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Admission Date: [**2200-7-8**] Discharge Date: [**2200-7-17**]
Date of Birth: [**2123-12-15**] Sex: M
Service: CARDIOTHORACIC SURGERY
Date of Operation: [**2200-7-10**]
CHIEF COMPLAINT: Dyspnea on exertion
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 76-year-old man
with several months of progressive dyspnea on exertion. He
has become short of breath given walking around his house.
He has never experienced any chest pain in the past. Stress
echocardiogram performed on [**2200-6-17**] revealed shortness of
breath and PVCs. There was an extension of an inferior
posterolateral defect with exercise. Ejection fraction was
30%. Mr. [**Known lastname **] was subsequently evaluated with cardiac
catheterization. Cardiac catheterization revealed a
completely occluded RCA, tight LAD and diagonal, and 90%
stenosed circumflex. Mr. [**Known lastname **] was subsequently evaluated
for cardiac surgery.
PAST MEDICAL HISTORY:
1. Past IMI
2. Congestive heart failure
3. SFS status post pacemaker [**December 2199**]
4. Diabetes mellitus with retinopathy
5. PAF
6. CRI
7. Chronic lower extremity edema
8. Previous history of anemia
9. Hypertension
10. Hyperlipidemia
PAST SURGICAL HISTORY:
1. Hydrocele surgery in [**2159**]
2. Remote head injury/broken arm
3. Right foot surgery
MEDICATIONS:
1. Aspirin 81 mg qd
2. Atenolol 25 mg qd
3. Prinivil 5 mg qd
4. Furosemide 40 mg [**Hospital1 **]
5. Chlor-Con 10 milliequivalents qd
6. Minitran
7. Nitroglycerin patch 0.1 mg per hour during the day
8. Cod liver oil
9. Vitamins
10. Colace
11. 70/30 insulin 35 units q a.m., 36 units at 4 p.m., 25 to
35 units q hs
12. Humalog sliding scale before meals
ALLERGIES: UNASYN CAUSES FACIAL SWELLING.
SOCIAL HISTORY: The patient lives alone.
PHYSICAL EXAM:
GENERAL: Mr. [**Known lastname **] is a pleasant gentleman in no apparent
distress.
HEAD, EARS, EYES, NOSE AND THROAT: Head is normocephalic,
atraumatic.
NECK: Supple with no carotid bruits.
CHEST: Lungs are clear to auscultation bilaterally.
HEART: Regular rate and rhythm, no murmurs, rubs or gallops.
ABDOMEN: Obese, but soft, nontender, nondistended with
normoactive bowel sounds.
EXTREMITIES: Normal pulses and are remarkable for 1+ edema.
HOSPITAL COURSE: Mr. [**Known lastname **] was admitted on [**2200-7-8**] and
evaluated for cardiac catheterization. Following the
catheterization, Mr. [**Known lastname **] was subsequently taken back to
the Operating Room on [**2200-7-10**] for coronary artery bypass
graft x4. Grafts included left internal mammary artery to
LAD, saphenous vein graft to D1, saphenous vein graft to OM1,
saphenous vein graft to PDA. Mr. [**Known lastname **] was then transferred
to the Cardiac Surgical Intensive Care Unit where he was
weaned off drips, extubated and hemodynamically stabilized.
He was transfused 2 units of packed red blood cells on
postoperative day #3 following a hematocrit of 23.4. Mr.
[**Known lastname **] [**Last Name (Titles) **] improved and was subsequently
transferred to the floor on postoperative day #5. Mr.
[**Known lastname 43437**] stay on the floor was remarkable for some dysuria
and a positive urinalysis. He is being treated with oral
ciprofloxacin. He also developed slight clear drainage from
the inferior portion of his incision which has been dressed
and changed several times daily. Otherwise, Mr. [**Known lastname **]
continued to progress well. He was tolerating oral diet and
his pain was controlled with oral medications. His
ambulation gradually improved with physical therapy
assistance. On postoperative day #7, Mr. [**Known lastname **] was felt
stable for transfer to rehabilitation facility for further
improvement of his ambulation.
DISCHARGE PHYSICAL EXAM:
HEAD, EARS, EYES, NOSE AND THROAT: The patient was
normocephalic, atraumatic.
NECK: Supple.
HEART: Regular in rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXTREMITIES: 1+ edema bilaterally. His incision was
draining slightly from inferior [**1-2**].
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg [**Hospital1 **]
2. Docusate 100 mg [**Hospital1 **]
3. Aspirin 325 mg qd
4. Captopril 6.25 mg tid
5. Ciprofloxacin 500 mg [**Hospital1 **] x5 days
6. Dilaudid 2 to 4 mg q 4 to 6 mg prn for pain
7. Lasix 40 mg [**Hospital1 **]
8. KCL 40 milliequivalents [**Hospital1 **]
9. Insulin 70/30 35 units q a.m., 36 units q p.m., 25 to 35
q hs
10. Regular insulin sliding scale for glucoses measured every
six hours. For glucoses 0 to 150 give 0 units, 151 to 200
give 3 units, 201 to 250 give 6 units, 251 to 300 give 9
units, 301 to 350 give 12 units, greater than 350 give 15
units. Give juice if glucose is less than 60.
FOLLOW UP: Mr. [**Known lastname **] should follow up with Dr. [**Last Name (STitle) 1537**] in four
weeks. He should also follow up with Dr. [**Last Name (STitle) **] in
three to four weeks.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: Mr. [**Known lastname **] is to be discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
graft x4
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Doctor First Name 24423**]
MEDQUIST36
D: [**2200-7-16**] 22:47
T: [**2200-7-17**] 06:59
JOB#: [**Job Number 43438**]
|
[
"41401",
"4280",
"42731",
"5990"
] |
Admission Date: [**2189-3-6**] Discharge Date: [**2189-3-10**]
Date of Birth: [**2138-9-29**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old man
who has complained of left sided chest pain for approximately
two days prior to arrival at an outside hospital. Once
admitted to the Emergency Room at the outside hospital the
patient continued to complain of pain. Cardiac monitor was
attached and showed a normal sinus rhythm with lateral T wave
inversions and elevated ST segments in V2 through V3. The
patient was started on Plavix, heparin and nitroglycerin drip
and transferred to [**Hospital1 69**] where
he was expected to undergo a cardiac catheterization.
PAST MEDICAL HISTORY: No significant past medical history.
PHYSICAL EXAMINATION: Alert and oriented. Pupils are equal,
round and reactive to light. Extraocular movements intact.
No discharge or injection. Neck is supple, nontender with no
lymphadenopathy. No JVD or bruits. Equal carotid pulses.
Chest is nontender, symmetrical with no retractions. Lungs
are clear to auscultation with equal breath sounds and no
wheezes or rhonchi. Heart is regular rate and rhythm. No
murmurs, rubs or gallops. Abdomen is soft and nontender,
nondistended. Neurological alert and oriented times three.
Sensory and motor functions are intact. Extremities no
clubbing, cyanosis or edema.
The patient was then transferred to [**Hospital1 190**] where he was admitted to the cardiac
catheterization laboratory. Please see the catheterization
report for full details. In the catheterization laboratory
the patient was found to have an left anterior descending
coronary artery with a long proximal stenosis of 80%
extending into diagonal and 80% tubular narrowing to a 95%
stenosis with TIMI two flow 1 cm beyond the 95% stenoses with
a separate 80% focal stenosis. Left circumflex was small,
but okay and the right coronary artery was okay with a
preserved EF of 50%. The patient continued to have
stuttering chest pain. An intraaortic balloon pump was
placed and cardiothoracic surgery was consulted. The patient
was seen by Cardiothoracic surgery and continued to complain
of chest pain, despite heparin nitroglycerin and in
intraaortic balloon pump and and he was emergently brought to
the Operating Room. Please see the Operating Room report for
full details. In summary, the patient had coronary artery
bypass grafting times two with a left internal mammary
coronary artery to the left anterior descending coronary
artery and a saphenous vein graft to the diagonal. He
tolerated the operation well and was transferred from the
Operating Room to the Cardiothoracic Intensive Care Unit.
The patient did well in the immediate postoperative period.
His anesthesia was reversed and he was weaned from the
ventilator and successfully extubated on the morning of
postoperative day one. The patient was weaned from the
intraaortic balloon pump and that was successfully removed.
On postoperative day two the patient continued to do well.
His chest tubes were removed and he was transferred from the
Cardiothoracic Intensive Care Unit to Far Two for continued
postoperative care and cardiac rehabilitation.
Over the next two days the patient's activity level was
increased with the assistance of physical therapy and the
nursing staff. His hospital course was uneventful. He
continued to be hemodynamically stable. On postoperative day
three his temporary pacing wires were removed. He had a
repeat echocardiogram, which showed some distal septal apical
hypokinesis with an EF of 50 to 55%. On postoperative day
four it was decided that he was stable and ready for
discharge to home.
At the time of discharge the patient's condition was stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times two with a left internal mammary
coronary artery to the left anterior descending coronary
artery and a saphenous vein graft to the diagonal.
PHYSICAL EXAMINATION ON DISCHARGE: Vital signs temperature
98.3. Heart rate 90 sinus rhythm. Blood pressure 119/60.
Respiratory rate 18. O2 sat 92% on room air. Alert and
oriented times three. Moves all extremities. Follows
commands. Breath sounds clear to auscultation bilaterally.
Cardiovascular regular rate and rhythm. S1 and S2 with no
murmur. Sternum is intact. Incision with Steri-Strips open
to air, clean and dry. Abdomen soft, nontender,
nondistended. Normoactive bowel sounds. Extremities warm
and well perfused with trace pedal edema.
LABORATORY DATA: White blood cell count 13.5, hematocrit
32.1, platelets 221, sodium 141, potassium 3.7, chloride 99,
CO2 29, BUN 13, creatinine 0.8, glucose 98. Weight
preoperatively was 85 kilograms. At discharge also 85
kilograms.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q.d., Lopressor 75
mg t.i.d., Lasix 20 mg q.d. times seven days, potassium
chloride 20 milliequivalents q.d. times seven days. Percocet
5/325 one to two tabs q 4 hours prn and Colace 100 mg b.i.d.
He is to have follow up in the wound clinic in two weeks.
Follow up with Dr. [**Last Name (STitle) 103980**] at [**Hospital3 1280**] in two to three
weeks and follow up with Dr. [**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2189-3-10**] 11:19
T: [**2189-3-10**] 11:25
JOB#: [**Job Number **]
|
[
"41401"
] |
Admission Date: [**2125-7-11**] Discharge Date: [**2125-7-17**]
Date of Birth: [**2052-9-15**] Sex: M
Service: MEDICINE
Allergies:
Sporanox / Ace Inhibitors / Penicillins
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
EGD (upper GI endoscopy), colonoscopy
History of Present Illness:
Mr [**Known lastname 104150**] is a 72 gentleman with ESRD status post failing
transplant, now on hemodialysis (HD), and recent GI bleed with
colonic angiodysplasias and gastritis who is presenting in
transfer from [**Location (un) 620**] with anemia and hematochezia. The patient
had been having small amounts of diarrhea for the past 2 weeks
which he was managing with immodium. On the morning of admission
he awoke having near continuous liquid stool. He describes it as
dark, giving way to bright red blood. He had some cramping
abdominal discomfort, one episode of nausea with dry heaves, no
vomiting. He was dizzy and weak and required assistance with
standing and ambulation. Denies recent EtOH, new medications,
NSAID use, recent antibiotics, travel, new foods or sick
contacts. [**Name (NI) **] notes that he will usually have GI upset after HD,
and he did have HD yesterday, but he describes these symptoms as
much more severe. Denies chest pain and shortness of breath.
Upon further discussion with his wife who is [**Name8 (MD) **] RN, he has been
having intermittent guaiac positive stool since [**Hospital1 **] day. He
presented initially to [**Location (un) 620**] ED, and his initial vital signs
there were: 98.8 60 20 134/35 98%. On initial labs he was noted
to have a Hct of 21. His last hematocrit on [**6-20**] was 34. He was
given 40mg IV nexium, 500mg IV levaquin and 1 unit PRBCs. In ED
noted to be incontinent of bloody BM. He underwent abdominal CT
scan with oral contrast and was transfered to [**Hospital1 18**] per request
of transplant nephrologist Dr. [**Last Name (STitle) 17253**] for further
management.
Past Medical History:
ESRD [**2-12**] FSGS s/p CRT [**4-15**] c/b chronic rejection
CAD s/p 3V CABG [**5-13**] (SVG to OM, SVG to PDA, LIMA to LAD)
Chronic diastolic CHF
Mild MR
COPD
E. coli pelvic abscess
HTN
Hyperlipidemia
Angiodysplasias in stomach, duodenum and colon
VZV c/b PHN
Gout
BCC
Umbilical hernia repair
BPH
Social History:
Retired HMS physiologist. He has been living at rehab since
recent discharge. Quit smoking in [**1-19**]. Former heavy ETOH use,
now rare use.
Family History:
Father had CAD and died of a CVA. Mother died of an unknown
cancer that had metastasized to the liver. One brother has CAD.
Physical Exam:
Vitals: T:98 BP:135/46 P:64 R:15 O2:100% RA
General: Pleasant, fatigued, pale elderly gentleman, thin. Sad
affect. NAD.
HEENT: Sclera anicteric, conjunctiva pale, MMM
Neck: neck veins flat, neck supple.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, crescendo blowing
murmur in systole, radiates to LUE, likely represents fisutla
bruit.
Abdomen: Soft, diffusely tender, most in LLQ. Negative [**Doctor Last Name **]
sign. No rebound. Some voluntary guarding with deep palpation.
Hyperactive BS. No tympany. Aorta not enlarged by palpation.
Large central incision. Renal transplant on left, non-tender, no
bruit.
Ext: B/L LE without edema. Upper extremities: s/p distal right
thumb amputation. Right extremity pink, well perfused. LUE with
intact fistula with thrill. LUE hand with marked thenar and
interosseus wasting. Sensation intact. Grip strength 5/5,
intrinsic muscles [**4-15**].
Pertinent Results:
From [**Location (un) 620**]:
WBC 6.7 Hb 6.7 Hct 21.3 Plt 198
INR 1.1
142 106 32 107
4.5 24 4.3
Ca 7.7 alb 2.9 --> corrected 8.6
Trop T 0.026
AST 14 ALT 23 AP 55 TB 0.38 DB 0.11 Lip 85
Lactic Acid 2.5
CT Abdomen report from [**Location (un) 620**]:
FOCAL WALL THICKENING OF THE LARGE BOWEL AT THE RECTOSIGMOID
JUNCTION. NEOPLASTIC DISEASE CANNOT BE EXCLUDED AND ENDOSCOPIC
CORRELATION IS RECOMMENDED.
EGD ([**7-12**]): Normal esophagus, stomach and duodenum
Colonoscopy ([**7-16**]): A single medium angioectasia was seen in the
cecum which bled with provocation. A gold probe was applied for
tissue destruction successfully.
Brief Hospital Course:
1. Acute GI Bleed. EGD negative. Most likely lower GI source,
especially given history of AVM. Colonoscopy revealed AVM which
bled when provoked. This was cauterized. Hematocrit was
monitored over the 24 hours following the cauterization. The
patient was advised to follow up with a gastroenterologist.
2. Acute blood loss anemia.
Secondary to GI bleeding. The patient was transfused 1 unit
packed RBCs at the OSH and an additional unit in the MICU. He
did not require additional transfusion.
3. ESRD
Secondary to failing transplant for FSGS. On Prograf. Dialyzed
according to home Tuesday, Thursday, Saturday schedule.
4. CAD, CHF, chronic, compensated, systolic and diastolic
ECG without ischemic changes. Aspirin and beta blocker were held
given active bleeding and hypotension. Statin continued.
Discharged on home meds. * was not discharged on ACEI for EF of
40% given documented allergies. Will follow-up with primary care
physician.
5. HTN
Patient was hypotensive initially. His medications were held
initially. Home lasix was restarted on [**7-14**]. Beta blocker was
held and blood pressure regimen kept liberal given risk for
rebleed. He was discharged on home medications.
6. Gout
Home allopurinol continued. Colchicine was discontinued as
patient did not have acute gout and had recent diarrhea.
7. Neuralgia
Secondary to zoster. Pregabalin and fentanyl patch continued.
Medications on Admission:
# Mycophenolate Mofetil 500 mg Tablet [**Hospital1 **]
# Trimethoprim-Sulfamethoxazole 80-400 mg Tablet daily
# Simvastatin 40 mg Tablet Daily
# Fentanyl 75 mcg/hr Patch 72 hr
# Isosorbide Mononitrate 60mg SR daily
# Pregabalin 75 mg Capsule [**Hospital1 **]
# Pantoprazole 40 mg Tablet [**Hospital1 **]
# Metoprolol Tartrate 25 [**Hospital1 **]
# B Complex-Vitamin C-Folic Acid 1 mg Capsule daily
# Furosemide 80 mg Tablet daily
# Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) mL
Injection QMOWEFR
# Aspirin 81 mg Tablet daily
# Tacrolimus 0.5 mg Capsule [**Hospital1 **]
# Colchicine 0.6mg MWF
# Allopurinol 200mg daily (recently increased by Dr. [**Last Name (STitle) 17253**]
# Renagel 800mg TIDWM
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Pregabalin 200 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for post-herpetic
neuralgia.
10. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
11. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Imdur 30 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO once a day.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Lower gastrointestinal bleed from colonic AVM,
hemodialysis-dependent renal disease from chronic rejection of
renal transplant for FSGS
Secondary: coronary artery diesease, hypertension, congestive
heart failure, gout, post-herpetic neuralgia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital and at first to the ICU
because you had bleeding from your rectum. You received blood
products to replace lost blood. You also had an upper GI
endoscopy (esophagus, stomach and first part of small intestins)
and a colonoscopy. There was no source of bleeding revealed by
the upper GI endoscopy. Colonoscopy revealed an AVM
(arterio-venous malformation), which is an abnormal collection
of blood vessels that began to bleed when it was provoked. This
was cauterized during endoscopy.
The following changes were made to your medications:
STOP colchicine. This medication is for gout attack. It can
cause diarrhea. You take allopurinol to prevent gout attacks.
Please continue to take all of your other medications.
Please keep all your outpatient appointments.
Call a doctor or 911 if you have dark tarry stools, blood in
your stool, chest pain, shortness of breath, lightheadedness,
fever, or any other concerning symptom.
Because you have some heart failure, we recommend that you weigh
yourself every morning, and adhere to 2 gm sodium diet.
Followup Instructions:
Please see your primary care [**2125-8-3**] at 11am. If this conflicts, please call.
Name: [**Last Name (LF) 6162**],[**First Name3 (LF) **] M.
Address: [**Street Address(2) 21374**], [**Apartment Address(1) 36507**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 6163**]
Fax: [**Telephone/Fax (1) 36518**]
Please make an appointment to see our gastroenterologists here
by calling ([**Telephone/Fax (1) 2233**] or make an appointment with a
gastroenterologist in [**Location (un) 620**].
You also have an appointment with Dr. [**Last Name (STitle) **]:
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2125-7-20**]
10:30
Please continue to receive hemodialysis according to your
regualr schedule.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"40391",
"4280",
"496",
"2724",
"32723",
"V4581",
"V5861"
] |
Admission Date: [**2199-8-14**] Discharge Date: [**2199-8-21**]
Date of Birth: [**2121-2-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
carcinoid tumor resection
Major Surgical or Invasive Procedure:
right hemiclamshell thoracotomy/ right pneumonectomy
SVC reconstruction - CP bypass
intubation with ICU monitoring
central venous lines
arterial lines x 2
chest tube
NG tube
History of Present Illness:
78F, non-smoker and history of carcinoid s/p right upper
lobectomy p/w worsening sympotoms of cough and chest discomfort
for two years. Hilar mass discovered by imaging mass on CXR this
past spring. CT and mediastinioscopy confirming presence of
mediastinal mass, encasing and narrowing right pulmonary artery,
compressing SVC. Plan for completion of pneumonectomy and
resection of this mass. Cardiac surgery also involved for
institution of cardiopulmonary bypass, division of the aorta,
and resection of the SVC with reconstruction of the SVC.
.
now w/ mediastinal mass, which narrows the right pulmonary
artery to 7 mm and also compresses and narrows the SVC to 2 mm.
Past Medical History:
hyperlipidemia, bronchial carcinoid s/p right lobectomy,
fibroids s/p hysterectomy, breast ca (DCIS) s/p mastectomy and
tamoxifen x 5 years
Social History:
Patient does drink alcohol ([**1-7**]) per day. Denies tobacco or
recreational drug use. Lives at home with husband
Family History:
Noncontributory
Physical Exam:
On admission
Vitals: VSS
HEENT: NCAT, EOMi, MMM
Neck: Supple, no lymphadenopathy
Pulm: CTA, no egophony, no dullness to percussion
Cardio: RRR
Abd: soft, NT, ND, act BS
Ext: no C,C,E, palpable pulses bilaterally
On discharge
VS: 98.7 98.7 81 118/64 18 93RA
Gen: NADS, AAOx3
Cardio: RRR
Pulm: rales at bases bilaterally, clear bs otherwise, no
egophony
Abd: soft, NT, ND, act BS
Wound: clean, dry, intact
Ext: no C/C/E
Pertinent Results:
Path intraoperatively - [**8-14**] Right lung, lobectomy (C-S):
Carcinoid tumor extensively involving hilar area with
infiltration of bronchial wall and replacement of nodes (2).
Extending to pulmonary arterial margin(G); tumor adjacent to
and superficially infiltrating cardiac muscle.
[**2199-8-14**] WBC-13.7*# RBC-2.74*# Hgb-8.7*# Hct-24.3*# Plt Ct-149*
[**2199-8-15**] WBC-16.7*# RBC-3.47* Hgb-10.9* Hct-30.2* Plt Ct-191
[**2199-8-16**] WBC-15.8* RBC-3.28* Hgb-10.5* Hct-28. Plt Ct-204
[**2199-8-19**] WBC-11.4* RBC-3.08* Hgb-9.5* Hct-27.3* Plt Ct-272
[**2199-8-14**] Glucose-147* UreaN-17 Creat-0.7 Na-141 K-4.1 Cl-111*
HCO3-26
[**2199-8-15**] Glucose-139* UreaN-19 Creat-0.8 Na-138 K-4.4 Cl-110*
HCO3-24
[**2199-8-18**] Glucose-106* UreaN-30* Creat-0.6 Na-142 K-3.7 Cl-106
HCO3-29
[**2199-8-21**] Glucose-92 UreaN-26* Creat-0.6 Na-140 K-4.1 Cl-102
HCO3-28
[**2199-8-17**] Type-ART pO2-103 pCO2-41 pH-7.44 calTCO2-29 Base XS-3
[**2199-8-20**] CXR: FINDINGS: In comparison with the study of [**8-19**],
there is little overall change. Almost complete opacification of
the right hemithorax is seen with several scattered air-fluid
levels projected over the area of the right lung apex. These
most likely represent regions of loculation. Small unchanged
left-sided pleural effusion.
Scoliosis persists and there is little change in the
subcutaneous emphysema.
The left chest tube remains in place with small pneumothorax in
the apical
region.
Brief Hospital Course:
Patient was admitted to our surgical service on [**2199-8-14**] and
taken to OR by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 78336**]. Patient tolerated
procedure and there were no intraoperative complications. Please
see dicated operative report for more details. Postoperatively
patinet taken to cardiac ICU for further monitoring. She
remained intubated and chest tube left to waterseal. Started on
fentanyl and propofol drips for sedation while being intubated
and neo to maintain pressor support. Patient was transfused 1u
pRBC later that evening for Hct 26.3. Post-transfusion Hct
stable at 31. On POD1, patient was weaned from intubation and
extubated successfully. She was also weaned from neo and started
on lopressor. Patient monitored closely with marginal urine
output. Her intraoperative antibiotics were held given rise in
BUN/Cr. Fentanyl was weaned off and morphine used to provide for
pain control. To assist with breathing, she was gently diuresed
with lasix and patient's urine responded well. On POD2,
patient's CT removed without complications. CXR confirmed clear
lung fields without any effusions or infiltrates. Patient's diet
advanced to clears later that evening. On POD3, patient was
transferred out of cardio ICU to thoracic surgical floors for
further postoperative recovery. She was advanced to regular diet
and medications transitioned to oral form. her femoral arterial
line was removed. During remainder of hospital stay, we
continued with gentle diuresis, keeping track of daily body
weights. She was placed on restriced intake to accomdate
negative fluid balance. Daily electrolytes checked and repleted
as necessary. Physical therapy consulted to help with
conditioning. She will be discharged to rehab postop day 8. She
is doing well, tolerating regular food, on all oral medications
and stable.
Medications on Admission:
albuterol, atenolol, lipitor, captopril, advair, hctz,
combivent, protonix, vitamin c, asa, calcium, vit b6, vit b12,
mvi
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-5**]
Puffs Inhalation Q6H (every 6 hours).
7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Regular Insulin Sliding Scale
Fingerstick QACHSInsulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
61-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-140 mg/dL 2 Units 2 Units 2 Units 2 Units
141-199 mg/dL 4 Units 4 Units 4 Units 4 Units
200-239 mg/dL 6 Units 6 Units 6 Units 6 Units
240-280 mg/dL 8 Units 8 Units 8 Units 8 Units
17. Captopril 25 mg Tablet Sig: One (1) Tablet PO twice a day:
Hold SBP < 100.
18. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] House Rehabilitation & Nursing Center - [**Location (un) 5087**]
Discharge Diagnosis:
Mediastinal tumor,
carcinoid, status post right upper lobectomy [**2175**]
Hyperlipidemia
Hypertension
Breast CA status post left mastectomy in [**2189**]
Bladder Suspension in [**2196**]
Hysterectomy in [**2168**]
Discharge Condition:
Deconditioned
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops drainage: steri-strips remove in 10 days or
sooner if start to peel off.
You may shower: No tub bathing or swimming for 6 weeks.
No lifting > 10 pounds for 10 weeks
No driving for 1 month.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**Telephone/Fax (1) 4741**]
Date/Time:[**2199-9-5**] 11:30am on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) 24**].
Chest X-Ray 45 minutes before your appointment on the [**Location (un) 861**]
Radiology Department.
|
[
"5119",
"2724",
"4019"
] |
Admission Date: Discharge Date: [**2100-8-23**]
Date of Birth: [**2035-3-27**] Sex: M
Service: CSU
.
HISTORY OF PRESENT ILLNESS: This 65 year old, white male has
a longstanding history of mitral valve prolapse which was
diagnosed as a teenager.
He was admitted to [**Hospital6 4620**] on [**2100-8-9**] with
cough and dyspnea starting three weeks prior to presentation
and was found to be in new rapid atrial fibrillation. He
also had congestive heart failure and a question of pneumonia
which ceftriaxone and Zithromax. An echo on [**8-10**] revealed
severe mitral regurgitation. Blood cultures were negative
and the patient was transferred to [**Hospital1 190**] for further management.
PAST MEDICAL HISTORY: Significant for a history of mitral
valve prolapse. History of gout. History of tinnitus.
History of basal cell CA.
MEDICATIONS ON ADMISSION:
1. Allopurinol 300 mg p.o. q day at home.
2. He was started in the hospital on a heparin drip.
3. Lasix 20 mg p.o. b.i.d.
4. Lisinopril 2.5 mg p.o. q. Day.
5. Diltiazem XL 240 mg p.o. q day.
6. Albuterol and
7. Atrovent nebs.
8. Protonix 40 mg p.o. q. Day.
9. Ceftriaxone one gram q day.
10. Zithromax 250 mg p.o. q. Day.
FAMILY HISTORY: Family history is significant for coronary
artery disease.
SOCIAL HISTORY: He does not smoke cigarettes and has rare
alcohol use.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION: He is a well-developed, white male, in
no apparent distress. Vital signs stable. Afebrile. HEAD,
EYES, EARS, NOSE AND THROAT: Normal cephalic, atraumatic.
Extraocular movements intact. Oropharynx benign. Neck is
supple, full range of motion. No lymphadenopathy or
thyromegaly. Carotids were 2 plus and equal bilaterally with
radiating murmurs. LUNGS: Bibasilar crackles, left greater
than right. Cardiovascular examination: [**3-16**] holosystolic
murmur which radiated to the axilla. Abdomen was soft and
nontender with positive bowel sounds, no masses or
hepatosplenomegaly. Extremities were without cyanosis,
clubbing or edema. Neurologic examination: Nonfocal.
His echo on [**2100-8-10**] at the outside hospital showed left
atrial enlargement, right atrial enlargement, LVEF of 65
percent, bileaflet mitral valve prolapse with severe MR [**First Name (Titles) **]
[**Last Name (Titles) 95051**] mitral leaflet and ruptured chordae.
HOSPITAL COURSE: He was admitted and seen by cardiology who
got a transesophageal echocardiogram and increased his
Captopril, started him on Lasix. He had a transesophageal
echocardiogram which showed thickened myxomatous mitral
leaflets, [**Last Name (Titles) 95051**] mitral leaflets and normal ejection
fraction. On [**8-13**], he underwent a cardiac catheterization
which revealed an EF of 60 percent, normal wall motion, 4+
mitral regurgitation and normal coronary arteries. Dr.
[**Last Name (STitle) **] was consulted and on [**8-17**], the patient underwent a
mitral valve replacement with a 31 mm St. Jude valve and a
Maze procedure. He was transferred to the CSRU on
epinephrine and Neo-Synephrine and Propofol. He was
extubated on his postoperative night and had some bleeding
requiring two doses of
Protamine. He was transferred to the floor on postoperative
day number one and starter on p.o. Amio for his Maze
procedure. He had his wires and chest tubes discontinued on
postop day number two and was started on Coumadin. He
continued to progress. On postoperative day number six, he
was discharged to home in stable condition.
LABORATORY DATA: On discharge, hematocrit was 28, white
count 11,800, platelets 303,000. PT 18.8; PTT 67.8. INR
2.2. His
sodium was 130; potassium of 4.2; chloride 92; C02 30, BUN
19, creatinine 1.1, blood sugar 117.
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg p.o. b.i.d.
2. Potassium 20 mEq p.o. twice a day for 7 days.
3. Colace 100 mg p.o. b.i.d.
4. Aspirin 81 mg p.o. q.d.
5. Percocet one to two every four to six hours prn for pain.
6. Allopurinol 300 mg p.o. q. Day.
7. Amiodarone 400 mg p.o. q. Day for 7 days and then decrease
to 200 mg p.o. q. Day.
8. Lasix 20 mg p.o. q. Day for seven days.
9. Coumadin 7.5 mg p.o. q. Day, to be followed by Dr. [**Last Name (STitle) **].
The patient will have coags on Monday, Wednesday and
Friday and his Coumadin will be adjusted appropriately for
an INR goal of 3 to 3.5. .
DISCHARGE DIAGNOSES: Mitral valve prolapse.
Mitral regurgitation.
Atrial fibrillation.
Gout.
FOLLOW UP: He will be seen by Dr. [**Last Name (STitle) **] in one to two weeks,
Dr. [**Last Name (STitle) **] in two to three weeks, and Dr. [**Last Name (STitle) **] in four
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2100-8-23**] 17:29:51
T: [**2100-8-24**] 05:43:33
Job#: [**Job Number **]
|
[
"4240",
"42731",
"4280"
] |
Admission Date: [**2105-2-15**] Discharge Date: [**2105-3-3**]
Date of Birth: [**2064-4-3**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Penicillins
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Acetominophen toxicity
Major Surgical or Invasive Procedure:
PICC line placement [**2105-2-16**]
History of Present Illness:
This is a 40 yo female with long h/o depression initially
admitted to MICU from OSH for eval for liver transplant for
likely acute tylenol toxicity possibly [**3-17**] suicide attempt and
now transferred to the [**Doctor Last Name 3271**] [**Doctor Last Name 679**] liver service with improving
liver enzymes and mental status.
Patient was admitted to [**Hospital 8641**] hospital on [**2105-2-14**] for worsening
depressive symptoms, auditory hallucinations, and altered mental
status. She was found to have an initial transaminitis of AST
1700 and ALT 1614 with T.bili 3.3 (direct 2.7). During her 24
hrs at [**Location (un) 8641**], she progressively worsened such that prior to
transfer, her AST was 5495, and ALT 5039 with T.bili of 3.4. Her
INR was 2.4 prior to transfer. Her creatinine was also elevated
initailly at 2.1 but improved to 1.5 prior to transfer.
At the OSH, her CT abdomen showed moderate fatty infiltration of
the liver, and abdominal US showed s/p cholecystectomy, but no
biliary dilation. There was no comment on portal vein
thrombosis. A CT head was also negative. Prior to transfer to
[**Hospital1 18**], the patient had been intubated due to worsening mental
status. There is no other documentation regarding that event.
Her vitals were stable prior to transfer. She was transferred on
a propofol gtt. She had also received a NAC infusion while at
[**Location (un) 8641**] for concern of acute acetaminophen induced hepatic
injury, though her acetaminophen level was low at the OSH. She
may have ingested large quantities of Tylenol ? days prior to
presentation - per notes, her mother states that she had emailed
her ex-husband stating she planned to OD on Tylenol and left a
suicide note.
Patient arrived at [**Hospital1 18**] on [**2-16**] and was extubated within 24
hours of arrival to [**Hospital1 18**] MICU. Patient found by transplant team
not to need liver transplant as labs have improved. Patient was
continued on NAC (INR on transfer is 1.8) and has been receiving
increasing lactulose (without bowel movements) for
encephalopathy. She also has acute renal failure, likely ATN
from Tylenol, and has been followed by the renal team. Patient
with NGT - she has had sips but otherwise not eating. Mental
status is currently somnolent.
On arrival to the floor, she is sleeping and appears
comfortable. She is not able to answer any questions. All
history was obtained from the medical records from the OSH and
the patient's husband and daughter.
Past Medical History:
1) Depression
2) s/p Appendectomy
3) s/p cholecytstectomy
4) s/p D&C
5) Acute bronchitis -> PNA in [**12/2104**]
6) Chronic R-sided chest pain with ? findings on imaging (per
husband - images were done as part of PNA work-up)
Social History:
Patient lives with her husband of ~2 years. She is unemployed.
She smokes [**2-14**] PPD and denied alcohol or drug use. Has two
sisters [**Name (NI) **] and [**Name (NI) 8771**], brother [**Name (NI) **]. [**Name (NI) 6961**] (father
[**Name (NI) **], mother [**Name (NI) 717**] [**Name (NI) 83747**] ([**Telephone/Fax (1) 83748**]) are also involved in
her life. Daughter from her previous marriage lives in
[**State 5111**].
Family History:
- Father with ETOH cirrhosis
- Both [**State **] living
Physical Exam:
Vitals - T: 97.4 BP: 127/73 HR: 101 RR: 22 02 sat: 99% on RA
GENERAL: Sleeping in bed. Opens eyes very briefly in response to
name, non-verbal at this time. Follows some commands, although
very weak/somnolent. NAD.
HEENT: NGT in place. Conjunctival hemorrhages (obtained during
transfer from OSH) obscure sclera bilaterally; skin does not
appear overtly jaundiced.
CARDIAC: Tachycardic but regular, no murmur/rub/gallop
LUNG: CTA bilaterally although exam compromised by somnolence
(cannot breathe deeply, difficult to position)
ABDOMEN: Soft, ? TTP worst over RUQ and epigastric regions, +
NABS
EXT: 2+ DP pulses bilaterally. Trace non-pitting pedal edema.
NEURO: Cannot assess sensation, strength at this time.
DERM: Some ecchymoses around eyelids (per husband, related to
taping her eyelids shut during transport from OSH)
Pertinent Results:
Labs on admission:
[**2105-2-15**] 10:16PM FIBRINOGE-202
[**2105-2-15**] 10:16PM PT-37.3* PTT-35.6* INR(PT)-3.9*
[**2105-2-15**] 10:16PM PLT COUNT-98*
[**2105-2-15**] 10:16PM NEUTS-93.5* BANDS-0 LYMPHS-4.6* MONOS-1.1*
EOS-0.3 BASOS-0.5
[**2105-2-15**] 10:16PM WBC-12.5* RBC-4.28 HGB-12.9 HCT-37.9 MCV-89
MCH-30.2 MCHC-34.1 RDW-13.9
[**2105-2-15**] 10:16PM HCV Ab-NEGATIVE
[**2105-2-15**] 10:16PM ACETMNPHN-NEG
[**2105-2-15**] 10:16PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV
Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2105-2-15**] 10:16PM OSMOLAL-292
[**2105-2-15**] 10:16PM ALBUMIN-3.4 CALCIUM-7.1* PHOSPHATE-2.8
MAGNESIUM-2.7*
[**2105-2-15**] 10:16PM ALT(SGPT)-7683* AST(SGOT)-8243* LD(LDH)-8510*
ALK PHOS-122* TOT BILI-4.0*
[**2105-2-15**] 10:16PM estGFR-Using this
[**2105-2-15**] 10:16PM GLUCOSE-155* UREA N-30* CREAT-1.6*
SODIUM-131* POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-13* ANION
GAP-22*
[**2105-2-15**] 10:21PM D-DIMER-GREATER TH
[**2105-2-15**] 11:14PM LACTATE-4.9*
[**2105-2-15**] 11:14PM TYPE-ART PO2-360* PCO2-26* PH-7.38 TOTAL
CO2-16* BASE XS--7
[**2105-2-15**] 11:17PM FDP-80-160*
Labs on discharge:
[**2105-3-2**]: WBC-9.4 Hb-10.3 Hct-30.9 Plt-228
[**2105-3-3**]: Na-137 K-4.0 Cl-103 HCO3-25 BUN-17 Cr-0.7 Glu-100
[**2105-3-3**]: Ca-9.1 Mg-1.8 Phos-3.5
[**2105-3-2**]: ALT-113 AST-80 TB-2.6 AP-139 Alb-3.6 LDH-177
[**2105-3-2**]: PTT-30.1 INR-1.0
================
IMAGING:
========
Echocardiogram [**2105-2-16**]: 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 diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild pulmonary artery systolic hypertension. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function.
========
Portable CXR [**2105-2-16**]:
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs: Very low lung volumes exaggerate heart size which
is probably normal, and produce or reflect atelectatic crowding
at the lung bases. The upper lungs are grossly clear. There is
no pleural effusion or evidence of central adenopathy. Tip of
the endotracheal tube is at the level of the lower margin of the
clavicles, no less than 15mm from the carina, probably 2 cm
below optimal placement.
========
Abdominal US with Doppler [**2105-2-16**]:
COMPARISON: None.
ABDOMINAL ULTRASOUND: The liver is diffusely echogenic. There
are no focal hepatic lesions. The right and left kidneys measure
10.7 cm and 11.9 cm in length, respectively. There is no
hydronephrosis. A right parapelvic cyst measures 2.4cm x 2.3cm x
1.8cm. The head of the pancreas is unremarkable. The body and
tail are not well seen due to bowel gas. There is no
intrahepatic ductal dilation. The patient is status post
cholecystectomy. The common duct measures 9 mm, normal in the
setting of cholecystectomy. The spleen is normal in size. The
aorta is not well seen due to bowel gas.
DOPPLER EXAMINATION: The main, right and left portal veins are
patent, with appropriate waveforms and anterograde, hepatopetal
flow. The common hepatic artery is patent, with appropriate
waveforms. The right, middle and left hepatic veins are patent,
with appropriate waveforms as well as the superior mesenteric
vein and inferior vena cava.
IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. Right parapelvic renal cyst.
3. Normal liver Doppler examination.
========
ECG [**2105-2-17**]: Sinus tachycardia, rate 103. Low R wave voltage in
leads V4-V6. Poor R wave progression. Mild non-specific ST-T
wave changes in II, III, aVF and V4-V6. These changes are
non-specific and non-diagnostic. No previous tracing available
for comparison.
Brief Hospital Course:
The following issues were addressed at this admission:
1. Acute hepatotoxicity. Believed secondary to acetominophen
overdose. Level at outside hospital was > 6, but patient likely
did not present for 1-3 days post-ingestion (patient states she
is unable to remember the exact circumstances surrounding
overdose, and husband reports that she seemed very tired/ill
about 2 days prior to admission). She was initially transferred
to the MICU for possible emergent transplantation. She was
evaluated by the transplant team here. However, with NAC and
supportive therapy, LFTs began to trend down and her mental
status slowly improved. At the time of transfer to the floor on
hospital day 3, she was still somnolent and not responding
verbally to questions. She continued to receive NAC until INR
dropped below 1.5. LFTs, bilirubin, INR have trended down
steadily. INR has now normalized, while LFTs, bilirubin are
approaching normal. She is expected to recover normal liver
function.
2. Acute renal failure. Believed secondary to ATN (muddy brown
casts, FeNa of 0.3) which is a known complication of
acetominophen toxicity. Creatinine peaked at 3.3 and then
trended down slowly to (presumed) baseline of 0.7-0.8 by the
time of discharge.
3. Electrolyte wasting. The patient was noted to become
hypokalemic and hypophosphatemic several days into this
admission, requiring maximum supplementation of 180 mEq of
potassium and [**7-21**] packets of neutra-phos daily. The potassium
wasting was suspected to be secondary to a renal tubular defect
(though patient was not acidotic at that time), given levels in
the urine > 50 mEq/L when serum values would indicate that < 5
mEq/L would be expected. She was started on amiloride at 2.5 mg
daily and increased to 5 mg daily, which reduced the urinary
potassium wasting and helped to stabilize serum K values at ~4.
She will be continued on this medication at discharge with a
plan to follow up with the nephrology team for further
outpatient management. The low phosphate may have been partially
secondary to wasting in the urine but is also common in hepatic
regeneration given increased physiologic demand. Her phos level
stabilized without the need for supplementation prior to
discharge (though patient has been encouraged to drink 1 cup of
skim milk with meals to help supplement). Finally, magnesium
levels were noted to drop several days after the K wasting
began. She continued to require [**3-19**] grams of supplementation
daily until [**2105-2-28**], when levels remained in the normal range
without supplementation. Amiloride was stopped on [**2105-2-28**] and
potassium levels remained stable in the normal range. She will
require follow up of her electrolytes at her outpatient renal
follow up appointment.
4. Depression. After regaining full consciousness, the patient
acknowledged that she has been struggling with depression for
some time. She states that she is "terrified" that she tried to
hurt herself in this way. After much negotiation, the patient's
husband brought in a note that she had written, stating that
voices were telling her that it was time to die. In addition,
her mother reported that she had sent an email to her ex-husband
threatening acetominophen overdose several days prior to
admission; her current husband denied knowledge of this event.
She was followed by psychiatry and social work throughout this
admission, and maintained off all psych meds (including home
Xanax and Seroquel). She is future-oriented and expresses
interest in inpatient psychiatric therapy. She has generally
received good social support from her family (sisters, daughter,
husband, [**Name2 (NI) **]) throughout this stay, and states that much
healing has taken place between her family members. Of note,
during her time on the floor, she was placed under 1:1
observation by a sitter for her own safety. Several mornings
prior to discharge, the patient told the team that she had been
verbally abused by three consecutive night sitters (stating that
they had made comments such as "If I were your daughter, I would
never forgive you" and "If I were your husband, I would never
let you leave the house again." This incident was reported to
the sitter coordinator and is under investigation. However,
there is suspicion that the patient either fabricated these
accusations or perhaps hallucinated (she had reported
hallucinations at the time of admission to the OSH, and could
possibly have depression with psychotic features or other
psychiatric disorder), as these were three independent staff
members and this is unexpected behavior from staff, who are
generally well-trained. These issues require further
investigation by her future psychiatry team. On the day of her
discharge, her psychiatry team determined that she was no longer
actively suicidal and cancelled her Section 12 and requirement
for 1:1 sitter. At the patient's request, she was discharged
later that same evening with the understanding that she will be
referred to an outpatient program or personal psychiatrist.
Medications on Admission:
1) Seroquel 300 mg QHS
2) Xanax 1 mg q8H PRN
3) Valerian root for insomnia (per husband)
4) Melatonin for insomnia (per husband)
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia: Please attempt to wean off of this
medication within 2 weeks.
Disp:*7 Tablet(s)* Refills:*0*
2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (FR) for 4 weeks.
Disp:*4 Capsule(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
4. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Acute hepatotoxicity secondary to acetominophen overdose
- Acute tubular necrosis secondary to acetominophen overdose
- Renal tubular defect (exact pathophysiology uncertain; no
acidosis) resulting in electrolyte wasting presumed secondary to
acetominophen overdose
- Depression
- Hypokalemia
- Hypomagnesemia
- Hypophosphatemia
SECONDARY:
- Anxiety
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were transferred to [**Hospital1 69**]
with liver toxicity related to acetominophen (Tylenol) overdose.
You were initially admitted to the ICU and evaluated by the
transplant team for possible liver transplantation. However,
with appropriate supportive care, your liver function recovered.
You were also noted to have kidney failure upon arrival to
[**Hospital1 18**]. You were evaluated by the renal team, who felt that your
kidney failure was related to the acetominophen overdose. You
were noted to pass large amounts of electrolytes in your urine,
which was felt also to be related to the kidney injury by the
acetominophen. Your electrolytes were closely monitored and you
received appropriate supplementation.
Because of concern that your overdose was intentional, you were
followed closely by the psychiatry team during your stay. They
initially recommended transfer to an inpatient psychiatric
facility where you would therapy to address issues of underlying
depression and mental health problems. Today the psychiatry team
met with you and felt as you were not longer endorseing suicidal
thoughts, it would be safe to be discharged home with a half day
program to be arranged tomorrow. You will be contact[**Name (NI) **] by the
psychiatric case manager tomorrow to arrange this. Please call
[**Telephone/Fax (1) 23827**] and ask for Dr. [**Last Name (STitle) 19784**] or Dr. [**First Name (STitle) **] if you do
not hear from someone tomorrow.
We have made the following changes to your medication regimen:
- STOP TAKING Xanax (you will be treated for anxiety according
to recommendations from your inpatient pscyhiatry team)
- STOP TAKING Seroquel (you will be treated for depression
according to recommendations from your inpatient pscyhiatry
team)
- TAKE AS NEEDED Ambien (zolpidem) for insomnia. You should try
to wean yourself off of this medication within two weeks, as it
may become habit-forming and is not intended for long-term use.
Please keep your follow up appointments as outlined below.
Followup Instructions:
You have a follow up appointment scheduled with your primary
care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2104-3-17**] at 1:30pm. Please
call if you need to reschedule: ([**Telephone/Fax (1) 83749**].
Liver:
You have a follow up appointment scheduled with Dr. [**Last Name (STitle) 696**] at
3:20pm on [**2104-4-23**] at the [**Hospital1 18**] Liver Center. Please call if you
have questions or need to reschedule.
Renal:
You will need to follow up with the kidney doctors who treated
[**Name5 (PTitle) **] while in the hospital. Someone from their department will be
contacting you to arrange an appointment with Dr. [**Last Name (STitle) **]
or one of her colleagues. Their office number is ([**Telephone/Fax (1) 10135**]
Completed by:[**2105-3-4**]
|
[
"51881",
"5845"
] |
Admission Date: [**2122-7-15**] Discharge Date: [**2122-7-21**]
Date of Birth: [**2065-6-6**] Sex: M
Service:
CHIEF COMPLAINT: Increasing shortness of breath.
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 42982**] is a 57-year-old
male who was diagnosed with a silent MI in [**2122-1-20**],
based on an abnormal EKG. Thallium stress test was
subsequently performed, which was positive. Consequently,
the patient was taken to cardiac catheterization. Cardiac
catheterization on [**2122-6-19**] revealed left main 40% stenosis
LAD 100% occluded, ramus 95% stenosed, circumflex 20%
stenosis, right coronary artery 95% stenosed. Cardiac
echocardiogram on [**2122-5-12**] revealed an ejection fraction of
35% to 40% with multiple akinetic areas. Over the past
several months, Mr. [**Known lastname 42982**] also experienced nausea,
diaphoresis, and increasing shortness of breath. He has not
noticed any symptoms of chest pain. Mr. [**Known lastname 42982**] was
subsequently evaluated for CABG.
PAST MEDICAL HISTORY:
1. Non-Insulin-dependent diabetes mellitus.
2. CVA three years ago without residual deficit.
3. Myocardial infarction.
4. Gastroesophageal reflux disease.
5. Peripheral vascular disease.
6. Morbid obesity.
7. Peripheral neuropathy.
8. Status post left knee scope.
9. Repair of left second finger laceration.
FAMILY HISTORY: The patient's father is deceased from a MI
at the age of 61. Mother is deceased from CVA was the age of
54.
SOCIAL HISTORY: The patient does not use tobacco and is a
rate drinker. The patient is a high school English teacher.
MEDICATIONS:
1. Aspirin 325 mg p.o.q.d.
2. Mavik 1 q.d.
3. Toprol 50 q.d.
4. Glucophage 250 mg p.o.b.i.d.
5. Glucotrol XL 5 mg p.o.b.i.d.
6. Indocin 75 mg p.o.b.i.d.p.r.n. last dose was on [**7-8**].
ALLERGIES: The patient has no known drug allergies.
REVIEW OF SYSTEMS: Review of systems is negative, unless
otherwise, stated above.
PHYSICAL EXAMINATION: Examination revealed the following:
GENERAL: The patient is morbid obesity, well nourished. He
is 6 feet 1 inch and weighs 300 pounds. VITAL SIGNS: Heart
rate 82, blood pressure 145/87 right arm; 106/76 left arm.
He is afebrile. HEENT: Normocephalic, atraumatic. NECK:
Supple. CHEST: Chest was clear to auscultation bilaterally.
HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender,
nondistended. EXTREMITIES: Extremities were well perfused
with 1+ pedal edema. NEUROLOGICAL: Examination was
nonfocal.
HOSPITAL COURSE: Mr. [**Known lastname 42982**] was taken to the operating room
on [**2122-7-15**], where a CABG times three was performed. Graft
included LIMA to LAD, SVG to ramus, SVG to descending RCA.
Mr. [**Known lastname 42982**] [**Last Name (Titles) 8337**] surgery well and was transferred to the
Surgical Intensive Care Unit. He was weaned off drips and
hemodynamically monitored. He was extubated on postoperative
day #1 and stabilized. Chest tubes and pacing wires were
discontinued on postoperative day #3. The patient was
adequately fluid resuscitated and hemodynamically stable.
The patient was thus transferred to the floor. Mr. [**Known lastname 42982**]
recovered well while on the floor. He was taking good p.o.
diet and ambulating well, completing a level 5 physical
therapy assessment.
On postoperative #5, Mr. [**Known lastname 42982**] had a few episodes of
bigeminy and PVCs. He was asymptomatic and hemodynamically
stable during these incidents. He was monitored for the next
twenty-four hours without incident. Mr. [**Known lastname 42982**] was
consequently found to be stable to be discharged to his home
with the visiting nurse assistance.
Examination on discharge revealed the following: VITAL
SIGNS: Temperature maximum 98.6, temperature current 97.9,
blood pressure 105/52, pulse 69, respirations 18, oxygen
saturation 98% on room air, 1300 in and 1700 out. The
patient was normocephalic, atraumatic. Neck was supple.
Heart was regular rate and rhythm. Lungs were clear to
auscultation bilaterally. Incision was clean, dry, and
intact. Abdomen was soft, nontender, nondistended,
normoactive bowel sounds. There was trace edema in bilateral
lower extremities.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o.q.d.
2. Docusate 100 mg p.o.b.i.d.
3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o.b.i.d. times 14 days.
4. Lasix 20 mg p.o.b.i.d. times 14 days.
5. Metoprolol 25 mg p.o.b.i.d.
6. Metformin 250 mg p.o.b.i.d.
7. Glucotrol XL 5 mg p.o.b.i.d.
8. Percocet 5/325 one to two tablets q.4h. to 6h.p.r.n.
pain.
FO[**Last Name (STitle) **]P CARE: Mr. [**Known lastname 42982**] is to follow up with Dr. [**Last Name (STitle) 37063**]
in three to four weeks. He is also to call Dr. [**Last Name (STitle) 37063**] to
discuss the diabetic regimen. The patient is also to follow
up with Dr. [**Last Name (Prefixes) **] in four weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient is to be discharged home with
[**Hospital6 **].
DIAGNOSIS: Status post coronary artery bypass graft times
three.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 12370**]
MEDQUIST36
D: [**2122-7-21**] 14:04
T: [**2122-7-21**] 14:15
JOB#: [**Job Number 42983**]
|
[
"41401",
"42731",
"25000",
"53081",
"412"
] |
Admission Date: [**2169-9-1**] Discharge Date: [**2169-9-2**]
Date of Birth: [**2119-6-16**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
none
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 50 year old right-handed man presenting
with a few weeks of progressively worsening headache. He rarely
has headaches (certainly no migraine or recurrent severe
headaches), but he started having a headache after sustaining a
head injury on [**2169-8-3**]. He was driving his car and was
broad-sided on the passenger side, causing him to hit the left
side of his head on the side window. He did not lose
consciousness and was not stunned, but actually was able to
drive
home (after the rather unpleasant other driver confronted him).
He had no external evidence of head trauma. He started having a
bitemporal, vertex, neck, and back achy that was predominantly
pulsatile, sometimes with a stabbing "needle-like" paroxysmal
pain in his eyes. The headache has been constant with no
temporal
relationship, but of concern it actually has awakened him from
sleep in the early morning hours. Getting up and walking around
has not helped; neither has the [**8-25**] Ibuprofen tablets he takes,
sometimes every day. The headache has been gradually worsening
over time, and he finds that he is becoming quite lethargic with
the headache, sleeping all day while he is usually a very active
person. He has had nausea with the headache and has started to
eat less, perhaps losing 5 lbs during this time due to the
nausea. Otherwise he had no weight loss before this. He does
think he has had some subjective (unmeasured) fevers. He denies
drenching night sweats but has felt slightly sweaty at times. He
thinks he may have had one of his usual "seizures" two days ago
(described as feeling lightheaded, then hot and sweaty, then he
lays down to prevent loss of consciousness, then has some [**Last Name (un) 5083**]
vu), but otherwise has had no apparent increased frequency above
his usual.
On neurologic review of systems, the patient endorses headache.
Denies lightheadedness, or confusion.
Denies difficulty with producing or comprehending speech.
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
Denies loss of sensation.
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient endorses subjective
fevers. Denies rigors, night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
[] Neurologic - Possible/questionable seizures (lightheaded,
fatigue, [**Last Name (un) 5083**] vu, +/- LOC), Left hearing loss
[] Psychiatric - Anxiety, depression
[] Cardiovascular - Hyperlipidemia
Social History:
Works as a waiter. +Tobacco, 1ppd x 20 years. No
ETOH. No illicit drug use.
Family History:
Heart valve issue (mother). No seizures. No
malignancies.
Physical Exam:
VS T: 98.8 HR: 68 BP: 136/78 RR: 18 SaO2: 98% RA
General: NAD, lying in bed comfortably, tired appearing
middle-aged man. / Head: NC/AT, no conjunctival icterus, no
oropharyngeal lesions / Neck: Supple, no nuchal rigidity, no
meningismus, no bruits / Cardiovascular: RRR, no M/R/G /
Pulmonary: Equal air entry bilaterally, no crackles or wheezes /
Abdomen: Soft, NT, ND, +BS, no guarding / Extremities: Warm, no
edema, palpable radial/dorsalis pedis pulses / Skin: No rashes
or
lesions / Psychiatric: Appropriate and friendly affect congruent
with mood, pleasant, joking manner
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily attained and maintained. Concentration
maintained
when recalling months backwards. Recalls a coherent history.
Structure of speech demonstrates fluency with full sentences,
intact repetition, and intact verbal comprehension. Content of
speech demonstrates intact naming (high and low frequency) and
no
paraphasias. Normal prosody. No dysarthria. Verbal registration
and recall [**3-18**]. No apraxia. No evidence of hemineglect. No
left-right agnosia.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number
counting. Funduscopy shows crisp disc margins, no papilledema.
[III, IV, VI] EOMI, 3-4 beats extreme end gaze nystagmus
bilaterally, fatigable. [V] V1-V3 without deficits to light
touch
bilaterally. [VII] Left lip downturned, but normal movement with
volitional smile; driver's license photograph reveals asymmetric
smile at baseline. [VIII] Hearing intact to finger rub
bilaterally. [IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]]
SCM/Trapezius strength 5/5 bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
tremor
or asterixis. No myoclonus.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [C5] [R 5] [L 5]
Biceps [C5] [R 5] [L 5]
Triceps [C6/7] [R 5] [L 5]
Extensor Carpi Radialis [C6] [R 5] [L 5]
Extensor Digitorum [C7] [R 5] [L 5]
Flexor Digitorum [C8] [R 5] [L 5]
Interosseus [C8] [R 5] [L 5]
Abductor Digiti Minimi [C8] [R 5] [L 5]
Leg
Iliopsoas [L1/2] [R 5] [L 5]
Hip Adductors [L3] [R 5] [L 5]
Hip Abductors [S1] [R 5] [L 5]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 5] [L 5]
Tibialis Anterior [L4] [R 5] [L 5]
Gastrocnemius [S1] [R 5] [L 5]
Extensor Hallucis Longus [L5] [R 5] [L 5]
Extensor Digitorum Brevis [L5] [R 5] [L 5]
Flexor Digitorum Brevis [S1] [R 5] [L 5]
- Sensory - No deficits to light touch, pinprick, or
proprioception bilaterally.
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. No Romberg.
