were 98.1, 181/103, 68, 18, 98% O2. He
reportedly had initial improvement and then recurrence of the
chest pain during which he became pink, appeared uncomfortable,
and was warm to the touch. He was lying down when the pain
occurred. He was given ativan, a GI cocktail, morphine, imdur,
and nitro gtt at various points in the ED there and it is
unclear which of these helped his pain. He was started on
heparin gtt at 1000 units/hr and nitro gtt at 10 mcgs. He was
also given bicarb 100/hr and mucomyst 600 mg po for possibility
of cath with his CRI. EKG's taken at the onset and peak of the
pain were unchanged. Labs there were significant for trop 0.02
and Hct 32.7. An echo showed moderately dilated LA, LVEF 55-60%,
and "distolic dysfunction." EKG showed stable biphasic t-waves
in V2-V4 and stable RBBB. There was borderline [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 8730**]. He
was transferred to [**Hospital1 18**] for possible cardiac cath but with
question as to cardiac nature of pain.
.
In the ED, initial vitals were 98.2, 66, 141/70, 18, 100%. Labs
significant for Hct 29.5, WBC 3.3, INR 1.1, lipase 32, LFTs WNL,
Cr 2.6, BUN 37, trop 0.01. Pt was continued on nitro gtt and
heparin gtt and transferred to [**Hospital1 **] service.
.
On arrival to the floor, VS 98.3, 160/83, 75, 20, 98% RA. He
currently denies CP or SOB.
.
REVIEW OF SYSTEMS
per HPI
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: CABG [**2153**], with SVG to RPDA, SVG to LAD, SVG to diagonal.
-PERCUTANEOUS CORONARY INTERVENTIONS:
SVG-Diag 100% occluded, DES to SVG-LAD graft in [**4-29**], DESx2 to
SVG-RPDA in [**9-30**], BMS to SVG-RCA in [**10-1**], DES to SVG to LAD [**2175**]
and DES x2 to proximal and mid SVG to LAD in [**1-4**], DESx2 to
proximal and ostial [**Date Range **] in [**2-5**]
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- right renal artery stenosis s/p stenting [**3-31**]
- CRI: baseline creat according to our records was 2.0 in [**2176**]
- Type 2 DM
- Hyperlipidemia
- Hypertension
- PTSD
- GI bleed [**2175**] s/p cath on integrilin and heparin (thought to
be [**2-26**] internal hemorrhoids vs bleeding diverticula)
- small AAA
- chronic dizziness
- spondylosis
- deviated septum
- hiatal hernia
- pneumonia
Social History:
Tobacco: 150+ pack years of tobacco use. Quit at the age of 64
at time of first MI. Smoked 3-4ppd when young.
EtOH: He uses alcohol occasionally.
Illicits: He has no history of recreational drug use.
- He lives with his wife. [**Name (NI) 2760**] gambling weekly. Two children,
both live in area. 4 grandchildren
Family History:
Father had a myocardial infarction at age 70. Mother had cancer
and myocardial infarction. Brothers have diabetes.
Physical Exam:
ADMISSION EXAM:
VS: 98.3, 160/83, 75, 20, 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 3cm above clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. faint heart sounds
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. mild left base
crackles, no wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. papery LE skin; trace edema in
LE bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE EXAM:
VS: 97.9, 135/65, 76, 20, 100% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 3cm above clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. faint heart sounds
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. mild left base
crackles, no wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. papery LE skin; trace edema in
LE bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
ADMISSION LABS:
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] WBC-3.3* RBC-3.65* Hgb-10.1* Hct-29.5*
MCV-81* MCH-27.7 MCHC-34.3 RDW-14.5 Plt Ct-115*
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] Neuts-66.7 Lymphs-23.1 Monos-4.2 Eos-5.6*
Baso-0.3
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] PT-12.2 PTT-35.9 INR(PT)-1.1
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] Glucose-96 UreaN-37* Creat-2.6* Na-141
K-4.2 Cl-108 HCO3-25 AnGap-12
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] ALT-39 AST-18 AlkPhos-99 TotBili-0.3
[**2178-3-22**] 06:55AM [**Month/Day/Year 3143**] Calcium-8.8 Phos-2.7 Mg-1.9
Cardiac labs
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] cTropnT-<0.01
[**2178-3-21**] 04:55PM [**Month/Day/Year 3143**] CK-MB-5 cTropnT-0.02*
[**2178-3-22**] 06:55AM [**Month/Day/Year 3143**] cTropnT-0.08*
[**2178-3-22**] 06:29PM [**Month/Day/Year 3143**] CK-MB-5 cTropnT-0.10*
[**2178-3-23**] 07:10PM [**Month/Day/Year 3143**] CK-MB-7 cTropnT-0.16*
[**2178-3-24**] 05:26AM [**Month/Day/Year 3143**] CK-MB-50* MB Indx-8.8* cTropnT-2.28*
[**2178-3-24**] 02:25PM [**Month/Day/Year 3143**] CK-MB-84* MB Indx-10.6* cTropnT-2.85*
[**2178-3-24**] 11:16PM [**Month/Day/Year 3143**] CK-MB-65* MB Indx-9.0* cTropnT-2.81*
[**2178-3-25**] 06:02AM [**Month/Day/Year 3143**] cTropnT-2.84*
[**2178-3-26**] 07:12AM [**Year/Month/Day 3143**] CK-MB-13* MB Indx-5.5 cTropnT-3.20*
[**2178-3-26**] 07:12AM [**Year/Month/Day 3143**] CK-MB-13* MB Indx-5.5 cTropnT-3.20*
[**2178-3-27**] 07:10AM [**Year/Month/Day 3143**] CK-MB-7 cTropnT-3.78*
Discharge labs
[**2178-3-29**] 07:34AM [**Year/Month/Day 3143**] WBC-3.1* RBC-3.34* Hgb-9.2* Hct-26.3*
MCV-79* MCH-27.5 MCHC-35.0 RDW-15.2 Plt Ct-191
[**2178-3-29**] 07:34AM [**Year/Month/Day 3143**] Glucose-101* UreaN-54* Creat-2.8* Na-141
K-3.8 Cl-109* HCO3-23 AnGap-13
[**2178-3-29**] 07:34AM [**Year/Month/Day 3143**] Calcium-8.2* Phos-3.1 Mg-2.1
OTHER LABS:
[**2178-3-21**] 04:55PM [**Month/Day/Year 3143**] Ret Aut-2.4
[**2178-3-21**] 04:55PM [**Month/Day/Year 3143**] LD(LDH)-247 CK(CPK)-37* TotBili-0.3
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] Lipase-32
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] Albumin-3.5 Iron-54
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] calTIBC-267 Hapto-169 Ferritn-71 TRF-205
IMAGING:
CXR [**2178-3-21**]: Frontal and lateral views of the chest were
obtained. Lung volumes are lower than on the prior study. There
is mild bibasilar atelectasis. No focal consolidation, pleural
effusion or pneumothorax. The cardiac silhouette is top normal
in size. Mediastinal silhouette and hilar contours are stable
allowing for lower lung volumes. Calcifications are seen along
the course of the thoracic aorta. Mediastinal post-surgical
changes including coronary stents and intact median sternotomy
wires are unchanged. IMPRESSION: No pneumonia, edema or
effusion. Mild bibasilar atelectasis.
TTE [**2178-3-24**]: The left atrium is dilated. The estimated right
atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Right
ventricular chamber size and free wall motion are normal. Right
ventricular chamber size is normal. Tricuspid annular plane
systolic excursion is depressed consistent with right
ventricular systolic dysfunction. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. Compared
with the prior study (images reviewed) of [**2174-1-22**], prior
views are suboptimal for comparison.
Cardiac cath [**2178-3-23**]: full report pending. POBA ISRS SVG-PDA.
RFA Perclose.
No issues
Brief Hospital Course:
[**Age over 90 **] yo M with PMH CAD s/p CABG [**2153**] with SVG to RPDA, SVG to LAD,
SVG to diagonal, s/p PCI to SVG-Diag 100% occluded, DES to
SVG-LAD graft in [**4-29**], DESx2 to SVG-RPDA in [**9-30**], BMS to SVG-RCA
in [**10-1**], DES to SVG to LAD [**2175**] and DES x2 to proximal and mid
SVG to LAD in [**1-4**], and DESx2 to proximal and ostial [**Date Range **] in
[**2-5**]; right renal artery stenosis s/p stenting [**3-31**], [**Month/Year (2) 2091**], DMII,
HLD, HTN, GI bleed, small AAA presenting to OSH with chest pain.
# chest pain: Pt was transferred to the CCU from the cardiology
service on both heparin gtt and nitro gtt. While on the
cardiology service the patient had troponins were neg x 3 the
day of admission (1 day prior) but bumped to 0.08 the morning
after. EKG stable. no tele events. Attempted to wean nitro gtt
the evening of admission and CP began to recur at level of [**2-3**]
when nitro drip stopped and resolved when it was restarted.
Given his initial chest pain and given the patient's extensive
cardiac history, plan was to go for cath on [**2178-3-23**], which
showed stenosis of the RCA graft. The RCA was balooned and
stented and during the procedure the patient complainted of
[**11-4**] chest pain. It is likely that a clot had embolized and
went downstream during the stenting procedured. Subsequently,
the patient cardiac enzymes started to rise and peaked at
CK-796, CK-MB->84 and trop at 2.85. EKG showed ST elevations in
inferior leads. The next day nitro drip was stopped and the
patient was started on his home dose ranolazine and stared on
imdur 60mg, and remained chest pain free. Back on the floor, he
was uptitrated to imdur 180 daily, and had no more chest pain or
discomfort.
.
# anemia: Hct stable near 29 on admission. No overt s/s
bleeding. iron studies normal. hemolysis labs neg, retic index
1.2. Review of prior records indicated pt has long history of
anemia that predates worsened [**Last Name (LF) 2091**], [**First Name3 (LF) **] it was thought that this
may be [**2-26**] thalassemia. [**Month/Day (2) 2091**] may also be contributor.
.
# [**Month/Day (2) 2091**]: baseline creat according to our records was 2.0 in [**2176**]
and it was 2.7 after discharge from [**Hospital1 18**] in [**2178-1-25**] for
stenting. unsure if this is new baseline or [**Last Name (un) **]. His Cr was 2.6
on admission and remained between 2.3 and 2.8 during his CCU
course. On the floor he, did develop [**Last Name (un) **] with Cr to 3.3, likely
[**2-26**] CIN, which was down to 2.8 on discharge.
.
# Rhythm: after coming out of CCU, found to have sinus
bradycardia, 2:1 block. Rate had been controlled with metop
succ. 100 daily, which was held. Rate improved during the rest
of his stay, though was still in 50's upon discharge, and he was
discharged off BB. When exercised on EKG, he did have a good
response and HR came up, indicating a higher AV block. No need
for pacemaker.
.
# Type 2 DM: continued lantus and humalog SS; diabetic diet
# Hyperlipidemia: had been on simvastatin 10mg daily. Discharged
on atorvastatin 80mg daily.
.
# Hypertension: Initially controlled with home doses of
amlodipine, metoprolol. Once bradycardia (above) developed,
those were stopped. Imdur 180mg daily was started. He went out
on amlodipine 10mg daily as well.
.
Medications on Admission:
aspirin 325 mg Delayed Release DAILY
clopidogrel 75 mg Tablet DAILY
amlodipine 10 mg Tablet once a day
insulin glargine Thirty Eight (38) units Subcutaneous once a day
metoprolol succinate 100 mg Tablet DAILY
simvastatin 10 mg Tablet once a day
Not sure of isosorbide mononitrate ER 60mg TID
metronidazole 500 mg Tab Oral Three times daily until [**3-24**] for
diverticolitis
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. insulin glargine Subcutaneous
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day: please avoid
drinking grapejuice while on this medication.
7. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI
Secondary Diagnoses:
chronic kidney disease
anemia
coronary artery disease
hypertension
2nd degree heart block
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 came to the hospital because you had chest pain. Your EKG
was unchanged but you had elevated [**Hospital **] markers that indicated
you could be having a heart attack. You were started on
medications to treat a heart attack and taken for a cardiac
catheterization which showed aqan obstruction in one of your
venous graphs which was stented. You were also monitored for low
heart rate which was stable and low kidney functions which seem
to have improved. You are now discharged home.
.
The following medications were stopped:
Please STOP Metoprolol
Please STOP Simvastatin
.
The following medications were started:
.
Please START Atorvastatin 80mg tablet, once daily.
please START Furosamide, 20mg tablet once daily.
.
Please weigh yourself everyday and call your PCP if you gain
more than 3 lb in 24 hour.
Followup Instructions:
Please call the number below to make an appointment with your
PCP and cardiologist within 1 week of your discharge. You will
also need to have your [**Hospital **] tests drawm within 1 week to test
electrolytes and renal functions.
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**]
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 8724**]
Phone: [**Telephone/Fax (1) 8725**]
Fax: [**Telephone/Fax (1) 8719**]
Email: [**University/College 8731**]
.
|
[
"41071",
"9971",
"5849",
"41401",
"V4582",
"412",
"4280",
"40390",
"5859",
"2724",
"V5867",
"V1582"
] |
Admission Date: [**2147-12-4**] Discharge Date: [**2147-12-17**]
Date of Birth: [**2085-10-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
preop for MVR-case aborted
History of Present Illness:
62 y/o male with severe CAD, s/p CABG [**2124**], s/p CABG [**2132**]
(LIMA-LAD, SVG-RCA, SVG-Diag, SVG-OM), s/p PTCA and BMS to
SVG-OM on [**2147-11-8**] at [**Hospital1 18**], dilated cardiomyopathy, severe MR,
moderate PA HTN, and chronic AF on coumadin. He was planned to
undergo MVR by Dr. [**Last Name (STitle) 1290**] [**12-11**] but after intubation patient
crashed, PA line with PA pressures equal to systemic pressures.
He had insertion & removal of ECMO femoral cannulas with closure
of R femoral [**Month/Year (2) **] with perclose device [**12-11**] Dr. [**Name (NI) **]
didn't want to do right thoracotomy and one lung ventilation
with high pulmonary pressures. The surgeons considered doing an
from mediansterotomy, but if doesn't go well then they wanted a
back-up out strategy of ? LVAD +/- ? heart transplant. The
patient refused this option and now is being medically managed
for his heart failure.
.
ON transfer to the CCU he was complaining of no CP or SOB. He
can lie flat in bed without SOB. Denies swelling in legs. Does
endorse feeling lightheaded when standing or walking. Few weeks
ago he had black stools for ~1wk. UGI and LGI scoping in last
1.5 years with only benign polyps. He was told to avoid ASA at
the time.
Past Medical History:
CAD-CABG '[**22**]/'[**31**],PCI '[**46**]
Cardiomyopathy
Sev MR
Afib
^chol
CVA after 2nd CABG
CCY
Appy
Tonsillectomy
Social History:
Lives with wife. retired
denies tobacco or etoh
Family History:
father MI @63yo
Physical Exam:
BP 117/54 (MAP 70), HR 73, O2 sat 100% on 2L NC
General: lying in bed in NAD; very pleasant male.
HEENT: PERRL, EOMI, MMM, anicteric sclera, non-injected
conjunctiva, OP mild erythema but no exudate. No cervical or
supraclavicular LAD. RIJ in place.
CV: irreg irreg, 3/6 systolic murmur heard best at apex but
throughout precordium.
Lungs: CTAB no w/r/r
Abdomen: +BS, soft, NTND
Ext: trace bilateral lower extremity edema. No clubbing or
cyanosis. R groin dressing c/d/i. no hematoma or bruit. DP
pulses 1+ BLE.
Neuro: CNII-XII in tact, strength 5/5 in right UE, [**1-22**] in left
UE distally. [**3-23**] in bilateral LE
Pertinent Results:
Hemo: Systemic pressures 110/50, PA 83/30 mean 50, PCW 30, CO 5.
PVR = 442, [**Doctor Last Name **] units = 5.5 on Milrinone 0.25
Milrinone 0.5 --> [**Doctor Last Name **] units 2.7, milrione 0.75 --> 4.0 [**Doctor Last Name **]
units
.
.
133 102 10
-------------<
-- 24 0.6
Ca: 9.4 Mg: 2.2 P: 3.9
.
91
6.0 8.9 139
>-------<
24.8
.
PT: 13.3 PTT: 56.1 INR: 1.2
.
[**2147-12-13**] ECHO:
Conclusions:
1. The left atrium is moderately dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed. 20% given the severity
of valvular regurgitation.] Global hypokinesis with inferior
wall akinesis.
3.The mitral valve leaflets are mildly thickened. Severe (4+)
mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure.
4.There is moderate pulmonary [**Month/Day/Year **] systolic hypertension.
5. The RV function is deverely reduced.
Compared with the findings of the prior study (images reviewed)
of [**2147-12-8**], the MR [**First Name (Titles) **] [**Last Name (Titles) **] are slightly less while the EF is
slightly reduced. However the MR is worse relative to the study
of [**2147-12-11**].
Brief Hospital Course:
A/P: 62 yo M with severe MR transferred to CCU for medical
management of his heart failure. As described in the HPI, he
was admitted to the surgery team for MVR. He was hospitalized
for about a week before the surgery, and he was planned to
undergo MVR by Dr. [**Last Name (STitle) 1290**] [**12-11**]. DUring induction, he
crashed. A PA line was placed and showed PA pressures equal to
systemic pressures. He had insertion & removal of ECMO femoral
cannulas with closure of R femoral [**Month/Year (2) **] with perclose device
[**12-11**]. He quickly stablized after this event and was transferred
to the CCU for medical management as the patient did not want
surgery with if the risk was LVAT and transplant. He wanted to
improve his CHF at least to allow him to walk across a room. The
rest of his hospital course is described below.
.
#cardiac:
.
PUMP: LVEF of 20% and severe MR 4+ on latest ECHO. Patient does
not want surgery if there is possibility of LVAD or transpant
needed if surgery fails. He prefers medical management. He was
euvolemic by exam. He was briefly tried on a milrinone drip;
but it became clear that he did not want to go home on an IV
infusion although the milrinone did help his [**Doctor Last Name **] units
improve. This was discontinued and his Swan line was pulled.
He was kept on lisinopril 10, coreg 3.125 [**Hospital1 **], lasix 20 daily.
He walked with nurses prior to leaving and was asymptomatic.
.
ISCHEMIA: s/p CABG x2 years ago and PCI in [**10-24**] with stent to
SVG to OM. He was continued on plavix and aspirin as well as a
beta blocker and ACEI.
.
RHYTHM: He remained in rate controlled afib throughout his
hospitalization.
He was kept on a heparin gtt during the hospitalization, and
then transitioned to warfarin 4 prior to discharge. He will
follow up with his PCP for INR check.
.
#anemia: normocytic anemia. HCT decreased likely secondary to
blood draws and surgical procedure. He had recent c-scope and
UGI in last 1.5 years with only benign polyps seen. He was told
to avoid ASA at that time. He was started on low dose ASA and
maintained on a PPI for GI ppx. He was transfused 1 Unit of
pRBCs for a low HCT of 24.8. His hct was stable prior to
discharge.
.
#FEN: heart healthy, low sodium diet. Replete lytes prn. Fluid
restriction
.
#PPX: coumadin for afib. PPI for GI ppx given possible h/o of GI
bleeding
.
#code: full code
Medications on Admission:
ASA 325'
Lisinopril 20'
Plavix 75'
Aldactone 25'
Crestor 20' Celexa 20'
Coreg 3.125"
Lasix 40"
Digoxin 0.125'
KCL 20'
Warfarin 4'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
CHF, severe MR
[**First Name (Titles) **] [**Last Name (Titles) **] disease
atrial fibrillation
Discharge Condition:
fair
BP 90/50, HR 70, 95% RA
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please continue to take all medications as prescribed. You
should seek medical attention if you have worsening shortness of
breath, fatigue, light headedness, palpitations, or for any
other concern.
.
You will need to see you primary care doctor for an INR check
within the week as well.
Followup Instructions:
please make a follow-up appointment with your cardiologist and
PCP [**Name Initial (PRE) 176**] 1 week
[**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 101099**]
[**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] [**Telephone/Fax (1) 4451**]
Dr. [**Last Name (STitle) 101100**], your cardiologist in NH
Completed by:[**2147-12-18**]
|
[
"4240",
"4280",
"4168",
"41401",
"42731"
] |
Admission Date: [**2120-1-13**] Discharge Date: [**2120-1-16**]
Date of Birth: [**2067-11-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Chest pain/STEMI
Major Surgical or Invasive Procedure:
1. Cardiac catheterization with percutaneous balloon
angioplasty and stenting - 2 bare metal stents in LAD.
2. Echocardiogram
History of Present Illness:
52-year old white male with hypercholesterolemia and no
significant cardiac history presented to [**Hospital1 **] for three episodes
of exertional chest pain over the previous four days. On [**1-10**]
during a round of volleyball, pt had dull mid-chest pain that
persisted until activity ceased. On [**1-11**], pt again had similar
symptoms of dull chest pain [**2123-6-3**] while lifting light weights,
again resolving with rest. Tonight, [**1-13**], pt had two episodes
of similar dull chest pain while playing volleyball, resolved
with cessation of activity. Medicine residents at the volleyball
game prompted him to call 911. Other ROS essentially negative,
denies overt diaphoresis, nausea, vomiting, or shortness of
breath that is out of the ordinary for him during acitivity. He
denies ever having chest pain of this sort before this week.
.
In [**Hospital1 **] ED, given morphine, slNTG, plavix 75, heparin.
Cath lab: 2 BM stents placed in the lad.
CI 6.11, CI 2.8, PCWP 20, RA mean 16, awave 20 vwave 18, PA
37/18 mean 27, RV 37/9 end 18. LAD 90% proximal before D1, LCX
no sig disease, RCA no sig disease. 2 Vision BMSs placed in LAD.
Past Medical History:
1. Primary: STEMI
2. Childhood rheumatic fever
3. Hypercholesterolemia (per pt, total 250 last year)
Social History:
Lives at home with wife, works as a psychologist, wife worked in
OT and as a secretary. Has two girls, 23 and 19, one in college
in [**State 8449**], one community service in [**Location (un) 5770**]. Denies overt
drinking, no smoking history. Played volleyball in college,
active currently as well. Denies poor diet.
Family History:
Father died in 80s, no heart disease, had gout. Mother alive, no
significant disease. Has one sister, diabetes.
Physical Exam:
PE: T: 98.7 BP: 111/70 HR: 65 RR: 99% RA
Gen: NAD, AOx3, cooperative, well appearing, concerned about
current condition. Asking many questions.
HEENT: No conjunctival pallor, no icterus. MMM. OP clear.
NECK: Supple, No LAD, JVD, thyromegaly.
CV: RRR. nl S1 - pronounced, S2. Poss S3 or physiologic split
S2. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good BS BL
ABD: +bs, sntnd, no HSM
EXT: no edema, R groin hematoma, no bruit appreciated, enlarged,
pitting at site, mild ecchymosis, 10cm high lateral to low
medial in inguinal ligament line
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-30**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2120-1-13**] 02:20PM BLOOD WBC-10.7 RBC-4.13* Hgb-13.7* Hct-37.2*
MCV-90 MCH-33.2* MCHC-36.9* RDW-12.4 Plt Ct-209
[**2120-1-14**] 04:52AM BLOOD WBC-9.2 RBC-3.50* Hgb-11.4* Hct-32.3*
MCV-93 MCH-32.6* MCHC-35.3* RDW-12.4 Plt Ct-166
[**2120-1-16**] 07:50AM BLOOD WBC-6.0 RBC-3.92* Hgb-12.3* Hct-36.0*
MCV-92 MCH-31.3 MCHC-34.1 RDW-12.3 Plt Ct-183
[**2120-1-13**] 02:20PM BLOOD Neuts-83.2* Lymphs-12.5* Monos-3.5
Eos-0.5 Baso-0.2
[**2120-1-13**] 02:20PM BLOOD Plt Ct-209
[**2120-1-14**] 04:52AM BLOOD PT-14.1* PTT-27.2 INR(PT)-1.3*
[**2120-1-14**] 04:52AM BLOOD Plt Ct-166
[**2120-1-16**] 07:50AM BLOOD PT-13.8* PTT-30.8 INR(PT)-1.2*
[**2120-1-16**] 07:50AM BLOOD Plt Ct-183
[**2120-1-13**] 02:20PM BLOOD D-Dimer-257
[**2120-1-13**] 02:20PM BLOOD Glucose-155* UreaN-22* Creat-1.1 Na-139
K-4.5 Cl-103 HCO3-28 AnGap-13
[**2120-1-16**] 07:50AM BLOOD Glucose-103 UreaN-15 Creat-1.0 Na-141
K-4.3 Cl-105 HCO3-31 AnGap-9
[**2120-1-13**] 02:20PM BLOOD CK(CPK)-134
[**2120-1-14**] 12:30AM BLOOD CK(CPK)-669*
[**2120-1-14**] 04:52AM BLOOD CK(CPK)-849*
[**2120-1-14**] 03:35PM BLOOD CK(CPK)-756*
[**2120-1-14**] 05:10PM BLOOD CK(CPK)-684*
[**2120-1-15**] 06:45AM BLOOD CK(CPK)-337*
[**2120-1-13**] 02:20PM BLOOD CK-MB-3
[**2120-1-13**] 02:20PM BLOOD cTropnT-0.03*
[**2120-1-14**] 12:30AM BLOOD CK-MB-75* MB Indx-11.2* cTropnT-1.92*
[**2120-1-14**] 04:52AM BLOOD CK-MB-83* MB Indx-9.8* cTropnT-3.02*
[**2120-1-14**] 03:35PM BLOOD CK-MB-54* MB Indx-7.1*
[**2120-1-14**] 05:10PM BLOOD CK-MB-46* MB Indx-6.7*
[**2120-1-15**] 06:45AM BLOOD CK-MB-16* MB Indx-4.7
[**2120-1-14**] 12:30AM BLOOD Calcium-7.5* Phos-3.4 Mg-1.9
[**2120-1-14**] 04:52AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.0
[**2120-1-15**] 06:45AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
[**2120-1-16**] 07:50AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
[**2120-1-14**] 04:52AM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE
.
CXR: CHEST, ONE VIEW: No prior for comparison. Extreme right
costophrenic angle is excluded from the study. Remainder of the
lungs are clear. No pleural effusion. No pneumothorax. Cardiac,
mediastinal, and hilar contours are within normal limits. No
fractures identified.
IMPRESSION: No acute cardiopulmonary process identified.
.
ECHOCARDIOGRAM:
Left Atrium - Long Axis Dimension: *4.3 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.1 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.3 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 25% to 30% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aorta - Arch: 2.8 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A Ratio: 1.40
Mitral Valve - E Wave Deceleration Time: 194 msec
Pulmonic Valve - Peak Velocity: 0.7 m/sec (nl <= 1.0 m/s)
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is
normal in diameter with <50% decrease during respiration
(estimated RAP 11-15mmHg).
LEFT VENTRICLE: Normal LV cavity size. Severe regional LV
systolic
dysfunction. Moderate LV thrombus. No resting LVOT gradient.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior - akinetic; mid anteroseptal - akinetic; mid
anterolateral - hypo; anterior apex - akinetic; septal apex-
akinetic; lateral apex - hypo; apex - akinetic;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta. Normal
aortic arch diameter. No 2D or Doppler evidence of distal arch
coarctation.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. There is severe
regional left
ventricular systolic dysfunction with EF of 30%. Resting
regional wall motion
abnormalities include akinesis of the mid to distal anterior
wall, anterior
septum, and apex.
3. A moderate sized thrombus is seen in the left ventricle.
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending aorta is mildly dilated.
6. The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
8. There is no pericardial effusion.
IMPRESSION: Several regional LV systolic dysfunction with
probable LV
thrombus. Mild mitral regurgitation.
Brief Hospital Course:
52-year old white male with hypercholesterolemia presented with
substernal chest pain, which was his fourth episode in the
previous four days, found to have a occlusion of the LAD artery,
prompting PCTA and placement of 2 bare metal stents. Course
umcomplicated, question of NSVT two days post-stent placement,
pending work-up for risk stratification for possible ICD
placement.
1. CV: pt initially had ST elevations in the anterior leads,
taken emergently to cath lab, resulting in placement of 2BMS in
LAD with good flow post placement. Patient was initiated on
standing plavix, with plan to continue for minimum of 1 month,
indefinitely for 12 months, aspirin, and a high dose statin. He
was initiated on lisinopril 5 qd and Toprol XL 12.5 qd, for
which he tolerated well while he was in the hospital.
Due to concern for reperfusion injury and arrythmogenic
predisposition, upon discharge patient was set-up with a number
of studies to risk stratify as per arrythmias. He was scheduled
for an outpatient cardiac MR, echocardiogram, average weighted
EKG. Upon discharge, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor was arranged for
outpatient care. Follow-up with cardiology in 1 month to
address these issues and to risk stratify for ICD placement.
2. HEME: Following cardiac catheterization, patient had a large
subcutaneous hematoma, for which pressure was applied. His
vital signs remained stable and pressure dressing was utilized
to stabilize the hematoma. The groin site remained stable over
the next three days with slow resolution of hematoma size, with
intact pulses and strength. On day of discharge, patient had no
pain at site, but reported some discomfort with presence of
hematoma with ambulation, which did not enlarge over the course
of the day. He was given explicit instructions about returning
to the ED if the hematoma changes in size, becomes painful, or
if his R lower extremity becomes cold. He was advised not to
lift weights and to use caution with exertion with his lower
extremity.
Due to question of thrombus in the LV cavity, patient was
initiated on lovenox SC and provided 6 days worth while bridging
with coumadin 5mg qhs. Patient's INR was 1.2 on day of
discharge after 1 dose of coumadin 5mg. Patient has follow-up
with his PCP to address his anticoagulation as an outpatient.
From a systems-based approach, Mr. [**Known lastname 70297**] had no active
pulmonary, gastrointestinal, neurological, or endocrine issues
during this hospitalization.
Medications on Admission:
None.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Minimum 1 months, indefinintely 1 year.
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please take at least a few hours apart from the beta blocker.
Disp:*30 Tablet(s)* Refills:*2*
6. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
every twelve (12) hours for 6 days.
Disp:*12 syringes* Refills:*0*
7. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One-half
pill. Tablet Sustained Release 24HR PO once a day: Please take
[**1-30**] pill once a day - 12.5mg once a day.
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. ST elevation myocardial infarction
2. Hyperchlesterolemia
Discharge Condition:
stable. chest pain free. ambulating unassisted. tolerating oral
medications and nutrition.
Discharge Instructions:
You have been evaluated and treated for chest pain. You were
found to have a heart attack. The heart attack was caused by a
blockage in one of the three main arteries in your heart. The
blockage was opened with a balloon and a stent was placed to
keep the artery open.
.
It is essential that you take the all medicines as prescribed to
you.
.
You will need to have your blood drawn in three days after
leaving the hospital to monitor the coumadin level ("the INR").
Your doctor will help adjust the dose as needed. You will need
to have the Lovenox shots every 12 hours until the coumadin dose
is stable as directed by your primary physician.
.
Follow the instructions for the Holter monitor that were given
to you at time of discharge.
.
If you develop any new concerning symptom, particularly chest
pain, shortness of breath, notable leg swelling please seek
medical attention.
.
For the next month you should not lift anything heavier than
[**11-17**] pounds.
Followup Instructions:
1) Primary Care physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30176**] - I spoke with PCP this
morning, knows of your admission. Please call his office to set
up an appointment, he will fit you in, to see Dr. [**Last Name (STitle) 30176**] and
to have you PT/INR level checked.
.
2) Cardiology:
- Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (1-[**Telephone/Fax (1) 2934**]) - [**2-21**], 3:00pm.
[**Hospital Ward Name 23**] [**Location (un) 436**].
3) Follow-up testing:
- [**Doctor Last Name **] of Heart/holter monitoring - they will instruct you on
how to manage this device.
- Please call 1-[**Telephone/Fax (1) 1566**] to schedule a T wave alternans test
in [**5-4**] weeks. The clinical was contact[**Name (NI) **] [**Name2 (NI) 70298**] about this
test.
- Please call 1-[**Telephone/Fax (1) 327**] to schedule a cardiac MRI in [**5-4**]
weeks. This order was already placed by the primary care team,
but a date needs to be verified.
|
[
"41401",
"2720"
] |
Admission Date: [**2130-1-25**] Discharge Date: [**2130-2-6**]
Date of Birth: [**2057-10-25**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Right sided weakness.
Major Surgical or Invasive Procedure:
-Endotracheal intubation
-Mechanical ventilation
-Intraventricular drain
-Tracheostomy
-PEG tube placement
History of Present Illness:
Patient is a 72 year old right handed female with past medical
history of hypertension, hypercholesterolemia, hypothyroidism,
macular degeneration who was in her usual state of health until
around 10:58am [**1-25**]. At that time, she was working out on her
Nautilus machine when she had sudden onset of right sided
weakness, notably her right arm and leg. EMS was called.
EMS vitals reported as BP 220/100 with pulse of 68, RR 18,
Oxygen 96%/RA, blood sugar 97. Noted her to have no facial droop
but weakness in right grip and leg.
She was transported to [**Hospital6 33**]. She was noted to be
initially awake and alert with temp 97.6, BP 240/100, P 63, RR
20. In the ED notes, she denied headache, speech disturbance,
visual disturbance. CT scan of her head demonstrated a 2.2x1.8
left thalamic hemorrhage with extension into the left lateral
ventricle. No blood in third ventricle. Around 12:35pm, she was
noted to be more somnolent and so she was intubated for airway
protection around 12:45 pm. Transport arranged to [**Hospital1 18**] for
higher level of care, and neurosurgical evaluation.
On arrival to [**Hospital1 18**], BP 240/100, HR 60-70, temp 98.0. BP ranged
from 99-256 systolic. Started on Labetalol drip. In the ED here,
on Labetalol drip and receiving [**Hospital1 61368**] for sedation.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Macular degeneration
Social History:
Married x 12 years; lives with husband. Worked in special
education. Former smoker x 15 years. Quit 42 years ago. Does
frequent physical activity with walking, swimming.
Family History:
Father deceased from stroke.
Physical Exam:
Tc: 98.0 BP: 99/53 HR: 52 RR: 16
O2Sat.: 100 on vent
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Coarse anterolaterally.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E. Legs rotated inwards,
extended. Arms at side extended.