Pertinent Results:
Laboratory and Imaging Data:
NC Head CT: large area of right temporal parietal enhaning mass
with
vasogenic edema, possibly underlying soft tissue abnormality,
about 10mm midline shift to left, possible minor hemorrhage
component
MRI Head c/s contrast: (my impression) contrast-enhancing right
frontal lesion with significant vasogenic edema and midline
shift, also with necrotic core
WBC 12.7, Hgb 16.8, Plt 346, MCV 92, Na 139, K 4.2, Cl 104, HCO3
28, BUN 16, Cr 0.7, Glu 93
Brief Hospital Course:
Patient was admitted to Neurosurgery on [**2169-9-1**] for further
evaluation. He was started on dexamethasone 4mg Q6h for
cerebral edema. A CT Chest was obtained given his smoking
history which showed no apparent lung mass.
Surgical intervention was discussed. Patient wished to be
discharged and follow-up for surgery this week. Now DOD, patient
is afebrile, VSS, and neurologically stable.
Medications on Admission:
keppra 1500bid, sertaline 50qd
Discharge Medications:
1. Acetaminophen-Caff-Butalbital [**1-16**] TAB PO Q4H:PRN pain,
headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s)
by mouth every six (6) hours Disp #*40 Tablet Refills:*0
2. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth Q6 hours Disp #*60
Tablet Refills:*0
3. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. LeVETiracetam 1500 mg PO BID
5. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch daily Disp #*30 Each
Refills:*0
6. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
right brain mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have been diagnosed with right temporal parietal brain mass.
You were started on dexamethasone 4mg Q6hours. You should
continue on this to keep the swelling in your head down.
You are on Keppra for seizures, you should continue on this.
You were started on pepcid, please continue this while on
dexamethasone
Followup Instructions:
Please call [**Telephone/Fax (1) 1669**] to schedulre your surgery with Dr.
[**Last Name (STitle) 739**] for this week.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2169-9-2**]
|
[
"2724",
"311",
"3051"
] |
Admission Date: [**2188-5-19**] Discharge Date: [**2188-6-20**]
Date of Birth: [**2166-7-20**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Pt presents on [**2188-5-19**] for one-stage Ileopouch-anal anastomosis.
Major Surgical or Invasive Procedure:
1. Ileopouch-Anal Anastomosis
2. Exploratory Laparotomy with diverting ileostomy
3. Primary Incision CLosure
History of Present Illness:
Pt has an established history of ulcerative colitis. He has been
on chronic steroids, at a dose of 5mg/d upon admission. Due to
recurrent symptoms, pt wishes for surgical therapy.
Past Medical History:
ulcerative colitis. No other significant medical history.
Social History:
21yo Graduate student.
Family History:
Positive for IBD. Father died of colon CA at 43yo.
Physical Exam:
Thin, healthy-appearing young man. Abdominal exam reveals no
masses, tenderness, ascites. Physical exam otherwise
unremarkable.
Brief Hospital Course:
Patient had long, complicated hospital course. In overview, pt
tolerated initial procedure well. On [**5-25**], pt began having
copious bilious vomiting as well as copious bowel movements.
Later that evening he became hypotensive and severely
tachycardic, with declining mental status. Pt transferred to
SICU, intubated, and taken to OR for exploratory laparotomy and
diverting ileostomy; primary incision left open due to abdominal
compartment syndrome. Pt continued to be hypotensive requiring
pressure support for several days, with significant accompanying
electrolyte abnormalities. Pt stabilized and normotensive in
SICU, abdomen closed with open superficial layers on [**5-28**]. Pt
remained in SICU until [**6-5**], transferred to floor. On floor, pt
had an erratic course with fluctuations in fluid status and
severe fluctuations in heart rate. In consultation with renal
and endocrine services, electrolyte and fluid status issues were
resolved, and patient discharged home with midline venous
catheter for prn fluid support, and appropriate VNA services.
In greater depth, consider hospital course by system:
Neuro: Pt admitted in excellent neuro condition, continued until
[**5-25**] during suspected hypoadrenal crisis when pt experienced
significant decline in mental status. Pt underwent appropriate
rapid sequence induction for intubation in SICU, and due to his
open abdomen was maintained on propofol and fentanyl until [**5-31**].
When these drips were stopped, pt recovered normal mental status
and was noted to have no neurologic deficits throughout the rest
of his hospital course.
Cardiovascular: Unremarkable until [**5-25**], when as noted pt became
hypotensive to 80s/40s and tachycardic to 180s. This continued
despite aggressive fluid resuscitation. Upon transfer to SICU,
patient started on levophed and pitressor to maintain blood
pressures. Gradually weaned off thsee drips with appropriate
recovery of blood pressure, pt essentially normotensive by [**5-31**].
Upon transfer to floor on [**6-5**], pt continued to have erratic HR.
Although pt denied any orthostatic symptoms, he would have HRs
of 80-90 at rest, and 160-170 upon standing or walking. BPs
remained on the low end of normal and were stable. As patient's
fluid status gradually stabilized, his HR also stabilized, with
modest changes in HR most likely due to deconditioning after a
[**Hospital 47424**] hospital stay.
Respiratory: Pt on vent while in SICU. Pt extubated [**5-29**].
Excellent use of incentive spirometer. On [**6-2**] pt was found to
have left pnuemothorax, and a chest tube was placed. Appropriate
suction therapy, wound healed and sealed and pneumothorax
resolved by [**6-17**].
Endocrine: A hypoadrenal crisis is believed to be the central
insult giving rise to pt's rapid decompensation and subsequent
arduous course. On night of [**5-25**] was administered stress dose
steroids in response to tachycardia unresponsive to fluid
resuscitation. In SICU pt noted to have bizarre electrolyte
abnormalities, including sodiums up to 160, with concomitant
concentrated urine. Electrolytes stabilized in SICU, and upon
transfer to floor pt remained eunatremic despite significant
fluid shifts and fluctuating urine osmolarity. Pt tried on
Florinef to assist mineralocorticoid function, but this was of
minimal help.
Renal: Initially no renal issues were suspected. However, late
in hospital course as it appeared that pt was unable to
concentrate urine despite net fluid loss, a more intensive renal
workup was pursued. Diagnosis of DI was considered and rejected
in the face of concentrated urine under light fluid load. Also
considered was a diagnosis of solute diuresis, powered by excess
urea creation from steroid therapy and increased protein intake.
24hr-urine studies argued against this, as urine osmolarity was
low. Renal team decided that, under stress of past month, pt had
simply washed out his interstitial gradient and in the presence
of polydipsia would be unable to appropriately concentrate
urine. As pt is otherwise quite healthy, they are quite
confident that he will recover this gradient through liberal
administration of salt.
ID: Although pt never had a confirmed infectious process
contributing to his condition, he was started empirically on IV
Levo/Flagyl on [**5-25**]. He subsequently developed oral thrush and
Fluconazole was added to his regimen. Levo/Flagyl discontinued
on [**6-5**], Fluconazole discontinued on [**6-8**].
FEN: After [**5-25**], pt's electrolytes fluctuated considerably, with
sodiums in the 160s while in the SICU. He had a complex diuresis
with confusing urine osmolarities, further complicated by
concomitant administration of pitressor. Pt nutrition status
while on the floor, although supplemented early in his hospital
course with TPN, continued to be poor, and he lost a significant
amount of weight. As he began tolerating more po intake, the
pt's diet was supplemented with Boost. Although there was
concern from Renal that excess protein may be driving a solute
diuresis, the opinion of the surgical team was that in the
setting of a large healing wound, a new ostomy, and general
post-operative condition, the pt needed significant protein
intake and as a compromise he was continued on a moderate
protein diet. Of note, pt was discharged home with a Midline for
prn IV fluids until his renal issues (as discussed above) could
be resolved.
GI: Pt with total colectomy and ileoanal pouch for UC. Pouch
output finally begun on [**5-25**], however the triumph of this was
overshadowed by darker events that evening. Due to abdominal
compartment syndrome of 6.27, pt was given diverting ileostomy
and open abdomen to assist recovery. [**Name (NI) 47425**] pt was
found to be in a profound ileus with copious dark fluid in the
small intestine, though the anastomosis remained quite secure.
Although abdomen was closed with resolution of intra-abdominal
pressure, ileostomy takedown will not be for a while. On the
floor, pt gradually began having good flow from his ostomy, and
in fact output became so high he was started on significant
doses of loperamide, as his ostomy output was felt to be
contributing to his general hypovolemia.
Medications on Admission:
6-Mercaptopurine
Prednisone 5mg qd
Discharge Medications:
1. Loperamide HCl 2 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) as needed for diarrhea for 30 days.
Disp:*120 Capsule(s)* Refills:*2*
2. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3
times a day) for 30 days.
Disp:*90 Tablet(s)* Refills:*2*
3. Florinef Acetate 0.1 mg Tablet Sig: Three (3) Tablet PO once
a day: Taper as per endocrine doctor's
recommendation.
Disp:*90 Tablet(s)* Refills:*2*
4. Prednisone 2.5 mg Tablet Sig: Five (5) Tablet PO every twelve
(12) hours for 4 weeks: You are one a steroid TAPER. Take 5
tablets in the morning and evening. Do this for 4 days. Then
take 5 tablets in the morning and 4 in the evening for 4 days.
Then take 4 and 4 for 4 days. Then take 4 and 3 for 4 days. Then
take 3 and 3 for 4 days. Then take 3 and 2 for 4 days. Then take
2 and 2 (10mg total per day), and stay on this dose until you
see the Endocrine doctor (Dr [**Last Name (STitle) **] to assess how best to
continue. You will be in regular contact with Dr [**Name (NI) **]
throughout this time, and he may change your dosages. In that
case, follow his instructions exactly, and disregard these.
Disp:*200 Tablet(s)* Refills:*2*
5. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day: DO
NOT TAKE THESE UNLESS SPECIFICALLY INSTRUCTED BY DR [**Last Name (STitle) **]
OR DR [**Last Name (STitle) 13645**]! These are being supplied to you so that, in
case they change your steroid taper, you will have
smaller-dosage pills available.
Disp:*150 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for chest pain.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Ulcerative Colitis
Dehydration
Hypoadrenal crisis
Renal Disorder Not Otherwise Specified, Polyuria
Discharge Condition:
Good.
Discharge Instructions:
No heavy lifting for 6 weeks. You may eat and shower as normal.
Please try to drink plenty of fluids, as you are at increased
risk for dehydration. Follow instructions on care for your Mid
line, your osotmy, and your wound care. Please follow up with
Renal service per their instructions, and follow up with Dr
[**Last Name (STitle) **] in 2 weeks.
Pay attention to signs of dehydration. If you feel unusually
weak, tired, or dizzy upon standing, you may need supplemental
fluids. If you notice your heart rate climbing, this may also be
a sign you need supplemental fluids. Hot weather and significant
sun exposure can cause you to be dehydrated more quickly, so be
sure to rehydrate often when outside.
Followup Instructions:
Pt to follow-up with Dr [**Last Name (STitle) **] in 2 weeks.
Please call Dr[**Name (NI) 47426**] office [**Telephone/Fax (1) 1803**] to set up an appt
with her. Please tell the receptionist she specifically wanted
to see you when your prednisone dose was 10mg/day.
Please call the [**Hospital 2793**] Clinic at [**Telephone/Fax (1) 60**] to set up an appt
with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1860**]. She will see you in conjunction with Dr
[**Last Name (STitle) **].
|
[
"2760"
] |
Admission Date: [**2105-2-6**] Discharge Date: [**2105-2-14**]
Date of Birth: [**2036-12-8**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old
male with a one month history of exertional angina and
occasional rest angina who underwent a cardiac
catheterization on [**2105-2-6**] which demonstrated a 70% stenosis
of left main, 30% stenosis at the origin of the LAD and a 70%
stenosis involving large first diagonal and a slightly more
serious 80% stenosis a bit distally on that vessel. Also a
30% stenosis of the left circumflex, 90% stenosis of the left
circumflex after the OM1 and 80% before larger branch back to
the OM2 and 100% right mid RCA stenosis.
PAST HISTORY: Significantly the patient has a past medical
history of chronic renal insufficiency, hypertension,
hypercholesterolemia, positive family history for father with
MI at 66 and a brother with an MI at age 53 and also had a
past surgical history of anal fissure surgery, some knee
surgery and appendectomy in the remote past. The patient has
no known drug allergies.
HOSPITAL COURSE: Based on the findings at cardiac
catheterization, cardiothoracic surgery was consulted and
deemed appropriate for coronary artery bypass surgery. So on
[**2105-2-9**] the patient was taken to the operating room where he
underwent a coronary artery bypass grafting times five, his
grafts were LIMA to LAD, sequential saphenous vein to OM1 and
OM2, saphenous vein to PDA and saphenous vein to diag. The
patient tolerated the procedure well without complication.
Postoperatively was transferred to the cardiac surgery
recovery unit, maintained on Neo-Synephrine and Amiodarone
was started for postoperative atrial fibrillation. The
patient was weaned off his pressors, started on a diet and
transferred out of the ICU. On the floor the patient was
weaned off his pacer, had his chest tubes and wires removed
and began working with physical therapy and was deemed safe
for discharge home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS: Colace 100 mg po bid, Lasix 20 mg po
bid for 7 days, Zantac 150 mg po bid, ASA 325 mg po q d,
Lescol 20 mg po q h.s., KCL 20 mEq po q day for 7 days,
Amiodarone 400 mg po q day, Metoprolol 12.5 mg po bid and
Percocet 5/325 [**11-19**] po q 4-6 hours prn for pain.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2105-2-14**] 09:04
T: [**2105-2-14**] 09:16
JOB#: [**Job Number **]
|
[
"41401",
"42731",
"4019",
"2720"
] |
Admission Date: [**2181-8-17**] Discharge Date: [**2181-8-30**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Acute Right SDH
Major Surgical or Invasive Procedure:
[**8-17**]: Right Sided Craniotomy for subdural hematoma evacuation
History of Present Illness:
[**Age over 90 **] year old female history of dementia, HTN, glaucoma, s/p fall
1 week prior to admission, now presenting with increasing
lethargy and unresponsiveness. She was taken to OSH where
imaging revealed a large right sided SDH, and she was then
transferred to [**Hospital1 18**] for definitive neurosurgical care.
Past Medical History:
Dementia
HTN
Glaucoma
CAD s/p stent and Pacemaker
Depression
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
On Admission:
T: 100.1 BP: 100/41 HR:68 R:14 100% O2Sats
Gen: Intubated not responsive, does not open eyes,slight grimace
and nox stim
HEENT: NC/AT
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:Mental status: Does not open eyes, slight grimace to
sternal rub.
Cranial Nerves: Patient appears to have gag reflex, corneal
reflexes intact. L pupil 3mm and fixed, Right pupil surgical.
VOR intact
Motor: Patient not moving or withdrawing arms. Withdraws legs
b/l to nox stim.
-Sensory: Patient has intact sensation to pain at LE, chest and
UE.
Patient has b/l Babinski
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Coordination and gait not tested
Exam on Discharge:
XXXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2181-8-17**] 03:00PM BLOOD WBC-11.7* RBC-3.26* Hgb-7.0* Hct-23.2*
MCV-71* MCH-21.4* MCHC-30.0* RDW-16.8* Plt Ct-296
[**2181-8-17**] 03:00PM BLOOD Neuts-83.6* Lymphs-10.6* Monos-5.2
Eos-0.4 Baso-0.2
[**2181-8-17**] 03:00PM BLOOD PT-13.5* PTT-28.0 INR(PT)-1.2*
[**2181-8-17**] 03:00PM BLOOD Glucose-148* UreaN-23* Creat-0.7 Na-139
K-3.4 Cl-107 HCO3-24 AnGap-11
[**2181-8-17**] 08:30PM BLOOD Calcium-8.8 Phos-4.3 Mg-2.0
[**2181-8-18**] 03:53AM BLOOD Phenyto-15.1
Labs on Discharge:
XXXXXXXXXXX
-------------------
IMAGING:
-------------------
Head CT [**8-17**]:
FINDINGS: There is a right crescentic hyper-attenuating area
layering over
the convexity, likely a subdural hematoma. At the level of the
lateral
ventricles superiorly (series 2, image 19), it measures
approximately 1.5 cm, similar to the study from approximately
three hours prior. Again, there is effacement of the right
lateral ventricle with leftward midline shift of approximately 7
mm, similar to prior. No new focus of intracranial hemorrhage is
seen. Some of the subdural extends into the parafalcine area on
the right. There is mild edema, and the ventricles, sulci, and
cisterns appear similar to prior. Basal cisterns are preserved.
There is no depressed skull fracture. Mastoid air cells and
visualized paranasal sinuses are unremarkable. Scleral plaques
are seen.
IMPRESSION: Stable appearance to right convexity subdural
hematoma with
unchanged leftward midline shift.
Head CT [**8-17**](Post-op):
FINDINGS: The patient is status post right-sided craniectomy for
evacuation
of a large right-sided subdural hematoma. Most of this hematoma
has been
evacuated although residual amount of hemorrhage is seen
overlying the right frontal lobe. There is extensive
pneumocephalus extending along the right hemisphere and also
over the left frontal lobe in addition to the right anterior
temporal lobe. A small focus of air is also seen anterior to the
left temporal lobe. There is still a mild leftward shift of
midline
structures of 4 mm, decreased from 7 mm. No intraparenchymal
hemorrhage is
seen. [**Doctor Last Name **]-white matter differentiation is preserved. Visualized
paranasal
sinuses and mastoid air cells remain clear.
IMPRESSION: Status post right-sided craniectomy for evacuation
of subdural
hematoma. Small amount of hemorrhage remains overlying the right
frontal lobe and right occipital lobe. Decrease in leftward
shift of midline structures, now 4 mm down from 7 mm.
CXR [**8-17**]:
IMPRESSION:
Satisfactory placement of a new right central venous catheter
with no
pneumothorax. Stable small right pleural effusion and left lower
lobe
atelectasis.
CXR [**8-21**]:
The Dobbhoff tube tip continues to be in proximal stomach. The
pacemaker
leads terminate in right ventricle. The right subclavian line
tip is at the
level of cavoatrial junction. Cardiomediastinal silhouette is
unchanged
including mild cardiomegaly. Bibasal atelectasis and bilateral
pleural
effusions are unchanged. No overt infection is present. Loose
bodies are
demonstrated in the right glenohumeral joint.
Rt Foot [**8-21**]:
FINDINGS: There is a comminuted, slightly angulated fracture of
the proximal phalanx of the fourth digit. The proximal phalanx
of the fifth digit is not well seen and the possibility of a
fracture in this region cannot be unequivocally excluded.
Brief Hospital Course:
#) Course with neurosurgery: Patient is a [**Age over 90 **]F who was
transferred to [**Hospital1 18**] after OSH imaging revealed a right sided
acute SDH. This finding was likely resultant from a fall that
the family reports occurred one week prior to admission. The
family was extensively counseled, and elected for decompressive
craniotomy and evacuation of blood products. She went to the OR
on the evening of [**8-17**]. Procedure was uneventful, and she was
returned to the ICU post-operatively. On [**8-18**], Aspirin was
started given her history of CAD with stend and pacemaker
placement. CXR imaging performed in the emergency department
revealed a consolidation consitent with a likely pneumonia and
antibiotics were started. On [**8-19**] bronchoscopy was performed for
confirmation and GNR were isolated. She was continued on
Ceftriaxone for this purpose. On [**8-20**] she was sucessfully
extubated. She was requiring oxygen. On [**8-21**] her right lateral
foot and 4th digit was noted to be ecchymotic and exquisitely
tender. X-ray imaging revealed a comminuted, slightly angulated
fracture of the proximal phalanx of the fourth digit. Transfer
orders for the Step Down unit were performed.
.
On transfer to medicine service:
.
#) Altered mental status: since her evacuation, patient had a
difficult time waking up, and arrived to us with sluggishly
reactive pupils, periodically spontaneously opening her eyes,
withdrawing to pain and moving all four extremities. Her mental
status was complicated by hypernatremia, hypoxia related to
volume overload and possible infection, in addition to her
recent SDH and midline shift. As her hypernatremia corrected,
her mental status initially improved after a few days, then she
again became more unresponsive, not opening her eyes
spontaneously and having more difficulty supporting herself in
bed.
.
#) Hypoxia: throughout her stay on the medicine service, patient
had a perisistent tachypneia and oxygen requirement. Initially,
her chest x-ray showed severe pulmonary edema and large
bilateral pulmonary effusions, which improved with IV diuresis,
however the effusions remained and her oxygen requirement also
did not improve. An echocardiogram was done earlier in her
hospital course, which showed right sided heart strain, and
concern for PE, however given recent SDH, patient would not be
anticoagulated, so no further imaging was obtained. Patient had
also had a persistent leukocytosis, and given the coarse breath
sounds on pulmonary exam, she was started on levaquin for
presumed pnuemonia. She had been receiving nebulizer
treatments, and morphine to help with her tachypneia during her
stay.
.
#) Hypernatremia: patient initially had a sodium of 155, daily
free water deficits were calculated and free water was repleted
via her dobhoff tube, once her sodium normalized, her mental
status did not improve with correction of her sodium.
.
#) Goals of Care: on transfer of care to medicine palliative
care had been consulted, and it was clear that the goals of care
from the daughter's point of view were comfort oriented. As the
patient's mental status improved and then deteriorated again, we
had a family meeting where the decision was made on [**2181-8-29**] to
make the patient comfort measures only, and she was started on a
morphine drip with ativan, and passed away at 0520 on [**2181-8-30**].
Medications on Admission:
Amlodipine 5mg QD
Aricept 5mg QD
ASA 81mg QD
Citalopram 20mg QD
Effexor 75mg QD
Lamotrigine 25mg QD
Plavix 75mg QD
Simvastatin 10mg QD
Timolol 0.5% eye drop each eye QHS
Lorazepam 0.5mg QD PRN
Discharge Medications:
None-patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute Right Subdural Hematoma
Comminuted, angulated fracture of the proximal phalanx of the
fourth digit.
Respiratory failure
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"51881",
"5070",
"486",
"5849",
"2760",
"9971",
"2851",
"4280",
"4019"
] |
Admission Date: [**2157-9-4**] Discharge Date: [**2157-9-27**]
Date of Birth: [**2095-12-13**] Sex: F
Service: NEUROLOGY
Allergies:
Bactrim
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation/Extubation
Ventricular Drain Placement
History of Present Illness:
Ms [**Known lastname **] is aged 61 year-old and is right-handed. She has a
history of chronic right posterioir tibial osteomyeltitis,
hypertension & LUE DVT on coumadin theraphy, presented with
acute mental status change upon waking up at 8am this morning.
According to her daughter, she found Ms [**Name (NI) **] lying in bed
moaning. She openned her eyes and was verbal. There were no
complaints of headache or pain. Ms [**Known lastname **] stood up and was
unstable. She returned to bed where she vomited once. There was
no LOC but she was noted to have blank staring spell which
lasted for less than a minute. No convulsive seizure episode was
witnessed.
EMS brought Mrs [**Known lastname **] to [**Hospital 883**] Hospital, where initial INR
was 3.5. Given FFP & Vit K once each. Her Head CT revealed
intraventricular bleed (L) with no underlying mass effect on the
preliminary read. Vitals were stable at OSH (SBP 130-150's).
Patient was stabilized and transferred to [**Hospital1 18**] for further
management (no neurosurgery available at OSH).
At [**Hospital1 18**] ER, she was noted to be increasing drowsy, lethargic.
Vitals were stable (SBP 150-165) with RR between 14-16 on 2
liter nasal canula. Initial GCS was 12. However, due to concern
for respiratory support patient was intubated.
She had difficulty speaking, general weakness. She did not have
a headache, and complained of pain in her right leg.
Past Medical History:
-LUE DVT: Thrombus identified within the left subclavian and
left brachial vein. Likely PICC associated from [**2157-7-29**]
admission.
-[**2157-6-30**]: I&D Right proximal tibia wound with excision of
posterior sinus and removal of antibiotics beads.
-Hypertension for ~20 years
-s/p GSW in [**2113**] s/p surgical repair
Social History:
She lives with her daughter and her two grandsons in an
apartment in [**Name (NI) 77913**] Plain. Originally from [**Location (un) 13366**],
[**Country 13622**] Republic. Moved to [**Location (un) 86**] area in [**2122**]. Denies
tobacco, EtOH, or other drugs.
Family History:
Mother died three months ago of a heart attack in her 70s, she
had diabetes. Father alive, healthy in the DR. 5 siblings, [**1-30**]
with hypertension, one with diabetes.
Physical Exam:
Vitals: T: P:85/min; R:16/min; BP:157/70, SaO2:
*prior to intubation
General: stuporous, lethargic; arouses to voice and can respond
verbally
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: lethargic, oriented to place & person. Verbal
with decrease fluency. Decrease arousal but obeys command. No
dysarthria, no spontaneous speech. Responds to verbal command
and deep pressure.
-Cranial Nerves: Olfaction not tested. PERRL 2 [**12-29**] to 1mm
sluggishly reactive. Opens and closes eyes spontaneously. No
ptosis bilaterally. Unable to perform funduscopic exam.
Conjugated gaze and limited upgaze with no nystagmus. Facial
sensation intact to pressure. No facial droop, facial
musculature symmetric. Hearing intact grossly. Able to protrude
tongue in midline.
-Motor: Decrease bulk UE/LE, normal tone. Unable to test for
pronator drift. No adventitious movements noted. No asterixis
noted. Unable to perform formal strength testing. Spontaneous
movement of upper extremities against gravity, lower extremities
limited to bilateral toe flexion/extension with spontaneous leg
movements. Mild RUE weakness on active movement.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
- Reflex: No clonus, no pathlogic reflexes
[**Hospital1 **] Tri Bra Pat An Toes
C5 C7 C6 L4 S1 CST
L2 2 2 2 2 down
R2 2 2 2 2 up
-Gait and coordination: unable to formally assess.
Prior to discharge, in terms of her neurological examination,
her short-term memory was still selective. However, her motor
exam was virtually normal.
Pertinent Results:
LABS
Hematology
CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**9-21**] 5.0 2.64* 8.6* 24.9* 95 32.6* 34.5 14.9 297
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2157-9-21**] 05:41AM 297 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2157-9-21**] 05:41AM 98 20 1.9* 137 3.9 102 29 10
ANTIBIOTICS Vanco
[**2157-9-21**] 05:41AM 40.8* Import Result
IMAGING
[**9-17**] CT Head
Near complete resolution of hemorrhage along the old
ventriculostomy tract. Mild decrease in extensive
intraventricular hemorrhage with trace increase in size of the
ventricular system. Continued followup is recommended.
[**9-4**] CT Head
Diffuse intraventricular hemorrhage in the left greater than
right
lateral ventricles and extending into the third and fourth
ventricle.
There is resulting hydorcephalus. There is no evidence of
midline shift. There is global predominantly left sided sulcal
effacement with no herniation. There is extensive
periventricular and white matter hypodensity which likely
represent chronic microvascular infarct.
Brief Hospital Course:
The pt is a 61 year-old right-handed, female, with history of
chronic right posterioir tibial osteomyeltitis, hypertension &
LUE DVT on coumadin theraphy who presented with mental status
change. Head CT from OSH showed large intraventricular blood
most of which is in the left lateral, third, and fourth
ventricles; hydrocephalus; no evidence of midline shift; no
intraparenchymal hemorrhage; 3 mm low attenuation density in the
pons which may be a lacunar infarct of indeterminate age;
moderate periventricular white matter chane most likely small
vessel occlusive disease. INR up to 3.5 at OSH, given 2 U FFP
and Vitamin K 10 mg IV. Neurologic exam on admission limited but
significant for increase lethargy, somnolence. Neurologic exam
on Day 2 of admission: intubated, attends to examiner, not
clearly following commands, PERRL, horizontal eye movement but
not vertical, gag intact, moves bilateral UE and LE against
gravity, localizes pain in all 4 extremities, reflexes brisker
on left (4+ in left biceps and brachioradialis), toes downgoing
bilaterally.
Her ICU course and treatment plan was as follows:
-s/p ventricular drain with neurosurgery, initially on Ancef 2
gm IV q8hr while drain was in place
-received intraventricular tPA [**Hospital1 **] x2 days. Increased pressure
on to drain 10->15 on [**9-8**], however altered mental status after
that so decreased pressure back down to 10, plan now is to clamp
drain and remove as tolerated (culture tip upon d/c)
-Goal ICP 5-18
-spiked temp to 102.1 on [**9-7**], f/u CXR, blood cx, CSF cx, UA
showed neg leuk/neg nitr, 0-2 WBC, no bact, f/u urine cx.
Started Vancomycin 1 gm IV q12, CTX 2 gm IV q12
-continued to spike temp to 102.4 on [**9-8**], f/u LENIs, repeat CXR
-BP controlled with SBP goal 140-160, and her home bp meds were
restarted: Lisinopril 20 PO daily, Avapro 75 mg daily, Atenolol
50 mg PO increased to [**Hospital1 **], HCTZ 25 mg daily
-Coumadin/ASA were held in setting of IVH
-Doxycycline, Fluconazole for chronic suppression of
osteomyelitis per ID recs
-Speech and Swallow: thin liquids and small bites of soft
solids, Pills may be given crushed or whole with puree
On [**9-19**] ID were consulted regarding the growth of
multi-resistant Staphylococcus epidermidis from the EVD tip that
had been pulled, approximately a week ago. They recommended that
she continue on Vancomycin until [**9-27**], trough between 15-20.
Unfortunately, her creatinine increased, and her Vanc level was
supratherapeutic, so the antibiotic was held for several doses.
ID also recommended continuing her Fluconazole and Doxycycline
for her chronic osteomyelitis, they will follow her up as an
outpatient. Discussions with Heme Onc and the [**Hospital1 18**] line
services advised the placement of a picc line (Right), as her
central line needed changing. Her picc line was taken out prior
to her discharge. Despite holding her Vanc, her Cr trended
upwards, so her ACE inhibitor and [**Last Name (un) **] were stopped, and a renal
artery US were requested. Renal ultrasound did not show renal
artery stenosis. she constantly needs encouragement to eat,
drink and go to the bathroom. Her course of Vancomycin was also
completed prior to discharge.
Medications on Admission:
-Coumadin 4mg daily (started [**2157-9-2**])
-Atenolol 50 mg Tablet (Daily).
-Aspirin 81 mg Tablet (Daily).
-Cholecalciferol (Vitamin D3) 400 unit(Daily).
-Calcium Carbonate 500 mg (2 times a day).
-Alendronate 70 mg QFRI (every friday).
-Lisinopril 20 mg daily
-Hydrochlorothiazide 12.5 mg DAILY
-Lovenox 60 mg = d/c
-Avapro 75 mg once a day.
Discharge Medications:
1. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
Disp:*0 Capsule(s)* Refills:*0*
2. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*0 Tablet(s)* Refills:*0*
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
Disp:*0 Tablet(s)* Refills:*0*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
Disp:*0 Tablet, Chewable(s)* Refills:*0*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*0*
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*0 * Refills:*0*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*0 Tablet(s)* Refills:*0*
8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*0 Tablet(s)* Refills:*0*
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for to groin as needed for irritation.
Disp:*0 * Refills:*0*
10. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*0 Tablet(s)* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain or temp > 100.
Disp:*0 Tablet(s)* Refills:*0*
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*0*
13. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
14. HydrALAzine 10 mg IV Q6H:PRN SBP >160
page HO if giving
15. Heparin Flush (10 units/ml) 1 mL IV PRN
16. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
17. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Intraventricular hemorrhage
Discharge Condition:
Problems with short term memory and motivation, needs to be
encouraged to eat. In terms of her strength, she is able to walk
and is almost back to her baseline.
Discharge Instructions:
You have been admitted with bleeding within the ventricles of
your brain.
If you have any of the following symptoms: worsening headache,
alteration of consciousness, weakness on any one side of your
body, or any other change in your function, please go to your
nearest emergency department.
Followup Instructions:
With Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) **] in [**6-5**] weeks, please call the office to
organize a convenient time [**Telephone/Fax (1) 7394**].
For follow-up with Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] (Infectious Diseases on
[**2157-10-11**]), she will need liver function tests drawn prior to
this appointment, and FAX'd to [**Telephone/Fax (1) 77914**].
Completed by:[**2157-9-27**]
|
[
"5849",
"4019",
"V5861"
] |
Admission Date: [**2132-10-28**] Discharge Date: [**2132-11-6**]
Date of Birth: [**2064-4-19**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
noninvasive positive pressure ventilation
History of Present Illness:
Mr. [**Known lastname 98193**] is a 68 yo male with h/o of MS, depression, HTN,
neurogenic bladder s/p multiple UTIs who presents after an
episode of hypoxia. Pt was lethargic and not answering questions
so hx was obtained from notes. Per NH notes pt had increasing
dyspnea for several days and was found to have a LLL PNA three
days ago. He had been treated with Rocephin (1gm IM x 3 doses)
for 3 days. Today at the nursing home his O2 sats dropped to 79%
on 2L NC (baseline on 2L NC) and increased to 86-88% on 5L NC
02. He was noted to be very congested and received nebs. At that
time his SBPs were noted to be in the upper 70s to 80s with HR
in the 90s and his temperature was 98. He was also more
lethargic than usual. At baseline he answers questions promptly
but was very slow to respond this morning. EMS was called and he
was brought to [**Hospital1 **].
.
In the ER his rectal temperature was 100.1. He was given flagyl,
levaquin, vancomycin and decadron 10 mg. His BP was initially
86/44 with a HR of 51 and improved to 102/48 after 2L of NS. His
sats were up to 100% on a NRB. He was then transferred to the
[**Hospital Unit Name 153**].
.
Upon arrival to the [**Hospital Unit Name 153**] his SBPs were in the low 100s and HR in
the 70s. Sats continued to be 100% on NRB. He denied chest pain,
SOB, abd pain or diarrhea. ABG was checked and was
7.25/63/107/29. His initial DNR/DNI status was confirmed with
his HCP, his [**Name2 (NI) 802**], but it was agreed he could start NIPPV. He
was started on CPAP of [**5-9**].
Past Medical History:
1. Progressive, relapsing, multiple sclerosis for the last 30
years. The patient is treated with monthly steroids, Solu-Medrol
and Avonex.
2. Prostate cancer status post brachytherapy.
3. Depression with multiple admissions in the past and history
of overdose of isopropyl alcohol.
4. Neurogenic bladder with recurrent urinary tract infections.
The patient has a suprapubic foley.
5. History of multiple UTIs. MRSA urine infection in [**Month (only) 404**]
[**2130**], also history of pansensitive Klebsiella and e.coli.
History of Pseudomonas UTI sensitive to Zosyn and enterococcal
UTI sensitive to vancomycin in [**2129**]. Both of the [**2129**] urine
cultures were resistant to levofloxacin.
6. History of right elbow bursitis with MRSA.
7. Hypertension.
8. Chronic lower back pain with cervical and lumbar spinal
stenosis.
9. Osteoarthritis.
10. Impotence with penile prosthesis.
11. Chronic polyps.
12. History of peptic ulcer disease with upper GI bleed in the
setting of chronic NSAIDs use.
13. History of alcohol abuse with history of generalized tonic
clonic seizures in the setting of alcohol (see neuro note
written in [**2130-3-6**]).
14. Coagulase negative staphylococcal bacteremia in [**5-8**].
15. Pemphigus
Social History:
Lives in [**Location **]. Denies alcohol or tobacco. [**Location **] involved in his
care.
Family History:
Non-contributory.
Physical Exam:
temp 97.4, BP 153/112, HR 108, RR 20, pox 94% on 4 liters
Tm 98.3 (on floor)
accuchek 143
gen: knows his full name. moves his hands to command. seems to
answer questions. says his age is 67 (he's 68.)
HEENT: EOM seem intact on my limited testing. pupils react to
light bilaterally. anicteric.
chest: on right side, sounds clear except for scattered exp
wheeze. i could not hear breath sounds on left side anteriorly.
heart: seemed slightly fast with occasional ectopic beat. I
didn't notice a murmur on a very limited heart exam.
abd: BS+. very obese. nontender. guiac negative.
ext: contracted LE and UE. He does feel me touch his toes and
when I pinch his toes, he does involuntarily contract his feet.
neuro: awake, alert. answers some questions. knows his full
name. when I tell him he looks like he is 47 (he is 68), he
tells me that I look young, too. pupils react bilaterally.
eyebrows up symmetric. handgrip is [**3-9**] on RIGHT and on [**4-9**] on
left.
Pertinent Results:
[**2132-10-28**] 01:00PM WBC-8.8 RBC-4.39* HGB-11.6*# HCT-34.9*
MCV-80* MCH-26.4* MCHC-33.2 RDW-19.6*
[**2132-10-28**] 01:00PM NEUTS-67.8 LYMPHS-24.1 MONOS-5.8 EOS-1.9
BASOS-0.3
[**2132-10-28**] 01:00PM PLT COUNT-234
[**2132-10-28**] 01:00PM GLUCOSE-138* UREA N-37* CREAT-1.5* SODIUM-137
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15
[**2132-10-28**] 01:32PM LACTATE-1.5
[**2132-10-28**] 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-SM
[**2132-10-28**] 02:15PM URINE RBC-0 WBC-[**6-14**]* BACTERIA-MOD YEAST-NONE
EPI-0
[**2132-10-28**] 10:24PM PT-13.5* PTT-30.9 INR(PT)-1.2*
[**2132-10-28**] 10:24PM CORTISOL-7.6
[**2132-10-29**] 12:00AM CORTISOL-31.7*
.
RPR NR, TSH 1.2, FOLATE 9.7, B12 569, URINE LEGIONELLA AG:
NEGATIVE
.
URINE CX [**11-3**]: NO GROWTH
BLOOD CX [**10-28**]: NO GROWTH
.
SPUTUM CX:
GRAM STAIN (Final [**2132-10-29**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2132-11-2**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**7-/2432**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
AP CHEST:
FINDINGS: AP single view of the chest obtained with patient in
sitting position demonstrates now a diffuse density overlying
the left lower lung field and obliterating the diaphragmatic
contour. The left lateral pleural sinus appears somewhat
blunted. On the right side, the pulmonary lung fields
demonstrate normal vasculature without evidence of CHF and the
right lateral pleural sinus is free. The heart may be mildly
enlarged and the thoracic aorta is moderately widened and
elongated but not excessive for age.
Available for comparison are multiple previous chest
examinations from [**2130**] and [**2129**]. The now present density in the
left lung base did not exist on previous examinations.
IMPRESSION: Portable AP chest view demonstrates parenchymal
infiltrate in left lower lobe area with possible pleural
reaction. No evidence of CHF.
.
HEAD CT W/O CONTRAST:
FINDINGS: This examination is limited by patient motion. There
is no evidence for hemorrhage, mass effect, shift of normally
midline structures, or acute major vascular territorial
infarction. There is prominence of the ventricles and sulci,
which are stable since the prior exam and may be secondary to
age-related involutional change. Also, stable periventricular
white matter hypodensity, which may be secondary to chronic
microvascular ischemic changes. The surrounding osseous
structures are unremarkable. The visualized paranasal sinuses
are well aerated.
IMPRESSION: No evidence for acute intracranial abnormality
including hemorrhage or mass effect.
.
KUB
FINDINGS: Two supine radiographs are reviewed. Evaluation is
limited secondary to body habitus. Multiple air-filled bowel
loops are identified that are presumed large bowel. There is no
definite evidence for dilated small bowel loops. Note of
prostate seeds.
IMPRESSION: Limited evaluation, but no definite evidence for
obstruction.
Brief Hospital Course:
# Pneumonia: Patient was on rocephin at the nursing home x 3
days without improvement. He was admitted to ICU for
noninvasive positive pressure ventilation and antibiotics were
expanded to vancomycin, zosyn, and azithromycin. Patient has
steadily improved and now is stable on room air and remains
afebrile. Given sputum results, plan to continue vancomycin x
14 days and patient will also complete a 14 day course of
levofloxacin for treatment of his pneumonia. He received chest
PT while in house but is currently coughing up his sputum well.
He is on scheduled nebs to optimize his airways in the setting
of his resolving pneumonia.
.
# Hypotension: Patient's blood pressure low on admission but
improved with IVF boluses. He did not require pressors and has
remained hemodynamically stable for days without additional
boluses. Cortrysn stim test in the ICU showed an appropriate
response.
.
# Altered mental status: Patient was lethargic on admission.
Head CT was unremarkable and mental status improved considerably
with treatment of his pneumonia. TSH, folate, B12, RPR, and
TFTs were all unremarkable.
.
# MS: Per [**Year (4 digits) 802**], patient is too weak to walk at baseline.
Recommend reevaluation at nursing home for modified wheelchair
to improve mobility. He was continued on his home doses of
baclofen and neurontin.
.
# Depression: Mood stable. Patient continued on his home
trazodone + celexa.
.
# Anemia: Hematocrit stable. Patient continued on his home
iron.
.
# HTN: Patient continued on his home beta blocker in house.
Plan to restart norvasc at the nursing home.
.
# FEN: While in house, patient had a swallow evaluation to rule
out overt aspiration. No overt aspiration on bedside
evaluation. Patient is on a ground diet with thin liquids.
Recommend all his meds be administered in pureed form.
.
# PPX: home PPI, SQ heparin, wound consult was obtained for
wound care
.
# DNR/DNI
.
# Dispo: patient discharged back to his nursing home
Medications on Admission:
Neurontin 200 mg PO
Rocephin 1 gm IM qd
Duoneb 3 ml neb qd
Atenolol 25 mg qd
Ditropan XL 10 mg po qd
Celexa 40 mg qd
Senna
Diazepam 5 mg po qhs
Baclofen 20 mg qid
percocet 2 tabs po aAM
Cymbalta 20 mg qhs
Trazodone po qhs
Zinc sulfate 220 mg qid
Prednisone taper 5 mg taken until [**10-23**]
Norvasc 2.5 qd
Prilosec 20 mg PO BID
Protein poweder
MVI
ciprofloxacin gtt 2 gtts to R ear [**Hospital1 **]
Vitamin C 500 mg PO BID
iron 325 mg qd
Discharge Medications:
1. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO at bedtime.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO qd as needed for pain: hold for rr < 8 or oversedation.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for sbp < 110 or hr < 55.
4. Norvasc 2.5 mg Tablet Sig: One (1) Tablet PO once a day: hold
for sbp < 120.
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day) for 7 days.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) for 10 days.
11. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
13. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO HS (at bedtime).
14. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
hold for rr < 8 or oversedation.
16. Ipratropium Bromide 0.02 % Solution Sig: Two (2) nebs
Inhalation Q6H (every 6 hours) for 14 days.
17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating/gas.
18. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Rehab & Nursing - [**Street Address(1) **]
Discharge Diagnosis:
bacterial pneumonia
mental status changes
history of hypertension
history of multiple sclerosis
Discharge Condition:
good: stable on room air, afebrile
Discharge Instructions:
Please monitor for temperature > 101, worsening mental status,
hypoxia, or other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 1 week for a check-up. Phone:
[**Telephone/Fax (1) 17503**]
|
[
"0389",
"78552",
"51881",
"99592",
"4019"
] |
Admission Date: [**2129-10-24**] Discharge Date: [**2129-10-27**]
Date of Birth: [**2078-7-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Acutely painful, ischemia RLE
Major Surgical or Invasive Procedure:
[**10-24**] R CIA stent
History of Present Illness:
This is a 51-year-old male with a longstanding
history of right calf and left calf claudication who
presented with 3 days of right foot pain which became
excruciatingly severe the morning of admission. The patient
normally has cramping in his right calf starting at 25 feet
and then he has this in his left calf. This is easily
reproducible with exercise and relieved by rest. On
Thursday, or 3 days prior to admission, the patient noted the
onset of right foot pain. However, he tolerated this and
this morning the patient noted excruciating right foot pain
which began to ascend up his leg. In the examination
emergency room, the patient had a very thready external iliac
pulse, but no common femoral pulse. He had very poor motor
function of his right foot and very limited sensation below
the knee. The patient had a cool foot and lower leg. He was
bolused with heparin and taken urgently to the operating
room. Of note, his blood sugar was 490 and he was put on an
insulin drip and hydrated extensively as well as given
bicarbonate.
Past Medical History:
Diabetes Mellitus, Type 1: diagnosed in [**2126-2-5**]. Denies any
complications, including eye and renal problems.
Hypertension
Hypercholesterolemia
"Circulation" problem to [**Name (NI) **]
Social History:
Firefighter with construction work on the side. Lives with
wife. Denies IVDU. [**5-15**] cigarettes/day x 1.5 years but used to
smoke 1 ppd x 30 years. Drinks 2-3 x per week with 2-4 beers
during each occasion.
Family History:
Mom - cancer history on mom's side; Dad - deceased from MI at
age 42
Physical Exam:
On Discharge:
VS: T98.7, HR 72, BP 134/73, RR 18, 96% RA
GEN: NAD, A&O x 3
NECK: Supple, no bruits
LUNGS: Clear B/L
CV: RRR, nl S1 and S2, no m/r/g
ABD: soft, NT, ND
Fem [**Doctor Last Name **] DP PT
R 1+ D dop dop
L 2+ D dop dop
Pertinent Results:
[**2129-10-26**] 05:51AM BLOOD WBC-11.3* RBC-3.70* Hgb-11.4* Hct-33.1*
MCV-90 MCH-30.9 MCHC-34.6 RDW-14.6 Plt Ct-203
[**2129-10-25**] 09:51AM BLOOD WBC-15.9* RBC-3.90* Hgb-11.9* Hct-35.3*
MCV-91 MCH-30.4 MCHC-33.6 RDW-14.6 Plt Ct-287
[**2129-10-24**] 05:55PM BLOOD Neuts-81.2* Lymphs-13.9* Monos-4.4
Eos-0.2 Baso-0.4
[**2129-10-27**] 06:40AM BLOOD PT-13.3 INR(PT)-1.1
[**2129-10-27**] 05:55AM BLOOD Glucose-54* UreaN-8 Creat-0.6 Na-139
K-4.0 HCO3-29
[**2129-10-25**] 09:51AM BLOOD CK(CPK)-186*
[**2129-10-25**] 04:01AM BLOOD CK(CPK)-73
[**2129-10-27**] 05:55AM BLOOD Calcium-8.3* Phos-4.5 Mg-1.8
Brief Hospital Course:
Admitted through ED with severe R leg and foot pain that started
approximately 10 hours ago. Taken to OR for emergent Right groin
exploration and bovine patch
angioplasty, thrombectomy of right iliac, femoral, profunda
femoral artery, angiogram with runoff of right lower extremity.
Remainded intubated post procedure for acidosis. B/L DP/PT
doppler. Lopressor IV for tachycardia.
[**10-25**]: VSS, acidosis improving, Extubated. [**Last Name (un) **] consulted for
BS>500 preop. Stated on Lovenox.
[**10-26**] VSS. Continue Lovnox, [**Month/Year (2) 197**] started.
[**Last Name (un) **] adjusting Lantus dose and carbohydrate counting
[**10-27**] No overnight events. Discharged to home on [**Month/Year (2) 197**] 5mg
daily, Lovnox 70mg SC until INR >2. INR to be followed by Dr. [**Name (NI) 43011**] office until patient has PCP.
Medications on Admission:
Crestor 10 mg qd, Ferrous Gluconate 325 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd,
Lisinopril 10 mg qd, MVI, Lantus 25 units sc qPM, Novolog SS
Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Continue until INR>2 as directed by Dr. [**Name (NI) 43011**] office .
Disp:*14 1* Refills:*0*
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*1*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Outpatient Lab Work
INR/pt 2x week and prn. Call/Fax results to Dr. [**Last Name (STitle) **]
p[**Telephone/Fax (1) 2625**],f [**Telephone/Fax (1) 51996**], Dr.[**Doctor Last Name 4849**] [**Telephone/Fax (1) 3637**],f
[**Telephone/Fax (1) 12142**]
12. Humalog Sliding Scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose 0-60 mg/dL 4 oz. Juice
61-120 mg/dL 0 Units
121-160 mg/dL 1 Units
161-200 mg/dL 2 Units
201-240 mg/dL 3 Units
241-280 mg/dL 4 Units
281-320 mg/dL 5 Units
321-360 mg/dL 6 Units
> 360 mg/dL call Dr.[**Name (NI) 4849**]
[**Name (STitle) 79349**] for NPO Patients: [**Name (STitle) 79349**] for NPO Patients:
please only give above sliding scale when NPO. When taking POs,
please give insulin AC with I:[**Doctor Last Name **] ratio of 1:20 1-20g carbs: 1
unit, 21-40 carbs: 2 units, 41-60 carbs: 3 units, 61-80 carbs 4
units IN ADDITION to above sliding scale
13. Lantus 100 unit/mL Solution Sig: 22 units daily
Subcutaneous once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
51M s/p R CIA stent [**10-24**] for acute limb ischemia
.
PMHx: DM1 (w/neuropathy), HTN, hypercholesterolemia
PSHx: None
Discharge Condition:
Good
INR 1.1- to continue Lovenox until INR >2.0
Continue [**Year (2 digits) 197**] 5mg daily or as directed by PCP or Dr.
[**Last Name (STitle) **]
Discharge Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (un) **] Diabetes Center Recommendations your Humalog
Insulin:Carb ratio should be 1:20 with all meals. You should
also take 20 Units of Lantus Nightly. Your Humalog sliding scale
sensitivity factor is 40 with a goal of 120.
Division of [**Last Name (un) **] and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 81mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or [**Last Name (un) 2875**] 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 [**1-9**]
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
[**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
You have been started on Lovenox (short term blood thinner) and
[**Telephone/Fax (1) 197**] (long term blood thinner). Contine both and have your
blood level (INR) checked at least 2x week. When your INR is >2,
you will stop the Lovenox injections but continue on [**Telephone/Fax (1) 197**].
Do not change your dose or discontiue either medication without
your PCP's instruction.
Discharge Instructions: Taking [**Telephone/Fax (1) 197**] (Warfarin)
Your doctor [**First Name (Titles) 2875**] [**Last Name (Titles) 197**] (warfarin) for you. Be sure to
take it as directed. Because [**Last Name (Titles) 197**] helps keep your blood from
clotting, you also need to protect yourself from injury, which
could lead to excessive bleeding.
Guidelines for Medication Use
Follow the fact sheet that came with your medication. It tells
you when and how to take your medication. Ask for a sheet if you
didn??????t get one.
Do not take [**Last Name (Titles) 197**] during pregnancy because it can cause birth
defects. Talk to your doctor about the risks of taking [**Last Name (Titles) 197**]
while pregnant.
Take [**Last Name (Titles) 197**] at the same time each day.
If you miss a dose, take it as soon as you remember??????unless it??????s
almost time for your next dose. In that case, skip the dose you
missed. [**Male First Name (un) **]??????t take a double dose.
Keep appointments for blood (protime/INR) tests as often as
directed.
[**Male First Name (un) **]??????t take any other medications without checking with your
doctor first. This includes over-the-counter medications and any
herbal remedies.
Other Precautions
Tell all your healthcare providers that you take [**Male First Name (un) 197**]. It??????s
also a good idea to carry a medical identification card or wear
a medical ID bracelet.
Use a soft toothbrush and an electric razor.
[**Male First Name (un) **]??????t go barefoot. [**Male First Name (un) **]??????t trim corns or calluses yourself.
Keep Your Diet Steady
Keep your diet pretty much the same each day. That??????s because
many foods contain vitamin K. Vitamin K helps your blood clot.
So eating foods that contain vitamin K can affect the way
[**Male First Name (un) 197**] works. You [**Male First Name (un) **]??????t need to avoid foods that have vitamin
K. But you do need to keep the amount of them you eat steady
(about the same day to day). If you change your diet for any
reason, such as due to illness or to lose weight, be sure to
tell your doctor.
Examples of foods high in vitamin K are asparagus, avocado,
broccoli, and cabbage. Oils, such as soybean, canola, and olive
oils are also high in vitamin K.
Alcohol affects how your body uses [**Male First Name (un) 197**]. Talk to your doctor
about whether you should avoid alcohol while you??????re using
[**Male First Name (un) 197**].
Herbal teas that contain sweet clover, sweet [**Location (un) **], or tonka
beans can interact with [**Location (un) 197**]. Keep the amount of herbal tea
you use steady.
Possible Side Effects
Tell your doctor if you have any of these side effects, but
[**Male First Name (un) **]??????t stop taking the medication until your doctor tells you to.
Mild side effects include the following:
More gas (flatulence) than usual
Bloating
Diarrhea
Nausea
Vomiting
Hair loss
Decreased appetite
Weight loss
When to Call Your Doctor
Call your doctor immediately if you have any of the following:
Trouble breathing
Swollen lips, tongue, throat, or face
Hives or painful rash
Black, bloody, or tarry stools
Blood in your urine
Vomiting or coughing up blood
Bleeding gums or sores in your mouth
Urinating less than usual
Yellowing of the skin or eyes (jaundice)
Dizziness
Severe headache
Easy bleeding or bruising
Purple discoloration of your toes or fingers
Sudden leg or foot pain
Any chest pain
Lovenox/Enoxaparin injection
What is enoxaparin injection?
ENOXAPARIN (Lovenox??????) is commonly used after knee, hip, or
abdominal surgeries to prevent blood clotting. Enoxaparin is
also used to treat existing blood clots in the lungs or in the
veins. Enoxaparin is similar to heparin. Enoxaparin is known as
an anticoagulant, and is sometimes called a blood thinner.
However, enoxaparin does not actually thin the blood, but
decreases the ability of blood to form clots. Generic enoxaparin
injections are not yet available.
What should my health care professional know before I receive
enoxaparin?
They need to know if you have any of these conditions:
bleeding disorders, hemorrhage, or hemophilia
brain tumor or aneurysm
decreased kidney function
diabetes
high blood pressure
infection of the heart or heart valves
receiving injections of medications or vitamins
liver disease
previous stroke
prosthetic heart valve
recent surgery or delivery of a baby
ulcer in the stomach or intestine, diverticulitis, or other
bowel disease
undergoing treatments for cancer
an unusual or allergic reaction to enoxaparin, heparin, pork or
pork products, other medicines, foods, dyes, or preservatives
pregnant or trying to get pregnant
breast-feeding
How should I use this medicine?
Enoxaparin is for injection under the skin. It is usually given
by a health-care professional, or you or a family member may be
trained on how to give the injections. If you are to give
yourself injections, make sure you understand how to use the
syringe, measure the dose if necessary, and give the injection,
and how to dispose of used syringes and needles. Use the
syringes only once, and throw away syringes and needles in a
closed container to prevent accidental needle sticks. Use
exactly as directed. Do not exceed the [**Male First Name (un) 2875**] dose, and try
not to miss doses.
To avoid bruising, do not rub the site where enoxaparin has been
injected.
Contact your pediatrician or health care professional regarding
the use of this medicine in children. Special care may be
needed.
What if I miss a dose?
It is important to administer enoxaparin at regular intervals as
[**Male First Name (un) 2875**] by your health care professional. Depending on your
condition, enoxaparin is usually given either once daily (every
24 hours) or twice daily (every 12 hours). If you have been
instructed to use enoxaparin on a regular schedule, use missed
doses as soon as you remember, unless it is almost time for the
next dose. Do not use double doses.
What drug(s) may interact with enoxaparin?
antiinflammatory drugs such as ibuprofen (Motrin??????), naproxen
(Aleve??????), or ketoprofen (Orudis-KT??????)
clopidogrel
dipyridamole
fish oil (omega-3 fatty acids) supplements
herbal products containing feverfew, garlic, ginger, gingko, or
horse chestnut
ticlopidine
Tell your prescriber or health care professional about all other
medicines you are taking, including non-prescription medicines,
nutritional supplements, or herbal products. Also tell your
prescriber or health care professional if you are a frequent
user of drinks with caffeine or alcohol, if you smoke, or if you
use illegal drugs. These may affect the way your medicine works.
Check with your health care professional before stopping or
starting any of your medicines.
What should I watch for while taking enoxaparin?
In case of an accident or emergency, it is recommended that you
place a notification in your wallet that you are receiving
enoxaparin.
Your condition will be monitored carefully while you are
receiving enoxaparin. Notify your prescriber or health care
professional and seek emergency treatment if you develop
increased difficulty in breathing, chest pain, dizziness,
shortness of breath, swelling in the legs or arms, abdominal
pain, decreased vision, pain when walking, or pain and warmth of
the arms or legs. These can be signs that your condition has
worsened.
Monitor your skin closely for easy bruising or red spots, which
can indicate bleeding. If you notice easy bruising or minor
bleeding from the nose, gums/teeth, in your urine, or stool,
contact your prescriber or health care professional immediately,
these are indications that your medication needs adjustment or
evaluation. Keep scheduled appointments with your prescriber or
health care professional to check on your condition.
If you are going to have surgery, tell your prescriber or health
care professional that you have received enoxaparin.
Be careful to avoid injury while you are using enoxaparin. Take
special care brushing or flossing your teeth, shaving, cutting
your fingernails or toenails, or when using sharp objects.
Report any injuries to your prescriber or health care
professional.
What side effects might I notice from receiving enoxaparin?
Side effects that you should report to your prescriber or health
care professional as soon as possible:
Rare or uncommon:
signs and symptoms of bleeding such as back or stomach pain,
black, tarry stools, blood in the urine, or coughing up blood
difficulty breathing
dizziness or fainting spells
More frequent:
bleeding from the injection site
fever
unusual bruising or bleeding: bleeding gums, red spots on the
skin, nosebleeds
Side effects that usually do not require medical attention
(report to your prescriber or health care professional if they
continue or are bothersome):
pain or irritation at the injection site
skin rash, itching
Where can I keep my medicine?
Keep out of the reach of children.