Neuro:
Mental Status: Intubated, sedated on [**Hospital1 **] (attempted to have
nurse [**First Name (Titles) **] [**Last Name (Titles) **] but patient became agitated and was
fighting vent.
Cranial Nerves:
I: Not tested
II: Pupils 1mm, minimally reactive. No blink to threat.
III, IV, VI: No oculocephalic reflexes.
V, VII: No corneal reflexes.
VIII: Unable to assess.
IX, X: +Gag.
[**Doctor First Name 81**]: Unable to assess.
XII: Unable to assess due to ETT.
Motor: Increased tone bilateral lower extremities. In upper
extremities, has extensor posturing response to noxious stimuli.
In lower extremities, she has posturing response in RLE but has
withdrawal in LLE.
Sensation: Extensor posturing in bilateral upper extremities and
RLE. Withdrawal in LLE.
Reflexes: B T Br Pa Ac
Right 2 2 2 4 4
Left 3 3 3 4 4
With left upper extremity brisker than right. Crossed adductors
at knees. Toes upgoing bilaterally. Several beats of clonus at
ankles bilaterally.
Coordination: Unable to assess.
Gait: Unable to assess.
Pertinent Results:
[**2130-1-25**] 02:15PM WBC-14.2* RBC-4.89 HGB-15.2 HCT-44.6 MCV-91
MCH-31.1 MCHC-34.0 RDW-12.9
[**2130-1-25**] 02:15PM NEUTS-67 BANDS-12* LYMPHS-17* MONOS-3 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2130-1-25**] 02:15PM GLUCOSE-181* UREA N-14 CREAT-0.8 SODIUM-137
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-24 ANION GAP-18
[**2130-1-25**] 02:15PM PLT COUNT-303
[**2130-1-25**] 02:15PM PT-12.9 PTT-22.6 INR(PT)-1.0
-----
Non-contrast Head CT [**2130-1-25**]: FINDINGS: A large approximately 3
cm left thalamic hyperdensity is noted, with extension into the
left lateral ventricle. There is minimal shift of the midline
structures, but the basal cisterns remain patent. A mild degree
of expansion of the left temporal [**Doctor Last Name 534**] is seen. Tiny
hypodensities in the cerebellum and cerebral periventricular
white matter are probably microvascualr infarctions. No extra-
axial fluid collection is noted. Osseous structures and soft
tissues are unremarkable. IMPRESSION: Left thalamic bleed with
extension into the lateral ventricle, exerting mass effect
causing minimal shift of the midline structures. The cisterns
remain patent. No herniation seen.
-----
Non-contrast Head CT [**2130-1-26**]: There has been no significant
interval change in the left thalamic hemorrahge with extension
of blood to the left lateral ventricle. A tiny amount of blood
is also demonstrated within the right occipital [**Doctor Last Name 534**]. There is
again minimal left to right midline shift, unchanged since the
prior examination. The ventricles are stable in size since the
prior examination with mild dilatation of the left temporal
[**Doctor Last Name 534**]. Periventricular white matter hypodensities are again noted
consistent with chronic microvascular infarction. No new areas
of hemorrhage are demonstrated. The osseous and soft tissue
structures are stable. IMPRESSION: Stable appearance of large
left thalamic hemorrhage with intraventricular extension and
mild left to right shift of midline structures. Stable
appearance of ventricles with mild dilatation of the left
temporal [**Doctor Last Name 534**].
-----
Non-contrast Head CT [**2130-1-28**]: FINDINGS: The left thalamic
hemorrhage with intraventricular extension is unchanged in size.
Mild rightward shift of normally midline structures is
unchanged. Prominence of the left temporal [**Doctor Last Name 534**] is unchanged.
There is a new drain entering the frontal [**Doctor Last Name 534**] of the right
lateral ventricle and terminating in the region of the foramen
of [**Location (un) 9700**]. The periventricular white matter hyperdensities are
again seen, consistent with chronic microvascular infarctions.
The visualized osseous structures appear unremarkable. There is
a new fluid level in the left sphenoid sinus. There is mild
mucosal thickening in the right maxillary sinus and moderate
mucosal thickening in the ethmoid air cells bilaterally. The
patient remains intubated.
-----
Non-contrast Head CT [**2130-2-2**]: FINDINGS: The left thalamic
intraparenchymal hemorrhage with extension into the lateral
ventricles is unchanged in size. The right-sided ventricular
drain is still in place, however, in the interval, there is
increased intraparenchymal hemorrhage around the drain,
especially in the right frontal region. Mild rightward shift of
the septum pellucidum is seen, which is stable. Cerebral
periventricular white matter changes are stable. Again seen is
opacification of the sphenoid sinus. Osseous structures are
unchanged. IMPRESSION: Increased intraparenchymal hemorrhage in
the right frontal lobe around ventricular drain. Otherwise, no
significant interval change.
-----
Brief Hospital Course:
Patient is a 72 year old female with past medical history of
hypertension, hypothyroidism, hypercholesterolemia who presented
as transfer from [**Hospital6 3426**] after developing acute onset right sided weakness
around 11am on [**2130-1-25**]. Head CT demonstrates 3 cm left thalamic
hyperdensity with extension into left lateral ventricle.
Etiology is likely hypertensive given patient's history and
location of bleed. She was admitted to the NeuroICU for
monitoring.
She was kept on q1h neuro checks. Blood pressure goal was less
than 160 systolic; initially, she was maintained on Labetalol
drip. Later, this was transitioned to Metoprolol and Lisinopril.
Bowel regimen was ordered to avoid straining and increased
intracranial hemorrhage. Serial head CTs showed stable size and
extension of her hemorrhage. Due to concerns for hydrocephalus,
neurosurgery was consulted and a ventricular drain was placed.
Post drain placement, CT scan demonstrated hemorrhage around the
drain track in the right frontal lobe. This remained stable on
serial exams. Her drain was clamped on [**2130-2-1**] and was
discontinued on [**2130-2-2**]. Follow up head CT on [**2130-2-3**] showed
stable size of ventricles and hemorrhage.
She was intubated on day of presentation out of concern for
airway protection. Sputum sample on [**2130-1-27**] demonstrated
Streptococcus pneumoniae. Ceftriaxone antibiotic therapy was
started. She will need to complete a 14 day course of
antibiotic, last day [**2130-2-10**]. Tracheostomy was placed on
[**2130-2-2**].
From a cardiac standpoint, she ruled out for myocardial
infarction with three sets of negative cardiac enzymes. Blood
pressure was initially controlled with a Labetalol drip. She was
later transitioned to Lisinopril and Metoprolol orally; theses
agents should be titrated up for blood pressure control as
necessary. She was continued on her anticholesterol [**Doctor Last Name 360**]
Simvastatin.
Due to mental status, patient was not a candidate for oral
feeding. She received nutrition via nasogastric tube until
[**2130-2-2**], when PEG was placed.
At time of discharge, patient's neurological status had been
stable for several days She occasionally opens eyes
spontaneously. No speech. Intermittently follows commands to
squeeze hands/wiggles fingers on left side. Eyes midline at
rest, with left gaze preference. Will track past midline.
Decreased blink to right eye threat. Intact oculocephalic,
corneal and gag reflexes. Has increased tone in both legs and
right upper extremity. Moves left side spontaneously and
withdraws this to pain. Some distal movement noted in right
foot. Moves right arm laterally on the bed to noxious stimuli.
Hyperreflexia in bilateral legs (4+) with clonus at ankles,
hyperreflexia right upper extremity (4+) and left upper
extremity (3+).
Medications on Admission:
1. Atenolol 50 mg po qd
2. Zocor 5 mg po qd
3. Levoxyl 100 mcg po qd
4. Lisinopril 20 mg po qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Insulin Regular Human 100 unit/mL Solution Sig: Variable
units Injection ASDIR (AS DIRECTED): Dispense qid via regular
insulin adult sliding scale.
3. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO BID (2 times a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units
units Injection TID (3 times a day).
8. Ceftriaxone Sodium 1 g Recon Soln Sig: One (1) gram
Intravenous once a day: Continue until [**2130-2-10**] for total of 2
week course for Strep. pneumoniae pneumonia.
9. Levoxyl 100 mcg Tablet Sig: One (1) Tablet PO once a day.
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Insulin Regular Human 100 unit/mL Solution Sig: Variable
units Injection ASDIR (AS DIRECTED): Dispense qid via regular
insulin adult sliding scale.
3. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO BID (2 times a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units
units Injection TID (3 times a day).
8. Ceftriaxone Sodium 1 g Recon Soln Sig: One (1) gram
Intravenous once a day: Continue until [**2130-2-10**] for total of 2
week course for Strep. pneumoniae pneumonia.
9. Levoxyl 100 mcg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Left thalamic intraparenchymal hemorrhage with
intraventricular extension, likely secondary to hypertension
2. Hypertension
3. Hyperlipidemia
4. Macular degeneration
Discharge Condition:
Neurologically stable. Occasionally opens eyes spontaneously. No
speech. Intermittently follows commands to squeeze hands/wiggles
fingers on left side. Eyes midline at rest, with left gaze
preference. Will track past midline. Decreased blink to right
eye threat. Intact oculocephalic, corneal and gag reflexes. Has
increased tone in both legs and right upper extremity. Moves
left side spontaneously and withdraws this to pain. Some distal
movement noted in right foot. Moves right arm laterally on the
bed to noxious stimuli. Hyperreflexia in bilateral legs (4+)
with clonus at ankles, hyperreflexia right upper extremity (4+)
and left upper extremity (3+).
Discharge Instructions:
Please take all medications as prescribed.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the [**Hospital 878**] Clinic
after discharge from rehab; call [**Telephone/Fax (1) 44**] to schedule an
appointment.
Please call primary care physician or return to emergency room
for fevers, chills, respiratory distress, increased lethargy,
decreased left sided movement.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the [**Hospital 878**] Clinic
after discharge from rehab; call [**Telephone/Fax (1) 44**] to schedule an
appointment.
Patient should be scheduled for follow up with her PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1356**] at [**Telephone/Fax (1) 17465**].
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"4019",
"2720",
"2449"
] |
Admission Date: [**2142-5-15**] Discharge Date: [**2142-6-21**]
Date of Birth: [**2074-5-16**] Sex: M
Service: SURGERY
Allergies:
Roxicet / Cefepime
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
[**2142-5-16**] CVL and Left IJ line placed.
[**2142-5-17**] Abdominal compartment syndrome due to left
retroperitoneal and sigmoid mesenteric hematoma status post
decompressive laparotomy with evacuation of retroperitoneal
hematoma and packing for hemostasis, placement of silo closure
with reinforced Silastic.
[**2142-5-18**]
Reopening of prior laparotomy for removal of packing, abdominal
washout and partial closure. Hemostasis of spleen.
[**2142-5-21**]
Abdominal washout and partial closure; [**Last Name (un) **] gastrostomy; drain
retroperitoneal hematoma.
[**2142-5-26**]
Reopening of postop abdomen. Adhesiolysis (x3 hours). Drainage
of left retroperitoneal hematomas times 2. Silastic silo closure
with "[**State 19827**] patch".
[**2142-6-2**]
Washout of the abdomen, partial closure.
[**2142-6-5**]
Irrigation and debridement of open abdomen with split-thickness
skin graft 800 sq cm
[**2142-6-11**]
US guided per-chole tube
[**2142-6-14**]
CT-guided drainage of a large retroperitoneal collection
History of Present Illness:
Mr. [**Known lastname 93612**] is a 67 year old male with a St. [**Male First Name (un) 1525**] mechanical
aortic valve admitted [**Date range (3) 93613**] for subtherapeutic [**Date range (3) 263**] who
presents with 2 days of low back pain. There was no associated
trauma or injury. The pain is in his central lower back, is
present almost all the time, and varies in severity up to [**11-4**].
It is throbbing in nature and worse when sitting up or flexing
his legs. It is worse with palpation. He has also noticed
increased abdominal distention in the last few days. He has
tried tylenol for pain without much relief. He was discharged on
[**5-9**] on lovenox bridge and coumadin. Other than his lovenox and
coumadin, he has no new medications or changes in his
medication. He was discharged 7.5 mg daily (up from 5mg 6 days
per week, 7.5mg on sundays), but his [**Month/Year (2) 263**] was 1.9 on [**5-11**] and his
dose was increased to 10 mg qd. His last dose of coumadin was
[**5-14**]. He was taking Lovenox 100mg SC BID, last dose 4/20 in the
morning. He took his antihypertensives and ASA this morning. He
denies any lightheadedness, CP, SOB, nausea, vomiting, diarrhea,
constipation (though no BM today), red/maroon/bloody stools,
hematuria.
.
In the ED, initial vitals were 97.2 66 102/68 18 98. He was then
noted to have systolic pressures in the 70s and he was
complaining of lightheadedness; he was transferred to the core.
EKG showed paced rhythm and hematocrit was noted to be 31.4 from
39.2 one week prior. CTA was done for concern of dissection and
showed a left RP bleed with active extravasation at the left
iliacus muscle. He received D5W with bicarb for renal
protection. [**Month/Year (2) 263**] was 4.2 and creatinine was newly elevated to
1.7. His pressures were noted to increase to the 100s systolic,
and he was given 2 units of FFP, 1 unit PRBCs, 3.2L IVF. He was
noted to void only 100 cc in the ED. Vascular surgery and IR
were both consulted for possible intervention. IR recommended
reversal of coagulopathy for [**Month/Year (2) 263**] < 2, and consider embolization
if HCT continues to fall. The patient received 4mg IV morphine x
2 for abdominal pain when pressures were improved, with
improvement in pain. Repeat vitals: HR 80, BP 111/70 18 100% RA.
FAST exam showed a small pericardial effusion. Cardiology
recommended slow reversal with FFP; no indication for vitamin K.
In ED, unable to place Foley due to resistance.
.
On the floor, patient was given second unit of pRBC. Repeat [**Month/Year (2) 263**]
2.4, and pt was ordered for 2 more units of FFP. Repeat Hct
stable at 26.6. Lactate 3.9. Attempted to place Foley but unable
to due to resistance; urology consulted. Creatinine stable at
1.6. Bladder scan showed 50 cc urine in bladder. IVF were
started at 150 cc/hr.
Past Medical History:
1. Mechanical AV: Pt had bicuspid AV requiring replacement.
Aortic valve replacement with the Bentall procedure done in
[**2124-4-26**] with a redo procedure done in [**2132-5-26**] secondary to
methicillin-sensitive Staphylococcus aureus abscess.
2. Afib: [**Year (4 digits) **] ([**Company 1543**] Sigma dual chamber) placed in
setting of CHB in [**1-/2139**], continues amiodarone.
3. Bronchomalecia and Bronchiectesis
4. H/O GI Bleed ([**2132**])
5. CAD requiring CABG: SVG to LAD, SBG to OM, and SVG to PDA
6. Hypercholesterolemia
7. HTN
8. COPD
9. Endocarditis: Pt has had multiple episodes of endocarditis,
most recently in [**2138**] with concern for culture negative
endocarditis (veg seen on valve), per recommendation of
infectious disease team at [**Hospital1 18**] (consulted in prior
hospitalization) he will require chronic Levofloxacin
10. Herniated disc
12. Thoracic aneurysm
13. Pulmonary hematoma in [**2132**] requiring pulmonary decortication
and surgical evacuation of hematoma from left upper lobe of
lung.
14. Septic Cerebral Emboli ([**2132**]) without residual defecits.
.
Percutaneous coronary intervention, in [**2124**] anatomy as follows:
No report on OMR
.
[**Year (4 digits) **]/ICD, in [**2139-1-26**], [**Company 1543**] Sigma dual chamber
[**Company 4448**] placed for complete heart block.
Social History:
Retired electrician. On disability since sustaining spinal
injury during fall at work. Divorced. Quit smoking in [**2124**]
prior to valve replacement, prior to this he smoked 2 packs per
day. He drinks wine occasionally. No illicit drugs. Lives
alone. Two children who live out of state.
Family History:
Mother died at 78 of intracranial aneurysm rupture
Father lived to 96 - "died of old age"
Two Sisters who are well.
Physical Exam:
Vitals: T: 97.1 BP: 109/66 P: 89 R: 16 O2: 100% on RA
General: Alert, oriented, mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Rhoncorous breath sounds bilaterally, no crackles
CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM at base
Abdomen: firm, tender to palpation in left flank > diffusely,
distended, bowel sounds present, no rebound tenderness or
guarding, multiple ecchymoses present at sites of lovenox
injections; firm mass in left flank at site of increased
tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2142-6-20**] BCx no growth
[**2142-6-20**] EGD severe SB ischemia that would explain GI bleeding
[**2142-6-16**] BCx no growth
[**2142-6-15**] Cdiff NEG
[**2142-6-15**] BCx no growth
[**2142-6-14**] Cdiff NEG
[**2142-6-13**] TEE LVEF > 55%, no veggies on valves or wires
[**2142-6-11**] Bile [**Female First Name (un) **] albicans
[**2142-6-10**] PICC tip Prelim - no significant growth
[**2142-6-6**] CVC Tip STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15
colonies
[**2142-5-28**] CXR ETT 7cm above carina otherwise no sig interval
change
[**2142-5-27**] CXR unchanged
[**2142-5-25**] ECHO nl LVEF, nl fxn mech AV, no mass/veg on valves, tr
AR [**2142-5-24**] CT Torso Sm B pl eff, RPH unchanged, Lg L abd wall
fl collection
[**2142-5-24**] CT head no ICH, no mass effect, no midline shift,
patent art, possible old stoke x2
[**2142-5-24**] pleural fluid gram stain negative, culture no growth
[**2142-5-20**] CXR pre-existing retrocardiac and left basal opacity
stable
[**2142-5-19**] Bcx no growth
[**2142-5-19**] Ucx no growth
[**2142-5-19**] Sputum no legionella, no growth.
[**2142-5-19**] KUB Tubular structure slightly diagonal to the spine is
projecting over the abdomen. No safe evidence for other foreign
bodies
[**2142-5-18**] cath tip culture: no growth
[**2142-5-18**] CXR LLL atelectasis. small bilateral pleural effusions
[**2142-5-17**] mrsa neg
[**2142-5-17**] CXR New RIJ catheter with tip at brachiocephalic-SVC
junction, no ptx
[**2142-5-17**] CXR NG tube appears to have been pulled back, now in
mid-esophagus
[**2142-5-17**] ECG new T wave inversions noted in the limb
leads,frequent PVC's ,NSR
[**2142-5-16**] bcx ngtd
[**2142-5-16**] sputum MORAXELLA SPECIES
[**2142-5-15**] ucx neg
[**2142-5-15**] 05:54PM FIBRINOGE-322
[**2142-5-15**] 12:15PM BLOOD WBC-10.3# RBC-3.43* Hgb-10.7* Hct-31.4*
MCV-92 MCH-31.1 MCHC-33.9 RDW-14.2 Plt Ct-218
[**2142-5-16**] 04:15AM BLOOD WBC-11.5* RBC-2.77* Hgb-8.7* Hct-24.6*
MCV-89 MCH-31.3 MCHC-35.3* RDW-14.9 Plt Ct-132*
[**2142-5-16**] 02:30PM BLOOD WBC-13.2* RBC-2.74* Hgb-8.6* Hct-23.7*
MCV-87 MCH-31.4 MCHC-36.2* RDW-14.7 Plt Ct-119*
[**2142-5-17**] 01:58AM BLOOD WBC-18.5* RBC-3.00* Hgb-9.3* Hct-25.9*
MCV-86 MCH-30.9 MCHC-35.8* RDW-15.1 Plt Ct-131*
[**2142-5-17**] 10:47AM BLOOD WBC-21.6* RBC-3.10* Hgb-9.5* Hct-27.2*
MCV-88 MCH-30.7 MCHC-34.9 RDW-15.2 Plt Ct-131*
[**2142-5-18**] 12:45PM BLOOD WBC-15.0* RBC-3.27* Hgb-10.3* Hct-27.8*
MCV-85 MCH-31.5 MCHC-37.1* RDW-16.2* Plt Ct-131*
[**2142-5-25**] 02:42AM BLOOD WBC-8.7 RBC-3.16* Hgb-9.6* Hct-29.4*
MCV-93 MCH-30.4 MCHC-32.8 RDW-15.7* Plt Ct-409
[**2142-6-1**] 10:23PM BLOOD Hct-24.3*
[**2142-6-2**] 06:13AM BLOOD Hct-25.3*
[**2142-6-2**] 06:22PM BLOOD Hct-28.9*
[**2142-6-5**] 05:52PM BLOOD WBC-10.8 RBC-3.13* Hgb-9.1* Hct-28.3*
MCV-90 MCH-29.2 MCHC-32.4 RDW-16.3* Plt Ct-311
[**2142-6-6**] 01:09AM BLOOD WBC-10.2 RBC-2.93* Hgb-8.5* Hct-26.1*
MCV-89 MCH-28.9 MCHC-32.5 RDW-16.1* Plt Ct-295
[**2142-6-14**] 01:02AM BLOOD WBC-21.6* RBC-2.95* Hgb-8.4* Hct-26.0*
MCV-88 MCH-28.6 MCHC-32.4 RDW-15.8* Plt Ct-423
[**2142-6-20**] 02:40AM BLOOD WBC-19.3* RBC-3.58*# Hgb-10.5*#
Hct-32.1*# MCV-90 MCH-29.3 MCHC-32.7 RDW-16.7* Plt Ct-220
[**2142-6-21**] 04:31AM BLOOD WBC-19.2* RBC-3.54* Hgb-10.1* Hct-31.0*
MCV-88 MCH-28.4 MCHC-32.4 RDW-16.3* Plt Ct-211
[**2142-5-15**] 12:15PM BLOOD PT-40.3* PTT-47.8* [**Month/Day/Year 263**](PT)-4.2*
[**2142-5-15**] 05:54PM BLOOD PT-25.1* PTT-39.2* [**Month/Day/Year 263**](PT)-2.4*
[**2142-5-16**] 04:15AM BLOOD PT-21.4* PTT-33.6 [**Month/Day/Year 263**](PT)-2.0*
[**2142-5-18**] 02:12AM BLOOD PT-13.2 PTT-28.2 [**Month/Day/Year 263**](PT)-1.1
[**2142-5-23**] 03:52AM BLOOD PT-12.7 PTT-38.0* [**Month/Day/Year 263**](PT)-1.1
[**2142-5-25**] 02:42AM BLOOD PT-12.5 PTT-48.4* [**Month/Day/Year 263**](PT)-1.1
[**2142-5-28**] 02:39AM BLOOD PT-13.4 PTT-63.5* [**Year/Month/Day 263**](PT)-1.1
[**2142-5-30**] 02:11AM BLOOD PT-13.3 PTT-60.9* [**Year/Month/Day 263**](PT)-1.1
[**2142-5-31**] 05:21AM BLOOD PT-12.6 PTT-52.3* [**Year/Month/Day 263**](PT)-1.1
[**2142-6-1**] 05:00AM BLOOD PT-12.9 PTT-36.6* [**Year/Month/Day 263**](PT)-1.1
[**2142-6-3**] 12:27AM BLOOD PT-13.0 PTT-32.2 [**Year/Month/Day 263**](PT)-1.1
[**2142-6-8**] 07:00AM BLOOD PT-15.8* PTT-77.9* [**Month/Day/Year 263**](PT)-1.4*
[**2142-6-10**] 05:02AM BLOOD PT-13.6* PTT-40.1* [**Month/Day/Year 263**](PT)-1.2*
[**2142-6-19**] 06:03AM BLOOD PT-13.2 PTT-51.2* [**Month/Day/Year 263**](PT)-1.1
[**2142-6-20**] 12:28AM BLOOD PT-13.9* PTT-150* [**Month/Day/Year 263**](PT)-1.2*
[**2142-6-21**] 12:20AM BLOOD PT-14.8* PTT-35.2* [**Month/Day/Year 263**](PT)-1.3*
[**2142-6-21**] 10:10AM BLOOD PT-13.6* PTT-33.6 [**Month/Day/Year 263**](PT)-1.2*
[**2142-5-15**] 12:15PM BLOOD Glucose-134* UreaN-24* Creat-1.7* Na-139
K-5.0 Cl-102 HCO3-27 AnGap-15
[**2142-5-17**] 10:32AM BLOOD Glucose-151* UreaN-37* Creat-2.9* Na-140
K-4.2 Cl-103 HCO3-26 AnGap-15
[**2142-5-18**] 12:45PM BLOOD Glucose-123* UreaN-38* Creat-2.2* Na-136
K-4.1 Cl-104 HCO3-23 AnGap-13
[**2142-5-21**] 02:49PM BLOOD Glucose-93 UreaN-22* Creat-1.0 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
[**2142-5-24**] 01:45PM BLOOD Glucose-103* UreaN-16 Creat-0.9 Na-138
K-4.3 Cl-99 HCO3-31 AnGap-12
[**2142-5-26**] 09:15PM BLOOD Glucose-115* UreaN-18 Creat-1.1 Na-137
K-4.9 Cl-103 HCO3-24 AnGap-15
[**2142-5-29**] 01:51AM BLOOD Glucose-106* UreaN-17 Creat-0.9 Na-137
K-3.8 Cl-105 HCO3-24 AnGap-12
[**2142-5-31**] 05:21AM BLOOD Glucose-87 UreaN-14 Creat-0.9 Na-142
K-3.9 Cl-108 HCO3-25 AnGap-13
[**2142-6-5**] 01:07AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-140
K-4.1 Cl-106 HCO3-29 AnGap-9
[**2142-6-13**] 02:54PM BLOOD Glucose-104* UreaN-46* Creat-1.6* Na-133
K-4.0 Cl-94* HCO3-26 AnGap-17
[**2142-6-19**] 06:03AM BLOOD Glucose-110* UreaN-15 Creat-0.6 Na-142
K-3.1* Cl-107 HCO3-26 AnGap-12
[**2142-6-21**] 08:29AM BLOOD Glucose-111* UreaN-29* Creat-2.2* Na-150*
K-3.9 Cl-118* HCO3-23 AnGap-13
[**2142-5-17**] 10:47AM BLOOD ALT-38 AST-65* LD(LDH)-263* CK(CPK)-2467*
AlkPhos-46 TotBili-1.2
[**2142-5-19**] 01:15AM BLOOD CK(CPK)-2890*
[**2142-6-20**] 12:28AM BLOOD ALT-28 AST-30 LD(LDH)-419* CK(CPK)-98
AlkPhos-127 TotBili-0.5
[**2142-6-20**] 02:45PM BLOOD ALT-102* AST-282* AlkPhos-113 TotBili-0.8
Brief Hospital Course:
67M with St. [**Male First Name (un) 1525**] mechanical aortic valve admitted
[**Date range (3) 93613**] for sub therapeutic [**Date range (3) 263**] now on Lovenox bridge
and Coumadin who presents with 2 days of low back pain and found
to have retroperitoneal hematoma
.
# RETROPERITONEAL BLEED. He was found to have a large
retroperitoneal hematoma with evidence of active arterial
extravasation on imaging in the setting of a supra therapeutic
[**Date range (3) 263**] and Lovenox bridge. He was admitted to the medical ICU for
further management. Initially he remained hemodynamically stable
but with declining hematocrits despite PRBC transfusion
suspicious for active bleeding His home aspirin, Coumadin,
Lovenox, and antihypertensives were held. His supra therapeutic
[**Date range (3) 263**] was reversed with fresh frozen plasma. The general surgery,
vascular surgery, and interventional radiology services were
consulted for possible operative/procedural management. He
underwent mesenteric angiogram although an active source of
bleeding was not able to be identified. He developed hypotension
requiring vasopressor support. He developed worsening renal
failure with limited urine output, elevated bladder pressures,
and elevated CK levels concerning for abdominal compartment
syndrome. He was evaluated by general surgery...
.
# ACUTE RENAL FAILURE. The patient developed oliguric acute
renal failure initially due to hypovolemia in the setting of
acute bleed, later exacerbated by abdominal compartment
syndrome. Medications were renally dosed...
.
# MECHANICAL AORTIC VALVE: The patient was found to have a supra
therapeutic [**Date range (3) 263**] in the setting of anticoagulation with Coumadin
with a Lovenox bridge. Given the active bleed, his
anticoagulation was held and his coagulopathy reversed with
fresh frozen plasma, which was discussed with cardiology.
.
# FEVER: He developed a fever to greater than 101 on hospital
day 3. There was concern for pneumonia given evidence of a new
infiltrate on imaging so he was empirically started on broad
spectrum antibiotics...
.
# ATRIAL FIBRILLATION. He was continued on his home dose of
amiodarone. Metoprolol was initially held in the setting of
active bleeding.
.
# CAD s/p CABG. His home aspirin was initially held in the
setting of an active bleed.
.
# HYPERLIPIDEMIA. His simvastatin was held in the setting of
increasing CK levels.
.
# HYPERTENSION. His home lisinopril, metoprolol, HCTZ were
initially held in the setting of active bleeding.
.
# COPD. He was continued on home Atrovent.
[**2142-5-15**]. General surgery was consulted for retroperitoneal bleed
secondary to anticoagulation. Recommendations: reverse [**Month/Day/Year 263**],
admit to micu, serial hcts, place Foley catheter, secure IV
access, Angio for possible embolization of vessel, type/cross,
transfuse if necessary.
IR consulted, recommended Ultrasound-guided left common femoral
artery access, abdominal aortogram, it reveled extensive
atherosclerotic disease as seen on prior CT, no active contrast
extravasation identified.
Patient was transfused 2 units of blood. Serial hematocrits
slowly treading down. Received 4 Units of FFP and Vitamine K.
Continue fluid resuscitation.
[**2142-5-16**] Patient increase respiratory distress, diaphoresis, cold
and clammy extremities. Attempted BiPAP which help respiratory
status but patient was unable to tolerate it. IV Lasix given
with minimal response. Patient was intubated for anesthesia.
Labs showed CK of 740, bladder presser of 29. Concerning for
abdominal compartment syndrome.
CVL and Left IJ line placed
[**2142-5-17**] patient was taken to the OR for abdominal compartment
syndrome due to left retroperitoneal and sigmoid mesenteric
hematoma status post decompressive laparotomy with evacuation of
retroperitoneal hematoma and packing for hemostasis, placement
of silo closure with reinforced Silastic.
Taking back to the SICU, intubated on PS, IVF resuscitation,
transfused 2U RBC.
[**2142-5-18**] Reopening of prior laparotomy for removal of packing,
abdominal washout and partial closure. Hemostasis of spleen.
[**2142-5-21**] Abdominal washout and partial closure; [**Last Name (un) **]
gastrostomy; drain retroperitoneal hematoma.
[**2142-5-23**] Transfused 1 unit pRBC
[**2142-5-24**] Patient underwent thoracentesis for bilateral pleural
effusions.
Noted to have decreased movement in his right, CT scan head
showed chronic infarct within the right PCA territory (present
on CT from [**2139**]). Hypo density noted within the margin between
the left PCA and MCA, suggestive of possible subacute watershed
infarct, neurology recommended to maintain anticoagulation with
goal PTT 50-70 to avoid new embolic events, though current
infarct was likely watershed in
the context of hypotension to the 70s systolic.
[**2142-5-26**]
Reopening of postop abdomen. Adhesiolysis (x3 hours). Drainage
of left retroperitoneal hematomas times 2. Silastic silo closure
with "[**State 19827**] patch".
Continue management in the ICU. Physical therapy was consulted.
Patient in Levaquin and Zosyn for pneumonia. Intubated and
sedated on mechanical ventilation, fentanyl and versed for
sedation. Neurology checks Q 4 hours. ARF for hypovolemia
improving.
Serial hematocrit checks.
[**2142-5-30**]
Patient transfused 2 RBC for HCT of 23. Patient continue to do
well.
[**2142-6-2**] Washout of the abdomen, partial closure. Patient was
transferred to the floor after procedure.
[**2142-6-3**] Pt extubated
[**2142-6-5**] Irrigation and debridement of open abdomen with
split-thickness skin graft 800 sq cm. Patient returned to the
floor after procedure.
[**2142-6-9**] Tube feeds re started.
[**2142-6-8**] Received 3U of PRBC for HCT drop from 26 to 17 -->
responded to 31
[**2142-6-10**] PICC dc'd, tip sent for culture, 2 PIVs placed. VAC
removed; Adaptic and gauze with wound VAC dressing ng overlying.
[**2142-6-11**] Ct scan torso: Newly distended gallbladder with wall
edema, internal sludge, and a gallstone, concerning for
cholecystitis. Stable retroperitoneal hematoma and anterior
fluid collection, not significantly changed in size since the
prior examination. Interval decrease in size of a previously
seen left lateral conal fascial fluid collection. No new fluid
collection seen. Improved bibasilar atelectasis. Near complete
resolution of a previously seen right pleural effusion.
Large amount of mesenteric stranding and edema about a large
abdominal
wall defect, compatible with post-surgical changes.
US guided per-chole tube. IR draining of gallbladder.
[**2142-6-12**] micafungin started-yeast in bile, + ID approval,
speciation ordered,Foley out.
[**2142-6-13**] TEE without vegetations, remained intubated overnight
[**2142-6-13**] transferred to unit for hypotension, transfused 1 RBC,
intubated, disimpact ed.
[**2142-6-14**] perch drain placement x2 by IR
ID summary: Over the past 10 days he has been intermittently
hypotensive,
febrile with a leukocytosis which raises concern for an infected
source. He is at risk for a number of sources of infection,
most obviously is his RP hematoma and open abdominal wound which
now has a drain placed in the hematoma. This collection of blood
is an excellent medium for varied organisms to grow. We will
await
culture data from this source. His gallbladder was distended on
imaging and now has [**Female First Name (un) **] albicans growing from the bile. This
yeast should be sensitive to fluconazole and we do not need the
micafungin. He has pleural effusions, his nurse reports
increased secretions and now has GNR and GPC's from his sputum
which may
indicate a pulmonary source of infection and a hospital acquired
source of infection is of additional concern. He has been a on a
chronic quinolone prophylaxis for years and now has increased
diarrhea in the setting of a rising WCC, which raises the
possibility of C difficile. Therefore we recommend broad
coverage for this chronically hospitalized critically ill
patient with [**Female First Name (un) **], Levofloxacin, Flagyl, and Fluconazole.
This should provide broad gram positive, fungal and anaerobic
coverage as well as some gram negative coverage. Should he
decompensate
overnight we recommend switching his levofloxacin for Meropenem
which would provide broader gram negative coverage.