Store at room temperature below 25 degrees C (77 degrees F); do
not freeze. If your injections have been specially prepared, you
may need to store them in the refrigerator - ask your
pharmacist. Throw away any unused medicine after the expiration
date.
Make sure you receive a puncture-resistant container to dispose
of the needles and syringes once you have finished with them. Do
not reuse these items. Return the container to your prescriber
or health care professional for proper disposal.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2129-11-9**] 1:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2129-11-9**] 9:15
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2129-11-9**] 8:45
Please call [**Telephone/Fax (1) 12068**] to schedule an appointment with
Dr[**Doctor Last Name **] at the [**Last Name (un) **] Diabetes Center.
Completed by:[**2129-10-27**]
|
[
"4019",
"2720"
] |
Admission Date: [**2129-6-22**] Discharge Date: [**2129-6-23**]
Date of Birth: [**2072-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
CC: Low Blood Pressure
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
57 y.o. Female with HCV cirrhosis, ESRD on HD s/p failed renal
transplant, seizure, HTN, recently dx ovarian mass,
hypothyroidism s/p thyroidectomy referred to the ED from HD for
hypotension. Admitted to ICU for hypotension.
.
Ms. [**Known lastname 3671**] states over the past few days she has noted
intermittent episodes of lightheadedness particularly
orthostasis symptoms, she denies any episodes of syncope. She
was in dialysis today with a reported (per pt) systolic BP 108
laying down and mid 90s sitting she thinks she fell asleep
during dialysis. She woke up at the end of dialysis and not her
dialysis run was finished, the HD RNs were also next to her
telling her her BP was low. Per report from the ED her BPs in
dialysis were in ther 70s after her run, she was given 1L of NS
with no improvement with her BPs which is why she was referred
to the ED. She denies any consitutional symptoms such as nausea,
vomiting, fevers, chills. She does endorse a 5 day history of
sore throat, rhinorrhea which has now improved. She has also had
a dry cough x 3 days. She denies any SOB or DOE. She states that
she has been under a lot of stress over the passt few days, she
lives at home with her sister who is 'unstable' and lead to them
having to move out. She has been trying to move out of her place
for the past few days. Due to the stress she states she is not
eating or drinking as much but denies feeling dehydrated.
.
In the ED initial VS were noted to be T97.8, HR 87, BP 102/47,
RR 16, Sat 96% RA. In the room however she was noted to be
'[**Name6 (MD) 98153**] [**Name8 (MD) **] RN note and triggered for a BP 78/47, HR 82, RR
12, Sat 100% on RA. Per ED signout pt was noted to have foggy
thinking but no evidence of chest pain, lightheadedness. Given
the level of hypotension which trended down to systolic of 69 a
rt femoral line was placed. Pt was given 1gm of Vancomycin, 2L
NS with a BP improvement to 89-93 systolic. An EKG showed SR 74
bpm, STD V3-V4, TWI V3-V6. Pt received and additional 2 L of NS
in the ED with BPs remaining 92/48, BP improved to 92/48 after 2
more litres of NS her BP was noted to be 101. In total pt
received 1L NS at HD and an extra 4L NS in the ED.
.
CXR in the ED showed linear scarring in lung bases that was
unchanged from priors. His initial labwork was notable for WBC
5.9, Hgb/Hct 12.1/35.4, plt 146. chem panel was notable for K of
6.2, BUN/Cr 13/3.3. Repear K was then 3.6 and then 2.9, lactate
1.7. Pt also 750mg Levofloxacin in addition to Vancomycin for
empiric coverage.
.
Of note she has been admitted twice over the past 2 months for
hypotension pre and post dialysis. Her first admission was
[**2129-4-23**] and was thought to be [**2-16**] aggressive BP regimen as
well as the pt inappropriately taking her medications. She was
taking nitroglycerin every day as opposed to PRN. She was also
noted to be hypothyroid, likely not adherent to her snythroid
medication. She was ruled out for adrenal insufficiency. Outpt
Nephrologist reports dry weight as 74kg. On [**5-12**] she was
referred to the ED for abdominal pain and triggered in the ED
for a BP in the 70s. Again her hypotension was easily corrected
with fluid and thought to be [**2-16**] BP regimen.
Past Medical History:
-HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy
-Rt ovarian mass
Social History:
Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years
Family History:
Father: ESRD and hypertension
Mother: lung cancer
Physical Exam:
GEN: African American Female laying down in bed tearful,
comfortable, NAD
HEENT: PERRL, EOMI, anicteric, mildly dry MM
Neck: No thyroid palpated, no cervical LAD
RESP: Bibasilar inspiratory crackles otherwise CTA
CV: S1, S2, II/VI murmur referred from the graft
ABD: Soft, mild tenderness over RLQ, tympanetic to percussion,
old surgical scars noted midline
EXT: No edema, no asterixis. Left arm fistula +bruits/+thrills
SKIN: no rashes/no jaundice/dry skin
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.
Pertinent Results:
[**2129-6-22**] 11:20PM SODIUM-142 POTASSIUM-4.6 CHLORIDE-106
[**2129-6-22**] 11:20PM CK(CPK)-59
[**2129-6-22**] 11:20PM CK-MB-3 cTropnT-0.05*
[**2129-6-22**] 07:01PM PT-16.4* PTT-28.1 INR(PT)-1.4*
[**2129-6-22**] 05:58PM LACTATE-1.7
[**2129-6-22**] 05:52PM GLUCOSE-109* UREA N-10 CREAT-3.0* SODIUM-144
POTASSIUM-2.9* CHLORIDE-106 TOTAL CO2-28 ANION GAP-13
[**2129-6-22**] 05:52PM TSH-0.45
[**2129-6-22**] 05:04PM GLUCOSE-130* K+-3.6
[**2129-6-22**] 05:00PM GLUCOSE-130* UREA N-13 CREAT-3.3*# SODIUM-137
POTASSIUM-6.2* CHLORIDE-95* TOTAL CO2-31 ANION GAP-17
[**2129-6-22**] 05:00PM estGFR-Using this
[**2129-6-22**] 05:00PM WBC-5.9 RBC-3.86* HGB-12.1 HCT-35.4* MCV-92
MCH-31.4 MCHC-34.3 RDW-17.0*
[**2129-6-22**] 05:00PM NEUTS-66.4 LYMPHS-24.6 MONOS-5.9 EOS-2.6
BASOS-0.5
[**2129-6-22**] 05:00PM PLT COUNT-146*
CXR [**2129-6-22**]: Stable scarring of bilateral lower lungs. No acute
process.
EKG [**2129-6-22**]: Sinus rhythm. Extensive ST-T wave changes are
non-specific although cannot exclude myocardial ischemia.
Compared to the previous tracing of [**2129-5-20**] the ST-T wave changes
are slightly more prominent in the precordial leads. The other
findings are similar.
EKG [**2129-6-23**]: Sinus rhythm. Non-specific inferior and anterior T
wave changes. Cannot exclude ischemia. Compared to the previous
tracing of [**2129-6-22**] no diagnostic interim change.
TTE [**2129-6-23**]:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). 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. Trivial mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. No clinically significant valvular
regurgitation or stenosis. Normal pulmonary artery systolic
pressure.
Compared with the prior study (images reviewed) of [**2128-2-20**],
mild mitral regurgitation is no longer present and the pulmonary
artery systolic pressure has normalized.
Brief Hospital Course:
57 y.o. Female with a history of HTN, HCV cirrhosis, ESRD on HD
s/p failed renal transplant, seizure d.o., depression,
hypothyroidism, substance abuse referred to the ED for
hypotension at dialysis. Admitted to the ICU for hypotension.
.
# Hypotension: Pt admitted with systolic BPs in the 70s with
improvement to 100s after 5L of NS. On review of Ms. [**Known lastname 21913**]
history in OMR this is the 3rd time she has presented to the ED
with BPs in the mid 70s requiring ICU care. On review of the
discharge summaries, her prior work ups have included infectious
(with neg cx), adrenal insufficiency ([**4-/2129**] [**Last Name (un) 104**] stim to 32.1
from 7.8). She has been noted to have TSH >100 and 5.6 in the
past; however most recent TSH was improved. There concerns that
this may be medication-related given she is taking multiple
medications for pain which may cause hypotension, but the
patient reports compliance with her medication regimen. During
this admission, the patient's episode occurred during HD and she
was given fluid back which was initially removed but still
became hypotensive to the 70's following HD. It is believed
that the fluid shifts and hypoveolemia [**2-16**] dialysis. She
endorsed decreased PO intake, orthostatic symptoms and her BP
and symptoms improved with IVF. She was placed on Levo/Vanc to
cover for possible HAP vs CAP initially, but antibiotics were
subsequently discontinued as she had no infectious symptoms, was
afebrile, and had no leukocytosis. Renal felt her hypotension
was again related to overuse of pain medications, and the
patient was informed the that strict medication compliance is
essential. Her blood pressures remained stable in the MICU back
at her baseline and she was discharged the following day.
.
# EKG Changes/CAD: Pt had acute on chronic non-specific ST
changes on EKG in the ED. She denied any chest pain or
tightness and her prior cath in [**2128-12-15**] showed non
obstructive CAD. Repeat EKG was unchanged, CE's were negative,
and the patient underwent a TTE which showed no wall motion
abnormalities. She was continued on ASA 81mg, Simvastatin and
was closely monitored without incident.
.
# Hypokalemia: Unclear as to the etiology, pt had dialysis but
her K bath is unlikely to have been as low as 2.9. The pt
received K in the ED, and her K+ was rechecked.
.
# Hypothyroidism: Continued levothyroxine 188mcg. TSH was wnl.
.
# ESRD on HD: Will notify renal of admission, continue on home
regimen of Calcium Acetate
.
# HCV Cirrhosis: Last liver bx [**2121**] grade 1 fibrosis. No
evidence of asterixis, hepatic decompensation on examination. Pt
has underlying mild coagulopathy with INR 1.4-1.5, thought [**2-16**]
depressed hepatic synthetic function.
.
# Thrombocytopenia: Pt has chronic thrombocytopenia likely [**2-16**]
cirrhosis, splenomegaly.
.
# Seizure Disorder: Continued on Keppra 250 mg [**Hospital1 **].
.
# Depression/Anxiety: Continued on fluoxetine 60 mg daily.
.
# Rt Ovarian Mass: Pt recently diagnosed with rt ovarian mass
which was thought to be benign, pt on Dilaudid PRN for RLQ pain.
Home Dilaudid PRN was continued.
.
# Methadone: Called Habit OpCo and confirmed Methadone dose was
54mg daily, and she was given a dose at 2pm the day of
discharge. Unclear if this is for her IVDU history vs chronic
pain. Was contact[**Name (NI) **] by the [**Hospital 228**] [**Hospital 2514**] Clinic following
her discharge and informed them of the hospital course.
.
## Code status: FULL CODE
Medications on Admission:
1. Levetiracetam 250 mg [**Hospital1 **]
2. Fluticasone-salmeterol 250-50 mcg/dose INH [**Hospital1 **]
3. Gabapentin 300 mg qHD
4. Clonazepam 0.5 mg [**Hospital1 **] PRN
5. Methadone 44mg daily
6. Fluoxetine 60 mg daily
7. ASA 81 mg daily
8. Simvastatin 20 mg daily
9. Omeprazole 20 mg daily
10. Folic acid 1 mg daily
11. Trazodone 50 mg qHS PRN
12. B complex-vitamin C-folic acid 1 mg Daily
13. Calcium acetate 667 mg 2 Capsule TID W/MEALS
14. Levothyroxine 188 mcg daily
15. calcium carbonate 200 mg calcium (500 mg) PO BID
17. Vitamin D 1,000 unit daily
18. Hydromorphone 4-8 mg q4hrs PRN
Discharge Medications:
1. methadone 10 mg/5 mL Solution Sig: Fifty Four (54) mg PO
DAILY (Daily).
2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
[**1-16**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
6. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
13. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Total of 188mcg daily.
15. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day: Total of 188mcg daily.
16. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
17. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
18. hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO every four (4)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension (low blood pressure)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You presented to the hospital for low blood pressures during
your hemodialysis sessions. Your electrocardiogram tracings of
your heart rhythm showed changes which were concerning for
insufficient blood supply to your heart when your blood
pressures were low. You underwent an echocardiogram which did
not show any concerning abnormalities, and a repeat
electrocardiogram showed improvement of the abnormalities in the
setting of improved blood pressures. Your low blood pressures
may be due to decreased fluid content in your body following
dialysis, or from some of your medications. You were seen by
the kidney specialists in the ICU and you will resume dialysis
according to your usual schedule when you leave the hospital.
No changes were made to your home medications. Please discuss
your medications, particularly your pain medications, with your
primary care physician to determine whether they may be causing
low blood pressure.
Followup Instructions:
Department: ENDO SUITES
When: FRIDAY [**2129-7-1**] at 3:00 PM
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2129-7-1**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: ADVANCED VASC. CARE CNT
When: TUESDAY [**2129-9-6**] at 2:00 PM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
|
[
"40391",
"41401",
"49390",
"311",
"3051"
] |
Admission Date: [**2107-1-9**] Discharge Date: [**2107-1-18**]
Service: MICU
ADMITTING DIAGNOSIS: Urosepsis.
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
with congestive heart failure with an ejection fraction of
20%, coronary artery disease with two vessel disease,
diabetes type 2, hypertension, who was last discharged from
[**Hospital1 69**] on [**2106-11-17**] for
congestive heart failure exacerbation, urinary tract
infection, who presented back on [**2107-1-8**], to the
[**Last Name (un) 14843**] Medicine team with intermittent chest pain,
left-sided, with radiation to her neck and diaphoretic with
dysuria and mental status changes and was found to have a
urinary tract infection. Secondary to crackles on
examination patient was treated with Lasix and was given
levofloxacin for a UTI. The patient's Lasix dose was
increased from 80 p.o. b.i.d. to 80 IV b.i.d. and patient
then on [**2107-1-9**], was found to be hypotensive,
60/palp, with increasing mental status changes. The patient
was given one liter of normal saline, was started on Levophed
and dopamine with appropriate response of increasing blood
pressures and she was transferred to the MICU and her
levofloxacin and dopamine were markedly weaned off. The
patient was then switched to intravenous antibiotics and
transferred to the MICU. Patient on admission to the MICU
denied any chest pain or shortness of breath and presently
patient's mental status was back to baseline.
PAST MEDICAL HISTORY:
1. Congestive heart failure with ejection fraction of 20%
Class II.
2. Diabetes mellitus type 2 with retinopathy and neuropathy.
3. Coronary artery disease with two vessel disease.
4. Hypertension.
5. Glaucoma.
6. Nephrolithiasis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Losartan 100 q. day.
2. Metoprolol 12.5 b.i.d.
3. Aspirin 81 q. day.
4. Metformin 500 b.i.d.
5. Nortriptyline 25 q. hs.
6. Glipizide 10 b.i.d.
7. Spironolactone 25 q. day.
8. Lasix 80 p.o. b.i.d.
PHYSICAL EXAMINATION ON ADMISSION: Patient's temperature was
95.9, heart rate 98, blood pressure 100/73, respiratory rate
26, 92% on 100% face mask. General: Lying in bed in no
apparent distress - speaking normally. Was awake and alert
and oriented times three. Cardiovascular: Regular rate,
positive systolic ejection murmur. HEENT: No jugular venous
distention. Chest with minimal bibasilar rales. Abdomen:
Soft and non-tender, non-distended, positive bowel sounds.
Extremities were warm bilaterally, pink in color, no
clubbing, cyanosis or edema were present.
LABORATORY ON ADMISSION: To the MICU, UA was positive for
many bacteria, no yeast. WBCs greater than 50. Her urine
cultures grew Gram negative rods greater than 100,000 at the
time. Her CBC was 9.8, 9.9, 30.8, 194. Chem-10 was
remarkable for anion gap of 16. CKs and troponins were
negative times three at that time.
ELECTROCARDIOGRAM: Showed left axis deviation, left bundle
branch block, otherwise normal sinus rhythm and no ST/T wave
changes. Good R-wave progression.
HOSPITAL COURSE:
1. Sepsis. Patient's sepsis was secondary to urosepsis in
which her urine culture eventually grew E. coli which was pan
sensitive. Patient initially was started on levofloxacin on
the floor and was continued in the MICU. Patient, however,
was then started on ceftazidine for double Pseudomonas
coverage in the MICU. The patient once in the MICU again
dropped her systolic blood pressures to the 60's to 70's
range with maps consistently below 65. Patient was then
quickly started on the sepsis protocol and _________ was also
initiated at that time. The patient was also started on
Levophed and dobutamine per the sepsis protocol. When seen
in the MICU patient was initially with good systolic blood
pressure off all pressors, however, when being admitted she
started breathing in a labored pattern again and was
tachypneic and coolness on the skin and was hypertensive with
decreased mental status. The patient at that time had
already been given five liters of normal saline and was
started on Levophed with little effect on blood pressure.
The patient's heart rate decreased to the 60's at which time
patient was given one amp of atropine with no changes in
heart rate. The patient was also started on dopamine and
intubated secondary to mental status changes. The patient
was started on ceftazidime in addition to her levofloxacin.
Per the sepsis protocol patient was also placed on _________
on hospital day two in the MICU-B, patient's hematocrit
dropped from 32 to 22 and patient's coags including INR and
PTT had doubled in value. For this reason patient's
____________ was stopped. DIC labs were checked and patient
was not in DIC. The patient was continued on the sepsis
protocol with good hemodynamic response and was completely
weaned off all of her pressors by day two in MICU-B. The
patient remained afebrile on levofloxacin and vancomycin,
however, due to no organisms supporting use of vancomycin
which were grown on cultures, vancomycin was stopped. The
patient remained on a course of levofloxacin for nine days in
the Intensive Care Unit and will be continued for one more
day on the floor. The patient remained afebrile on the
levofloxacin and had no blood pressure or heart rate changes
once off all pressors.
2. Pulmonary: Patient was intubated on [**1-9**]
secondary to mental status changes. The patient remained
intubated while on the sepsis protocol, however, when
attempting to extubate on [**1-11**] it was noted that
patient was not able to pull in good tidal volumes. At that
time patient's airway resistance was calculated to be in the
20's which was much higher than normal being 5 for her and
her compliance was normal. Unsure of why her airway
resistance was high a bronchoscopy was done in which no mucus
plugs and no airway collapse was found. However, patient
continued to have a left lower lobe collapse on her chest
x-ray. The patient remained intubated and was started on IV
Solu-Medrol secondary to her increased airway resistance.
However, after three to four days of being on intravenous
Solu-Medrol patient's airway resistance did not change going
from 22 to 21. Her compliance remained the same. The
patient was also started on increasing frequency of
nebulizers at that time. After further discussion with the
family it was decided that the patient, if extubated, code
status was changed to "Do Not Re-intubate." Therefore,
patient was tried on inhaler therapy and maximal diuresis
with Lasix responding to 40 IV b.i.d. and was then extubated
on [**2107-1-15**]. The patient did well post extubation
with no problems and no changes in her respiratory rate.
However, the etiology of her increased airway resistance was
still unclear. The patient remained on pulmonary toilet
including chest PT, was started on scheduled and p.r.n.
nebulizers and was changed back to her home dose of Lasix 80
p.o. b.i.d. on transfer to the floor. Patient again remains
a "Do Not Re-intubate." The patient may need outpatient
thyroid function tests as her reason for increased airway
resistance was unclear with a negative bronchoscopy.
3. Congestive heart failure with ejection fraction of 20%.
Patient was effectively diuresed in the MICU with Lasix 40 IV
p.r.n. Patient's I's and O's goals were met and on leaving
the ICU patient's total length of stay net as positive 819
cc. The patient never had any congestive heart failure
exacerbation while in the unit. On day of transfer to the
general [**Hospital1 **], the patient was restarted on a low dose of
captopril and changed from intravenous Lasix to p.o. Lasix 80
b.i.d.
4. Hematology: Patient's hematocrit dropped while being on
the _________ overnight. However, with three units of packed
red blood cells the patient had an appropriate response with
hematocrits remaining in the high 30's to 40's throughout the
rest of her hospitalization. The patient had no other
hematologic complications during her hospitalization in the
MICU.
5. Renal: Patient's creatinine was 1.9 on admission,
however, with adequate fluid resuscitation and removal of all
nephrotoxic drugs, the patient's creatinine fell to 1.1 on
day of discharge to the general [**Hospital1 **] service. Patient had no
other renal issues and had good urine output with the Lasix.
6. Gastroenterology: Patient was found to have ischemic
hepatitis with liver function tests going into the 3000's on
both ALT and AST with ALT being 3811 and AST _______. Again,
patient's ischemic hepatitis was resolving on __________.
The patient also had a right upper quadrant ultrasound which
was negative at the time. Right upper quadrant ultrasound
was done because patient only showed ischemic changes in her
liver and no other organs. At the end patient was tolerating
p.o.'s and a regular diet on discharge to the floor.
7. Diabetes type 2: Patient when on tube feeds and steroids
was on an insulin drip with good control of sugars. Patient
was then changed to regular insulin sliding scale on
discharge to the floor. The patient may be able to wean off
to p.o. hyperglycemic agents in the future.
Patient remained on Protonix, subcu heparin and Pneumoboots
throughout this hospitalization.
Patient had a right IJ placed and an A-line placed on
admission to the ICU. Patient's lines were all discontinued
on [**1-14**] with no complications.
CODE STATUS: Patient remained a "DNR Do Not Re-intubate DNI"
throughout this hospitalization.
CONTACTS: Contact with the son, [**Name (NI) **], who is the health
care proxy.
DISCHARGE DIAGNOSES:
1. Urosepsis.
2. Increased airway resistance.
3. Congestive heart failure with ejection fraction of 20%.
4. Acute renal failure which is now resolved.
5. Ischemic hepatitis resolving.
6. Diabetes type 2.
DISCHARGE MEDICATIONS: Will be dictated on a future date as
well as follow-up plans.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 22260**]
MEDQUIST36
D: [**2107-1-17**] 13:53
T: [**2107-1-17**] 14:12
JOB#: [**Job Number 101548**]
|
[
"5990",
"51881",
"78552",
"4280",
"99592",
"4019"
] |
Admission Date: [**2189-9-15**] Discharge Date: [**2189-9-23**]
Date of Birth: [**2125-4-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Crescendo Angina
Major Surgical or Invasive Procedure:
[**2189-9-18**] - CABGx4 (Left internal mammary-> left anterior
descending artery, Saphenous vein graft(SVG)->Obtuse marginal
artery 1, SVG->Obtuse marginal artery 3, SVG->Posterior
descending artery.)
[**2189-9-15**] - Left heart catheterization and coronary angiography
History of Present Illness:
Presented to outside hospital with 3-4 weeks of exertional back
and right shoulder pain. He had an episode of nocturnal angina
that awoke him the night of admission. NSTEMI was diagnosed
elsewhere (TropI 9,12.3) and tranferred, painfree, to [**Hospital1 18**] for
definitive care.
Past Medical History:
Hypertension
Appendectomy
benign testicular tumor 15 yrs ago
Social History:
Never smoked.
Works as a dialysis technician
lives with his wife
Rare ETOH
Family History:
Father died of Cancer
Mother died of MI age 72
Brother A & W.
Physical Exam:
A &O x 3.Afebrile
Lungs- clear
Cor- NSR 70s. BP usually 120s/80s
Exts- trace edema. Wounds clean and dry. Fully ambulatory.
Sternum stable and healing well.
Pertinent Results:
[**2189-9-22**] 05:45AM BLOOD WBC-6.1 RBC-3.11* Hgb-9.8* Hct-27.2*
MCV-87 MCH-31.5 MCHC-36.0* RDW-13.0 Plt Ct-216
[**2189-9-22**] 05:45AM BLOOD Glucose-121* UreaN-13 Creat-0.8 Na-141
K-3.8 Cl-104 HCO3-25 AnGap-16
[**2189-9-22**] 05:45AM BLOOD Mg-2.1
Brief Hospital Course:
Catheterization showed 70% distal LM, 80% LAD, mild origin
OM1,40-50% OM2, 50% OM3,prox.RCA 60%.
Echo demonstrated LVEF ~50%.
he was Heparinized and remained painfree. On [**9-18**] he underwent
CABG X 4 as noted. See operative note for details. He was weaned
from CPB easily in SR. He remained stable and was easily
extubated that day. Beta blockers were begun and he was diuresed
towards his preoperative weight.
CTs and wires were removed and he progressed nicely. he was
preparing for discharge on [**9-22**] (POD4) when he had a vagal
episode in the bathroom. He was diaphoretic transiently but
quickly recovered and felt fine. His BP and pulse were normal
immediately after this episode.he subsequently remained stable.
Wounds were clean and dry and he was ready for discharge on
[**9-23**].
Medications on Admission:
Plavix 75mg
ASA 325mg
lisinopril 10mg
MVI
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day.
Disp:*30 Packet(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
coronary artery disease
s/p CABG x4
Hypertension
Discharge Condition:
good
Discharge Instructions:
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**].
Report any fever greater then 100.5. Report any weight gain of
2 pounds in 24 hours or 5 pounds in 1 week.
No lotions, creams or powders to incision until it has healed.
Shower daily. No baths or swimming.Gently pat the wound dry.
o lifting greater then 10 pounds for 10 weeks.
No driving for 1 month and off all narcotics
Take all medications as directed
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 4 weeks. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. ([**Telephone/Fax (1) 18658**]
Please follow-up with Dr. [**Last Name (STitle) 7047**] in [**2-15**] weeks. [**Telephone/Fax (1) 8725**]
Completed by:[**2189-9-23**]
|
[
"41071",
"41401",
"4019"
] |
Admission Date: [**2197-5-29**] Discharge Date: [**2197-6-7**]
Date of Birth: [**2121-12-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Quinine / Aspirin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2197-5-31**]:
Redo aortic valve replacement with a [**Street Address(2) 17167**]. [**Hospital 923**] Medical
Regent mechanical valve
Replacement of the ascending aorta with a 26 mm Gelweave
tube graft
History of Present Illness:
75 year old woman with past medical history significant for an
aortic valve replacement in [**2188**] with Dr. [**Last Name (STitle) 29790**]. She has done
fairly well since that time however had been followed for
progressive bioprosthetic aortic valve stenosis
with serial echocardiograms. She underwent back surgery at
[**Hospital **] Hospital on [**2197-3-13**] however her postoperative course was
complicated by acute heart failure and a myocardial infarction
(Troponin 0.49). Repeat echo showed a normal ejection fraction
with severe bioprosthetic aortic valve stenosis. Her aortic
valve area was 0.7cm2 with a peak of 59mmHg. Her preoperative
peak was noted at 98mmHg with a mean of 59mmHg. She underwent a
cardiac catherization [**5-29**] which revealed left main coronary
artery with an ostial 30% stenosis, left anterior descending 70%
stenosis in the mid-portion, left circumflex had mild
non-significant coronary artery disease and the right coronary
artery had a 40% stenosis in the proximal portion. She was
admitted to the cardiac service post cardiac catherization for
AVR/CABG on wednesday [**2197-5-31**].
Past Medical History:
Diabetes Mellitus type 2
Coronary Artery Disease
Hypertension
Hyperlipidemia
Degenerative Joint disease
Spinal stenosis
Gastric Esophogeal Reflux Disease
Bleeding ulcer
Glaucoma
Recent dental extraction of right lower incisor
AVR(#19 CE pericardial)CABGx1 (Likely LIMA->LAD)-[**2188**] Dr. [**Last Name (STitle) 46826**]
at [**Hospital6 **]
Left carotid endarterectomy roughly 25 years ago
Back Surgery [**2197-3-13**]
Left knee replacement
Surgical intranasal clipping for epistaxis
Social History:
Lives with: Husband in [**Name2 (NI) 5110**] MA
Occupation: Retired
Tobacco: Quit 25 years ago/ 1.5ppd x 40 years
ETOH: Rare
Family History:
Father/Brother and mother with strokes. Brother with
cardiomyopathy
Physical Exam:
Pulse: 75 SR Resp: 16 O2 sat: 98% RA
B/P Right: 148/61 Left: 133/67
Height: 60 inches Weight: 204 lbs
General: WDWN in NAD
Skin: Warm, dry and intact. Well healed left CEA Scar, Well
healed sternotomy. Well healed Left Knee incision.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric.
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2 +S3, III/VI Systolic murmur heard at left
sternal border
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Trace Edema
Varicosities: Likely dilated GSV by palpation. Small superficial
varicosities noted.
Neuro: Grossly intact, nonfocal
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit Right: + Left: +++
Pertinent Results:
[**2197-5-31**]:
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. All four pulmonary veins identified and
enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in ascending aorta. Simple atheroma in
aortic arch. Simple atheroma in descending aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Abnormal motion of AVR leaflets/discs. Thickened AVR leaflets.
Severe AS (area 0.8-1.0cm2). Trace AR.
MITRAL VALVE: 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.
CHEST (PA & LAT)[**2197-6-5**] 9:41 AM Clip # [**Clip Number (Radiology) 86133**]
[**Hospital 93**] MEDICAL CONDITION: 75 year old woman s/p AVR
Final Report
Patient is status post AV replacement. A right internal jugular
central venous catheter is unchanged in position. Median
sternotomy wires are intact. The cardiomediastinal silhouette is
stable. There is mild pulmonary vascular engorgement without
frank edema. The left pleural effusion is increased, with
persistent bibasilar atelectasis.
There is no evidence of pneumothorax.
IMPRESSION: Increased moderate left pleural effusion. Persistent
bibasilar
atelectasis. Mild pulmonary vascular engorgement without
pulmonary edema.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 8083**] [**Name (STitle) 8084**]
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Admission Labs:
[**2197-5-29**] 09:20AM PT-12.2 PTT-24.1 INR(PT)-1.0
[**2197-5-29**] 09:20AM PLT COUNT-286
[**2197-5-29**] 09:20AM WBC-6.3 RBC-3.84* HGB-11.0* HCT-32.8* MCV-86
MCH-28.6 MCHC-33.5 RDW-14.0
[**2197-5-29**] 09:20AM %HbA1c-6.1* eAG-128*
[**2197-5-29**] 09:20AM ALBUMIN-4.0 CALCIUM-9.0 CHOLEST-176
[**2197-5-29**] 09:20AM ALT(SGPT)-11 AST(SGOT)-13 CK(CPK)-45 ALK
PHOS-68 AMYLASE-59 TOT BILI-0.4 DIR BILI-0.1 INDIR BIL-0.3
[**2197-5-29**] 09:20AM GLUCOSE-131* UREA N-21* CREAT-0.9 SODIUM-137
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
[**2197-5-29**] 08:50PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2197-5-29**] 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2197-5-29**] 08:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018
Discharge Labs:
[**2197-6-6**] 04:16AM BLOOD WBC-8.5 RBC-3.37* Hgb-9.9* Hct-28.8*
MCV-85 MCH-29.4 MCHC-34.4 RDW-15.7* Plt Ct-333
[**2197-6-7**] 05:30AM BLOOD PT-20.8* PTT-28.6 INR(PT)-1.9*
[**2197-6-6**] 04:16AM BLOOD Plt Ct-333
[**2197-6-6**] 04:16AM BLOOD PT-19.9* PTT-27.5 INR(PT)-1.8*
[**2197-6-7**] 05:30AM BLOOD UreaN-12 Creat-0.9 K-3.8
Brief Hospital Course:
She underwent cardiac catheterization and was admitted for
preoperative evaluation. On [**5-31**] she was brought to the
operating room and underwent a redo aortic valve replacement
with a [**Street Address(2) 17167**]. [**Hospital 923**] Medical Regent mechanical valve and
replacement of the ascending aorta with a 26 mm Gelweave tube
graft. See operative note for details. The operation went
without complications and the patient was transferred to the
CVICU in stable condition. POD 1 found the patient extubated,
alert and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Beta blockers were titrated up. All tubes lines and
drains were removed per cardiac surgery protocol. The patient
received 2 doses of 4 mg of Coumadin and INR peaked at 3.6. INR
was allowed to drift down and pacing wires were then removed
without incidence. She was re-anticoagulated with Coumadin for
mechanical valve with INR goal 2.5-3.5. INR at discharge was
1.9. Coumadin will be followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] [**Telephone/Fax (1) 4475**].
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 7 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home with services in good condition with
appropriate follow up instructions.
Medications on Admission:
****Plavix 75mg daily- LAST DOSE [**2197-5-4**] due to dental
extraction*******
Aciphex 20mg daily
HCTZ 25mg daily- d/c'd
Lisinopril 20mg daily
Toprol XL 100mg daily (50mg XL [**Hospital1 **] per pt)
[**Name (NI) 86134**] 5mg daily
Lasix 40mg Daily
Vytorin 10/80mg daily
Lumigan eye gtts
MVI
Viactiv chews
Tylenol Arthritis
Glucosamine & Chonrotin
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. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Bimatoprost 0.03 % Drops Sig: One (1) gtt Ophthalmic qhs ().
Disp:*1 QS 1 month* Refills:*0*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day:
2mg on [**6-7**] then as directed by Dr [**Last Name (STitle) 10543**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p redo [**Doctor Last Name **]/AVR(19StJude mech)Asc Ao replacement [**2197-5-31**]
PMH: Non Insulin Diabetes Mellitus, Coronary Artery Disease,
Hypertension, hyperlipidemia, Degenerative Joint Disease, spinal
stenosis, Gastric Esophogeal Reflux Disease, Glaucoma, s/p
AVR/CABG [**2188**], s/p laminectomy, s/p Left Total Knee Replacement
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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) **] Thursday [**7-6**] at 1:30 pm
Please call to schedule appointments:
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ( [**Telephone/Fax (1) 39848**]) in [**2-4**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] ([**Telephone/Fax (1) 4475**]) in [**2-4**] weeks
Labs: PT/INR for Coumadin dosing ?????? indication Mechanical AVR
Goal INR 2.5-3.5
First draw [**2197-6-8**]
Results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] @[**Telephone/Fax (1) 4475**] fax [**Telephone/Fax (1) 41630**]
**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:[**2197-6-7**]
|
[
"4241",
"2859",
"41401",
"412",
"25000",
"4019",
"2724",
"53081"
] |
Admission Date: [**2195-5-21**] Discharge Date: [**2195-5-29**]
Date of Birth: [**2119-1-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea on exertion/fatigue
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x4: [**2195-5-22**]
1. Left internal mammary artery to left anterior descending
artery.
2. Saphenous vein graft to posterior left ventricular.
3. Saphenous vein graft to first obtuse marginal branch of
the circumflex.
4. Saphenous vein graft to the first diagonal branch of the
left anterior descending.
5. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
76 year old man with complaint of severe fatigue and dyspnea on
exertion which has been worsening over the past 3 years. He had
a positive dobutamine stress echocardiogram. Admitted to [**Hospital1 18**]
for prehydration prior to cardiac catheterization.
Past Medical History:
Diabetes mellitus 2
Hypertension
Hyperlipidemia
Chronic kidney disease(baseline creat 1.8)
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Severe depression
Vertigo
Fatigue
h/o ETOH abuse
Obesity
Celiac trunk atherosclerotic disease
Past Surgical History:
Tonsillectomy
Cervical disc surgery
Transurethral resection prostate
nose surgery for fractured bones
Social History:
Lives with wife and mother-in-law
retired IRS auditor
+tobacco <1 pack per day(h/o [**1-3**] ppd x40 years)
+ETOH-2 martinis/day at times supplemented with beer
Family History:
Father s/p MI @52yo
Physical Exam:
HR 60 BP rt 157/65 lft 170/69 RR 14 O2 sat 100%-RA
Ht 5'9" Wt 212 lbs
Gen NAD
Skin warm and dry
HEENT PERRL-EOMI
Neck supple, full ROM
Chest CTA bilat
Cor RRR, no murmur
Abdm soft, NT/ND/+BS
Ext warm well perfused, no varicosities
Neuro A&O x3, grossly intact. Caotid- no bruits
Pulses fem 2+ bilat, Rad 2+ bilat, DP/PT 2+ bilat
Pertinent Results:
[**2195-5-21**] 07:50AM HGB-12.4* calcHCT-37
[**2195-5-21**] 07:50AM GLUCOSE-99 LACTATE-1.2 NA+-139 K+-4.1 CL--108
[**2195-5-21**] 12:17PM PT-15.8* PTT-36.7* INR(PT)-1.4*
[**2195-5-21**] 12:17PM PLT COUNT-179
[**2195-5-21**] 12:17PM WBC-8.5# RBC-2.78* HGB-9.4* HCT-28.6*
MCV-103* MCH-33.8* MCHC-32.9 RDW-15.2
[**2195-5-21**] 12:18PM GLUCOSE-105 LACTATE-2.8* NA+-139 K+-4.7
CL--112
[**2195-5-21**] 01:33PM UREA N-23* CREAT-1.2 CHLORIDE-116* TOTAL
CO2-21*
=============================================
[**Known lastname **],[**Known firstname **] [**Medical Record Number 73392**] M 76 [**2119-1-11**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2195-5-26**]
6:26 PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2195-5-26**] 6:26 PM
CT HEAD W/O CONTRAST
[**Hospital 93**] MEDICAL CONDITION: 76 year old man with altered
mental status/delerium
REASON FOR THIS EXAMINATION: ischemic event
CONTRAINDICATIONS FOR IV CONTRAST: None.
Final Report
HISTORY: 76-year-old male with altered mental status and
delirium concerning for ischemic event.
COMPARISON: MR head from [**2193-7-16**].
TECHNIQUE: MDCT-axial imaging was performed through the brain
without
administration of IV contrast.
NON-CONTRAST HEAD CT: Slight tilting of the patient's head
during imaging
limits evaluation for symmetry somewhat. Allowing for this, no
evidence of
acute intracranial hemorrhage, edema, mass effect,
hydrocephalus, or large
vascular territory infarction is seen. Study is also limited due
to patient motion, particularly the imaging through the skull
base. Again prominence of the sulci and ventricles is consistent
with age-related involutional change.
Periventricular white matter hypodensities are likely due to
chronic small
vessel ischemic disease. Note is also made of likely chronic
small lacunar
infarcts in bilateral basal ganglia. The soft tissues, orbits,
and skull
appear intact. The visualized paranasal sinuses and mastoid air
cells are
normally aerated. Vascular calcifications are noted along the
cavernous
carotid arteries.
IMPRESSION: No acute intracranial process seen. There is
evidence of chronic microvascular as well as old lacunar
infarction, as on the previous MR. If there is persistent
concern for acute infarction, MRI with diffusion-weighted
imaging would be recommended for more sensitive evaluation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
=================================================
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 73393**] (Complete)
Done [**2195-5-21**] at 10:11:20 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2119-1-11**]
Age (years): 76 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Coronary artery disease. Left ventricular function.
Mitral valve disease. Preoperative assessment.
ICD-9 Codes: 440.0, 424.0
Test Information
Date/Time: [**2195-5-21**] at 10:11 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.4 cm <= 3.0 cm
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right
shunt across the interatrial septum at rest.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
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.
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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Prebypass
A patent foramen ovale is present. A left-to-right shunt across
the interatrial septum is seen at rest. 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. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen at a systolic blood pressure of 110
mm Hg.. At a systolic blood pressure of 180 mm Hg and
Trendelenburg position the mitral regurgitation increased to
mild to moderate (2+).
Postbypass.
There is preserved biventricular systolic function. MR is now
trace/mild. The remaining study is unchanged from the prebypass
period.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2195-5-21**] 12:12
=====================================
Brief Hospital Course:
Mr [**Known lastname 16905**] was admitted to [**Hospital1 18**] for cardiac catheterization
which revealed 3 vessel disease and preserved ejection fraction.
Cardiac surgery was consulted and on [**5-21**] the patient was
brought to the operating room where he had coronary artery
bypass grafting. Please see operative report for details. In
summary he had coronary artery bypass grafts including left
internal mammary to left anterior descending artery, reverse
saphenous vein graft to Diagonal artery, reverse saphenous vein
graft to obtuse marginal and reverse saphenous vein graft to
posterior left ventricular artery. His bypass time was 105
minutes with a crossclamp time of 90 minutes.
He tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition.
Once in the ICU he remained hemodynamically stable his
anesthesia was reversed and he was extubated.
On POD1 he was transferred from the cardiac surgery ICU to the
stepdown floor for continued care and recovery. Over the next
several days his tubes, lines, and drains were uneventfully
removed according to protocol. His activity level was advanced
with the assistance of nursing and physical therapy. He was
noted to have intermittent episodes of atrial fibrillation that
were treated with beta blockers and amiodarone following which
he returned to [**Location 213**] sinus rhythm. He also had some confusion,
he was seen by psychiatry and had a negative head CT. the
confusion cleared after stopping his narcotics. Additionally he
had a chest CT that revealed a 5 mm right lower lobe density
that will require a follow up CT in [**4-6**] weeks.
On POD seven he was discharged to rehabilitation at [**Location (un) 8641**] on
[**Location (un) **] Care Rehabilitation Center.
Medications on Admission:
Effexor 75"
Glipizide 5"
Avodart 0.5'
Januvia 50'
Metoprolol 50'
Simvastatin 10'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily ().
Disp:*30 Capsule(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. 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*
10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 8641**] on [**Location (un) **] Care Rehab Center
Discharge Diagnosis:
Coronary artery disease
NIDDM
Chronic renal insufficiency
Hyperlipidemia
Depression
ETOH abuse
COPD
Obstructive sleep apnea
Celiac atherosclerotic disease
BPH-status post TURP
status post cervical disc surgery
Discharge Condition:
Good.
Discharge Instructions:
Take medications as directed in discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 pounds for 10 weeks.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temperature >101.5, sternal drainage or
redness.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 68527**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 911**] for 3 weeks.
Make an appointment with Dr. [**First Name (STitle) **] for 4 weeks.
Will need a chest CT in [**4-6**] weeks to evaluate lung nodules seen
on chest CT during your admission. Your primary care physician
can arrange this study.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2195-5-29**]
|
[
"41401",
"42731",
"25000",
"32723",
"V5867",
"3051",
"496",
"2724",
"2720"
] |
Admission Date: [**2174-9-25**] Discharge Date: [**2174-9-28**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 88 year-old
woman who was hit in the head four weeks prior to admission
in the bathtub with no loss of consciousness, no headache and
no nausea or vomiting. After a week of headache on the left
side, no vomiting, but it did wax and wane and she did have
had a CT, which showed minuscule bleed. She did not get any
improvement with Tylenol. She was getting dinner and could
not pick up anything with her right hand and having
clumsiness for a week and now having shaking in the right
hand and unable to cut things and went to the Emergency
Department.
noninsulin dependent diabetes, congestive heart failure.
MEDICATIONS: Prevacid, atenolol 12.5 po q day, K-Ciel 10
milliequivalents po q day, Lasix 20 mg po b.i.d., ASA q.o.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Mental status, awake and alert,
oriented times three. She is able to speak fluently and
appropriately. Repetition intact. Attentive. Spelled world
forward and backward. Fund of knowledge intact. Cranial
nerves II through XII intact. Extraocular muscles are
intact. Positive nystagmus. Cataracts. Visual fields full.
Face symmetric. Palette rises symmetrically. Tongue
midline. Motor strength, trace pronator drift in the right
upper extremity, right grasp 4 - out of 5, interossea 5- out
of 5 otherwise all muscle groups are 5 out of 5. Sensory
decreased in the palm to temperature, question increase to
pin prick otherwise intact. Coordination finger to nose
slower on the right then on the left. Reflexes bilaterally
up going toes, otherwise intact. No clonus. Reflexes
symmetric.
LABORATORIES ON ADMISSION: White blood cell count 8.5,
hematocrit 31.6, platelet count 278, sodium 132, K 4.5,
chloride 94, CO2 26, BUN 21, creatinine 1.8, glucose 114.
Head CT shows subacute left subdural hematoma with no
increasing in the interval.
The patient was monitored in the Surgical Intensive Care Unit
for close observation. Her neurological status was awake,
alert and oriented times three with no drift. Moving all
extremities symmetrically. The patient was discharged to the
floor on [**2174-9-26**]. On the evening of [**2174-9-26**] the patient
became extremely confused and combative. The patient was
given Haldol and was provied with sitters. The patient's mental
status was clear by the morning of [**9-27**]. She was without
sitters. Her vital signs were stable and she was cognesent
of the events of the previous evening and apologetic. The
patient's mental status continued and remained clear after
that one episode of confusion. Her vital signs remained
stable and she was afebrile throughout her hospital stay.
MEDICATIONS ON DISCHARGE: Lopressor 12.5 mg po b.i.d.,
Tylenol 650 po q 4 hours prn, Dilantin 100 mg po t.i.d.,
Colace 100 mg po b.i.d.
CONDITION ON DISCHARGE: Stable.
The patient was seen by physical therapy and occupational
therapy and found to require a short rehab stay prior to
discharge home. The patient will follow up with Dr. [**First Name (STitle) **] in
two weeks time with follow up head CT.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2174-9-28**] 13:52
T: [**2174-9-28**] 14:06
JOB#: [**Job Number **]
|
[
"25000",
"4280",
"4019"
] |
Admission Date: [**2145-5-30**] Discharge Date: [**2145-6-14**]
Date of Birth: [**2095-7-24**] Sex: F
Service: CICU
CHIEF COMPLAINT: The patient was admitted to the cardiac
intensive care unit on [**2145-5-29**], with a chief complaint
of nausea and chills.
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old
Hispanic female with a history of diabetes, hypertension, and
elevated cholesterol, who presented to the Emergency
Department with 24-hour symptoms of nausea and chills. The
patient was found to have ST elevations at that time in leads
II, III, and aVF as well as third-degree AV heart block. The
patient was heparinized and taken to the cardiac
catheterization laboratory where she was found to have a
proximal right coronary artery lesion with recent clot
visible which received Angioject and had two stents placed.
The patient returned to sinus rhythm after Angioject. The
patient was also found to have an 80% left anterior
descending artery lesion and an 80% OM lesion. A pacing wire
was left in the right heart after borderline low blood
pressures were detected while the patient was in heart block,
and a question of right ventricular involvement of her
cardiac event was entertained. The right-sided leads showed
1-mm ST elevations in V4. The patient denied symptoms of
fever, chills, shortness of breath, chest pain, paroxysmal
nocturnal dyspnea, orthopnea, cough or diarrhea. She does
note that her exercise activity has been limited to walking
two blocks and experiences occasionally dyspnea on exertion.
PAST MEDICAL HISTORY: (As mentioned)
1. Diabetes mellitus with retinopathy and legally blind.
2. Hypertension.
3. Elevated cholesterol.
4. Anxiety.
5. Depression.
MEDICATIONS ON ADMISSION: Insulin, Valium, Lasix,
Glucophage, and Lipitor (doses unknown).
ALLERGIES: The patient has allergies to SULFA MEDICATIONS.
SOCIAL HISTORY: She smokes one to two packs per day of
tobacco. She has a prior history of alcohol excess but does
not drink currently. The patient lives at home with her
husband.
FAMILY HISTORY: Family history was unobtainable.
PHYSICAL EXAMINATION: Physical examination was as follows.
Temperature 97.3, blood pressure 124/76, heart rate ranging
75 to 95, oxygen saturation 96% to 99% on 2 liters nasal
cannula, a respiratory rate of 21. In general, the patient
was in no apparent distress, lying in bed, status post
catheterization, well-developed, well-nourished. HEENT
examination showed oropharynx was clear, edematous. Mucous
membranes were dry. Neck was supple. No jugular venous
distention. No lymphadenopathy. Lungs were clear to
auscultation anteriorly and laterally bilaterally.
Cardiovascular examination revealed a regular rate and
rhythm, S1 and S2. No murmurs, rubs or gallops. Abdomen was
soft, nontender, and nondistended, with normal active bowel
sounds. Extremities had 1+ pulses bilaterally. No edema.
Right groin sheath in place.
LABORATORY VALUES ON ADMISSION: White blood cell count 14.6,
hematocrit 33.8, platelets 314, MCV 90. INR 1. Sodium 137,
potassium 3.4, chloride 99, bicarbonate 29, BUN 28,
creatinine 1.5, glucose 272. ALT 36, AST 96, total
bilirubin 0.1, LDH 910. Creatine kinase was 1288 with an MB
of 31, troponin greater than 50. Amylase 33, alkaline
phosphatase 107, albumin 1.9, protein 4.5.
As mentioned, pre-catheterization electrocardiogram showed
third-degree AV block with 2-mm ST elevations in leads II,
III, and aVF with 2-mm ST depressions in lead V2, right
bundle-branch block, Q waves in leads II, III, and aVF.
Post catheterization electrocardiogram demonstrated sinus
rhythm at 60, normal axis, borderline first-degree AV block,
1-mm ST depressions in lead aVF, T wave inversions in leads
II, III, aVF as well as leads V4 through V6 with delayed R
wave progression, Q waves visible in II, III, aVF as well as
V1 through V3.
Chest x-ray was unremarkable for infiltrates or evidence of
failure.
HOSPITAL COURSE: The patient was admitted to the cardiac
intensive care unit for further monitoring. The patient was
placed on Integrilin, aspirin, Plavix, and had temporary
pacing wires in place on admission.
On the second day of her hospitalization, the patient's
fasting lipid profile returned with a total cholesterol
of 264, triglycerides 177, LDL 181, and HDL of 48. The
venous sheath in the patient's groin was left in with
temporary pacing wires intact while the arterial sheath was
removed without complications. The patient continued to be
in second-degree AV heart block with rate in the 40s to 50s.
Ventricular pacing at a rate of 90 without a quick capturing
of temporary wires.
The patient was evaluated by the Electrophysiology fellow for
possible consideration of more permanent pacemaker once the
patient was stable post myocardial infarction. However,
these plans were put on hold when the patient spontaneously
converted to normal sinus rhythm with a rate of 50 to 70
beats per minute. The patient's creatine phosphokinases
continued to trend down after her cardiac intervention, and
she was considered stable from a cardiac standpoint and had
the temporary wires removed on [**2145-6-2**], with no
complications.
The patient continued to be in normal sinus rhythm thereafter
without any further electrophysiology intervention. The
patient did become quite agitated by [**2145-6-2**],
intermittently pulling at lines and requiring some degree of
sedation for management and safety. It was determined that
better fluid status and hemodynamic measuring would be
obtained by placing a Swan-Ganz catheter, which was done
through a right internal jugular cordis, placed on [**2145-6-2**].
The patient subsequently required intubation by the evening
of [**2145-6-2**], after further hemodynamic instability and
apparent evidence of septic shock by Swan-Ganz numbers.
Throughout the remainder of her Intensive Care Unit stay, the
patient also intermittently required pressors and significant
ventilatory assistance. The patient was sedated with
morphine and propofol and placed on vancomycin, gentamicin,
and levofloxacin to cover empirically for organisms causing
her septic picture. While the patient was repeatedly
cultured, she grew only Klebsiella pan-sensitive organisms
from her urine with no evidence of blood infection or line
contamination from any site. The patient required
significant fluid resuscitation and hemodynamic support for
the following week. However, the patient was also placed on
deep venous thrombosis prophylaxis as well as given tube
feedings for nutritional support.
By [**2145-6-8**], the patient was progressively weaned off of
her ventilator settings to SIMV with pressure support and
tolerated this well. Her sedation was also weaned throughout
the day, and the patient's dopamine was able to be
discontinued. Plans were made for the patient to be
extubated on [**2145-6-10**], as she had recovered quite nicely
from both her infectious picture and from a cardiac
standpoint. However, the patient self-extubated at 12 noon
on [**2145-6-10**], luckily without any complications or
sequelae. A STAT portable chest x-ray showed no evidence of
infiltrate or complications. The patient was speaking and
coughing immediately after the event and was placed on a face
mask. The patient subsequently did quite well and required
very little oxygen therapy by nasal cannula over the next 24
hours. The patient also self diuresed after significant
amounts of intravenous Lasix drip while she was ventilated,
and the patient was transferred to the stepdown cardiac floor
on Eleven Riseman on [**2145-6-12**].
While the patient's central line access was discontinued on
[**2145-6-13**], the patient remained stable with a peripheral
IV. She tolerated a p.o. diet and p.o. medications
wonderfully, and was evaluated by Physical Therapy for two
days prior to discharge. The patient was able to walk with
assistance and appeared to be mentally intact.
It was determined that the patient could be discharged safely
to home with the assistance of her family with whom she lives
and to have visiting nurse assistance for several days after
discharge as well as home physical therapy.
MEDICATIONS ON DISCHARGE:
1. Enteric-coated aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d. through [**7-8**].
3. Levofloxacin 250 mg p.o. q.d. through [**6-17**] (to
complete a 14-day course).
4. Prilosec 40 mg p.o. q.d.
5. Lopressor 25 mg p.o. b.i.d.
6. Captopril 12.5 mg p.o. t.i.d.
7. Lipitor 10 mg p.o. q.h.s.
8. Colace 100 mg p.o. b.i.d.
9. Tums 500 mg p.o. t.i.d. with meals.
10. Prozac 20 mg p.o. q.d.
11. Tylenol 650 mg p.o. q.6-8h. p.r.n.
12. Glucophage 500 mg p.o. q.d.
FOLLOWUP: The patient was to receive cardiac rehabilitation
physical therapy at home as previously discussed, and the
patient was also to call the office of Dr. [**Last Name (STitle) 1789**], her
primary care physician, [**Name10 (NameIs) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment within
one to two weeks of discharge from the hospital.
DISCHARGE DIAGNOSES:
1. Inferior myocardial infarction with coronary artery
disease.
2. Type 2 diabetes with retinopathy.
3. Hypertension.
4. Elevated cholesterol.
5. Anxiety.
6. Depression.
7. Status post Klebsiella urinary tract infection and sepsis
requiring intubation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 7118**]
MEDQUIST36
D: [**2145-6-14**] 12:59
T: [**2145-6-16**] 05:43
JOB#: [**Job Number 24035**]
cc:[**Telephone/Fax (1) 24036**]
|
[
"41401",
"51881",
"5990"
] |
Admission Date: [**2151-12-22**] Discharge Date: [**2152-1-11**]
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Cholangitis
Major Surgical or Invasive Procedure:
Transcutaneous Biliary Drain
ERCP
History of Present Illness:
83 y F with cholangitis due to pancreatic CA (end stage). Pt
brought for ERCP (failed) treated with transcutaneous billiary
drain. Pt worsened over admission, with recurrent tense ascites.
Pt made DNR/DNI and to be transferred to hospice
Past Medical History:
Hypertension
atrial fibrillation
Social History:
+ TOB, - ETOH, - IVDU
Lives with Son, also has daughter
Family History:
NC
Physical Exam:
Gravely ill woman, moaning in pain
rales b/l
ascites, NT/ND
[**Last Name (un) **], S1/S2, - MRG
4+ edema
Pertinent Results:
[**2152-1-11**] 03:46AM BLOOD WBC-7.2 RBC-2.95* Hgb-8.4* Hct-26.3*
MCV-89 MCH-28.5 MCHC-32.0 RDW-26.8* Plt Ct-61*
[**2152-1-8**] 05:15AM BLOOD Neuts-87.6* Bands-0 Lymphs-5.3* Monos-4.8
Eos-2.2 Baso-0
[**2152-1-11**] 03:46AM BLOOD Plt Ct-61*
[**2152-1-11**] 03:46AM BLOOD UreaN-73* Creat-2.2* Na-142 K-3.7
[**2152-1-11**] 03:46AM BLOOD TotBili-9.1*
[**2152-1-9**] 05:14AM BLOOD ALT-49* AST-50* AlkPhos-357* TotBili-8.9*
[**2151-12-25**] 04:17AM BLOOD CK-MB-4 cTropnT-0.02*
[**2152-1-11**] 03:46AM BLOOD Albumin-1.9* Mg-2.3
cholangiogram:IMPRESSION:
1. Cholangiogram demonstrating biliary obstruction at the level
of the common bile duct with moderate intrahepatic ductal
dilatation.
2. Exchange of an 8 French biliary catheter over a wire.
3. Proper drainage of bile was demonstrated both visually via
the external route and radiographically via the internal route
into the duodenum.
4. Given severe narrowing of the common bile duct, if clinically
indicated, a metallic stent could be placed by interventional
radiology in the future.
Brief Hospital Course:
Patient now ready to go to hospice. Long family discussion, and
medical futility of further treatment, decision to withdraw
primary care, and move to comfort care and hospice.
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Kinwell
Discharge Diagnosis:
Pancreatic Cancer
Cholangitis
Tense Ascites
Discharge Condition:
Critical
Discharge Instructions:
Hospice Care
Followup Instructions:
Hospice Care
|
[
"0389",
"78552",
"42731",
"99592",
"4019"
] |
Admission Date: [**2180-8-29**] Discharge Date: [**2180-9-4**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Hypertensive urgency/transfer for epidural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F (Haitian Creole speaking) w/ h/o dementia, HTN, CHF, AF
on digoxin (not on warfarin) presented to OSH from nursing
facillity after unwitnessed fall, found to have intracranial
hemorrhage at OSH and transferred to [**Hospital1 18**] for neurosx eval.
.
Per daughter, patient in her usual state of health w/ baseline
delerium (A&Ox1 - self, auditory hallucinations, and poor po) on
Sunday when she visited her in nursing facillity. Patient was
w/o complaints, and had no n/v, d/c, cp, sob. At 2AM of day
admission, pt was found down at her nursing facillity after
unwitnessed fall. She was transferred to [**Hospital1 **] where head CT
showed 4mm acute epidural hemorrhage vs subdural hemorrhage
w/very mild midline shift as well as suspected L eye globe
hemorrhage. Pt recv'd ativan 1mg for CT scan. CT c-spine
negative. She was transferred to [**Hospital1 18**] for neuro [**Doctor First Name **] eval.