Successful CT-guided drainage of a large retroperitoneal
collection likely hematoma. Drain was placed in the left psoas
collection, however no fluid was drained. A drain was left in
situ as requested by the referring physician.
[**2142-6-15**] extubated, WBC treading down, VAC changed, on and off
neo.
[**2142-6-16**] confused but otherwise stable in TSICU
[**2142-6-17**] Ceftriaxone started for E coli in sputum
[**2142-6-18**] d/c VAC
Speech and swallow evaluation suggest initiating a PO diet of
thin liquids and moist, ground solids when fully awake and
alert. 1:1 supervision- hold meals if too lethargic. Continue
tube feeds as needed to meet nutritional needs. Pt
will benefit from continued nutrition input to adjust tube feeds
as needed
[**2142-6-19**] cholecystostomy tube fell out; desat w/ LLL collapse on
CXR .
[**2142-6-20**] Patient had massive GI bleeding, coded in the floor was
intubated on mechanical ventilation, transfused and fluid
resuscitated, on pressors
EGD today revealed severe erythema and ulceration in the entire
visualized area from the duodenum and up to proximal jejunum
consistent with diffuse bowel ischemia.
- Agree with efforts to maintain the hemodynamic status of the
patient via transfusions and fluids. Recommend PPI gtt or
pantoprazole 40 mg IV BID to prevent further acid induced damage
to the duodenum
- Poor prognosis.
EEG
This is an abnormal portable EEG due to a burst suppression
pattern which can be seen in anoxic ischemic encephalopathy
secondary to cardiac arrest or in the setting of high dose
sedating medications like Midazolam. In the absence of high dose
sedating medications, the presence of a burst suppression
pattern is a poor prognostic sign. No epileptiform discharges or
electrographic seizures were seen during this recording.
Family meeting, patient expired on [**2142-7-23**]
Medications on Admission:
Amiodarone 200mg daily
Aspirin 81mg daily
Atrovent
Iron 325mg daily
HCTZ 25mg daily
Lipitor 80mg daily
Lisinopril 20mg daily
Metoprolol 100mg [**Hospital1 **]
MVI
Omeprazole 20mg [**Hospital1 **]
Senna prn
coumadin 10mg daily (increased from 5mg 5 days prior)
Lvenox bridge
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
New diagnosis
Retroperitoneal hematoma secondary to anticoagulation.
Compartment syndrome secondary to retroperitoneal hematoma.
Subacute watershed cerebral infarct.
Acute renal failure dur to hypovolemia
Pneumomia
Gastrointestinal bleeding
Diffuse bowel ischemia
Old diagnosis
1. Mechanical AV: Pt had bicuspid AV requiring replacement.
Aortic valve replacement with the Bentall procedure done in
[**2124-4-26**] with a redo procedure done in [**2132-5-26**] secondary to
methicillin-sensitive Staphylococcus aureus abscess.
2. Afib: [**Year (4 digits) **] ([**Company 1543**] Sigma dual chamber) placed in
setting of CHB in [**1-/2139**], continues amiodarone.
3. Bronchomalecia and Bronchiectesis
4. H/O GI Bleed ([**2132**])
5. CAD requiring CABG: SVG to LAD, SBG to OM, and SVG to PDA
6. Hypercholesterolemia
7. HTN
8. COPD
9. Endocarditis: Pt has had multiple episodes of endocarditis,
most recently in [**2138**] with concern for culture negative
endocarditis (veg seen on valve), per recommendation of
infectious disease team at [**Hospital1 18**] (consulted in prior
hospitalization) he will require chronic Levofloxacin
10. Herniated disc
12. Thoracic aneurysm
13. Pulmonary hematoma in [**2132**] requiring pulmonary decortication
and surgical evacuation of hematoma from left upper lobe of
lung.
14. Septic Cerebral Emboli ([**2132**]) without residual defecits.
Percutaneous coronary intervention, in [**2124**] anatomy as follows:
No report on OMR
[**Year (4 digits) **]/ICD, in [**2139-1-26**], [**Company 1543**] Sigma dual chamber
[**Company 4448**] placed for complete heart block
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2142-7-10**]
|
[
"0389",
"99592",
"78552",
"5849",
"51881",
"2851",
"4019",
"496",
"2724",
"42731",
"V4581"
] |
Admission Date: [**2153-1-23**] Discharge Date: [**2153-1-30**]
Date of Birth: [**2071-9-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
SOB and atrial fibrillation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 81F with h/o HTN, hypercholesterol, PAF, and s/p TIA 17yrs
ago presented to the ED today with complaint of shortness of
breath x1 day. Pt. complains of about 2 weeks of cough -
occasionally productive of greenish sputum - though mostly
feeling she has post-nasal drip that she is unable to clear. Pt.
awoke this am feeling quite week and short of breath - difficult
to characterize other than feeling difficult to breath with all
the junk in her throat. Of note, the daughter has noticed her
mother having difficulty completing sentences (secondary to
coughing near the enc) for about as long as she has had the
cough. Pt. denies fevers, chills, nausea, emesis, headache,
stomach pain, chest pain, palpitations, diarrhea, dysuria, or
rash. The patient's daughter felt she was wheezing this am.
.
ED course: Vitals on presentation: 97.3 146 104/58 28 94%ra ->
pt. was given dilt 5mg IV followed by 30mg PO. Her SBP initially
dropped into the 70s and she was given ~4L IVF with good
responce in SBP - pt. also converted back to sinus. The initial
UA was dirty -> repeat negative. Pt. was give levaquin for ?
pna. Vitals on transfer to floor: 97.8 91 121/49 20 99% 2Lnc
CXR: read as no acute cardio-pulm process
EKG: afib/RVR
Past Medical History:
HTN
CVA [**59**] yrs ago
Hypercholesterolemia
Osteoporosis
Social History:
Live in her house in [**Location (un) 620**] by herself. Has 2 daughters, one
lives in [**Name (NI) **]. Quit smoking 22 years ago. Sporadic EtOH.
No recreational drugs.
Family History:
NC
Physical Exam:
Admit Exam:
.
VS: 98.8 88 132/60 20 93 2Lnc
GEN: WD, WN, NAD
HEENT: NCAT, EOMI
NECK: supple, no lad
Chest: CTAB, no w/c/r
Cardiac: RRR, 2/6 systolic murmur at RUSB
Abd: soft, nt, nd, nabs
ext: no c/c/e, DP 2+ bilaterally
neuro: A & O x3, MAE, II-XII intact
....................................................
Exam on discharge:
.
VS: 96.5 64 126/60 20 96% 2l nc
GEN: WD, WN, NAD
HEENT: NCAT, EOMI
NECK: supple, no lad
Chest: diffuse bilateral wheezes, occasional ronchi - clear
somewhat with coughing
Cardiac: RRR, 2/6 systolic murmur at RUSB
Abd: soft, nt, nd, nabs
ext: no c/c/e, DP 2+ bilaterally
neuro: A & O x3, MAE, II-XII intact
Pertinent Results:
[**Name (NI) 706**] Final Report
CHEST (PORTABLE AP) [**2153-1-23**] 10:46 AM
IMPRESSION: No acute cardiopulmonary process.
..................................
[**Year/Month/Day 706**] Final Report
CHEST (PA & LAT) [**2153-1-24**] 9:32 AM
HISTORY: Two weeks of cough and shortness of breath.
IMPRESSION: AP chest compared to [**2155-1-23**]:56 a.m.
New opacification of the right lower lobe accompanied by
elevation of the right lung base and elevation and rightward
displacement of the heart is most likely atelectasis accompanied
by small right pleural effusion. Left lung clear. Heart size top
normal. No pneumothorax. Dr. [**First Name (STitle) **] was paged to report
these findings, at the time of dictation.
.........................................
[**First Name (STitle) 706**] Final Report
CHEST (PORTABLE AP) [**2153-1-25**] 12:17 PM
IMPRESSION:
1. New left lower lobe linear atelectasis and a more hazy
opacity. Aspiration cannot be excluded and followup is
recommended.
2. Unchanged right lower lobe opacity which more likely
represents atelectasis.
>
>
>
>
>
>
>
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
[**Month/Day/Year 706**] Preliminary Report
CHEST (PORTABLE AP) [**2153-1-26**] 1:05 PM
IMPRESSION:
1. Slightly worsened right-sided atelectasis at the base with
new right-sided small pleural effusion.
2. Improved left-sided opacification at the base with new
paramediastinal opacity which, with such rapid appearance, most
likely represents atelectasis or pleural effusion.
.
.
.
.
.
.
.
.
.
................................................................
Echo [**2153-1-26**]:
.
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is no ventricular septal defect. 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. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2145-8-2**], the findings are
similar.
.
.
.
.
.
.
.
.
.
................................................................
[**Year (4 digits) 706**] Final Report
CHEST (PA & LAT) [**2153-1-29**] 10:20 AM
FINDINGS: In comparison to the previous radiograph, the
right-sided atelectasis has resolved. Unchanged is the extent of
the left-sided atelectasis. The size of the cardiac silhouette
is unchanged. No evidence of pleural effusion. No newly appeared
parenchymal opacities.
.
.
.
.
.
.
.
.
.
................................................................
[**2153-1-30**] 06:50AM BLOOD WBC-7.3 RBC-3.93* Hgb-11.8* Hct-36.5
MCV-93 MCH-30.0 MCHC-32.3 RDW-13.0 Plt Ct-252
[**2153-1-29**] 06:45AM BLOOD WBC-6.9 RBC-4.10* Hgb-12.8 Hct-37.7
MCV-92 MCH-31.2 MCHC-34.0 RDW-12.9 Plt Ct-222
[**2153-1-28**] 05:15AM BLOOD WBC-7.4 RBC-3.98* Hgb-12.8 Hct-37.4
MCV-94 MCH-32.1* MCHC-34.2 RDW-12.7 Plt Ct-185
[**2153-1-23**] 10:50AM BLOOD WBC-7.1 RBC-4.43 Hgb-13.7 Hct-40.6 MCV-92
MCH-31.0 MCHC-33.8 RDW-12.9 Plt Ct-227
[**2153-1-30**] 06:50AM BLOOD Plt Ct-252
[**2153-1-29**] 06:45AM BLOOD PT-22.7* INR(PT)-2.2*
[**2153-1-30**] 06:50AM BLOOD Glucose-106* UreaN-21* Creat-1.0 Na-143
K-3.8 Cl-101 HCO3-36* AnGap-10
[**2153-1-29**] 06:45AM BLOOD Glucose-103 UreaN-17 Creat-0.8 Na-143
K-3.7 Cl-101 HCO3-35* AnGap-11
[**2153-1-28**] 05:15AM BLOOD Glucose-96 UreaN-15 Creat-0.8 Na-142
K-3.8 Cl-100 HCO3-34* AnGap-12
[**2153-1-26**] 04:27AM BLOOD ALT-21 AST-26 AlkPhos-33* TotBili-0.3
[**2153-1-25**] 12:21PM BLOOD CK-MB-6 cTropnT-0.01
[**2153-1-25**] 06:25AM BLOOD CK-MB-7 cTropnT-<0.01
[**2153-1-24**] 06:00AM BLOOD cTropnT-0.01
[**2153-1-24**] 05:50AM BLOOD CK-MB-7
[**2153-1-23**] 07:48PM BLOOD CK-MB-7 cTropnT-0.01
[**2153-1-23**] 10:50AM BLOOD cTropnT-0.01
[**2153-1-23**] 10:50AM BLOOD CK-MB-6
[**2153-1-30**] 06:50AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.4
[**2153-1-26**] 04:27AM BLOOD TSH-4.7*
[**2153-1-25**] 03:33PM BLOOD freeCa-1.21
Brief Hospital Course:
Pt. was admitted to the general medical floor after being
treated for pneumonia, atrial fibrillation, and hypotension in
the emergency department. She underwent pulmonary toilet/pt on
the floor and her beta blockade was being titrated during the
initial part of her stay. Over night on the second day of her
admission the patient became tachycardic and was given diltiazem
with marginal effect of slowing her heart rate. However, she
had several episoded of bradycardia after the medication was
given - with her heart rate settling in the 90-100s. During the
morning of HD 3 the pt. was with persistant tachycardia - was
given some additional doses of IV lopressor - with close
monitoring because of her prior episodes of bradycardia. Around
noon on HD 3 the pt. dropped her O2 saturations to the hight
70s/low 80s -> was given nitro, lopressor, lasix, and lopressor,
a CXR and EKG were done, and coardiology was consulted. She
improved clinically with this, however, several hours later the
pt. again dropped her o2 saturation. During this time the pt
was given additional lopressor but was persistantly tachycardic.
The pt. was then transferred to the cardiac intensive care unit
- monitored closely overnight - and started on amiodarone under
the guidance of the cardiology consult service. The evening of
HD 5 the pt. transferred out to the general medical floor. Here
she underwent continued diuresis, phyiscal therapy, continued
antibiotic therapy, and gradually improved. On HD 8 the patient
has a low oxygen requirement - 2L nc - and will need continued
pulmonary and physical therapy - but is ready for discharge to
rehab.
.
# Afib: pt. with known history of afib documented in prior
notes. For this she is on coumadin. Pt. with acute
exacerbation of afib may be related to volume status - as
patient's blood pressure responded well to IV hydration in the
ED. Also, risk of pt. having had cardiac ischemic event sending
her into the abnormal rhythm.
- check labs and fluids as indicated for dehydration
- EKG in ED -> afib
- check lytes and repleat as necessary
- cycle cardiac enzymes -> negative x3
- telemetry monitoring -> has been NSR overnight -> atrial tach
prior to transfer to the CCU -> has now been in sinus and rate
controlled x24 horus
- Added amiodarone when pt. xfr to the ccu - continue loading as
we are and f/u EP recs
- [**1-29**] amiodarone changed to 200mg qday and pt. will need to
continue this until follow-up with cardiology
- [**1-29**] doing well with the amio -> continuing to monitor
- WBC normal, ua negative with culture pending
- repeat CXR pa and lateral [**1-24**] -> RLL infiltrate: atelect vs
pna --> continue antibiotics; changed to doxy -> total of 10
days
.
# Hypertention: history of, although pt. transiently hypotensive
to systolic of the 80s in the ED. she responded to fluids -
likely due to dehydration after rate controlled.
- continue home meds
- changing to metoprolol while in house as easier to titrate and
can convert on d/c --> presently on 50mg tid
.
# Hypercholesterol: continue home meds
.
# Osteoporosis: continue fosamax
.
# h/o TIA: On admission pt. INR is 3.1
- hold evening dose 3/11
- recheck INR in am -> 2.2 today -> giving 2mg dose tonight and
will start her qOday doses
- INR pending today but will need daily INR checks and coumadin
dosing -> likely will need 1mg qHS since starting amio but this
has yet to be determined -> goal INR [**12-17**]
.
# elevated Cr: pt. with initially elevated Cr in ED at 1.3 that
came down with IV fluids - likely due simply to dehydration
- will follow am labs
- stable and normal now -> improved with hydration
- [**1-29**]: slight elevation in Cr today (0.8-->1.0) so will hold on
further diuresis as of now and continue aggressive pulmonary
toilet
.
# FEN:
- Cardiac diet
- daily lytes w/repleation prn
.
# ACCESS: PIVs
.
# PPX:
- protonix
- coumadin -> INR pending today -> will need coumadin dosed
daily
.
# CODE: FULL
.
# Communication: with patient; daughter in HCP
Medications on Admission:
- fosamax 70mg qWeek
- Lisinopril 20'
- Atenolol 50'
- HCTZ 12.5'
- Simvastatin 20'
- Coumadin 2 / 1 alternating
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
7. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 3 days.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours).
12. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: - to
be adjusted according to your INR.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
atrial fibrillation
pneumonia
pulmonary edema
Secondary:
hypertension
hypercholesterol
osteoporosis
h/o TIA
Discharge Condition:
fair - still with minimal oxygen requirement of 2L nc
Discharge Instructions:
You were admitted and treated for your irregular heart beat and
shortness of breath. Your dose of beta blocker was titrated up
and you were given antibiotics. You were started on a new
medication that you will need to take regularly - this is to
help control your heart rate. You have improved greatly. You
were also seen by physical therapy and it was determined that
you would benifit from intensive physical therapy and continued
pulmonary physical therapy prior to going home.
You will need to take all medications as prescribed.
You will need to keep all of the following appointemnts.
Call your primary care doctor or return to the ED if T>101.5,
chills, nausea, vomiting, chest pain, shortness of breath,
worsening pain, irregular heart beat, or any other concern.
Followup Instructions:
- you have a follow-up appointment with Dr. [**Last Name (STitle) **] scheduled for
[**2153-2-8**] at 10:45 in the morning - please call to confirm this
appointment.
- You have an appointment scheduled with Dr. [**Last Name (STitle) **] of Cardiology
on [**2153-2-5**] at 10:20 in the morning - [**Hospital Ward Name 23**] building [**Location (un) 436**].
Please call [**Telephone/Fax (1) 285**] to confirm this appointment.
- Once out of rehab you will need to follow-up with the
pulmonary function lab to have your lung function tested -> this
can be arranged through your primary care doctor or you can call
([**Telephone/Fax (1) 12124**] to schedule an appointment with the pulmonary
function lab here at the [**Hospital1 18**].
- You need to schedule an appointment with an ophthomologist and
have your eyes evaluated as well. This should be set up once
you have completed rehab and can be done through your primary
care doctor.
*It is very important that you keep the following appointments*
- Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2153-2-12**] 10:00
- Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2153-10-15**]
10:20
- Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2153-10-15**]
10:40
|
[
"486",
"4280",
"42731",
"2720",
"4019"
] |
Admission Date: [**2131-5-17**] Discharge Date: [**2131-7-5**]
Date of Birth: [**2103-3-21**] Sex: M
Service: MEDICINE
Allergies:
Meropenem
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Endotracheal intubation [**2131-5-17**]
Central venous line [**2131-5-18**]
Hemodialysis line [**2131-5-24**]
History of Present Illness:
The patient is a 28 year old male with a history of alcohol
abuse who walked into the ED with the complaint of hematemesis.
The patient has been a significant drinker for 5-6 years,
reporting drinking 6 mixed drinks a day, with tremulations on
withdrawl, but no prior seizure. For the last week, he has felt
increasing weakness and fatigue, and has become slightly
disoriented and confused. He reports no head trauma. 3 days
prior to presentation, he began to notice that he was coughing
up blood and mild epigastric tenderness. These episodes were
occuring 2-3 times per day. He additonally noted black tarry
stools, but unable to quantify the number of bowel movements.
With mild abdominal discomfort, nausea, and hematemesis, the
patient was unable to tolerate a PO diet, but continued to
drink. His last drink was the night prior to presentation.
.
On arrival to the ED, vitals were 97.8, BP 53/palp, HR of 143.
He was immediatly given 1unit of unmatched pRBC, a cordis was
placed, and he was given 3L of NS. His BP improved, but the
patient remained tachycardic. He has a low grade temp of 100.1,
and blood and urine cultures were went. With a WBC of 23, the
patient was given cipro/flagyl. A CT scan and laboratory
evaluation was consistent with acute pancreatitis and hepatitis.
An NG tube was placed and lavaged, at first showing
coffee-grounds, but then developing bright red blood, and an
octreotide gtt was started. The patient was admitted to the MICU
for further manegment.
.
On arrival to the flor, the patient's vitals were 99.9, HR 132,
BP 115/80, 94% on RA.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. No dysuria. Denied arthralgias or
myalgias.
.
Past Medical History:
Depression
Alcoholism
Social History:
Patient originally from Western Mass. Works for a IT computing
company. Not married and without children, lives with a roomate
in [**Last Name (un) 813**]. Significant alcohol use for 5-6 years, drinking 6
mixed drinks daily with withdrawl symptoms. 1.5 ppd of
cigarrettes, denies drug use.
Family History:
Mother with DM2.
Physical Exam:
Vitals: T: 99.9 BP: 115/80 P: 132 R: 18 O2 95% RA
General: Alert, oriented, appears uncomfortable with NG tube
with coffee grinds to clamp
HEENT: Scleral icterus, markedly dry MM with dry blood on lips
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, mild RUQ tenderness and LUQ tenderness,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Tremulous.
.
Pertinent Results:
BRONCH CYTOLOGY [**2131-6-6**]
NEGATIVE FOR MALIGNANT CELLS.
Pulmonary macrophages, bronchial epithelial cells, and
inflammatory cells, including eosinophils.
.
ECG Study Date of [**2131-5-17**] 10:22:14 AM
Baseline artifact. Sinus tachycardia. Otherwise, within normal
limits. No
previous tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
135 122 76 300/431 62 27 59
.
LIVER/GALLBLADDER U/S [**2131-5-17**]
Limited study demonstrating marked liver echogenicity,
consistent with fatty infiltration, although more severe liver
disease including significant hepatic fibrosis and cirrhosis
cannot be excluded on this study. There is no intrahepatic
biliary dilatation, and the common bile duct measures 4 mm.
There is normal flow in the portal vein.
.
CT ABDOMEN W/CONTRAST Study Date of [**2131-5-17**] 10:52 AM
IMPRESSION:
1. Diffuse peripancreatic stranding which, in the setting of
known alcohol
use is likely indicative of pancreatitis. Necrosis is difficult
to quantify
though there appears to be roughly 30-40% necrosis.
2. Enlarged diffusely fatty infiltrated liver.
3. Orogastric tube terminating in the duodenum.
.
CHEST (PORTABLE AP) Study Date of [**2131-5-17**] 11:08 AM
IMPRESSION:
Low lung volumes with clear lungs. No free air noted under the
hemidiaphragms.
.
CT HEAD W/O CONTRAST [**2131-5-23**]
1. Diffuse loss of [**Doctor Last Name 352**]-white matter differentiation concerning
for global
hypoxia or edema with hypodensities in bilateral thalami.
2. No hemorrhage, mass effect, or herniation.
3. Fluid seen in bilateral temporal subcutaneous tissue.
Near-complete
opacification of bilateral mastoid, maxillary, frontal, and
ethmoid sinuses.
.
CT TORSO W/ CONTRAST [**2131-5-23**]
1. New multifocal airspace consolidation, suspicious for acute
infiltrates.
2. Diffuse colonic wall thickening, which could reflect colitis.
3. Diffuse soft tissue edema.
4. Peripancreatic stranding, in keeping with pancreatitis.
Extent of
necrosis cannot be evaluated on a non-contrast exam. There are
no new
peripancreatic fluid collections.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2131-6-3**]
3:24 PM
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Interval worsening of the consolidation of the dependent
portions of the
bilateral upper and lower lobes, which may represent
atelectasis; however, a superimposed infection cannot be
excluded.
3. Marked fatty infiltration of the liver.
.
CT HEAD W/O CONTRAST [**2131-5-30**]
1. Interval improvement in the [**Doctor Last Name 352**]-white matter
differentiation, overall,
suggesting slow resolution of diffuse cerebral edema.
2. No hemorrhage, herniation or evidence of acute vascular
territorial
infarction.
3. Persistent opacification of paranasal sinuses, nasal cavity
and mastoid
air cells, likely related to intubation and supine positioning.
.
CT TORSO W/CONTRAST Study Date of [**2131-6-5**] 4:31 PM
IMPRESSION:
1. Persistent atelectasis/consolidation in the dependent
portions of the
lungs bilaterally. Ground-glass opacity in the dependent
portions of the
lungs is suggestive of edema.
2. Diffuse fatty infiltration of the liver with areas of sparing
about the
gallbladder fossa.
3. Persistent area of necrosis within the pancreas as described
above, not
significantly changed. Minimally decreased peripancreatic fluid
collection.
Resolution of the collection previously seen adjacent to the
greater curvature of the stomach.
4. Unchanged diffuse colonic bowel wall thickening for which an
infectious
etiology is not excluded.
5. Increased attenuation of the splenic vein. The SMA and SMV is
patent. No
evidence of pseudoaneurysm.
.
CT SINUS [**2131-6-5**]:
1. Near-opacification of the nasopharynx, sphenoid sinuses and
ethmoid air cells. Moderate-to-severe left maxillary sinus
disease. Mild right maxillary sinus disease. Non-pneumatized
frontal sinuses.
2. Persistent opacification of bilateral mastoid air cells and
middle ear cavity.
CT HEAD [**2131-6-13**]: No acute intracranial abnormality.
.
EEG [**2131-6-13**]: This is an abnormal routine EEG due to three
independent
focal onset electrographic seizures in the right posterior
quadrant
without obvious clinical correlate. The background rhythm was
slow and
poorly modulated indicative of a moderate to severe
encephalopathy.
There was also recurrent sharp activity seen over the right
posterior
quadrant indicative of acute cortical and subcortical
dysfunction
.
EEG [**2131-6-15**]: This is an abnormal video-EEG study because of
severe
diffuse background slowing and attenuation, and continuous
periodic
lateralized epileptiform discharges (PLEDs) in the right
posterior
quadrant. These findings are indicative of a severe
encephalopathy and
a highly potentially epileptogenic focal structural lesion in
the right
posterior quadrant. Compared to the routine EEG yesterday,
repetition
rate of PLEDs has decreased and there are no electrographic
seizures.
.
ABD U/S [**2131-6-14**]: Nondistended gallbladder, with lumen entirely
replaced with echogenic material, likely sludge. No shadowing
stones identified. No hyperemic thickened wall.
.
GALLBLADDER SCAN [**2131-6-18**]: 1. Non-visualization of the
gallbladder but cannot evaluate for cholecyctitis in the setting
of poor hepatic function.
2. Tracer excretion into the bowel is observed, excluding common
bile duct
obstruction.
.
CT ABD/PELVIS [**2131-6-20**]:
1. Persistent atelectasis/consolidation in the dependent portion
of the lungs
bilaterally.
2. Diffuse fatty infiltration of the liver.
3. Continued evolution of areas of necrosis within the pancreas.
New fluid
collection anterior to superior segment of the duodenum, 5.6 x
2.9 cm, and
along pancreatic uncinate process, 2.2 x 1.9 cm.
4. Delayed enhancement of the kidneys, with no excretion of
contrast, and
dense material within the gallbladder; these findings could
suggest renal
failure, if clinically correlated.
5. Similar appearance of the colonic bowel wall, which could be
due to bowel
wall collapse; however, infectious etiology cannot be excluded.
6. Similar appearance of increased attenuation of the splenic
vein. No
evidence of pseudoaneurysm.
Brief Hospital Course:
28 year-old male with a history of alcoholism presenting with
acute hepatitis, pancreatitis, and UGIB.
# Hematemesis: He presented with complaints of hematemesis and
was started on a PPI drip and octreotide prior to EGD. He was
found to have a diulefoy lesion on endoscopy but no active
bleeding. He had no recurrence of hematemesis during his
hospitalization.
# Pancreatitis: His lipase was elevated on presentation to
1600 in the setting of alcohol abuse. He underwent a CT that
demonstrated significant pancreatitis necrosis, but no clear
phlegmon. Because he became hypotensive, febrile, and developed
a leukocytosis, he was thought to be septic or in shock
secondary to pancreatitis and was started on meropenem and
aggressive IVF repletion, along with levophed and phenylephrine.
The surgical service was also consulted but found no evidence
of an abscess or pseudocyst requiring surgical intervention.
Repeat CT abdomen showed fluid collections around his pancreas
and duodenum but thought to be sterile per Surgery and not
sampled; ID agreed with this. Kept on broad spectrum
antibiotics. Pt likely to continue to spike fevers due to
necrotizing pancreatitis.
# Sepsis: As noted above, he became hypotensive, febrile, and
developed a leukocytosis shortly after admission. He required
levpohed and phenylephrine initially but was eventually able to
maintain normal perfusion pressure with levophed alone. No
clear source of infection was initially identified but he was
treated empirically with several different antibiotic regimens
because of concerns about inadequate coverage, allergic drug
reactions, or new possible sources of infection. Possible
sources of infection considered included pancreatitis,
cellulitis, C. diff given colonic wall thickening seen on
abdominal CT, line infections, endocarditis, and sinusitis but
most likely source thought to be necrotizing pancreatitis. HIDA
with persistent sludge but not thought to have cholecystitis
requiring intervention. There was evidence of fluid collections
around his pancreas and duodenum but thought to be sterile per
Surgery and not sampled. His antibiotic courses included
meropenem ([**Date range (1) 82129**]; may have contributed to eosinophilia per
ID); Aztreonam 6(/3- ; Metronidazole IV ([**Date range (1) 82130**], [**Date range (1) 30320**],
[**Date range (1) 22666**], [**Date range (1) 13152**]); Vancomycin IV ([**Date range (1) 82131**]; may have
contributed to eosinophilia per ID); Daptomycin ([**Date range (1) 30320**] ->
increased dose on [**5-9**]); Linezolid ([**Date range (1) 82132**]); Vancomycin
po ([**Date range (1) 82133**], [**Date range (1) 47946**]); Vancomycin PR ([**Date range (1) 75035**]); Micafungin
([**Date range (1) 82134**], [**Date range (1) 82135**]); and Cipro ([**Date range (1) **], [**Date range (1) 47433**]). He did
have one bottle of blood cultures grow coagulase negative staph,
otherwise no source was found. His fever curve and leukocytosis
trended down and antibiotics were slowly weaned off. He
continued to spike fevers requiring restarting of pressors a few
times for accompanying hypotension. However, these were thought
to be due to necrotizing pancreatitis and expected to continue
for a while. Decision made not to tap abd fluid collections as
he would be at very high risk of bleeding. He has continued to
have recurring low grade fevers, tachycardia and tachypnea
without any identified source (blood, urine, sputum cultures;
CXR. His fevers at discharge were felt to be centrally driven
and not from any organism.
# Respiratory failure: He was intubated for hypercapnia on
[**2131-5-17**] in the setting of recent EGD and shortly after
admission. He was managed with assist control/CMV and underwent
tracheostomy placement on [**2131-6-8**] by the thoracic surgery
service. He was noted to have blood oozing around trach site
with clots suctioned from trach and oropharynx. He received
DDAVP x 2 for this. On [**2131-6-11**] pt had PEA arrest [**2-5**] clot
plugging (see below). Bedside bronch was done by Thoracics who
determined that trach appropriately sized. No evidence of DIC.
Completed a 24-hour course of Amicar per Heme-Onc recs. Pt
eventually weaned to trach mask with FiO2 40%. He did require
additional DDAVP on [**6-21**] for return of bloody secretions but
bronched with no evidence of bleed. He is able to clear most
secretions on his own requiring occasional suctioning.
# PEA Arrest: On [**6-11**], he developed respiratory distress
progressing to cardiac arrest with PEA reportedly lasting
minutes. He received compressions and atropine with return of
spontaneous circulation. A large clot was suctioned from trach
with resolution before arrival of code team. Further
respiratory issues were addressed as above.
# Renal failure: He went into renal failure a few days after
admission that was thought to be ATN in the setting of sepsis
and hypotension. He required CVVH therapy afterward. He then
had a tunneled HD line placed on [**2131-6-14**] and started HD once
blood pressures stable off pressors. Renal function improved
and no longer required HD after [**6-23**]. With Cr. of 0.8 and good
UOP on discharge from MICU.
# Seizures/Intercerebral edema: He underwent a head CT that
demonstrated loss of [**Doctor Last Name 352**]/white matter differentiation on
[**2131-5-23**]. On the same day, he also developed eye twitching
concerning for seizure activity. Neurology was consulted and
recommended starting keppra and hypertonic saline to treat his
edema, which was thought to be secondary to both volume overload
in the setting of IVFs and toxic-encephalopathy, likely
secondary to elevated ammonia. His cerebral edema improved
significantly over the next several days, as a follow-up head CT
demonstrated significant improvement. He also underwent an EEG
that was nondiagnostic for seizure activity. After several weeks
he again was noted to have seizure-like activity with twitching
of the mouth and eye deviation upward. He was initially thought
to be withdrawing from benzodiazepines as this activity occured
in the setting of weaning his midazolam gtt and he was treated
with higher doses of benzos, which are being weaned with change
of valium to 5mg qhs on [**2131-7-5**] with plan for 2wks at this dose
before d/c'ing. After an EEG showed only seizures in the
occipital lobe, his keppra dose was increased. He then underwent
a repeat EEG that was negative for seizures. Upper extremity
tremors thought more consistent with clonus and thought to be
more reactive in setting of waking up.
# Acute Hepatitis: This was thought to be secondary to
alcoholic hepatitis, with a CT scan showing extensive fatty
infiltration.
# Alcoholism: Patient describd history of withdrawal symptoms
but not prior seizure. Last drink was night prior to
presentation. He was given thiamine, folate, and vitamin B12.
He was started on a CIWA but received fentanyl and midazolam
after being intubated.
# Hyperbilirubinemia: Initially this was attributed to his
alcoholic hepatitis and pancreatitis. However, it continued to
rise in the setting of receiving TPN. The TPN was d/c'd and the
bilirubin decreased.
#. Adrenal Insufficiency: The patient developed profound
eosinophilia and was persistently hypotensive despite adequate
antibiotic coverage for sepsis. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test showed 0, 30,
60 levels of 12->18->19, but he was started on high dose
hydrocortisone anyway with decrease in his eosinophilia and
decreased pressor requirement. The steroids were then slowly
weaned off prior to discharge.
...
...
...
In essence, [**Hospital 228**] hospital course has been complicated by
respiratory failure (currently with a trach), cyclic fevers (no
organism identified, felt to be centrally mediated from the
brain), and anoxic brain injury (possibly from PEA arrest) with
limited but improving neuro status. His low grade fevers with
tachypnea have not been related to an infection, but rather his
brain injury, as assessed by the neurologists here and also due
to the lack of an isolated microorganism.
Medications on Admission:
Prozac
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
8-15 Puffs Inhalation Q2H (every 2 hours) as needed for sob,
cough, bronchospasm.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Injection TID (3 times a day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levetiracetam 100 mg/mL Solution Sig: One (1) 500 mg PO BID
(2 times a day).
7. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. insulin
please see attached insulin regimen
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary
- Diulefoy lesion
- Necrotic pancreatitis
- Hepatitis
- Respiratory failure
- Renal failure
- Cerebral edema/anoxic brain injury
- Seizures
- Likely colitis
- Adrenal insufficiency
Secondary
- Alcohol abuse
- Depression
Discharge Condition:
Stable on trach
Discharge Instructions:
You were admitted with bloody emesis in the setting of alcohol
abuse. You were intubated for an upper endoscopy, which showed a
diulefoy lesion (ulcer). Other studies also showed hepatitis and
necrotic pancreatitis. You required reintubation for respiratory
failure. You had multiple complications during your hospital
stay, including cerebral edema, seizures, likely colitis, renal
failure, adrenal insufficiency, and fevers which are centrally
driven by the brain. A trach was placed as you still require
ventilatory support, but the above issues are now stable. You
are being transferred to a Rehab for further care.
The following changes were made to your medications:
- tyleonol 650 mg every 6 hrs for fevers
- albuterol inhaler every 2 hrs for wheezing
- diazepam 5 mg by mouth at night for 2 weeks
- famotidine 20 mg every 12 hours
- lasix 40 mg daily
- heparin 5000 units sq three times a day
- insulin
- keppra 500 mg twice a day
Please take all medications as prescribed.
Please call your doctor or 911 if you develop chest pain,
difficulty breathing, change in mental status, dizziness,
bleeding, severe pain, or any other concerning symptoms.
Followup Instructions:
Please schedule follow-up with your PCP on discharge from Rehab.
Completed by:[**2131-7-10**]
|
[
"0389",
"99592",
"78552",
"51881",
"5849",
"2875"
] |
Admission Date: [**2188-4-28**] Discharge Date: [**2188-5-2**]
Date of Birth: [**2141-6-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
cardiac catheterization with no intervention
endotracheal intubation
History of Present Illness:
46 y/o man with EtOH abuse and no other significan PMHx who
became uncousious while at the bar, received CPR and presented
to SLH where he was found to have Vfib arrest s/p shock x1 and
transferred to [**Hospital1 18**] for further care.
.
Pt. was in USOH until Saturday night when he awoke from sleep
and was c/o of chest pain. He felt it was [**2-13**] GERD and this
apparently improved with repositioning. When he awoke, he was
not himself (usually drinks with his brother in AM, but this
time did not due to not feeling well). He felt malaised all
day, no frank CP complaints. He then arrived at the bar around
6pm, ordered a beer, was talking with friends and then suddenly
was noted by bystanders not to respond appropriately/confused.
Seconds later he fell backwards, eyes rolled up, no shaking or
urinary incontinence. CPR was started within 1 minute b/c the
patient was apneic, CPR was for ~ 5 minutes, by time ambulance
arrived, patient had a pulse.
.
He was apparently given Narcan and became "awake" (per EMS
reports) though unclear if he followed commands. Apparently
upon arrival to SLH he became unresponsive and was found to be
in Vfib arrest. He received 150mg of Amiodarone, 1 shock and
had return of pulse within 1 minute of the arrest. S/p shock was
confused but moving all extremities. Earliest BP noted is
187/105 at [**2107**]. Was then intubaed and received ASA 325mg,
Amiodarone gtt. EKG SR, tachy, STe V1 3mm and aVR 1mm, STd I,
aVL, V2-6. Started on heparin gtt. EKG then NSR, < 1mm STe V1
and aVR; STe III, aVF < 1mm; STd I, aVL, V4-6 of < 1mm.
Underwent CT H/N with concern for ICH, thus heparin gtt was
stopped. Transferred to [**Hospital1 18**] for possible cath. Of note, had
a "posturing" episode, treated with 2mg of versed w/ resolution.
Labs at OSH notable for CK 257, MB 2.4, MBI 0.9%, Troponin 0.14
(0 - 0.3), + urine cannabinoids, WBC 15K, K 3.2, AST 52, ALT of
39, EtOH of 107, and ... "+pregnancy test"
.
VS in ED arrival were 97 157/93 30. Pt. was bucking the vent
and moving all extremities. He was started on
Propofol/Midazolam/Fentanyl. EKG showed SR, STe V1 4mm, aVR
<1mm and III/aVF < 1mm; STd I, aVL, V4-6. Labs in the ED notable
for Troponin of 0.28 and WBC of 14K. CT head was repeated and
was negative for ICH. He received Amiodarone 1mg/min IV gtt,
Heparin gtt, Clopidogrel 600 mg, Atorvastatin 80mg. TTE showed
no sign. WMA and low/normal EF. Repeat EKG: SR, nl axis, STe V1
as above but not elsewhere and no STd. Cooling not initiated
given spontaneous movements and mouthing of words. Patient
transferred to CCU for further care.
.
In CCU, VS were 84 124/84 26 on AC 50%FiO2, 500/5/22. Sedated,
intubated.
.
Unable to obtain ROS but per girlfriend: has been c/o of
intermittent chest pressure since [**Month (only) **], started on PPI with
some improvement.
.
No 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. No
recent fevers, chills or rigors. All of the other review of
systems were negative.
.
.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
.
Social History:
Landscaping, cuts trees. Lives near [**Location (un) 5503**] with
girlfriend.
-Tobacco history: 1.5ppd x since teens.
-ETOH: 6-8 per day, has had withdrawal sx in past, no DTs or
seizures.
-Illicit drugs: marijuana, daily. no IVDU, no cocaine.
Family History:
Fa - MI at 60s. Cancer - Burkitt's lymphoma.
Mo - healthy
2 Brothers - etoh abuse
1 Sister - etoh abuse
No sudden cardiac death; otherwise non-contributory.
Physical Exam:
NEURO: Intubated, off sedation:
Opens eyes to command, sticks tongue out, squeezes both hands
symmetrically and moves feet b/l. Nods for yes and shakes for
no.
CNs: L 3->2mm, R 2.5->1.5mm, EOMi no nystagmus, face symmetric,
+ gag, + corneals.
Motor: normal tone, symmetric movements, UEs are AG at least.
No clonus. Toes down b/l. DTRs deferred.
.
HEENT: NCAT. in Collar. No xanthalesma.
NECK: in collar.
CARDIAC: PMI located in 5th intercostal space.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: CTA laterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
I. Labs
A. Admission
[**2188-4-28**] 12:00AM BLOOD WBC-14.0* RBC-4.83 Hgb-15.9 Hct-44.3
MCV-92 MCH-32.9* MCHC-35.8* RDW-13.2 Plt Ct-220
[**2188-4-28**] 06:04AM BLOOD Neuts-86.0* Lymphs-10.0* Monos-3.1
Eos-0.4 Baso-0.6
[**2188-4-28**] 12:00AM BLOOD PT-11.7 PTT-21.7* INR(PT)-1.0
[**2188-4-28**] 12:00AM BLOOD Fibrino-331
[**2188-4-28**] 12:00AM BLOOD UreaN-8 Creat-0.6
[**2188-4-28**] 12:00AM BLOOD ALT-45* AST-74* LD(LDH)-318*
CK(CPK)-[**2139**]* AlkPhos-86 TotBili-0.5
[**2188-4-28**] 12:00AM BLOOD Albumin-4.0 Calcium-7.7* Phos-2.8 Mg-1.8
[**2188-5-2**] 07:30AM BLOOD VitB12-773
[**2188-4-28**] 06:04AM BLOOD %HbA1c-5.6 eAG-114
[**2188-4-28**] 06:04AM BLOOD Triglyc-90 HDL-67 CHOL/HD-2.7 LDLcalc-97
[**2188-4-28**] 12:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2188-4-28**] 12:08AM BLOOD Glucose-115* Lactate-1.7 Na-137 K-4.1
Cl-105 calHCO3-19*
B. Cardiac biomarkers
[**2188-4-28**] 12:00AM BLOOD CK-MB-19* MB Indx-1.0
[**2188-4-28**] 12:00AM BLOOD cTropnT-0.28*
[**2188-4-28**] 06:04AM BLOOD CK-MB-133* MB Indx-4.6 cTropnT-0.86*
[**2188-4-28**] 12:15PM BLOOD CK-MB-214* MB Indx-7.6* cTropnT-1.04*
[**2188-4-28**] 07:51PM BLOOD CK-MB-157* cTropnT-1.26*
[**2188-4-29**] 04:10AM BLOOD CK-MB-96* MB Indx-5.4 cTropnT-1.51*
[**2188-4-29**] 02:21PM BLOOD CK-MB-58* MB Indx-5.1 cTropnT-1.13*
[**2188-4-30**] 12:14AM BLOOD CK-MB-23* MB Indx-4.1 cTropnT-1.11*
[**2188-4-30**] 06:08AM BLOOD CK-MB-17* MB Indx-4.0 cTropnT-1.23*
C. Discharge
[**2188-5-2**] 07:30AM BLOOD WBC-9.3 RBC-4.69 Hgb-14.8 Hct-43.2 MCV-92
MCH-31.5 MCHC-34.2 RDW-13.2 Plt Ct-314
[**2188-5-2**] 07:30AM BLOOD Glucose-101* UreaN-14 Creat-0.9 Na-137
K-4.1 Cl-99 HCO3-27 AnGap-15
[**2188-4-30**] 06:08AM BLOOD ALT-49* AST-60* CK(CPK)-424*
[**2188-5-2**] 07:30AM BLOOD Calcium-9.4 Phos-4.1# Mg-1.9
D. Urinary
[**2188-4-28**] 12:00AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2188-4-28**] 12:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2188-4-30**] 03:00PM URINE Hours-RANDOM UreaN-1489 Creat-190 Na-43
K-53 Cl-57
[**2188-4-30**] 03:00PM URINE Osmolal-911
[**2188-4-28**] 12:00AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
II. Cardiology
A. C. cath ([**2188-4-29**]) ** PRELIM REPORT **
BRIEF HISTORY: 46 year old male with history of etoh and
tobacco abuse
with recent cardiac arrest at a bar after several days of chest
discomfort.
INDICATIONS FOR CATHETERIZATION:
PROCEDURE:
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
LEFT VENTRICULOGRAPHY:
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA DISCRETE 100
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 20
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 DISCRETE 40
10) DIAGONAL-2 NORMAL
11) INTERMEDIUS NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
17) LEFT PDA NORMAL
17A) POSTERIOR LV NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour33 minutes.
Arterial time = 0 hour33 minutes.
Fluoro time = 10 minutes.
IRP dose = 354 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 130 ml
Premedications:
Midazolam 1 mg IV
Fentanyl 100 mcg IV
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Lidocaine 5ml subq
Cardiac Cath Supplies Used:
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, LEFT HEART KIT
COMMENTS:
1. Selective coronary angiography of this left dominant system
reveale
single vessel coronary artery disease. The LM was free from
angiographic
disease. The LAD had a short segment of myocardial bridge
proximally
with 20% focal disease; the single diagonal branch takes off
relatively
proximally and has 40% tubular proximal disease; the distal LAD
filled the distal RPDA retrogradely. The LCx is a hyperdominant
vessel
giving rise to 4 OM branches. The AV groove LCx is a well
developed
vessel; the OM3 and OM4 also supply bridging collaterals to the
distal
RPDA; well developed atrial branch is also noted. The RCA is a
non-dominant vessel occluded proximally with a "peaked"
appearance
suggestive of recent occlusion; the occlusion is past the
takeoff of the
conus branch and just beyond the sinus node and a small RV
branch; the
distal RPDA reconsituted via collateral with the LAD (mostly)
and the
OM3-4. sided filling pressure LVEDP of 19mmHg. There was mild
aortic
stensosis with a peak-to-peak gradient of 30mmHg. There was
severely
elevated systemic arterial pressure of 186/104mmHg.
3. Left ventriculography revealed mitral regurgitaion, and LVEF
of 60%
and somewhat sluggish inferior wall.
FINAL DIAGNOSIS:
1. Single vessel CAD with total occlusion of the proximal RCA.
2. Mild disease in the D1 and mid LAD with myocardial bridge in
the
proximal-mid LAD.
3. Elevated LVEDP consistent with mild-moderate diastolic
dysfunction.
4. Normal LVEF without MR.
5. Medical therapy.
6. Mild aortic stenosis.
B. TTE ([**2188-4-28**])
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Right ventricular chamber
size is normal. Free wall motion could not be assessed, but may
be hypokinetic. The aortic sinus is normal in diameter. The
aortic valve leaflets may be mildly thickened. Mild aortic
regurgitation is suggested. The mitral valve leaflets are
structurally normal. At least mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Technicaly suboptimal study. Normal biventricular
cavity size with low normal global left ventricular systolic
function. ? Mild aortic regurgitation. At least mild mitral
regurgitation.
If clinincally indicated, a follow-up study by laboratory
personnel/son[**Name (NI) 930**] is suggested.
C. TTE ([**2188-4-28**])
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened (?#) but mobile. An increased
velocity is detected across the valve which likely represents
high output, though cannot fully exclude mild aortic stenosis.
Very mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Possible
mild aortic valve stenosis (vs. high output). Mild mitral
regurgitation with normal valve morphology. Very mild aortic
regurgitation.
CLINICAL IMPLICATIONS:
Based on [**2184**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
D. ECG (admission on [**2188-4-27**])
Cardiology Report ECG Study Date of [**2188-4-27**] 11:58:20 PM
Normal sinus rhythm. ST segment elevation most marked in lead V1
but also seen
in leads III and aVF. J point depression seen in lead V2 and
non-specific
ST-T wave abnormalities. Cannot exclude acute myocardial
infarction. Suggest
clinical correlation and repeat tracing.
TRACING #1
Read by: [**Last Name (LF) 10516**],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 154 72 [**Telephone/Fax (2) 88644**] 74
E. ECG ([**4-29**])
Cardiology Report ECG Study Date of [**2188-4-29**] 8:01:56 PM
Sinus tachycardia. ST-T wave configuration may be due to early
repolarization
pattern. Clinical correlation is suggested. Since the previous
tracing of same
date sinus tachycardia is now present.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
101 136 78 332/403 62 -13 26
III. Radiology
A. CXR
HISTORY: CPR after cardiac arrest, to assess for rib fractures.
FINDINGS: In comparison with the earlier study of this date,
there is no
definite evidence of rib fracture. If this is a serious clinical
concern, a
dedicated rib series could be obtained. Central fullness of
pulmonary vessels
persists. No evidence of acute focal pneumonia or pneumothorax.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
46-year-old male with alcohol abuse and no other significant
past medical history became unconscious at a bar with resultant
CPR for ventricular fibrillation arrest. He was taken to an OSH
where he was thought to have ventricular fibrillation arrest s/p
shock x1 and transferred to [**Hospital1 18**] for further care with cardiac
cath showing recent RCA occlusion suggestive of ischemic
mechanism for arrest and aortic stenosis. Hospital course
complicated by femoral groin site bleed, alcohol withdrawal,
severe systemic hypertension, and encephalopathy.
# One vessel coronary artery disease with cardiac arrest
The patient arrived intubated for airway protection in setting
of cardiac arrest. Etiology of cardiac arrest may be related
to RCA occlusion; however, complete data are not available
especially from EMS to state whether or not this was a true
cardiac arrest as no rhythm strips are available from EMS. The
OSH documented ventricular fibrillation; however, only one strip
available in the chart and per electrophysiology review,
uncertain if represents such arrest. No further work-up for
abnormal heart rhythm was advised by EP. Initial ECG on
admission showed ST-elevation in V1, III, and aVF with j-point
depression in V2 and non-specific ST-T abnormalities. Cardiac
biomarkers peaked with troponinT peak of 1.51 and CK-MB 214 and
trended down with some component likely attributable to CPR and
electrical shock during resuscitation. Therapeutic hypothermia
was not initiated in the [**Hospital1 18**] emergency department as mental
status was not impaired. He was started on empiric treatment for
ACS including nitroglycerin infusion secondary to high systemic
hypertension in setting of alcohol withdrawal and underwent c.
cath showing one-vessel coronary artery disease with peaked
appearance of RCA suggestive of recent occlusion. There was no
intervention performed as there appeared to be collaterals to
PDA and right-sided vessels from LCx, the lesion appeared to be
acute-on-chronic with LCx-dominant anatomy, and RCA did not
supply a significant amount of myocardium at baseline LVEF > 55
%)
After extubation, patient reported several day history of chest
discomfort supporting likely possible ischemic etiology of
arrest.
Cardiac cath was complicated by left femoral groin site bleed
secondary to patient leg movement despite instructions. Pressure
was held for 20 minutes. Bedside US did not indicate
pseudoaneurysm. On discharge, there was a soft hematoma
measuring at least 2 cm x 2 cm around the area with no femoral
bruit.
The patient continued to report severe chest pain consistent
with MSK etiologies especially in setting of recent CPR with
serial ECGs and cardiac biomarkers not suggestive of acute
ischemic event. His pain was treated with oxycodone. CXR was not
suggestive of rib fractures.
He remained in NSR throughout hospitalization.
Labs indicated A1c 5.6 and cholesterol panel of total
cholesterol 182, TG 90, HDL 67, LDL 97.
He was discharged on aspirin 325 mg PO qD, atorvastatin 80 mg PO
qD, clopidogrel 75 mg PO qD, lisinopril 10 mg PO qD, and
metoprolol succinate 50 mg PO qD.
He will follow-up with cardiology after discharge for aggressive
medical optimization.
# Mild aortic stenosis
Patient endorses family history of aortic stenosis with possible
bicuspid valve in family member. C. cath indicated peak-to-peak
gradient of 30 mmHg suggestive of mild aortic stenosis.
He will follow-up with cardiology as above.
# Probable peripheral vascular disease
Patient reported symptoms of claudication and exam significant
for disparate pulses notably in femoral area. He will follow-up
with cardiology for further evaluation.
# Alcohol abuse with alcohol withdrawal and tobacco abuse
The patient was actively drinking about [**6-18**] drinks per day. It
is uncertain what "a drink" constitutes for the patient, so his
effective alcohol intake may be much higher than 6-8 days. He
was given a banana bag and nutritional supplementation in
addition to other supportive measures. He has had withdrawal
symptoms in the past without a history of seizures or DTs. He
also has concurrent substance abuse with marijuana. Urine tox
was negative for other substances such as cocaine. He was placed
on a CIWA scale and treated for withdrawal. He had not seizures
or adverse events related to alcohol withdrawal during
hospitalization. Social work was consulted and discussed
substance abuse. Patient plans to schedule outpatient evaluation
including mental health appointment for treatment of anxiety
symptoms.
# Transaminitis
Admission LFTs significant for ALT 45, AST 74 and CPK in [**2177**]
supporting a potential muscular etiology in setting of CPR and
electrical shocks. LFTs trended down to ALT 49, AST 60 with no
disturbances in synthetic markers such as Tbili or INR. Given
concurrent alcohol abuse, it is uncertain if another process
such as a primary liver process is contributing somewhat to
elevation. Repeat LFTs and CK are advised at PCP [**Last Name (NamePattern4) 702**].
He was discharged on a multivitamin, folate, and thiamine.
# Acute toxic-metabolic encephalopathy
The patient seemed to be inattentive. Occupational therapy
evaluation noted severe short term memory deficits, decreased
safety awareness, and issues with functional mobility and
balance. His function was below baseline level and required
verbal cues to be safe. [**Hospital 6266**] rehab secondary to
impulsiveness, cognitive impairments, and poor insight was
recommended. Exam was significant for positive romberg,
nystagmus, and ataxia. Given concern for Wernicke's
encephalopathy, neurology was consulted with impression of
subtle cerebellar deficits and mild ataxia on finger to nose.
These findings were thought to be due to combination of
pre-existing cerebellar atrophy secondary to alcohol abuse as
well as possible mild anoxic brain injury due to cardiac arrest.
It was also thought that the component of inattentiveness may be
secondary to resolving encephalopathy due to alcohol withdrawal.
Wernicke's encephalopathy was unlikely given that he lacked
ophthalmoplegia.
Overall, it was felt that the patient will likely improve over
time.
He should follow-up in the cognitive neurology clinic if
cognition remains problem[**Name (NI) 115**] in [**2-14**] weeks.
He was discharged home with 24-hour supervision by family.
CODE: full
COMM:
[**Name (NI) **] [**Telephone/Fax (1) 88645**], [**Name2 (NI) **]iend.
Father - HCP - [**Name (NI) 25368**] [**Name (NI) 88646**] - [**Telephone/Fax (1) 88647**], cell [**Telephone/Fax (1) 88648**].
Medications on Admission:
Prilosec
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 6 weeks.
Disp:*30 Patch 24 hr(s)* Refills:*2*
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total of 3 tablets as needed for
chest pain.
Disp:*25 tablets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Non ST Elevation Myocardial Infarction s/p cardiac arrest
Coronary Artery Disease
Peripheral Artery Disease
Aortic Stenosis
Alcohol Abuse
Tobacco abuse
Discharge Condition:
Mental Status: confused sometimes
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - gait unsteady, needs supervision
Discharge Instructions:
You had chest pain and collapsed in a bar. You were unresponsive
but it is unclear why. You were defibrillated and brought to [**Hospital6 84784**], then transferred to [**Hospital1 18**]. A cardiac
catheterization showed that you have blockages in your heart
arteries but they did not appear to cause your collapse. We did
not place any stents at this time. An Electrophysiology doctor
team saw you here and did not think that you need to have any
further workup for an irregular heart rhythm. You did have a
heart attack and we started many new medicines to help your
heart recover from the heart attack. It is very important that
you take these medicines every day and go to the scheduled
doctor's appointments. You also need to stop drinking and
smoking to prevent another similar incident and to help the
medicines work. A neurology team evaluated you and thought that
your forgetfulness and unsteadiness is due to your collapse and
possible lack of oxygen to your brain. They do not think that
more tests are necessary and they feel that you will improve
gradually.
.
Start taking the following medicines:
1. Aspirin 325 mg daily to prevent another heart attack
2. Plavix 75 mg daily to prevent another hear attack
3. Atorvastatin 80 mg daily to prevent further blockages in your
arteries.
4. Metoprolol 50 mg daily to slow your heart rate and prevent
another heart attack
5. Lisinopril 10 mg daily to lower your blood pressure
6. Nitroglycerin under your tongue as directed for chest pain
7. Folic acid 1 mg daily and thiamine 100 mg daily for
nutritional reasons as you were drinking heavily
8. Nicotine patch one daily to help you quit smoking.
Followup Instructions:
Primary care:
[**Hospital3 **] Primary Care
[**Street Address(2) 74742**]
[**Location (un) 5503**], [**Numeric Identifier 88649**]
Phone: ([**Telephone/Fax (1) 68439**]
Fax: ([**Telephone/Fax (1) 88650**]
The office will call you with an appt for next week
Department: CARDIAC SERVICES
When: THURSDAY [**2188-6-5**] at 11:40 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
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"41071",
"41401",
"4280",
"4241",
"4019",
"3051"
] |
Admission Date: [**2195-5-1**] Discharge Date: [**2195-5-11**]
Service: [**Hospital1 3253**] MED
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a [**Age over 90 **] year old
female with severe aortic stenosis who was straining on the
toilet yesterday for several hours. She had some chest
discomfort, took a Nitroglycerin and later was found by her
home health aide passed out on the toilet. The patient was
brought to [**Hospital1 69**] after
regaining consciousness.
In the Emergency Department, the patient was found with
melanotic stool by the resident, taken by GI for EGD, which
showed gastritis but no reason for bleed. Also had some
melanotic stool in the GI Suite.
She has chronic abdominal pain; has had constipation for the
past week without bowel movement.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.625 q. day.
2. Imdur 60 q. day.
3. Amiodarone 200 twice a day.
4. Lactulose p.r.n.
5. Colace 100 twice a day.
6. Multivitamin q. day.
7. Lasix 40 q. day.
8. Amaryl 1 q. day.
ALLERGIES: Include penicillin.
PAST MEDICAL HISTORY:
1. Aortic stenosis; valve area is 0.6. Left ventricular
ejection fraction of 80%. The patient refuses surgery.
2. Type 2 diabetes mellitus.
3. Atrial fibrillation.
4. Osteoporosis.
5. Bilateral cataracts.
SOCIAL HISTORY: Lives at home with a Home Health Aide. No
tobacco, no alcohol.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission, temperature 97.4 F.;
heart rate 76; blood pressure 114/40; respiratory rate 25; O2
saturation 100% on two liters nasal cannula. In general, she
was in no acute distress. HEENT: Unremarkable. Chest clear
to auscultation bilaterally. Coronary: III/VI systolic
ejection murmur. Abdomen had decreased bowel sounds, soft,
nontender, melanotic stool on rectal examination.
Extremities two plus bilateral lower extremity edema.
Neurologic was nonfocal.
LABORATORY: On admission included a white count of 24.8,
hematocrit of 29.3, down from 37.5 on initial admission to
the Emergency Department. Platelets are 446. Chem-7:
Sodium 138, potassium 4.8, chloride 99, bicarbonate 29, BUN
42, creatinine 1.4, glucose 293.
Head CT scan in the Emergency Room showed no hemorrhage, no
acute changes.
Chest x-ray showed no acute cardiac or pulmonary process.
Abdominal x-ray showed that the patient was status post left
open reduction and internal fixation. No acute changes.
HOSPITAL COURSE: The patient was admitted to the Floor for
management of presumed lower GI bleed given the negative EGD.
1. Gastrointestinal: The patient was initially transferred
to the Medical Intensive Care Unit where she was transfused a
total of four units during the course of her first 48 hours
in-house. The plan was to get the patient prepped for a
colonoscopy but this proved to be difficult as the patient
refused the prep on the first day. On the second day, she
agreed to it but only with magnesium citrate. She was
finally prepped by hospital day three and taken to the GI
Suite.
When colonoscopy was ultimately done, it revealed blood in
the entire colon, diverticulosis in the entire colon and the
entire colon was visualized except the cecal cap but no
evidence for source of the GI bleed could be found. As such,
a bleeding scan was recommended.
The patient was approached with these results and told that
she needed a bleeding scan, however, the patient refused this
test. Therefore, she was watched overnight. The night
following her colonoscopy, her hematocrit had dropped
approximately a point. She then agreed to the bleeding scan
at that time. She was taken for a bleeding scan on hospital
day four, which showed no acute evidence of bleeding.
Following this, the recommendation of the GI Team was to have
a small bowel follow through to rule out significant small
bowel pathology. The patient, however, flat out refused this
test. Because of this, we simply monitored her hematocrit
for the remaining time in-house.
Her hematocrit remained essentially stable although it had
drifted down approximately a half to one point a day, down to
28.5 on the day of discharge. Because of this, she was given
one final unit of blood and will be discharged out with
instructions to see her primary care physician regularly, to
have her hematocrit checked, and to watch her stools for
evidence of melena, given the fact that no source of this
bleed was ever found.
2. Cardiovascular: The patient's initial syncopal event was
almost certainly due to the fact that she took a
Nitroglycerin with a stenotic aortic valve area of 0.6.
In-house we wrote strict orders for the patient to have no
Nitroglycerin if she developed chest pain. She had no
further evidence of syncope or lightheadedness.
3. Infectious Disease: In the hospital, her urine came back
dirty, with evidence for a urinary tract infection. She was
started on Ciprofloxacin for seven days.
4. Hypokalemia: The patient's potassium was low at several
points during her hospital stay. It was repleted. The day
of discharge, it had been stable for several days.
5. DISPOSITION: The patient was safe for discharge [**Last Name (LF) 2974**],
[**5-8**], however, she refused to leave saying that there was
no one at home. Her attending approached her regarding this
and the house staff approached her and the nursing staff.
She simple flat out refused. It was decided to allow her to
stay until Monday when she said her home health aide would be
available at home. She also was seen by Physical Therapy and
they recommended a short course of rehabilitation but she
refused to go to any rehabilitation facility.
As such, we are discharging her on Monday, the 13th, to home.
She will have [**Hospital6 407**] follow-up and home
Physical Therapy evaluation.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To home with services.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed.
2. Anemia.
3. Cystitis.
4. Hypokalemia.
DISCHARGE INSTRUCTIONS:
1. Follow-up will be with the patient's primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**].
DISCHARGE MEDICATIONS: Unchanged from admission.
1. Digoxin 0.625 q. day.
2. Imdur 60 q. day.
3. Amiodarone 200 twice a day.
4. Lactulose p.r.n.
5. Colace 100 twice a day.
6. Multivitamin q. day.
7. Lasix 40 q. day.
8. Amaryl 1 q. day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**]
Dictated By:[**Last Name (NamePattern1) 1213**]
MEDQUIST36
D: [**2195-5-11**] 08:05
T: [**2195-5-11**] 13:15
JOB#: [**Job Number 107763**]
|
[
"42731",
"4241",
"4280"
] |
Admission Date: [**2100-9-5**] Discharge Date: [**2100-9-22**]
Date of Birth: [**2019-7-19**] Sex: M
Service: MEDICINE
Allergies:
Tetanus&Diphtheria Toxoid / Amoxicillin / Vicodin / Levaquin
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
right colon cancer
Major Surgical or Invasive Procedure:
[**2100-9-5**] open R colectomy
History of Present Illness:
Mr. [**Known lastname 103570**] is an 81 y/o M w/h/o renal transplant, 5-vessel
CABG, AAA repair, sigmoid colectomy, anemia, DVT/PE on coumadin
who p/w fungating circumferential non-bleeding 5 cm mass of
malignant appearance in the hepatic flexure noted on colonscopy
[**6-/2100**] for R open colectomy tomorrow. He currently notes no
symptoms from his colon cancer, no abd pain, no change in bowel
habits, no hematochezia, no melena. He had a CT torso in w/u
showing no metastatic disease, but a thyroid nodule which, on
u/s was shown to be a simple cyst. He does, however note chronic
leg swelling, and over the last 6 months to a year has noted
worsening fatigue on excertion, currently he is able to walk 40
feet without fatigue. He had a nuclear stress test in [**3-12**]
showing a fixed, severe perfusion defect in mid and basal
inferior wall and basal inferoseptum, and
basal inferior wall hypokinesis with normal systolic function.
He has a note from Dr. [**Last Name (STitle) **] stating that he should be
lovenox bridged post op. He stopped his coumadin 6 days ago.
His baseline creatinine is 1.1. He has a note from Dr. [**Last Name (STitle) **]
advising NS at 100cc/hr preoperatively. Of note he has two skin
cancers (basal cell) that were removed from his legs in [**Month (only) **]
and [**Month (only) 596**] which are not healing. He has daily dressing changes
with antibiotic ointment per his dermatologist.
Past Medical History:
PMH:
Hypertension
Hyperlipidemia
Coronary Artery Disease
Hiatal hernia per wife
gout
h/o DVT, PE (on coumadin)
Hemorrhoids
PSH:
renal transplant [**2077**]
h/o diverticulitis s/p sigmoid colectomy [**2087**]
CABG [**2086**] ([**Doctor Last Name 14714**])
EVAR [**3-/2092**] ([**Doctor Last Name **])
Revision of aortic stent graft [**1-/2096**] ([**Doctor Last Name **])
Social History:
Nonsmoker. Occassional drinker. He used to be employed by the
utility company but is currently retired. Mr. [**Known lastname 103570**] lives
with his wife- no home services.
Family History:
Noncontributory.
Physical Exam:
On admissioN:
Vitals: T:97.7 HR:59 BP:141/73 RR:20 Sat:100%RA
Gen: NAD
HEENT: NC/AT
CV: RRR, no m,r,g
Resp: CTA, old well healed median sternotomy
Abd: S, NT/ND, multiple well healed abdominal incisions
Ext: 2+ edema b/l LE, nonhealing wounds with fibrinous base on
both R and L anterior legs.
Pertinent Results:
[**2100-9-5**] 03:00PM WBC-7.7 RBC-3.83* HGB-8.3* HCT-27.5* MCV-72*
MCH-21.8* MCHC-30.3* RDW-19.0*
[**2100-9-5**] 03:00PM GLUCOSE-156* UREA N-21* CREAT-0.9 SODIUM-141
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-20* ANION GAP-17
[**2100-9-5**] 03:00PM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-1.9
[**2100-9-8**] 04:42AM BLOOD WBC-13.5* RBC-3.92* Hgb-9.6* Hct-29.3*
MCV-75* MCH-24.6* MCHC-32.9 RDW-20.4* Plt Ct-132*
[**2100-9-8**] 04:42AM BLOOD Neuts-65 Bands-30* Lymphs-3* Monos-0
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**9-7**] CXR: FINDINGS: As compared to the previous radiograph, the
monitoring and support devices are in unchanged position. There
are newly developed bilateral mild-to-moderate pleural effusions
with subsequent atelectasis. However, the signs indicative of
pulmonary edema have slightly improved. Unchanged size of the
cardiac silhouette
[**9-8**] CT head:
FINDINGS: Evaluation is limited by streak artifact from
overlying wires.
There is no extra-axial collection, intracranial hemorrhage, or
mass effect. Streak artifact passes through the region of the
left central sulcus. There is subtle hypodensity in the left
caudate, as well as basal ganglia and insular ribbon(series 2;
images 14-17). There is mild prominence of the extra-axial
spaces consistent with atrophy, with a predominantly frontal
distribution. The ventricles are slightly enlarged likely the
result of atrophy.
The orbits are unremarkable. The visualized soft tissues are
normal.
Incidental note is made of a lipoma along the anterior falx. The
visualized paranasal sinuses demonstrate minimal mucosal
thickening of the right maxillary sinus as well as several
ethmoid air cells, the remainder are clear.
IMPRESSION: Hypodensity in the region of the left thalamus, and
insular
ribbon. If clinically indicated, this might be further evaluated
with MRI to exclude stroke.
[**9-9**] Echo:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%) secondary to inferior hypokinesis and posterior
dyskinesis; the other walls are hyperdynamic. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility. The
aortic root is mildly 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. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**9-9**] CT chest:
FINDINGS: The airways are patent to the segmental level. In the
right lobe
of the thyroid gland a hypodense lesion measuring aprox. 29x24
mm is
unchanged. Patient is status post CABG. Native coronary arteries
have dense calcifications. Hypodensity of the cardiac [**Doctor Last Name 1754**]
compared to the myocardium suggests anemia. There is no
pericardial effusion. Mild-to-moderate bilateral pleural
effusions are increasing from [**9-6**]. Mediastinal lymph nodes
are unchanged. The ascending aorta measures AP 44 mm was 41 mm
in [**Month (only) 205**], the descending and visualized portion of the proximal
abdominal aorta show dense wall ateromatous calcifications, and
probably stable focal mural thrombus at the level of the
diaphragm. Abdominal aorta aneurism is incomplety imaged.
Right central line tip is in mid to lower SVC. There is large
bibasilar
atelectasis in lower lobes bilaterally and in the right middle
lobe, which is almost collapsed.
The aorta is very tortuous and has extensive diffuse
atherosclerotic plaques.
This examination is not tailored for subdiaphragmatic
evaluation. There are gallstones. The kidneys are atrophic with
a hypodense exophytic lesion from the left upper pole kidney
unchanged from study. The pancreas is atrophic. The adrenal
glands are normal. Hypodense lesion in the left lobe of the
liver is barely visualized.
There are no bone findings of malignancy. There are stable
sclerotic changes in the vertebral body of T9.
IMPRESSION: Bilateral pleural effusions associated with large
bibasilar
atelectasis and almost collapse of the right middle lobe. No
evidence of CHF or pneumothorax.
Lesion in the right lobe of the thyroid gland. If ultrasound has
not been
performed, it is recommended for further evaluation.
1-cm lesion in the left kidney is unchanged.
.
[**9-15**] Hand:
IMPRESSION:
1. Findings concerning for osteomyelitis in the carpus, proximal
radiocarpal
joint and distal radioulnar joint as questioned. Further
evaluation with
arthrocentesis may be helpful.
2. Degenerative changes as above.
.
[**9-15**] Renal ultrasound:
IMPRESSION:
1. Patent vasculature with resistive indices in the upper, mid
and lower pole of the transplant kidney ranging from 0.74 to
0.83 somewhat increased from [**2092**].
2. No hydronephrosis or perinephric fluid collection.
.
[**9-16**] CXR:
FINDINGS: In comparison with the study of [**9-9**], there are low
lung volumes in
this patient with intact midline sternal wires. Left subclavian
catheter
extends to about the lower SVC or cavoatrial junction. The
hemidiaphragms are now sharply seen, with mild atelectatic
changes at the bases. No evidence of acute focal pneumonia.
...
LABS ON DISCHARGE:
[**2100-9-22**] 09:45AM BLOOD WBC-9.0 RBC-3.29* Hgb-7.9* Hct-25.6*
MCV-78* MCH-24.1* MCHC-30.9* RDW-21.5* Plt Ct-498*
[**2100-9-15**] 06:03AM BLOOD Neuts-78* Bands-1 Lymphs-10* Monos-5
Eos-3 Baso-1 Atyps-0 Metas-2* Myelos-0
[**2100-9-22**] 09:45AM BLOOD PT-18.7* PTT-31.7 INR(PT)-1.7*
[**2100-9-22**] 09:45AM BLOOD Glucose-82 UreaN-40* Creat-1.7* Na-138
K-4.1 Cl-105 HCO3-23 AnGap-14
[**2100-9-22**] 09:45AM BLOOD Calcium-8.6 Mg-1.9
[**2100-9-17**] 04:30AM BLOOD CRP-140.8*
Brief Hospital Course:
81 yo M with hypertension, CAD s/p CABG, prior DVT/PE, prior
renal transplant (due to polycystic kidney disease) and prior
AAA repair admitted for right hemicolectomy for colon cancer
with complications of hypoxia, A Fib, altered mental status as
well as left wrist pseudogout.
.
The patient was admitted for right hemicolectomy for colon
cancer. Pre-op he received FFP and 2 units PRBC's for an
elevated INR and chronic anemia. He underwent the procedure on
[**2100-9-6**]. With conservative management he had return of bowel
function and his diet was slowly advanced. At the time of
discharge he was tolerating a normal diet. Most of his staples
were removed at the time of discharge but a few were left in.
He will need to follow-up with Dr. [**Last Name (STitle) 1120**] within two weeks of
discharge. This was explained to the patient.
.
Post-operatively, the patient developed acute hypoxia. This was
felt to be multifactorial - from a component of fluid overload
(he was several liters positive during and after surgery),
probable hospital acquired aspiration pneumonia (with new
bandemia and fever) and compressive atelectasis. The patient was
transferred to the ICU, started on a lasix drip and empiric
Vanc/Cefepime. He clinically improved. At the time of
discharge, he was euvolemic and had excellent oxygen saturations
on room air. He completed an 8-day course of Vancomycin and
Cefepime on [**2100-9-17**].
.
On transfer to the ICU, the patient was hypotensive. He
transiently required pressor support. He then developed rapid a
fib. He was started on a diltiazem drip and transitioned to oral
diltiazem with good rate control but intermittent a fib/flutter.
He was started on a heparin drip as a bridge to coumadin. His
diltiazem was slowly converted to a beta blocker given his
history of coronary artery disease as well as some runs of
nonsustained ventricular tachycardia noted on telemetry. His
heart rate was well controlled on the beta blocker. Of note,
his rhythm was predominantly atrial flutter. He was discharged
on Toprol XL of 200 mg daily, an increased dose compared to his
beta blocker on admission.
.
The patient did have new findings on echocardiogram of posterior
LV dyskinesia but negative cardiac enzymes and he was felt NOT
to have suffered any ischemic cardiac injury.
.
The patient developed profound altered mental status while in
the ICU. A head CT found possible hypodensity in the left
thalamus. With conservative therapy and limiting of sedating
medications, the patient's mental status returned to [**Location 213**] and
he had no apparent neurologic deficits. The CT scan finding was
not further worked up as it was unlikely to change management.
He may need a MRI of his head in the future. His mental status
was at his baseline at the time of discharge.
.
The patient developed acute onset left wrist pain on [**2100-9-14**].
Rheumatology was consulted and his wrist was tapped. This
revealed CPPD crystals. The white count was borderline however,
and as such orthopedic hand surgery took the patient for a wash
out. Cultures were followed carefully and these were no growth.
Infectious diesease was consulted and they agreed that
antibiotics were not warranted. Once the cultures were
negative, he was started on a brief prednisone taper. At the
time of discharge, he was not having any left wrist pain. He
has sutures in place that will need to be removed by the hand
surgery team. He will need to follow-up with them on Tuesday
[**9-28**]. The number for their clinic was given to him and
the need to follow-up was explained.
.
The patient has a history of renal transplant due to
complications of polycystic kidney disease. He was followed
throughout his hospitalization by the nephrology consult
service. He was continued on immunosuppressives throughout his
course. His creatinine did increase to 1.6 two days after his
foley catheter was discontinued. It was possible that he has a
component of post-obstructive renal failure. Creatinine improved
to 1.4, then worsened to 1.6. Renal felt as though pt may be
intravascularly dry and recommended a fluid bolus as well as
checking cyclosporine levels. Despite several fluid challenges,
his creatinine remained between 1.6 and 1.7. His outpatient
nephrologist, Dr. [**Last Name (STitle) **] was consulted. He preferred to not
pursue any further diagnostic procedures and recommended
watchful waiting. He was fine with the patient being
discharged. He recommended that Mr. [**Known lastname 103570**] receive feraheme
prior to discharge and be set-up to have a repeat injection on
Monday [**9-27**]. He planned on seeing the patient at that
visit, having repeat labs and managing his renal function from
there. His ACE-I was held during his hospitalization and was
NOT restarted on discharge. This should be discussed at the
time of his renal follow-up. He was instructed to continue his
immunosuppressants including prednisone at 5 mg daily until he
sees Dr. [**Last Name (STitle) **]. Of note, his foley catheter was removed
prior to discharge with a post-void residual of only 40 cc.
.
For his iron deficiency anemia, he received one dose of IV
ferrlecit and one dose of feraheme. He is [**Last Name (STitle) 1988**] to receive
another injection of feraheme.
.
For his colon cancer, he will follow-up as an outpatient for
ongoing care.
.
The patient has a history of HTN, CAD, DVT/PE on coumadin,
chronic anemia and AAA repair. These issues were stable
throughout his hospitalization.
.
Incidental: CT chest on [**2100-9-9**] showed a lesion in the right
lobe of the thyroid gland. If ultrasound has not been performed,
it was recommended for further evaluation.
***
TRANSITIONAL ISSUES:
- thyroid ultrasound if not performed in past
- consideration of head MRI if clinically warranted
- consideration of restarting ACE-inhibitor
- follow-up of his creatinine
Medications on Admission:
Azathioprine 25', Cyclosporine 100', Fluticasone 50mcg 1-2 puffs
nasal daily, Folic Acid 1', Metoprolol 25'',Mupirocin 2% to
wound daily, Nitroglycerin 0.4 PRN, Ramipril 2.5', Ranitidine
150'', triamcinolone 0.1% to wound daily, Warfarin 5', ASA 81'
Discharge Medications:
1. azathioprine 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. cyclosporine 100 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: please take 1.5 pills on [**9-22**] and [**9-23**], have your INR
checked on [**9-24**] and then follow instructions from your primary
care doctor.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Itch.
7. prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
take four tablets on [**9-23**], then take two tablets on [**9-24**] and
[**9-25**] and then take 5 mg daily until you see your kidney doctor.
[**Last Name (Titles) **]:*40 Tablet(s)* Refills:*0*
8. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
[**Last Name (Titles) **]:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Outpatient Lab Work
Check INR, PTT, basic metabolic panel on [**2100-9-24**] and send
results to pt's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7790**] at [**Telephone/Fax (1) 6443**] (fax number).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Colon cancer s/p right hemicolectomy
Hypoxia due to fluid overload, hospital-acquired aspiration
pneumonia and compressive atelectasis
A Fib
Altered mental status
Hypertension
CAD
DVT/PE, in the past
AAA
Anemia
Prior renal transplant
Pseudogout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for surgery to remove colon cancer.
You suffered several complications including atrial flutter and
fibrillation, pneumonia, left wrist pseudogout. You were started
on prednisone with improvement in your wrist symptoms. You
should take 20 mg through [**2100-9-23**] and then 10 mg from [**9-24**]
through [**9-25**] and then 5 mg daily. You should discuss this dose
with your nephrologist when you see him on [**2100-9-27**].
Your kidney suffered some damage during your hospitalization.
It is crucial that you follow-up with your kidney doctor. At
that time, please confirm with him your medications.
Specifically, please confirm with him your prednisone dose.
Finally, we recommended that you have skilled nursing placement
for more intensive physical therapy. However you refused. You
stated understanding the risks of leaving deconditioned, which
includes fall, hip fracture and death.
You need to follow-up with the doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
Additionally, you should follow-up with the hand surgery service
next week. Please call to schedule. You also need to call to
schedule your general surgery follow-up within the next two
weeks to get the remainder of your staples removed.
***
MEDICATION CHANGES:
- take 7.5 mg of coumadin daily, have INR checked [**9-24**] and then
follow instructions from your primary care doctor
- stop taking metoprolol 25 mg twice daily and START Toprol XL
200 mg daily
- stop Ramipril until otherwise instructed by your doctors
Followup Instructions:
Please call Dr.[**Name (NI) 3377**] office to schedule follow-up within two
weeks of discharge. Her number is [**Telephone/Fax (1) 160**].
Please call the Hand surgery office at [**Telephone/Fax (1) 3009**] to schedule
follow-up for Tuesday [**2100-9-28**] to have your staples
removed.
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: WEDNESDAY [**2100-9-29**] at 10:10 PM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Infusion/[**Hospital **] Clinic
[**2100-9-27**] at 11:15 AM. However, please arrive 30 minutes
in advance to be seen by your nephrologist.
[**Location (un) 830**]
[**Hospital Ward Name 2104**] [**Location (un) 442**]
[**Location (un) 86**], [**Telephone/Fax (1) 103571**]
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2100-10-5**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: Cardiology
Name: Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]
When: Wednesday [**2100-10-20**] at 2 PM
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
|
[
"5070",
"5849",
"5119",
"5180",
"9971",
"4019",
"V4581"
] |
Admission Date: [**2129-12-12**] Discharge Date: [**2130-1-2**]
Service: CARDIAC
HISTORY OF PRESENT ILLNESS: This is a 78-year-old patient
referred for an outpatient cardiac catheterization due to
anginal symptoms and a recent abnormal exercise tolerance
test.
PAST MEDICAL HISTORY: Hypertension. Cigarette smoking.
Mildly elevated glucose levels which have been diet
controlled. History of prostate cancer. Peripheral vascular
disease. He is status post prostatectomy, status post
appendectomy, and status post hernia repair.
ALLERGIES: THE PATIENT STATED AN ALLERGY TO PENICILLIN, BUT
NO OTHER DRUG ALLERGIES REPORTED.
PHYSICAL EXAMINATION: Vital signs: Normal sinus rhythm,
rate of 53, blood pressure 126/68. Lungs: Clear to
auscultation. Heart: Sounds were normal. Extremities: All
peripheral pulses were palpable.
MEDICATIONS ON ADMISSION: Imdur 60 mg p.o. q.d., Atenolol 25
mg p.o. b.i.d., Norvasc 5 mg p.o. b.i.d., Plavix 75 mg p.o.
q.d.
HOSPITAL COURSE: The patient was taken to the Cardiac
Catheterization Lab on [**2129-12-12**]. Catheterization
revealed a left ventricular ejection fraction of 65%, 90%
left main coronary artery disease with three-vessel disease.
An intra-aortic balloon was placed due to a significant left
main disease, and the patient was admitted to the Cardiac
Care Unit.
On [**2129-12-13**], the patient was taken to the Operating
Room where he underwent coronary artery bypass grafting times
four which included LIMA to the left anterior descending,
saphenous vein to the right posterior descending artery,
saphenous vein to the OM, saphenous vein to the diagonal, and
saphenous vein to the distal left anterior descending.
The patient had a prolonged operative time. Please see
operative report for full details of surgical procedure and
events in the operating room.
Postoperatively the patient was transported to the Cardiac
Surgery Recovery Unit on Dobutamine, Neo-Synephrine drip, and
intra-aortic balloon pump. The Dobutamine was quickly weaned
off. The Neo-Synephrine had started to be weaned. The
patient was weaned from mechanical ventilator and extubated
on postoperative day #1.
Over the next few days, the patient remained in the Intensive
Care Unit due to respiratory issues. He had fluid overload
complicated by significant wheezes and some hypoxia. This
was treated with diuretics and bronchodilators over the next
few days. The patient also had some episodes of rapid atrial
fibrillation. He was placed on Amiodarone for this.
Lopressor was not begun initially due to wheezes but was
started later during his hospital course. The patient's
Swan-Ganz catheter and chest tubes were removed on
postoperative day #2; however, he remained in the Intensive
Care Unit for pulmonary toilet.
On postoperative day #3 and postoperative day #4, the patient
remained hemodynamically stable. Low-dose Lopressor was
initiated. His Amiodarone was switched to oral, and the
patient's respiratory status had improved significantly with
bronchodilators, diuresis and pulmonary toilet.
On postoperative day #6, the patient remained stable from
hemodynamic and respiratory standpoint. He was subsequently
transferred to the Telemetry Floor. The patient remained
hemodynamically in normal sinus rhythm on Amiodarone and
Lopressor with no further episodes of atrial fibrillation.
Pulmonary toilet was continued with bronchodilators.
The patient had been started on low-dose Coumadin due to
postoperative atrial fibrillation. On [**12-23**],
postoperative day #11, the patient was noted to have
serosanguinous sternal drainage from the distal part of the
incision which had increased significantly over approximately
a 24-hour period.
Since the patient had received some Coumadin postoperatively,
his INR was elevated. It was planned to take the patient to
the Operating Room for a sternal rewiring; however, his INR
was 3.2 at the time. Therefore, on [**12-23**], the patient
was treated with some Vitamin K.
On the following day, Plastic Surgery consultation was
obtained. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13797**] saw the patient, and
recommended muscle flap to be done concurrent with his
sternal debridement; however, the patient's remained with an
elevated INR and was treated with Vitamin K.
On[**2129-12-25**], the patient was taken to the Operating
Room for sternal debridement and a right rectus flap closure
done by Drs. [**Last Name (Prefixes) **], [**Doctor Last Name 21815**], and [**Doctor Last Name 13797**].
Postoperatively the patient remained intubated initially and
was transported to the Cardiac Surgery Recovery Unit where he
was subsequently weaned from mechanical ventilator and
extubated. The patient was started on Vancomycin. The
Vancomycin was given empirically since there had not been any
positive cultures.
The patient was again transferred from the Cardiac Surgery
Recovery Unit to the Telemetry Floor on postoperative day #2
from his sternal debridement and rectus flap. The patient
remained hemodynamically stable in normal sinus rhythm and
was not anticoagulated further due to the patient remaining
in normal sinus rhythm with no more episodes of atrial
fibrillation.
Over the next few days, the patient remained stable on the
Telemetry Floor. [**Location (un) 1661**]-[**Location (un) 1662**] drains were in place. He had
a brief episode of hypotension on [**12-28**] which responded
to intravenous fluid bolus. He did not have any problems
with hypotension since that time. The patient had stable
blood pressure in the 120s systolic. He has been ambulatory.
He had a PICC line placed in the Interventional Radiology
Department to continue his Vancomycin upon discharge.
Today the patient remains stable, and he is ready to be
discharged in good condition to a rehabilitation facility.
The patient also had a couple of brief episodes of
disorientation over night about [**12-29**] and 3, which
required a sitter because he was trying to ambulate
independently and felt to be unsteady on his feet. This has
resolved. He has had no further use of sitters and has been
ambulating appropriately with some assistance.
CONDITION ON DISCHARGE: Vital signs: Temperature 98.6??????,
blood pressure 110/60, heart rate 78, normal sinus rhythm,
respirations 18, oxygen saturation 95% on room air.
Neurological: Intact. Cardiac: Within normal limits.
Regular, rate and rhythm. Lungs: Clear to auscultation
bilaterally. Chest: The patient's sternal showed evidence
of a small amount of serosanguinous drainage at the inferior
aspect of the wound. A staple was removed by the Plastic
Surgery Service, and dry packings have been applied.
DISCHARGE LABORATORY DATA: Most recent values from [**2129-12-29**], revealed a white blood cell count of 5.4, hematocrit
29.5, platelet count 372; sodium 137, potassium 4.2, chloride
101, CO2 29, BUN 20, creatinine 0.9, glucose 193.
DISCHARGE MEDICATIONS: Aspirin enteric coated 325 mg p.o.
q.d., Colace 100 mg p.o. b.i.d., Amiodarone 200 mg p.o. q.d.,
Vancomycin 1 g IV q.12 hours, this is to continue through
[**2130-1-10**], when it can [**Doctor First Name **] discontinued, Tylenol with
Codeine #3 1 tab p.o. q.4 hours p.r.n. pain, Metoprolol 50 mg
p.o. b.i.d., this should be held for heart rate less than 60
or systolic blood pressure less than 100.
DISCHARGE INSTRUCTIONS: The patient should be on a diabetic
diet. He has had fingersticks checked regularly and has been
below 120 for a least the past 2-3 days initially in the
Intensive Care Unit. He had required some sliding scale
Insulin coverage, but this has not been significant for the
past couple of days. The patient remains with [**Location (un) 1661**]-[**Location (un) 1662**]
drains. Once the drains are draining less than 20 cc/day,
they are ready to be removed. He needs to follow-up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13797**], office number [**Telephone/Fax (1) 19606**]. His office
should be called for follow-up within 1-2 weeks or if at any
time the total [**Location (un) 1661**]-[**Location (un) 1662**] output is less than 20 cc/day.
His office can be called for an appointment to be scheduled
for drain removal. The patient should also follow-up with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], [**Telephone/Fax (1) 170**], for postoperative check at
approximately six weeks after his surgery. Dr.[**Name (NI) 27686**]
office should be called for any questions related to his
cardiac Surgery. The patient should also follow-up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], upon discharge
from the rehabilitation facility.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2130-1-2**] 10:58
T: [**2130-1-2**] 13:15
JOB#: [**Job Number 46669**]
|
[
"41401",
"9971",
"42731",
"4019",
"25000",
"2720"
] |
Admission Date: [**2118-7-26**] Discharge Date: [**2118-8-1**]
Date of Birth: [**2051-9-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Recurrent chest pain
Major Surgical or Invasive Procedure:
[**2118-7-26**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending
with vein grafts to obtuse marginal and posterior descending
artery.
History of Present Illness:
This is a 66 year old gentleman with a fairly extensive cardiac
history beginning in [**2094**] which has included five stents. He
underwent his most recent stent in [**2117-9-15**] which was a drug
eluting stent to his circumflex artery. He did well with this up
until the past month when he began to develop recurrent episodes
of his typical angina. He underwent a cardiac catheterization
last week whcih revealed severe two vessel disease. Given the
severity of his disease and his inset of symptoms, he has been
referred for surgical revascularization.
Past Medical History:
CAD, s/p IMI and multiple stents
CVA in [**2102**] without residual deficits
TIA in [**2102**]
Insulin dependent diabetes mellitus
Hypertension
Hyperlipidemia
Bell ??????s palsy in [**2106**]
Anemia, s/p rectal bleeding from hemorrhoids, s/p transfusions
(last episode 4 years ago)
[**Doctor Last Name 15532**]??????s esophagus
GERD
History of NSVT
Systolic murmur
Arthritis
obesity
Past Surgical History :
S/P right ankle fracture
Hemorroidectomy x 2
S/P cyst removal from elbow
S/P left knee arthroscopy
Blepharoplasty
Cataract Surgery
Social History:
Occupation: owns pawn shop
Last Dental Exam: Full dentures.
Lives with: wife
[**Name (NI) **]: Caucasian
Tobacco: 30pack year hx. Quit 35 years ago.
ETOH: 4 drinks per month
Family History:
Brother died of MI at age 62.
Physical Exam:
Pulse: 56 SB Resp: 16 O2 sat: 97
B/P Right: 138/84 Left: 134/84
Height: 70" Weight: 265#
General: Well developed, well nourished male in NAD
Skin: Dry [X] intact [X] no C/C
HEENT: PERRLA [X] EOMI [X], anicteric sclera, OP benign
Neck: Supple [X] Full ROM [X] no JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR Nl S1-S2, No M/R/G
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X] obese. Negative [**Doctor Last Name **] sign.
Extremities: Warm [X], well-perfused [X] Trace Edema
Varicosities: Some anterior varicosities noted. GSV appears
suitable.
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left:2
DP Right: 1 Left:1
PT [**Name (NI) 167**]: 1 Left:1
Radial Right: 2 Left:2
Carotid Bruit Right: ?Faint Left: None
Pertinent Results:
[**2118-7-26**] Intraop TEE:
Prebypass: No atrial septal defect is seen by 2D or color
Doppler. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
Post bypass: Patient is A paced and receiving an infusion of
phenylephrine. Biventricular systolic function is unchanged.
Trivial mitral regurgitation present. Aorta is intact post
decannulation.
[**2118-7-26**] 11:37AM BLOOD WBC-11.0# RBC-2.85*# Hgb-8.6*# Hct-24.9*#
MCV-87 MCH-30.1 MCHC-34.5 RDW-15.0 Plt Ct-106*
[**2118-7-29**] 06:05AM BLOOD WBC-12.3* RBC-3.39* Hgb-9.8* Hct-29.5*
MCV-87 MCH-28.9 MCHC-33.2 RDW-15.6* Plt Ct-123*
[**2118-7-26**] 11:37AM BLOOD PT-14.8* PTT-31.1 INR(PT)-1.3*
[**2118-7-26**] 12:54PM BLOOD PT-14.3* PTT-31.2 INR(PT)-1.2*
[**2118-7-29**] 06:05AM BLOOD Glucose-174* UreaN-30* Creat-1.1 Na-140
K-4.4 Cl-101 HCO3-29 AnGap-14
[**2118-7-27**] 03:08AM BLOOD Glucose-105 UreaN-19 Creat-1.1 Na-139
K-4.7 Cl-107 HCO3-26 AnGap-11
Brief Hospital Course:
[**7-26**] Mr. [**Known lastname **] was taken to the operating room and underwent
coronary artery bypass grafting x3(Left internal Mammary Artery
grafted to the left anterior descending artery/Saphenous vein
grafted to the Obtuse Marginal artery/Posterior descending
artery) by Dr. [**Last Name (STitle) **]. Cross clamp time= 53 minutes,
Cardiopulmonary Bypass time= 71 minutes. Please see Dr[**Last Name (STitle) **]
operative note for further surgical details. He tolerated the
procedure well and was transferred to the CVICU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated without complication. All lines and drains were
discontinued in a timely fashion. Beta-blocker, aspirin, statin
and diuresis was initiated. He maintained good hemodynamics and
transferred to the step down unit on postoperative day one.
Physical therapy was consulted for evaluation.POD#2 his rhythm
went into rapid atrial fibrillation with a rate in the 150s. He
was treated with Amiodarone and increased Beta-blockade. He
converted to sinus rhythm and than over the next day went back
into rate controlled atrial fibrillation. POD#3 Anticoagulation
was started with Coumadin. Empiric antibiotics was started for
an elevated white blood cell count, urine culture was negative
and Cipro was discontinued. Mr.[**Known lastname **] failed to void and a
foley was reinserted and Flomax was started. He continued to
progress and was cleared for discharge to home with VNA by
Dr.[**Last Name (STitle) **] on POD #6. He was set up with coumadin follow-up by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on the day of discharge. All follow up
appointments were advised.
Medications on Admission:
celebrex 200 mg daily
clonidine 0.2 mg [**Hospital1 **]
plavix 75 mg daily - last dose 5 days prior to OR date
cartia XT 120 mg daily
HCTZ 25 mg daily
isosorbide mononitrate SR 120 mg daily
losartan 75 mg [**Hospital1 **]
toprol XL 100 mg daily
protonix 40 mg daily
crestor 40 mg daily
ASA 325 mg daily
regular insulin SS QACHS
Humulin N 30 units qAM, 20 units qPM
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
take 400mg (two 200mg tablets) [**Hospital1 **] for one week, then 400mg
daily for one week, and then decrease to 200mg.
Disp:*120 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
INR to be drawn on [**2118-8-3**] with results sent to the [**Company 191**]
anticoagulation office. INR goal for Afib [**1-18**].
7. Losartan 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. 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*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty
(30) units Subcutaneous QAM.
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
(20) units Subcutaneous QPM.
12. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*2*
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: INR
to be drawn on [**2118-8-3**] with results sent to the office of Dr.
[**First Name4 (NamePattern1) 3979**] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 52849**]. INR goal for Afib [**1-18**].
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Postop Atrial Fibrillation
History of Myocardial Infarction
Cerebrovascular Disease
Type I Diabetes Mellitus
Hypertension
Dyslipidemia
Anemia
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in [**3-20**] weeks, call for appt. #[**Telephone/Fax (1) **]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-18**] weeks, call for appt
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-18**] weeks, call for appt. #[**Telephone/Fax (1) **]
INR to be drawn on [**2118-8-3**] with results sent to the office of
Dr. [**First Name4 (NamePattern1) 3979**] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 52849**]. INR goal for Afib [**1-18**].
Completed by:[**2118-8-1**]
|
[
"41401",
"9971",
"42731",
"4019",
"V4582",
"412",
"25000",
"V5867",
"2724",
"53081"
] |
Admission Date: [**2146-1-14**] Discharge Date: [**2146-1-28**]
Date of Birth: [**2097-8-4**] Sex: M
Service: MEDICINE
Allergies:
Bactrim Ds / Indomethacin / Linezolid
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
seizures, mental status changes
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
The patient is a 48M w/ HIV/AIDS/HCV/IVDA sent from [**Hospital1 1099**] Rehab for evaluation of 2 witnessed tonic-clonic
seizures. Seizures occurred on evening [**2146-1-13**], lasted 30
seconds - 1 minute, resolved spontaneously. First seizure
occured while he was being cleaned up, second seizure occured
while family member (mother?) was in the room. His nurse
reported 'whole body shaking' L>R, not responsive to name or
sternal rub, dilated pupils, no LOC. Patient w/ foley, so not
able to assess loss of bladder function, no bowel movement
yesterday. Patient appeared 'sleepy' afterwards but then seemed
to return to his normal self between seizures. Hypertensive -
received nitropaste. Afebrile, T max 99.8, BP 116-120's/86-106,
HR 78-129, O2 sat96% on 2L. Also found to be hypokalemic with K
2.6, started on IVF @10cc/hrKcl 40 mEq [**Hospital1 **] x 6 doses.
.
No nausea/vomiting/diarrhea, no fevers/chills, no seizure
history.
Per brother, patient has had HIV encephalopathy x 1 month, not
completely oriented at baseline. His nurse describes his
baseline as oriented to self only, Spanish speaking with some
English, has sensation of pain to minimal stimulus.
.
ED Course: arrived [**1-13**] @9pm. Never oriented, drowsy --> very
agitated. VS 98.5, HR 97, PB 134/89, RR 16, 02 sat 100% on 2L.
Negative head CT. Midnight - noted to have tonic clonic seizure
activity lasting 1-2 minutes, post-ictal. O2 sat 100% on non
rebreather, weaned easily. Given Ceftriaxone 2gm, Vanc 1gm,
Ampicillin 2gm, Acyclovir 700mg. Sedated for LP (2mg Versed and
2mg Ativan). 200mg IV Diflucan for thrush. Morphine for pain,
received total of 12mg. Also received 2 gm IV magnesium, NS w/
40 mEq of K x 2L. Hypertensive in 140-150s and tachy up to 130's
throughout ED stay, Tmax 100.9 (not during seizure).
.
After arrival to the ICU, it was discovered that he had a urine
culture positive for acinetobacter at rehab and was started on
imipenem. BCx had reportedly been negative after 5 days.
.
Previous hospitalization ([**Date range (1) 1100**]) for change in MS after
being found down and minimally responsive; he was intubated for
airway protection; course complicated by R neck hematoma [**1-8**] to
line placement, alkalosis, hypernatremia, hypercacemia, improved
ARF, elevated lactate, transaminitis. Concern for toxic
metabolic encephalopathy, improved somewhat with fluids but did
not return to baseline. Also with rhabdomylosis - CK peaked at
3996, and improved to normal with IVFs, renal failure also
resolved. He was positive for c-diff, had MRSA positive sputum,
and sparse pseudomonas growth in sputum. When discharged he
needed 6 more days to finish 14 day course of vancomycin, 10
more days to complete 15 day course of meropenem and needed to
continue on flagyl for 14 days after all other ABX completed.
Past Medical History:
1. HIV/AIDS - last CD4 105, VL > 100,000 on [**11-13**], off HAART
because of suicidality and depression, on dapsone ppx for PCP [**Name Initial (PRE) **]
[**Name10 (NameIs) 1095**] noncompliant. Thought to have HIV encephalopathy.
2. Hepatitis C: treatment deferred because of
depression/suicidality. Last viral load [**8-14**] was 5,860,000.
3. Asthma
4. h/o Tuberculosis ([**2129**], now resolved)
5. h/o PCP x 2
6. h/o pericarditis ([**2139**])
7. h/o pneumococcal pneumonia with bacteremia ([**11-10**])
8. h/o LLL pneumonia ([**12-11**])
9. h/o MAC on BAL ([**5-11**])
10. h/o Neuropathy, thought [**1-8**] HIV
11. Disseminated herpes zoster [**2144**]
12. ? depression.
13. h/o pseudomonal pneumonia (+BAL- pan sensitive)
Social History:
Patient came to [**Hospital1 18**] from [**Hospital3 672**] Rehab. Smoker (less
than 1 ppd x 25 years), + h/o IVDA in past, occasional marijuana
use. No EtOh. Sexually active "occasionally" with one partner,
same partner for several years.
Family History:
NC
Physical Exam:
Admission Physical Exam:
VS: Temp: 98.1 BP: 142/100 HR: 112 RR: 20 O2sat 100% 2L
GEN: agitated, crying out, not oriented, cachectic
HEENT: PERRL, EOMI, anicteric, MM dry, thrush on tongue
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: tachy, RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, initially with voluntary guarding but
later without
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx0, unable to cooperate with neuro exam
At discharge, vitals were stable. The patient was afebrile.
The patient was more oriented. He was able to communicate his
needs in English. His neck was rotated the left and he had some
muscular spasm. His abdomen was benign. The remained of his
exam was unchanged.
Pertinent Results:
CXR ([**2146-1-23**]): Cardiomediastinal contours are normal. NG tube
tip is in the stomach. There is no pneumothorax or pleural
effusion. The lungs are grossly clear. Surgical clips projecting
over the left supraclavicular area are again noted. Left PICC
remains in place.
EKG: Sinus tachycardia, rate 115 beats per minute. Right atrial
abnormality. Possible old septal myocardial infarction. Possible
left ventricular hypertrophy. Tracing is compatible with
pulmonary disease. Compared to the previous tracing of [**2145-12-9**] QS
complexes in leads V1-V2 are less prominent and there is less
suggestion of possible left ventricular hypertrophy. Both
tracings are compatible with pulmonary disease.
CT Head ([**2146-1-13**]):
FINDINGS: Multiple acquisitions were performed due to patient
compliance. Despite this, there is motion artifact on the study
acquired limiting the evaluation.
There again noted is extensive confluent low attenuation
throughout the deep white matter of the brain. This is likely
related to underlying HIV encephalopathy. There is a advance
atrophy for age which is consistently seen in HIV encephalopathy
as well. There is no acute interval change or midline shift. No
intracranial hemorrhage is evident.
IMPRESSION: Stable head CT examination, although the current
examination is limited as above. Findings most consistent with
HIV encephalopathy with no superimposed acute process.
CT Neck: FINDINGS:
The patient is rotated to the left side, with the neck being
rotated to the left side. Hence, this study is limited in
acquiring the images in a proper manner, centered onto the
midline of the neck. In addition, lack of IV contrast,
significantly limits evaluation for any focal infection.
Within these limitations, there are no large masses noted on the
visualized images of the neck.
However, subtle areas of increased attenuation in the fat and
inflammation cannot be assessed.
There is moderate dilatation of the esophagus with small amount
of fluid/debris within the esophagus. This finding is new
compared to the CT chest on [**2145-12-16**], with interval removal of
the nasogastric tube.
Right-sided PICC line is incompletely included on the present
study.
There are a few surgical clips, noted lateral to the left side
of the thyroid, unchanged in position, compared to the prior CT
chest on [**2145-12-16**].
There is moderate dilatation of the ventricles on the visualized
images of the brain, which was noted on the prior MRI of the
head; however, the brain is incompletely included on the present
study.
There is a small 4-mm soft tissue density nodule in the upper
lobe of the left lung, unchanged.
There appears to be resolution of the previously noted
pneumothorax in the apices. However, the chest is not completely
evaluated on the present study.
There is moderate dilatation of the ventricles on the visualized
images of the brain, which was noted on the prior MRI of the
head; however, the brain is incompletely included on the present
study.