.
In the ED, initial VS were: Temp: 97.6 HR: 80 BP: 178/80 Resp:
20 O2 Sat: 98. A repeat CT Head demonstrated no interval change
in what was determined to be an epidural hematoma. The patient
was started on nicardipine gtt with target goal of SBP<140. The
nicardipine gtt was stop due to hypotension with SBP in the
90's. Then the patient was transfered to the MICU for BP
monitoring and q4hr neuro check given epidural hematoma.
On arrival to the MICU, the initial vitals were 96.2 80 152/82
16 99% on RA. The patient was given hydralazine 10 IV and
responded with a BP in the 120's/50's.
Past Medical History:
Afib
HTN
CHF
Dementia
Psychosis
s/p cataract sx
s/p ccy
Social History:
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Family History:
Not pertient in a [**Age over 90 **]F with dementia.
Physical Exam:
Admission Physical Exam:
Vitals: 96.2 80 152/82 16 99% on RA
General: Alert, oriented x 1, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear larger
periorbital hematoma
Neck: supple, no LAD
CV: irregularly irregular rhythm normal rate, 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 organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:
Vitals: 97.0 92 181/91 20 100% on RA
General: Alert, oriented x 1, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear larger
periorbital hematoma; healing laceration
Neck: supple, no LAD
CV: irregularly irregular rhythm normal rate, 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 organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Most Recent Labs:
[**2180-9-2**] 11:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2180-9-2**] 11:00AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG
[**2180-9-2**] 11:00AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2180-9-2**] 11:00AM URINE Mucous-RARE
URINE CULTURE (Final [**2180-9-3**]): NO GROWTH.
.
Admission Labs:
[**2180-8-29**] 08:55AM BLOOD Neuts-81.8* Lymphs-13.5* Monos-3.1
Eos-1.4 Baso-0.2
[**2180-8-30**] 02:12AM BLOOD Plt Ct-134*
[**2180-8-30**] 02:12AM BLOOD PT-14.2* PTT-23.8 INR(PT)-1.2*
[**2180-8-30**] 02:12AM BLOOD Glucose-131* UreaN-22* Creat-0.8 Na-142
K-3.5 Cl-110* HCO3-22 AnGap-14
[**2180-8-29**] 08:35PM BLOOD CK-MB-4 cTropnT-<0.01
[**2180-8-30**] 02:12AM BLOOD Calcium-9.5 Phos-2.1* Mg-1.9
[**2180-8-29**] 08:55AM BLOOD Digoxin-1.1
[**2180-8-29**] 08:44PM BLOOD Type-[**Last Name (un) **] pO2-21* pCO2-32* pH-7.48*
calTCO2-25 Base XS-0
[**2180-8-29**] 08:44PM BLOOD Lactate-2.5*
[**2180-8-29**] 09:25AM BLOOD Glucose-99 Na-146* K-4.6 Cl-QNS
calHCO3-18*
[**2180-8-29**] 08:44PM BLOOD freeCa-1.28
.
EKG [**2180-8-29**]:
Atrial fibrillation. Inferolateral ST-T wave changes consistent
with digoxin effect. No previous tracing available for
comparison.
.
Rate PR QRS QT/QTc P QRS T
74 0 102 346/370 0 33 -110
CXR [**2180-8-29**]:
FINDINGS: Single AP upright portable view of the chest was
obtained. The
patient is rotated to the right. Given this, no focal
consolidation is seen. There is minimal blunting of the left
costophrenic angle which is likely positional, although a trace
effusion cannot be entirely excluded. No evidence of
pneumothorax is seen. The cardiac silhouette is mildly enlarged.
The aorta is calcified and tortuous. No displaced fracture is
seen.
.
IMPRESSION: No focal consolidation. Minimal blunting of the left
costophrenic angle is likely positional, although a very trace
pleural
effusion cannot be excluded. Mild cardiomegaly.
.
CT SINUS/MAXILLARY/MANDIBLE [**2180-8-29**]:
.
FINDINGS: There is extensive soft tissue swelling of the left
periorbital and preseptal region. The left globe contour is
intact with no CT evidence of rupture, but ophthalmology
examination is advised. There is hemorrhage seen within the left
globe both in the anterior and posterior [**Doctor Last Name 1754**]. Vitreous
hemorrhage is seen contiguous with the anterior chamber
hemorrhage. The hemorrhage within the posterior chamber along
the posterior aspect of the globe likely represents choroidal
hemorrhage/detachment as the hemorrhage is seen to cross the
optic nerve. No retrobulbar hematoma is seen. Osseous structures
of the orbits appear intact with no fluid or blood seen within
the paranasal air spaces. Minimal mucosal thickening is seen in
the left maxillary sinus. The cribriform plate is intact.
.
IMPRESSION:
1) Hemorrhage in the anterior and posterior [**Doctor Last Name 1754**] of the left
globe.
Vitreous hemorrhage is seen contiguous with the anterior chamber
hemorrhage. Posterior hyperdensity most likely represents
choroidal hemorrhage/detachment.
Globe appears intact, but direct examination advised.
2) Left periorbital and preseptal soft tissue swelling/hematoma
without
underlying fracture seen. No retrobulbar hematoma.
.
FINDINGS: There is a small 4-mm epidural hematoma seen in the
left
occipitoparietal region with possible subdural hematoma
extension, unchanged from previous outside hospital study. There
are periventricular white matter hypodensities most likely
representing chronic small vessel disease. There is mild
prominence of the ventricles but the sulci are of normal size
and configuration. There is no shift of normally midline
structures.
.
There is extensive soft tissue swelling in the left periorbital
and preseptal region. There is hemorrhage seen within the left
globe in the posterior and anterior chamber as well as the
vitreous. The posterior hemorrhage most likely represents
choroidal hemorrhage. No fractures are observed in the orbital
structure. There is no hemorrhage seen within the orbits or
evidence of extraocular muscle entrapment.
.
There is opacification of several ethmoid air cells on the left,
which most likely represent inflammatory changes; however,
hemorrhage cannot be ruled out. If there is clinical concern for
hemorrhage, temporal bone CT is recommended.
.
IMPRESSION:
1. 4-mm epidural hematoma in the left parieto-occipital region
with possible adjacent subdural hematoma.
2. Hemorrhage in the left globe both in the posterior and
anterior [**Doctor Last Name 1754**]. Posterior hemorrhage most likely represents
choroidal hemorrhage. Globe appears intact. See dedicated
maxillofacial CT for further details.
3. Opacification of a very few left mastoid air cells, most
likely representing inflammation; however, but in the setting of
trauma, hemorrhage and a nondisplaced temporal bone fracture can
not be excluded. If there is clinical concern, temporal bone CT
can be obtained.
.
Head CT [**2180-8-30**]:
.
FINDINGS: Foci of hyperdensity in the left occipitoparietal
region previously described as epidural hematoma are more likely
in the subdural space. The more posterior vertex blood
collection (2a:19) appears centered on and spans an intact
lambdoid suture, making this unlikely to lie in the epidural
space. Both foci of hyperdensity within the occipitoparietal
region are unchanged in size when compared to the prior study.
There is evidence of thin subdural hematoma, unchanged from the
prior study.
.
Mild prominence of ventricles and sulci are unremarkable for the
patient's
age. There is no shift of normally midline structures.
Periventricular white matter hypodensities are unchanged from
the prior study. Soft tissue swelling in the left periorbital,
preseptal region is unchanged. Amorphous material in poster
chamber and hyperdense layering material in dorsal part of the
left globe. No fractures are observed in the orbital structures.
.
Opacification of ethmoid air cells is unchanged. No fractures
are seen in the osseous structures.
.
IMPRESSION:
1. Unchanged foci of extra-axial, likely subdural hemorrhage,
when compared
to the study from [**2180-8-29**].
2. Hemorrhage within the left globe, now incompletely layering.
.
Brief Hospital Course:
[**Age over 90 **]F (Haitian Creole speaking) with baseline dementia/psychosis
presented to OSH after unwitnessed fall with subdural hematoma,
hemorrhage in anterior and posterior chamber of left globe, and
was transferred to [**Hospital1 18**] for management.
.
# Hypertensive Urgency: Patient on nicardipine gtt in the ED
that was stopped secondary to hypotension. Given ICH,
anti-hypertensives titrated w/ a goal of SBP<140, per
neurosurgery. She was switched over to hydralazine IV and
metoprolol IV due to inability to tolerate PO meds. Neuro checks
q 4hrs with no acute changes. Cardiac enzymes were sent and were
negative for acute ischemic event. Patient is paranoid/actively
hallucinating and believes that staff is trying to poison her
and so would not take PO meds. Pt started taking home PO meds
when family administers the medication. Therefore, BP has been
difficult to control, but after she takes her home PO pindolol,
BPs stabilize to SBP 120s. We believe that she is stable to
leave if she continues taking home meds.
.
# Subdural hematoma: Stable on repeat head CT, with no need for
neurosurgical intervention at this time. Neuro exam non-focal,
neuro checks q4 hours throughout hospitalization showed no acute
changes. Blood pressure control as described above. Final Report
of his repeat head CT ([**8-30**]) showed "unchanaged areas of
subdural hematoma when compared to the study from [**2180-8-29**].
Hemorrhage in left globe now incompletely layering."
.
#Episode of unresponsiveness on [**2180-9-1**]: The patient was
unable to be arroused by sternal rub and so an extensive and
emergent unresponsiveness workup ensued. A NCHCT showed no
acute changes. Blood gas was nonrevealing. EKG was unchanged.
Metabolic derangement seemed unlikely as the CHEM 10 was within
normal limits. Infection unlikely as CBC wnl and no fever. The
patient was loaded on dilantin and there was no seizure activity
on EEG. Blood glucose normal. The patient did have some
cogwheeling on exam and had received haldol for hyperactive
delerium about 24 hours before the episode, and so
extrapyrimidal symptoms secondary to dopaminergic medication was
considered; patient treated with benztropine and patient
returned to baseline. Haldol was avoided the remainer of the
admission and home olanzapine dose was resumed prior to d/c. At
time of discharge, patient appeared to be at her baseline
functioning.
.
# L globe hemorrhage: Patient evaluated by optho in the ED and
were initially discussing role for surgery although there was no
acute need. She was placed on vigomox and steroid gtt. Will
continue to monitor. Will start glaucoma gtts and should
continue as outpatient. Patient has outpatient appointment with
opthomology immediately following discharge to be evaluated by
B-scan. Patient should follow up with opthomology pending those
results.
.
# AG acidosis: No ABG done, VBG: 7.48, PCO2 32. Lactate 2.5.
Given IVF. Per daughter has very poor po intake, can be element
of starvation ketosis. No fevers or leukocytosis to invoke
infectious process. Resolved by time of discharge.
.
# Fall: Unclear etiology as fall was unwitnessed. No events on
telemetry.
.
# Dementia: Appears to be at baseline after discussing w/
daughter. [**Name (NI) **] received prn haldol and zyprexa with
inconsistent results throughout admission. Continue psych meds
from Nursing home and have them administered by family members.
.
# Afib: Monitored on telemetry. Not on coumadin. Discharged on
home dose of digoxin.
.
# Urinary retention: patient had difficulty urinating at times
throughout her admission. Straight catheterizations put out
concentrated urine. Patient was not drinking much during her
admission, and so low volume status could have been a
contributor. Urinalysis was unrevealing and urine culture was
negative.
.
Pt was confirmed full code this admission.
Medications on Admission:
1. aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. olanzapine 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid
Dissolves PO HS (at bedtime).
Disp:*45 Tablet, Rapid Dissolve(s)* Refills:*2*
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. pindolol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aspirin 81 mg PO daily
Discharge Medications:
1. aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. olanzapine 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid
Dissolves PO HS (at bedtime).
Disp:*45 Tablet, Rapid Dissolve(s)* Refills:*2*
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. pindolol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
11. ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H
(every 4 hours).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnoses:
Epidural Hematoma
Subdural Hematoma
Left Eye Globe Hemorrhage
Facial laceration and eccymoses
.
Secondary Diagnoses:
Hypertension
Dementia
Psychosis
Extrapyrimidal Side Effects from Dopaminergic Medications
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert but not appropriately interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 39238**],
.
It was a pleasure taking care of you at [**Hospital1 **].
You were admitted to the hospital after you had a fall.
.
After you fell, you have been diagnosed with multiple bleeds in
your brain and left eye. It is recommended that you control
your blood pressure with your outpatient pinolol. You should
have regular (at least daily) blood pressure checks at your
nursing facility. If your blood pressure is high, your doctor
may want to change or increase the dose of your current
medications.
.
You were taking aspirin 81 mg daily before you came to the
hospital. You should stop taking this medication for the time
being. When your ophthomologist tells you it is safe to restart
this medication, you may do so.
.
You also had an episode while hospitalized in which you could
not wake up. This issue has resolved. It is not certain, but
it seems that some of the medications you received while
hospitalized may have been the reason this happened to you. In
the future, you should avoid one medicine in particular which is
called Haldol or haloperidol.
.
We made the following changes to your meds:
- You will START taking some eye drops.
Followup Instructions:
You have been scheduled for an eye appointment imediately
following discharge today. Depending on what the test shows,
you may need to return to the hospital for treatment.
Otherwise, you should follow up with your ophthomologist as per
their decision.
Completed by:[**2180-9-5**]
|
[
"2762",
"4280",
"42731"
] |
Admission Date: [**2137-5-22**] Discharge Date: [**2137-5-27**]
Date of Birth: [**2059-8-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Enalapril / Lidocaine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Left main Coronary Artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 (left internal mammary artery
to left anterior descending coronary; reverse saphenous vein
graft to OM1,reverse saphenous vein graft first diagonal
coronary artery,saphenous vein graft to posterior descending
coronary artery.
History of Present Illness:
This is a 77 year old woman who presented to an outside hospital
with acute chest pain at rest, lasting 1/1/2 hrs. In retrospect
she had an episode of "indigestion" which was not persued by her
primary care provider [**Name Initial (PRE) **] week earlier. She went to the ED at [**Location (un) 21541**] Hospital where ECG showed ST depressions in anterolateral
leads and Heparin and ASA were given. Her initial troponin was
1.9. She had recurrent pain later in the day which led to
cardiac catheterization which revealed 75% LM,prox 95%LAD with
subsequent 40-50%s,99% osteal circumflex and significant,
diffuse RCA disease.Integrelin was begun. No LVgram wasdone. An
Intra-aortic balloon pump was placed due to anatomy and she
became pain free subsequently. Troponins peaked 9. A right
heart catheterization was normal (25/5,PCWP 10,CVP 2). She was
transferred to [**Hospital1 18**] for revascularization.
Past Medical History:
hyperlipidemia
hypertension
esophageal spasm
radical neck dissection and parathyroidectomy 10 yrs ago
Social History:
Race:caucasian
Last Dental Exam:3months
Lives with:husband
Occupation:
[**Name2 (NI) 1139**]:non smoker
ETOH:2 drinks/day
Family History:
noncontributory
Physical Exam:
Admission:
General:WDWN in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:N Left:N
Pertinent Results:
[**2137-5-23**]
Pre-bypass: The left atrium and right atrium are normal in
cavity size. A patent foramen ovale is present. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. 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 a trivial/physiologic
pericardial effusion.
Post-bypass: The patient is not receiving inotropic support
post-CPB. Biventricular systolic function is preserved and all
findings are consistent with pre-bypass findings. The aorta is
intact post-decannulation. All findings communicated to the
surgeon intraoperatively.
[**2137-5-26**] 06:00AM BLOOD WBC-9.0 RBC-2.86* Hgb-8.8* Hct-25.7*
MCV-90 MCH-30.8 MCHC-34.3 RDW-14.0 Plt Ct-179
[**2137-5-26**] 06:00AM BLOOD Glucose-110* UreaN-14 Creat-0.7 Na-139
K-3.5 Cl-102 HCO3-27 AnGap-14
[**2137-5-27**] 06:20AM BLOOD WBC-8.8 RBC-2.61* Hgb-8.2* Hct-23.3*
MCV-89 MCH-31.5 MCHC-35.2* RDW-14.1 Plt Ct-196
[**2137-5-27**] 06:20AM BLOOD UreaN-14 Creat-0.7 K-3.9
[**2137-5-27**] 06:20AM BLOOD Mg-2.3
[**2137-5-27**] 06:20AM BLOOD WBC-8.8 RBC-2.61* Hgb-8.2* Hct-23.3*
MCV-89 MCH-31.5 MCHC-35.2* RDW-14.1 Plt Ct-196
Brief Hospital Course:
She was transferred to [**Hospital1 69**] at
the request of her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**], for
surgical revascularization. She remained stable and painfree. On
[**2137-5-23**] she underwent coronary artery bypass graft surgery x 4.
See operative report for full details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The intra-aortic balloon pump was removed on post operative day
1. The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight.
The patient was transferred to the telemetry floor for further
recovery on post operative day 2. Chest tubes and pacing wires
were discontinued without complication. She did develop a
maculopapular rash on her back, which was thought to be due to
allergic reaction to tape and sheets. She was treated with
Sarna lotion, hydrocortisone cream and Benadryl. Beta blockers
were titrated up secondary to tachycardia. Iron sulfate was
started for hematocrit of 23.3 (she was asymptomatic with this
level). 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 with assistance
and thought to benefit from a stay at a rehabilitation facility.
The wounds were healing and pain was controlled with oral
analgesics. The patient was discharged to the [**Hospital 1886**] rehab in
[**Location (un) **],MA in good condition with appropriate follow up
instructions.
Medications on Admission:
Lipitor 20mg HS,HCTZ,Quinapril 5mg
daily,Omeprazole 40mg daily,Ambien 5mg HS,Proventil,Nasonex
AT CCH added:Lopressor 25mg [**Hospital1 **],Heparin 1000units/hr,Integril;in
14u, ASA 325mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruitis.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed for pruitis.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO every
twenty-four(24) hours for 7 days.
11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for pruitis.
12. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day for 1 months.
13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for constipation for 1 months.
14. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN line flush
Peripheral IV - Inspect site every shift
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 23638**]
Discharge Diagnosis:
Coronary Artery Disease
s/p coronary artery bypass grafts
hypertension
s/p radical neck dissection & parathyroidectomy
hyperlipidemia
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with unsteady gait and assist of one.
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg 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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**6-25**] at 1:00 PM
Please call to schedule appointments with your
Primary Care: Dr. [**First Name (STitle) 1313**] ([**Telephone/Fax (1) 7318**]in [**1-26**] weeks
Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 34148**] in [**1-26**] 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:[**2137-5-27**]
|
[
"41071",
"41401",
"2859",
"4019",
"2724"
] |
Admission Date: [**2176-12-9**] Discharge Date: [**2176-12-26**]
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: This 78-year-old concentration
camp survivor with a history of known arrhythmias, status
post cardioversion, presented with a one week history of
increasing dyspnea. He had some left-sided chest pain and
some pain behind jaw and ear which went away. He had some
coughing and production of yellow sputum which was treated
with a Z-Pak. He was also febrile and had decreased
appetite. He stated that he had increased DOE and occasional
PND, occasional orthopnea and sleeping on two pillows. His
cough had resolved already by the time he was seen by the
medicine service and admitted on the 28.
PAST MEDICAL HISTORY: 1) History of DVT, 2) Chronic renal
insufficiency, 3) Pronestyl-induced SLE, 4) Chronic leg
edema, 5) History of atrial fibrillation, status post
cardioversion, 6) Status post cholecystectomy, 7) Status post
nephrectomy secondary to renal cell cancer in [**2162**].
MEDS ON ADMISSION: Quinidine 325 tid, Pepcid 20 mg qd,
Zestril 30 mg qd, lasix 20 mg qod as needed, Norvasc 5 mg qd,
coumadin 3 mg qd, and alprazolam 0.25 mg [**Hospital1 **].
ALLERGIES: He had no known drug allergies.
He was seen by the medicine service. EKG showed an old left
bundle branch block with first degree AV block and left axis
deviation. His chest x-ray showed tiny calcified granulomas
at the left apices and new bilateral pleural effusions with a
question of early right upper lobe pneumonia. Blood cultures
were pending.
LABS ON ADMISSION: Sodium 137, K 4.0, chloride 101, CO2 24,
BUN 35, creatinine 1.8, blood sugar 118. White count 11.4,
hematocrit 35.4, platelet count 178,000. PT, PTT and INR
were pending at that time.
HOSPITAL COURSE: He was referred in from [**Hospital3 2358**], and
the patient was referred to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for his new congestive
heart failure with effusions. This was most likely due to a
recent MI. Lasix diuresis was begun. His baseline
creatinine was approximately 1.6 which was monitored. He was
seen by ID. PPD was placed to evaluate for TB exposure, and
rule out any active infection. He continued to have all
these systems worked on to improve his medical picture.
He was seen by Dr. [**First Name8 (NamePattern2) 3228**] [**Last Name (NamePattern1) **] of cardiology. He did have
crackles halfway up bilaterally. His enzymes showed non-ST
elevation myocardial infarction with some ischemia. He
continued on aspirin. Heparin was held, as his INR was
supertherapeutic. At admission it was 5.2 which went down to
4.3. His beta blocker was held while he was in failure, and
the plan was that he would have a cardiac cath as soon as his
INR dropped below 1.8. His hematocrit was at 35.6, and he
received some gentle rehydration precath. He received IV
lasix for diuresis and continued on his ACE inhibitor and
remained on telemetry. His creatinine was at 1.7.
He was seen by the heart failure nurse practitioner to
discuss his congestive heart failure and some planning for
home diet. He was seen by case management. He was also seen
by Dr. [**Last Name (STitle) **] of cardiology and EPS service for some
nonsustained VT in the setting of his MI, with
recommendations to try beta blocker, or decrease his Norvasc
if possible. A discussion was had about mapping him, but it
was determined that he should have a cardiac catheterization
as soon as possible as first line evaluation, as his INR
continued to drop.
He was also seen by the GI service, and Dr. [**Last Name (STitle) 1940**] who was
his former primary care physician. [**Name10 (NameIs) **] continued with his
lasix diaphoresis, as he was prepared for cardiac
catheterization. He had a hematology consult for his
longstanding, increased PTT. He had no further NSVT. On the
3, his INR dropped to 1.7. Hematology recommended checking
additional factors including lupus anticoagulant, and noted
also that his quinidine could produce lupus-like symptoms.
He was seen by the EP service on the 4, Dr. [**Last Name (STitle) **]. They
studied him and saw dual AV node physiology with some
short-lived episodes of SVT that were slow. Please refer to
their note, and they recommended getting his diagnostic
cardiac cath done, and then having his ICD after his cardiac
surgery and work-up. They also recommended continuing him on
beta blocker and ACE inhibitor.
Hem/Onc saw him again now that he had been off his coumadin
for seven days, but his INR remained resistant and elevated
at 1.8. They thought that this was possibly due to his
antibiotic which was causing a decreased Vitamin K producing
bacteria. Antibiotic were already stopped, and they
determined there was no need for Vitamin K. They were still
awaiting results of his factor panels and his lupus
anticoagulant.
He was seen by the nursing case manager. He had a cardiac
cath done on the 5, and it was recommended intra-aortic
balloon pump be placed and the patient transferred to the CCU
prior to his operation. He was seen by cardiac surgery
resident on the 5, who noted his history. His cardiac cath
showed a left main stenosis and LAD irregularity, some trace
MR, global hypokinesis, a nondominant right. Please refer to
the cardiac catheterization report.
His labs preoperatively were sodium 142, K 4.2, chloride 104,
CO2 26, BUN 37, creatinine 1.5, white count 7.0, hematocrit
34.2, blood sugar 108, platelet count 248,000, PT 16.3, PTT
56.9, INR 1.8 with positive lupus anticoagulant. Blood gases
7.43/39/72/27/1. His chest x-ray showed some mild pulmonary
edema from the 28. The plan was CABG.
HOSPITAL COURSE: The patient had his balloon placed and was
transferred to the Coronary Care Unit. The patient was seen
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], with plans for more Vitamin K today
and FFP, if needed in the OR, for his INR, and plans to
operate on him on the following day after he got his balloon.
He was followed by hematology. The patient was also seen by
Dr. [**Last Name (STitle) 21815**] from cardiothoracic surgery, the Chief
Resident, and on the 7 he underwent coronary artery bypass
grafting x 3 with a LIMA to the LAD, and a vein sequentially
from OM to his left PDA. He was transferred to
Cardiothoracic ICU on a Nitroglycerin drip at 2.0 and an epi
drip at 0.025 in stable condition.
On postoperative day #1, he had a T-max of 100.2, blood
pressure 114/58, satting 97% at 3 liters nasal cannula, as he
had been extubated overnight. His balloon pump remained at
1:1. White count 11.9, hematocrit 32.6, platelet count
100,000. Sodium 141, K 4.7, chloride 105, CO2 23, BUN 41,
creatinine 2.1, with a blood sugar of 125. He was awake and
alert. His heart was regular in rate and rhythm. He had an
index of 2.5 with the balloon in and a mixed venous of 68.
His lungs were clear bilaterally. His wounds were clean, dry
and intact. He had no extremity edema. He was on a dopamine
drip at 2.0 overnight, and this was weaned again in the
morning. He remained with his Swan and his A-line. He had
no bleeding complications postop, and hematology signed-off.
On postoperative day #2, his balloon came out. He continued
on his perioperative vancomycin. His creatinine dropped to
1.8 with a K of 4.6. His hematocrit remained stable at 28.
He was on a Nitro drip at 0.75. The lungs had decreased
breath sounds at the bases. He continued on aspirin and the
Nitroglycerin weaned. He was seen by physical therapy for
evaluation.
On postoperative day #3, he was started on the amiodarone
drip at 1.0 for new atrial fibrillation in the 70s, with a
blood pressure of 127/62. His creatinine remained stable at
1.8 with a white count of 9.4. His lungs were clear
bilaterally, but had decreased breath sounds at the bases.
He was switched to oral pain med. He was restarted on his
coumadin. He had a good urine output.
On postop day #4, he remained in atrial fibrillation. He was
on a heparin drip at 600, coumadin dosing at 3, with a PT of
14.2, INR of 1.3, and a PTT of 52.4. His creatinine rose
slightly to 1.9. He had a normal rate, but remained in
atrial fibrillation. His wounds were clean, dry and intact.
His lungs were clear bilaterally. He remained on heparin
while his INR became therapeutic. He was started on a PO
diet and had good urine output and was transferred to the
floor. He was seen by the venous access nurse who noted that
he did not have good peripheral access. He was seen by case
management and had a Cordis placed. His pacing wires were
discontinued. His line was changed over a wire to allow him
to continue to have central access. He remained on heparin
with the INR climbing slightly now to 1.5 with a goal of
[**3-16**].5 for his atrial fibrillation. He received chest PT. He
remained on an amiodarone drip, as well as his coumadin.
He continued to work with physical therapy. He was seen by
the EP Fellow who recommended an ICD which could be done in
three to four weeks as an outpatient, and be followed by Dr.
[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Of note, his AST rose
to 95, with an ALT of 57, and a total bili of 1.6. They
recommended holding his amiodarone until his LFTs were
repeated. His amiodarone was held pending his LFTs. He
remained in atrial fibrillation. He continued on his
coumadin with the goal of [**3-17**]. He continued his ACE
inhibitors. Amiodarone was held. Plans were made for
follow-up with Dr. [**Last Name (STitle) **], and to have his ICD placement done
in the Cath Lab on Wednesday, [**1-22**], and EP signed-off
until that time.
On postoperative day #6, he had no complaints. He had a
T-max of 99.0, continued with his regular rate, remained off
amiodarone, still in atrial fibrillation, continuing his
coumadin, waiting to get therapeutic. He was a little
unsteady on his feet. This was discussed with case
management and physical therapy. He continued his
anticoagulation pending his therapeutic INR. He was screened
by clinical nutrition, and on the 14, his INR hit 2.0 with a
PT of 17.5. He was out of bed to chair. He was increasing
his work with physical therapy. Incisions were clean, dry
and intact. The sternum was stable. He remained in atrial
fibrillation. He was discharged to rehab with the [**Hospital3 1761**] on the following medications:
DISCHARGE MEDICATIONS: Coumadin daily dosing with the last
dose of 3 mg the night prior, to be followed for a goal INR
of 2.0-2.5; captopril 6.25 mg po tid; ranitidine 150 mg po
bid; lasix 20 mg po bid; KCL 20 mEq po bid; metoprolol 12.5
mg po bid; percocet 5, 1-2 tabs po prn q 4-6 h; colace 100 mg
po bid; Milk of Magnesia 30 ml prn; Xanax 0.25 mg po bid.
They recommended his PT and INR be checked daily for three
days in a row and then qod. Follow-up with physical therapy.
DISCHARGE DIAGNOSES: 1) Status post coronary artery bypass
grafting x 3 with intra-aortic balloon pump. 2) Atrial
fibrillation. 3) Chronic renal insufficiency. 4) History of
deep venous thrombosis. 5) Pronestyl induced systemic lupus
erythematosus. 6) Chronic leg edema. 7) Status post
cholecystectomy. 8) Status post nephrectomy. 9) Abnormal
electrophysiology study with automatic implantable
cardioverter-defibrillator placement planned for [**1-22**].
The patient had been given instructions for follow-up with
electrophysiology and Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], his cardiologist, as
well as discharge instructions to follow-up with Dr.
[**Last Name (STitle) 70**] in the office in approximately four to six weeks.
The patient was discharged to rehab on [**2176-12-26**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2177-3-24**] 10:40
T: [**2177-3-24**] 09:44
JOB#: [**Job Number **]
|
[
"41071",
"4241",
"42731",
"41401"
] |
Admission Date: [**2164-4-30**] Discharge Date: [**2164-5-4**]
Date of Birth: [**2108-1-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
rigid bronchoscopy
intubation
bronchial embolization
History of Present Illness:
56 y/o female with PMH significant for metastatic renal cell CA
with mets to the lung and multiple lymph node chains admitted to
[**Hospital1 18**] on [**4-30**] with hemoptysis and now transferred to the MICU
for further care after bleeding from right upper lobe during
bronchoscopy. Pt was recently admitted to [**Hospital1 18**] from [**4-24**] to
[**4-27**] with hemoptysis at which time she underwent rigid
bronchoscopy with argon photocoagulation therapy on [**4-26**].
Following this, the pt had no further hemoptysis. CT scan
obtained during this admission showed interval progression of
disease.
Pt was only home for a few [**Known lastname **] when she had three episodes of
hemoptysis and returned to [**Hospital1 18**]. Per notes, pt had no SOB on
admission. She was admitted and on the morning of [**5-1**] went to
the OR for rigid bronchoscopy. This showed heavy bleeding from
the posterior segment of the right upper lobe. Pt remained
intubated underwent successful right bronchial artery
embolization by IR. Later that morning, Pt extubated without
complication and transferred to medical service.
ONCOLOGICAL HISTORY(per OMR): Ms. [**Known lastname **] is a 55-year-old female
with metastatic renal cell cancer to the lungs and lymph nodes
noted on work-up for shortness of breath ([**1-3**]) associated with
a hgb=17: CT [**5-1**] demonstrated bilateral cystic kidneys and
confirmed pulmonary nodules as well as prevascular, supracarinal
and infracarinal, mediastinal and bilateral hilar lymph nodes.
CT-guided biopsy of the right lung nodule at [**State 48444**] Center [**5-1**] was suspicious for, but not diagnostic of
malignancy. She was diangosed with metastatic renal carcinoma
based on the large left kidney necrotic hypernephroma and
polycystic kidney disease.
After one cycle of IL-2 [**8-1**] Ms. [**Known lastname **] was followed with stable
CT scans every three months until [**3-2**] when extensive
periaortic adenopathy, pulmonary nodules and an 8.8 cm left
renal mass were noted. At this time she had episodes of
shortness of breath and hemoptysis, including an episode during
bronchoscopy that required emergent intubation [**4-2**]. She began
[**Doctor Last Name **] 43-9006 [**6-2**]. She has done well on [**Doctor Last Name 1819**] with resolution
of hemoptysis, shortness of breath and a decrease in target
lesions initially and stable since then.
Her course on the trial has been complicated by high [**Doctor Last Name **]
pressure, leg pain/scaliness, both of which have resolved. Her
diarrhea has stabilized on immodium. Her hct has risen to
pre-hemotypsis levels, but is generally under 50. In [**1-4**] she
developed new onset asymptomatic Grade II a-fib requiring
cardioversion s/p TEE (? virally related). The study drug was
held until after procedure. She was restarted in [**2-4**].
Past Medical History:
1. Metastatic renal cell carcinoma-treated with IL-2 now on
[**Doctor Last Name **] protocol, overall course c/b hemoptysis, AF, SOB
2. Adult polycystic kidney disease
3. Hypertension
4. Hyperthyroidism
5. S/P tonsillectomy
6. H/O atrial fibrillation in 01/[**2163**]. Pt was cardioverted s/p
TEE with good response.
7. Acute renal failure- Pt was admitted for ARF in 04/[**2163**]. Her
BUN and creatinine had increased from 33/1.7 to 83/4.4. By the
time of discharge, her creatinine had decreased to 2.2.
8. h/o hemoptysis after bronch ([**2163-4-6**])
Social History:
The patient lives in [**State 1727**]. She works as a bank teller for the
last 29 years. She is divorced. Positive tobacco history; quit
ten years ago. Alcohol with occasional use.
Family History:
Father died at age 72 of lung cancer.
Mother living, age 76 with hypertension and cerebrovascular
accident.
Physical Exam:
vs: Afeb, 87, 150/66, 20 94% 2LNC
gen- sitting comfortably in chair, NAD
heent- PERRL, EOMI, anicteric sclera, OP wnl, MMM
neck- supple, no LAD
cvs- RRR, nl S1/S2, no M/R/G
pulm- CTAB
abd- soft, NT, ND, NABS, no HSM but palpable kidneys
ext- no edema, 2+ DPs
skin- warm and well perfused
neuro- A&O-3, CNs roughly intact, strength 5/5, sensation intact
Pertinent Results:
142 100 21
97 AGap=17
3.3 28 1.4
Ca: 8.8 Mg: 1.9 P: 3.0
89
14.0
8.0 272
42.2
PT: 13.6 PTT: 32.9 INR: 1.2
CXR (PA/LAT): The heart is upper limits of normal in size. There
is bulky bilateral hilar lymphadenopathy as well as mediastinal
lymphadenopathy. The mediastinal nodes are most prominent in the
right paratracheal, aorticopulmonary window and subcarinal
regions. Numerous pulmonary nodules are seen in both lungs,
ranging in size from less than a cm in diameter to several cm in
diameter. The nodules appear more conspicuous than on the prior
study were likely more difficult to visualize previously due to
portable technique. The lungs reveal no focal areas of
consolidation or areas of significant atelectasis. There are
trace pleural effusions which have improved compared to
[**2164-4-24**] chest radiograph. Skeletal structures reveal diffuse
demineralization and degenerative changes.
IMPRESSION:
1. Extensive metastatic disease involving the thoracic lymph
nodes and pulmonary parenchyma. No areas of collapse are
identified.
2. Improved pleural effusions with small residual effusions
remaining.
IR Embolization:
1) Thoracic aortogram revealed a single, hypertrophied right
bronchial artery supplying the right lung field. No active
extravasation was identified. However, there was significant
hypervascularity from this vessel within the right lung field.
Of note, the right upper lobe is collapsed with compensatory
hypertrophy of the right middle and lower lobes.
2) Superselective embolization of 3 tortuous branches arising
from the right bronchial artery using 3 vials of 700-900
micron-sized embosphere particles with good angiographic
success.
Brief Hospital Course:
A/P: 56 y/o female with PMH significant for metastatic renal
cell CA with mets to the lung and multiple lymph node chains
admitted with hemoptysis after bleeding from right upper lobe
during bronchoscopy.
1. [**Name (NI) 48445**] Pt with episodes of hemoptysis in the past and
now returns with similar complaints. Underwent rigid
bronchoscopy on admission where bleeding was seen from the right
upper lobe. Bleeding controlled with right bronchial
embolization. Transferred to medical service after successful
extubation. While on the floor Pt stable without evidence of
respiratory distress. Morning after embolization/bronch, Pt c/o
some residual hemoptysis that resolved. Pt without evidence of
further bleeding. If after D/C, Pt to have hemoptysis, she will
contact Dr [**Name (NI) 48446**] and considerations made for repeat bronchoscopy
in the future.
2. Metastatic renal cell carcinoma- Pt is currently on the
experimental [**Doctor Last Name **] protocol followed by Dr [**Last Name (STitle) **] and Dr
[**Last Name (STitle) **]. Pt to be discharged home with f/u in Oncology on Monday
[**2164-5-7**]. Pt will likely resume treatment after being seen by
Dr [**Last Name (STitle) **].
3. Hypertension- hypertensive regimen held during MICU stay but
quickly restarted afterwards Pt to be d/c on pre-admission
regimen.
4. Hyperthyroid: Pt continued outpt regimen (Methimazole 5 mg PO
Q5days)
Medications on Admission:
1. Methimazole 5 mg PO Q5days
2. Bydrochlorothiazide 25 mg daily
3. Atenolol 100 mg daily
4. Amlodipine 10 mg daily
5. Experimental [**Doctor Last Name **] protocol
Discharge Medications:
1. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Renal Cell CA
HTN
Hemoptysis
Discharge Condition:
good
Discharge Instructions:
Please take all medications as prescribed; you will be restarted
on your previous medical regimen without changes. Do not
restart your [**Doctor Last Name **] protocol until told to by your oncologist.
Please make all follow up appointments; if unable reschedule as
soon as possible.
Please call your PCP or return to ED if you have: persistent
fever >101, shortness of breath, Chest pain, hemoptysis.
Followup Instructions:
1) You have several Oncology follow-up appointments scheduled.
Your next one is for [**2164-5-29**]. Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) 48447**]
would like to see you on [**2164-5-7**]. Their office will contact
you to schedule a time. Please feel free to call them at
[**Telephone/Fax (1) 3237**].
a) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-5-29**] 1:40
b) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-6-25**] 1:30
c) Provider: [**Name10 (NameIs) 2502**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2164-6-25**] 1:30
2) Please call your PCP and update her as to your recent
admission and ask if she wished to see you in follow up.
|
[
"42731",
"4019"
] |
Admission Date: [**2139-7-31**] Discharge Date: [**2139-8-12**]
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Right hip fracture s/p fall
Major Surgical or Invasive Procedure:
Right hemiarthroplasty
History of Present Illness:
Ms. [**Known lastname 79**] is a 89 yo woman with questionable history of rheumatic
fever/rheumatic heart disease who was admitted to [**Hospital1 18**] 1 day
ago after a mechanical fall resulting in a right hip fracture.
She was taken to the OR on [**7-31**] for right-hemiarthroplasty which
proceded without complication. Her post-operative course was
complicated by an episode of SVT with rate 180-90's and BP
98/64. This broke with IV esmolol drip (40mg total) to NSR with
rate 90. She was transferred back to the floor where she had 3
further episodes of SVT with HR 180 lasting approximately 15-30
seconds each (self-terminating), and then [**2-22**] similar episodes
lasting 1-10 minutes being associated with hypotension to the
60's systolic. She was asymptomatic throughout all of this. Over
the past 18 hours she has received 25mg po metoprolol x 3 as
well as 2.5mg IV metoprolol x 2, and 1L NS bolus. Between these
episodes her HR has been 90 with SBP 130's/70's.
.
Currently Ms. [**Known lastname 79**] complains only of thirst and of rt hip pain.
She denies chest pain, SOB, palpitations, nausea, vomiting,
BRBPR, or any other complaints. She is unaware of any lifetime
history of cardiac arrhythmia/palpitations or any family history
of sudden death or arrhythmia.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- blindness (unknown etiology)
- some type of vertebral/spinal problem resulting in leg
weakness
- ?rheumatic fever
Social History:
- Ms [**Known lastname 79**] lives in [**Hospital3 **] after deterioration of her
vision and ability to walk.
- she has never been married by helped raise the children of her
9 brothers and sisters.
- She worked as a nurse [**First Name (Titles) **] [**Last Name (Titles) 112**] for many years and was the head
of their first intensive care unit.
- She quit tobacco and alcohol use in the mid [**2111**]'s.
Family History:
No known history of coronary disease, sudden cardiac death, or
arrhythmias.
Physical Exam:
VS: T 100.6, BP 130/78, HR 92, RR 16, 96%O2 % on 2L n/c
Gen: blind elderly female in pain from her hip, but in no other
distress. oriented x 3 and somewhat irritable.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, unable to assess JVP due to intolerance of sitting
up.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
CBC: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2139-8-7**] 25.0* 3.64* 11.0* 32.3* 89 30.3 34.3
13.9 728*
[**2139-8-1**] 22.4* 3.57* 10.7* 31.7* 89 29.9 33.7
13.6 380
[**2139-7-31**] 34.8* 3.98* 12.3 36.3 91 31.0 33.9
13.2 434
[**2139-7-31**] 25.0* 4.12* 12.6 36.1 88 30.5 34.7
13.3 397
.
CHEMISTRIES Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2139-8-7**] 95 12 0.5 137 3.7 98
28 15
[**2139-8-6**] 98 17 0.5 138 3.7 99
28 15
[**2139-8-1**] 130 11 0.5 131 4.1 100
21 14
[**2139-7-31**] 132* 12 0.6 134 4.0 97
26 15
.
Pre-operative hip film: There is an impacted fracture through
the
right femoral neck with varus angulation and cephalad migration
of the distal
fracture fragment. The femoral head appears properly located.
No other
fractures are identified. There is severe bilateral hip
osteoarthritis
characterized by marginal osteophytes and axial joint space
narrowing.
Multiple phleboliths are present in the pelvis. A sclerotic
focus, likely a bone island is seen in the right iliac bone.
There is severe degenerative change at L5-S1.
.
EKG demonstrated (no baseline EKG available)
EKG #1: atrial tachycardia with possibly 2 p wave morphologies;
ventricular rate 133. left axis deviation. No delta waves.
Evidence of old inferior and anterior infarctions with Q in II,
III, aVF and V1-V3, diffusely flattened T waves, no ST segment
elevation or depression. AV delay with PR interval of 220. QRS
within normal limits.
.
EKG #2: atrial rhythm at rate of 92 with 2-3 different P wave
morphologies, with ALTERNATING PR INTERVALS OF 220 and 250ms.
similar findings of old IMI and anterior infarct.
.
EKG #3: narrow complex regular tacycardia with ventricular rate
of 182. Electrical alternans noted. No P waves appreciable.
TELEMETRY demonstrated: all tachycardic episodes initiated with
APB. Unable to see ABP with termination of episodes. During
tachycardia, may have hidden retrograde P-wave hidden at the end
of QRS.
.
LABORATORY DATA: please see below
CK of 402 with CK-MB of 8,
Trop T of 0.02 on admission, increased to 0.10, then 0.07
.
CTA of chest [**2139-8-1**]: negative for PE, there is a LLL superior
segment nodule 2.3*1.4 cm that may compress a branch of the
pulmonary artery. Large hiatal hernia displacing the heart
anteriorly (no evidence of compression). Right kidney atrophic,
left kidney mildly enlarged, liver with cyst vs hemangioma.
.
Echo [**2139-8-3**]: Right ventricular cavity enlargement with free
wall hypokinesis c/w a primary pulmonary process (e.g.,
pulmonary embolism, pneumonia, bronchospasm, etc.) . EF > 55%.
.
Right lower ext U/S [**2139-8-6**]: No evidence of DVT.
.
Brief Hospital Course:
Ms. [**Known lastname 79**] is a 89 yo F with ? hx of rheumatic fever/rheumatic
heart disease who was admitted to [**Hospital1 18**] after a mechanical fall
resulting in a right hip fracture then underwent hip replacement
surgery. Her post-operative course was complicated by an episode
of SVT with rate 180-90's and BP 98/64. This broke with IV
esmolol drip (40mg total) to NSR with rate 90, then requiring
oral beta-blockers.
.
# Atrial tachycardia: Appeared to be atrial fibrillation occ &
sinus tachycardia on other EKG's. Given no significant cardiac
history except for questionable rheumatic fever, most likely
related to surgery and infection. She was placed on telemetry.
She initially received Metoprolol 50mg TID, but had to be
titrated up to 100mg TID to maintain HR < 110's. She remained
asymptomatic during these episodes of tachycardia while on the
[**Hospital1 **] maintaining an adequate blood pressure. Although cardiac
enzymes were elevated at first, there was no evidence of
ischemia based on EKG or echocardiogram. Probably elevated due
to demand ischemia. Although Echo showed RV enlargement c/w pulm
process, CTA was negative for pulmonary emboli. Pt's BP SBP
110-130's & HR 70-90's on Metoprolol 100mg TID.
.
# Post obstructive/Aspiration pneumonia: Pt with left lower lobe
pulmonary nodule, possibly associated with an area of infection.
Pt was started on Levaquin 250mg by mouth daily for a total of 7
days. Also received Vanc, Cipro & Flagyl x 2 as although with
low grade temp, pt with leukocytosis. We stopped antibiotics as
there was no obvious infection that we were treating. At
discharge, pt had no cough, no shortness of breath or chestpain
and also was afebrile.
.
# Oropharyngeal candidiasis: Probably related to age as well as
poor nutrition. [**Month (only) 116**] have contributed to continued leukocytosis
during admission. Pt received 4 days of Diflucan 200mg by mouth
daily. Candidiasis had resolved at time of discharge.
.
# Leukocytosis of unknown origin: From labs obtained during
admission, she presented with a leukocytosis; WBC 25. Continued
to trend up during admission with peak of 34; however began to
trend down with initiation of Levaquin. Unsure of reason for
leukocytosis. RLE u/s neg for DVT, c.diff neg; Perhaps related
to candidiasis, although thrush resolved at this point after
treatment [**Last Name (un) **] Diflucan. Although right incision site slightly
erythematous, no drainage. ?Pulm nodule malignancy contributing
to leukocytosis as pt without temperature spikes.
.
# Right hip fx: Underwent R hemi arthroplasty. Was followed by
orthopedic surgery who did dressing changes. Her pain was well
controlled on morphine & oxycodone. She was also on Enoxaparin
for DVT prophylaxis during entire admission. Staples were
removed on the day prior to discharge and steristrips placed.
Wound slightly erythematous but no discharge or drainage at time
of discharge.
.
# Anemia: Appeared to have normal hct on admission, however
anemia present post surgery. Iron studies consistent with anemia
of chronic disease. She was guaiac stool negative. There were no
signs of active bleeding and her hct stabilized during
admission. She did receive 1U PRBC during this admission. We
repleted her iron daily as Iron levels were low.
.
# Constipation: required lactulose, Bisacodyl, docusate as well
as fleets enema x1. Had resolved, however on standing Narcotics,
would continue standing bowel regimen.
.
# Thrombocytosis: Most likely reactive secondary to post
surgical; however may to r/t to some underlying infectious
process, however pt without fever spikes. Also possibility of
elevation due to malignancy given incidental pulmonary nodule.
.
# Pulmonary nodule: Incidental finding on CT, Left lower lobe
superior segment pulmonary nodule measuring 2.3 cm. Workup
deferred to primary care physician.
.
Code: Initially FULL, now DNR/DNI
.
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**]
.
Pt has reached maximal hospital benefit and ready for discharge
to rehabilitation facility.
.
Medications on Admission:
Calcium/Vit D
Oxycodone extended-release
Omeprazole
Ibuprofen prn
Bisacodyl
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: Please do not give if sedated or if RR
< 10.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
10. Artificial Tears Drops Sig: 1-2 drops Ophthalmic twice a
day as needed for Dry eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Right hip fracture s/p hemiarthroplasty
Supraventricular tachycardia
Oropharyngeal candidiasis
Left lower lobe pulmonary nodule
Leukocytosis, unknown etiology
Discharge Condition:
Good
Discharge Instructions:
You had a fall and were diagnosed with a right hip fracture. You
underwent surgery to repair your hip fracture. You also
developed a very fast heart rate (atrial tachycardia) after your
surgery, which is now controlled on medications.
.
You have been found to have a nodule in your lung. We do not
know if it a malignancy. Please discuss this with your primary
care physician.
.
You were also diagnosed with oropharyngeal candidiasis "yeast".
This was treated with Diflucan and has resolved.
.
We have made some changes to your medications. We have added
Metoprolol 100mg by mouth three times daily for your fast heart
rate, as well as pain medications including Oxycodone q6h.
Please discuss these changes with your doctor. Please take your
other medications as prescribed.
.
Please follow up with your primary care physican Dr. [**Last Name (STitle) 5351**]
[**Telephone/Fax (1) 608**] within 2 weeks of discharge.You also need to follow
up with Dr. [**Last Name (STitle) **] on [**2139-8-27**] @ 0930am. Please call
[**Telephone/Fax (1) 1228**], if you need to reschedule or cancel.
.
Please return to the emergency room or call your primary care
physician if you develop any fevers, chills, CP, shortness of
breath or any other worrisome signs.
Followup Instructions:
Orthopedic followup [**2139-8-27**] at 0930am with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
(Orthopedic surgeon). Location: [**Location (un) **] of [**Hospital Ward Name 23**] bldg.
[**Telephone/Fax (1) 1228**]
.
Please follow up with your primary care physican Dr. [**Last Name (STitle) 5351**]
[**Telephone/Fax (1) 608**] within 2 weeks of discharge.
.
|
[
"42731",
"5070",
"42789"
] |
Admission Date: [**2148-4-29**] Discharge Date: [**2148-5-16**]
Date of Birth: [**2076-7-26**] Sex: M
Service: Cardiothoracic Service
HISTORY OF PRESENT ILLNESS: This is a 71 year old man with
hypertension and hyperlipidemia, presently with shortness of
breath since 1 AM on the day of admission. The patient
describes one similar episode two years ago at which time he
was admitted to [**Hospital6 **] and underwent cardiac
catheterization. At that time he reports being told he
needed coronary artery bypass grafting but declined and he
has remained well at home since then. He denies any history
of angina, although he does have chronic dyspnea on exertion
and fatigue. No paroxysmal nocturnal dyspnea and no
orthopnea until last night when he awoke at 1 AM with
shortness of breath. Over the next several hours he woke up
with shortness of breath and had to sit up to relieve the
shortness of breath. Finally he called emergency medical
services at 6 AM and was brought to the Emergency Room. In
the Emergency Room the patient was found to be tachycardiac
and markedly hypertensive with a systolic blood pressure
greater than 200 and oxygen saturations less than 89% on room
air. Electrocardiogram initially showed sinus tachycardia
with PR prolongation, evidence of an old inferior myocardial
infarction and a question anterior myocardial infarction with
diffuse ST wave changes. At that time he was given Aspirin,
Lasix, and Nitroglycerin and subsequent became bradycardia
with a heartrate in the 50s. Electrocardiogram revealed
sinus bradycardia with deep anterolateral T wave inversions,
initial enzymes were negative. The patient does not have any
lower extremity edema.
MEDICATIONS ON ADMISSION: Medications at home include
Lipitor, Zestril, Atenolol and Aspirin.
ALLERGIES: He has no known drug allergies.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, status post myocardial infarction, question of an
angioplasty at [**Hospital6 **]. Congestive heart
failure, hyperlipidemia, hypertension.
SOCIAL HISTORY: Denies alcohol use, denies tobacco use.
Unemployed. Married. Lives at home.
PHYSICAL EXAMINATION: Afebrile. Heartrate was 50 to 60.
Blood pressure 123/61, respiratory rate 17 and oxygen
saturation 97% on room air. General, in no acute distress.
Neurologically appropriate. Alert and oriented times three.
Head, eyes, ears, nose and throat, mucous membranes moist.
Oropharyngeal mucosa clear. Neck, 6 to 8 cm of jugulovenous
distension. Cardiovascular, regular rate and rhythm. No
murmurs, rubs or gallops. Pulmonary, diffuse crackles
bilaterally. Abdomen, soft, nontender, nondistended with
positive bowel sounds. Extremities, no edema. 2+ pulses
bilaterally.
LABORATORY DATA: On admission sodium 141, potassium 4.1,
chloride 110, carbon dioxide 26, BUN 20, creatinine 1.4,
glucose 133, creatinine kinase 224, MB 5, troponin less than
.03. White blood count 12.3, hematocrit 40, platelets 203,
PTT 13.1, INR 1.1. Chest x-ray shows congestive heart
failure without cardiomegaly. Electrocardiogram, sinus
rhythm, Qs in 2 and F, ST elevation in 3 and F, ST depression
in V5 and 6. Echocardiogram done after admission shows an
ejection fraction of 25% with global hypokinesis, posterior
basal inferior akinesis, 3+ mitral regurgitation with an
eccentric jet.
HOSPITAL COURSE: The patient was admitted to the Medicine
Service, seen by the Cardiology Service and referred for
cardiac catheterization. On [**5-1**], the patient was
brought to the Catheterization Laboratory. Please see the
catheterization report for full details and summary. This
catheterization showed an ejection fraction of 25%, left main
with mild disease, left anterior descending with 50% proximal
and 80% mid lesion. Large diagonal with an 80% lower pole
stenosis, the left circumflex was occluded, mid distal with
an 80% obtuse marginal 1 and right coronary artery was
occluded, mid distal and fills by collaterals. Following
cardiac catheterization, Cardiothoracic Surgery was
consulted. The patient was seen by Cardiothoracic Surgery
and was accepted for coronary artery bypass grafting. On
[**5-3**], he was brought to the Operating Room at which time
he underwent coronary artery bypass grafting times five.
Please see the operative report for full details. In
summary, the patient had coronary artery bypass graft times
five with left internal mammary artery to the left anterior
descending, saphenous vein graft to the diagonal and a Y
graft to obtuse marginal 1 and obtuse marginal 3 and a
saphenous vein graft to the posterior descending artery. He
tolerated the surgery well and was transferred from the
Operating Room to the Cardiothoracic Intensive Care Unit. At
the time of transfer, the patient had a mean arterial
pressure of 48, a central venous pressure of 12, he was
atrioventricularly paced at 84 beats/minute. He had
Neo-Synephrine at 0.3 mcg/kg/min and Propofol at 50
mcg/kg/min. The patient did well in the immediate
postoperative period. His anesthesia was reversed and the
sedation discontinued. The patient moved all extremities,
although at that time he was unable to follow commands. He
became very anxious and hypertensive. Therefore he was
resedated. On postoperative day #1, the patient was
hemodynamically stable. The sedation was again weaned.
Following the discontinuation of his sedation, the patient
awoke at which point he was agitated and thrashing about in
bed, unable to follow commands. Therefore he was resedated
with Precedex and another attempt was made to awaken and wean
the patient while on a Precedex drip. Despite the Precedex,
the patient again awoke thrashing in bed, unable to follow
commands with a systolic blood pressure in the 170s and
heartrate in the 110s. He was again started on Propofol and
resedated. On postoperative day #2 another attempt was made
to extubate the patient. He remained sedated with a Precedex
infusion. His blood gases were adequate with 5 of pressure
support and 5 of positive end-expiratory pressure and he was
successfully extubated. Following extubation, the patient
remained hemodynamically stable and his sedation was weaned
to off. Following the weaning of the patient's sedation he
did continue to be somewhat agitated, consistently following
commands. At that time psychiatry was consulted as was the
stroke service. It was felt that the patient had a likely
toxic metabolic encephalopathy and he was treated as such.
Over the next several days, the patient remained in the
Intensive Care Unit while a toxic metabolic workup was being
completed. He remained somewhat lethargic with periods of
confusion and agitation. He could not consistently follow
commands. From a cardiopulmonary standpoint he remained
hemodynamically stable with a productive cough and sating 95%
on nasal cannula. Head computerized axial tomography scan
was done which showed old white matter disease with no new
infarctions. On postoperative day #6, it was decided that
the patient was stable and ready to be transferred to the
floor where he could undergo further postoperative care and
cardiac rehabilitation. Once on the floor, the patient's
activity level was increased with the assistance of the
nursing staff and physical therapy. He continued to be
somewhat confused neurologically although much less agitated
and not combative. The patient remained on the floor for
several days showing gradual improvement. He continued to
followed by the Neurology Service who felt that this course
was consistent with a toxic metabolic encephalopathy. The
patient remained hemodynamically stable throughout this
period.
On postoperative day #13, it was felt that the patient was
stable and ready to be transferred to the rehabilitation
center for continuing postoperative care and cardiac
rehabilitation. At the time of that decision the patient's
physical examination was as follows: Vital signs,
temperature 98, heartrate 87 sinus rhythm, blood pressure
142/82, respiratory rate 20, oxygen saturation 96% on room
air. Weight preoperatively was 89.9 kg and the day prior to
discharge is 86.1 kg. Laboratory data revealed white count
13.5, hematocrit 32, platelets 476, sodium 140, potassium
4.0, chloride 107, carbon dioxide 20, BUN 28, creatinine 0.8,
glucose 84. On physical examination he was responsive, moves
all extremities and follows commands, oriented times two.
Respiratory, scattered rhonchi. Heartsounds, regular rate
and rhythm, S1 and S2, no murmurs. Sternum is stable.
Incision clean and dry, open to air. Abdomen is soft,
nontender, nondistended, normoactive bowel sounds.
Extremities are warm and well perfused with no edema. Right
leg incision was open to air, clean and dry.
DISCHARGE MEDICATIONS:
Enteric coated Aspirin 325 q.d.
Metoprolol 100 mg b.i.d.
Prilosec 40 mg q.d.
Atorvastatin 40 mg q.d.
Magnesium oxide 400 mg b.i.d.
Ferrous Gluconate 300 mg q.d.
Vitamin D 500 mg b.i.d.