Brief Hospital Course:
# Seizures: The patient had two witnessed tonic-clonic seizures
before presenting to [**Hospital1 18**] ED and one seizure in the ED. The
most likely etiology for patient's seizures is imipenem which
was used to treat his urine culture positive for acinetobacter
and elavil which was given at high doses for neuropathy. Mr.
[**Known lastname 1071**] is thought to have HIV encephalopathy and this condition
combined with imipenem may have lowered his seizure threshold.
Patient's amitriptyline was also considered as possible cause of
patient's seizures.
Infectious etiology or mass effect were ruled out by [**Hospital 228**]
hospital course, benign appearance of CSF, and head CT;
however, initially the patient was given empiric IV acyclovir,
ceftriaxone, and vancomycin because of suspicion of viral or
bacterial central nervous system infection. Of note, patient has
had no seizures since admission and stopping of imipenem and
amitriptyline. The patient was started on 500 mg levetiracetam
(Keppra) [**Hospital1 **] as anti-seizure medication. Per the neurology
service, the patient should be on Keppra indefinitely.
# Mental status changes: The patient's mental status changes
are likely due to HIV encephalopathy. CT showed no CNS mass
effect and no acute CNS infectious etiology found. Patient's
mental status changes date back to [**11-13**] admission when patient
left hospital AMA, never having gone back to baseline mental
status s/p presumed fall. Patient's CMV viral loads were low
(2160) and treatment was deferred since there was no sign
end-organ disease. The patient was examined by Ophthomaology
who did not see any signs of CMV retinitis.
# Urine: The patient was found to have acinetobacter in his
urine sensitive to gentamicin. He was started on a three day
course of IV gentamicin on [**1-26**]. He will need his final dose
today at rehab ([**2146-1-28**]). Please recheck a UA and culture
tomorrow ([**2146-1-29**]) to confirm his urine has cleared
appropriately. The patient has also had urinary retention
during this hospitalization. He failed two voiding trials
during this stay. As he improves, he can be given another
voiding trial or can follow up with Urology if needed.
# Neck position: The patient had head turned to left and was
resistant to changing position and has point tenderness
bilaterally on sides of neck. Neck CT without contrast obtained
(could not use contrast as could not obtain peripheral IV access
necessary) but study was inconclusive due to patient positioning
and lack of contrast. Patient continuesd to keep head turned to
left with some improvement noted with use of clonazepam. Please
continue low dose clonazepam to help with muscular spasm. If
the patient continues to have neck pain, consider re-imaging the
neck.
# Allodynia: The patient had complaints of allodynia on last
admission and reports of neuropathic pain dating back to [**2142**].
This allodynia may be part of the spectrum of his neuropathy
which is thought to be secondary to HIV. According to OMR, the
patient has not had relief of his neuropathy with gabapentin in
the past. However, after patient left ICU for floor, opiates
were held because of worries of sedation affecting mental
status. His pain was treated with gabapentin and acetaminophen.
We did not restart his opiates during this hospitalization nor
his Remeron.
# Hypokalemia/hypomagnesmia: On admission, the patient was
hypokalemic (K of 3.0) and hypomagnesemic (1.1). Patient's poor
nutrition (albumin of 2.6) and no PO intake most likely cause.
As feeding via NG tube began, lytes were monitored [**Hospital1 **] in order
to assess refeeding syndrome. At the time of discharge, the
patient's PO intake was improving. He was able to eat his
entire breakfast with help from the nursing staff. Please
continue to monitor his electrolytes while he is on TPN at least
daily replete his electrolytes as needed and change TPN based on
electrolytes. Once he is able to increase his PO intake, please
consider discontinuing the TPN. Once discontinued, the patient
will not need his electrolytes monitored daily. Please
discontinue his PICC line once he no longer needs TPN.
# HIV: The patient is not on HAART (as he has declined it). ID
did not recommend HAART as HAART carries increased risk of
toxicity in setting of poor nutrition, and patient is vulnerable
to immune reconstitution syndrome with low CD4 count at start of
HAART and patient has known Hepatitis C. ID's recommendation
was that HAART not be initiated until Mr. [**Known lastname 1101**] nutritional
status improves and that Dr. [**Last Name (STitle) 1057**] (outpatient ID doctor for
patient) should make decisions about implementing HAART.
Patient has follow up appointment on [**3-2**] at 9:30 AM with
Dr. [**Last Name (STitle) 1057**]. Please continue his Dapsone for PCP [**Name Initial (PRE) 1102**].
# Fluid, electrolytes, nutrion: Patient was profoundly
cachectic, had not eaten in several days and failed a speech and
swallow evaluation. GI did not wish to place PEG because of
patient's low albumin (which would impede healing) and prominent
epigastric surgical scar. Patient received NG tube on [**2146-1-21**]
after neck was imaged with CT. NG tube feeds began at midnight
on night of [**2146-1-21**] at 10 ml/hr. Rate was increased by 10 ml/hr
every 12 hours with a goal rate of 50 ml/hour acheived at
midnight on Sunday [**2146-1-23**]. However, tube came out and patient
refused replacement. Patient did ask for tube to be replaced on
[**1-25**] but after primary medical team could not place tube,
patient refused IR placement of NG tube. Patient was begun on
TPN on [**2146-1-27**]. Patient's lytes were repleted PRN as mentioned
above. The patient is having improved PO intake and TPN can be
discontinued when patient is taking adequate oral intake. If
needed, the patient can be re-evaulated by Speech and swallow in
the future.
Despite numerous discussions with the family regarding poor
prognosis, the patient remained full code throughout his
hospital course.
Medications on Admission:
Medications at Rehab (per rehab notes):
Primaxin 500mg IV Q6 (started [**2146-1-11**])
Elavil 100mg PO QHS
Lactinex 1 Packet TID
Zantac PEG 150 mg Q12
Heparin subQ 5000u TID
Senokot [**Hospital1 **]
Atrovent Neb 2.5ml Q6 PRN
Albuterol 3ml Q6 PRN
Tylenol 500mg Q6 PRN
Discharge Medications:
1. Outpatient Lab Work
Please check chem-10 [**Hospital1 **] if possible, otherwise please check
daily electrolytes and replete lytes PRN as patient is
vulnerable to refeeding syndrome (hypokalemia, hypophosphatemia,
hypomagnesiema).
2. Nutrition TPN:
Non-Standard TPN For Date: [**2146-1-27**] Volume(ml/d)= 1000; Amino
Acid(g/d) = 0; Branched-chain AA(g/d) = 0; Dextrose(g/d)=
100; Fat(g/d) = 20.
Trace Elements will be added daily
Standard Adult Multivitamins
NaCL = 30; NaAc = 0; NaPO4 = 40; KCl = 10; KAc = 0; KPO4 = 0;
MgS04 = 15; CaGluc = 5.
Total volume of solution per 24 hours.
Rate of continous infusion determined by pharmacy-See Label
3. [**Month/Day/Year 1098**] 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
7. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
9. PICC line care
Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN
10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Order was filled by pharmacy with a dosage form of Syringe and a
strength of 100 U/ML
10. Gentamicin
Gentamicin 60 mg IV Q8H Duration: 3 Days
Order was filled by pharmacy with a dosage form of Piggyback and
a strength of 60MG/50ML. Pt has had 8 doses. He will need to
complete his additional 1 dose today.
11. Clonazepam 0.125 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO twice a day: please hold for sedation.
12. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day:
please crush in purees.
13. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO three
times a day: please open capsule and give in purees.
14. Vitamin B-12 50 mcg Tablet Sig: Two (2) Tablet PO once a
day.
15. Outpatient Lab Work
Please check a urinanalysis and culture on [**2146-1-29**] to ensure the
patient has cleared his urinary infection.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary:
# Seizures thought due to Imipenem treatment
# Multi-drug resistent Acinetobacter UTI
# HIV/AIDS
# Urinary retention requiring foley catheter placement (failed
voiding trials x2)
# Cachexia requiring TPN
.
Secondary:
# HIV/AIDS
# HCV
# Asthma
# AIDS related neuropathy
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with seizures. While you were
in the hospital we treated you with IV antibiotics for a
question of an infection in your spinal column. We also gave
you anti-seizure medication. Please continue taking this
anti-seizure medication.
Because you were having trouble swallowing, we put a tube from
your nose into your stomach and gave you nutrition through this
tube. This tube came out and you did not want it replaced. We
then gave you nutrition through the IV in your arm. We will
continue nutrition through your arm until you are able to keep
up with oral nutrition.
We also treated an infection in your urine with IV antibiotics.
Followup Instructions:
The following appointments have been made for you. Please
follow up at these appointments.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2146-2-3**] 2:40. Please call ahead of time to update
address, phone number, and insurance information.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1085**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2146-3-2**] 9:30
|
[
"5990",
"49390",
"311",
"3051"
] |
Admission Date: [**2124-6-19**] Discharge Date: [**2124-6-20**]
Date of Birth: [**2081-10-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Tegretol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Unresponsive, overdose
Major Surgical or Invasive Procedure:
intubation/extubation
History of Present Illness:
Patient is a 42year old female with history of depression,
anxiety, suicide attempts who was brought in by EMS
unresponsive, found to have toxocology screen positive for
benzodiazepines and amphetamines and intubated for airway
protection.
Per report, the patient's neighbor heard a crash, and to the
patients apartment to check up on her and found her flailing
around. EMS was called. She was brought to the [**Hospital1 18**] ED
unresponsive.
Her vitals on admission to the ED were T97.4, BP 104/64, RR 16,
O2 sat 98% NRB She was given narcan 0.4mg x2. She was not
responsive to pain, and had a minimal gag and was intubated. She
was initially given versed, did not tolerated CT scan, as she
was thrashing around, and then was given a dose of vecuronium.
After the CT scan she got ativan, and is now sent to the ICU on
a propofol drip.
On admission to the ICU, she was intubated and sedated, but
following commands
Past Medical History:
Suicide attepts
over 20 psych admissions
Depression
Axiety
Iron deficiency anemia
Cervical dysplasia
Anorexia
Dissociative disorder
Etoh abuse
Borderline Personality Disorder
ADHD
[**Doctor First Name 147**] HX:
chest tube
facial surgery at age 21 due to trauma from abuse
Social History:
Social History: unable to obtain as is intubated
Per history: estranged from family as was abused growing up.
smoking history and hx of ETOH abuse. multiple psych admissions.
Family History:
Family history: per PCP note from [**1-10**]
Not able to give much details of her family's hx as estranged
from most of them.
Mother: 65 yo
Father: d. in prison in his 60s
Siblings: 6 B 2 sisters - she talks to one of her sisters.
Physical Exam:
Physical Exam:
Vitals: T: 97.5 BP: 126/88 P: 75 RR: 14 O2Sat: 100%
Gen: intunbated, sedated, follows commands
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions, multiple healed scars on b/l wrists
Pertinent Results:
[**2124-6-19**] 03:40PM WBC-7.2 RBC-4.56 HGB-14.7 HCT-42.8 MCV-94
MCH-32.2* MCHC-34.3 RDW-13.8
[**2124-6-19**] 03:40PM ASA-NEG ETHANOL-220* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2124-6-19**] 03:52PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
.
[**2124-6-19**] CT C Spine: prelim: no acute fractures or dislocations
of the cervical spine
.
[**2124-6-19**] CT Head: prelim: no acute intracranial process.
.
[**2124-6-19**] CXR: no acute process
.
DISCHARGE LABS:
[**2124-6-20**] 06:09AM BLOOD WBC-10.8 RBC-4.82 Hgb-15.5 Hct-45.5
MCV-94 MCH-32.0 MCHC-34.0 RDW-13.7 Plt Ct-284
[**2124-6-20**] 06:09AM BLOOD Glucose-77 UreaN-3* Creat-0.6 Na-143
K-3.6 Cl-109* HCO3-26 AnGap-12
[**2124-6-19**] 03:40PM BLOOD ALT-23 AST-41* LD(LDH)-147 AlkPhos-42
Amylase-48 TotBili-0.2
[**2124-6-20**] 06:09AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3
Brief Hospital Course:
Patient is a 42 year old female with a history of anxiety,
posttraumatic stress disorder, abuse, anorexia, ETOH abuse
admitted unresponsive, intubated, with urine toxicology notable
for positive benzodiazepines, positive amphetamines, ETOH of
220. The patient was initially unresponsive and was intubated
for airway protection. Unresponsiveness was attributed to
multiple drugs on urine toxicology. As propofol sedation was
weaned and as medications cleared from her system, the patient
became more responsive. The patient was successfully extubated.
Trauma was ruled out as cause of the altered mental status as
per negative CT head, spine. There was concern that the drug
overdose was related to a suicide attempt and the patient was
Section 12'ed when she tried to leave AMA. Code purple was
called and security had to restrain the patient. Valium was
given as per CIWA scale and home dose medications given to
reduce withdrawals. Patient refused most of her medications.
Psychiatry evaluated the patient who felt that she would benefit
from an inpatient psychiatric stay. With the resolution of the
patient's active medical issues, namely her altered mental
status, the patient was cleared for transfer to psychiatric
care.
The patient has been admitted to [**Hospital1 **] 4 at [**Hospital1 18**] for
further care.
Medications on Admission:
Medications on Admission:
unclear, but per EMS on antabuse, valium and trazadone. no note
in chart.
Discharge Medications:
1. Valium 10 mg Tablet Sig: 1-2 Tablets PO three times a day: 20
mg in am
10mg in afternoon
20mg qhs.
2. Haldol Decanoate 50 mg/mL Solution Sig: Five (5) mg
Intramuscular TID:PRN as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
Deconesse 4
Discharge Diagnosis:
Drug overdose: benzodiazepines, amphetamines, EtOH
Discharge Condition:
stable
Discharge Instructions:
You were admitted due to a change in your mental status which
has resolved and was felt to be due to trouble taking your
medications. You have a need to be in an inpatient psychiatric
facility for further care at this time.
Please continue to see your psychiatist and go to the emergency
room if you have any suicidal or homicidal idealations.
You are strongly encouraged to speak with your psychiatrist
about additions and treatment counseling.
If you develop fevers, chills, nausea, vomiting, chest pain,
shortness of breath or any other concerning symptom please
notify your primary care provider or go to the emergency room.
Followup Instructions:
Please follow up with your PCP and outpatient psychiatrist
|
[
"3051"
] |
Admission Date: [**2201-1-17**] Discharge Date: [**2201-2-10**]
Date of Birth: [**2136-5-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Neck pain, right sided weakness
Major Surgical or Invasive Procedure:
[**2201-1-23**]: IVC filter insertion
[**2201-2-6**]: IVC filter removal
PICC line placement
Arterial line placement
Intubation and mechanical ventilation
SURGERY [**2201-1-25**]:
1. C6 corpectomy.
2. Kyphectomy C7.
3. Open biopsy, deep bone.
4. Anterior body fusion C5-C6, C6-C7, C7-T1.
5. Interbody reconstruction C5 through T1.
6. Anterior cervical plate instrumentation C5 through T1.
SURGERY [**2201-2-2**]:
1. Deep bone biopsy.
2. Open treatment cervical fracture/dislocation.
3. Posterior cervical arthrodesis C5-C6, C6-C7.
4. Posterior thoracic arthrodesis C7-T1.
5. Posterior instrumentation C5-T1.
6. Iliac crest bone graft harvest for fusion.
7. Allograft for fusion.
History of Present Illness:
The patient is a 64 y/o M with PMHx significant for spinal
stenosis with multiple discectomies ~4yrs ago c/b wound
infection, Afib on coumadin, CHF EF 25-30%, HTN, who presents
from rehab and transfered from OSH for neck pain, R sided
weakness, and concern for osteomyelitis. Pt states that he has
had increasing neck pain for the last 1-2d, with increased
weakness in his right arm and leg. He states that he is able to
walk several steps at a time at baseline, but that he has been
unable to walk at all. His outside hospital CT was concerning
for osteomyelitis.
.
On arrival to the ED, the patient's VS were 98.4 84 96/70 16 98%
RA. Exam was significant for inability to lift right arm above
30' as well as weakness with right hip and knee flexion. OSH CT
was reread by [**Hospital1 18**] radiology, who noted destructive process
centered at the C6-C7 intervertebral disc space, concerning for
disciitis / osteomyelitis. MRI was ordered for further
evaluation. The patient was seen by ortho spine, who recommended
admission to medicine with plans for possible OR early next
week. VS prior to transfer were 97.7 97 18 117/94 96 with 4L NC.
.
Currently, the patient reports [**7-17**] pain in his neck, radiating
into the bilateral arms. He endorses 2 days of worsening neck
pain and weakness on the right side. He also reports occasional
blurred vision. He endorses nausea and vomiting earlier today.
He also endorses urinary incontinence, which is long-standing
but has been slightly worse recently. He also endorses having a
cough recently. Denies fevers or chills.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, shortness of breath, chest
pain, abdominal pain, diarrhea, constipation, dysuria,
hematuria.
Past Medical History:
Atrial fibrillation on coumadin
CHF (systolic) EF 25-30%
Spinal stenosis
HTN
? OSA
Pulmonary HTN
Antiphospholipid syndrome
Prior PE
Depression
Social History:
Denies tobacco, alcohol, or illicit drug use. Reports that he
used to work as [**Name6 (MD) **] anesthesia RN. Has not worked for 4 years due
to back issues.
Family History:
Father died of pancreatitis. Mother died of CVA. 1 brother died
of hepatitis/liver failure. 1 other brother who is healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 96.8 F, BP 128/99, HR 98, RR 20, O2-sat 94% 2L
GENERAL - obese male, cervical collar in place, lying in bed,
NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - cervical collar in place
LUNGS - CTA anteriorly, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - irregular rhythm, no MRG, nl S1-S2
ABDOMEN - obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - no significant edema, 2+ DP pulses
SKIN - no rashes or lesions note
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, 4/5 strength in
RUE (shoulder extension, elbow flexion/extension) and RLE (hip
flexion, knee flexion/extension), [**4-11**] in the LUE and LLE, [**4-11**]
strength on bilateral hand squeeze as well as bilateral foot
dorsiflexion and plantarflexion, diminished sensation to LT in
the RUE and RLE compared to the left, DTR's difficult to elicit
DISCHARGE EXAM:
Vitals: 98.2 108/67 62 18 98% RA
General: awake, alert, resting more comfortably, NAD
HEENT: sclera anicteric, MMM
Neck: [**Location (un) 2848**]-J collar in place, anterior cervical incision
healing well, posterior cervical incision with overlying gauze
C/D/I
CV: irregularly irregular, no r/m/g
Lungs: CTAB without wheezing/rales/rhonchi, good air movement
bilaterally
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present
Ext: warm, well perfused, 2+ pulses, trace lower extremity
edema, chronic venous stasis changes
Neuro: strength 4+/5 in RUE and RLE, [**4-11**] on left
Pertinent Results:
ADMISSION LABS:
[**2201-1-17**] 02:00PM BLOOD WBC-7.2 RBC-3.80* Hgb-11.1* Hct-32.7*
MCV-86 MCH-29.3 MCHC-34.0 RDW-16.9* Plt Ct-226
[**2201-1-17**] 02:00PM BLOOD Neuts-79.4* Lymphs-9.3* Monos-5.8
Eos-5.2* Baso-0.2
[**2201-1-17**] 02:00PM BLOOD PT-46.7* PTT-51.3* INR(PT)-4.6*
[**2201-1-17**] 02:00PM BLOOD Glucose-85 UreaN-31* Creat-1.2 Na-133
K-4.5 Cl-99 HCO3-26 AnGap-13
OTHER PERTINENT LABS:
[**2201-1-31**] 12:04PM BLOOD Fibrino-682*
[**2201-2-2**] 03:18AM BLOOD ESR-69*
[**2201-1-31**] 04:26AM BLOOD ESR-126*
[**2201-1-29**] 03:14PM BLOOD ESR-95*
[**2201-1-21**] 04:25AM BLOOD ESR-118*
[**2201-1-18**] 06:15AM BLOOD ESR-85*
[**2201-2-2**] 03:18AM BLOOD CRP-38.7*
[**2201-1-31**] 04:26AM BLOOD CRP-93.3*
[**2201-1-28**] 02:02AM BLOOD CRP-54.9*
[**2201-1-21**] 04:25AM BLOOD CRP-223.9*
[**2201-1-18**] 06:15AM BLOOD CRP-46.7*
[**2201-1-18**] 06:15AM BLOOD CK(CPK)-201
[**2201-1-18**] 06:15AM BLOOD CK-MB-3 cTropnT-<0.01
[**2201-1-19**] 06:40PM BLOOD CK(CPK)-60
[**2201-1-19**] 06:40PM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-4840*
[**2201-1-20**] 02:00AM BLOOD ALT-11 AST-18 LD(LDH)-175 CK(CPK)-41*
AlkPhos-59 TotBili-1.0
[**2201-1-20**] 02:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2201-1-31**] 04:26AM BLOOD ALT-7 AST-14 LD(LDH)-128 AlkPhos-64
TotBili-0.3
[**2201-2-3**] 12:55AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.0
DISCHARGE LABS:
[**2201-2-10**] 05:23AM BLOOD WBC-4.8 RBC-3.14* Hgb-8.9* Hct-26.6*
MCV-85 MCH-28.5 MCHC-33.6 RDW-16.9* Plt Ct-276
[**2201-2-10**] 05:23AM BLOOD PT-35.5* PTT-96.9* INR(PT)-3.5*
MICROBIOLOGY:
Blood cultures 2/11, [**1-18**], [**1-19**], [**1-20**]: negative
Urine cultures 2/11, [**1-20**]: negative
C6 Bone tissue culture [**1-25**]: gram stain negative, culture
negative, anaerobic culture negative,
acid fast culture negative (prelim), acid fast smear negative,
fungal culture negative (prelim), KOH prep negative
C6 Bone biopsy tissue culture: gram stain negative, culture
negative, anaerobic culture negative, fungal culture negative
(prelim), KOH prep negative
Universal PCR [**2201-1-25**]:
Bacterial PCR results: No bacterial DNA detected with 16s rDNA
primer set.
Fungal PCR Results: No fungal DNA detected with 28s rDNA and ITS
primer sets.
PATHOLOGY:
C6 Vertebral body [**2201-1-25**]:
1. Bone, C6 vertebral body, excision (A): Fragments of viable
and non-viable bone and cartilage.
Granulation tissue. No definitive evidence of osteomyelitis.
2. Intervertebral disc, cervical, excision (B): Fibrocartilage
with degenerative change. See note.
Fragments of viable and non-viable bone and cartilage.
Note: In part 2, there is a detached cluster of neoplastic
cells, favored to be neoplastic epithelial cells, present. As
this cluster of cells is present on another level, it is present
in the tissue block. Given the apparent lack of a history of
neoplasia, as well as the appearance of this cluster of cells on
the slide, it is favored to be a contaminant from another case.
(Discussed with Pathology and felt to be a contaminant from
another sample).
C6 Vertebral body [**2201-2-2**]: results pending at time of discharge
IMAGING:
[**2201-1-17**] CT C-spine w/o contrast: Laminectomy changes at C3-C6
with osseous destructive process
centered around the C6-C7 intervertebral disc space concerning
for vertebral osteomyelitis and discitis. MRI C-spine is
recommended for further evaluation.
CXR [**2201-1-18**]: Substantial cardiomegaly. No evidence of acute
disease.
MR [**Name13 (STitle) **] w/ and w/o contrast [**2201-1-19**]:
1. No significant changes are demonstrated since the prior
examinations, persistent abnormal signal identified at C6/C7
level, with moderate pattern of enhancement and retropulsion.
2. Kyphotic deformity at C6/C7 level, causing anterior thecal
sac deformity, these findings are concerning for discitis,
osteomyelitis. Epidural thickening with moderate pattern of
enhancement, likely consistent with a combination of prominent
epidural veins and dural thickening, no frank evidence of
epidural collection is identified. Unchanged prevertebral soft
tissue swelling extending from C4 through C7 levels.
3. Multilevel degenerative changes throughout the cervical spine
as described above. There is no evidence of focal or diffuse
lesions within the cervical spinal cord; however, the
examination is limited due to patient motion.
MRI Brain [**2201-1-19**]:
1. No acute intracranial process, specifically no evidence of
intracranial infection or infarction.
2. Mild chronic small vessel ischemic disease.
3. A lesion which lies superiorly to the right parotid is likely
an enlarged lymph nodes, although a parotid tumor cannot be
excluded. Could correlate clinically and with prior imaging
studies.
4. No stenosis, occlusion, or aneurysm visualized within the
cerebral vasculature.
TTE [**2201-1-20**]: The left atrium is moderately dilated. The right
atrium is markedly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is dilated.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. The LV ejection fraction
appears depressed (? 35 percent). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm. The right ventricle also
appears hypokinetic. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Bilateral lower extremity ulratsound [**2201-1-20**]: Limited assessment
of the peroneal veins bilaterally, otherwise no evidence of DVT
in the bilateral lower extremities.
CXR [**2201-1-27**]: As compared to the previous radiograph, the patient
has received a cervical fusion. The endotracheal tube has been
removed, the nasogastric tube is also removed, but the right
PICC line remains in unchanged position. Unchanged moderate
cardiomegaly with small areas of atelectasis but no evidence of
pneumonia or other pathological changes. No pneumothorax.
Brief Hospital Course:
64M with Afib on Coumadin, CHF with EF 35%, antiphospholipid
antibody syndrome, multiple DVTs and PEs, HTN, cervical spinal
stenosis s/p C3-C7 laminectomies and C3-C4 fusion [**2194**] c/b MSSA
wound infection, who was transferred from [**Hospital6 302**]
with 1-2 days of increased neck pain, R sided weakness, with
imaging evidence of C6-C7 discitis/osteomyelitis.
# Osteomyelitis: Patient with history of cervical spinal
stenosis s/p C3-C7 laminectomies and C3-C4 fusion [**2194**] c/b MSSA
wound infection that required prolonged antibiotics. He was
admitted with increased neck pain, R sided weakness, and with
imaging evidence on CT C-spine of C6-C7 discitis/osteomyelitis.
Was seen by Ortho-Spine in the ED and placed in a [**Location (un) 2848**] J
cervical collar due to his unstable C-spine. He was afebrile,
without leukocytosis, and numerous blood cultures were negative.
Antibiotics were initially held per ID consult while awaiting
cultures, and given the clinical stability of the patient from
an infectious standpoint. MRI with and without contrast was
obtained on third attempt, requiring general anesthesia due to
patient discomfort in the scanner and motion artifacts. MRI/MRA
of the brain revealed no evidence of intracranial pathology,
including septic emboli. TTE showed no evidence of endocarditis,
and TEE was not obtained due to low suspicion of endocarditis.
Origin of the infection was not clear, possibly related to the
prior MSSA infection in [**2194**]. History, physical, and work-up
revealed no other infectious source that could have led to the
osteomyelitis. Due to the proximity of the infection to the
carotids, Neuro IR decided they would not be able to obtain an
IR-guided biopsy. Thus, the patient needed an operative biopsy,
which was delayed due to the patient's Afib with RVR and
antiphospholipid antibody syndrome (discussed below).
.
His first procedure was an anterior stabilization and operative
biopsy, involving C6-7 corpectomies and anterior C5-T1 fusion on
[**2201-1-25**]. The procedure went well. He was left intubated
following the procedure, and required brief MICU admission
notable for hypotension and Afib with RVR. His heparin gtt was
restarted 48 hours after the surgery, and the patient was kept
in the MICU for the first day after restarting the heparin for
frequent neuro checks, as there was concern for high risk of
bleeding post-operatively. He did not develop any new
neurologic deficits, and was stable for transfer back to the
medicine floor.
Cultures from the biopsy were negative, and pathology from C6
vertebral body biopsy revealed no definitive evidence of
osteomyelitis. The patient received cefazolin peri-operatively,
and was continued on this antibiotic after the surgery.
However, after cultures remained negative, ID consult
recommended again holding antibiotics and obtaining repeat
cultures when the patient went back to the OR on [**2201-2-2**] for
posterior stabilization. The patient underwent deep bone
biopsy, open treatment cervical fracture/dislocation, posterior
cervical arthrodesis C5-C6, C6-C7, posterior thoracic
arthrodesis C7-T1, posterior instrumentation C5-T1, iliac crest
bone graft harvest for fusion, and allograft for fusion on
[**2201-2-2**]. Again, he tolerated the procedure well. Was again
briefly admitted to MICU post-op, but stable for transfer to the
floor the following day. Patient was placed back on cefazolin
perioperatively, though cultures from the repeat biopsy also
remained negative. Universal PCR for bacterial and fungal
pathogens was sent, and was negative. Given increasingly low
suspicion for active infection, ID recommended stopping all
antibiotics on [**2201-2-5**]. They will see patient in follow-up in
several weeks, and will monitor CBC, ESR, and CRP at the 2-week
and 4-week marks.
With regard to the patient's cervical spine stability, he will
wear the [**Location (un) 2848**] J collar until Ortho-Spine follow-up in [**1-9**]
weeks. His pain was controlled during the admission with
acetaminophen, gabapentin, tramadol, methadone, and oxycodone
prn pain. He was placed on a dilaudid PCA post-operatively.
Home tizanadine was used to help control muscle spasms. Of
note, his ECG was monitored for QTc prolongation with patient on
both methadone and tizanadine. He worked with PT/OT, and acute
rehab was recommended.
# Atrial fibrillation: The patient was on warfarin for
anticoagulation, and carvedilol for rate control prior to
admission. He had initial bursts of RVR on arrival to the
floor, which improved with his home carvedilol. After MRI
obtained under general anesthesia, the patient was transferred
to the MICU in the setting of Afib with RVR with rates in
120s-150s and SBPs 90s-100. He received metoprolol 5mg x3
without response in the PACU. His CXR showed question of RML
atelectasis; no signs of pulmonary edema or obvious infiltrate.
EKG c/w Afib with RVR but no signs of ischemia. In the MICU, the
patient was started on a diltiazem drip with good control of
heart rate, and the patient was started on PO metoprolol. He
briefly required pressors. His carvedilol was d/c-ed in order to
reduce alpha blockade in setting of relative hypotension. [**Name2 (NI) **] was
weaned off dilt gtt with good control of heart rate on
metoprolol 25 mg TID and SBP>100. After transfer back to the
floor from the MICU, he maintained good HR control on this dose
of metoprolol. Following his first surgery, C6-7 corpectomies
and anterior C5-T1 fusion, the patient was again transferred to
the MICU for Afib with RVR and hypotension with SBP in the 70s.
He received fluids and dilt drip, resulting in good rate
control. He was successfully extubated and rate control was
transitioned to metoprolol 25 mg TID with SBP>100. After
transfer back to the floor from the MICU, he maintained good HR
control on metoprolol, though dose was increased to 37.5mg TID
prior to discharge.
.
# Antiphospholipid antibody syndrome/Anticoagulation management:
Patient has history of antiphospholipid antibody syndrome, RUE
DVT, and PEx3. INR was supratherapeutic on arrival to the
hospital. Coumadin and aspirin were held given his
supratherapeutic INR, and pending surgical procedures. Heme/onc
was [**Name2 (NI) 4221**] for assistance with anticoagulation management
peri-operatively. He was maintained on heparin drip initially.
INR was reversed with vitamin K and FFP. Due to the need to be
off of anticoagulation peri-operatively for his spine surgeries,
a temporary IVC filter was placed by IR on [**2201-1-23**]. Heparin drip
remained off 6 hours before and 48 hours after the surgery on
[**2201-1-25**]. After the first procedure, the patient was monitored
with frequent neurologic exam checks, especially after resuming
therapeutic anticoagulation. Heparin drip was continued with
goal PTT 80-100 between his two C-spine surgeries. His INR
trended up despite not receiving Coumadin, and he received
additional vitamin K prior to his second C-spine procedure.
Heparin drip was again discontinued before the second surgery,
and restarted after the second procedure. After the second
procedure, the patient was again monitored with neurologic exam
checks, especially after resuming therapeutic anticoagulation.
His IVC filter was removed on [**2201-2-6**], and his warfarin was
resumed that same day. He should continue on the heparin gtt
until INR has been therapeutic at 2-3 for >48 hours. INR was
3.5 on day of discharge, and warfarin was held. If INR
therapeutic on [**2201-2-11**], heparin gtt can be discontinued. Would
recommend restarting warfarin at 3mg daily once INR <3.
# Chronic sCHF: Prior EF documented as 25-30%; TEE this
admission revealed EF 35%. Patient did not have any evidence of
exacerbation this admission. He was initially continued on home
medications, but later in his course his furosemide/lisinopril
were held in the setting of hypotension due to Afib with RVR and
narcotics use. These medications can be restarted as BP will
allow in the outpatient setting. At this time, will plan to
restart furosemide on discharge. Of note, as above his beta
blocker was switched from carvedilol to metoprolol this
admission for better HR control.
.
# HTN: BP remained well controlled during admission, with
occasional episodes of lower SBP in the 90s-100s. These lower
pressures were attributed to narcotics use, and occasionally
occurred in the setting of Afib with RVR. Patient was
asymptomatic. In this setting, his home carvedilol was changed
to metoprolol, which was uptitrated to a dose of 37.5mg TID
prior to discharge. His home lisinopril can be started back
following discharge if BP remains stable. Furosemide will be
restarted on discharge.
.
# Depression: Continued sertraline.
.
TRANSITIONAL ISSUES:
-Given low suspicion for active infection, patient will not be
discharged on antibiotics.
-Patient needs CBC, ESR, and CRP checked at 2 weeks and 4 weeks,
with results sent to [**Hospital **] clinic. ID follow-up scheduled for
[**2201-3-6**].
-Patient has Ortho follow-up with Dr. [**Last Name (STitle) 1007**] scheduled for
[**2201-2-25**], though this appointment may be moved. Should wear
[**Location (un) 2848**] J collar until that time.
-Patient restarted on warfarin [**2201-2-6**]. Please monitor INR
daily and adjust warfarin dose accordingly. Please continue
heparin gtt with goal PTT 80-100 until INR therapeutic ([**1-9**]) for
>48 hours. If INR therapeutic on [**2201-2-11**], can d/c heparin. As
INR 3.5 on day of discharge, would recommend continuing to
monitor INR and restarting at 3mg daily once INR <3.
-Please continue to reassess pain and increase/taper narcotic
regimen as needed. Patient may benefit from a pain consult
after discharge if narcotics requirements continue to be an
issue.
-Patient's lasix and lisinopril held this admission given
relatively lower BP (90s-100s) and that patient appeared
euvolemic. Can be restarted in outpt setting as tolerated, and
would recommend restarting lasix at this time.