Zinc sulfate 220 mg q.d.
Captopril 50 mg t.i.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: He is to have follow up with Dr. [**Last Name (STitle) **] in three
to four weeks after he is discharged from rehabilitation and
follow up with Dr. [**Last Name (STitle) 70**] in four to six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 49159**]
MEDQUIST36
D: [**2148-5-15**] 15:04
T: [**2148-5-15**] 14:47
JOB#: [**Job Number 49160**]
|
[
"41071",
"4280",
"4241",
"41401",
"412",
"4019",
"2724",
"2859"
] |
Admission Date: [**2193-9-5**] Discharge Date: [**2193-9-23**]
Date of Birth: [**2120-11-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2193-9-9**] Total aortic arch replacement(28mm Gelweave
graft),Aortic valve replacement ([**Street Address(2) 11688**]. [**Male First Name (un) 923**] tissue),
Coronary artery bypass graftx 2 (LIMA-LAD,SVG-PDA), Endoscopic
harvesting of the long saphenous vein.
[**2193-9-8**] - Dental extractions of teeth #4, 7, 10, 12, 14, 29 and
30.
[**2193-9-6**] - left heart catheterization, coronary angiogram
History of Present Illness:
72 year old female with no past
medical history presented [**9-4**] to OSH with shortness of breath.
She states she went about her usual routine, and was walking to
start doing laundry, when her legs felt "rubbery," she became
more short of breath, and she presented to [**Hospital3 3583**]
emergency room. She notes she remembers little after the ride to
the OSH ED. In the ED, she was found to have respiratory
distress, CXR with pulmonary edema, and she was intubated and
transferred to the CCU. Initial troponin was 0.16, which trended
to 1.79 peak. Her initial EKG showed nonspecific ST-T wave
changes, with new ST depressions in V3-V5 while in the ICU. No
ST
elevations. Overnight, the patient had hypotension (thought to
be
in setting of getting propofol) requiring dopamine. Initially
covered with broad spectrum abx for presumed pna, later stopped.
She had a TTE showing 30% EF with moderate Ao insufficiency,
small pericardial effusion, aneurysmal sounding of apex and
akinesis of anterior wall and adjacent septum. On [**9-5**], she was
weaned of dobutamine, extubated, transferred to [**Hospital1 18**] for
further
workup. She is now being referred to cardiac surgery for
revascularization and repair of ascending aorta aneurysm/
+/-AVR.
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:
- s/p 4 pregnancies with 3 vaginal deliveries and 1 emergent
c-section and subsequent hysterectomy
Social History:
married, lives with her husband. Former nurse [**First Name (Titles) **] [**Last Name (Titles) 3325**].
-Tobacco history: 30 pack-year smoking history, [**1-27**] PPD.
-ETOH: denies
-Illicit drugs: denies
Family History:
Mother alive at 96, has pacemaker for syncope, pt is unsure of
diagnosis.
No family history of early MI, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory
Physical Exam:
Adm PE:
VS: T=99.4BP=139/70HR=88RR=14O2 sat= 100% 2L
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: Forceful PMI. RR, normal S1, S2. Early systolic murmur
at LLSB. 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. Decreased air movement b/l.
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:
Imaging:
[**9-5**] CXR: Large lung volumes suggest obstructive airways
disease. Heart is moderately enlarged. Thoracic aorta is
generally large, minimal diameter in the aortic arch 6 cm. No
pneumonia. Possible mild residual interstitial edema best
appreciated at the right lung base. Pleural effusion minimal on
the right, if any. No pneumothorax. Right jugular line ends in
the mid SVC.
[**9-6**] TTE: The left atrium is elongated. The estimated right
atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. LV systolic function appears moderately-to-severely
depressed secondary to severe hypokinesis/akinesis of the
inferior and posterior walls; the apex also appears hypokinetic
(no thrombus seen). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is moderately dilated.
The aortic arch is mildly dilated. There are focal
calcifications in the aortic arch. The abdominal aorta is
moderately dilated. The aortic valve leaflets are moderately
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Mild to moderate ([**1-27**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
[**9-6**] Cath:
1. Selective coronary angiography of this left dominant system
revealed
a two vessel disease. The LMCA had no angiographically-apparent
flow-limiting stenosis. The LAD had a mid 70% stenosis. The LCX
was
samll with no hemodynamically significant lesions. The RCA was
diffusely
disease with fresh appearing occlussion of the mid vessel and
collateral
supply from septal branches of the LCA robustly filling the
distal RCA
and PLA branches.
2. Limited resting hemodynamics revealed a normal systolic
pressure at
the aorta (139/59 mmHg).
3. Supravalvular aortography revealed an ascending arch aneurysm
of 6.2
cm2 with at least 2+ aortic regurgitation.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Ascending aortic aneurysm.
[**9-6**] CTA: 1. Aortic aneurysm of the ascending aorta as noted,
with 3D measurements as noted; greatest dimension 5.8 x 5.4 cm.
Mild noncalcified plaque in the descending thoracic aorta.
2. Atherosclerotic changes also noted at the bilateral internal
iliac
arteries, and the left common femoral artery.
3. Possible nonocclusive thrombus of the right internal jugular
vein. It is also possible that this represents a mixing artifact
from inflow of small veins into the right internal jugular
artery, but this would be unusual.
4. Left adrenal nodule measuring 12 mm, which may represent an
adenoma.
5. Nonspecific mild thickening of the tracheal wall in the
subglottic region as noted. It should be noted that if
previously intubated, this may represent a stenotic change,
although other etiologies cannot be excluded. Please compare
with prior imaging if available. If not, direct visualization by
bronchoscopy may be indicated to ensure no underlying pathology.
Intra-op TEE [**2193-9-9**]
Conclusions
PREBYPASS: Moderate Aortic insufficiency with severely dilated
LV. Severely dilated ascending aorta with aorta measuring
5.5-5.8 cm just distal to ST ridge. The left atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is severely dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. Moderate (2+) aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. TV and PV appear normal. There is no pericardial
effusion. Dilated LV but preserved LV systolic function with LV
FAC >60%. No segmental wall motion abnormalities.
POSTBYPASS: The patient is on an epinephrine infusion. There is
a well-seated, well-functioning bioprosthetic valve in the
aortic position. No aortic regurgitation is seen. There is no
aortic stenosis. Mean gradient across the aortic valve is < 10
mmHg. The ascending aorta now measures 3.0 cm in diameter. There
is no dissection flap seen in the aortic arch or descending
thoracic aorta. Biventricular function is unchanged. No
segmental wall motion abnormalities. Mitral regurgitation is
unchanged.
Discharge labs:
Brief Hospital Course:
On [**2193-9-8**], she underwent extraction of 7 teeth. On [**2193-9-9**], She
was taken to the operating room where she underwent coronary
artery bypass grafting to two vessels, and aortic valve
replacement and an ascending aorta and total arch replacement.
Please see operative note for details. Overall the patient
tolerated the procedure well. She was transferred to ICU
intubated on Epi and Neo. She was extubated on POD #1 and found
to alert and oriented and breathing comfortably. The Epi was
weaned off her 1st night post-op, but she remained on Neo 24hrs
longer due to continued hypotension. She required 1 unit of
blood to optomize her hemodynamics. Her batablockade was
delayed due to borderline hypotension. She had significant
nausea in immediate post-op period and required several
antiemetics. She was transferred to floor on POD #3. Chest
tubes remained in 2nd to continued drainage. Her pacing wires
were removed without difficulty. She had a PICC line placed IN
IR that was pulled back to a midline. On POD#4 she had two hours
of rapid a-fib and was started on IV amiodarone. She converted
to SB and medications were adjusted. She continued to have
brief episodes of rapid a-fib and was started on Coumadin.
Unable to increase betablocker significanlty due to SB baseline.
Lisinopril and norvasc were added for hypertension. She has had
persistent nausea that had limited her po intake activity and
prolonged her hospital stay. She has required several
antiemetics. Her LFTS, amylase and Lipase have been negative,
she has moved her bowels, medications were minimized and her
nausea resolved eventually. She developed an elevated WBC in
POD #7, urine and CXR were unremarkable. Her left upper
extremity midline was discontinued and tip culture was negative.
Her WBC remained elevated but she was afebrile and her white
count is slowly trending down. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD # 14 the patient was
ambulating freely, the wound was healing and pain was minimal
The patient was discharged to home in good condition with
appropriate follow up instructions.
Medications on Admission:
None
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Coronary artery disease
aortic insufficiency
s/p coronary artery bypass grafts x2, ascending/arch replacement
Hypertension
ascending Aortic aneurysm
Discharge Condition:
Alert and oriented x3, nonfocal
Deconditioned, Ambulating with assistance
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema -trace
Discharge Instructions:
1) 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.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) 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. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2193-10-14**] at 1:30pm
Cardiologist: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2193-10-15**] at 9:00 am
Please call to schedule appointments with:
Primary Care Dr. [**Last Name (STitle) 87157**] [**Name (STitle) 17996**] ([**Telephone/Fax (1) 6699**]in [**4-30**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2193-9-23**]
|
[
"41401",
"41071",
"9971",
"4241",
"42731",
"4019",
"3051"
] |
Admission Date: [**2164-4-2**] Discharge Date: [**2164-4-8**]
Date of Birth: [**2103-12-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
bupropion
Attending:[**Known firstname 4679**]
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
[**2164-4-2**]
1. Laparoscopic jejunostomy feeding tube.
2. Esophagogastroduodenoscopy and balloon dilation of
stricture to 18 mm.
3. Biopsy of gastric conduit.
[**2164-4-3**]
EGD/Esophageal stent placement
4. Bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
The patient is a 60-year-old
gentleman who underwent a minimally-invasive esophagectomy
with an intrathoracic anastomosis in [**2163-8-25**]. He has
developed metastatic disease to the brain and underwent a
craniotomy. He has also had ongoing issues with a productive
cough and weight loss. CT scans have not demonstrated
evidence for fistula, but have demonstrated pneumonia in the
right lower [**Year (4 digits) 3630**]. He was admitted to the hospital for further
management.
Past Medical History:
stage III adenocarcinoma at GE jxn s/p chemoradiation
esophagectomy- pathology showed complete response.
AF w/ RVR s/p cardioversion [**2163-8-19**]
-he does not feel when he is in atrial fibrillation
PE ([**7-4**]) & R axillary DVT ([**2163-8-17**])
Rheumatoid arthritis- s/p enbrel, currently on prednisone
+ PPD (never treated)
bilateral pleural effusions (s/p drainage by IP)
h/o pericarditis
Recent aspiration/pneumonia ([**2164-1-10**])- tx with doxycycline
COPD
Onc history (Per OMR):
[**Date range (2) 6545**]: chemoradiation with cisplatin (75 mg/m2, D1 and
D29) and 5-FU (1000 mg/m2/day D1-4, D29-32)
[**Date range (1) 6546**]/11: admission for PE (RLL segmental) causing pleuritic
chest pain; therapeutic lovenox initiated
[**Date range (3) 6547**]: admission with new atrial fibrillation
and acute right axillary DVT. CT showed improving PE.
Cardioverted. Therapeutic lovenox continued.
[**2163-8-26**] PET/CT: Gastrohepatic and left paratracheal lymph nodes
now without FDG-avidity. Low level FDG-avid RLL consolidations,
non-specific (aspiration/pneumonia vs infarct vs atelectasis).
[**2163-9-19**]: esophagectomy, J-tube placement (Dr. [**First Name (STitle) **]
-J-tube discontinued [**2163-12-30**]
PSHx:
-R forearm surgery
-minimally invasive eosphagectomy [**2163-9-19**] & J-tube placement
-s/p Esophagogastroduodenoscopy and dilation of a stricture
([**1-5**])
Social History:
He lives with his wife. [**Name (NI) **] has been on disability for the past
ten years related to RA. Formerly was a manager at a bottling
plant and [**Location (un) 6350**] [**Location 6351**]. He has four children. He quit
smoking in [**2161**], previously smoked 30-35 years, 1-1.5 PPD. He
had drinks [**12-26**] cocktails very few weeks. Denies drug use. He
has traveled extensively in the Caribbean. No known TB contacts.
Family History:
His mother and [**Name2 (NI) 1685**] sister have [**Name2 (NI) **]. There is no family
history of cancer. No clotting disorders in the family.
Physical Exam:
ON ADMISSION:
-------------
Vitals: BP: 93/69. HR: 84. Temp: 96.8. RR: 16. Pain: 0. O2 Sat%:
94.
Weight: 120.2. Height: 64. BMI: 20.6.
awake alert, very thin
lungs with good air movement
heart regular
abd soft, not distended
.
ON DISCHARGE:
-------------
VS: stable
Gen: A&O X 3, in NAD
HEENT: atraumatic
Neck: supple
Lungs: cta bilaterally no r/w/r
CV: RRR s1s2 no m/r/g
Abd: soft mildly tender @ j tube site +bs no HSM no stigmata of
chr liver dz
Ext: no erythema or edema
Neuro: CNii-xii grossly intact
Pressure ulcer: sacrum, 1cm X 1cm, superficial, no signs of
infection
Pertinent Results:
LABS ON DISCHARGE:
------------------
[**2164-4-8**] 10:20AM BLOOD Glucose-111* UreaN-12 Creat-0.5 Na-134
K-4.4 Cl-101 HCO3-26 AnGap-11
[**2164-4-8**] 10:20AM BLOOD Calcium-7.8* Phos-1.2* Mg-1.8
.
IMAGING & STUDIES:
------------------
[**2164-4-3**] EGD/ Esophageal stent placement: A slight narrowing was
noted in the mid/upper esophagus at 26 cm likely corresponding
to known anastamotic stricture. Once anastamotic stricture was
traversed there was a large saccular area identified which was
ulcerated and friable - Per Dr. [**First Name (STitle) **], this represents the
gastric conduit. Again identified was a 1-2 mm area concerning
for fistula. After extensive discussion with Dr. [**First Name (STitle) **], decision
was made to place a fully covered metal stent to attempt closure
of the fistula and symptom control. A 23 mm x 155 mm Wallflex
Esohpagael fully covered metal stent [Ref# 1675; Lot# [**Serial Number 6548**]]
was placed successfully into the esophagus under fluoroscopic
guidance.
Time Taken Not Noted Log-In Date/Time: [**2164-4-2**] 6:03 pm
BRONCHOALVEOLAR LAVAGE LEFT LOWER [**Year/Month/Day **].
GRAM STAIN (Final [**2164-4-2**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
4+ (>10 per 1000X FIELD): BUDDING YEAST.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH OROPHARYNGEAL FLORA. SMEAR REVIEWED; RESULTS
CONFIRMED.
RESPIRATORY CULTURE (Final [**2164-4-5**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage regimen
of 2g every 8h. Piperacillin/tazobactam sensitivity testing
available on request.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. SECOND
MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage regimen
of 2g every 8h. Piperacillin/tazobactam sensitivity testing
available on request.
YEAST. 10,000-100,000 ORGANISMS/ML [**Last Name (un) **]: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Preliminary): NGTD.
FUNGAL CULTURE (Preliminary): NGTD.
Brief Hospital Course:
Mr. [**Known lastname 6352**] was admitted to the hospital and taken to the
Operating Room where he underwent Laparoscopic jejunostomy
feeding tube placement, Esophagogastroduodenoscopy and balloon
dilation of stricture to 18 mm., Biopsy of gastric conduit and
Bronchoscopy with bronchoalveolar lavage. He tolerated the
procedure well and returned to the PACU in stable condition.
After full recovery from anesthesia, he transferred to the
surgical floor and was evaluated by the GI service for possible
stent placement for the stricture and also to help heal a
possible fistulous tract. He was taken to the GI suite on
[**2164-4-3**] for placement of a metal stent. He tolerated the
procedure well and returned to the Surgical floor in stable
condition.
The Nutrition service evaluated his nutritional needs and
recommended Isosource 1.5 to be cycled at 120 mls/hr over a 12
hour period. His feedings were started slowly and advanced and
tolerated well. His pre admission Lovenox was also started for
atrial fibrillation and DVT. As his beta blocker was held for
48 hours he had some problems with RAF to 150 after ambulation.
His beta blocker was resumed and his rate returned to sinus
rhythm at 86 BPM.
He had no abdominal pain and his j tube site was clean. He was
reluctant to eat much due to his recent problems but realizes
that he can have food if he desires. Home care was arranged
with VNA, oxygen therapy and tube feeding capabilities. He was
discharged to home on [**2164-4-8**].
Medications on Admission:
albuterol 90mcg'' q4h prn, amiodarone 100', benzonatate 100 q8h
prn cough, lovenox 60/0.6ml'', levothyroxine 100mcg', lorazepam
0.5 qhs prn, metoprolol tartrate 100', omeprazole 40',
prednisone 10', tylenol extra-strength 500 q4h prn pain, vitamin
D3 400 unit'', guaiatussin AC 100 mg-10 mg/5 ml 1 tsp q4-6h prn
cough, mucinex DM 600mg-30mg ER q12h prn cough (not take with
benzonatate), senna 8.6'for cough do not take along with
benzonatate
Discharge Medications:
1. Nutrition
Jevity 1.5 @ 120 ml's per hour over 12 hours
6 cans per day
disp 1 case
refills for 6 months
2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous Q12H (every 12 hours).
Disp:*30 syringes* Refills:*2*
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Respiratory Therapy
O2 at 2-4 liters per minute via nasal cannula, continuous
Pulse dose
Dx COPD
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
[**12-26**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 HFA* Refills:*1*
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. levofloxacin 250 mg/10 mL Solution Sig: Thirty (30) mls PO
once a day: thru [**2164-4-11**].
Disp:*250 mls* Refills:*0*
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
12. home services
Patient to have PT, OT, Speech therapy, VNA nursing, home
services, home O2 therapy, Tube feeding, and home suction for
comfort and medical management.
13. oxycodone 5 mg/5 mL Solution Sig: [**5-3**] mL PO every 4-6 hours
as needed for pain: Do not drink alcohol or drive while taking
this medication.
Disp:*300 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical Services
Discharge Diagnosis:
esophageal cancer
severe malnutrition
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital with repeated episodes of
difficulty swallowing and coughing. A feeding tube was placed
to help you maintain your calories. You can also eat soft foods
and liquids if you feel like it.
* You should continue to take deep breaths and cough to keep
your lungs clear. The incentive spirometer will also help.
* When you are in [**Last Name (un) 6550**] make sure you turn from side to side
every 2 hours to decrease skin breakdown.
* Continue Lovenox twice daily.
* The VNA will continue to follow you at home.
* If you develop any fevers > 101, increased pain, shortness of
breath or any other symptoms that concern you, call Dr. [**First Name (STitle) **] at
[**Telephone/Fax (1) 2348**].
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2164-4-17**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2164-4-17**] at 10:30 AM
With: [**Known firstname **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
Department: RHEUMATOLOGY
When: FRIDAY [**2164-5-4**] at 12:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2164-4-11**]
|
[
"496",
"42731",
"V5861"
] |
Admission Date: [**2133-12-23**] Discharge Date: [**2134-1-1**]
Date of Birth: [**2055-7-6**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 16068**] is a 78-year-old
retired police officer with six month history on exertion
without chest pain or discomfort. The patient has positive
exercise tolerance test an outside hospital. He had a
cardiac catheterization done at [**Hospital6 3872**] on
the [**9-22**] which showed an 80% main, tight left
circumflex and moderate right coronary artery disease. An
echocardiogram done in [**2133-10-19**] showed an ejection
fraction of 45-50% with dilated left ventricle with a mean
gradient of 12. The patient was transferred from [**Hospital6 3873**] for preoperative balloon placement and
coronary artery bypass grafting.
PAST MEDICAL HISTORY: Significant for hypertension, total
left knee replacement, gun shot wound to the right thigh in
[**2071**] with no known retained shrapnel.
ALLERGIES: Include lobster from which he gets hives and
bees.
MEDICATIONS ON ADMISSION: Include Accupril 20 mg q. day,
hydrochlorothiazide 12.5 mg q. day, aspirin 325 mg q. day,
Coreg 3.125 mg b.i.d. He was also transferred to [**Hospital1 346**] on a heparin drip.
REVIEW OF SYSTEMS: Denies transient ischemic attack,
cerebrovascular accident, diabetes, thyroid problems. [**Name (NI) **]
bleeding problems or clotting problems. [**Name (NI) **] gastrointestinal
bleeds or dysphagia or claudication. No paroxysmal nocturnal
dyspnea or orthopnea. No edema. Occasional palpitations.
Positive dyspnea on exertion. No chest pain or angina.
Positive ________________ times one month which is improving.
SOCIAL HISTORY: Married with three children. Retired police
officer. Positive tobacco use, both cigar and pipe.
Positive alcohol use, about seven drinks per week.
PHYSICAL EXAMINATION: Vital signs: Heart rate 61, blood
pressure 140/61, respiratory rate 16, oxygen saturation 98%
on room air. General: Pleasant overweight man in no acute
distress. HEENT: Left pupil 3 mm, right pupil 2 mm, both
reactive to light. Neck is supple with no jugular venous
distention, no bruit. Cardiovascular: Regular rate and
rhythm, 2/4 systolic ejection murmur. Respiratory:
Rhonchorous throughout. Abdomen: Soft and non-tender,
non-distended with positive bowel sounds. Extremities: Warm
and well-perfused with no varicosities. Pulses: On the
right there is an intra-aortic balloon pump and the left is
2+ femoral. Popliteal 1+ bilaterally. Dorsalis pedis on the
left 2+, on the right 2+. Posterior tibial 1+ bilaterally.
Radial 2+ bilaterally.
ELECTROCARDIOGRAM: Sinus rhythm at 60 beats per minute,
normal intervals, [**Street Address(2) 4793**] depression in V1, V4 and V5.
T-wave inversion in V4 through 6.
LABORATORY DATA: At the outside hospital white count 15.9,
hematocrit 39.6, platelet count 219,000. Sodium 139,
potassium 3.4, chloride 104, carbon dioxide 29, BUN 26,
creatinine 0.9, glucose 137.
HOSPITAL COURSE: The patient was initially scheduled to go
to surgery the day after admission to [**Hospital1 190**], however, he suffered from delirium tremens on
the day after admission and his surgery was delayed. He
continued to be followed by the Medicine Service and his
hospital course, other than delirium tremens, was uneventful
until [**12-28**] when he was brought to the Operating Room
for coronary artery bypass grafting. Please see the op note
for full details. He had a coronary artery bypass grafting
times two with saphenous vein graft to the left anterior
descending and saphenous vein graft to the OM. His bypass
time was 60 minutes with a crossclamp time of 24 minutes. He
tolerated the operation well and was transferred from the
Operating Room to the Cardiothoracic Intensive Care Unit. At
the time of transfer his mean arterial pressure was 89 with a
CVP of 7. He was A-paced at a rate of 90. He had propofol
at 20 mg/kg and Neo-Synephrine at 0.3 mcg/kg/min. He did
well in the immediate postoperative period. His anesthesia
was reversed. He was weaned from the ventilator and
successfully extubated on postoperative day one. The patient
was hemodynamically stable. He was weaned from all
intravenous medications and transferred to the floor for
continuing postoperative care and cardiac rehabilitation.
Over the next four days the [**Hospital 228**] hospital course was
uneventful. With the aid of Physical Therapy and Nursing
staff the patient's activity level gradually increased. He
remained hemodynamically stable throughout that time.
Postoperative day two his chest tubes were removed. On
postoperative day three he was noted to have a five beat run
of ventricular tachycardia. Electrophysiology Service was
consulted. Given the patient's ejection fraction of greater
than 40% it was felt that increasing the patient's beta
blockade would be the best therapy. On postoperative day
four it was felt that the patient was stable and ready to be
discharged to home.
PHYSICAL EXAMINATION AT DISCHARGE: Vital signs: Temperature
99, heart rate 76, sinus rhythm, blood pressure 112/50,
respiratory rate 20, oxygen saturation 97%. Weight
preoperatively 85 kilos, at discharge 83 kilos. Alert and
oriented times three. Moves all extremities. Follows
commands. Respiratory: Breath sounds clear to auscultation
bilaterally. Cardiac: Regular rate, S1, S2. The sternum is
stapled. Incision with Steri-Strips open to air, clean and
dry. Abdomen: Soft, non-tender, non-distended. Normoactive
bowel sounds. Extremities were warm and well-perfused with
1+ edema bilaterally. Right leg incision with Steri-Strips
open to air, clean and dry.
LABORATORY DATA: White count 12, hematocrit 25.8, platelet
count 272,000. Sodium 138, potassium 5.1, chloride 102,
carbon dioxide 29, BUN 40, creatinine 0.9, glucose 106.
DISCHARGE MEDICATIONS: Include Lasix 20 mg q. day times two
weeks, enteric coated aspirin 325 mg q. day, Toprol 25 mg
b.i.d., Percocet 5/325 one to two tabs q. 4h. p.r.n.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times two with a saphenous vein graft to the
left anterior descending artery and saphenous vein graft to
OM.
2. Hypertension.
3. Arthritis.
4. Status post total left knee replacement.
5. Status post gun shot wound to the right thigh.
CONDITION AT DISCHARGE: Good.
DISCHARGE INSTRUCTIONS: He is to follow up in the [**Hospital 409**]
Clinic in two weeks, follow up with Dr. [**Last Name (STitle) **] and/or Dr.
[**Last Name (STitle) 5874**] in three to four weeks and follow up with Dr.
[**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2134-1-1**] 12:56
T: [**2134-1-1**] 13:22
JOB#: [**Job Number 16069**]
|
[
"41401",
"5180",
"4019",
"2720"
] |
Admission Date: [**2154-6-11**] Discharge Date: [**2154-6-21**]
Date of Birth: [**2089-6-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy
IR embolization
History of Present Illness:
65 yo M with multiple medical problems presented to [**Name (NI) **] on Thursday [**6-6**] with bright red blood per rectum. He
had a colonoscopy on Friday [**6-7**] which showed multiple
diverticuli but he is not sure where in the colon the
diverticuli were located. No intervention was performed. His
bleeding
stopped and he was discharged on Sunday. He began experiencing
copious amounts of bright red blood per rectum again the
afternoon of admission. He went to [**Hospital3 2783**] and was
given 2 units of pRBC and transferred to [**Hospital1 18**]. He has minimal
lower abdominal crampy pain. He has not had any fever, chills,
shortness of breath, chest pain. He does have fatigue.
In our ED, initial VS 98.7 100 117/62 16 100. Initial PE
notable for pallor and bright red blood per rectum. NG lavage
reportedly negative. Given an additional 2U PRBC in our ED.
Briefly with SBP 60s. Given 1U FFP and 2U with approximately 3L
NS. No other medications given. On aspirin, [**Hospital1 **]. No chest
pain. Upon transfer from ED, SBP 90s, HR 80s and 100/2L. His
access includes three PIVs 16g, 18g, 20g.
GI consult was contact[**Name (NI) **] and thought with diffuse bleeding from
below and minimal role for EGD or colonoscopy given poor
visualization. At the soonest, would plan for colonoscpy
[**2154-6-13**]. Discussed with surgical team. Has AAA s/p repair with
graft so increased risk of aorto-enteric fistula. CTA would be
used to rule-out fistula but GI fellow thinks this unlikely at
this time unless significantly worsens. Per discussion with ED
resident, IR paged about tagged RBC scan.
Past Medical History:
Diverticulosis
AAA
CAD s/p CABG and stenting, EF 25% to 30% ([**2154-5-14**])
CVA
HTN
HLD
GERD
obsessive compulsive disorder
PSH:
Sigmoid colectomy for perforated colectomy in [**2124**]
S/p ostomy reversal ([**Hospital3 3583**])
s/p triple vessel CABG [**2137**]
s/p multiple cardiac stents ([**2141**], [**2149**], [**4-/2154**] - Dr [**Last Name (STitle) **];
lastly with stenting of the mid-LCx with a 3.5 x 23mm Promus
drug eluting stent
s/p Endovascular aneurysm repair [**2153**] ([**Doctor Last Name **])
Social History:
On disability since his CVA in [**2141**]. Divorced with 2 children.
Non smoker, 2 drinks/week
Family History:
Mother - deceased at [**Age over 90 **] y/o, CAD. Father - 83 y/o, CAD s/p
cardiac catheterization. 1 brother - 61 y/o A&W. Denies any FHx
of melanoma, breast or colon cancer.
Physical Exam:
Vitals: 97.6, 75, 108/71, 15 and 100/RA
Gen: Alert and oriented, NAD, with pallor and diaphoresis
HEENT: scleral pallor, MMM
CV: tachycardic, sinus rythmn
Pulm: CTA b/l anteriorly
Abd: soft, active bowel sounds, mildly tender in lower abdomen
Ext: [**2-14**] but mildly diminished pulses in radial pulses
bilaterally
Pertinent Results:
CBCs:
[**2154-6-11**] 06:07PM BLOOD WBC-12.3*# RBC-4.10* Hgb-13.4*# Hct-37.8*
MCV-92 MCH-32.7* MCHC-35.5* RDW-13.3 Plt Ct-241#
[**2154-6-12**] 12:04AM BLOOD WBC-11.5* RBC-2.77*# Hgb-8.5*# Hct-24.0*#
MCV-87 MCH-30.6 MCHC-35.2* RDW-14.8 Plt Ct-216
[**2154-6-12**] 05:59AM BLOOD WBC-10.4 RBC-4.26*# Hgb-12.7*# Hct-36.5*#
MCV-86 MCH-29.9 MCHC-34.9 RDW-15.1 Plt Ct-140*
[**2154-6-12**] 09:14PM BLOOD WBC-9.6 RBC-3.56* Hgb-11.5* Hct-31.0*
MCV-87 MCH-32.3* MCHC-37.1* RDW-15.9* Plt Ct-115*
[**2154-6-13**] 08:40AM BLOOD Hct-27.7*
[**2154-6-14**] 04:39AM BLOOD WBC-7.8 RBC-3.97* Hgb-12.0* Hct-34.8*
MCV-88 MCH-30.2 MCHC-34.5 RDW-15.8* Plt Ct-150
[**2154-6-16**] 06:06AM BLOOD WBC-3.8* RBC-3.68* Hgb-11.1* Hct-33.2*
MCV-90 MCH-30.0 MCHC-33.3 RDW-15.9* Plt Ct-200
[**2154-6-21**] 05:59AM BLOOD WBC-5.3 RBC-3.59* Hgb-10.6* Hct-31.8*
MCV-89 MCH-29.6 MCHC-33.4 RDW-15.6* Plt Ct-332
.
COAGS:
[**2154-6-11**] 06:07PM BLOOD PT-13.5* PTT-27.4 INR(PT)-1.2*
[**2154-6-14**] 11:22PM BLOOD PT-13.2 PTT-24.8 INR(PT)-1.1
.
FIBRONIGEN:
[**2154-6-12**] 12:04AM BLOOD Fibrino-248
[**2154-6-12**] 05:59AM BLOOD Fibrino-253
[**2154-6-12**] 09:48AM BLOOD Fibrino-265
.
CHEMISTRIES:
[**2154-6-11**] 06:07PM BLOOD Glucose-129* UreaN-21* Creat-1.0 Na-139
K-4.7 Cl-109* HCO3-20* AnGap-15
[**2154-6-16**] 06:11PM BLOOD Glucose-85 UreaN-18 Creat-0.8 Na-142
K-4.3 Cl-108 HCO3-22 AnGap-16
.
Cardiac Enzymes:
[**2154-6-13**] 08:10PM BLOOD CK-MB-3 cTropnT-<0.01
[**2154-6-13**] 08:10PM BLOOD CK(CPK)-73
[**2154-6-14**] 04:39AM BLOOD CK-MB-3 cTropnT-LESS THAN
[**2154-6-14**] 04:39AM BLOOD CK(CPK)-39*
.
MICRO:
[**2154-6-11**] 9:47 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2154-6-14**]**
MRSA SCREEN (Final [**2154-6-14**]): No MRSA isolated.
.
IMAGING/PROCEDURES:
[**6-13**] CT-A ABD/PEL:
IMPRESSION:
1. Evidence of active bleeding site in the mid transverse colon.
2. Soft tissue nodule adjacent to pancreatic tail is unchanged
since the
prior CT.
3. Patent aortobiiliac stent graft without evidence of endoleak.
.
KUB [**6-15**]:
There is dilatation of small bowel loops up to 4.8 cm with a few
air-fluid
levels. There is air in the colon including the sigmoid and
probably the
rectum. The dilatation has increased from CT. This is
nonspecific and could be ileus or early obstruction and
follow-up is recommended.
.
[**6-15**] CT A/P:
PROVISIONAL REPORT:
FLUID FILLED LOOPS OF BOWEL WITH NO DEFINATE TRANSITION POINT.
MILD
INFLAMMATORY CHANGES AT THE DISTAL ANATOMOSIS SITE IN THE LEFT
LOWER QUADRANT [**Month (only) **] BE SEQULAE OF RECENT ANATOMOSIS VERSUS FAT
NECROSIS. NO DRAINABLE ABSCESS OR COLLECTION. TRACE FREE FLUID
IN THE ABDOMEN AND PELVIS.
Brief Hospital Course:
65M with history of diverticular bleeding and profuse bleeding
per rectum.
1. GI bleed: With known diverticuli and BRBPR, suspicion was for
a large diverticular bleed and patient was admitted to the MICU
for stabilization. However, given h/o AAA repair, a AE fistula
was ruled out first with CT-A. No graft leak was identified, but
active extravasation was seen in the mid-colon. The patient went
emergently to IR for angioembolization of the mid transverse
colon. He required 14 units of pRBCs for stabilization, plus 5
FFP, 3 Platelets. After this intervention, he continued to have
occasional maroon stools, and HCT drifted down to 27. 1
additional unit pRBCs transfused, with stabilization of HCTs. GI
performed colonoscopy which showed pan-colonic diverticulosis
with some pseudomembranes, but no active bleeding. Patient was
transferred to medical floor where serial monitoring of Hct was
continued, initially [**Hospital1 **] and then daily. Patient did have 1
episode of bright red blood requiring 1 additional UpRBC but
subsequent stools were guiac negative. At time of discharge,
Hct had stabilized at 30 - 31. Follow up was arranged with
gastroenterology. Of note, patient may need referral to general
surgeon for semi-elective hemicolectomy in several months. If
possible, patient should wait until at least 1 year from last
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] (see below) so that he can safely stop [**Last Name (Prefixes) 4532**].
2. CAD s/p CABG and DES 1 month prior to admission: [**Last Name (Prefixes) **] and
ASA were initially held given his active bleeding. Once this
issue was stabilized, his [**Last Name (Prefixes) 4532**] and ASA were restarted ASAP.
However, since the pt developed an ileus (see below), and was
NPO, his ASA was changed to PR, and instead of [**Last Name (LF) 4532**], [**First Name3 (LF) **]
integrillin drip was recommended by cardiology, who followed
closely during his admission. He did occasionally complain of
chest pain, but this was usually in the setting of anxiety, and
there was never any ekg changes, and serial cardiac enzymes were
always flat. Once ileus had resolved and patient had no
further signs of rebleeding, oral aspirin 81mg was resumed and
[**First Name3 (LF) 4532**] restarted. Additionally patient was restarted on his
bblocker and 1/2 dose of ACEI. As patient had no symptoms of
angina and blood pressure was still low, imdur was held on
discharge.
3. N/V ileus - After his colonoscopy, for which he was
electively briefly intubated, he developed profound nausea and
bilious vomiting. A KUB showed air in colon and possible dilated
SB loops. A repeat CT abdomen pelvis did not show SBO. Surgery
was consulted and also did not think there was an SBO. An NG
tube was placed, and over the course of 2 days over 2 liters of
bilious material was suctioned. On [**6-17**], the tube was clamped
successfully and diet advanced. After patient began to have
bowel movements, NGT was removed (see below regarding subsequent
diarrhea)
4. colonic pseudomembrane/ diarrhea - on colonoscopy, GI
reported small pseudomembranes adherent to the mucosa in the
ascending colon, possibly compatible with pseudomembranous
colitis. Once patient's ileus resolved he also began to have
profuse watery diarrhea with some abdominal cramping.
Differential dx included infection (especially c.diff), ischemia
(in setting of prior partial colectomy plus recent
embolization), vs physiologic/ diet related. Infectious
evaluation was negative including c. diff x 3 and lactate was
normal. With advancement of diet from clears, diarrhea
improved.
5. Hypertension: Initially, home medications were held in
setting of acute bleeding. Following embolization with
stabilization of bleed antiypertensives were slowly added back
to medication regimen, beginning with bblocker and 1/2 dose of
home ACEI. By time of discharge, blood pressure was still well
controlled with SBP from 100- 110s, so imdur was not restarted.
6. Hyperlipidemia: Severe coronary history. Continued home
statin when not NPO
Medications on Admission:
- Lipitor 80 mg qday
- [**Month/Day (4) **] 75 mg qday
- Isordil dinitrate 40 mg qday
- Lisinopril 10 mg qday
- Metoprolol 25 mg qday
- ASA 325 mg qday
- MVI
- Fish oil 1,200 mg-144 mg daily
- Vit E
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*10 Tablet(s)* Refills:*0*
3. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain: please do not exceed
more than 4 grams tyelenol per day.
Disp:*15 Tablet(s)* Refills:*0*
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Diverticular Bleed
Ileus
Hypotension
Secondary Diagnosis:
Coronary Artery Disease s/p recent [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] systolic heart failure
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 rectal bleeding from a
diverticular bleed. You required a large amount of blood
products- in total 15 units of red blood cells through your
hospital stay. The interventional radiologists embolized the
vessel causing the bleed.
During your hospitalization, you also developed severe
constipation caused by an ileus. You were treated
conservatively with bowel rest and a nasogastric tube. Your
symptoms improved; you started having bowel movements and you
tolerated a normal diet.
Please make the following changes to your medication regimen:
1. Please STOP your imdur until seeing your cardiologist or
primary care physician
2. Please REDUCE your lisinopril to 5mg until you see your
primary care physician
3. When you have abdominal pain, take tyelenol first. If that
does not relieve your symptoms you make take a percocet (please
do not drink or drive while taking this medication as it can
make you sleepy).
4. You may take ambien as needed for sleep
Followup Instructions:
Department: RADIOLOGY
When: MONDAY [**2154-10-14**] at 11:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: ADULT SPECIALTIES
When: TUESDAY [**2154-11-12**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 8645**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"2851",
"V4582",
"4019",
"4280",
"2724",
"53081",
"V4581"
] |
Admission Date: [**2121-1-27**] Discharge Date: [**2121-1-29**]
Date of Birth: [**2076-1-22**] Sex: M
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is a 45-year-old man with
history of suicidal attempts, depression and bipolar disorder
who was found to be unresponsive at home and taken to
[**Hospital3 **] where he was intubated for airway
production and then brought to the [**Hospital6 649**] Medical Intensive Care Unit. The patient was
stabilized in the Medical Intensive Care Unit overnight and
extubated. Upon extubation, the patient reports that he
spoke to his mother at 7:30 a.m. on day of admission and was
later found to be obtunded at home. He has been out of work
for the last six days, feeling very depressed. His mother
checked on him at 10 a.m. and he appeared to be sleeping.
She returned at 5 p.m. and found him unresponsive. At that
point, he was taken to [**Hospital3 **] and intubated for
airway production. He also received Narcan, nasogastric
lavage and charcoal. No pill bottles were found near him and
initially it was unclear what he took and in how much
quantity. After his one day stay in the Medical Intensive
Care Unit and post extubation, the patient was transferred to
the [**Hospital1 139**] firm. He reported feeling depressed and wanted to
take his life. He reportedly took 30 pills of either Ativan
or Zyprexa, which he was not sure.
The patient has a history of suicidal attempts. Six years
ago, he took multiple pills of Klonopin, one year ago another
suicide attempt with Ativan. He was last admitted at [**Hospital 1191**]
Hospital two months ago.
PAST MEDICAL HISTORY:
1. Depression
2. Bipolar disorder, on Lithium until two years ago
3. Over a dozen psych hospitalizations, most recently at
[**Hospital 1191**] Hospital two months ago. The patient's psychiatrist
is Dr. [**Last Name (STitle) 7469**].
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Ativan
2. Wellbutrin
3. Lamictal
4. Zyprexa
SOCIAL HISTORY: The patient works at post office, two packs
per day x25 year history. No alcohol for 15 years. No
intravenous drug use.
FAMILY MEDICAL HISTORY: Diabetes
PHYSICAL EXAMINATION ON ADMISSION:
VITAL SIGNS: Temperature 99??????, pulse 90, blood pressure
120/70, respiratory rate 16, saturations 98% on room air.
GENERAL: Alert and oriented x3, agitated.
HEAD, EARS, EYES, NOSE AND THROAT: Mucous membranes dry.
Pupils are equal and reactive to light. Supple neck.
CARDIOVASCULAR: S1, S2, tachycardic.
PULMONARY: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended, positive bowel
sounds.
EXTREMITIES: No cyanosis, erythema or edema.
NEUROLOGIC: Alert and oriented x3, anxious, no sensory
deficits, no suicidal ideation, depressed mood, mood and
affect congruent. Denies any delusions or hallucinations.
LABS: White blood cell count 16.4, hematocrit 42.4,
platelets 204. Chem-7: Sodium 146, potassium 3.8, chloride
111, bicarbonate 25, BUN 13, creatinine 0.9, calcium 8.5,
phosphate 3.8, magnesium 1.8.
HOSPITAL COURSE:
1. PSYCH: The patient's symptoms are likely secondary to
overdose of Ativan and/or Zyprexa. At [**Hospital6 649**], the patient's urine toxicology was negative
for benzodiazepines. In the Medical Intensive Care Unit, the
patient was successfully extubated. On the floor, he
remained stable from a hemodynamic and respiratory
standpoint. His level of anxiety decreased during the course
of his stay on the floor. At the time of discharge, he
denied any suicidal ideation. The patient was put on a CIWA
scale for Ativan withdrawal. The patient's psych medications
were discontinued per psychiatry consultation. The patient
was put on low dose Ativan prn per CIWA scan.
2. INFECTIOUS DISEASE: The patient had an elevated white
count. However, there were no focal signs or symptoms of
infection. His elevated white count was thought to be a
stress reaction.
DISCHARGE MEDICATIONS: To be determined at [**Doctor First Name 1191**]
Psychiatric Facility.
DISCHARGE DIAGNOSIS:
1. Suicidal attempt by Ativan and/or Zyprexa overdose
Discharge to [**Hospital 1191**] Hospital Psychiatric Facility.
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**MD Number(1) 1335**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2121-1-29**] 14:42
T: [**2121-1-29**] 14:06
JOB#: [**Job Number 38894**]
|
[
"311",
"3051"
] |
Admission Date: [**2196-1-6**] Discharge Date: [**2196-3-13**]
Date of Birth: [**2196-1-6**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl, twin number two, [**Known lastname 37198**] is a former
32 [**3-17**] week gestation, born to a 37-year-old gravida I, para
0 mother on [**2196-1-6**] at [**Hospital1 69**].
Infant born by cesarean section secondary to decelerations.
In utero, noted to have polyhydramnios and duodenal atresia.
Amniocentesis not performed. At birth, noted to have Downs
syndrome features. Required blow-by oxygen at birth,
otherwise stable in room air. Apgars were 7 at one minute, 8
at five minutes.
The infant was transferred to the [**Hospital3 1810**] for
surgical repair of duodenal atresia.
PHYSICAL EXAMINATION: On admission, birth weight 1645 grams
(50th percentile), length 42.5 cm (50th percentile), head
circumference 29.5 cm (25th to 50th percentile). Anterior
fontanel normal size, sutures split, palate intact, no
macroglossia, positive epicanthal folds, positive Downs
facies. Mild retractions, good breath sounds bilaterally,
few scattered crackles. Pink, well perfused, regular rate
and rhythm, normal S1 and S2, no murmur, pulses 2+ x 2.
Abdomen slightly distended, three vessel cord, no
hepatosplenomegaly, no masses. Normal female genitalia, anus
patent with fissures. Moderate diffuse hypotonia, positive
suck and grasp, unable to elicit Morrow. Right transverse
palmar crease, normal spine, hips and clavicles stable.
The infant was transferred to the [**Hospital3 1810**] for
repair of duodenal atresia on [**2196-1-7**].
HOSPITAL COURSE AT [**Hospital3 **]:
1. Gastrointestinal/fluids, electrolytes and nutrition: Her
time at [**Hospital3 1810**] was complicated. She went for a
primary resection and anastomosis of the duodenal atresia on
[**2196-1-19**]. This developed a leak, confirmed by
gastrointestinal dye study, and required re-exploration on
[**2196-1-22**] to correct the leak. There was serious peritonitis
resulting from this event, leading to prolonged bowel rest,
generalized systemic illness, and supportive mechanical
ventilation for a prolonged period of time. She was
eventually re-fed and escalated to 30 calories of formula, or
breast milk when available, without difficulty.
2. Cardiovascular: Cardiac evaluation confirmed an ASD and
persistent patent ductus arteriosis. Cardiology wanted to
ligate the patent ductus arteriosis given signs of congestive
heart failure, poor waking, and persistent right ventricular
hypertension. The patent ductus arteriosis was ligated on
[**2196-2-19**], under general anesthesia. After chest tube
removal on [**2-21**], the infant developed a tension
pneumothorax, needled for 60 cc of air with no further
reaccumulation on follow-up chest x-rays.
3. Respiratory: Had a history of intermittent apnea,
bradycardia and desaturations. She was treated with
caffeine, which was discontinued on [**2196-2-17**].
4. Infectious Disease: The infant received a 14 day course
of ampicillin, gentamicin and clindamycin postoperatively.
The infant also received a seven day course of ampicillin,
gentamicin and clindamycin for presumed urinary tract
infection and a sputum culture that was positive for H. flu.
Blood cultures were negative at that time.
5. Genitourinary: Renal ultrasound on [**2196-1-8**],
small kidneys bilaterally, mild increase in echogenicity of
kidneys bilaterally, and echogenic tubular structure, likely
secondary to trisomy 21. No further workup was necessary
since kidney function had remained normal.
The infant was transferred to [**Hospital1 188**] on day of life number 42.
HOSPITAL COURSE BY SYSTEM AT [**Hospital1 **]:
1. Respiratory: The infant was transferred from the
[**Hospital3 1810**] on nasal cannula 25 cc, 100%. The infant
weaned to room on day of life number 53, and has remained
stable in room air, with respiratory rates 40 to 60.
2. Cardiovascular: The infant continues to have a soft
audible murmur, consistent with atrioseptal defect. The
infant has remained hemodynamically stable this
hospitalization, with heart rates 120 to 150. Cardiology
recommends follow up for the atrioseptal defect at 12 months
of age.
3. Fluids, electrolytes and nutrition: Infant transferred
over from [**Hospital3 1810**] on premature Enfamil or breast
milk 30 calories/ounce with ProMod at 120 cc/kg/day.
Calories were decreased with weight gain, and the infant is
now taking Neosure 28 calories/ounce or breast milk 28
calories/ounce, minimum of 130 cc/kg/day by mouth. Most
recent weight is 2760 grams, head circumference 33 cm, length
49 cm.
4. Gastrointestinal: The infant has had a few episodes of
abdominal distention this hospitalization. KUBs have
remained within normal limits, with no pneumatosis, no
evidence of obstruction. The infant has been tolerating
feedings without difficulty.
5. Hematology: Most recent hematocrit on [**2196-3-11**],
showed a hematocrit of 30.1, with a reticulocyte count of
6.3. The infant has not received any packed red blood cell
transfusions this hospitalization.
6. Infectious Disease: The infant received ampicillin and
gentamicin for a total of four days, from day of life number
52 to day of life number 55, for initial positive blood
culture showing gram-positive rods. A repeat blood culture
on the next day was negative to date. Urine culture at that
time was also negative to date. The infant has not had any
issues with sepsis.
7. Neurology: The infant does not meet criteria for head
ultrasound.
8. Sensory: Audiology: Hearing screen was performed with
automated auditory brain stem responses. The infant passed
in both ears. Ophthalmology: Eyes were examined, revealing
mature retinal vessels. A follow-up examination is
recommended at eight months of age with Dr. [**Last Name (STitle) 36137**].
9. Psychosocial: [**Hospital1 69**]
social work involved with family. The contact social worker
is [**Name (NI) 4457**], and she can be reached at [**Telephone/Fax (1) 8717**]. The mother
is from [**Name (NI) **] [**Name (NI) 19118**], and speaks English very well.
CONDITION AT DISCHARGE: Stable in room air, former 32 [**5-15**]
week twin gestation, now 42 weeks corrected gestational age.
DISCHARGE DISPOSITION: Home with [**Month/Day (4) **].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**], phone
number [**Telephone/Fax (1) 1792**].
CARE RECOMMENDATIONS:
1. Feedings at discharge: Neosure 28 calories/ounce or
breast milk 28 calories/ounce by mouth, minimum 130
cc/kg/day.
2. Medications: Fer-in-[**Male First Name (un) **] 0.2 cc once daily by mouth (2
mg/kg/day).
3. Car seat position screening was performed and the infant
failed car seat testing twice. The infant is being sent home
in a car bed.
4. State newborn screening status: The most recent state
newborn screen was sent on [**2196-2-18**], results were
within normal range.
5. Immunizations received: Hepatitis B vaccine on [**2196-3-4**]. The infant received DTAP, HIB, IPV and Prevnar on
[**2196-3-7**]. The infant received first dose of Synagis
on [**2196-3-6**].
6. Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation; (2) Born
between 32 and 35 weeks, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
Influenza immunization should be considered annually in the
fall for pre-term infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
7. Follow-up appointments:
a. Dr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**], phone number [**Telephone/Fax (1) 1792**].
b. [**Hospital3 1810**] Downs Early Intervention Program was
called on [**2196-3-3**], and they will contact the
[**Name2 (NI) **].
c. [**Location (un) 86**] [**Hospital6 407**], fax number
[**Telephone/Fax (1) 37119**].
d. Cardiology follow up at [**Hospital3 1810**] with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], phone number [**Telephone/Fax (1) 37199**], at 12 months of
age.
e. Genetics, Dr. [**Last Name (STitle) 36467**], phone number [**Telephone/Fax (1) 37200**],
appointment scheduled for [**4-5**] at 9:30 A.M.
DISCHARGE DIAGNOSIS:
1. Prematurity, twin gestation
2. Trisomy 21
3. Status post duodenal atresia repair
4. Status post patent ductus arteriosis ligation
5. Atrioseptal defect, follow up with Cardiology
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 37196**]
MEDQUIST36
D: [**2196-3-13**] 02:16
T: [**2196-3-13**] 02:52
JOB#: [**Job Number **]
|
[
"V053"
] |
Admission Date: [**2182-9-6**] Discharge Date:
Date of Birth: [**2114-9-30**] Sex: M
Service:
IDENTITY: 67-year-old right handed man.
DISCHARGE DIAGNOSIS: Primary CNS angiitis.
HISTORY OF PRESENT ILLNESS: This is a 57-year-old man who
vasculitis on [**2182-9-6**]. Mr. [**Known lastname 2093**] has had history of numerous
strokes on presentation. In 4/98 he had a right sided
hemorrhagic stroke in basal ganglia with extension to the
ventricles. Then in 9/00 he presented with right sided
ataxic hemiparesis and was found to have a left internal
capsule basal ganglia infarct on MRI. Per old hospital
record the patient recovered from a motor standpoint but was
was placed on antihypertensives and Aggrenox at some point in
his past history. The patient subsequently presented on [**8-27**]
with an acute onset of right sided weakness. On history
patient apparently had stopped taking his antihypertensives
and Aggrenox for about a month duration. Neurologic work-up
for stroke back then included an echocardiogram on [**8-30**]
showing EF of 45-50%, aortic sclerosis, trace aortic
insufficiency, trace tricuspid regurgitation. MRA and MRI
showed moderate global atrophy with diffuse extensive small
vessel disease. Acute infarct seen on DWI in the left pons.
His neck vessels were intact with question of mild stenosis
of left carotid. Based on the study results, differential
diagnosis was made to include small vessel disease vs
vasculitis. An LP was recommended. This was reported to be
a moderately traumatic tap with only one out of four tubes
sent where there were 110 red blood cells, 30 monocytes, no
polys with a glucose of 69, protein 167. Gram stain was
negative and culture showed question of coag negative staph
aureus which was thought to be a contaminant. Fungal AFB and
cryptococcal antigens were negative in the CSF. Based on
this result the patient was transferred to [**Hospital1 346**] for positive angiography and biopsy
for work-up of possible CNS vasculitis.
PAST MEDICAL HISTORY: Hypertension, GI bleed, retinal
emboli, glaucoma, hyperbilirubinemia, [**Doctor Last Name 9376**], history of
hypokalemia, history of low platelets on Heparin, history of
mild ITP, no history of diabetes or MI.
ALLERGIES: None.
MEDICATIONS: On admission, Lopressor 50 mg [**Hospital1 **], K-Dur,
Gemfibrozil, Folic Acid, Vitamin E, Vitamin C, Labetalol and
Aggrenox.
SOCIAL HISTORY: The patient has no history of nicotine or
etoh use. He was a salesman.
PHYSICAL EXAMINATION: On admission blood pressure 140/80.
General exam, head, eyes, ENT is unremarkable. Neck supple
without bruit. Cardiovascular exam showed regular rate and
rhythm. Lungs were clear to auscultation. Abdomen benign.
Extremities were warm and well perfused. Neurological exam,
patient was alert, awake, oriented to [**Hospital1 190**], [**Location (un) 86**], [**Month (only) 216**] and [**2182**]. The patient showed
slight perseveration. The patient was slow to respond to
questions and his speech was general, thought was tangential.
There was mild degree of echolalia. The patient recalled [**1-30**]
objects in three minutes. His word generation was very poor.
Language is fluent with intact [**Location (un) 1131**] and repetition. He
had difficulty following multi-step commands, mild grasp
glabellar bilaterally. Claw construction is atrocious and he
did not attempt 3D object. On cranial nerve exam pupils were
equal and reactive. Visual fields were not reliably tested.
Extraocular movements show no nystagmus nor diplopia. His
tongue and palate were midline. On motor exam there is
increased tone in the lower extremities. On upper extremity
exam there is questionable deltoid weakness on the left,
otherwise full strength on the left upper extremity. Over
the right extremity there is more proximal than distal upper
extremity weakness. Reflexes were brisk and toes were
upgoing. Sensation was grossly intact to pinch.
LABORATORY DATA: On admission RPR negative, [**Doctor First Name **] negative,
ESR 20, platelet count 115,000, cholesterol 186,
triglycerides 173, LDL 123, Lyme titers were negative.
HOSPITAL COURSE: The patient was admitted to neurology
service. A lumbar puncture was repeated to verify the
abnormal [**Location (un) 1131**] in the CSF. On repeat lumbar puncture the
patient still was found to have an elevated protein of 133 in
his cerebrospinal fluid. Cerebral angiogram showed narrowing
of the P1 segment in his posterior circulation which was
uncommon for atherosclerotic disease. Based on these
results, the patient underwent diagnostic brain biopsy of the
right frontal region on [**2182-9-12**]. The patient tolerated this
procedure well. Results of the brain biopsy were consistent
with a microangiopathic vasculitis. Meeting with the
patient's wife and brother was held to discuss this diagnosis
of CNS vasculitis as well as treatment options and future
prognosis. The patient's family were in agreement with a
trial of treatment with Cytoxan and Prednisone. The patient
was started on Cytoxan 100 mg and Prednisone 60 mg q day on
[**9-21**]. The patient was hydrated with IV fluids at 100 cc per
hour while on Cytoxan therapy with regular urine dipstick to
monitor for hematuria. The patient had microscopic hematuria
noted two days after starting Cytoxan therapy with 6-10 red
blood cells per high power field. On [**9-25**] the patient had
one transient episode of [**Known lastname **] hematuria which was thought to
be traumatic as it was noted during movement and the Foley
catheter might have been pulled. His urine cleared soon
after. The patient received regular fingersticks to monitor
for blood glucose level while on Prednisone. The patient
showed no sign of hyperglycemia on Prednisone and this was
stopped.
During his hospital admission the patient had a waxing and
[**Doctor Last Name 688**] of mental status. On [**9-21**] the patient had one episode
of tremor of left extremity with eye deviation to the right
side times five minutes per report. This was controlled with
2 mg of IV Ativan administration. The patient was loaded on
Dilantin and CT of head was immediately obtained to evaluate
intracranial status and ruled out any postoperative bleeding.
CT head was normal. The patient had no more episodes of
seizure during this hospitalization and remained therapeutic
on Dilantin. Of note, during his hospitalization the patient
was also treated for one bout of urinary tract infection with
Ciprofloxacin. EKG obtained also suggested the diagnosis of
left ventricular hypertrophy with ST changes that are
chronic.
The patient showed marked mental status improvement since
starting on Dilantin. On [**9-25**] the patient was alert, awake,
oriented to place and person and month of the year. The
patient was tolerating Cytoxan and Prednisone well. Decision
was made to discharge the patient to rehabilitation center as
soon as a bed becomes available. The patient will require
weekly CBC to monitor his white blood cell count while on
Cytoxan therapy. The patient will also need to be
aggressively hydrated while on Cytoxan therapy to prevent
potential toxicity including hemorrhagic cystitis. The
patient will require regular urine dipsticks to monitor for
any microscopic hematuria while on Cytoxan. Recommended
frequency is 2-3 times per week. The patient will remain on
Cytoxan therapy with a follow-up with Dr. [**Last Name (STitle) **] at the
neurology clinic at the [**Hospital1 69**]
on [**10-23**] when the effect of Cytoxan and Prednisone therapy
will be reevaluated and treatments tailored.