-MRI during admission revealed enlarged lymph node superior to
right parotid gland (though differential includes Warthin's
tumor or adenoma). Should be compared to prior imaging and
followed up after discharge.
-On pathology report of C6 vertebral body biopsy, note was made
of a detached cluster of neoplastic cells, favored to be
neoplastic epithelial cells. This cluster of cells was favored
to be a contaminant from another case (discussed with
Pathology).
-Pathology and finalized culture data from [**2201-2-2**] C6 biopsy
still pending at time of discharge and will need to be
followed-up.
Medications on Admission:
Lisinopril 2.5 mg [**Hospital1 **]
Omeprazole 20 mg daily
MVI daily
Aspirin 81 mg daily (per patient, not taking)
Colace 100 mg [**Hospital1 **]
Carvedilol 12.5 mg TID
Oxycodone 5-20 mg QID prn pain
Acetaminophen 650 mg Q4H prn pain
Lasix 20 mg daily
Gabapentin 600 mg TID (per patient, dose was higher but causing
confusion)
Sertraline 100 mg daily
Tizanidine 4 mg TID
Methadone 15 mg QID
Warfarin 5-7.5 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
3. methadone 10 mg Tablet Sig: Two (2) Tablet PO three times a
day.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. sertraline 50 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
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. oxycodone 5 mg Tablet Sig: Four (4) Tablet PO Q4H (every 4
hours) as needed for pain.
12. heparin (porcine) in NS Intravenous
13. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
14. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for muscle spasm.
15. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
16. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Anticoagulation
Please check INR [**2201-2-8**] and if <3 restart warfarin at 3mg daily,
goal INR [**1-9**]
18. oxycodone 5 mg Tablet Sig: Five (5) Tablet PO twice a day as
needed for breakthrough pain: may take extra 5 mg dose up to
twice daily prior to working with PT for breakthrough pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
Primary Diagnoses:
C-spine osteomyelitis and instability
Antiphospholipid antibody syndrome
Atrial fibrillation with rapid ventricular response
Secondary Diagnoses:
Chronic systolic congestive heart failure
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 487**],
You were admitted to the hospital for neck pain and right-sided
weakness. CT and MRI scans of your neck were obtained. There
was concern for an infection in the bones in your neck
(osteomyelitis), and the Orthopedic-Spine and Infectious Disease
doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**]. You underwent surgery two times (one
procedure done from the front of the neck and one from the back
of the neck) with the Orthopedic doctors [**First Name (Titles) **] [**Last Name (Titles) **] your neck
and hopefully to prevent further pain and weakness. We did
cultures of your blood and of the bone removed from your neck,
which revealed no evidence of infection. You received IV
antibiotics after the spine procedures, but the Infectious
Disease doctors [**Name5 (PTitle) **] not feel you need to continue on antibiotics
after you leave the hospital. You received pain medication, and
you worked with physical therapy to start regaining your
strength and mobility.
Because of your history of antiphospholipid antibody syndrome
and multiple prior blood clots, we [**Name5 (PTitle) 4221**] the Hematology
doctors to help manage your anticoagulation. Your INR was high
on admission and too high for surgery, so we stopped your
coumadin and reversed your anticoagulation. You received heparin
while the coumadin was stopped. You also had an inferior vena
cava (IVC) filter placed prior to the spine procedures, due to
the need to stop the heparin temporarily for the procedures. The
inferior vena cava filter was removed after your two spine
procedures. After all of these procedures, we re-started your
coumadin. You will take coumadin after discharge.
With regard to your atrial fibrillation, your heart rate was
high on several occasions. This improved with changing your rate
control medications, intravenous fluids, and better pain
control.
Due to your lower blood pressure, we held your furosemide and
lisinopril while you were here. You should discuss restarting
these medications with your doctor after you leave the hospital,
but it is reasonable to restart your furosemide (lasix) at this
time.
We made the following changes to your medications:
- STOPPED carvedilol (coreg)
- STOPPED lisinopril
-CHANGED gabapentin dose (Neurontin)
-CHANGED methadone dosing
-CHANGED warfarin dosing
-STARTED metprolol (for heart rate control)
-STARTED senna and bisacodyl as needed for constipation
-STARTED miconazole powder as needed for skin irritation
-STARTED heparin (until your INR is at the right level)
-STARTED oxycodone 20mg every four hours as needed for pain
(with an additional 5mg twice daily as needed for breakthrough
pain when working with PT)
We did not make any other changes to your medications. Please
continue to take them as you have been doing. Please discuss
with your doctor whether you should be taking aspirin (this
medication was on your medication list, but you do not recall
taking it recently).
Please keep follow-up appointments as below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 21377**] [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Address: [**Last Name (un) 59485**], [**Location **],[**Numeric Identifier 21478**]
Phone: [**Telephone/Fax (1) 9674**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge.**
Department: ORTHOPEDICS
When: WEDNESDAY [**2201-2-25**] at 9:10 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SPINE CENTER
When: WEDNESDAY [**2201-2-25**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 8603**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
***It is recommended you follow up with Dr [**Last Name (STitle) 1007**] in 3 weeks
time, however this appt is 2 weeks out. The office may call you
at home with an appt for a week later than above.
|
[
"51881",
"5180",
"2761",
"42731",
"V5861",
"4280",
"311",
"32723",
"4168"
] |
Admission Date: [**2147-11-15**] Discharge Date: [**2148-2-5**]
Date of Birth: [**2147-11-15**] Sex: F
Service: NB
HISTORY: [**Known lastname 65231**] was born at 27-1/7 weeks and admitted to the
newborn ICU with respiratory distress and prematurity. She
weighed 1.02 kilograms at 27-1/7-weeks gestation to a 28-year-
old gravida 3, para [**12-11**] mother, [**Name (NI) 37516**] of [**2148-2-13**].
Prenatal labs included blood type B-positive, antibody
negative, RPR nonreactive, rubella immune, hepatitis B
surface antigen negative, group B Strep negative. Maternal
history notable for previous early gestation loss and
cerclage placement in this pregnancy at 14 weeks.
Pregnancy was complicated by premature prolonged rupture of
membranes on [**11-3**] at 25-4/7 weeks. Mother was admitted
and started on antibiotics, ampicillin and erythromycin; also
given betamethasone. She received 7 days of ampicillin and
erythromycin and was beta complete on [**11-5**]. Ultrasound
at that time showed estimated fetal weight of 1100 grams with
a very low amniotic fluid index.
The mother remained stable until the night prior to delivery
when she developed a fever to 100.7 and painful contractions.
Ultrasound revealed estimated fetal weight of 1028 grams and
a biophysical profile of [**5-16**] with an amniotic fluid index of
1.4. Due to concerns for chorioamnionitis, mother was started
on ampicillin and gentamicin, and labor was induced. Delivery
proceeded via vaginal route and infant emerged with good
tone, but limited respiratory effort and poor aeration. She
was resuscitated with stimulation, oxygen, and positive
pressure ventilation. Heart rate greater than 100 decreased
briefly to 60-80 and then increased again. Apgars were 6 at 1
minute and 9 at 5 minutes. She was intubated at approximately
6 minutes of life for persistent respiratory distress and
brought to the newborn ICU where she was placed on
synchronized intermittent mechanical ventilation and given
surfactant.
PHYSICAL EXAM UPON ADMISSION: Weight 1.02 kilograms, 50th-
75th percentile; head circumference 24.5 cm, 25th percentile;
length 37.5 cm, 50-75th percentile. In general, she was an
active, appropriately developed preterm infant vigorous with
exam in moderate respiratory distress at rest with SIMV. Her
skin was warm, pink, and well perfused without rashes. HEENT:
Fontanels soft and flat. Sutures: Appropriate. Mild molding.
Eyes: Opening spontaneously. Ears and nares: Patent. Palate:
Intact. Neck: Supple. Chest: Tight breath sounds, poor
aeration, coarse grunting, flaring, and retracting.
Cardiovascular: Regular rate and rhythm, no murmur or gallop.
Abdomen: Soft, 3-vessel cord, no masses, no
hepatosplenomegaly, quiet bowel sounds. GU: Normal premature
female. Anus: Patent. Extremities: No lesions. Back: Intact.
Neuro: Appropriate tone, activity for gestational age.
HOSPITAL COURSE BY SYSTEMS: Cardiovascular: A UAC and UVC
line were both placed upon admission. The UAC line was
removed at day of life 1. The UVC remained in place for 7
days and was replaced with a peripheral central venous
catheter which remained in place until day of life 30. She
remained hemodynamically stable with normal blood pressures.
However, on day of life 2, became symptomatic for patent
ductus arteriosus which was confirmed by echocardiogram. She
was given a course of indomethacin and clinically improved.
She had a continuous soft grade 1/6 systolic murmur on exam
and remained with normal blood pressures.
A cardiac consult was obtained on [**12-23**] at which time an
EKG was obtained which was normal. A repeat echocardiogram
was performed which revealed a clinically insignificant PDA
without left-to-right shunting. Cardiology recommended a
followup with their clinic at [**Hospital3 1810**] 1-2 months
after discharge. Currently, her heart rate is 140-160, blood
pressure 73/40 with a mean of 51 and a soft holosystolic
murmur is present at the left upper sternal border. She is
pink and well perfused in room air.
Respiratory: [**Known lastname 65231**] was intubated and given surfactant x2.
She was extubated at 24 hours and placed on 5 cm of CPAP in
room air and transitioned to a nasal cannula on day of life 6
for 4 days. At that time because of increase work of
breathing, she was placed back on CPAP at 6 cm where she
remained until day of life 44 where again, she was placed in
a nasal cannula.
In the interim, she received caffeine for apnea of
prematurity on day 1 through day 49. Her last apneic episode
with any bradycardia or desaturation occurred on [**1-27**].
She has been free from any event since that time. She was
also started on Diuril on day of life 38 which was 114
because of chronic lung disease. She also received a couple
of doses of Lasix, last 1 being given on [**1-4**]. She
currently is on room air which she was placed in on day 67 on
[**1-21**]. She continues to breathe comfortable in room
breathing 40s-50s with very mild subcostal retractions with
activity. She continues on Diuril 60 mg by mouth twice a day.
She is outgrowing this dose at present time based on her
increasing weight.
She was also started on potassium chloride supplements with
her Diuril and continues with [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] supplements at
discharge 2 mEq by mouth twice a day.
FEN: Initially, [**Known lastname 65231**] was made NPO. She started on
parenteral nutrition on day of life 0 which she received
through day of life 11. She had 1 episode of hypoglycemia
noted on day of life 8 which responded to an increased
glucose infusion rate. Her electrolytes were in range. She
had transient decreased carbon dioxide in her serum which was
corrected with adjustments to her parenteral nutrition.
She started on enteral feeds on day of life 5 and advanced
without incident to full enteral volume by day of life 12 at
which time her calories were increased to a maximum of breast
milk 32 calories with ProMod fed over an hour and a [**12-11**] by
gavage. She started p.o. feeding at approximately 34 weeks
corrected gestational age and has been p.o. ad-lib since
postmenstrual age of 37 weeks. Currently, she is taking 150
cc per kilogram per day of InfaCare 28, 26 by concentrate and
2 calories by corn oil. Her current weight at discharge is
3.210 kilograms. Her length is 50 cm. Her head is 35 cm. Her
last electrolytes were on [**2-3**]: Sodium 138, potassium
5.9, chloride 105, CO2 29. She was noted to have transient
idiopathic hypernatremia which has resolved without
treatment.
GI: She passed stool meconium on day of life 1. She tolerated
her enteral advance of feedings and increased calories
without incident. She received phototherapy from day of life
2 through 11 with a peak serum bilirubin of 5.7/0.3 on day of
life 7.
Hematology/ID: Baby's blood type is O-positive, DAT negative.
She received 1 blood transfusion on [**12-8**] of pack red
blood cells for a hematocrit of 28.9. In the interim, she was
started on iron and vitamin E supplementation and continues
on iron supplementation at time of discharge. Her most recent
hematocrit is 33.2 with a reticulocyte of 1.4%, and her
current iron dose is 0.3 mL by mouth daily.
Infectious disease: A CBC and blood culture were obtained
upon admission. Her CBC revealed a white count of 12 with 28
polys, 18 bands, 40 lymphocytes, 2 metamyelocytes, and 2
myelocytes. Her blood culture remained negative. Her
placental pathology revealed cellular changes consistent with
acute chorioamnionitis. She received 7 days of antibiotics at
which time a lumbar puncture revealed pleocytosis with a
white count of 15,000, 33,000 red blood cells, protein 231,
glucose 20. Culture and Gram stain remain negative.
[**Known lastname 65231**] was changed to ampicillin and cefotaxime for which she
received a total of 21 days of antibiotics. A repeat lumbar
puncture upon completion of antibiotics reveals a white blood
cell count of 28, a red blood cell count of 600, total
protein 157, and glucose 39. Gram stain and culture remained
negative.
Neurology: Head ultrasound on day 7 revealed moderate
ventriculomegaly. Serial ultrasounds performed subsequent to
that on day of life 10 and subsequent to that on [**11-27**],
[**12-15**], [**12-27**] revealed ventriculitis, echogenic
material in the lateral and 4th ventricle consistent with
meningitis. On [**12-27**], a follow-up ultrasound showed the
ventricles to be normal size. The debris was gone.
Her most recent head ultrasound on [**1-31**] revealed the
ventricles to be normal in size, parenchymal echotexture is
normal, and no extra-axial fluid collections seen. Her most
recent head circumference is 35 cm.
[**Known lastname 65231**] was followed by occupational therapy. She was noted to
have upper extremity tightness upon her initial exam felt to
be due to the oligohydramnios. She has received
developmentally appropriate care and occupational therapy
feels she is appropriate for her postmenstrual age at this
time. She will be followed up through the infant follow-up
program in early intervention.
Sensory: [**Known lastname 65231**] passed her hearing screen. However, due to
meningitis, will need a formal diagnostic auditory brainstem
response after discharge.
Ophthalmology: Initial exam was performed on [**12-18**] at a
month of age at which time her retinas were shown to be
immature. Serial exams revealed progressive retinopathy of
prematurity advancing to stage I, zone II in the left,
immature zone II on the right. Most recent eye exam: Immature
zone II in the left, immature zone III in the right. Followup
is on [**2-13**] at 1:00 in the afternoon with O'[**First Name9 (NamePattern2) **] [**Doctor Last Name **] of
[**Location (un) **] Eye Associates in [**Location (un) 3307**].
Psychosocial: This English speaking intact family also has a
2.5-year-old sibling. They live in [**Location (un) 2268**]. [**Known lastname 65231**]'s last
name at discharge will be [**Name (NI) 65232**].
CARE AND RECOMMENDATIONS AT DISCHARGE: Condition is good.
Discharge disposition is to home with family.
Name of primary pediatrician is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29768**] [**Hospital2 59306**] [**Hospital3 37830**], ([**Telephone/Fax (1) 65233**].
Feedings at time of discharge are InfaCare 28 calorie p.o. ad-
lib made with InfaCare powder concentrated to 24 calories and
corn oil 4 calories per ounce.
Medications at discharge include Diuril 60 mg by mouth twice
a day, potassium chloride 2 mEq by mouth twice a day, and
iron supplements 0.3 mL by mouth once a day.
Car seat position screening was performed prior to discharge
and was passed.
Newborn state screens performed. Initial screen showed
increased tyrosine level likely secondary to parenteral
nutrition with normal follow up. Subsequent screens reveals an
alpha-thalassemia trait. FU testing is pending in the state lab.
Immunizations received include 1st hepatitis B vaccine on
[**12-19**]. Subsequent to that, [**Known lastname 65231**] received Pediarix on
[**1-25**] and also received the pneumococcal conjugate,
Prevnar on [**1-25**], and HIB vaccine on [**1-25**]. She
also received Synagis on [**1-25**] and should continue to
receive Synagis monthly throughout the cold and flu season.
Follow-up appointments scheduled are with [**Hospital2 34240**]
[**Hospital3 37830**] practice with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29768**] after discharge. She
will be followed by [**Location (un) 86**], VNA. Joy is the liaison. Her
number is ([**Telephone/Fax (1) 65067**]. The Early Intervention Criterion
Program in [**Location (un) 86**], phone number ([**Telephone/Fax (1) 65066**]. [**Hospital3 18242**] Infant Follow-up Program with Neurology ([**Telephone/Fax (1) 65234**].
Cardiology program at [**Hospital3 1810**], appointment on [**3-12**]; telephone number is ([**Telephone/Fax (1) 52423**] and Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **],
[**Location (un) **] Pediatric Ophthalmology ([**Telephone/Fax (1) 65064**].
DISCHARGE DIAGNOSES: Prematurity at 27-1/7 weeks, premature
prolong rupture of membranes, respiratory distress syndrome
status post surfactant replacement, patent ductus arteriosus
status post indomethacin, apnea of prematurity, physiologic
jaundice, sepsis suspect, meningitis with ventriculitis,
retinopathy of prematurity, anemia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern1) 55876**]
MEDQUIST36
D: [**2148-2-5**] 02:55:25
T: [**2148-2-5**] 04:59:22
Job#: [**Job Number 65235**]
|
[
"7742"
] |
Admission Date: [**2190-11-13**] Discharge Date: [**2190-11-16**]
Service: MEDICINE
Allergies:
Iodine / Aspirin / Nsaids / E-Mycin / Ciprofloxacin /
Levofloxacin / Phenylephrine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
craniotomy
History of Present Illness:
This is an 89 year old male with a history of dementia,
hypertension, ESRD on hemodialysis and recent admission for
fevers and failure to thrive who presents from dialysis with a
syncopal episode. Per notes he received 2.5 hours of his
dialysis session but during the last 15 minutes he was noted to
slump in his chair and to lose consciousness for 2-3 minutes.
There was no overt seizure activity noted. No tongue biting or
loss of bowel or bladder function. No head trauma. Per EMS on
arrival he was arrousable but not at his baseline. He was
immediately transferred to [**Hospital1 18**]. As per recent discharge
summary his baseline is "confused" and has been deteriorating
rapidly over the past several months with episodes of delerium
and generalized failure to thrive.
.
In the ED, initial vs were: T: 98.3 P: 90 BP: 150/62 R: 14 O2
sat 95% on NRB, FS 98. He had a CXR which was unchanged from
prior films. EKG showed normal sinus rhythm, left axis
deviation, normal intervals, no acute ST segment changes, no
change from prior dated [**2190-10-3**]. He had a head CT which shows a
large new left sided fluid collection with mass effect. Exam in
the emergency room was notable for inability to follow commands
and withdrawal to painful stimuli. He was seen by neurosurgery
who felt that he would be a candidate for burr hole placement if
this were within the patient's goals of care. He is admitted to
the MICU for further management.
.
On the floor he is unable to respond to questions. He screams
out with painful stimuli to extremities. He is able to follow
commands to smile and close his eyes tightly. Otherwise further
history is unable to be obtained.
Past Medical History:
-ESRD on HD
-AV graft thrombosis and stenosis
-Dementia
-Malnutrition/Failure to Thrive
-Asthma
-pulmonary hypertension secondary to VSD
-Anxiety/Depression
-Chronic Bronchitis/COPD
-Traumatic Type II Dens fracture with chronic left jaw, eye,
ear, and neck pain
-Hypertension
-Hypercholesterolemia
-Incontinence of stool
-Benign prostatic hypertrophy
-12-mm left superior parietal meningioma
-Macular degeneration and anterior ischemic optic neuropathy
-Pancytopenia, possible MDS
-Left Renal calculi s/p lithotripsy
.
Social History:
born in [**State 350**]. Married for 55 years. Three children.
Attended college at [**University/College **] and got his doctorate in political
science from [**University/College **]. In [**2168**] he retired as a professor of
political science. He smoked a pipe decades ago. No alcohol
history.
Family History:
per records) sister with [**Name (NI) 5895**] disease who, in her final
years became demented. Brother has [**Name (NI) 5895**] disease.
Physical Exam:
99.8 BP: 139/50 P: 87 R: 17 O2: 94% on RA
General: Alert, unable to respond to questions of orientation,
no acute distress
HEENT: Sclera anicteric, MM dry, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, loud HSM at apex
radiating to axilla
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, well healed
surgical scars in left abdomen
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema, left upper extremity fistula with palpable thrill
Neurologic: PERRL, EOMI, blinks to threat bilaterally, smiles
symmetrically, will not stick out tongue, increased tone in
upper and lower extremities throughout, withdraws upper
extremities to pain, screams in pain to painful stimuli in lower
extremities and withdraws slightly, reflexes 2+ and symmetric in
biceps, triceps, brachioradialis and patellar, toes downgoing,
gait not tested.
Pertinent Results:
WBC 8.4 N66.3 L21.6 M9.9 E1.4 B0.9
Hct 35.8 MCV 102
Plts 223
PT 13.8 PTT 36.2 INR 1.2
142 100 18
--------------------Gluc 106
4.1 35 2.2
ALT 14 AST 19 LDH 187 CK 12 AlkP 150 Tbili 0.4
CE negative x1
Ca 9.3 Phos 2.0 Mg 1.7
Alb 3.3
Dilantin 17.7, 19.2
Serum tox negative
Ua negative for blood, negative for infxn 100 protein, negative
glucose, 10 ketones
BCx negative x2, UCx negative
[**2190-11-13**] EKG
us rhythm. Left anterior fascicular block. Cannot exclude a
prior inferior
myocardial infarction. Compared to the previous tracing of
[**2190-10-3**] precordial
R waves are more prominent.
[**2190-11-13**] CXR
us rhythm. Left anterior fascicular block. Cannot exclude a
prior inferior
myocardial infarction. Compared to the previous tracing of
[**2190-10-3**] precordial
R waves are more prominent.
[**11-13**] CT head
IMPRESSION: Lentiform left frontoparietal fluid collection
measuring 2.6 cm,
new with mass effect. Attenuation values suggest mostly CSF
densoty with some
hemorrhagic elements. This may represent a subdural hygroma
mostly containing
CSF secondary to hypotension.
[**11-14**] EEG
Markedly abnormal portable EEG due to the very frequent and
occasionally rhythmic and persistent sharp waves with following
slowing,
primarily in the left posterior temporal region or left
hemisphere but
occasionally with a generalized distribution, and due to the
slow and
disorganized background. The background abnormalities signifies
an
encephalopathy. The focal sharp waves indicate an area of
cortical
hypersynchrony in the left hemisphere, likely more posteriorly.
They
suggest a focal lesion in that area. The repetitive discharges
suggest
brief electrographic seizures, but there was no definite
clinical
effect. The discharges certainly indicate potential for longer
seizures
at other times.
[**11-15**] CT head
1. Stable large predominantly chronic subdural fluid collection
overlying the
left frontoparietal convexity reaching that vertex; the overall
appearance is
suggestive of a chronic process, either "liquefied" subdural
hematoma or true
hygroma, with fibrovascular strand formation.
2. While the significant degree of mass effect on the subjacent
brain is
unchanged, there is further subfalcine herniation, with 12 mm
rightward shift
of the normally-midline structures; this measured 8 mm on the
admission study.
3. No new cerebral edema or hemorrhage.
[**11-16**] CT head
1. Status post left subdural evacuation with post surgery
changes.
2. Persistent left subdural fluid collection with mass effect,
with mild
decrease in size and attenuation when compared to prior study.
[**11-16**] CXR
Slight improvement of the left lower lobe atelectasis with
stable
small left pleural effusion, otherwise unchanged.
Brief Hospital Course:
89yoM with a history of dementia, hypertension, ESRD on
hemodialysis and recent admission for fevers and failure to
thrive who presents from dialysis with a syncopal episode found
to have a new left sided fluid collection on head CT.
Had focal seizures activity on EEG and per Neuro started on
Dilantin.
Pt was taken to OR for evacuation of fluid collection with
Neurosurgery. MAC was used and pt was not intubated. On day
after procedure, pt noted to be unresponsive, tachypneic and
very stridourous. Bronched, but no obvious abnormality seen.
Discussion with family and pt was made CMO. Pt deceased [**2190-11-16**]
at 2035.
Medications on Admission:
Fluticasone 110 mcg 2 puffs [**Hospital1 **]
Mirtazapine 15 mg QHS
Simvastatin 10 mg daily
Captopril 6.25 mg PO TID
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2190-11-30**]
|
[
"40391",
"4168",
"2724"
] |
Admission Date: [**2156-12-18**] Discharge Date: [**2156-12-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Hypercarbia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 yo female with history of COPD and CHF who per her son was
increasingly lethargic over the course of the week. She had URI
symptoms, cough and SOB. He took her to her PCP on two days PTA
and was given a Z-Pack. Still lethargic all day on the day PTA
so he brought her to [**Hospital1 **] [**Location (un) 620**].
At [**Location (un) 620**], ABG 7.18 / 108 / ?. Placed on BiPap with improvement
in mental status. Transferred to [**Hospital1 18**] for further work-up and
eval.
At the time of admission, the patient was placed on BiPap with
her home settings. It was learned that there may have been a
problem with the patient's home oxygen tubing. Her CXR was c/w
mild CHF but the patient was not diuresed as her SBP was in the
80s (per her son, baseline usually in the 90s).
Past Medical History:
CHF
CAD s/p MI [**3-/2156**]
HTN
CKD (1.1-1.7)
Fe Deficiency Anemia
TIA x2
Afib
OSA
COPD on home O2 X 2 years.
Social History:
Widowed. Former smoker but quite many years ago. Lives with her
2 daughters.
Family History:
Two daughters with muscular dystrophy.
Physical Exam:
T 97.3 P78 R 21 103/42 O2 Sat 100%
Gen: Frail appearing.
HEENT: PERRL, EOMI. Dry MM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy. JVP 8 cm at 45 degress.
Chest: Coarse crackles at bases bilat.
Cor: Normal S1, S2. II/VI holosystolic murmur.
Abdomen: Soft, non-tender and non-distended. +BS, no HSM.
Extremity: Warm, without edema. No CCE.
Neuro: Alert and oriented to person and place. Responds to
verbal stimulii and follows commands.
Pertinent Results:
[**2156-12-17**] 08:30PM BLOOD WBC-10.3 RBC-3.83* Hgb-10.7* Hct-34.8*
MCV-91 MCH-27.9 MCHC-30.7* RDW-13.9 Plt Ct-308
[**2156-12-21**] 10:00AM BLOOD WBC-11.1* RBC-3.48* Hgb-9.6* Hct-31.4*
MCV-90 MCH-27.5 MCHC-30.5* RDW-14.1 Plt Ct-292
[**2156-12-23**] 06:00AM BLOOD WBC-20.3*# RBC-3.52* Hgb-9.8* Hct-30.7*
MCV-87 MCH-27.7 MCHC-31.8 RDW-14.2 Plt Ct-316
[**2156-12-27**] 06:05AM BLOOD WBC-9.0 RBC-3.32* Hgb-9.0* Hct-29.1*
MCV-88 MCH-27.2 MCHC-31.0 RDW-14.2 Plt Ct-266
[**2156-12-17**] 08:30PM BLOOD PT-41.4* PTT-35.7* INR(PT)-4.5*
[**2156-12-17**] 10:20PM BLOOD PT-42.0* PTT-39.5* INR(PT)-4.6*
[**2156-12-20**] 05:57AM BLOOD PT-36.1* PTT-34.7 INR(PT)-3.8*
[**2156-12-21**] 10:00AM BLOOD PT-19.8* PTT-29.4 INR(PT)-1.8*
[**2156-12-23**] 06:00AM BLOOD PT-18.7* PTT-27.7 INR(PT)-1.8*
[**2156-12-23**] 06:50PM BLOOD PT-18.9* PTT-65.5* INR(PT)-1.8*
[**2156-12-24**] 06:10AM BLOOD PT-21.3* PTT-56.1* INR(PT)-2.1*
[**2156-12-25**] 07:30AM BLOOD PT-25.4* PTT-76.1* INR(PT)-2.5*
[**2156-12-26**] 07:45AM BLOOD PT-25.7* PTT-32.6 INR(PT)-2.5*
[**2156-12-27**] 06:05AM BLOOD PT-25.0* PTT-31.5 INR(PT)-2.5*
[**2156-12-17**] 08:30PM BLOOD Glucose-114* UreaN-84* Creat-2.4* Na-137
K-5.4* Cl-94* HCO3-37* AnGap-11
[**2156-12-19**] 04:19AM BLOOD Glucose-118* UreaN-106* Creat-2.9* Na-137
K-5.5* Cl-97 HCO3-32 AnGap-14
[**2156-12-20**] 05:57AM BLOOD Glucose-113* UreaN-100* Creat-2.6* Na-139
K-4.8 Cl-101 HCO3-35* AnGap-8
[**2156-12-22**] 03:50PM BLOOD Glucose-148* UreaN-81* Creat-2.1* Na-142
K-4.2 Cl-95* HCO3-42* AnGap-9
[**2156-12-23**] 06:00AM BLOOD Glucose-138* UreaN-78* Creat-2.0* Na-142
K-3.9 Cl-93* HCO3-43* AnGap-10
[**2156-12-25**] 07:30AM BLOOD Glucose-113* UreaN-60* Creat-1.8* Na-142
K-3.4 Cl-91* HCO3-44* AnGap-10
[**2156-12-26**] 07:45AM BLOOD Glucose-111* UreaN-55* Creat-1.6* Na-143
K-4.1 Cl-94* HCO3-44* AnGap-9
[**2156-12-27**] 06:05AM BLOOD Glucose-155* UreaN-54* Creat-1.7* Na-142
K-3.8 Cl-91* HCO3-46* AnGap-9
[**2156-12-17**] 08:30PM BLOOD CK(CPK)-21*
[**2156-12-18**] 03:15AM BLOOD CK(CPK)-34
[**2156-12-23**] 12:50PM BLOOD CK(CPK)-16*
[**2156-12-23**] 06:50PM BLOOD CK(CPK)-14*
[**2156-12-24**] 06:10AM BLOOD ALT-5 AST-13 LD(LDH)-195 CK(CPK)-15*
AlkPhos-65 TotBili-0.7
[**2156-12-17**] 08:30PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2156-12-18**] 03:15AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2156-12-23**] 12:50PM BLOOD CK-MB-3 cTropnT-0.05*
[**2156-12-23**] 06:50PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2156-12-24**] 06:10AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2156-12-17**] 08:30PM BLOOD Calcium-8.7 Phos-5.3* Mg-2.7*
[**2156-12-27**] 06:05AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.1
[**2156-12-22**] 03:50PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.4 Iron-24*
[**2156-12-22**] 03:50PM BLOOD calTIBC-369 Ferritn-57 TRF-284
[**2156-12-24**] 06:10AM BLOOD %HbA1c-6.0*
[**2156-12-24**] 06:10AM BLOOD Triglyc-90 HDL-48 CHOL/HD-2.3 LDLcalc-42
[**2156-12-18**] 03:15AM BLOOD TSH-1.2
[**2156-12-17**] 08:30PM BLOOD Digoxin-2.0
[**2156-12-19**] 04:20PM BLOOD Digoxin-2.6*
[**2156-12-20**] 05:57AM BLOOD Digoxin-2.1*
[**2156-12-17**] 07:55PM BLOOD Type-ART pO2-69* pCO2-89* pH-7.24*
calTCO2-40* Base XS-7
[**2156-12-17**] 11:08PM BLOOD Type-ART pO2-47* pCO2-63* pH-7.29*
calTCO2-32* Base XS-1
[**2156-12-18**] 04:59AM BLOOD Type-ART Temp-37.3 pO2-31* pCO2-90*
pH-7.23* calTCO2-40* Base XS-5
[**2156-12-18**] 04:01PM BLOOD Type-ART pO2-75* pCO2-84* pH-7.24*
calTCO2-38* Base XS-5
[**2156-12-19**] 11:42AM BLOOD Type-ART pO2-66* pCO2-80* pH-7.29*
calTCO2-40* Base XS-7
[**2156-12-18**] 04:01PM BLOOD Lactate-1.0
EKG [**12-17**]:
Atrial fibrillation. Marked left axis deviation.
Intraventricular conduction delay. Left bundle-branch block.
Inferior Q waves - consider previous inferior myocardial
infarction but may be reflecting the intraventricular conduction
delay.
Imaging:
CXR [**12-17**]:
Moderate cardiomegaly and increased interstitial markings likely
representing mild CHF.
Renal US [**12-19**]:
1. No evidence of hydronephrosis.
2. Renal size asymmetry with left kidney smaller and atrophic.
3. Ascites, with largest pocket in right lower quadrant.
TTE [**12-20**]:
The left atrium is dilated. The right atrium is markedly
dilated. There is asymmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets are mildly
thickened. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is moderate
thickening of the mitral valve chordae. Mild to moderate ([**1-13**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
CT Head without contrast [**12-23**]:
There is no evidence of hemorrhage or recent infarction.
Bilateral well-defined round areas of hypodensity near the basal
ganglia may represent small areas of previous lacunar
infarction/sequela of previous small vessel disease. There is
periventricular white matter hypodensity consistent with chronic
small vessel ischemia. There is no midline shift. Visualized
portions of the paranasal sinuses are clear.
MRI brain [**12-23**]:
No evidence of intracranial hemorrhage, mass effect,
hydrocephalus, or shift of normally midline structures. No
diffusion abnormalities are identified to suggest acute
ischemia. A chronic left cerebellar infarct is noted with
associated encephalomalacia. T2 hyperintensity in the
periventricular and deep cerebral white matter is consistent
with chronic microvascular infarction. Prominence of the sulci
and ventricles is consistent with moderate cerebral atrophy.
MRA Brain [**12-23**]:
The major tributaries of the circle of [**Location (un) 431**] are patent. Within
limits of this study, there is no evidence of significant
intracranial stenosis, aneurysm, or arteriovenous malformation.
MRA Carotids [**12-23**]:
The carotid arteries are patent bilaterally. There is at least
moderate stenosis of the proximal left internal carotid artery
for a segment measuring approximately 1 cm. There is mild
irregularity of the right internal carotid artery but no
significant stenosis is identified. The vertebral arteries are
patent and unremarkable in appearance.
Carotid Ultrasound [**12-24**]:
Less than 40% right ICA stenosis. 60-69% left ICA stenosis.
Brief Hospital Course:
87yo woman with h/o COPD and CHF admitted with lethargy and
hypercarbic respiratory failure in the setting of URI and
damaged biPAP tubing and CO2 to 108.
Patient's symptoms began with URI syndrome and dyspnea [**12-14**].
She was given a Z-Pack by her PCP but developed lethargy and
presented to [**Hospital1 **] [**Location (un) 620**] with ABG: 7.18/108/? O2. She was
admitted to the MICU, where she was put on her home BiPAP with
improvement in her COPD. She was also given solumedrol and her
azithromycin was continued. Antihypertensives were held and she
was given small boluses of IV fluids for hypotension. Digoxin
was also held because of slightly elevated digoxin levels. Her
INR was noted to be elevated in the setting of getting
antibiotics, and her coumadin was held. There was no evidence
of bleeding.
# Hypercarbic respiratory failure:
Patient admitted with lethargy and hypercarbia in setting of URI
superimposed on COPD and damaged home BiPAP. She was diuresed
for heart failure and her biPAP was repaired. She did well on
her home setting of BiPAP 17/5 with target O2 90-92% as she is a
chronic CO2 retainer. In addition to spiriva and advair, she
did well with a prednisone taper and returned to her baseline,
using 2L of oxygen by nasal cannula.
# ARF on CKD: Baseline Cr 1.5-1.7.
Cr on admission 2.5, increased to 2.9 after getting IV fluids,
and then decreased to 1.7 with diuresis. She was felt to have
prerenal renal failure in the setting of heart failure. After
diuresing with IV lasix, she was sent home at her home dose of
lasix.
Her quinapril was held and her family was instructed not to give
it to her until her primary physician recommended it again.
# TIA w/ h/o prior CVA:
The patient had new onset dysarthria and left facial droop
[**12-23**]. Neurology was emergently consulted. Her symptoms
resolved within 24 hours and there were no findings on head CT
or MRI of brain to indicate acute stroke. Carotid ultrasound
demonstrated moderate plaques, and the team agreed to pursue
medical management. At the time of discharge, her INR was
therapeutic on coumadin and she had follow-up with neurology.
# CHF, diastolic, acute on chronic:
The patient had evidence of diastolic heart failure on TTE
performed during her admission. Given that her digoxin was
supratherapeutic and that she had diastolic heart failure, the
digoxin was stopped and she was instructed not to take it as an
outpatient. After IV lasix for diuresis, her respiratory and
renal status improved. Her metolazone was held and she was
advised not to continue it for the time being.
# Coagulopathy/AFib:
Anticoagulated for AFib. INR 4.6 on admission in setting of
antibiotics, falling nicely with holding coumadin. Once her INR
had dropped, she was restarted on coumadin and advised to
continue at her previous dose with close follow-up with her PCP.
[**Name10 (NameIs) **] was noted to have irregular rhythm with normal rate on her
exam.
# Anemia, iron deficiency:
Unknown baseline Hct, admitted with Hct 34.8, drifting down to a
nadir of 29 and then stabilized at 31. She was noted to have
guaiac positive stools in the setting of her elevated INR. Her
family was advised that colonoscopy should be discussed with her
PCP.
# CAD: Not active
Aspirin initially held in the setting of concern for GI bleed
with elevated INR. At the time of discharge, she was receiving
her aspirin, beta blocker and statin (lovastatin was increased
to 20mg in the setting of new stroke). The ACE inhibitor was
held because of renal failure as discussed above. It can be
restarted by her PCP once her Cr has completely stabilized.
# Chronic benzodiazepine use:
The patient takes diazepam 2.5mg TID at home. This was
decreased to 2mg TID during her stay. Her family was informed
of the risks of continuing diazepam, particularly the risk of
causing confusion or falls. They were advised to work with her
primary providers to try to wean her off of the diazepam.
# Code: DNR but would want to be intubated.
# Comm: HCP is daughter [**Name (NI) **] [**Telephone/Fax (1) 75839**]
# Dispo: Discharged home with PT and VNA.
Medications on Admission:
Carvedilol 6.25mg [**Hospital1 **]
Digoxin 0.125mg QOD
Quinapril 10mg daily
Lasix 80mg two days in a row, then 120mg next day then repeat
Coumadin 5mg QHS [**Doctor First Name **]-F, Sa 7.5mg--INR followed by Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 17753**]
Lovastatin 10mg QHS
ASA 81mg daily
Colace 100mg [**Hospital1 **]
Metolazone 2.5mg Qweek on Wednesdays--?did this affect her
kidneys
Diazepam 2.5mg TID prn anxiety
Advair [**Hospital1 **]--taking once a day
Spiriva inh daily
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. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16): Continue to take 7.5mg on Saturday but please
watch your INR closely as you may only need 5mg every day.
Please have your INR checked within several days following
discharge.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Lasix 40 mg Tablet Sig: Two (2) Tablet PO once a day: Take
80mg for two days, then 120mg. Repeat this 3 day cycle
continuously. You were given 120mg on Monday [**12-27**].
Disp:*64 Tablet(s)* Refills:*2*
9. Lovastatin 10 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Hypercarbic Respiratory Failure
Acute Kidney Injury
Congestive Heart Failure
Stroke
Secondary:
coronary Artery disease
Atrial fibrillation
Discharge Condition:
Ambulating, tolerating PO diet
Discharge Instructions:
You were admitted with hypercarbic respiratory failure. This was
felt to be secondary to a poorly functioning BiPap Machine. You
were treated for heart failure and kidney failure with lasix,
and your kidneys are now back to your baseline. You also
suffered a ministroke. This did lot leave you with any
functional deficits and the MRI showed no new brain damage.
It is very important to take all medications as prescribed as
well as to make and attend all follow up appointments. The
following are medication changes:
Your digoxin was stopped
Your metolazone was stopped, and can be re-started by your
primary care physician
Your Warfarin will be continued at 5mg/day, but your INR needs
VERY close monitoring
Your lovastatin was increased to 20mg a day.
Your diazepam was decreased to 2mg three times a day as needed.
Please do not take your quinapril until your primary care doctor
directs you to restart it.
Please discuss an outpatient colonoscopy with your PCP for
evaluation of hidden blood in your stool.
Please return to the hospital if you become confused, develop
fevers, cough, or any other concerning symptom.
Followup Instructions:
Please contact your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8446**], for a
follow up appointment within 1-2 weeks following discharge. The
phone number is [**Telephone/Fax (1) 17753**]
You should be seen by neurology. You have an appointment with
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] Wed [**1-20**] at 1pm. [**Hospital Ward Name 23**] building
(corner of [**Location (un) **] [**Hospital1 39240**]), [**Location (un) **]. Call
[**Telephone/Fax (1) 2574**] if you need to reschedule.
Also, please contact your pulmonologist, Dr. [**First Name (STitle) **], to schedule a
follow up appointment.
Continue to follow-up with your cardiologist.
Completed by:[**2157-2-5**]
|
[
"5849",
"4280",
"5859",
"32723",
"4240",
"41401",
"42731",
"2767",
"412",
"V5861",
"4168"
] |
Admission Date: [**2101-6-30**] Discharge Date: [**2101-7-10**]
Date of Birth: [**2037-6-24**] Sex: M
Service: ACOVE
CHIEF COMPLAINT: Epigastric pain times two days.
HISTORY OF THE PRESENT ILLNESS: This is a 64-year-old male
with history of acute pancreatitis attributed to
hypertriglyceridemia in [**2100-1-28**]. The patient complained
of severe epigastric pain, which radiated to his back. He
had also experienced right upper quadrant pain over the last
two days. The patient experienced nausea and vomited times
one. There was no blood or bile in the vomit. The patient
denied alcohol use. The patient also reports polydipsia,
polyuria, and polyphagia over the preceding eight weeks. The
patient denies PO intake since the onset of pain.
REVIEW OF SYSTEMS: System review was negative for chest
pain, shortness of breath, melena, hematochezia, dysuria,
hematuria, dizziness, or headache.
PAST MEDICAL HISTORY:
1. Acute pancreatitis [**2100-1-28**], attributed to
hypertriglyceridemia.
2. Hypertriglyceridemia.
3. Hypertension. The patient is not currently on
medication.
4. Adenomatous colon polyp removed in [**2099-1-28**].
5. Peyronie disease.
6. Fatty liver.
7. Left adrenal adenoma.
8. Gout.
ALLERGIES: The patient is allergic to CHYMORAL, WHICH GIVES
THE PATIENT A RASH.
MEDICATIONS:
1. Lipitor 10 mg PO q.d.
2. Colchicine 0.6 mg PO b.i.d.
3. Multivitamin ginseng, gingko biloba, saw [**Location (un) 6485**],
vitamin E, vitamin C, vitamin B complex, coenzyme Q, marine
fish oil, glucosamine, and chondroitin sulfate.
SOCIAL HISTORY: The patient is an osteopathic physician and
practices manipulative medicine in [**Location (un) 583**]. He resides in
[**Location (un) **] with his wife. [**Name (NI) **] denies tobacco and alcohol use,
as well as intravenous drug use.
PHYSICAL EXAMINATION: Examination revealed the following:
Vital signs: Temperature 96, blood pressure 163/86, pulse
93, respirations 20, oxygen saturation 93% on room air.
GENERAL: The patient appeared to be resting comfortably when
examined. This was likely secondary to morphine received in
the emergency room. HEENT: Sclerae are nonicteric,
conjunctiva without pallor, oropharynx clear and mucous
membranes moist. NECK: Supple, no lymphadenopathy, no
thyromegaly, no jugulovenous distention. NEUROLOGICAL: The
patient was alert and oriented times three. There was no
sensory or motor deficit. Coordination was intact. Cranial
nerves II through XII intact. CARDIOVASCULAR: Regular rate
and rhythm, no rubs, or murmurs. Third heart sound was
ausculted, unable to discern whether it was a gallop or a
split S2. PULMONARY: Lungs were clear to auscultation
bilaterally. ABDOMEN: Soft, nondistended, extremely tender
to palpation in the egigastric area, positive bowel sounds,
no organomegaly, no rebound, no rigidity, no guarding.
EXTREMITIES: No edema, no calf tenderness, negative [**Last Name (un) 4709**]
retractor.
HOSPITAL COURSE: (by problem)
#1. Acute pancreatitis: Upon admission, the patient's white
blood cell ranged from 6.7 to 12.7. Amylase was 1,374,
lipase 6,500, LDH 192. LFTs were all normal. Triglycerides
were 5,170, and cholesterol was 648. The patient was
hydrated with 0.9 normal saline at 200 cc per hour and pain
controlled with morphine. The patient was kept NPO and
called out to the floor on hospital day #2. He was then
placed on a morphine PCA, kept NPO and IV hydration
continued. Attempt was made to advance the patient to clear
liquids on hospital day #3, but this resulted in recurrent
epigastric pain so the patient was once again made NPO.
Right upper quadrant ultrasound revealed perihepatic ascites,
but no biliary obstruction, dilatation, or gallstones.
On hospital day #5 the patient was started on PPN. Because
of the need for total parenteral nutrition, an attempt was
made to place a PIC line, but it was unsuccessful.
The patient's epigastric pain gradually began to abate and
the patient was started on clear fluids on hospital day #9.
He was quickly advanced to full liquid and finally to a
normal [**Doctor First Name **] diet on hospital day #10. At the time of
discharge, amylase and lipase were normal and triglycerides
were 230. The patient was discharged on Tricor.
#2. Diabetes mellitus: Admission labs were as follows:
Urinalysis revealed ketones of 40, glucose of greater than
1000 and protein of greater than 300. Blood glucose was 403,
bicarbonate 15, and the anion gap was 23. Hemoglobin Alc was
11.6.
The patient was treated with an insulin drip at two units per
hour and the patient was hydrated with 0.9 normal saline at
200 cc per hour. Anion gap closed within 48 hours and the
patient was transferred to the floor. The [**Last Name (un) **] staff was
following the patient. NPH insulin and regular insulin
sliding scale were used and adjusted as the patient went from
NPO to a full PO diet with good glycemic control achieved
throughout the hospitalization. The patient received inhouse
diabetes education. The patient was discharged to followup
with the [**Hospital 109687**] [**Hospital 982**] Clinic.
#3. Left lower lobe pneumonia with parapneumonic effusion:
On hospital day #3, rales were ausculted in the base of the
left lung. At this time, chest x-ray was read as left lower
lobe atelectasis with small left pleural effusion. Also, at
this time, the patient's oxygen saturations were within
normal limits The white blood cell count was 9.4, He was
afebrile and without cough.
On hospital day #4, the patient's white blood cell count rose
to 12. On hospital day #5, the white blood cell count rose
to 15.5. At this time, blood cultures were drawn from the
patient, although he was still afebrile and without
localizing symptoms.
On hospital day #6, the patient's white blood cell count was
12.4. He spiked a temperature to 101. Repeat chest x-ray
revealed a left lower lobe infiltrate larger from the one
seen on previous chest x-ray and it was consistent with left
lower lobe pneumonia with effusion. The patient was still
asymptomatic at this time. Levofloxacin 500 mg IV q.d. was
started. A left lateral decubitus film revealed a
significant (greater than 1.0 cm) freely layering left
pleural effusion.
On hospital day #9, the patient underwent thoracentesis.
Analysis of the pleural fluid revealed a pleural protein
level of 2.3 and pleural LDH of 153, compared to serum
protein level of 5.5 and serum LDH of 314. Blood cultures
and pleural cultures demonstrated no growth. The pH of the
pleural fluid was 7.68.
The patient was discharge on Levofloxacin to complete a
10-day course.
DISCHARGE STATUS: The patient is stable for discharge home.
DISCHARGE DIAGNOSES:
1. Acute pancreatitis secondary to hypertriglyceridemia.
2. Diabetes mellitus.
3. Left lower lobe pneumonia with parapneumonic effusion.
4. Hypertriglyceridemia.
5. Hypertension.
6. History of adenomatous colonic polyp removed in [**2099-1-28**].
7. Peyronie disease.
8. Fatty liver.
9. Left adrenal adenoma.
10. Gout.
DISCHARGE MEDICATIONS:
1. Fenofibrate 67 mg PO q.d. with PM meal.
2. Levofloxacin 500 mg PO q.d. with lunch through [**2101-7-14**].
3. Protonix 40 mg PO q.d. in a.m.
4. Insulin regimen: 18 units NPH plus 6 units regular
insulin before breakfast; 12 units NPH plus four units of
regular insulin before PM meal plus a regular insulin sliding
scale.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern4) 109688**]
MEDQUIST36
D: [**2101-7-10**] 13:57
T: [**2101-7-10**] 14:02
JOB#: [**Job Number 109689**]
|
[
"486"
] |
Admission Date: [**2184-10-4**] Discharge Date: [**2184-10-6**]
Date of Birth: [**2130-7-23**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Kefzol
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Intubation
CPR
defibrillation
History of Present Illness:
Ms. [**Known lastname **] is a 54 year old G2P2 lady, with a past medical
history of symptomatic uterine fibroids and multinodular goiter
(euthyroid), who was admitted for an elective TAH, complicated
by hypotension, ventricular tachycardia and cardiac arrest.
Patient presented on [**2184-10-4**]. Following induction of
anesthesia and intubation, Kefzol was administered. While
antibiotics were being given, patient developed hypotension to
40/20s, and was given 1 mg epinephrine IV, out of concern for
anaphylaxis, which resulted in narrow-complex tachycardia. EKG
at the time showed ST segment elevation in the inferior leads.
Bedside TEE performed showing hyperdynamic ventricle with poor
filling. At 15:10, the patient's rhythm degenerated to VT/VF.
After a first DC shock of 200J, there was initial return of
sinus bradycardia, which degenerated into VT again. Patient
received another dose of epinephrine 1 mg IV and lidocaine 100
mg, followed by amiodarone 300 mg. Second DC shock of 300J
failed to convert patient out of VT/VF. The patient then was
noted to be pulseless and received CPR for 3-5 minutes with
resultant ROSC. EKG
following the arrest showed sinus tachycardia, with less then
1mm ST elevations in inferior leads and persistent ST
depressions in anterior precordial leads. Repeat bedside TEE
with ?inferior wall hypokinesis. At that time, the patient was
noted to have a potassium of 2.4 as well. During this episode,
the patient
developed a diffuse pink, blanching rash. For her rash, patient
was given diphenhydramine 25 mg and famotidine 30 mg. Due to
these complications, TAH was cancelled. In the OR, patient at
17 cc of urine output, and was given 2200 cc IV fluids.
.
Full ROS was not obtained on admission to ICU as pt was
intubated and sedated.
.
Past Medical History:
1.) Symptomatic uterine fibroids: had caused pain in the past,
and patient was recommended to have TAH due to size of fibroids
2.) Endometrial polyp
3.) Multinodular thyroid: found on physical exam in [**2171**],
asymptomatic, TSH and T4 normal
4.) G2P2
5.) Hyperlipidemia
Social History:
Lives at home in [**Location (un) 86**] with two daughters.
[**Name (NI) 1403**] in a factory on assembly line. No known chemical
exposures. No history of tobacco, alcohol or drug use.
Family History:
Mother, still living, with DM and HTN. No family history of
cardiovascular disease or anaphylaxis. No family history of
sudden cardiac death.
Physical Exam:
On Admission to ICU
VS T35.3 HR 59 BP 109/92 RR 14 O2 sat 100 on the vent
Vent settings: TV 500, RR 14 PEEP 5, FiO2 50%
Gen: Intubated, responds to voice, follows commands
HEENT: PERRL, EOMI, anicteric
CV: RRR, S1/S2, no m/r/g
Pulm: Good air entry b/l
Abd:soft, NT, ND, normal BS
Ext: no edema, clubbing, cyanosis
Skin: rash resolved
Neuro: awakens to voice and follows commands
Access: femoral A-line, peripheral IV's
Pertinent Results:
[**2184-10-4**] 05:10PM BLOOD WBC-16.7*# RBC-5.18 Hgb-16.6*# Hct-47.8#
MCV-92# MCH-32.1*# MCHC-34.7# RDW-12.9 Plt Ct-231
[**2184-10-5**] 04:18AM BLOOD WBC-15.3* RBC-4.54 Hgb-14.0 Hct-40.8
MCV-90 MCH-30.9 MCHC-34.4 RDW-13.2 Plt Ct-226
[**2184-10-6**] 06:25AM BLOOD WBC-7.6# RBC-3.72* Hgb-11.3* Hct-33.7*
MCV-91 MCH-30.5 MCHC-33.7 RDW-13.0 Plt Ct-180
[**2184-10-6**] 12:55PM BLOOD WBC-6.8 RBC-3.69* Hgb-11.6* Hct-34.0*
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.0 Plt Ct-182
[**2184-10-4**] 05:10PM BLOOD PT-14.9* PTT-33.0 INR(PT)-1.3*
[**2184-10-4**] 05:10PM BLOOD Glucose-155* UreaN-15 Creat-0.6 Na-138
K-3.3 Cl-106 HCO3-17* AnGap-18
[**2184-10-5**] 04:18AM BLOOD Glucose-144* UreaN-12 Creat-0.7 Na-138
K-4.9 Cl-107 HCO3-20* AnGap-16
[**2184-10-6**] 06:25AM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-141 K-4.1
Cl-108 HCO3-30 AnGap-7*
[**2184-10-4**] 05:10PM BLOOD ALT-48* AST-56* LD(LDH)-186 CK(CPK)-84
AlkPhos-39 TotBili-0.6
[**2184-10-5**] 04:18AM BLOOD ALT-35 AST-29 LD(LDH)-151 AlkPhos-39
TotBili-0.8
[**2184-10-4**] 05:10PM BLOOD CK-MB-3 cTropnT-0.05*
[**2184-10-5**] 04:18AM BLOOD CK-MB-5 cTropnT-0.02*
[**2184-10-5**] 11:41AM BLOOD CK-MB-4 cTropnT-<0.01
[**2184-10-4**] 05:10PM BLOOD Calcium-7.9* Phos-3.3 Mg-1.6
[**2184-10-5**] 04:18AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0
[**2184-10-6**] 06:25AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.1
[**2184-10-4**] 05:10PM BLOOD TRYPTASE-PND
[**2184-10-5**] 11:42AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.023
[**2184-10-5**] 11:42AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2184-10-5**] 11:42AM URINE RBC-77* WBC-14* Bacteri-NONE Yeast-NONE
Epi-0
[**2184-10-5**] 11:42AM URINE CastHy-10*
.
Microbiology
Catheter tip culture ([**2184-10-5**]): pending, NGTD
Urine culture ([**2184-9-25**]): pending, NGTD
Blood culture ([**2184-10-5**]): pending, NGTD
MRSA screening ([**2184-10-4**]): pending
.
PCXR ([**2184-10-4**]):
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Lungs are low in volume but clear. No pneumothorax or pleural
effusion.
Normal cardiomediastinal silhouette. Tip of the endotracheal
tube is no less than 22 mm above the carina, with the head in
neutral or extension.
Withdrawal 15 mm is recommended.
.
PCXR ([**2184-10-5**]):
FINDINGS: In comparison with the study of [**10-4**], the
endotracheal tube has
been removed. No evidence of acute pneumonia or vascular
congestion.
.
Echo ([**2184-10-5**]):
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
EKG [**2184-10-4**] (#1): sinus tach with inferior and lateral ST
elevations
EKG [**2184-10-4**] (#2): sinus tach with new Q-waves in inferior leads
Brief Hospital Course:
Briefly, the pt is a 54 yo F who presented initially on day of
admission for an elective hysterectomy for symptomatic uterine
fibroids. Prior to surgery, following intubation and
administration of IV Cefazolin, the patient developed
hypotension to the 40's/20's. Then given IV epinephrine with
subsequent development of narrow-complex tachycardia, which
degenerated into VT/VF, with unsuccessful debibrillation,
subsequent PEA arrest, received CPR for approximately 4 minutes
and return of spontaneous circulation. TAH was cancelled and pt
was then transferred from the OR to the ICU, kept intubated. Of
note, during this incident, pt had 2 bedside echocardiograms
done showing some inferior wall hypokinesis, and EKG's showed
initially some ST elevations that resolved but with some new
inferior Q waves. During the episode, the pt was noted to have
a diffuse body rash, which responded to Benadryl and famotidine.
Pt was successfully extubated the following day on [**10-5**] and
transferred to the medical floor in stable condition.
.
Acute Medical Issues:
.
# Anaphylactic Shock: given the patient's acute hypotension and
rash following administration of IV cefazolin, the pt is
presumed to have a severe allergy to cephlasporins. Following
the acute episode in the OR, the patiet remained hemodynamically
stable without any pressors or aggressive IVF. She remained
hemodynamically stable on the floor after transfer to the
medical floor. The patient and her daughter were informed that
she has a severe allergic, potentially fatal, reaction to
cephlasporins. She has been instructed to abstain from
cephlasporins and penicillins, and to avoid antibiotics in
general if possible for now, until she follows-up in [**Hospital 9039**]
Clinic after discharge. She may need further allergen testing
once the acute phase of her anaphylaxis has resolved. She also
received a prescription for Epipen's, and was instructed on how
to administer and also given an informational handout. With
regards to concern for the epinephrine potentially triggering
her arrhythmia and cardiac arrest, this was discussed with
Cardiology, and felt that the low dose of Epinephrine would make
this very unlikely and was not contraindicated. The epinephrine
administered during the hypotensive shock had been given IV and
at a much higher dose. Furthermore, if she did have symptoms
consistent with anaphylactic shock, Epipen would be the
appropriate immediate treatment. A tryptase level is currently
still pending.
.
# VT arrest: The patient developed VT/VF following her
anaphylactic shock and administration of IV epinephrine, and was
noted to have some wall motion abnormality on bedside Echo, EKG
changes, and elevated troponin. As such, Cardiology Consult was
asked to see the patient. Her follow-up echocardiogram showed
resolution of the wall motion abnormality, her EKG returned to
baseline, and her troponin quickly downtrended to within normal
range. As such, Cardiology felt it was very unlikely for the
patient to have underlying coronary artery or structural heart
disease. They also did not think that her EKG was concerning
for risk factors of sudden cardiac death. Overall, they felt
that vasospasm due to epinephrine most likely caused transient
ischemia. However, they did recommend that she be on an Aspirin
for the next 2 weeks and to have a follow-up Exercise-stress
echocardiogram in 2 weeks with appropriate Cardiology follow-up.
She may also need to have her lipids rechecked in the
outpatient setting given a reported prior history of
dyslipidemia.
.
# Uterine Fibroids: Unfortunately, given the pt's pre-operative
course, the pt's TAH was cancelled. Given that it was an
elective surgery, the pt and her Gynecologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**],
have opted to postpone the surgery indefinitely until she has
further Cardiac and Allergy follow-up.
.
Transitional Issues:
1. She will need to continue on Aspirin for 2 weeks and have a
outpt exercise-stress echocardiogram, which has already been
scheduled, and follow-up with Cardiology after the stress
testing.
2. She will follow-up with [**Hospital 9039**] Clinic for possible further
allergen testing. She also has a pending tryptase level that
may aid in the confirmation of her diagnosis of anaphylaxis
reaction to cephlasporins.
3. She will follow-up with her PCP, [**Name10 (NameIs) **] she has pending culture
data, including a MRSA screen, blood culture, urine culture, and
catheter-tip culture.
4. She will follow-up with her Gynecologist to determine when
to pursue her hysterectomy that was originally scheduled for
this admission.
.
Pending Studies:
1. Tryptase level
2. Urine culture, blood culture, catheter tip culture ([**10-5**])
3. MRSA screen ([**10-4**])
.
Medications on Admission:
Vitamin D
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks: please continue for 2 weeks till [**10-20**].
Disp:*14 Tablet(s)* Refills:*0*
2. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular once as needed for anaphylaxis - shortness of
breath, tongue swelling, rash, low blood pressure: please keep 1
injection on you at all times or in your purse, keep 1 in your
car or your house. please call your doctor or 911 after using.
Disp:*2 injectors* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Anaphylactic allergic reaction medication
Ventricular Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital for an elective GYN surgery for
fibroids, however, prior to your sugery, your developed an
anaphylactic allergic reaction with low blood pressure to an
antibiotic (cefazolin) and also developed a cardiac arrest,
requiring CPR and electric shocks. You were kept intubated and
monitored in the ICU. You did well in the hospital, but your
surgery has been deferred indefinitely at this time. There
were some mild abnormalities seen on ultrasound of the heart, so
the cardiologists recommend that you take Aspirin for the next 2
weeks. You will then have follow-up testing of your heart and
will follow-up with Cardiology outpatient. You will also have a
referral to [**Hospital 9039**] Clinic. You will also follow-up with your
Gynecologist and PCP.
[**Name10 (NameIs) 357**] note the following medication changes:
1. Aspirin was STARTED.
2. Epipen is being PRESCRIBED
.
Please follow-up with all the appointments listed below.
.
The Epipen is to be used if you develop any reaction similar to
what you experienced here in the hospital, with low blood
pressure, difficulty breathing, shortness of breath, rash.
Please carry one in your purse or on you at all times, and keep
one in your car if you drive or at home if you don't. We also
recommend that you also avoid any antibiotics until you are seen
in follow-up by the Allergy Specialists, especially the class of
antibiotics known as penicillins and cephlasporins.
.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Address: [**Last Name (un) 4805**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 4806**]
Appointment: WEDNESDAY [**10-13**] AT 1:30PM
.
Department: CARDIAC SERVICES
When: THURSDAY [**2184-11-4**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: ALLERGY AND [**Hospital **] CLINIC
Address: ONE [**Location (un) **] PLACE, [**Apartment Address(1) **] [**Location (un) **], [**Numeric Identifier 103822**]
Phone: [**Telephone/Fax (1) 9316**]
**We are working on a follow up appointment with the Allergy and
[**Hospital **] clinic within 2-4 weeks. You will be called at home
with the appointment. If you have not heard from the office
within 2 days or have any questions, please call the number
above.**
.
You will need to have a stress echo test performed prior to your
appointment with Dr. [**Last Name (STitle) **] in Cardiology. The test has been
scheduled for [**10-27**] (Wed) at 9AM at [**Hospital Ward Name 23**] Building [**Location (un) 436**].
Please call [**Telephone/Fax (1) 62**] if you have questions, need to
reschedule, or need directions. You should receive additional
instructions in the mail 1 week prior to your study.
.
Please keep your previously scheduled follow-up appointment with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] for next Tuesday ([**10-12**]).
|
[
"51881"
] |
Admission Date: [**2183-1-9**] Discharge Date: [**2183-1-16**]
Date of Birth: [**2132-5-3**] Sex: F
Service: Thoracic Surgery
CHIEF COMPLAINT: Stridor.
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old
woman with a history of tracheal stenosis who presented with
shortness of [**Year (4 digits) 1440**] and stridor. The patient was admitted
for treatment of airway edema and monitoring.
The patient has a history of subglottic stenosis secondary to
intubation in [**2181**] for severe pneumonia. She has had
progressive stridor and planned an elective resection of the
stenosis next week. She is presenting today with increasing
shortness of [**Year (4 digits) 1440**] and stridor. She actually is unable to
climb a flight of stairs secondary to her shortness of
[**Year (4 digits) 1440**].
In the Emergency Department, the patient was treated with
epinephrine twice, 10 mg of intravenous Decadron, and heliox
with good affect and maintained saturations of greater than
98%. At the end of these therapies, she was able to speak in
complete sentences.
The onset of her shortness of [**Year (4 digits) 1440**] was not acute, it just
progressed to the point where it was just not bearable any
more. She currently feels comfortable. She has a dry
baseline cough. No chest pain.
She denies any chest pain, palpitations, any abdominal pain,
any nausea, vomiting, fevers, chills, or any lower extremity
edema.
PAST MEDICAL HISTORY: (Her prior medical history includes)
1. Subglottic tracheal stenosis; status post intubation in
[**2182**].
2. She has a history of a staphylococcal pneumonia in [**2182**].
3. She also has a history of pancreatitis secondary to
hypertriglyceridemia with multiple episodes over the last 20
years.
4. Diabetes mellitus with neuropathy.
5. She is status post cholecystectomy.
6. She has had cataract surgery.
7. She has hypertriglyceridemia.
8. Hypercholesterolemia.
MEDICATIONS ON ADMISSION: (Her medications at home included)
1. Nexium 20 mg once per day.
2. Actos 30 mg once per day.
3. Neurontin three times per day.
4. Lipitor 80 mg once per day.
5. NPH insulin with a regular insulin sliding-scale.
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: She is a computer programmer. She is
married with two children. She does not use ethanol. She
does not smoke.
PHYSICAL EXAMINATION ON PRESENTATION: On admission, she was
afebrile at 98.1, her pulse was 86, her blood pressure was
154/74, her respiratory rate was 24, and her oxygen
saturation was 98% on room air. In general, she was sitting
comfortably, breathing easily. Head and neck examination
revealed her oropharynx was clear. The mucous membranes were
moist. She was anicteric. The neck was supple. No
lymphadenopathy. No thyromegaly. Her trachea was midline.
Cardiovascular examination revealed a regular rate and
rhythm. No murmurs, rubs, or gallops. The lungs were clear
to auscultation with a distinct inspiratory stridor. The
abdomen was soft, nontender, and nondistended. Positive
bowel sounds. Extremities were without any clubbing,
cyanosis, or edema. Pulses were 2+ and equal in all four
extremities. She had no focal neurologic deficits.
PERTINENT LABORATORY VALUES ON PRESENTATION: Her admission
laboratories were all within normal limits.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no foreign
bodies and no acute disease. No infiltrates. No edema.
A computerized axial tomography from [**2182-12-19**] showed
focal tracheal stenosis at the thoracic inlet secondary to
wall thickening up to 7 mm. There were no masses identified.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient is a woman who was admitted to the Thoracic Surgery
Service for treatment of this tracheal stenosis. In terms of
her issues:
1. DIABETES MELLITUS ISSUES: She was continued on her home
regimen of NPH with a regular insulin sliding-scale and
Actos. She was also continued on her home dose of Neurontin
for her diabetic neuropathy.
2. GASTROINTESTINAL ISSUES: She was continued on a proton
pump inhibitor throughout the course of her admission. Her
nutritional status was a diabetic diet as tolerated.
3. TRACHEAL STENOSIS ISSUES: After being admitted to the
Medical Intensive Care Unit, the patient went to the
operating room for a rigid bronchoscopy on hospital day two;
during which Dr. [**Last Name (STitle) **] confirmed the presence of a subglottic
stenosis which was subsequently balloon dilated with a 10
French balloon.
On hospital day three ([**1-10**]), the patient was taken to
the operating room by Dr. [**Last Name (STitle) 952**] for a tracheal
reconstruction. Please refer to the previously dictated
Operative Note for the specifics of this operation. The
patient tolerated the procedure well and was treated to the
Trauma Surgical Intensive Care Unit in good condition with
her chin immobilized with a suture between her chin, and her
chest, and upper sternum.
In the Trauma Surgical Intensive Care Unit, the patient was
advanced to a regular diabetic diet without complications and
was maintained with an immobilized chin.
On postoperative day four ([**1-14**]), the patient was
finally transferred to the floor in good condition.
On [**1-15**], the patient underwent another bronchoscopy to
remove the sutures from the tracheal anastomosis on [**1-10**]. She tolerated this well.
On [**1-16**], the patient was afebrile with stable vital
signs. She was alert and oriented times three. She was in
no apparent distress. The lungs were clear to auscultation
bilaterally with minimal stridor. Heart was regular in rate
and rhythm. The abdomen was soft, nontender, and
nondistended. She was tolerating a regular diet and on her
home insulin. She was up walking around. The patient's
chin immobilizing suture was cut.
DISCHARGE STATUS: The patient was discharged home.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE DIAGNOSES:
1. Airway obstruction.
2. Subglottic tracheal stenosis.
3. History of staphylococcal pneumonia.
4. Status post bronchoscopy and tracheal dilatation.
5. Status post tracheal reconstruction.
6. Diabetes mellitus.
7. Nephrolithiasis.
8. Chronic pancreatitis.
9. Hyperlipidemia.
MEDICATIONS ON DISCHARGE: She was restarted on all of her
home medications and given prescriptions for Percocet as
needed for pain.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was recommended to have follow-up
appointments with Dr. [**Last Name (STitle) 952**] and Dr. [**Last Name (STitle) **].
2. She was told to contact the office if she had any
increasing shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] stridor, any fevers, or
any other concerns.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2183-1-27**] 15:05
T: [**2183-1-27**] 15:39
JOB#: [**Job Number 53964**]
|
[
"25000"
] |
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