DISCHARGE MEDICATIONS: IV fluid D5 ?????? NS plus 20 mEq of KCL
at 120 cc per hour, Dilantin 100 mg IV tid, Cytoxan 100 mg po
q d, Prednisone 60 mg po q d, Protonix 40 mg IV q d,
Hydralazine 50 mg po qid, Lopressor 100 mg po bid, potassium
chloride 10 mEq po q d, Milk of Magnesia 30 cc po q d prn
constipation, Dulcolax suppository one pr q d prn
constipation, Tylenol 325 mg to 650 mg po q 4 hours prn.
DR.[**Last Name (STitle) 726**],[**First Name3 (LF) 725**] 13-268
Dictated By:[**Doctor Last Name 35271**]
MEDQUIST36
D: [**2182-9-25**] 14:28
T: [**2182-9-25**] 14:58
JOB#: [**Job Number 35272**]
|
[
"5990"
] |
Admission Date: [**2200-7-19**] Discharge Date: [**2200-7-26**]
Date of Birth: [**2200-7-19**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: This 37 and [**1-1**] week gestation
born to a 33 year old gravida 3, para 1 mother. [**Name (NI) 37516**] [**2200-8-9**].
Prenatal screens - A positive, antibody negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative, GBS unknown. Artificial rupture of membranes less
than 24 hours prior to delivery, not maternal fever.
The infant was born by normal spontaneous vaginal delivery
with Apgar scores of 8 at 1 minute, and 8 at 5 minutes.
The infant was transferred to the newborn nursery where he
was noted to be some grunting and cyanosis. He was found to
have an oxygen saturation in the 60's in the newborn nursery.
He was subsequently transferred to the Neonatal Intensive
Care Unit for further management of respiratory distress.
PHYSICAL EXAMINATION: Birth weight 3410 grams (75th
percentile), head circumference 33.5 cm (50th percentile),
length 49.5 cm (75th percentile).
Active with obvious grunting. Normocephalic, anterior
fontanelle open and flat, red reflex present bilaterally.
Palate intact. Intermittent grunting. Mild intercostal
retractions, clear breath sounds bilaterally. Regular rate
and rhythm, no murmur, femoral pulses are equal bilaterally.
Abdomen soft with active bowel sounds, no masses or
distention. Normal male genitalia with testes distended
bilaterally. Anus patent. Spine intact. No sacral dimple.
Hip stable. Clavicles intact.
HOSPITAL COURSE BY SYSTEMS: Upon arrival to the Neonatal
Intensive Care Unit, the infant was placed on C-PAP, 7 cm of
water requiring 35 percent FIO2. Arterial blood gas on
admission showed pH of 7.28, CO2 57, PAO2 130, bicarb 28.
The infant requires oxygen up to 50 percent. Subsequent gases
were normal with CO2 in the 30's, and 40's. Infant's chest x-
ray initially was consistent with transient tachypnea of the
newborn. Subsequent chest xray showed improvement with
question of basilar opacities. The infant remained on C-PAP
until day of life 2 and transition to nasal cannula at that
time requiring 50 to 100 cc of 100 percent FIO2. The infant
was transitioned to room air by day of life 3 and has
remained in room air with oxygen saturations greater than 95
percent, respiratory rate 30 to 60. The infant has not had
any apnea or bradycardia.
Cardiovascular - the infant was
noted to have an intermittent murmur initially. No murmur has
been heard pre and postductal saturations on admission were
normal. Her rates have been 120 to 140's. Blood pressures
have been stable with mean blood pressures of 42 to 62.
Fluids, electrolytes and nutrition - the infant was initially
receiving nothing by mouth, on D10W at 60 cc per kg per day.
Infant was started on enteral feeds on day of life 3, PO ad
lib, Similac 20 calories per ounce and is currently taking
120 to 130 cc per kg per day.
Gastrointestinal - the infant did not require phototherapy
during this hospitalization. Peak bilirubin level on day of
life 3 was 11.9 with direct of 0.4. The most recent
bilirubin level on day of life 5 was 10.8 with direct of 0.3.
Hematology - infant has not received any blood transfusions
at this hospitalization. Hematocrit on admission was 43.2
percent, repeat hematocrit on day of life 2 was 41.5.
Infectious disease - CBC on admission showed white blood
cell count of 4.8, hematocrit 43.2 percent, platelets
273,000, 52 neutrophils and 9 bands. Repeat CBC on day of
life 2 showed white blood cell count of 12.4, hematocrit
41.5, platelets 299,000, 61 neutrophils, 0 bands. The infant
received a 7-day course of ampicillin and gentamycin for
presumed pneumonia. A lumbar puncture on day of life 4
showed white blood cell count of 11, red blood cells [**Pager number **],
protein 107, glucose 47.
Neurology - normal neuro examination.
Sensory - hearing screen was performed with automated auditory
brainstem responses ..
Psychosocial - parents involved.
CONDITION ON DISCHARGE: Stable on room air.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 58399**] (phone No. [**Telephone/Fax (1) 25350**]).
CARE RECOMMENDATIONS: Similar 20 calories per ounce minimum,
60 cc per kg per day po ad lib.
MEDICATIONS: None.
STATE NEWBORN SCREEN: Sent on [**2200-7-22**]. Results are
pending.
IMMUNIZATIONS: The infant received hepatitis B vaccine on
[**7-23**].
Immunizations recommended - influenza immunization is
recommended annually in the Fall for all infants once every 6
months of age. Before this age and for the first 24 months
of the child's life, immunizations against influenza is
recommended for household contacts and home care givers.
Follow up appointment with pediatrician, Visiting Nurses
Association.
DISCHARGE DIAGNOSES:
1. Status post respiratory distress.
2. Presumed pneumonia treated with 7 days of antibiotics.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2200-7-26**] 01:58:59
T: [**2200-7-26**] 04:07:40
Job#: [**Job Number 58400**]
|
[
"V053"
] |
Admission Date: [**2111-3-2**] Discharge Date: [**2111-3-11**]
Date of Birth: [**2039-2-13**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Altered mental status / Bifrontal Contusions
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 yo M significant PMH on Coumadin, Fondaparinaux and ASA 81
mg who per his family has not been acting like himself for 2
days, since Saturday [**2-28**]. Saturday he c/o not feeling well and
went to bed early. He stayed in bed all day Sunday, not eating,
only getting up to use the bathroom. Today his family contact[**Name (NI) **]
his PCP who sent him for [**Name (NI) **] evaluation. CT head from OSH shows
bifrontal ICH. PT himself does not recall trauma. C/O
headache.
Denies nausea, vomiting, dizziness, blurred vision, double
vision. He has baseline right hand weakness. Denies numbness,
tingling, neck pain.
ROS: Denies CP, SOB, palpitations
Pt is somewhat of a poor historian and he states that he is in
the hospital now for drainage of his lung.
Past Medical History:
PMHx: AICD defib implant [**2103**], CAD including ischemic
cardiomyopathy, lung CA, s/p right middle lung lobectomy, right
pleural effusion, metastatic adenocarcinoma, HTN, anemia, PE,
COPD, asbestosis, chronic Afib, high cholesterol, PVD s/p left
femoral endarterectomy [**2106**] at [**Hospital1 18**]
Social History:
hx ETOH use 12 beers daily
Family History:
NC
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: old left occipital laceration
Neck: Supple. No tenderness
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date but unable to
clearly state why he is at the hospital.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 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.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-2**] throughout except right Grip
[**3-2**]
and finger intrinsics [**4-2**] (baseline).
No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: normal on finger-nose-finger
Upon discharge:
Awake, alert, oriented x3, follows commands, MAE [**5-2**], L
nasolabial flattening.
Pertinent Results:
Head CT [**2111-3-2**]:
Significant bifrontal contusions, left occipital skull fx.
Head CT [**2111-3-3**]:
IMPRESSION:
1. Overall similar appearance to extensive inferior bifrontal
parenchymal
hemorrhages, inferior bitemporal parenchymal hemorrhages, and
right frontal subdural hematoma.
2. Minimal layering hyperdense material in bilateral occipital
horns likely represents acute blood.
ECHO [**2111-3-3**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. Overall left ventricular systolic
function is moderately depressed with inferior/inferolateral
akinesis/hypokinesis and hypokinesis elsewhere (LVEF= 30%).
Right ventricular chamber size and free wall motion are normal.
The right ventricular cavity is dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. Mild (1+) 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.
LENIS [**2111-3-3**]:
IMPRESSION: No evidence of deep vein thrombosis in either leg.
Carotid Ultrasound [**2111-3-3**]:
IMPRESSION:
1. 60-69% stenosis in the left internal carotid artery with no
significant
stenosis in the right internal carotid artery.
2. Diffuse moderate heterogeneous calcified plaque in the
bilateral common
carotid and internal carotid artery, left more than the right.
EEG [**2111-3-5**]:
IMPRESSION: This is an abnormal continuous telemetry because of
mild to
moderate diffuse background slowing. These findings are
indicative of
mild to moderate diffuse encephalopathy which is etiologically
non-
specific. In addition, there is right more than left
centrotemporal
slowing indicative of a more severe cerebral dysfunction in the
right
centrotemporal region. There are no epileptiform features.
CT Head [**2111-3-5**]:
IMPRESSION:
1. No significant interval change in the extensive hemorrhagic
contusions and surrounding edema in the inferior frontal lobes
bilaterally. Stable bilateral temporal lobe hemorrhagic
contusions. Stable small parafalcine frontal subdural hematoma.
2. No evidence of herniation or significant interval change.
EEG [**2111-3-6**]:
IMPRESSION: This EEG is evidence for diffuse slowing of
background
frequencies into the theta and delta bandwidth. There is some
focality
over the central regions with a slight rightsided preference. No
epileptiform activity was identified. No seizures were recorded.
LENIS [**2111-3-11**]:
Negative for DVT
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the ICU on the Neurosurgery service
for frequent neuro checks and systolic blood pressure control
less than 140. He was loaded with Dilantin for seizure
prophylaxis and started on 100mg TID. He was given 2 units of
FFP to reverse an INR of 2.4 and started on Vitamin K daily x 3
days. Given his history of heavy EtOH use he was placed on a
CIWA protocol and observed for signs and symptoms of alcohol
withdrawal.
Syncope work up was performed as the patient had no recollection
of falling.
An EKG was done that revealed sinus rhythm with some ectopy.
A TTE was done that revealed mild left atrium dilation and an
LVEF of 30%. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
An EEG was done that revealed no seizures.
Carotid ultrasounds were performed that revealed: 1. 60-69%
stenosis in the left internal carotid artery with no significant
stenosis in the right internal carotid artery. 2. Diffuse
moderate heterogeneous calcified plaque in the bilateral common
carotid and internal carotid artery, left more than the right.
Lower extremity ultrasound was performed to assess for lower
extremity DVT: No evidence of deep vein thrombosis in either
leg.
EP was also consulted to interrogate his pacemaker/defibrillator
for any discharges. No arrhythmias were found during pacemaker
interrogation.
On [**3-5**]: patient continued to be disoriented and at 12:30, while
working with PT, patient had a sudden onset episode of speech
arrest and confusion that self resolved. It was thought that
patient may have had a seizure and underwent an EEG that
revealed no seizure activity on final read.
On [**3-6**]- A UTI was noted and Cipro was started. EEG continued to
be negative. [**Date range (1) 25583**], patient remained stable and was awaiting
dispo planning. Physical therapy felt Acute Rehab was needed.
Screening began and patient was approved. On [**3-9**], he had a
short episode of speech arrest that self resolved. Keppra was
added. Patient remained stable.
On [**3-10**] his right pleurex catheter was drained.
On [**3-11**]- we began tapering down Dilantin as there was no EEG
confirmation of seizure. Keppra 1000 mg [**Hospital1 **] was continued.
Bilateral lower extremity doppler ultrasound was performed for
extended bedrest and was negative for DVT.
Patient was discharged to [**Location (un) 16493**]Rehab in [**Location 9583**].
At the time of discharge the patient was tolerating a regular
diet, ambulating with assistance, afebrile with stable vital
signs.
Medications on Admission:
Patanol 0.1% to each eye twice
weekly, Methadone 5mg Q am and 20mg QPM, Meclizine 12.5mg [**Hospital1 **],
Carvedilol 6.25mg [**Hospital1 **], ASA 81mg Daily, Amiodarone 100mg Daily,
MVI daily, Magnesium 40mg Daily, Simvastatin 10mg QHS,
lisinopril
5mg daily, MOM PRN, [**Name (NI) **] daily, Folic acid 1mg daily, Coumadin
2mg Daily, Furosemide 40mg Daily, Potassium 20 MEQ daily,
Omeprazole 40mg [**Hospital1 **], Percocet PRN, Isosorbide 30mg Daily,
Fondaparinaux pen 500mg 4 xdaily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, HA.
2. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for HA.
3. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO twice a day for 7 days.
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: started [**3-6**], d/c [**3-13**].
12. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
17. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
Bifrontal contusions
Occipital skull fx
Subdural hematoma
Traumatic Subarachnoid hemorrhage
Alcoholism
Delirium
confusion
Seizures
Urinary Tract infection
Slurred speech
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:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate ([**Location **])
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this once cleared by your Neurosurgeon. We
will discuss this in clinic at your follow-up.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, but we started you on Keppra and would like to taper
your Dilantin off. Continue Dilantin 100mg [**Hospital1 **] x 7 days then
discontinue. You have been discharged on Keppra (Levetiracetam)
as well, you will not require blood work monitoring. Please
continue until follow-up.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**Known firstname **], to be seen in 1 week.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
Completed by:[**2111-3-11**]
|
[
"5990",
"V5861",
"496",
"42731",
"2720",
"2859"
] |
Admission Date: [**2158-3-24**] [**Year/Month/Day **] Date: [**2158-3-29**]
Date of Birth: [**2101-12-1**] Sex: M
Service: MEDICINE
Allergies:
Ativan
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
intubation and extubation
History of Present Illness:
56 M w/ ESLD [**2-22**] HCV and EtOH cirrhosis, w/ locally advanced
unresectable end-stage HCC s/p TACE, trial of sorafenib &C1
xeolda, palliative chemo w/ capecitabine and cyberknife therapy,
who presents from home after being found altered by his wife.
Reportedly, pt was in his USOH until this morning when he fell
forward out of a chair, striking his forehead. He then went to
bed at 8am and when his wife went to arouse him, she found him
unresponsive so called EMS. EMS found him to have normal SaO2
and FSBS. His wife who is his HCP states she has had similar
episodes in the past but she is unable to say what those events
were and how they were treated. She gives him his medications at
home and denied possibility of overdose although pt is on
massive doses of narcotics at home and has been admitted for
narcotics overdose in the past, most recently from [**Date range (1) 72225**].
.
In the ED, VS initially 93 89/57 20 100% NRB. He appeared
unresponsive to noxious stimuli and had no gag, so was intubated
for airway protection via rapid-sequence without medications.
Initially he tolerated intubation without any medication but was
moving extremities while in CT scanner so was given etomidate
and succinylcholine. Initial ABG on 550x16 PEEP 5 FiO2 100% was
7.49/ 43/ 164.
.
In the ICU, he was intubated, sedated and not following
commands.
Past Medical History:
-HCC s/p s/p resection in [**2154**], recurrence in [**2156**], s/p TACE,
trial of sorafenib, & C1 xeloda, currently s/p palliative
chemotherapy 1 cycle with capecitabine (recently stopped 3 days
prior to admission due to concern of worsening ataxia)
-EtOH cirrhosis
-HCV
-Seizure disorder
-Bipolar disorder - psych hosp [**5-30**], SA in the [**2137**] with soma
and EtOH
-Anxiety disorder
-Peripheral neuropathy
-Chronic ataxia - unknown etiology
-Lyme disease
-HTN
Social History:
Lives w/ partner [**Name (NI) **]. Currently on disability. Prior prison
sentence for assault many decades ago. ETOH history in past,
current use unknown. Smokes [**1-22**] PPD. History IVDU, none in 8
yrs. His partner does not think he is taking additional
non-prescription opiate meds that she knows of. Had recent
admission for narcotics overdose.
Family History:
Father died of a type of bone cancer. Paternal grandfather may
also have had bone cancer. Maternal grandfather had lung cancer.
Physical Exam:
ADMISSION EXAM:
VS: T 103 HR 109 BP 109/65 RR 16 SaO2 97% on 550x16 FiO2 50%
PEEP 5
GEN: intubated, sedated not following commands
HEENT: PERRLA 4-->2 cm B/L
CV: tachycardic rate, regular rhythm no murmurs appreciated
LUNGS: no crackles/wheeze anteriorly, coarse ventilated breath
sounds
ABD: +BS soft NT ND, no HSM
EXT: no edema B/L LE, w/w/p
NEURO: intubated, sedation
.
[**Month/Day (2) 894**] EXAM:
VS: T: 98.3 143/92 76 18 95%RA
GA: AOx3, NAD
HEENT: Sclera anicteric. PERRLA. No nystagmus. MMM. no LAD. no
JVD. neck supple.
CV: RRR. III/VI SEM best heard at RUSB, radiating to carotids.
No pulsus parvus et tardus.
Pulm: CTAB, fair aeration. Decreased BS on L>R, mild inspiratory
crackles. No egophony or tactile fremitus. No w/r/r.
Abd: soft, ND. TTP at epigastrium. +BS. no g/rt. neg HSM. neg
[**Doctor Last Name 515**] sign. No fluid wave or shifting dullness.
Extremities: WWP, no edema. PTs 2+.
Skin: No jaundice.
Neuro: CNs II-XII intact. +Asterixis, no clonus. No pronator
drift. Resting tremor. No dysmetria or dysdiadhochinesia on
exam. 4/5 strength distal muscle groups in UE and LE, [**5-25**] in
large muscle groups in UE and LE. Fair performance on FNF. 2+
BR. Light touch,deep touch, and proprioception intact on UE
C5-T1 and LE L3-S1, but L>R.
Psych: Unable to perform MOYB (?effort), but can do DOW forward
and backwards. No dysarthria. Good performance on Go-No Go
level. [**3-23**] recall at 0 mins, [**3-23**] at 5 mins.
Pertinent Results:
ADMISSION LABS:
[**2158-3-24**] 01:04PM BLOOD WBC-6.5 RBC-3.51* Hgb-11.1* Hct-33.5*
MCV-95 MCH-31.5 MCHC-33.1 RDW-14.2 Plt Ct-330#
[**2158-3-24**] 01:04PM BLOOD Neuts-76.9* Lymphs-16.8* Monos-3.9
Eos-2.1 Baso-0.3
[**2158-3-24**] 01:04PM BLOOD PT-14.1* PTT-31.9 INR(PT)-1.2*
[**2158-3-24**] 01:04PM BLOOD Glucose-123* UreaN-10 Creat-0.5 Na-137
K-4.3 Cl-98 HCO3-35* AnGap-8
[**2158-3-24**] 01:04PM BLOOD Ammonia-52
[**2158-3-24**] 01:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2158-3-24**] 01:14PM BLOOD Glucose-117* Lactate-1.0 Na-142 K-4.5
Cl-92* calHCO3-36*
[**2158-3-24**] 01:14PM BLOOD Hgb-11.3* calcHCT-34
.
[**Year/Month/Day 894**] LABS:
.
MICRO:
[**2158-3-24**] Blood cultures: pending
[**2158-3-24**] Urine culture: negative
[**2158-3-24**] MRSA screen: negative
[**2158-3-24**] Sputum culture: S. pneumoniae, H. influenzae, GNRs
.
IMAGING:
[**2158-3-23**] CT Torso w/ con:
1. Status post left lateral hepatic segmentectomy and cyberknife
for the gastrohepatic lymphnode, with stable appearance of the
resection margin. Previosuly mentioned four lesions in the liver
have slightly increased in size and are concerning for foci of
HCC. Stable appearing caudate lobe lesion worrisome for another
HCC focus.
2. Gastrohepatic lymph node, slightly smaller since the prior
study.
3. Interval appearance of new ground glass opacities in the
lungs likely
representing inflammatory process.
.
[**2158-3-24**] CT Head w/o con: No acute intracranial process.
.
[**2158-3-24**] CT C-Spine w/o con:
1. No evidence of an acute fracture.
2. Stable appearance of multilevel degenerative joint changes,
most
pronounced at C5-C6 with posterior osteophyte disc complex
formation mildly impinging upon the thecal sac without evidence
of critical central canal stenosis. In the setting of high
clinical suspicion for ligamentous or central cord injury, may
consider MR.
3. Large amount of fluid pooling in the pharynx and hypopharynx,
which may put the patient at risk for aspiration.
CXR [**3-25**]: Extensive bilateral consolidation in the lower lungs,
right greater than left, most likely pneumonia. Upper lungs are
clear. Pleural effusions are small if any. Heart size normal. ET
tube in standard placement. Nasogastric tube passes into the
stomach and out of view. Dr. [**Last Name (STitle) 5850**] was paged.
Liver u/s [**3-25**]: 1. No significant ascites.
2. Multiple liver lesions are better appreciated on [**2158-3-23**] CT
scan.
Brief Hospital Course:
56 M w/ HCV and EtOH cirrhosis w/ locally advanced unresectable
HCC found down and unresponsive.
.
#Altered Mental Status: Etiology of unresponsiveness was unclear
at time of admission. Initial CT head was negative for acute
process or for metastatic lesions. On admission, ddx included
meniningoencephalitis vs. hepatic encephalopathy vs
anticholinergic delirium vs. narcotic overdose vs. sepsis, with
ddx for possible LOC prior to admission including orthostatic
syncope (especially given sepsis physiology and poor PO intake
prior to admission). Given fever to 103.8 on admission to MICU,
sepsis was considered most seriously, and coverage was begun for
SBP (h/o cirrhosis) and meningitis (fever and AMS) with
vanco/ceftriaxone/ampicillin/acyclovir. Lactulose was also
started given concern for possible hepatic encephalopathy. CXR
ultimately showed development of PNA, and sputum culture was
positive for S. pneumoniae and H. influenza; thus, all abx but
CTX were discontinued on [**3-26**]. Sedation weaned as tolerated, and
patient was extubated [**2158-3-26**]. He was AAOx3 following extubation
and at baseline per outpatient providers and girlfriend.
.
#Community Acquired PNA: While initial CXR on [**3-24**] not concerning
for acute process, subsequent CXR on [**3-25**] showed development of
extensive bilateral consolidation in the lower lungs (R>L), most
likely pneumonia in the setting of fevers and hypotension.
Sputum culture from [**2158-3-24**] was positive for S. pneumoniae and H.
influenza, both penicillin-sensitive. He was continued on
ceftriaxone and other abx were discontinued. He defervesced and
remained afebrile and normotensive throughout his course. He
was weaned from the ventilator on [**2158-3-26**], and on [**2158-3-27**] was
stable for transfer to medicine floor. Prior to transfer,
patient was no longer requiring supplemental oxygen. On [**3-28**], he
was transitioned to amoxicillin 875 PO BID whch he will continue
for total 10 day course.
.
#Hypotension: Patient hypotensive with SBP in 70s on day of
admission, likely secondary to sepsis in setting of PNA, as well
as due to effects of sedating meds while intubated. Patient
responded to IVF boluses. Pressures remained stable following
aggresive IVF administration and antibiotics. No further events
of hypotensoin on the medical floor.
.
#Terminal HCC in setting of ELSD [**2-22**] EtOH & HCV cirrhosis.
Patient did not have any evidence of ascites on exam, and RUQ
ultrasound did not show significant ascites. He was started on
lactulose for his h/o cirrhosis. Patient was seen by his
outpatient heme/onc fellow, Dr. [**First Name (STitle) **], during this hospital
course. He was also seen by palliative care, who discussed the
option of hospice. Patient was agreeable to hospice care and
will be discharged with home hospice.
.
#Seizure Disorder, NOS: Patient was continued on divalproex
while in-house. Was monitored on seizure precautions.
#Cachexia: Pt has Cre of 0.4 and BUN of 4, and relates hx of
poor PO intake. He endorsed to medical floor team that he and
his partner could not afford food, however SW was consulted and
he did not bring up these concerns. Would consider nutrition
f/u as outpatient, or possibly Megace or other medication to
stimulate appetite.
.
#Ataxia: Chronic problem per pt and per [**Name (NI) **] (lead to disability
in [**2142**]). Neurology evaluation in [**11-30**] was c/w with L5/S1
sensory neuropathy as well as central issue (nystagmus, ataxia),
possibly a Wernicke??????s encephalopathy. Of note, pt has had two
falls at home, both being followed by AMS and requiring
admission. MRI showed bilateral foraminal narrowing at L5/S1,
with nerve impingement L>R. Pt ambulates with cane. He asserts
that a neuropathy causing weakness and sensory problems led to
him quitting his job on disability in [**2142**]. Prior eval showed
elevated TSH (which normalized two weeks after admission),
normal RPR, elevated B12. Evaluated by PT who recommended home
PT, however patient went home on hospice.
.
#Bipolar disorder c/b SA x4 and legal issues s/p multiple
hospitalizations: Denied active SI,HI, hallucinations and
illusions. Also denied prior attempts at overdose, which he had
been admitted to the hospital for in the psat. Outpt
psychiatrist, Dr. [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) **], was consulted who
recommended no inpatient intervention and outpatient f/u was
scheduled. Continued home thorazine
.
Medications on Admission:
BACLOFEN 20mg QID
CHLORPROMAZINE 50mg QHS
DIVALPROEX - 250 mg - 4 tabs [**Hospital1 **]
GABAPENTIN - 800 mg QID
HYDROMORPHONE - 4-8mg PO q4-6h PRN pain
MORPHINE - 15 mg [**Hospital1 **] (MS contin)
MORPHINE - 30 mg [**Hospital1 **] (MS contin)
PROCHLORPERAZINE MALEATE 10 mg Tablet q6h PRN nausea
RANITIDINE HCL- 150 mg [**Hospital1 **]
Docusate 100mg [**Hospital1 **]
Loperamide PRN episode of diarrhea. [**Month (only) 116**] take up to 8 tablets per
day.
[**Month (only) **] Medications:
1. baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
2. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
Disp:*1350 ML(s)* Refills:*2*
5. chlorpromazine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
10. Amoxicillin 875 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days.
Disp:*11 Tablet(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Month (only) **] Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
[**Hospital **] Diagnosis:
Community acquired pneumonia
[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Hospital **] Instructions:
You were seen in the hospital for being found down at home. This
was most likely due to being ill with pneumonia, for which you
stayed in the ICU and received IV antibiotics. Your breathing
and symptoms improved. You should continue taking antibiotics
by mouth at home
Because you were found down at home, there was also a concern
that your dosage of pain medications was too high. We decreased
your MS contin to 15 mg twice a day and the dilaudid for
breakthrough pain to 2 mg every 4 to 6 hours as needed for pain.
If your pain is not being well controlled, please discuss this
with Dr. [**First Name (STitle) **] who can adjust your medications with you.
Changes to your medications:
START taking amoxicillin (antibiotic) 875 mg twice a day for
five more days
START taking lactulose 15 mg four times a day
DECREASE MS contin to 15 mg twice a day
DECREASE hydromorphone to 2 mg every 4 to 6 hours as needed for
pain (please cut the 4 mg pills you have at home in half)
Followup Instructions:
You should follow up with your oncologists in [**1-22**] weeks, they
will call you and let you know when your appointment is.
Department: PSYCHIATRY
When: MONDAY [**2158-4-3**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23908**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Name: [**Last Name (LF) 72224**],[**First Name3 (LF) **] E
Location: [**Hospital **] COMMUNITY HEALTH CENTER
Address: 409 [**Location (un) 61346**], [**Location **],[**Numeric Identifier 46146**]
Phone: [**Telephone/Fax (1) 6511**]
Appointment: Tuesday [**4-4**] at 12:10PM
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2158-4-17**] at 2:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2158-4-17**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12766**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2158-3-29**]
|
[
"2760",
"4019",
"3051"
] |
Admission Date: [**2140-2-15**] Discharge Date: [**2140-2-22**]
Date of Birth: [**2057-6-29**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Percocet
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
shortness of breath, chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 yo M w/ CAD s/p CABG, multi PCIs, with chronically occluded
SVG-RCA., NSTEMI in [**2-3**], mod. AS, HTN, CRI, hyperchol, Prostate
CA, PVD, dementia, p/w SOB since 6am and CP (c/w chronic angina)
not relieved by NTG SL. The CP was described as worse w/
coughing. Per daughter, pt. has had poor PO intake and a dry
cough over the past week and has not felt well. EMS was called
[**1-30**] to his SOB. He was given ASA by EMS and transported to
[**Hospital1 18**].
In the ED: initial vitals were 100.4, 189/93, 92, 20, 95%2L NC.
A CXR showed a RLL consolidation and pt. was given 750 IV
levaquin. 1mg IV morphine for CP and was made CP free, 1L of
NS/K+, 40 po K+, 5mg IV lopressor. Pt then desat. to 90% on 5L
and was placed on an NRB with impr. of sats to 98%. He was
started on a nitro gtt and given lasix 40mg IV. ECG changes were
noted (STD in I, avL, v4, v5) and trop was elevated to 0.71 (in
setting of ARF on CRI) pt was started on a heparin GTT,
cardiology was notified and rec. continued medical management. A
foley was placed w/ 1600ml of clear urine emptied. Now bloody,
therefore hep GTT was stopped. Admitted to icu for resp.
distress.
Past Medical History:
# CAD
- CAD s/p CABG [**2125**]: LIMA to LAD, SVG to Diagonal, SVG to OM1,
and SVG to rPDA and rPL.
- PCI [**2136-3-26**]: Cath showed 3VD, LM 99%, LAD occluded (filling
via LIMA, patent), LCX occluded (filling via SVG, patent). RCA
occluded (filling via collaterals from distal LAD and OMs). SVG
to diag and OM's patents. SVG to RCA occluded. Successful
rotatonal atherectomy, PTCA, and stenting of the distal LMCA
into the proximal LCX with Taxus DES. withs 2.75 x 20 mm Taxus
DES.
- PCI [**10-2**]: 3VD, SVG to D, significant new disease in SVG to OM
with successfull POBA performed (failed attempt at stent), known
occluded
SVG to RCA.
- PCI [**12-2**]: 3VD, patent SVG-D1, patent SVG-OM with 80% stenosis
in the distal graft with successful PTCA performed, SVG-RCA
known to be occluded, LIMA-LAD not engaged.
- PCI [**2138-2-5**]: 3VD, SVG to OM1 90% lesion at anastomosis site of
prior POBA, successfull angioplasty performed.
- NSTEMI [**5-3**] - medically managed
Social History:
Social history is significant for the absence of current tobacco
use (quit 15 yrs ago, had smoked 1ppd for 50 yrs. There is no
history of alcohol abuse, although the patient drank in the
past, quit 15 hrs ago. Father died of MI at 48, brother died in
70's of MI, other 2 brothers with CAD.
Family History:
Social history is significant for the absence of current tobacco
use (quit 15 yrs ago, had smoked 1ppd for 50 yrs. There is no
history of alcohol abuse, although the patient drank in the
past, quit 15 hrs ago. Father died of MI at 48, brother died in
70's of MI, other 2 brothers with CAD.
Physical Exam:
VS: Temp:97.8 BP:138 /77 HR:98 RR: O2sat 99 on 5L NC
GEN: AA0x1, comfortable, sitting in chair
HEENT: dry MM, no JVD at 90 degrees
RESP: CTA b/l with good air movement throughout
CV: RRR, III/VI harsh systolic murmur throughout precordium
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
Pertinent Results:
ADMIT LABS:
[**2140-2-15**] 08:15AM BLOOD WBC-14.7*# RBC-3.21* Hgb-9.2*# Hct-27.6*
MCV-86 MCH-28.7 MCHC-33.3 RDW-13.2 Plt Ct-295
[**2140-2-15**] 08:15AM BLOOD Neuts-88.3* Bands-0 Lymphs-7.9* Monos-3.1
Eos-0.5 Baso-0.2
[**2140-2-15**] 08:15AM BLOOD Plt Ct-295
[**2140-2-15**] 08:15AM BLOOD Glucose-161* UreaN-31* Creat-2.1* Na-140
K-2.6* Cl-99 HCO3-26 AnGap-18
[**2140-2-15**] 07:45PM BLOOD Calcium-10.5* Phos-3.7 Mg-1.8
[**2140-2-15**] 08:35AM BLOOD Lactate-1.5
.
Cardiac labs:
[**2140-2-15**] 08:15AM BLOOD CK-MB-8
[**2140-2-15**] 08:15AM BLOOD cTropnT-0.71*
[**2140-2-15**] 02:00PM BLOOD cTropnT-1.02*
[**2140-2-15**] 07:45PM BLOOD CK-MB-33* MB Indx-8.3* cTropnT-2.06*
proBNP-GREATER TH
[**2140-2-16**] 03:40AM BLOOD CK-MB-18* MB Indx-6.6* cTropnT-3.00*
[**2140-2-16**] 03:00PM BLOOD CK-MB-12* MB Indx-5.4 cTropnT-3.14*
[**2140-2-17**] 02:11AM BLOOD CK-MB-7 cTropnT-2.08*
[**2140-2-15**] portable CXR:
Comparison is made with prior study performed four hours
earlier.
Moderate cardiomegaly is stable. There has been slight interval
worsening in asymmetric moderate pulmonary edema, worse in the
right side. There is no pneumothorax or pleural effusion.
Patient is post-median sternotomy and CABG.
[**2140-2-15**]: Mild cardiomegaly has increased. There is
mild-to-moderate pulmonary edema asymmetric on the right, with
more dense consolidation in the right lower lobe. There is no
pneumothorax. If any, there is small right pleural effusion.
There are low lung volumes. The patient is post-median
sternotomy and CABG.
[**2140-2-15**] ECG 7 am:
Sinus tachycardia. Left atrial abnormality. Frequent atrial
ectopy. Left
ventricular hypertrophy. Compared to the previous tracing of
[**2139-5-27**] the rate
has increased, atrial ectopy has appeared and there is ST
segment depression
in leads I, II, aVL and V3-V6 consistent with inferolateral
ischemic process.
Followup and clinical correlation are suggested.
TRACING #1
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
99 200 114 390/458 79 -26 134
[**2140-2-15**] 9 am ECG:
Sinus rhythm with slowing of the rate as compared with prior
tracing
of [**2140-2-15**]. Atrial ectopy has abated. The ST segment depression
persists.
No diagnostic interim change.
TRACING #2
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 [**Telephone/Fax (3) 9544**]/383 101 -25 133
[**2140-2-15**] 12pm ECG:
Sinus tachycardia with recurrence of tachycardia as compared
with prior tracing
of [**2140-2-15**]. Otherwise, no diagnostic interim change.
TRACING #3
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
104 188 114 386/463 73 -26 107
[**2140-2-16**] ECHO:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is mild to moderate regional left ventricular
systolic dysfunction with inferior/inferolateral hypokinesis.
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I (mild) LV diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-30**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] The left ventricular inflow pattern suggests
impaired relaxation. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2138-5-6**], left ventricular systolic function is
now depressed.
[**2140-2-16**] ECG 1:30 pm:
Sinus rhythm with marked slowing of the rate as compared with
prior tracing of [**2140-2-15**]. There is Q-T interval prolongation.
Atrial ectopy has reappeared and the ischemic appearing ST
segment changes persist. Clinical correlation is suggested.
TRACING #4
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
61 184 108 454/455 26 -7 135
[**2140-2-17**] CXR portable:
AP UPRIGHT CHEST: Moderate cardiomegaly is stable. The patient
is status post median sternotomy and CABG. Pulmonary edema has
substantially cleared. No sizable pleural effusion is
identified. There is no pneumothorax. Visualized osseous
structures are unremarkable.
IMPRESSION: Clearing pulmonary edema.
Discharge labs [**2140-2-22**]:
Na 137, K 3.8, Cl 106, CO2 22, BUN 15, Creat 1.1, glucose 107,
ca 7.9, mg 2.1, P 2.1. WBC 10.4, Hct 27.1, Plt 352.
Brief Hospital Course:
82 yo M w/ CAD s/p CABG, mult PCI, mod AS, angina, prostate CA,
admitted with NSTEMI, CHF, PNA, and acute on chronic renal
failure.
# CHF: Pt was found to have NSTEMI with pulmonary edema. Pt's
hypoxia required NRB and was admitted to MICU for observation
and iv lasix. He received nitroglycerin and iv lasix with good
diuresis and at the time of transfer to the floor, he no longer
required supplement O2. Repeat echo on [**2-17**] revealed a new
decreased EF of 40% as well as a mild to moderate regional left
ventricular systolic dysfunction with inferior/inferolateral
hypokinesis likely [**1-30**] NSTEMI. Pt autodiuresed well and did not
require any lasix while on the floor. His I/O were initially
negative and then were even on the floor.
# NSTEMI: Pt has had periodic anginal pain which is chronic per
his daughter, and he has a known occluded [**Name (NI) 9545**]. Pt ruled in
for NSTEMI and was seen cardiology who recommended medical
management and daughter and pt. did not want intervention. He
was continued on BB, nitro patch, ASA, and plavix. ACEI was
held due to ARF. Pt received heparin gtt briefly but was stopped
due to hematuria liekly [**1-30**] to traumatic foley insertion.
Statin was added on the floor. Once ARF resolved, he was
restarted on his home ACEI. Pt remained chest pain free on the
floor.
# RLL PNA: Likely contributed to hypoxia in addition to
pulmonary edema. Levofloxacin was started at the time of
admission for community acquired pneumonia and finished a 7 day
course.
# Acute on chronic renal failure: His baseline creatinine is
around 1.3-1.5. At admission, creatinine was 2.1. Pt. had
significant urinary retention/prostate cA which probably caused
ARF as well as poor flow due to CHF. His creatinine eventually
returned to baseline and ACEI was restarted and his creatinine
and 'lytes remained stable thereafter.
# Hematuria: likely [**1-30**] to traumatic foley insertion. Pt has
known bph and prostate ca, with urinary retention in the past.
Hematuria eventually resolved after d/cing heparin and hct
remained stable. He did nto require any blood transfusion. He
has an appointment with Dr. [**Last Name (STitle) 770**] (urology) on [**2140-2-25**] to
decide on further treatment (i.e TURP) or continuing foley.
# Anemia: He had hematuria but hct remained stable. His iron
studies were consistent with anemia of chronic inflammation.
# HTN: continued BB and then later re-started ace-I when
creatinine normalized. His BP was well-controlled on the
regimen.
Medications on Admission:
flomax 0.8mg qhs
lisinopril 20mg [**Hospital1 **]
lopressor 100 [**Hospital1 **]
nitr-dur 0.4 patch qdaily
plavix 75mg qdaily
proscar 5mg qdaily
seroquel 100mg qhs
ASA 325 qdaily
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours): 12-14 hours/day and off.
6. Quetiapine 25 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
Primary diagnoses:
NSTEMI
Congestive heart failure
Community acquired pneumonia
Acute renal failure- resolved
Secondary diagnoses:
Hypertension
Dementia
Prostate cancer
Hyperlipidemia
Discharge Condition:
Stable, satting 97-99% on RA
Discharge Instructions:
Please call your doctor or report to emergency room if you
develop chest pain not relieved with nitroglycerin, shortness of
breath, nausea, vomiting, diarrhea, abdominal pain, fevers,
chills or any other worrisome symptoms.
Please take medications as instructed. Keep all your
appointments. We added levofloxacin for pneumonia and started
simvastatin for your cholesterol and heart disease. It is very
important that you keep your appointment so that you can discuss
with Dr. [**Last Name (STitle) 770**] about your prostate and foley catheter and
possible surgery.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9546**], MD Phone:[**Telephone/Fax (1) 1047**]
Date/Time:[**2140-2-23**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2140-2-24**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD
Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2140-2-25**] 9:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**], MD (Cardiology) on [**2140-3-1**] at 3:00PM
|
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"2724",
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] |
Admission Date: [**2125-8-31**] Discharge Date: [**2125-9-5**]
Date of Birth: [**2052-4-11**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycodone/Acetaminophen / Morphine Sulfate
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
dyspnea, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 2816**] is a 73 year old female s/p liver [**Known lastname **] for
cryptogenic cirrhosis in [**2121**] complicated by post-[**Year (4 digits) **]
lymphoproliferative disease s/p R-CHOP with [**Doctor First Name **] at present, and
moderate pulmonary fibrosis admitted for lower extremity
swelling, increased work of breathing, and generalized weakness.
.
In the ED, she was noted to have a equivocal UA though denied
urinary frequency or dysuria though she did report an episode of
urinary incontinence. She had a CXR that showed possible RLL
Pneumonia. She was given Vancomycin and Levaquin for UTI and
PNA. She was noted to have a BP of 94/66 and HR of 140 that
improved to 120 with fluids.
.
On review of systems, patient reports increased leg swelling and
difficulty. Patient unable to state ifthere is a difference in
her oxygen tolerance. No SOB at rest. No change in 3 pillow
orthopnea, no PND.
Past Medical History:
Interstitial pulmonary fibrosis, home oxygen dependent 2-2.5L NC
S/p Liver [**Doctor First Name **] [**4-26**] for cryptogenic cirrhosis
Post-[**Month/Year (2) **] lymphoproliferative disorder s/p CHOP and
rituximab
Type 2 DM
HTN
Hypothyroidism
Social History:
Married, previously lived at home but recently discharged to
rehab. Denies tobacco use.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Afib in sister
Physical Exam:
VS: T 96.7, HR 121, BP 135/65, RR 27, 91% on 4LNC
Gen: chronically ill appearing obese famale
HEENT: facial hair, tachypneic, unable to speak in full
sentences
CV: Tachycardic, regular, no m/r/g
Pulm: crackles diffusely, no wheezes
Abd: obese, soft, NT, ND, bowel sounds present
Ext: trace peripheral edema b/l
Neuro: CNs [**2-6**] intact, moving all extremities
Pertinent Results:
Imaging:
[**2125-8-31**]. CXR.
IMPRESSION:
Possible superimposed right middle lung field infection on
background of pulmonary fibrosis.
.
Chest CT. [**2125-7-10**].
IMPRESSION:
1. Minimal improvement in moderately severe generalized
interstitial lung disease. Persistent air trapping. No evidence
of pulmonary hypertension, intrathoracic malignancy or
infection.
2. Longstanding pneumobilia.
.
PFTs [**2125-7-5**].
Mechanics: The FVC is markedly reduced. The FEV1 is moderately
to markedly reduced. The FEV1/FVC ratio is elevated.
Flow-Volume Loop: Marked restrictive pattern.
.
Impression:
Results are consistent with a restrictive ventilatory defect,
which is confirmed by the markedly reduced TLC measured on
[**2125-3-21**]. Compared to the prior study of [**2125-5-17**] there has
been no significant change.
.
Echo [**2125-3-9**].
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is no ventricular septal defect. The right
ventricular cavity is markedly dilated with depressed free wall
contractility. The ascending aorta is moderately dilated. There
are focal calcifications in the aortic arch. 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. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. The main pulmonary artery is dilated. The branch
pulmonary arteries are dilated. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2125-1-22**], the right ventricle is markedly dilated.
.
Admit labs
137 | 92 | 24 /
-------------- 164
4.7 | 36 | 1.0 \
.
.
.. \ 13.9 /
6.1 ------ 170
.. / 40.8 \
.
Diff: 87.2N, 0 Bands, 9.2L, 3.1M, 0.3E, 0.3 Basos
.
PT 11.7
PT 21.6
INR 1.0
.
CK 11
TropT 0.03
.
ALT 17
AST 14
AP 79
Lipase 28
T. Bili 0.4
Alb 3.8
.
Lactate 2.3
.
Micro:
UA: cloudy, trace LE, lg Blood, 100 protein, Tr ketones, 21-50
RBCs, 0-2 WBCs, Many bacteria, [**2-28**] epis
Brief Hospital Course:
Ms. [**Known lastname 2816**] is a 73 yo female with PTLD s/p R-CHOP, s/p liver
[**Known lastname **] in [**2117**] for cryptogenic cirrhosis, pulmonary
fibrosis, type 2 diabetes, and HTN admitted for constellation of
non-specific symptoms such as fatigue, urinary incontinence,
shortness of breath, and leg swelling.
.
#Dyspnea/fatigue: Her dypnea on admission was concerning for
PNA. She was started on Vanco but PNA was ruled out and this
was stopped after 3 days. Diastolic HF was also considered, but
TTE was unchanged from prior. Patient only required 3L 02
maximum and was quickly weaned to her home 02 is 2L. She felt
at baseline during the admission. [**Month (only) 116**] be secondary to
deconditioning. Also may be component to known pulmonary
fibrosis and moderate pulmonary HTN (but not changed from prior
per repeat TTE yesterday). Patient was continued on home dose
of prednisone 40mg PO daily. Patient weaned back to home O2 dose
at 2L NC. Hemodynamically stable.
.
# Atrial fibfillation: Patient had sinus tachycardia and then
A. fib with RVR on day of admission (has h/o a fib). Her TSH
was normal, no evidence of dehydration. Patient was started on
25 mg metoprolol TID and this was weaned up to 37.5 TID as her
blood pressure tolerated. Her CHADS score was 3. We spoke to
her oncologist who said there was no hematologic reason she
couldn't be anti-coagulated. However, she was not immediately
started on anti-coagulation because of her high risk for falls.
We also apoke with her PCP about following up this issue as an
outpatient after the patient has undergone rehab.
-f/u PCP appointment to address question of anti-coagulation
.
# S/p liver [**Month (only) **]: Liver [**Month (only) **] surgery aware patient
is in hospital. We continued her on her home tacrolimus and
checked levels daily.
.
#IPF: Patient requires 2-2.5L/NC at home, which was continued
while she was in the hospital. TTE showed no worsening of
pulmonary hypertension, so we continued her on her home dose of
Prednisone 40 mg daily.
.
#DM. On NPH and RISS: Patient was hyperglycemic into the
400s/500s while in the MICU. She was briefly on insulin gtt,
but discontinued as caused hypoglycemia. NPH uptitrated due to
high BS to 30/10 and then downtirated to 30/8 given early
morning hypoglycemia. Also continued on sliding scale.
.
#Dispo: PT saw the patient and recommended short term rehab.
Patient will follow up with her [**Month (only) 1326**] doctor, in particular
to follow up her tacrolimus.
Patient will see her heme/onc doctors who [**Name5 (PTitle) **] decide about
anticoagulation.
Medications on Admission:
Advair 250-50 [**Hospital1 **]
Glyburide 5 mg daily
Atrovent QID
Levothyroxine 75 mcg daily
Metformin 500 mg [**Hospital1 **]
Omeprazole 20 mg daily
Metoprolol 12.5 [**Hospital1 **]
Prednisone 40 mg daily
Tacrolimus (Prograf) 3 mg [**Hospital1 **]
Bactrim TIW
Aspirin 325
Colace
NPH 30 qam, 5 untis qpm
RISS
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. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours).
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
8. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days: last dose should be on [**2125-9-7**].
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Thirty (30) units Subcutaneous once a day: PLEASE GIVE
30units NPH qam, 8units qPM and SS as directed by sheet that is
in patient's chart.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**] [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis:
Urinary Tract Infection
DM2
Intersitial Pulmonary Fibrosis
Secondary Diagnosis:
Crypotogenic Cirrhosis s/p liver [**Location (un) **]
PTLD s/p R-CHOP
Discharge Condition:
stable
Discharge Instructions:
You came to the hospital with shortness of breath and lower
extremity swelling. We believe this was due to your pulmonary
fibrosis and to a urinary tract infection. We treated your
infection with levofloxacin and your breathing with steroids and
increased oxygen. We also found you to have atrial fibrillation
which we treated with metoprolol. Finally, your blood sugar was
high and we treated you with sliding scale insulin.
We made the following changes to your medications:
Started Levofloxacin for total 7 day course.
Changed NPH to 30 units qAM and 8 units qPM
Started Metoprolol 37.5 po tid
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2125-9-12**] 10:00
Please call and make an appointment with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 931**]
|
[
"5990",
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"4019",
"2449",
"V5867"
] |
Admission Date: [**2192-9-20**] Discharge Date: [**2192-10-1**]
Service: NEUROLOGY
BRIEF HISTORY AND PHYSICAL: This is a 79-year-old woman with
a past medical history of asthma, chronic obstructive
pulmonary disease, hypertension, ITP, depression, increased
cholesterol and status post old cerebrovascular accident who
presents with unresponsivity at home. She was brought to the
[**Hospital6 1708**]. Earlier this evening, she was
apparently in her usual state of health, but when the
daughter returned home from work, found her to be
unresponsive and basically responsive only to pain.
According to the daughter, her eyes were apparently initially
deviated to the left.
continued to be unresponsive there. No adventitious
movements were seen. The only other history that could be
obtained at that time was that she had apparently been
complaining of some headache for two to three days and had
had some nausea and vomiting at home on the day of admission,
but her general health and mentation had apparently been at
baseline. Apparently, at home, she is able to ambulate
around the house, although she is limited by the fact that
she is blind from longstanding glaucoma. Her mental status
is that she is apparently able to converse quite well with
her daughter, although she is Romanian speaking.
VITAL SIGNS: In the Emergency Room, she was noted to have a
heart rate of 110. Temperature was 99.8??????. Blood pressure
was 128/86. Respirations were 19 and pulse oximetry was 98%.
HEART: Regular rate and rhythm.
NECK: Supple without mass.
LUNGS: Clear to auscultation.
ABDOMEN: Benign.
NEUROLOGIC: She was unresponsive, but she was slated to
receive an MRI emergently upon admission to rule out stroke
and so she had received some sedation prior to me seeing her.
On cranial nerve exam, pupils were 4 mm, equal and poorly
reactive. The eyes were midline without deviation. GAG was
very weak. Cephalic reflex was intact. On motor exam, she
withdrew all four limbs to pain and would grimace. Reflexes
were brisk, but symmetric throughout.
LABORATORY EXAM ON ADMISSION: White count of 12.4, but
otherwise CBC was normal, except for a raised platelet count
of 773 which is chronic secondary to hydroxyurea treatment
for her ITP. Coagulation studies were normal. Chem-7 was
normal. Amylase was mildly elevated at 142. Urinalysis was
pending at that time.
ADMISSION MEDICATIONS:
1. Xalatan eyedrops
2. Univasc 7.5 q day
3. Levoxyl 0.025
4. Lipitor 10
5. Albuterol and Atrovent nebulizer and inhaler treatments
6. Wellbutrin 100
7. Prilosec 20
8. Singulair 10
9. Hydrochlorothiazide 25
10. Hydroxyurea 500
11. Aspirin daily
HOSPITAL COURSE: The patient was seen and accepted to the
Neurologic Intensive Care Unit. She was initially intubated
in the Emergency Room for airway protection. This was
quickly weaned off and she tolerated extubation well. Her
mental status continued to remain depressed, however and she
was not completely responsive for several days. She remained
in the Intensive Care Unit until [**9-24**] when she was felt to be
medically stable and thus be transferred to the floor. At
that time, she was able to awaken to voice, but did not speak
spontaneously and continued to have very low level of
communication. Per her daughter, this was definitely not at
her baseline and she was found to be fairly encephalopathic.
Her mental status would wax and wane somewhat and she was
intermittently oriented and then would become disoriented.
Communication was carried on by her daughter due to the
language barrier.
EEG was done to establish whether this initial event truly
was a seizure. No activity was seen, however she had loaded
on Dilantin in the Emergency Department and it was decided to
keep her on Dilantin, although at a lower level at the end of
the therapeutic range. She continued to have some low grade
fevers which were investigated. Chest was found to be clear.
Urinalysis was negative. She was seen by OT and PT who were
able to get her out of bed from time to time and it was found
that her functional status was actually better than what she
looked like in the bed, in that she was able to walk, albeit
slowly, and for short distances. In the bed, she would adopt
a strange adducted posture of her leg and so x-ray of the hip
was obtained to rule out fracture around the time of her
initial event, but this was negative.
Once her mental status has improved, a full physical exam was
carried out in the presence of her daughter to facilitate
communication. At that point in time, it seemed like her major
issues were that she still remained slightly decreased level of
consciousness and a little bit disoriented, as well as that she
had some right upper quadrant pain. Further work up was obtained
in the form of a right upper quadrant ultrasound which was
negative. Liver function tests were obtained which were also
negative. An abdominal CT scan was done which was negative. She
received a repeat MRI of the brain which showed no interval
change. MRI was done of the C-T and L-spine which showed
degenerative changes of the spine, but there was no acute
cord compression or cord edema.
She would also have episodes where she would complain of
shortness of breath which were felt to be related to
underlying chronic obstructive pulmonary disease.
While in house, the frequency of her nebulizer treatments was
increased with good outcome. It was always somewhat
questionable whether or not the underlying comorbidities
including the lung disease might not be the cause of a toxic
metabolic encephalopathy in this patient, as this was felt to
be a likely good explanation for her deficits, despite the
lack of a hard findings on diagnostic testing.
She slowly improved over the course of her hospitalization
and became more consistently oriented during this time also,
although she was still intermittently drowsy throughout the
day. However, in discussion with her daughter, it was felt
that medically she appeared stable and that she might benefit
more from rehabilitation facility at this point in time. It
was decided that she would go to [**Hospital 2716**] Rehabilitation
Facility which is close to the daughter's home for management
there.
DISCHARGE CONDITION: The patient was afebrile. She was
hemodynamically stable. She was respiratorily stable on
frequent nebulizer treatments. She was not able to walk
safely without assistance at this time.
DISCHARGE STATUS: She was to be discharged to rehabilitation
for further work on her functional goals.
DISCHARGE DIAGNOSES:
1. Altered mental status, questionable seizure versus toxic
metabolic encephalopathy due to multiple underlying illnesses
2. Asthma/chronic obstructive pulmonary disease
3. Hypertension
4. History of ITP
5. Depression
6. Hypercholesterolemia
7. Status post stroke
8. Blindness secondary to glaucoma
DISCHARGE MEDICATIONS:
1. Xalatan eyedrops
2. Univasc
3. Levoxyl
4. Lipitor
5. Albuterol
6. Atrovent
7. Wellbutrin
8. Prilosec
9. Singulair
10. Hydrochlorothiazide
11. Hydroxyurea
12. Aspirin at the doses that she was admitted on
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**]
Dictated By:[**Last Name (NamePattern1) 92112**]
MEDQUIST36
D: [**2192-10-1**] 10:12
T: [**2192-10-1**] 11:18
JOB#: [**Job Number 92113**]
|
[
"51881",
"2449",
"311"
] |
Admission Date: [**2129-3-17**] Discharge Date: [**2129-3-25**]
Date of Birth: [**2047-12-6**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
ERCP [**3-17**]
percutaneous chole tube [**3-22**]
History of Present Illness:
This is a 81 year-old male with a history of HTN and afib on
coumadin who was transfered from on [**Hospital3 **] Hospital due to
hypotension and choledocholititasis/cholangitis. Pt was admitted
[**2129-3-16**] at OSH due to a abd pain that started as substernal CP
[**7-22**] 9 hours after dinner on [**3-15**]. Pain improved on arrival to
ER. Also has nausea. Later in OSH started having more lower abd
pain that was different that presentation pain. CT showed a 7mm
in lower CBD stone with 11mm CBD. Pt became febrile after
admission with rigors and temp to 104.2 rectally. Pt became
hypotensive to 80s and was bolused with IVF with improvement to
100s. Earlier he also had some temporarty MS changes with a neg
head CT. He was given zosyn x 1. EKG vpaced at 60 bpm. PT was
transfered for ERCP.
.
OSH Labs: [**2129-3-16**] 3AM WBC 8.7, 75%N, Hb 14.5, Plt 222, Tbil
0.5, Alk 62, ALT 13, AST 16, Lipase 27, INR 2.8 initially, 10AM
INR 2.0 after 2 FFP.
.
On arrival to [**Name (NI) 153**] pt is having [**4-21**] RUQ pain. No nausea. No CP,
SOB, dysuria, diarrhea, constipation, vision changes, or HA. Pt
does report 2-3 weeks of a productive cough. Feels bloated, but
passing some gas.
Past Medical History:
Afib on coumadin
Pacemaker
HTN
GERD
SBO in [**2053**]
Ischemic cardiomyopathy, EF 60%
Modearate MR on last echo
appendectomy
Esaphageal stricture
Social History:
Lives with his wife on [**Location (un) **]. No tobacco, no drugs. Drinks 2
glasses of wine and a cocktail daily, no hx of withdrawal.
Family History:
NC
Physical Exam:
Vitals:97.9 137/79 60 17 96%RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM, clear OP
NECK: no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: some expiratory wheezes
ABD: Soft, mild distention, and tender in RUQ, +BS
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
Admission labs:
[**2129-3-17**] 07:41AM WBC-12.5* RBC-3.65* HGB-12.1* HCT-36.0*
MCV-99* MCH-33.2* MCHC-33.7 RDW-13.8
[**2129-3-17**] 07:41AM NEUTS-87.0* BANDS-0 LYMPHS-9.5* MONOS-3.3
EOS-0.1 BASOS-0.2
[**2129-3-17**] 07:41AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2129-3-17**] 07:41AM PT-19.7* PTT-29.9 INR(PT)-1.8*
[**2129-3-17**] 07:41AM ALT(SGPT)-21 AST(SGOT)-28 LD(LDH)-205
CK(CPK)-163 ALK PHOS-45 TOT BILI-1.6*
.
Discharge labs:
[**2129-3-25**] 06:10AM BLOOD PT-16.7* PTT-24.4 INR(PT)-1.5*
[**2129-3-25**] 06:10AM BLOOD Glucose-129* UreaN-9 Creat-0.9 Na-141
K-3.7 Cl-103 HCO3-30 AnGap-12
[**2129-3-23**] 06:05AM BLOOD ALT-59* AST-52* AlkPhos-84 TotBili-0.9
[**2129-3-24**] 06:05AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.9
.
[**3-17**] CXR: There is a single-lead pacer seen projecting over the
left chest. The heart size remains at the upper limit of normal.
No frank pulmonary edema. The lungs are grossly clear.
.
[**3-17**] ERCP: FINDINGS: Eight fluoroscopic spot views from an ERCP
are submitted for review. A filling defect is noted in the
distal common bile duct with minimal upstream dilatation of the
main common bile duct and consistent with a 7-mm stone.
Sphincterotomy was not performed due to elevated INR as per ERCP
note. A 7 cm x 10 French plastic biliary stent was placed in the
common bile duct for decompression.
IMPRESSION: Single 7-mm distal common bile duct stone.
Sphincterotomy was
not performed in the setting of elevated INR. Instead, a 7 cm x
10 French
plastic biliary stent was placed for decompression.
.
[**3-19**] CXR: Lateral view shows mild peribronchial infiltration, in
both lower lobes, new since [**3-17**]. Findings suggest
aspiration. Small right pleural effusion is new. Moderate
cardiomegaly is unchanged, and there is no interstitial edema or
particular vascular engorgement. Transvenous pacer lead is
continuous from the left pectoral pacemaker to floor of the
right ventricle.
.
[**3-22**] CT abd/pelvis:
IMPRESSION:
1. Extensive gallbladder wall edema and pericholecystic
stranding, consistent with cholecystitis. Additional 2-cm
gallstone at the base of the gallbladder, likely not within the
neck. No definite obstructive stone seen within the cystic duct
or common bile duct, though CT is not exquisitely sensitive for
detection of biliary calculi. Surgical/IR consult is
recommended.
2. Small bilateral pleural effusions and left lower lobe
consolidation which may represent pneumonia.
3. Incidentally noted moderate sliding hiatal hernia, large
fat-containing right spigelian hernia, and diverticulosis.
Findings were discussed with [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] at 3 p.m. and 4 p.m. on
[**2129-3-22**].
.
[**3-22**] IR report:
The risks and benefits of the procedure were explained to the
patient.
Written informed consent was obtained. Preprocedure timeout
confirmed the
identity of the patient and the procedure to be performed.
Patient was
prepped in the usual fashion. With aseptic technique, an 8
French [**Last Name (un) 2823**]
catheter was inserted into the gallbladder. Brownish material
was drained. Post-procedure instructions were documented on the
electronic patient record. No immediate post-procedure
complications were identified.
IMPRESSION:
Successful placement of percutaneous cholecystostomy tube.
Brief Hospital Course:
This is a 81 year-old male with a history of afib, CAD, ICM
(?EF) who presents with fevers, RUQ, hypotension, and dilated
CBD [**3-16**] to obstructing stone from [**Hospital3 **] hospital for ERCP.
.
# Choledocholithiasis, acute cholangitis, acute cholecystitis -
Patient had a obstructing stone causing fever, RUQ pain, and
hypotension at OSH. He improved with IVF and IV unasyn. His BP
soon stabilized after aggressive hydration. ERCP was performed
and it revealed a distal CBD measured approximately 10mm. A
single 7 mm round stone that was causing partial obstruction was
seen at the distal CBD. Otherwise, the proximal CBD, the CHD and
the intrahepatic biliary tree appeared unremarkable. A
sphincterotomy was not performed due to elevated INR. In setting
of acute cholangitis, A 7cm by 10FR Cotton-[**Doctor Last Name **] biliary plastic
stent was placed successfully for decompression.
AFter the plastic stent was placed he initially felt
symptomatically improved and demonstrated quick normalization of
his LFTs. He was able to tolerate Pos without difficulty. IV
unasyn was switched to PO augmentin. Blood cxs are negative to
date. He however he spiked to 101 on this regimen and cipro was
added for added coverage. He continued to have low-grade
temperatures on this regimen, so the antibiotics were broadened
to zosyn and vancomycin. Repeat LFTs were stable. The patient
had minimal RUQ pain, but no other symptoms. In discussion with
ERCP, a CT abd/pelvis was pursued on [**3-22**] given ongoing low-grade
temperatures. This demonstrated findings consistent with acute
cholecystitis.
Upon discussion with surgery (Dr. [**First Name (STitle) **] and ERCP (Dr. [**Last Name (STitle) 99779**],
a percutaneous chole tube placement for GB decompression was
felt to be the best option rather than CCY, given the extent of
inflammation and the [**Hospital 228**] medical co-morbidities (though no
active medical issues). He underwent placement of the tube by
IR the evening on [**3-22**] without any complications. He was
continued on zosyn and vancomycin, and had good output through
the tube. Fluid prelim cultures demonstrated GNR, but were
still PENDING upon discharge. Blood cultures drawn on [**3-22**] were
still NGTD, but PENDING upon discharge.
Once his WBC and fevers improved, he was switched to
cipro/flagyl to complete a 2-week course total. He will
follow-up with surgery (Dr. [**First Name (STitle) **] on [**4-15**] for removal of the tube
and discussion regarding CCY.
In addition, he will need a repeat ERCP in 1 month for stent
removal, sphincterotomy and stone extaction, when off of
coumadin.
.
# Atrial fibrillation - the patient was continued on metoprolol
for rate control. The coumadin was discontinued post-ERCP and
re-started, but discontinued again in preparation for the perc
chole tube on [**3-22**]. He was restarted on coumadin on [**3-24**] per
discussion with IR; this will need to be titrated up slowly to
achieve goal INR [**3-17**]. He will have repeat INR on [**3-27**] to help
with titration; to be followed by his cardiologist. His primary
cardiologist, Dr. [**Last Name (STitle) 20948**], was notified of the current
admission and agreed that bridging with heparin wasnot required
as patient had not had a prior embolic event.
.
# Acute on chronic sCHF - patient has an EF of 35% per
discussion with his primary cardiologist [**3-16**] ischemic
cardiomyopathy, and is maintained on metoprolol, lasx, and
ACE-I. He developed acute on chronic sCHF [**3-16**] IVF resuscitation
in the ICU; this was treated with IV lasix with good response.
His lisinopril was increased from 5 mg to 20 mg for good blood
pressure control, as he continued to be hypertensive on his
usual regimen (SBPs 160s).
.
# Productive cough: CXR with posssible retrocardiac abnl causing
sx, or could be acute bronchitis. A repeat CXR with PA and L was
done to eval further the possible infiltrate and it showed signs
of aspiration pneumonia. He was continued on unasyn and cipro
for it (on it anyway for acute cholangitis). A swallow eval was
done and it showed no evidence of aspiration pneumonia. He was
also treated with atrovent/albuterol for treatment of possible
COPD component. His O2 sats were maintained at 95% on RA and
did not desat with ambulation.
.
# GERD: continued on PPI.
.
# Dispo: discharged home with services to aid with tube
management on [**3-25**]. He has f/u with his PCP [**3-26**] (home visit),
INR check ([**3-27**]) to be faxed to his cardiologist, surgery f/u
with Dr. [**First Name (STitle) **] on [**4-15**], and ERCP f/u in 1 month to be scheduled
pending surgery appt on [**4-15**].
.
PENDING LABS AT THE TIME OF DISCHARGE:
1. [**3-22**] GALLBLADDER GLUID CULTURES (prelim GNR)
2. [**3-22**] BLOOD CULTURES (NGTD)
Medications on Admission:
Per cardiologist's list:
Metoprolol 25 mg [**Hospital1 **]
Coumadin 5 mg 5x/week, 2.5 mg 2x/week
Lasix 20 mg daily
Omeprazole 20 mg daily
Zocor 20 mg daily
Lisiniprol 5 mg daily
Atrovent
...............
Folic acid 1 mg Daily
Lisinopril 5 mg Daily
Lopressor 25 mg [**Hospital1 **]
Protonix 40 mg IV Daily
Thiamine 100 mg Daily
Zosyn 4.5 mg IV Q8hours
Albuterol Q2 PRN
Tylenol PRN
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
5. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO 5X/WEEK
([**Doctor First Name **],MO,TU,TH,FR).
8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(WE,SA).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-13**]
puffs Inhalation every six (6) hours.
Disp:*1 inhalor* Refills:*2*
11. Outpatient Lab Work
Draw PT, PTT on Sunday, [**3-27**] and fax results to Cardiologist Dr.
[**Last Name (STitle) 20948**] at [**Telephone/Fax (1) 99780**]. Coumadin will be titrated
accordingly.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Acute cholecystitis
Ascending cholangitis
Acute on chronic systolic Congestive heart failure
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted here for a condition called cholangitis -
infection of the bile duct due to an obstructing gall stone.
You were treated with iv fluids and antibiotics with improvement
of the infection. An endoscopic retrograde
cholangiopancreatiography (ERCP) was performed where a 7 mm
partially obstructing stone was found. This stone will be
removed in 1 months time (for a repeat ERCP) when you are off
the coumadin for at least a 5 day period. In the meantime, a
plastic stent was placed to aid in the passage of the bile
fluids and stone. You developed acute cholecystits , requiring
placement of a percutaneous tube. This tube should stay in until
you see Dr. [**First Name (STitle) **] on [**4-15**]. If there are any problems with the
tube, such as stopped drainage, please call her office or
Interventional Radiology at [**Telephone/Fax (1) 99781**].
MEDICATION RECONCILICATION:
1. START Cipro and flagyl for 10 more days (last day [**2129-4-4**]).
2. Increased lisinopril to 20 mg daily (from 5 mg)
3. Continue current warfarin dosing (5 mg 5x/week, 2.5 mg
2x/week) but this may change depending on INR test Sunday, [**3-27**]
Followup Instructions:
ERCP in 1 month at the Gastroenterology suite at [**Hospital1 18**]. Please
call [**Telephone/Fax (1) 463**] to confirm follow up scheduling.
.
Name: [**Last Name (LF) 353**],[**First Name3 (LF) 354**] E
Address: [**Doctor Last Name 99782**], [**Location (un) **],[**Numeric Identifier 58635**]
Phone: [**Telephone/Fax (1) 99783**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **] within
4-8 days. You will be called at home with the appointment. If
you have not heard from the office within 2 days or have any
questions, please call the number above.
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2129-4-15**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2129-3-26**]
|
[
"0389",
"41071",
"78552",
"5070",
"4280",
"99592",
"4019",
"42731",
"53081",
"V5861",
"4240"
] |
Admission Date: [**2182-7-23**] Discharge Date: [**2182-7-28**]
Date of Birth: [**2123-12-12**] Sex: M
Service: CSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
58 yo male schedulle for hernia repair preop work up showed
abnormal ECG. Cath bicuspid AV
Major Surgical or Invasive Procedure:
ascending aorta repai CABG X1
History of Present Illness:
PATINET ON PREOP HERNIA WORK UP FOUND TO HAVE ASCENDING AORTA
5.2 CM AND BYCUSPID AV EF 55% CT SURGERY CONSULTED FOR ASCENDING
AORTA REPAIR
Past Medical History:
Hypertension
Hyperlipidimia
oBESITY
Social History:
DENIES X3
Family History:
FATHER DIED OF LUNG CA
Physical Exam:
LUNGS CTA B BS
HEART RRR NM NG
ABD SOFT POS BS
CNS ORIENTD WOUND NO SX INFECTIONS STABLE MEDIASTINUM
Pertinent Results:
[**2182-7-23**]
10:16p
Source: Line-ALINE; GREEN TOP
3.9
Source: Line-ALINE
23.3
[**2182-7-23**]
6:24p
7.38 / 46 / 76 / 28 / 0
Type:Art
K:4.0 Glu:129 freeCa:1.22
O2Sat: 95
[**2182-7-23**]
4:47p
7.36 / 48 / 261 / 28 / 1
Type:Art
Na:135 K:4.4 Glu:93 freeCa:1.08
[**2182-7-23**]
4:41p
LINE: ALINE; GREEN TOP TUBE / SAMPLE SLIGHTLY HEMOLYZED
105 20
24 1.1
LINE: ALINE
102
25.0 D
LINE: ALINE
PT: 14.7 PTT: 37.9 INR: 1.4
Comments: Note New Normal Range As Of 12am Of [**2182-7-23**]
[**2182-7-23**]
4:01p
7.39 / 42 / 230 / 26 / 0
Type:Art; Intubated; Rate:8/ ; TV:800
Na:133 K:4.6 Hgb:8.5 CalcHCT:26 Glu:118 freeCa:1.04
Other Blood Gas:
Vent: Controlled
[**2182-7-23**]
3:27p
7.41 / 38 / 244 / 25 / 0
Type:Art; Intubated; Rate:8/
Na:129 K:5.1 Hgb:8.8 CalcHCT:26 Glu:122 freeCa:1.19
Other Blood Gas:
Vent: Controlled
[**2182-7-23**]
2:42p
7.50 / 29 / 181 / 23 / 0
Type:Art
K:5.4 Glu:128
[**2182-7-23**]
2:06p
7.25 / 63 / 330 / 29 / 0
Comments: Verified
Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art
K:5.1 Glu:121
[**2182-7-23**]
1:25p
7.29 / 64 / 422 / 32 / 2
Comments: Verified
Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art
K:4.4 Glu:119
[**2182-7-23**]
11:20a
7.42 / 45 / 298 / 30 / 4
Type:Art; Intubated; Rate:8/ ; TV:800
Na:136 K:4.7 Hgb:13.1 CalcHCT:39 Glu:110 freeCa:1.25
Other Blood Gas:
Vent: Controlled
Brief Hospital Course:
PATIENT WITH UNCOMPLICATED POST UP COURSE POST OP #2 WAS DC FROM
CRSU TO FLOOR. CHEST TUBES REMOVED WITH OUT COMPLICATIONS
AFEBRILE STABLE
Medications on Admission:
DYAZIDE, LIPITOR, ATENOLOL
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. 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*
9. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a
day for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) **] VNA
Discharge Diagnosis:
HTN
CAD
s/p CABG/repair of ascending aortic aneurysm
post op atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not swim or take a bath for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
do not lift anything heavier than 10 pounds for 1 month
do not drive for 1 month
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in [**12-14**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**12-14**] weeks
follow up with Dr. [**Last Name (STitle) 1290**] in [**2-14**] weeks
Completed by:[**2182-7-27**]
|
[
"9971",
"42731",
"41401",
"4019"
] |
Admission Date: [**2118-4-29**] Discharge Date: [**2118-5-28**]
Date of Birth: [**2044-8-28**] Sex: F
Service: SURGERY
Allergies:
Milk
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
GI Bleed
Hepatic Flexure Hemorrhage
Major Surgical or Invasive Procedure:
Extended Right Colectomy with Primary Anastomosis with
Incidental Appendectomy [**2118-4-29**]
Right IJV nontunnelled 3-Lumen CVC insertion
History of Present Illness:
This is a 73 year old female with dementia, tardive dyskinesia,
schizophrenia, diabetes, hypertension, congestive heart failure
and a history of a GI bleed that now presents with bright red
blood per rectum (BRBPR) x 24 hours. She was transfered here
from a nursing home and admitted to the MICU for hypotension.
She had 3 episodes of brisk BRBPR without hypotension or
tachycardia. (HR 80-90, SBP 130's). A tagged RBC scan showed
bleeding from the Hepatic Flexure. Angio subsequently was
performed demonstrating bleeding from [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of the middle
colic artery feeding the hepatic flexure. This was not embolized
due to the risk of gut ischemia. He was transfered back to the
ICU from Angio. Shortly thereafter, she dropped her pressure to
SBP 50's and became unresponsive. She was volume resusciatated
with 4 Units PRBCs and 3 liters of NS. Her BP responded to the
volume and was 127/47, HR 89.
Past Medical History:
adrenal insuff., hypothyroidism,
schizophrenia, tardive dyskinesia, TIA (on coumadin), DM, HTN,
CHF, cataracts, venous thrombosis, recent hx of vaginal bleeding
Social History:
2 Daughters, [**Name (NI) 9619**] and [**Name2 (NI) 66554**]
Physical Exam:
VS: 95.6, 88, 130/58, 17, 98% 3L
Gen: Verbal, responds to commands, denies abdominal apin,
confused.
Resp: CTA
CV: RRR
Abd: soft, distended, + BS, tympanic, nontender, no guarding
Rectum: gross blood per rectum
Ext: WNL
Pertinent Results:
Reason: embolize source of GI bleeding.
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with h/o dementia, schizophrenia, h/o GI bleed
with profuse bleeding per rectum. 3 point hct drop and positive
bleeding at hepatic flexure on tagged RBC scan.
REASON FOR THIS EXAMINATION:
embolize source of GI bleeding.
FINAL REPORT.
HISTORY: 73-year-old woman with GI bleed localize to hepatic
flexure on tagged red blood cell scan.
PHYSICIANS: [**First Name8 (NamePattern2) **] [**Doctor Last Name 26181**] and [**First Name8 (NamePattern2) **] [**Doctor Last Name 380**] with Dr. [**Last Name (STitle) 380**], the
attending radiologist, present and supervising during the
procedure.
PROCEDURE: Following written informed consent, the patient was
positioned supine on the angiography table. A preprocedure
timeout was performed to confirm patient, procedure, and site.
Standard sterile prep and drape of the right inguinal region.
Local anesthesia with 10 cc of 1% lidocaine subcutaneously.
Using palpatory and fluoroscopic guidance, a 19-gauge single
wall puncture of the right common femoral artery was performed.
A 0.035-inch guidewire was advanced through the needle into the
abdominal aorta using fluoroscopic guidance. Needle was
exchanged for a 5-French introducer sheath, which was attached
to continuous heparinized saline flush. Using a Cobra catheter,
the superior mesenteric artery was selected. Superior mesenteric
arteriography was performed to image the entire superior
mesenteric artery territory. Then, using a 3-French
microcatheter, the right colic and middle colic arteries were
selected and arteriograms were performed of the respective
arteries. In the middle colic artery, the microcatheter was
advanced into a branch of the middle colic artery supplying the
hepatic flexure (third order branch from the aorta) and
arteriography was performed.
Based on the findings of the diagnostic arteriograms, it was
determined that the patient would not be a suitable candidate
for embolization despite the fact that active extravasation of
contrast was seen. All wires, catheters and the sheaths were
removed and hemostasis was ensured with direct manual
compression. The patient was transferred back to the ICU and the
case was discussed with the ICU resident (Dr. [**Last Name (STitle) **] and surgery
resident (Dr. [**Last Name (STitle) 9768**].
There were no immediate complications.
FINDINGS: Superior mesenteric arteriography demonstrated patency
of the superior mesenteric artery and its major branches.
Initially, no active bleeding or potential source of bleeding
was identified.
Based on the findings of the nuclear medicine study, selective
arteriography of potential arterial feeders to the hepatic
flexure was performed. Right colic arteriography did not
demonstrate any active extravasation or potential source of
bleeding.
In the course of the procedure, the patient experienced
hematochezia and superior mesenteric arteriography was repeated
without the microcatheter. This demonstrated a source of active
extravasation from the area of the hepatic flexure. As the right
colic arteriography performed immediately previously had not
demonstrated any source of bleeding, middle colic arteriography
was performed. This confirmed that the bleeding arose from a
branch of the middle colic artery supplying the hepatic flexure.
The microcatheter was advanced distally in the middle colic
artery territory and arteriography was repeated, confirming that
this branch was supplying the source of bleeding. However, the
main artery-feeding vessel that was bleeding was too small to
accept the microcatheter. The position in the middle colic
artery branch where the microcatheter was, also supplied several
other small arterial feeders to other parts of the hepatic
flexure without collateral arterial supply from elsewhere in the
middle colic or right colic artery territories. As such, it was
determined that the patient was not a suitable candidate for
embolization, as a large segment of the hepatic flexure would
have undergone ischemia had embolization been performed.
Moderate sedation was provided by administering divided doses of
Versed (total 2 mg intravenously) and fentanyl (total of 50 mcg
intravenously) over a total interservice time of two hours
during which the patient's hemodynamic parameters were
continuously monitored by the Radiology nursing service. The
patient's heart rate was stable throughout the procedure at
approximately 90 beats per minute.
290 cc of Optiray radiographic contrast was utilized.
IMPRESSION: Active bleeding from a branch of the middle colic
artery. Embolization could not be safely performed.
GI BLEEDING STUDY
Reason: H/O GI BLEEDING CURRENTLY WITH LARGE BLOODY BOWEL
MOVEMENTS EVALUATE SOURCE OF BLEEDING THAT CAN BE EMBOLIZED
RADIOPHARMECEUTICAL DATA:
16.2 mCi Tc-[**Age over 90 **]m RBC;
HISTORY: 73 year old female with a history of a GI bleed. Now
large bloody BM.
INTERPRETATION: Following intravenous injection of autologous
red blood cells l
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen for 39 minutes
were obtained.
Blood flow images do not show any focal abnormality.
Dynamic blood pool images show brisk bleeding from the hepatic
flexure of the
colon.
IMPRESSION: There is brisk bleeding from a site near the hepatic
flexure of the
colon.
The team was notified of the results of the test at study
completion.
PORTABLE ABDOMEN [**2118-4-29**] 11:58 AM
PORTABLE ABDOMEN
Reason: EVAL NG TUBE PLACEMENT
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with schizophrenia (tardive dyskinesia), h/o
gi bleeds s/p NG tube placement.
REASON FOR THIS EXAMINATION:
evaluate for tube placement.
73-year-old schizophrenic woman with tardive dyskinesia now with
gastrointestinal bleeding. Referred for evaluation of
nasogastric tube placement.
ABDOMEN SINGLE SUPINE VIEW: There is a nasogastric tube which
crosses from the left upper abdomen over the spine to terminate
in the right mid abdomen, probably within the second portion of
the duodenum. There are no dilated loops of bowel or air fluid
levels. There is a normal bowel gas pattern. No definite free
intra-abdominal air is identified on this study, which does not
include the hemidiaphragms. Two ovoid shaped calcific densities
projecting over the right upper quadrant measuring 4 x 3 cm and
1.7 x 1.6 cm are probably large gallstones. The patient is
status post right hip arthroplasty.
IMPRESSION:
1) Nasogastric tube terminates within the second portion of the
duodenum.
2) Gallstones
Sinus rhythm at lower limits of normal range with sudden P-R
interval
prolongation and subsequent block and then restoration of sinus
rhythm.
Mild P-R interval prolongation. Low voltage, especially in the
limb leads.
Q waves in leads VI-V2. Since the previous tracing of [**2118-4-30**] the
episode
of A-V block is new. The Q wave in lead V2 is new. The Q-T
interval is shorter.
Clinical correlation is suggested.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
52 198 100 [**Telephone/Fax (2) 66555**] -7 36
CHEST (PORTABLE AP) [**2118-5-10**] 7:23 AM
CHEST (PORTABLE AP)
Reason: acute cardiopulm [process?
[**Hospital 93**] MEDICAL CONDITION:
post intubation, line placement
REASON FOR THIS EXAMINATION:
acute cardiopulm [process?
AP CHEST 7:37 [**Initials (NamePattern4) **] [**5-10**]:
HISTORY: Line placement.
IMPRESSION: AP chest compared to [**2118-5-7**]:
ET tube now in standard placement. Tip of the left subclavian
line projects over the SVC. Nasogastric tube passes into the
stomach and out of view. Moderate bilateral pleural effusions
and mediastinal vascular engorgement have increased. Bibasilar
lung opacification is probably atelectasis. Vascular congestion
and borderline interstitial edema are present in the upper
lungs. No pneumothorax.
CT ABDOMEN W/CONTRAST [**2118-5-12**] 10:27 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: Please assess for fluid collection/abscess, colitis, etc
Field of view: 48 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman s/p R hemicolectomy w/ hypothermia, WBC 24,
and abd pain
REASON FOR THIS EXAMINATION:
Please assess for fluid collection/abscess, colitis, etc
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: Patient with recent right hemicolectomy with
hypothermia, leukocytosis, abdominal pain.
STUDY: CT abdomen and pelvis with contrast.
TECHNIQUE: Axial multidetector CT was obtained of the abdomen
and pelvis after the administration of intravenous and oral
contrast.
No comparisons are available.
ABDOMEN CT WITH CONTRAST:
There are bilateral pleural effusions and compressive
atelectasis. Heart size is within normal limits. NG tube is in
expected position.
There is moderate amount of ascites, mostly within the upper
abdomen. _____ two large gallstones are calcified within the
gallbladder, though no gallbladder wall, separate from the
stones is seen and the possibility of porcelain gallbladder
exists. There is fluid within the gallbladder fossa. No
intrahepatic or extrahepatic biliary ductal dilatation. Pancreas
is normal in appearance. Bilateral adrenal glands, and kidneys
are normal in appearance. The bowel within the abdomen is within
normal limits with the ileocolonic anastomosis having a normal
appearance. No small bowel dilatation. No lymphadenopathy.
CT PELVIS WITH CONTRAST:
There is free fluid within the pelvis. No loculated collections
to suggest abscess. Bowel within the pelvis is normal in
appearance, though there is a fair amount of fluid within the
colon, which would be consistent with diarrhea. Below the
patient's midline skin incision, is a small mildly heterogeneous
fluid collection without abnormal enhancement likely
representing a seroma. There is sigmoid diverticula without
evidence of diverticulitis. Much of the pelvis is obscured by
streak artifact from the right hip prosthesis. Foley catheter is
within the urinary bladder.
BONE WINDOWS:
The L5 vertebral body is mildly collapsed but markedly
sclerotic, raising the question of a sclerotic metastasis.
Superior aspect of the L4 vertebral body is sclerotic, but this
may relate to disc generation. The L1 vertebral body is markedly
collapsed and sclerotic.
IMPRESSION:
1. No evidence for abscess and the patient is status post right
hemicolectomy with normal-appearing anastomosis and no bowel
obstruction. There is free ascites.
2. Likely large gallstones, though separate wall of the
gallbladder cannot be seen and porcelain gallbladder is a
consideration. The ascites limit the specificity for the
pericholecystic fluid. If there is clinical concern for acute
cholecystitis, ultrasound could be performed.
3. L1 and L5 vertebral compression fractures with more sclerosis
within L5 than expected for the compression. Bone scan could be
performed as clinically indicated.
OBJECT: GASTROINTESTINAL BLEED. RULE OUT SEIZURE.
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
FINDINGS:
ABNORMALITY #1: Throughout the recording the background rhythm
was slow
and disorganized, typically remaining in the maximum of [**4-2**] Hz
in most
regions.
ABNORMALITY #2: There were additional bursts of delta slowing
seen
primarily in the left parsagittal and parietal area or left
fronto-temporal region and an additional area of focal slowing
in the
right fronto-central region. By video, the patient had frequent
head
movements, likely to lead artifact.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background throughout and due to the additional focal slowing
primarily
in the left parasagittal and parietal area. The background
abnormalities indicate a widespread encephalopathy. Medications
are a
common cause. The focal slowing raises concern for an additional
subcortical dysfunction especially in the left hemisphere, but
the
tracing cannot specify the nature of that disturbance. Some of
the
slowing could have represented head movement artifact, but at
least some
of the slowing appeared to indicate a true focal abnormality.
Nevertheless, there were no epileptiform features throughout the
recording.
Brief Hospital Course:
This is a 73 year old female admitted on [**2118-4-29**] with BRBPR and
taken to the OR on [**2118-4-29**] for a Right Colectomy. She remained
intubated post-operatively for acidosis. On [**5-25**], she was made
comfort care measures only. This happened to due the wishes of
the family after a long discusion on [**5-23**]. We then consulted Dr.
[**Last Name (STitle) 4261**] on pallative care.
#Respiratory
She self-extubated on POD 2. She was stable initially after
surgery. She passed a speech and swallow test and was allowed to
start on sips. On [**2118-5-6**], she developed respiratory distress.
She was hypotensive, oliguric and somnolent and required
intubation, sedation, swanned, a-lined in unit. It was presumed
urospesis from a UTI. She was started on broad spectrum
antibiotics (Vanco/Levo/Flagyl). On [**5-23**], she became comfort
measures only so she was extubated and all her antibiotics were
discontinued. She remained stable for a few days then went into
respiratory failure which led to cardiovascular arrest.
#Nutrition
She was started on TPN for nutritional support while intubated.
POD 10 ([**2118-5-10**]) a Dobhoff was placed for enteral feeds. Tube
Feedings were changed to Promote c Fiber at a goal 80cc/hr. On
[**5-23**], she became comfort measures therefore her tube feeds were
discontinued.
#Cardiovascular
On [**5-15**], she was still having apneic episodes and bradycardic to
30s with Mobitz type I morphology. Cardiology was consulted. The
patient continued to have a prolonged intubation and poor mental
status. AV Nodal agents were avoided, pressure was stable and
The Mobitz I was seen as a benign rhythm and not further
cardiology management was needed.
Pertinent MICRO: [**5-23**] MRSA/VRE P; [**5-21**] UCx: yeast;
SputCx-Providenci stuartii (cefipime), UA-no bact, [**5-7**] WBC, mod
yeast (fluc),[**5-6**] SputCx GNR (GS GPC/GNR); [**5-6**] UCx GNR
Pertinent RADS: [**5-13**] Head Xray: metallic density along medial
wall of LLat orbit
[**5-12**] Head CT-unchanged appearance of brain w/dolichocephaly,
chronic small vessel ischemia/atrophy; [**5-10**] B moderate effs,pulm
edema;
#GI Bleed
Her HCT was trending down over 10 days from (40's-> 30's-> 20's)
and on [**2118-5-20**] was 21.2 with guaiac positive maroon stool. She
was tranfused 2 Units and her HCT responded to 30.7. A NGT
lavage was done wiht clear return and tube feedings were held. A
scope on [**5-20**] showed EGD -gastritis, duodenitis, no source of
bleeding. A colonoscopy was held since stable HCT and a clean
prep.
#Neurology
Neuro exam reveals eye deviation in and downward. Motor exam
with upper extremity flaccidity right more than left and moving
left side more. Only able to elicit reflexes in right upper
extremity. Findings might be more suggestive of LMN lesion (i.e
previous neuropathy or ICU polyneuropathy), but given somewhat
preserved reflexes and along with apneic episodes, we need to
consider basilar insufficiency. Also need to rule out thalamic
infarct given eye deviation.
Updates:
[**5-11**]: Head CT with odd head shape and skull base irregularities,
with diffuse perventricular white matter disease. Needs MRI to
assess posterior fossa.
[**5-13**]: Can't get MRI because she has metal artifact signal in
left orbit.
[**5-16**]: Weaning to extubate. Having episodes of bilateral shoulder
shaking so checking EEG..
[**5-19**]: EEG with left>right slowing. No epileptiform features.
Shoulder and chest wall movements not epileptic. Unfortunately
not much more for us to add so signing off.
#Psychiatry Consult
Tardive Dyskinesia is irreversible, so Haldol 1mg q4 hours for
agitation.
She had a very difficult, complicated post-op course. It has
been complicated by urosepsis, hypotension, somnolence and
required reintubation. In total she has received 10 units of
PRBCs. She had down treading hct which became stable in the last
week. She became comfort care only on the [**5-23**] so we
discontinued all her medications and IV fluids and extubated
her. She was only on morphine tritated to comfort. She then
developed respiratory failure which lead to cardiovascular
arrest.
Medications on Admission:
Nursing Home Meds:
coumadin
Actos 30 mg qd
paroxetine 10 mg qd
levothyroxine 25 mcg qd
metformin 500 mg [**Hospital1 **]
hydrocortisone 20 mg [**Hospital1 **]
MOM prn
kaopectate
tylenol prn
guiafenisis prn
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiovascular arrest
Discharge Condition:
Expired
Completed by:[**2118-5-28**]
|
[
"4280",
"0389",
"51881",
"5849",
"5990",
"2851",
"99592",
"V5861",
"4019",
"25000",
"2449"
] |
Admission Date: [**2182-8-9**] Discharge Date: [**2182-8-21**]
Date of Birth: [**2130-8-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fentanyl
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
intubation, extubation
History of Present Illness:
Ms. [**Known lastname **] is a 51 yo woman with PMH significant for MELD 20
EtOH cirrhosis c/b esophageal varices, encephalopathy, and
ascites, EtOH abuse with history of DTs, and asthma admitted to
the MICU for hematemesis. The patient woke this morning with and
found blood coming from her mouth. The patient also notes
diarrhea, abdominal pain and headache. The patient was found in
the field to be confused with a bottle of alcohol and unable to
provide a history. She was transferred to [**Hospital1 18**] ED. Of note, the
patient was admitted to [**Hospital1 18**] from [**Date range (1) 31378**] for shortness
of breath secondary to a large pleural effusion, EtOH withdrawl,
alchohol hepatitis, and acute on chronic pancreatitis.
.
In the [**Hospital1 18**] ED, VS 137/77, HR 92-100, RR 20-30, 99% on face
mask. The patient was intubated for airway protection. An OGT
revealed 5cc of bright red blood and the patient was guaiac
positive. Octreotide and PPI were started. Hepatology was
consulted. Pt was given vanco and pip/tazo over concern for
right lung field white out and ceftriaxone for SBP prophylaxis.
The patient was then transferred to the MICU for further
management.
.
ROS: Unable to obtain.
Past Medical History:
1. Alcoholic cirrhosis: Diagnosed in [**2178**], course has been
compicated by esophageal varices, ascites, and hepatic
encephalopathy
2. Chronic pancreatitis
3. Alcohol abuse: h/o DTs
4. Asthma: Patient has required intubation on prior
hospitalizations
5. Uterine and cervical cancer: s/p hysterectomy in [**2166**]
Social History:
Patient lives alone. She has one son who lives in [**State 15946**] and is
involved with legal troubles. She had a significant male partner
for 8 years who died sudden 3 years ago with ICH. As a result,
this has been extremely difficult for her and her alcohol
consumption has continued to increase.
Usually drinks mixed drinks with vodka - unable to say how many
per day, but at least 4. Smokes 1/2ppd for many years. Denies
IVDU
Family History:
Mother- died in 70s from GI bleeding [**1-21**] alcohol abuse
Father- died in 70s from some type of cancer, also had alcohol
abuse
Physical Exam:
vs: temp 99.3 F, BP 149/82, HR 120 (sinus tachy on monitor), O2
sat 94-100% on 4 L NC
Gen: lethargic, easily arousable by verbal stimuli, Ox3, +
asterixis
HEENT: Scleral icterus, small pupils 2mm/PERRLA, intact EOM
CV: Nl S1+S2, no m/r/g
Pulm: Decreased breath sounds on right base, dullness to
percusion, + upper airway and upper lung fields with exp wheeze,
Rales bil
Abd: patient guarding during abdominal exam, abdomen distended,
tender to palpation on epigastric area, +BS x4,
Ext: Trace edema bilaterally.
Neuro: lethargic and resposive to verbal stimuli, CNII-XII
intact, able to follow commands
Skin: Spider angioma
GU: foley to BSD with dark yellowish/brownish urine
Pertinent Results:
[**2182-8-9**] 10:59PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->1.050*
[**2182-8-9**] 10:59PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG
[**2182-8-9**] 10:59PM URINE RBC-7* WBC-12* BACTERIA-NONE YEAST-NONE
EPI-0
[**2182-8-9**] 09:20PM TYPE-ART TEMP-35.8 PO2-301* PCO2-44 PH-7.31*
TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED
[**2182-8-9**] 09:04PM GLUCOSE-127* UREA N-5* CREAT-0.4 SODIUM-138
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-21* ANION GAP-16
[**2182-8-9**] 09:04PM CALCIUM-7.6* PHOSPHATE-3.8 MAGNESIUM-2.0
[**2182-8-9**] 09:04PM WBC-10.1 RBC-2.73* HGB-9.4* HCT-29.8*
MCV-109* MCH-34.6* MCHC-31.7 RDW-19.6*
[**2182-8-9**] 04:23PM LACTATE-2.4*
[**2182-8-9**] 04:15PM ALT(SGPT)-70* AST(SGOT)-176* ALK PHOS-112 TOT
BILI-9.5* DIR BILI-4.7* INDIR BIL-4.8
[**2182-8-9**] 04:15PM LIPASE-136*
[**2182-8-9**] 04:15PM ALBUMIN-3.3* CALCIUM-8.4 PHOSPHATE-3.7
MAGNESIUM-2.3
[**2182-8-9**] 04:15PM NEUTS-59.9 LYMPHS-25.7 MONOS-8.6 EOS-5.1*
BASOS-0.7
Micro:
URINE CULTURE (Final [**2182-8-9**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
WARNING! This isolate is an extended-spectrum beta-lactamase
(ESBL) producer and should be considered resistant to all
penicillins, cephalosporins, and aztreonam. Consider Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ <=1 S
.
Studies:
CTH: no significant change from prior study or acute process.
.
Chest Xray: Large right sided pleural effusion compared to the
xray from recent admission that had small pleural effusion
on....
2nd x-ray; ET Tube in place.
.
CT Abdomen/pelvis [**8-4**]:
1. Diffuse thickening of mucosal folds throughout the jejunum.
Although thickened folds may be seen from portal hypertension,
usually the right colon shows the most prominent fold thickening
in that scenario. Findings may accordingly be more consistent
with an infectious or inflammatory process. Hemorrhage and
ischemia are felt less likely particularly given selective
jejunal involvement, but please correlate with INR, platelets
and recent clinical course. The major mesenteric arteries and
veins are not optimally assessed, but appear patent. Please
correlate with clinical findings.
2. Known cirrhosis of the liver with small amount of free
peritoneal fluid.
3. Right moderate pleural effusion.
.
US abdomen [**2182-8-1**]
Limited Doppler study due to bowel gas establishing patent left
and right portal veins with a new hepatofugal flow.
Cirrhotic-appearing liver with minimal ascites and right pleural
effusion as well as borderline splenomegaly.
.
EGD [**3-28**]:
4 cords of grade 1 varices at the lower third of the esophagus
Erythema, congestion and mosaic appearance in the whole stomach
compatible with portal hypertensive gastropathy
Abnormal mucosa in the duodenum. 2 small nonbleeding ulcers were
seen
in duodenum.
.
EGD [**2-25**]:
Mosaic pattern; erythematous in the fundus and body compatible
with congestive gastropathy (biopsy)
Ulcers in the duodenal bulb
Polyps in the duodenal bulb and second portion of duodenum
(biopsy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Ms. [**Known lastname **] is a 51 yo woman with PMH significant EtOH
cirrhosis c/b esophageal varices, encephalopathy, and ascites,
hepato hydrothorax, EtOH abuse, asthma admitted for questionable
hematemesis and was found to have E.coli ESBL UTI transferred
out from MICU on [**2182-8-10**] now with improved mental status.
.
ALCOHOL HEPATITIS/Cirrhosis: Given AST:ALT ratio >2:1, this was
likely secondary to EtOH cirrhosis. Discriminant function of
decreased from 60s->49->51. Her LFTs and t bili trended down to
ALT/AST 41/88 (from 60/155 on admission) and tbili 6.7 (from
12.2 on admission). She was continued lactulose and ursodiol,
and started rifaxamin [**8-14**]. She was also restarted on
diuretics, spirolactone 100mg and lasix 40mg Qday on [**8-15**]. She
was on SBP prophylaxis with meropenem which was transitioned to
nitrofurantoin ([**8-19**]). At time of discharge her MELD was 20.
.
CHANGE MS: Pt was lethargic in the first 3 days of admission.
She was on CIWA protocol and on dilaudid IV, both were d/ced
given that patient was lethargic. As per addiction nurse who has
been following her she was hospitalized for 9 days up to [**8-5**]
and only had 3 days of drinking prior to readmission on [**8-9**], so
less likely to be DTs. Mental status overall improved after
stopping ativan and dilaudid. During her admission, she was
emotionally distressed, crying and threatening to leave AMA; she
was seen by social work on this admission. Her mood improved
over hospitalization. Options for alcohol rehabilitation were
discussed, however the patient ultimately stated she wanted to
go home to her sisters with plans for rehab in the future.
.
CHRONIC PAIN: Pt has been taking narcotics for several years.
There is a note on OMR that pt had been getting narcotics from
multiple providers. She was started on low dose methadone 5mg
[**Hospital1 **] and titrated up to 10mg which alleviated the pain but made
her feel nauseous. Pain control was an issue given that the
patient has a history of narcotic seeking. She was transitioned
to oxycodone on discharge, given the side effects of methadone.
.
ANEMIA/Hematemesis: This was related to gastritis in the setting
alcohol intake as recent EGD which showed gastritis and small
ulcers. Hct 33->26.3 in the setting of hydration. Hct trended
down from 23->19.9 ([**8-15**]) and patient received 2 units of
PRBCs. Her PPI was changed to [**Hospital1 **], she did not experience any
further bleeds, and her hct remained stable at 30.
.
Wheezing/Pleural effusion: Patient intubated ([**8-10**]) for airway
protection in setting of hematemesis. Patient received vanco and
pip/tazo for aspiration/nosocomial pneumonia at admission which
was then changed to meropenem for ESBL UTI. She also has large
pleural effusion on right lower lobe and has history of asthma.
Patient with diminished LS on right base, exp wheezes and
prolonged exp phase. She had a right lung thorocentesis on [**8-12**]
with a total of 2.5 L of fluid removed. She was on prednisone
for her lung issues and was tapered from 20-> 15-> 10 ->5 , and
finished last dose on day of discharge. Her respiratory status
has overall improved, no wheezing, diminished BS at base and
crackles on the right. This also improved with prednisone taper,
nebulizers, and diurectics (lasix 40mg and spirolactone 100mg)
which were restarted on [**9-14**]. Her meropenem was transitioned
to nitrofurantoin for total of 14 days.
.
UTI: urine culture from [**2182-8-5**] demonstrated ESBL E.coli. Final
sensitivity panel which shows resistant to amp, unasyn,
cefalosporins and senstive to gent, meropenem, nitrofurantoin,
zozyn , trobamycin. Patient was started on Meropenem ([**8-10**]) and
was transitioned to nitrofurantoin ([**8-19**]).
.
Pancreatitis: Patient with acute on chronic pancreatitis during
last admission in setting of EtOH abuse, c/o epigastric pain.
Pain was started on methadone and switched to oxycodone (see
above). She was restarted on pacreatic enzymes on [**8-14**].
.
EtOH abuse: Pt with history of DTs, last drink on day of
admission. She was without drinking for 9 days since she was
hospitalized up to [**8-5**] and was readmitted on [**8-9**]. Pt initally
stated that she would like to go to rehabilitation facility, did
not want hospice care. The severity of her clinical condition
was discussed with her and she was told of the morbidity
associated with continued drinking. She verbalized
understanding. She also has plans to stay with her sister for
while until she is more stable. She was continued on Thiamine,
folate, MVI
.
HYPONATREMIA: Patient had her Na trended down during this
admission. This was due cirrhosis and possibly pre-renal causes
given that she had decreased PO intake. She was given albumin
and encouraged to have food and fluids. Na is 132 at time of
discharge.
.
Medications on Admission:
Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID
Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
Pantoprazole 40 mg Tablet daily
Thiamine HCl 100 mg Tablet daily
Folate 1 mg daily
MVI daily
Ursodiol 300 mg daily
Tramadol 50 mg po Q12H
Albuterol MDI Q4H prn
Nadolol 20 mg daily
Bactrim 1 tab po bid x7 days
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*qs ML(s)* Refills:*2*
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*3*
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 12 days: Until [**9-2**].
Disp:*24 Capsule(s)* Refills:*0*
13. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*30 Cap(s)* Refills:*2*
14. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Alcoholic Hepatitis
Hepatic Hydrothorax
Urinary tract infection
Secondary:
Alcoholism
Alcoholic liver disease
Chronic pain
Chronic pancreatitis
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with alcoholic hepatitis, which is
inflammation of your liver secondary to alcohol use. You have
improved while in the hospital, but the condition can be fatal
if you continue to drink alcohol. During your hospitalization
you also were found to have fluid around your lung secondary to
your liver disease, and a urinary tract infection. We tried to
remove the fluid, but it continues to come back. This process
is also related to continued alcohol intake. Your urinary
infection was treated with antibiotics.
.
We made the following changes to your medications:
1. Continue your ursodiol, folate, thiamine, lactulose,
albuterol, fluticasone-salmeterol, and nadolol
2. Stop pantoprazole, and start omeprazole 40mg twice daily for
your stomach
3. Start rifaximin 400mg three times a day
4. Start Furosemide 40mg daily and spironolactone 200mg daily to
reduce the fluid in your lungs
5. Start magnesium supplements for your leg cramps
6. Start Macrobid 100mg twice a day for 12 days for your UTI
.
Please consider alcoholic rehabilitation on discharge. If you
continue to drink alcohol, you liver disease may progress to a
fatal condition.
.
If you develop any further episode of blood in your vomit,
confusion, or any other concerning symptoms, please return to
the emergency department to be evaluated.
Followup Instructions:
Please follow up with your PCP on discharge.
Completed by:[**2182-8-23**]
|
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"5990",
"2761",
"49390",
"3051"
] |
Admission Date: [**2135-1-6**] Discharge Date: [**2135-3-1**]
Date of Birth: [**2055-1-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
malaise
Major Surgical or Invasive Procedure:
bone marrow biopsy
intrathecal chemo-therapy
pheresis line placement
Ommaya IT Port placement
History of Present Illness:
79 year old gentleman from transferred from [**Hospital 1562**] Hospital
with a new diagnosis of ALL. States previously with only
surgeries and mild GERD, but had developed severe, progressive
fatigue and malaise for about one week. He denies any other
localizing symptoms such as fever, sore throat, cough, chills,
myalgias, arthralgias, dyspnea, or chest pain. He was given
empiric antibiotics without any change in his progressive
fatigue by his primary care earlier this week. Given the lack of
improvement he presented to an OSH ED earlier today. ED labs
notable for profound leukocytosis with WBC 140.1k, 90% blasts,
6% PMNs, 2%bands, 2% lymphs, Hgb 11.6, Hct 34%, Plts 89k. He was
also quite hypokalemic with potassium of 2.0 (repleted with 40
mEq of KCl via IV fluids) and had a creatinine of 2.67 (unknown
baseline). A nasal swab was negative for influenza A and B. He
was transferred to the [**Hospital1 18**] ED for presumed acute leukemia.
In the ED the patient's vital signs were initially temp 97.5, hr
80, bp 136/65, rr 15, and breathing 94% on room air. CXR showing
possible left side pneumonia and U/A showed many bacteria.
Past Medical History:
s/p CCY
s/p Hernia repair
h/o perforated gastric ulcer with surgical management
peptic ulcer disease
Social History:
Smoked a pipe infrequently many years ago. Denies alcohol or
drug
use. Lives with his daughter and son-in-law on [**Hospital3 **]. Stays
active with hunting and fishing. Built his own house out of
logs.
Family History:
No known malignancies; daughter has had recent "heart trouble".
Physical Exam:
VS: 99.1, 110/58, 78, 22, 98/RA
GEN: The patient is in no distress and appears comfortable
SKIN: No rashes or skin changes noted
HEENT: No JVD, neck supple
CHEST: Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES: No peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact.
Pertinent Results:
LABS ON ADMISSION:
[**2135-1-6**] 08:40PM BLOOD WBC-138.3* RBC-3.71* Hgb-10.8* Hct-31.6*
MCV-85 MCH-29.3 MCHC-34.3 RDW-17.0* Plt Ct-89*
[**2135-1-6**] 08:40PM BLOOD Neuts-9* Bands-0 Lymphs-5* Monos-1* Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0 Blasts-84* Other-0
[**2135-1-6**] 08:40PM BLOOD PT-19.2* PTT-30.5 INR(PT)-1.8*
[**2135-1-6**] 08:40PM BLOOD Fibrino-113*
[**2135-1-7**] 01:29AM BLOOD FDP-80-160*
[**2135-1-13**] 12:00AM BLOOD Gran Ct-434*
[**2135-1-6**] 08:40PM BLOOD Glucose-128* UreaN-23* Creat-2.9* Na-143
K-2.6* Cl-106 HCO3-23 AnGap-17
[**2135-1-6**] 08:40PM BLOOD ALT-107* AST-115* LD(LDH)-2975*
CK(CPK)-37* AlkPhos-115 TotBili-0.5
[**2135-1-6**] 08:40PM BLOOD Lipase-16
[**2135-1-6**] 08:40PM BLOOD cTropnT-0.03* proBNP-748
[**2135-1-6**] 08:40PM BLOOD Calcium-8.3* Phos-3.6 Mg-1.7
UricAcd-22.7*
[**2135-1-6**] 09:02PM BLOOD D-Dimer-GREATER TH
[**2135-1-10**] 04:21AM BLOOD Hapto-100
[**2135-1-7**] 05:41AM BLOOD freeCa-0.85*
KEY LABS ACROSS ADMISSION:
COMPLETE BLOOD COUNTS
[**2135-1-6**] 08:40PM BLOOD WBC-138.3* RBC-3.71* Hgb-10.8* Hct-31.6*
MCV-85 MCH-29.3 MCHC-34.3 RDW-17.0* Plt Ct-89*
[**2135-1-7**] 07:50AM BLOOD WBC-47.3* RBC-3.19* Hgb-9.4* Hct-27.3*
MCV-86 MCH-29.5 MCHC-34.4 RDW-16.2* Plt Ct-46*
[**2135-1-10**] 04:21AM BLOOD WBC-2.4* RBC-2.48* Hgb-7.4* Hct-21.8*
MCV-88 MCH-29.8 MCHC-33.8 RDW-15.9* Plt Ct-17*
[**2135-1-13**] 08:00PM BLOOD WBC-0.8* RBC-2.50* Hgb-7.3* Hct-21.5*
MCV-86 MCH-29.3 MCHC-34.1 RDW-15.5 Plt Ct-67*
[**2135-1-22**] 12:00AM BLOOD WBC-0.2* RBC-2.99* Hgb-9.2* Hct-25.3*
MCV-85 MCH-30.8 MCHC-36.3* RDW-14.2 Plt Ct-11*
[**2135-2-3**] 12:45AM BLOOD WBC-0.1* RBC-3.05* Hgb-9.1* Hct-25.8*
MCV-84 MCH-29.9 MCHC-35.4* RDW-13.4 Plt Ct-7*#
[**2135-2-6**] 12:20AM BLOOD WBC-0.3* RBC-3.12* Hgb-9.1* Hct-26.0*
MCV-84 MCH-29.3 MCHC-35.1* RDW-13.4 Plt Ct-23*
[**2135-2-8**] 12:00AM BLOOD WBC-0.3* RBC-3.17* Hgb-9.4* Hct-26.5*
MCV-84 MCH-29.8 MCHC-35.5* RDW-13.7 Plt Ct-31*
[**2135-2-11**] 12:00AM BLOOD WBC-1.0*# RBC-2.99* Hgb-8.7* Hct-25.3*
MCV-85 MCH-29.1 MCHC-34.4 RDW-14.3 Plt Ct-91*
[**2135-2-14**] 12:30AM BLOOD WBC-2.6*# RBC-3.29* Hgb-9.4* Hct-27.9*
MCV-85 MCH-28.5 MCHC-33.7 RDW-15.0 Plt Ct-129*
[**2135-2-17**] 12:28AM BLOOD WBC-4.0 RBC-2.97* Hgb-9.0* Hct-25.8*
MCV-87 MCH-30.2 MCHC-34.7 RDW-15.6* Plt Ct-155
[**2135-2-18**] 12:00AM BLOOD WBC-3.0* RBC-3.04* Hgb-9.3* Hct-26.7*
MCV-88 MCH-30.5 MCHC-34.7 RDW-16.1* Plt Ct-164
[**2135-2-19**] 12:00AM BLOOD WBC-2.6* RBC-3.03* Hgb-9.3* Hct-26.4*
MCV-87 MCH-30.6 MCHC-35.1* RDW-16.5* Plt Ct-159
[**2135-2-20**] 12:00AM BLOOD WBC-3.4* RBC-3.05* Hgb-9.5* Hct-27.1*
MCV-89 MCH-31.0 MCHC-34.8 RDW-16.6* Plt Ct-158
[**2135-2-21**] 12:00AM BLOOD WBC-5.3# RBC-2.86* Hgb-9.0* Hct-25.3*
MCV-88 MCH-31.4 MCHC-35.5* RDW-16.9* Plt Ct-138*
[**2135-2-22**] 12:40AM BLOOD WBC-8.7# RBC-3.05* Hgb-9.3* Hct-27.2*
MCV-89 MCH-30.6 MCHC-34.4 RDW-17.1* Plt Ct-129*
[**2135-2-23**] 12:15AM BLOOD WBC-5.0 RBC-2.52* Hgb-7.8* Hct-22.7*
MCV-90 MCH-30.9 MCHC-34.3 RDW-17.5* Plt Ct-117*
[**2135-2-25**] 12:00AM BLOOD WBC-3.1* RBC-3.09* Hgb-9.5* Hct-26.9*
MCV-87 MCH-30.6 MCHC-35.1* RDW-17.5* Plt Ct-143*
[**2135-2-27**] 12:05AM BLOOD WBC-3.3* RBC-2.87* Hgb-8.9* Hct-25.6*
MCV-89 MCH-30.8 MCHC-34.6 RDW-17.1* Plt Ct-122*
[**2135-2-28**] 12:05AM BLOOD WBC-5.5# RBC-3.08* Hgb-9.5* Hct-27.0*
MCV-88 MCH-30.9 MCHC-35.3* RDW-17.2* Plt Ct-120*
[**2135-3-1**] 01:10AM BLOOD WBC-3.8* RBC-2.96* Hgb-9.2* Hct-26.6*
MCV-90 MCH-31.2 MCHC-34.7 RDW-17.5* Plt Ct-102*
MICROBIOLOGY:
All Urine and Blood Cultures were negative or NGTD at the time
of discharge.
LABS ON DISCHARGE:
130 102 14
-----------< 109
3.4 26 0.9
9.2
3.8 > ---- < 102
26.6
anc: 2770
inr: 1.3
ldh: 178
IMAGING:
CHEST RADIOGRAPHS:
[**2135-1-6**] CXR: Subtle opacity at the left lung base is concerning
for developing infection.
[**2135-1-31**]: Interval increase in small left pleural effusion. No
focal consolidation.
[**2135-2-27**]: Patchy opacities at the right lung base and in left
retrocardiac
area appear similar to the recent study, and may reflect very
slowly resolving pneumonia considering appearance on prior CTA
of the chest of [**2135-2-10**]. An area of adjacent linear
atelectasis at right base has slightly improved. No new areas of
consolidation are identified.
ECHOCARDIOGRAMS:
[**2135-1-7**] ECHO: The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. The
right ventricular cavity is mildly dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
[**2135-2-14**]: The estimated right atrial pressure is 0-10mmHg. There
is moderate global left ventricular hypokinesis (LVEF = 30 %).
RV with depressed free wall contractility. There is a small to
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade. Compared with the prior
study (images reviewed) of [**2135-2-11**], the pericardial effusion
appears slightly smaller (still mainly anterior). LV systolic
function appears slightly lower.
[**2135-3-1**]: The left atrium and right atrium are normal in cavity
size. The estimated right atrial pressure is 0-5 mmHg. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is globally depressed (LVEF=
25 %). No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size is normal. with mild global free
wall hypokinesis. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of [**2135-2-14**], the pericardial effusion has resolved.
Left ventricular systolic function is similar (was overestimated
on the prior study).
OTHER STUDIES:
[**2135-1-7**] Renal U/S: No evidence of hydronephrosis. 3-mm
non-obstructing left renal stone and left parapelvic cyst.
[**2135-1-7**] CT Head w/out Contrast: 1. No intracranial hemorrhage
or edema.
2. Prominence of the bifrontal CSF spaces, which may be due to
parenchymal
atrophy or chronic subdural hygromas.
[**2135-1-12**] Bilateral Upper Extremity U/S: No DVT.
PATHOLOGY
Pathology Examination
SPECIMEN SUBMITTED: BONE MARROW (1 JAR)
[**2135-2-17**] [**2135-2-18**] [**2135-2-23**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21496**]/ttl
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS: HYPERCELLULAR MARROW FOR AGE WITH MILD DYSPOIESIS AND
LEFT-SHIFTED MYELOPOIESIS, SEE NOTE.
Note: Blasts comprise 5% of aspirate differential. Review of
marrow core biopsy shows focal interstitial areas with
left-shifted maturation and clusters of immature cells. Of
note, the patient's original blast phenotype was CD34-, CD117-
precluding further immunohistochemical characterization of these
immature cells. The morphologic differential diagnosis includes
residual disease versus recovering hematopoiesis. By
immunohistochemistry, CD34 highlights rare scattered
interstitial myeloblasts, which are less than 5% of marrow
cellularity. A CD4 stain highlights scattered small lymphoid
cells without definite staining in immature cells. CD117
staining shows several interstitial clusters of immature myeloid
precursors, overall comprising 20% of marrow cellularity. The
latter may be indicative of recovering left-shifted
hematopoiesis.
Please correlate with clinical and cytogenetic findings. If
clinically indicated, a re-biopsy to assess interval change may
be contributory.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are
decreased in number, are normochromic, with anisopoikilocytosis
including echinocytes, acanthocytes, microcytes, and
dacryocytes. The white blood cell count appears decreased.
Platelet count appears normal; large forms are seen.
Differential count shows 79% neutrophils, 6% bands, 3%
monocytes, 11% lymphocytes, less than 1% eosinophils, 1%
basophils.
Aspirate Smear:
The aspirate material is adequate for evaluation and consists of
several cellular spicules. The M:E ratio is 2.6. Erythroid
precursors are normal in number and show overall normoblastic
maturation; rare erythroid precursor with asymmetric nuclear
budding is seen. Myeloid precursors appear normal in number and
show full spectrum maturation. Megakaryocytes are present in
normal number; occasional abnormal megakaryocytes with
disjointed nuclei are seen.
Differential shows: 5% Blasts, 3% Promyelocytes, 11% Myelocytes,
10% Metamyelocytes, 22% Bands/Neutrophils, 2% Plasma cells, 27%
Lymphocytes, 20% Erythroid.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation, and consists of
a 1.1 cm core biopsy of trabecular bone. Overall cellularity is
estimated to be 50%. The M:E ratio estimate is normal.
Erythroid precursors are normal in number and exhibit mildly
megaloblastic maturation. Myeloid elements are normal in number
with complete maturation to neutrophils noted in some areas.
However, focally maturation is markedly left-shifted with
interstitial clusters of immature mononuclear cells noted.
Megakaryocytes are present in normal numbers, and are focally
tightly clustered.
A non-paratrabecular lymphoid aggregate comprised of
predominantly small lymphocytes is present, and accounts for 5%
of the marrow cellularity.
Cytogenetics studies: see separate report
Flow cytometry studies: see separate report
Cytogenetics Report BONE MARROW - CYTOGENETICS Procedure Date of
[**2135-2-18**]
Specimen Type: BONE MARROW - CYTOGENETICS
Date and Time Taken: [**2135-2-17**] 5:30 PM Date Processed: [**2135-2-18**]
KARYOTYPE: 47,XY,+8[2]/46,XY[18]
INTERPRETATION:
Two of 20 metaphases contained an extra chromosome 8
(TRISOMY 8).
Small chromosome anomalies may not be detectable using the
standard methods employed.
Cytogenetics Report FLUID,OTHER Procedure Date of [**2135-2-14**]
Date and Time Taken: [**2135-2-14**] TIME NOT NOTED Date Processed:
[**2135-2-14**]
Requesting Physician: [**Name (NI) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Location: INPATIENT
FISH evaluation for a chromosome 8 aneuploidy was attempted
with the Vysis CEP 8 DNA Probe (chromosome 8 alpha
satellite DNA) at 8p11.1-q11.1. However, there were an
insufficient number of cells in the specimen. The FISH
analysis could not be performed.
Brief Hospital Course:
80 year old gentleman with minimal PMH admitted as a transfer
from an outside hospital with new diagnosis of AML and concern
for tumor lysis and evolving DIC.
# AML: Newly diagnosed with complications of DIC, tumor lysis
syndrome and acute renal failure on admission. Initially treated
with leukopheresis, hydration, hydroxyurea and rasburicase, then
developed worsening renal failure and was transferred to the ICU
for CVVH as discussed below. After discussion with the patient
and family, it was decided that he will recieve chemotherapy. He
completed a 7 day course of azacitidine and received gentuzumab
on day 8 which he tolerated well with an appropriate response in
his counts. CNS involvement of his AML is discussed below.
# CNS/Leptomeningeal Involvement of CML: During the patient's
course he complained of back and leg pain that were thought to
be due to neurologic involvement of his AML. He had a MRI head
which revealed leptomeningeal involvement. He received 4 courses
of IT chemotherapy via LP (MTX x2, Cytarabine x2). A family
meeting was held and it was decided that the patient would
continue to receive IT chemotherapy. An Ommaya port was placed
by neurosurgery and used for IT chemotherapy. At the time of
discharge the patient had had 2 rounds of IT MTX and 1 round of
IT cytarabine. Arrangements were made for the patient to be seen
by Dr. [**First Name8 (NamePattern2) 15139**] [**Last Name (NamePattern1) 22114**] at [**Hospital3 3583**]. Last treatment of IT
chemo was cytarabine on [**2135-2-25**].
# Neutropenic Fevers: His neutropenic course was complicated by
persistent fevers due to pneumonia. He received a prolonged
course of cefepime, vancomycin, metronidazole and micafungin. He
became afebrile ~7 days prior to his counts returning to normal
levels. Once he was no longer neutropenic his cefepime and
vancomycin were discontinued and metronidazole and micafungin
continued.
# PNA: Neutropenic course with pneumonias as discussed above,
treated with cefepime and flagyl. After resolution of his
neutropenia the patient was afebrile for several weeks. He
developed low grade fevers again shortly before discharge and a
repeat CXR showed possible ongoing vs slowly resolving PNA. A
7-day course of levoquin was started and continued at discharge.
# Tumor Lysis Syndrome: Patient presented with elevated uric
acid, LDH and acute renal failure. S/p Rasburicase on [**2135-1-7**] x
1 for hyperuricemia. Initially was treated with Allopurinol,
Hydroxyurea, Rasburicase and Leukopheresis. WBC initially
improved but DIC & tumor lysis were noted to be worsening. He
also had increased O2 requirement which was thought to be likely
multifactorial related to leukemic infiltrate, volume overload,
and question of a LLL pneumonia for which patient has been
receving vancomycin and cefepime. Patient had been having
relative hypotension on the floor with blood pressures in the
80s to 90s for which patient was triggered twice on floor
yesterday, though these have responded well to small (250 mL)
fluid bolus x 2.
# Acute Renal Failure: likely due to leukostasis effects from
elevated WBC and TLS. Urine cultures were NGTD x 2. Renal u/s
with no evidence of hydronephrosis. 3-mm non-obstructing left
renal stone and left parapelvic cyst. Patient received CVVH (as
above). After CVVH his renal function returned to [**Location 213**] and he
had no further issues with renal failure.
# Hyperphosphatemia: On [**1-8**] the patient was transferred to the
[**Hospital Unit Name 153**] when it was noted that his phosphate level was 11.9 and
nephrology thought that urgent dialysis was appropriate. Patient
was also noted to have hypocalcemia as discussed below.
# Hypocalcemia: with hyperphosphatemia as above. Transient
numbness as noted during episode of hypocalcemia. Corrected
serum calcium fell to 7 and ionized calcium was 0.71. Treated
with calcium gluconate.
# Heart Failure/Pericardial effusion: Patient's EF was 60% prior
to chemotherapy. During his course patient was found to be in
mild respiratory distress with a RR in the 30s. A CTA was done
which again revealed pneumonia but no PE. A TTE was done to
evaluate for tamponade and the patient was found to have
developed a moderate loculated pericardial effusion but had no
signs of tamponade. His EF was found to be 40-45% on this study.
His respiratory distress subsequently resolved without new
interventions. A repeat TTE was done to evaluate his pericardial
effusion and this was found to be stable, but his EF was now
30%. Cardioglogy was consulted and it was decided to treat with
maximal medical therapy for new heart failure.
- a repeat echo was performed on [**2135-3-1**], results of which were
pending at the time of discharge
# Hypoactive Delirium: During his hospital course the patient
was found to less interactive and shuttered. This was initially
thought to be due to depression. A psychiatry consult was
obtained and they concluded that the patient had developed a
hypoactive delirium. He was then started on low dose zyprexa and
this resolved. Ritalin was started with good initial affect, and
the patient was briefly noted to be significantly more alert and
participatory, although this change did not seem to last more
than one day. His ritalin dose might be titrated up if this
continues to be an issue.
# Transient Numbness: During hospitalization patient was noted
to have perioral numbness, numbness of left face and left hand,
and some concern for left facial droop. Head CT showed no acute
abnormality. His parasthesias abated with treatment of his
hypocalcemia.
# Coagulopathy: This was [**2-22**] underlying DIC secondary to acute
leukemia and tumor lysis syndrome. Patient was provided support
with cryo and FFP. He had no issues with bleeding and his DIC
resolved.
# Transaminitis: Mild, likely due to leukemia, leukostatic
effects. No h/o infectious exposure or mediation effect
(Tylenol, etc). It subsequently resolved.
COPY OF DISCHARGE SUMMARY TO BE SENT TO:
[**First Name8 (NamePattern2) 15139**] [**Last Name (NamePattern1) 22114**], MD
[**Location (un) 81195**]
[**Location (un) 3320**], [**Numeric Identifier 40624**]
([**Telephone/Fax (1) 84082**]
Fax: [**Telephone/Fax (1) 84083**]
Medications on Admission:
Omeprazole
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-22**]
Drops Ophthalmic PRN (as needed) as needed for eye irritation.
2. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
4. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO QAM (once a
day (in the morning)).
5. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO QNOON ().
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Saliva Substitution Combo No.2 Solution Sig: One (1) ML
Mucous membrane QID (4 times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
12. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center- [**Location (un) 11792**]
Discharge Diagnosis:
AML
Hypoactive Delirium
PNA
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 69**]. You were originally
admitted to the hospital with elevated blood counts. We
performed bone marrow biopsy and found that you had acute
leukemia. We found that your kidneys were overwhelmed by the
leukemia, which we had to help you with a form of hemodialysis.
Your kidney recovered after a period of time. We provided you
with supportive care and transfusions of red blood cells and
plaletes. We also started you on chemotherapy which we injected
into your central nervous system. We started you on a medication
called ritalin (methylphenidate) to help stimulated your mood
and your appetite. Finally, we started you on a course of
antibiotics for a pneumonia which you had developed.
We have changed several of your medications during your stay.
Please take all of your medications exactly as prescribed.
Please follow up with the following doctors [**First Name (Titles) 3**] [**Last Name (Titles) 8757**] below.
Followup Instructions:
[**First Name8 (NamePattern2) 15139**] [**Last Name (NamePattern1) 22114**], MD
[**Location (un) 81195**]
[**Location (un) 3320**], [**Numeric Identifier 40624**]
Phone: ([**Telephone/Fax (1) 84082**]
Appointment:
Friday, [**3-4**], 9:40AM
|
[
"5845",
"486",
"42731",
"4280"
] |
Admission Date: [**2111-2-16**] Discharge Date: [**2111-2-20**]
Date of Birth: [**2057-12-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 49413**]
Chief Complaint:
hypotension, weakness, dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53W w/HIV (CD4 217), HepC (1,1), ESRD on HD, CHF (EF 30-35%, E/A
1.2, 3+MR, 3+TR, moderate [**Last Name (un) 6879**] on TTE [**2-6**]) presented to HD this
morning weak and dizzy after missing last HD. No HD was
performed b/c of hypotension to SBP60 and the patient was
transferred to the ED.
.
In the ED, the patient was afebrile w/VS 95.0 58 75/50 25
99%2L. Following 750cc and peripheral dopamine at 10ug/min, SBP
rose to 110. She was SOB, at her baseline and could not lie
flat. ECG demonstrated TWI in V2, flat T in V3. K was 6.8 and
phos 13. BNP was 31,000. Bedside TTE was negative for
tamponade. She was given vanco, ctx, flagyl, dex 10mg,
dextrose, Cagluconate, insulin. Nephrology was consulted; they
reported 8kg weight gain and indicated a desire to initiate
gentle HD in the MICU.
.
ROS notable for cough X 2 associated w/straining abdominal
discomfort and 1 episode emesis. At this time, she denies
fevers, chest pain, back pain, urinary symptoms. She says that
she forgets her HAART about once per week.
Past Medical History:
HIV (CD4 Ct in [**1-7**] was 217)
ESRD on HD
HTN
AVNRT diagnosed at [**Hospital1 2177**]
Recent vaginal bleed s/p conization
HCV
ESRD on hemodialysis
Asthma/COPD (on 4L O2 at home)
Cardiomyopathy w/ echo on [**8-6**] EF>55%, mild MR
[**First Name (Titles) 106113**] [**Last Name (Titles) 106114**] pneumonitis followed by Dr. [**Last Name (STitle) **] [**Name (STitle) **]
at [**Hospital1 2177**] ([**Telephone/Fax (1) 7799**] #6564
.
PSurgH:
C-section
R knee surgery
Ovarian cysts removed
Social History:
Lives with her 17 year old son; has been medically handicapped
for many years. She has 4 children; one son is incarcerated. 45
pack years tobacco history, reports having quit for last 1
weeks. Denies alcohol, or drug use. History of crack use.
Family History:
Her mother had a stroke and has DM, Her Daughter only has one
kidney and has a thyroid problem.
Physical Exam:
Gen: well appearing, in no acute distress,
HEENT: NC AT, mouth dry, PERRL, EOMI
CV: RRR, holosystolic murmur, +S3
Lungs: generally clear to auscultation bilaterally with
occasional faint rhonchi throughout
Abd: soft NT ND + BS
Ext: no cyanosis clubbing or edema
Neuro: alert and oriented x3, 5/5 strength of all four
extremities, nl sensation, CN II-XII intact
Brief Hospital Course:
53W w/hypotension and renal failure after having had more than 5
days since last HD. also she had stopped her low dose prednisone
since she did not like its side effects.
.
#Hypotension- Likely multifactorial: initially thought to be
related to adrenal insufficiency b/c patient had self d/ced
steroids which she was on for [**Telephone/Fax (1) **] [**Telephone/Fax (1) 106114**]
pneumonitis as well as in the ED she responded to minimal
interventions including a small fluid boluses, IV dex and
antibiotics. However, pt had a single cortisol
result(29.4)within normal levels. No evidence sepsis: lactate
3.4 but trended down to 1.8 w/HD, Abx were held; ruled out MI-
three sets of cardiac enzymes:(0.12,0.11,0.11); TTE [**2-17**]:
Compared with the prior study (images reviewed) of [**2111-2-6**],
findings are similar except that the effusion is now smaller. In
MICU, periperal dopa was successfully weaned during dialysis and
pt maintained BP's of 110-140.
steroids for two reasons: seemed to improve her condition
dramatically in ED, assume partial adrenal insufficiency;
asthma/ CPOD exacerbation that is helped with steroids.
anti-hypertensives were held, and pt's BP stabilized HD2.
.
ESRD- AG metabolic acidosis, high K, high Phos, and uremia [**3-6**]
missed HD- underwent HDx2 in ICU (first time w/high bicarb bath
w/small amount of dopamine support) last [**2111-2-18**], plan to repeat
in AM [**2111-2-19**]. ABG on admission showed bicarb of 8, improved on
labs first morning after admission so no repeat ABG obtained.
Lactate improved w/HD from 3.4 on admission to 1.8 [**2111-2-18**].
Renal followed, HD Friday [**2111-2-20**] before d/c. continued
nephrocaps, calcium acetate throughout admission.
.
[**Name (NI) 15197**] pt w/COPD/asthma, history of chronic cough and [**Name (NI) 106113**]
[**Name (NI) 106114**] pneumonitis, CHF w/worsening of EF over the past
year exacerbated by fluid overload from missed HD. Currently
lungs are clear, saturating well on RA. completed course of
Azithromycin because of leukocytosis w/left shift and pt's good
clinical response to ABx. continued albuterol nebs and started
pt on prednisone taper from doses of steroids pt received while
in the ICU.
.
HIV- CD4 count just above 200. Cont ppx with bactrim DS and
HAART as above.
.
Hep C- stable.
Medications on Admission:
Bactrim DS QD
Imdur 60mg PO QD
Cozaar 50mg PO QD
Lopressor 37.5 PO BID
Cardizem 120mg PO QD
Nephrocaps QD
Phoslo 4 tabs tid
Seroquel 25mg QHS
Didanosine 125mg after each HD
Nevirapine 400 QD
Abacavir 600mg [**Hospital1 **]
Benadryl 50 QHS
Claritin 10mg PO QD
Spiriva 18ug PO QD
Ibuprofren PRN
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Didanosine 125 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day: please hold for
sbp<100.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 1 days.
Disp:*2 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD
Discharge Condition:
stable
Discharge Instructions:
Please present to your outpatient hemodialysis as scheduled. It
is very important to your health that you do not miss [**First Name (Titles) **] [**Last Name (Titles) 106116**]s.
Please call your primary care physician or present to the
hospital if you have chest pain or shortness of breath, fever or
chills, headache or dizzyness.
Please follow up with your appointments and take your
medications as directed.
Followup Instructions:
You have the following appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2111-3-9**] 8:40
You should follow up with your primary care physician-
[**Telephone/Fax (1) 3581**]
|
[
"4280",
"40391"
] |
Admission Date: [**2161-4-24**] Discharge Date: [**2161-5-29**]
Date of Birth: [**2161-4-24**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: This is a 33-4/7 week
gestational age twin # 1 admitted with respiratory distress.
MATERNAL HISTORY: A 28-year-old, G9P5->7 woman with past
obstetric history notable for full-term SVD x5, spontaneous
abortions x3. Past medical history notable for smoking 1 pack per
day and depression (on no meds). Prenatal screens were as
follows: A+ blood type, antibody negative, hepatitis B
surface antigen negative, RPR nonreactive, rubella immune,
GBS unknown.
ANTENATAL HISTORY: [**Last Name (un) **] [**2161-6-8**] by ultrasound with
uncertain LMP. Spontaneous diamniotic-dichorionic twin
gestation with normal fetal survey in both twins at 19 weeks.
Pregnancy was complicated by preterm contractions leading to
admission, with treatment with mag sulfate tocolysis and
betamethasone at that time ([**4-5**]). Spontaneous
recurrence of preterm labor occurred leading to C-section under
spinal anesthesia for breech presentation. There was no
intrapartum fever or other clinical evidence of
chorioamnionitis. Rupture of membranes occurred at delivery
yielding clear amniotic fluid. The infant delivered by breech
extraction and was noted to have nuchal cord x1. She cried
prior to completion of delivery.
NEONATAL COURSE: Infant emerged with good tone, poor
respiratory effort and well-maintained heart rate. Oral and
nasal bulb suctioning was done. Infant was dried. Bag mask
ventilation was provided with rapid onset of regular
spontaneous respirations. Apgars were 6 at 1 minute and 9 at
5 minutes.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 1695 grams,
head circumference 29 cm, length 44 cm. Heart rate 170,
respiratory rate 70-80, temperature 97.3, blood pressure
57/25 with a mean of 35, saturation of 79% in room air which
improved to 95% on 30% FIO2 with CPAP of 6. The anterior
fontanel was soft and flat. Baby [**Name (NI) 43619**]. Palate
intact. Neck and mouth normal. Mild nasal flaring. Red reflex
normal. Chest with mild intercostal retractions. Fair breath
sounds bilaterally. No adventitious sounds. Heart regular
rate and rhythm. Femoral pulses normal. No murmur
appreciated. Baby well-perfused. Abdomen soft, nondistended,
no organomegaly, no masses. Bowel sounds active. Anus patent.
Three-vessel umbilical cord. Baby was active, alert,
responsive to stimulation. Tone appropriate for gestational
age. Moving all extremities equally. Baby had suck, rooting,
gag and grasp. The spine, limbs, hips and clavicles were all
normal.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The baby was on CPAP for less than 24 hours. She was
weaned to room air by day of life 2. She had occasional episodes
of apnea of prematurity which have now resolved.
CARDIOVASCULAR: An EKG was done on [**2161-5-21**] and as for sinus
arrythmia. It read by [**Hospital3 **] cardiolgy as occasional
atrial premature beats and was otherwise
normal. She has been clinically stable throughout admission.
FLUIDS, ELECTROLYTES AND NUTRITION: She was started on feeds
on day of life 3 and was advanced gradually to Special Care
Formula 26 kilocalorie/oz. She is currently on Similac 20
kilocalorie/oz, taking all p.o. The weight on [**5-29**] was 2865
grams.
GI: She was on phototherapy until day of life 7 with a
rebound bilirubin of 5/0.2.
HEMATOLOGY: She is currently on iron which was started on day
of life 8. Her hematocrit at birth was 46.6.
INFECTIOUS DISEASE: She was on amp and gent for 48-hour rule
out. Her blood culture on admission was negative.
NEUROLOGY: No head ultrasounds have been done.
SENSORY:
1. AUDIOLOGY: On the first hearing screen, she was
referred in right ear. She passed the repeat hearing screen.
2. OPHTHALMOLOGY: No eye exam was performed because of her
gestational age at birth.
Upon discharge home, the baby is stable and feeding well with
good weight gain. The primary pediatrician is Dr. [**Last Name (STitle) 38832**], phone
number [**Telephone/Fax (1) 7976**], fax number [**Telephone/Fax (1) 13238**].
CARE/RECOMMENDATIONS:
1. She will be discharged to home on Similac 20 kilocalories per
ounce.
2. Medications on discharge: Iron.
3. Car seat test was passed prior to discharge.
4. State newborn screens on [**4-27**] and [**5-8**] were normal.
5. She received her hepatitis B vaccine on [**5-12**].
6. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following 3
criteria: 1) Born at less than 32 weeks; 2) Born between 32
and 35 weeks with 2 of the following: daycare during RSV
season, a smoker in the household, neuromuscular disease,
airway abnormalities, or school-aged siblings; or 3) With
chronic lung disease.
Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
7. Follow-up appointments include an appointment with the
pediatrician, Dr. [**Last Name (STitle) 38832**], on [**6-1**].
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Respiratory distress.
3. Hyperbilirubinemia.
4. Premature atrial beats.
5. Apnea of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Name8 (MD) 67154**]
MEDQUIST36
D: [**2161-5-14**] 15:29:06
T: [**2161-5-14**] 15:58:42
Job#: [**Job Number 67901**]
|
[
"7742",
"V053"
] |
Admission Date: [**2164-2-24**] Discharge Date: [**2164-2-25**]
Date of Birth: [**2115-12-1**] Sex: M
Service: MEDICINE
Allergies:
Methadone / Levofloxacin / Penicillins
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] is a 48 yo male with PVD, ESRD on HD, currently
undergoing treatment for c. difficile found by his VNA with
diarrhea, fatigued, BPs in 80's and down to 60's while standing.
He was reported to have intermittent altered mental status. He
was sent to [**Hospital3 7362**] where T 97, HR 68, RR 16, BP 83/52,
SpO2 100%. He was found to have WBC 15.1 with 35% bands,
lactate 2.0. He received NS 500 cc, IV azithromycin 500 mg IV
and rocephin 1 gram IV, as empiric therapy for possible
infiltrate on CXR. He was started on a dopamine drip for SBP
persistently in the 70's for approximately two hours.
He was transferred to the [**Hospital1 18**] ED via [**Location (un) **] on a dopamine
drip. In our ED, T 100, HR 80, BP 101/42, RR 16, SpO2 100% on
NRB. RIJ was placed. Patient received 2L NS, vancomycin 1 gram
IV, and dopamine gtt was transitioned to leveophed gtt. On
examination in ED, patient was reported to be confused and
somnolent, requiring sternal rub to arouse. When aroused,
complained of abdominal pain with palpation. Abdomen was noted
to be distended and firm, without rebound or peritoneal signs.
CT abdomen/pelvis was peformed and general surgery, [**Location (un) 1106**]
surgery were called.
Past Medical History:
PMH:
1. Insulin dependent diabetes mellitus, diagnosed age thirteen.
2. ESRD on HD
3. Hypertension.
4. Gastroesophageal reflux disorder.
5. Hiatal hernia.
6. Renal transplant, [**2154**], with chronic rejection.
7. Depression.
8. Peripheral [**Year (4 digits) 1106**] disease.
9. Chronic pain.
10. Lactose intolerance.
.
PSH:
1. Bilateral third finger amputations.
2. Left second and third toe amputations.
3. Left hand sympathectomy.
4. Left below knee popliteal to posterior tibial bypass with
non reverse saphenous vein graft.
5. Right inguinal hernia.
6. Renal transplant, [**2154**].
7. Bilateral lower extremity angiogram with angioplasty of
left distal graft and angioplasty of right posterior
tibial ([**2161-1-2**]).
8. Left knee incision and drainage [**9-16**]
Social History:
lives w/ father, denied ETOH , quit tob in [**2147**]
Family History:
Non-contributory
Pertinent Results:
.
EKG: sinus rhythm, rate 80, normal axis, normal intervals. +
1-[**Street Address(2) 1766**] elevations in V1-V3, also seen on prior EKG dated
[**2163-12-4**].
.
CXR [**2-23**]: Lung volumes are now quite low with new patchy
opacity at the right more than left lung base, likely
atelectasis. Allowing for this, the heart size and pulmonary
vessels are likely within normal limits, and there is no
significant pleural effusion.
.
CT ABDOMEN PELVIS [**2-23**]:
1. Moderate ascites may be secondary to third spacing, but can
also be seen secondary to more significant pathologies. Bowel
ischemia cannot be excluded.
2. Moderately distended gallbladder. Acalculous cholecystitis
is possible.
3. Stool distended colon.
4. Bibasilar atelectasis and superimposed pneumonia.
[**2164-2-23**] 08:10PM BLOOD WBC-16.3*# RBC-4.50* Hgb-10.9* Hct-38.0*
MCV-84 MCH-24.2* MCHC-28.7* RDW-16.8* Plt Ct-255
Neuts-68 Bands-17* Lymphs-7* Monos-5 Eos-3 Baso-0 Atyps-0
Metas-0 Myelos-0
[**2164-2-24**] 10:45AM BLOOD Glucose-28* UreaN-44* Creat-5.3* Na-144
K-4.2 Cl-104 HCO3-30 AnGap-14
[**2164-2-23**] 08:10PM BLOOD ALT-38 AST-37 LD(LDH)-292* CK(CPK)-36*
AlkPhos-204* TotBili-0.5 [**2164-2-23**] 08:10PM BLOOD Lipase-9
[**2164-2-23**] 08:10PM BLOOD cTropnT-0.38*
.
[**2164-2-24**] 01:55AM BLOOD CK(CPK)-34*
[**2164-2-24**] 01:55AM BLOOD cTropnT-0.36*
.
[**2164-2-24**] 10:45AM BLOOD CK-MB-7 cTropnT-0.34*
[**2164-2-24**] 10:45AM BLOOD CK(CPK)-91
.
[**2164-2-24**] 10:45AM BLOOD Calcium-8.9 Phos-5.0* Mg-1.8
[**2164-2-23**] 08:10PM BLOOD Albumin-2.4* Calcium-9.2 Phos-4.8* Mg-1.8
[**2164-2-23**] 08:10PM BLOOD Cortsol-32.8*
[**2164-2-24**] 08:31AM BLOOD Type-MIX FiO2-100 pO2-59* pCO2-56*
pH-7.34* calTCO2-32* Base XS-2 AADO2-613 REQ O2-98
[**2164-2-24**] 05:10AM BLOOD Type-ART pO2-80* pCO2-29* pH-7.51*
calTCO2-24 Base XS-0
[**2164-2-23**] 09:28PM BLOOD Type-MIX pO2-148* pCO2-56* pH-7.34*
calTCO2-32* Base XS-3 Comment-GREEN TOP
[**2164-2-23**] 08:22PM BLOOD Glucose-95 Lactate-2.7* K-3.7
[**2164-2-24**] 05:04AM BLOOD Glucose-105 Lactate-2.0
[**2164-2-24**] 10:55AM BLOOD Lactate-1.3
Brief Hospital Course:
Pt presented with hypotension, thought in ICU to be possibly due
to sepsis. He also was markedly sedated, and responded to
narcan. Please see hard copy of medical record for detailed
discussion between ICU attending, Dr. [**Name (NI) 4507**], pt, and family,
regarding pt's decision to discontinue dialysis and have comfort
measures only. Palliative care consulted and pain and
aggitation management as per their recommendations. Pt was
transferred to medical floor. Pt passed away less than 24 hours
after transfer to medical floor, family at bedside.
Medications on Admission:
Vancomycin 250 mg PO q 6 hours
Amlodipine 10 mg Tablet daily except dialysis days
Clopidogrel 75 mg Tablet daily
Gabapentin 300 mg daily
Ambien 10 mg qHS PRN
Sensipar 60 mg daily w/ dinner
Hydromorphone 4 mg Q 4 PRN pain
Lantus 23 units SQ qHS
Humalog SSI
Metoprolol 50 mg [**Hospital1 **]; skip AM dose on HD day
Metronidazole 500 mg [**Hospital1 **]
MSContin 30 mg [**Hospital1 **]
Naprosyn 500 mg [**Hospital1 **]
Nortriptyline 100 mg qHS
Omeprazole 20 mg [**Hospital1 **]
Sevalamer 3200 mg with meals, 1600 mg with snacks x 2
Simvastatin 40 mg daily
ASA 81 mg daily
B-complex vitamin
Renaltab II MVI daily
Discharge Disposition:
Expired
Discharge Diagnosis:
na
Discharge Condition:
na
Discharge Instructions:
na
Followup Instructions:
na
Completed by:[**2164-3-1**]
|
[
"0389",
"78552",
"486",
"40391",
"99592",
"53081"
] |
Admission Date: [**2126-10-20**] Discharge Date: [**2126-11-1**]
Date of Birth: [**2061-5-2**] Sex: M
Service: [**Company 191**] East
CHIEF COMPLAINT: Severe abdominal pain, nausea, and vomiting.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old male with
a history of diabetes, hypertension, and a past episode of
pancreatitis in [**2126-1-25**] who presents with severe [**10-3**]
abdominal pain which awoke him from sleep, lasting approximately
25 minutes. The pain was constant, not intermittent, not
radiating with change in position. Nausea and vomiting times
three. He denies recent alcohol intake, medication changes,
abdominal trauma, history of gallstones, or flu-like symptoms.
PAST MEDICAL HISTORY:
1. Diabetes.
3. Pancreatitis in [**2126-1-25**].
4. Hand surgery for carpal tunnel syndrome.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Propranolol 40 mg p.o. b.i.d.
2. Naproxen 375 mg p.o. b.i.d. as needed.
3. Glipizide 5 mg p.o. b.i.d.
4. Metformin 850 mg p.o. q.a.m. and 1700 mg p.o. q.p.m.
5. Moexipril 7.5 mg p.o. q.d.
6. Mysoline 250 mg p.o. t.i.d. as needed.
SOCIAL HISTORY: The patient is single. He lives with a friend
in [**Name (NI) 669**]. No alcohol use since [**2096**].
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98.6,
blood pressure was 176/85, heart rate was 83, respiratory
rate was 30, oxygen saturation was 99% on 2 liters. In
general, this patient was a moderately obese male,
intermittently moaning in pain. Head, eyes, ears, nose, and
throat examination revealed sclerae were anicteric.
Conjunctivae were clear. Extraocular movements were intact.
Pupils were equal, round, and reactive to light and
accommodation. The oropharynx was clear and moist, no
icterus. Neck was supple. Skin with no lesions.
Cardiovascular examination revealed normal first heart sound
and second heart sound. No murmurs, rubs, or gallops. No
bruits. Point of maximal impulse at 2 cm at left
midclavicular line. Respiratory examination was clear to
auscultation bilaterally. Abdominal examination was firm,
diffuse epigastric tenderness to palpation. Bowel sounds
were present. No guarding tenderness or rebound. Negative
[**Doctor Last Name **] sign. No Cullen sign. No [**Doctor Last Name **] sign. Extremities
revealed no clubbing, cyanosis, or edema. Pulses were 2+
bilaterally. Neurologic examination revealed alert and
oriented times three. Cranial nerves II through XII were
intact. No focal deficits.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
revealed white blood cell count was 9.7, hematocrit was 44.2,
platelets were 262. Sodium was 135, potassium was 4.2,
chloride was 100, bicarbonate was 24, blood urea nitrogen was
14, creatinine was 1, and blood glucose was 262. Creatine
kinase was 12, MB fraction was 3, troponin I was less
than 0.3. Calcium was 10, magnesium was 2.5, phosphorous
was 4.9. ALT was 514, AST was 298, amylase was 4976, lipase
was 14,300, total bilirubin was 3, albumin was 4.5, alkaline
phosphatase was 122, LDH was 1176. Hemoglobin A1c was 8.3.
Urinalysis revealed clear yellow, specific gravity was 1015,
and glucose was 250.
RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus
rhythm with normal axis and 1-mm ST elevations in V2 and V3,
normal R wave progression, and normal intervals.
A right upper quadrant ultrasound revealed multiple
gallstones in the gallbladder, gallbladder wall 7-mm
thickness with edema. No pericholecystic fluid. No
son[**Name (NI) 493**] [**Name (NI) **] sign. Consider acute cholecystitis in
appropriate clinical setting.
A CT of the abdomen and pelvis revealed moderate inflammatory
changes associated with pancreatitis.
HOSPITAL COURSE:
1. PANCREATITIS: Acute pancreatitis meeting four [**Last Name (un) **]
criteria. The patient was made nothing by mouth with aggressive
intravenous fluid hydration and noted on hospital day two to have
an acute elevation of his total bilirubin.
He was taken emergently to endoscopic retrograde
cholangiopancreatography. They performed a sphincterotomy with
stone fragment and sludge extraction. Imipenem was empirically
started at 500 mg intravenously q.6h., and the patient was
transferred to the Intensive Care Unit for hypoxia.
A CT of the abdomen and pelvis revealed poor uptake of contrast
suggestive of a necrotic pancreatitis. Serial liver function
tests revealed downtrending levels of amylase and lipase. A
nasojejunal tube was placed on hospital day four for low-level
feeds.
Surgery was consulted to evaluate whether emergent
cholecystectomy was indicated, and they suggested that this would
be performed as an outpatient six weeks after hospital discharge.
The patient had a fever curve which gradually throughout his
hospital stay. A pancreatic biopsy was deferred secondary to
resolving temperatures and improving clinical examination.
On hospital day six, the patient was found to have a nasogastric
tube and nasojejunal tube displaced and was subsequently pulled.
Total parenteral nutrition was initially started at this point.
His diet was advanced slowly, and he was tolerating this well.
At the time of this dictation, the patient was tolerating a low-
residue and low-fat and non-lactose diet without complications.
He was to have a repeat CT of the abdomen and pelvis in
approximately three weeks for further evaluation. He was to
follow up with Dr. [**Last Name (STitle) 8499**] (his primary care physician) in
three weeks as well and with Dr. [**Last Name (STitle) **] for a cholecystectomy
in approximately four to six weeks.
2. HEMATOLOGY: The patient was noted on CT scan to have
superior mesenteric vein thrombosis. Due to the recent
sphincterotomy, it was felt that anticoagulation would be held
until the pancreatitis issue is resolved. Also of note is that
his hematocrit was slowly downtrending throughout his hospital
course. Hemolysis laboratories were unremarkable, and his stool
was guaiac-negative.
It was presumed that his pancreas may be oozing slowly, but given
that he would not be an ideal candidate for surgery, he was
conservatively managed. At the time of this dictation, his
hematocrit was 25.3 which has been stable over the last 24 hours
to 48 hours, and he was not transfused during this admission.
3. DIABETES: His metformin and glipizide were held throughout
his admission with the addition of tube feeds/total parenteral
nutrition. He was placed on a sliding-scale and had increasing
amounts of insulin in his total parenteral nutrition. He was
restarted with half dose of glipizide and will need to be managed
accordingly.
4. HYPERTENSION: The patient was hemodynamically stable, and
his blood pressure medications were slowly restarted. He was
tolerating his ACE inhibitor without complications. At this
time, we did not restart the propranolol, and he will need
further management of his hypertension.
5. INFECTIOUS DISEASE: Imipenem will be continued for a total
of three weeks. A peripherally inserted central catheter line
was inserted for this course. Multiple blood and urine cultures
were obtained without any growth.
6. PULMONARY SYSTEM: Noted hypoxia in the Intensive Care Unit
with a chest x-ray revealing bibasilar infiltrates. He was
subsequently saturating well and was encouraged to use incentive
spirometry.
7. FLUIDS/ELECTROLYTES/NUTRITION: He was to continue a soft,
low-residue, low-fat, and non-lactose diet until cholecystectomy.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to Centennial [**Hospital6 **].
DISCHARGE FOLLOWUP:
1. To follow up with Dr. [**Last Name (STitle) 8499**] in three weeks and with
Dr. [**Last Name (STitle) **] in four to six weeks for a cholecystectomy.
2. He was to have a CT of the abdomen and pelvis on [**11-22**]
at 10 a.m. to further evaluate his pancreas.
MEDICATIONS ON DISCHARGE:
1. Oxycodone 5 mg to 10 mg p.o. q.4-6h. as needed.
2. Moexipril 7.5 mg p.o. q.d.
3. Imipenem 500 mg intravenously q.6h. (times 12 days).
4. Glipizide 2.5 mg p.o. q.d.
5. Ambien 5 mg p.o. q.h.s.
DISCHARGE DIAGNOSES:
1. Acute pancreatitis.
2. Status post sphincterotomy and sludge removal.
3. Hypertension.
4. Diabetes.
5. Anemia; rule out hemolysis of unknown etiology.
6. Gallstones.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1302**], M.D.
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2126-11-1**] 14:23
T: [**2126-11-2**] 06:18
JOB#: [**Job Number 43004**]
|
[
"2760",
"2859",
"25000",
"4019"
] |
Admission Date: [**2182-4-12**] Discharge Date: [**2182-4-19**]
Date of Birth: [**2120-10-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide
Antibiotics) / Reglan / Ampicillin / Lactose / Neomycin /
metoclopramide / Doxepin
Attending:[**First Name3 (LF) 1242**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
Left femoral CVL [**4-13**]
History of Present Illness:
61F with DM1, ESRD on PD, s/p pancreatic transplant, CAD with
[**Month/Year (2) **] [**10-3**] s/p CABG in [**2-3**], p/w rigors and fever to 103. Pt
reports being n her USOH until she developed diarrhea two nights
ago X 3 BMs, none since. On the morning of admission she
developed chills that became severe and quickly developed a temp
of 101. She was sent to the ED.
.
In our ED, Temp was 103.5 at triage. She was noted to have RLE
erythema, warmth and tenderness consistent with cellulitis. She
was evaluated by transplant surgery who supported diagnosis of
cellulitis and recommended avoidance of central line if
possible. Renal was also made aware. Hct 23, lactate 2.2.
Blood culture and peritoneal cultures were sent. CXR with LLL
opacity worse than prior. Peritoneal WBC 24 with no left shift.
Patient was started empirically on Vanco/Meropenem/Flagyl for
coverage of cellulitis and posible Cdiff. During her ED
course systolic blood pressures dropped to 70s despite receiving
3L NS, so she was transferred to the ICU for management of
sepsis. Access 2 PIVs. Vital signs on transfer were: BP 83/36 HR
101 RR 19 O2 sat 100%.
.
Of note patient has history of relative hypotension since her
cardiac surgery with blood pressures usually in the low 100s on
midodrine. Ocassionally pressures drop to the 70s at her rehab
and quickly improve after small gatorade bolus. She also has a
history of multidrug resistant organisms including VRE.
.
On the floor, she looks tired, but answering questions
appropriately. She reports feeling better, still has RLE pain.
.
Review of systems:
as above.
Denies cough, sore throat, abdominal pain, further diarrhea,
blood in stools, change in urinary output, dysuria, any other
skin changes, feeling confused.
Past Medical History:
#CHF; EF 25% in [**2182-1-23**]
# h/o severe MR s/p repair in [**2181**]
# NSTEMI [**7-/2181**], s/p [**Year (4 digits) **] to LAD [**9-/2181**]
# CABGX5 vessel [**1-/2182**]
# s/p renal transplant ([**2157**])
-- c/b chronic rejection
-- second renal transplant ([**2160**])
# s/p pancreas transplant
-- with allograft pancreatectomy ([**5-/2174**])
-- redo pancreas transplant ([**6-/2175**])
-- admission for acute rejection ([**7-/2180**]), resolved with
increased immunosupression
# Diabetes mellitus type I
-- c/b neuropathy, retinopathy, dysautonomia
-- no longer requires regular insulin after the pancreas
transplant, but has been given SS while on high-dose prednisone
in house
# Autonomic neuropathy
# Sleep disordered breathing
-- Unable to tolerate CPAP; uses oxygen 2L NC at night
# Osteoporosis
# Hypothyroidism
# Pernicious anemia
# Cataracts
# Glaucoma
# Anemia of CKD, on Aranesp in the past
# R foot fracture c/b RLE DVT
# Chronic LLE edema
# Recurrent E. coli pyelonephritis
# s/p anal polypectomy ([**5-/2176**])
# s/p bilateral trigger finger surgery ([**8-/2178**])
# s/p left [**Year (4 digits) 6024**] ([**8-/2179**])
Social History:
Child psychiatrist, on disability. Has been in and out of
hospitals in the last 8 months. Was longest at [**Hospital3 **],
most recently at [**Location (un) **] in [**Location (un) **]. Mobile with
wheelchair but unable to do transfers.
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Father with MI at 57.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
.
General: Alert, oriented, drowsy, responding appropriately to
questions
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Few rales at LL base, but otherwise clear.
CV: Normal rate and regular rhythm, 2/6 SEM at USB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Peritoneal
[**Last Name (un) **] in place, no skin changes or tenderness surrounding the
site.
GU: No foley
[**Last Name (un) **]: 2+ edema, warm, well perfused, no clubbing. RLE with
erytehma warmth and tenderness, no crepitus.
Neuro: CNII-XII in tact. Grossly in tact
Discharge PE:
Vitals: 98.5 110/60 (110-128/60-74) 83 (69-84) 18 99CPAP
Gen: NAD, pleasant woman laying comfortably in bed,
well-appearing
chest: old HD line site, clean/dry, no tenderness to palpation
or erythema
HEENT: angular cheliosis b/l improving, + thrush on tongue,
improving
CVS: ?soft SEM heard at USB, no m/r/g
PULM: bibasilar crackles, L>R, improving, with slightly
decreased breath sounds at the bases b/l
ABD: soft, nontender, distended, no tenderness to palpation
around PD site
extremities: L [**Last Name (un) 6024**], RLE erythema continues to improve
Pertinent Results:
ADMISSION LABS:
.
[**2182-4-12**] 09:50PM BLOOD WBC-5.0 RBC-2.22* Hgb-7.2* Hct-23.3*
MCV-105*# MCH-32.3* MCHC-30.8* RDW-22.7* Plt Ct-251
[**2182-4-12**] 09:50PM BLOOD Neuts-94.6* Lymphs-4.1* Monos-0.8*
Eos-0.3 Baso-0.2
[**2182-4-12**] 09:50PM BLOOD PT-27.7* PTT-32.1 INR(PT)-2.7*
[**2182-4-12**] 09:50PM BLOOD Glucose-81 UreaN-56* Creat-5.9*# Na-136
K-4.0 Cl-96 HCO3-26 AnGap-18
[**2182-4-12**] 09:50PM BLOOD ALT-21 AST-33 AlkPhos-65 TotBili-0.2
[**2182-4-12**] 09:50PM BLOOD Albumin-2.7* Calcium-7.3* Phos-3.7
Mg-1.1*
[**2182-4-12**] 10:06PM BLOOD Lactate-2.2*
.
CXR [**4-12**]:
1. Bilateral pleural effusions, improved on the right compared
to the prior
examination, but worsened on the left. Increased opacification
at the left
lung base may represent underlying infection.
2. Low lung volumes with crowding of bronchovascular markings
and minimal
increased pulmonary vascular engorgement.
.
LENI'S [**4-13**]:
TECHNIQUE: Doppler son[**Name (NI) **] of right common femoral, superficial
femoral,
deep femoral, popliteal and proximal calf veins were performed.
There is
normal compressibility, flow and augmentation throughout. Mild
subcutaneous
edema is seen in the right calf. Left common femoral vein
waveforms could not
be obtained due to the overlying dresing.
IMPRESSION: No evidence of DVT in the right lower extremity.
Discharge labs:
[**2182-4-19**] 05:55AM BLOOD WBC-4.7 RBC-2.77* Hgb-8.8* Hct-28.0*
MCV-101* MCH-31.7 MCHC-31.4 RDW-21.8* Plt Ct-133*
[**2182-4-19**] 05:55AM BLOOD PT-13.8* PTT-27.5 INR(PT)-1.3*
[**2182-4-19**] 05:55AM BLOOD Glucose-86 UreaN-45* Creat-5.1* Na-137
K-3.5 Cl-97 HCO3-30 AnGap-14
[**2182-4-19**] 05:55AM BLOOD ALT-16 AST-20 AlkPhos-66 TotBili-0.2
[**2182-4-19**] 05:55AM BLOOD Albumin-2.1* Calcium-8.3* Phos-3.5 Mg-1.6
[**2182-4-19**] 05:55AM BLOOD Vanco-17.3
[**2182-4-19**] 05:55AM BLOOD tacroFK-9.7
[**2182-4-13**] 11:57AM BLOOD Lactate-2.4*
Brief Hospital Course:
60 year old female with a complicated past medical history
including DMI, on peritoneal HD, s/p pancreas transplant, CHF
who presents with cellulitis of RLE who later developed
enteroccocus sepsis.
.
# enterococcus sepsis: Most likely etiology is RLE cellulitis
given clinical findings on exam. Blood cultures growing
enterococcus from 1/4 bottles. She was maintained on pressors
overnight of admission and was eventually weaned off with stable
BPs. CXR also showed some suggestion of opacification at left
long base so was was covered broadly with meropenem/linezolid to
start, but the linezolid was changed to daptomycin on [**4-13**].
LFTs/CK subsequently increased, so she was changed back to
linezolid. Urine and peritoneal cultures were pending, but no
sign of SBP on cell count. No diarrhea to suggest c.diff. She
was put onto stress dose steroids on admission, but was tapered
back to her home dose of prednisone 5mg daily. Cellulitis was
trended with marked borders and improved. The patient's HD line
was pulled given her bacteremia, and she was switched to PD
Vanc. The patient also had TTE and TEE, both of which were
negative.
.
The patient will continue PD vanc for 2 weeks after negative
culture (first negative culture [**2182-4-13**]); end date of abx [**4-27**]. As per ID, the patient should have Vancomycin 1000 grams
q4days with random vanc levels checked two times per week, with
trough goal of 15-20.
.
# RLE cellulitis: The patient was found to have RLE cellulitis,
which was potentially the source of her sepsis, though unclear.
She was initially treated with meropenem/linezolid which was
ultimately switched to vancomycin. Of note, the patient still
has some slight RLE erythema. This will have to be followed as
an outpatient.
.
# Anemia: HCT on admission down to 23 from baseline of about 30,
with an increased MCV of 105, now s/p 1 unit of PRBC's with a
stable HCT of 25. No evidence of hemolysis. Retic count 3.6.
The patient was given one more unit of blood prior to her
discharge. She will continue her EPO as an outpatient.
.
# Transaminitis/Elevated CK: Thought to be secondary to
daptomycin. Was changed back to linezolid given this.
Ultimately liver enzymes downtrended after dapto was stopped,
and CK also normalized. The patient's atorvastatin was held
during this time, but was restarted upon discharge.
.
# ESRD s/p renal transplant: The patient continued on PD, phos
binders, and nephrocaps while in patient. The patient was
continued on her home dose of prednisone, after initially
receiving stress dose steroids in the ED. Tacrolimus and MMF
were restarted on [**2182-4-15**]. Daily tacro levels were followed and
dose changed as per transplant recs.
#. DM1 s/p pancreas transplant: Maintained on immunosuppression
as above
.
# sCHF: The patient was maintained on PD while in patient, in
order to help maintain euvolemia.
# afib: The patient was in sinus; coumadin was initially held in
the unit, and then restarted at a small dose. INR was trended
daily, and the patient's coumadin dose was changed accordingly.
INR will have to be followed as an outpatient, as the patient's
INR upon discharge was 1.3. Caution will have to be taken with
coumadin dosage, as the patient is on many other drugs and
antibiotics that can interact with her INR.
.
# presumed esophageal [**Female First Name (un) **]/thrush: The patient was found to
have oral thrush, as well as symptoms of dysphagia (was getting
harder for her to swallow pills). Given her history of
esophageal [**Female First Name (un) **], the patient was started on fluconazole for
treatment of thrush and presumed esophageal [**Female First Name (un) **]. The
patient's tacro levels were closely followed, as fluconazole can
interact with her tacro.
.
# CAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] and CABG: The patient was contined on ASA
while in patient. He statin was held while the patient had
elevated LFTs. It was restarted upon discharge. Of note, the
patient was also not getting Plavix (s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **]). This was
restarted this admission, as per her outpatient cargiologist,
Dr. [**Last Name (STitle) 171**].
.
# Hypothyroidism: Continue home levothyroxine
.
# Glaucoma: Continue home eye drops.
.
Transitional Issues:
- The patient will continue PD vanc for 2 weeks after negative
culture (first negative culture [**2182-4-13**]); end date of abx [**4-27**]. As per ID, the patient should have Vancomycin 1000 grams
q4days with random vanc levels checked two times per week, with
trough goal of 15-20. Please fax trough results to [**Telephone/Fax (1) 697**]
attn: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7749**].
.
- The patient has INR of 1.3, getting daily coumadin. Given
antibiotics and other medications, will continue coumadin 1 mg
daily. Will have to check INRs daily until therapeutic.
.
- Of note, the patient still has some slight RLE erythema. This
will have to be followed as an outpatient.
Medications on Admission:
acyclovir 200 mg [**Hospital1 **]
amiodarone 200mg daily
aspirin 81mg dialy
brimonide tartrate tid
calcum carbonate 1250mg [**Hospital1 **]
cellcept 500mg [**Hospital1 **] after meals
cosopt daily
coumadin 1mg daily
creon [**Numeric Identifier 890**] units tid before meals
epogen 10000munits weekly (wed)
folic acid 1mg daily
lanthanum carbonate 500mg tid before meals
imodium 2mg [**Hospital1 **] prn
artificial tears prn
lactaid 3000units tid before meals
lipitor 80mg qhs
midodrine 15mg tid
nephrocaps daily
neurontin 100mg daily
nystatin swish and spit qid
prednisone 5mg daily
prilosec 20mg daily
restasis [**Hospital1 **]
synthroid 100mg Tuesday, [**Hospital1 5929**], Sun; 112mcg MWFSaturday
Tacrolimus 4mg [**Hospital1 **]
Tucks pads
APAP 650 tid prn
Xalatan qhs
Zofran 4mg q8h prn
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
5. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO BID (2 times a day).
6. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
10. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic DAILY (Daily).
11. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
12. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
13. Epogen 10,000 unit/mL Solution Sig: One (1) Injection once
a week: every Wednesday.
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
15. lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day: please take before meals.
16. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for diarrhea.
17. Artificial Tears Drops Ophthalmic
18. Lactaid 3,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day: before meals.
19. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
20. midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
21. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
22. Neurontin 100 mg Capsule Sig: One (1) Capsule PO once a day.
23. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
24. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] ().
25. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
([**Doctor First Name **],TU,TH).
26. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK
(MO,WE,FR,SA).
27. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
28. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
29. Xalatan 0.005 % Drops Sig: One (1) Ophthalmic at bedtime.
30. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **]
Discharge Diagnosis:
primary diagnosis:
enterococcal sepsis
cellulitis
secondary diagnosis:
coronary artery disease
glaucoma
diabetes
kidney failure
renal and pancreas transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 17759**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you were
having fevers at the rehab; you were found to have an infection
of your skin, and found to have bacteria in your blood. We
treated your infection with antibiotics. You will have to
continue taking antibiotics until [**4-27**].
We made the following changes to your medications:
INCREASE acyclovir to 400 mg [**Hospital1 **]
CONTINUE Plavix 75 mg daily
START Fluconazole 200 mg daily
DECREASE Tacrolimus to 2 mg [**Hospital1 **]
START vancomycin
Followup Instructions:
Department: TRANSPLANT
When: MONDAY [**2182-4-22**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2182-4-24**] at 2:40 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: TRANSPLANT CENTER
When: MONDAY [**2182-5-13**] at 4:00 PM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2182-4-21**]
|
[
"2449",
"4280",
"V4582",
"V4581"
] |
Admission Date: [**2111-7-27**] Discharge Date: [**2111-7-29**]
Date of Birth: [**2044-10-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Blood in stool
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
Mr [**Known lastname 68135**] is a 66 year old man, originally from [**Country 3396**], with
history of hypertension, hyperlipidemia and diverticulosis,
presenting with bloody bowel movements for 5 days PTA. Patient
reports he was in his otherwise good state of health when he
began having diarrhea. Shortly thereafter, he noted his stool
turned dark colored and the toilet water began turning red. He
did not see any blood clots. Patient denies any recent travel,
but does report recently trying cambodian food.
Patient denies any nausea, vomiting, chest pain, but does report
some dyspnea with exertion (going up the stairs) that has
conincided with the above complaints. Denies feeling dizzy when
he gets up, but does report some palpitations.
In the ED, vital signs T 97.4, HR 75, BP 84/64, RR 16, O2 Sat
100% RA. Rectal vault with bright red blood. Two large bore IV
placed on Bilateral UE, patient given 1L NS bolus and 1 unit of
PRBC, with ipmrovement in SBP to 102/64. NG lavage performed;
negative for blood. Patient admitted to MICU for further
monitoring.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Diverticulosis
4. Inguinal hernia s/p repair
5. Colonic adenomas s/p resection
Social History:
Patient originally from [**Country 3396**], lives with wife. [**Name (NI) **] etoh or
cigarette use.
Family History:
No familial history of colon cancer, no chronic medical
conditions.
Physical Exam:
Vitals Temp: HR: 77 BP: 126/68 RR: 20 O2 Sat: 100% RA
GEN: Well appearing man in no distress
HEENT: PERRL, sclera anicteric, pale conjunctiva
CV: Regular rate, soft systolic flow murmur at apex, no
rubs/gallops. Normal S1/S2
Lungs: Clear to auscultation bilaterally, no
rales/rhonchi/wheezes
Abdomen: Soft, non tender non distended, normoactive bowel
sounds. No guarding, no hepato/spleno megaly
Extremities: Cold, 2+ pulses, no clubbing cyanosis or edema.
Pertinent Results:
CT ABDOMEN AND PELVIS
.
There is no pericardial or pleural effusion. The lung bases are
clear.
There are several subcentimeter hepatic hypodensities, likely a
combination of cysts and hemangiomas. There is a subcentimeter
right renal hypodensity, too small to characterise. The spleen,
adrenal glands, pancreas, and left kidney appear unremarkable.
There is no upper abdominal lymphadenopathy.
.
There is no pelvic lymphadenopathy. There is no free fluid in
the pelvis. There is colonic diverticulosis without evidence of
diverticulitis. The appendix is visualized and appears
unremarkable.
MUSCULOSKELETAL:
There are minor degenerative changes present in the lumbar
spine.
CONCLUSION:
1. No evidence of diverticulitis or appendicitis. Scattered
diverticulosis
is seen throughout the colon.
2. Scattered hepatic hypodensities, likely a combination of
cysts and
hemangiomas.
.
---------------
CHEST X-RAY
---------------
Portable view of the chest in upright position demonstrates the
cardiomediastinal silhouette to be within normal limits. There
is no
pneumothorax, consolidation, or pleural effusion. The pulmonary
vasculature is normal. The osseous structures are unremarkable.
.
Colonoscopy
Diverticulosis of the colon
Grade 2 internal hemorrhoids
Brief Hospital Course:
66 year old male with history of diverticulitis and colon
adenomas who presented with hematochezia.
1. Hematochezia: The patient was initially admitted for
hematochezia the night prior to admission. He was also
symptomatic with dizziness, chills, and dyspnea on exertion. He
was [**Hospital 1801**] transferred to the MICU, where he received 2 units
of PRBC. Upon transfer to the floor, he was hemodynamically
stable with resolution of sypmtoms, and remained this way
throughout the rest of his admission. CT abdomen and pelvis did
not demonstrate diverticulitis or appendicitis, but did
demonstrate diverticulosis throughout the colon. A colonoscopy
was performed which demonstrated diverticulosis throughout the
colon and grade 2 internal hemorrhoids, but no source of acute
bleeding. At this point, both diverticulosis and internal
hemorrhoids may be the source of the patient's painless
bleeding. He was recommended by GI to have a repeat colonoscopy
performed in 5 years and to follow-up in [**Hospital **] clinic for a
possible capsule study if symptoms persist.
2. Liver hypodensities: Incidentally found on CT abdomen and
pelvis. Per radiology report, likely to represent cysts or
hemangiomas.
3. Hypertension: On admission, the patient's anti-hypertensive
medications were held given intravascular volume status. He was
normotensive throughout his admission, and on discharge was
instructed to resume his home medication regimen.
4. Diabetes: The patient's home glucophage regimen was help on
admission, and he was controlled with ISS during his hospital
course. On discharge, he was instructed to resume his home
diabetic regimen including glucophage.
5. Hyperlipidemia: The patient was continued on home statin
therapy while admitted.
Medications on Admission:
Lipitor 10mg
Glucophage 500mg daily?
Monopril 10mg daily
Atenolol 50mg daily
Lisinopril 20mg daily
Vicodin 5/500mg PRN
Colace 100mg daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Glucophage 500 mg Tablet Sig: One (1) Tablet PO once a day.
3. Monopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary - Hematochezia
Secondary
Diverticulosis
Internal hemorrhoids
Hypertension
Hyperlipidemia
Inguinal hernia s/p repair
Colonic adenomas s/p resection
Discharge Condition:
Patient was discharged in stable condition.
Discharge Instructions:
1. You were admitted for bloody stools. You were also
complaining of new shortness of breath, chills, and dizziness
since you started bleeding, which was likely due to blood loss.
You had a colonosocpy performed while admitted that demonstrated
diverticulosis and internal hemorrhoids, but no source of
obvious bleeding. You were also transfused with red blood cells
while hospitalized. You will need to follow-up with
gastroenterology in [**2-9**] weeks as listed below.
2. Please resume all of your home medications as taken prior to
admission. It is very important that you take all of your
medications as prescribed.
3. It is very important that you make all of your doctors
[**Name5 (PTitle) 4314**].
4. If you have another episode of large amounts of bright red
blood with stools, chest pain, shortness of breath, fever, or
other concerning symptoms, please call your PCP or go to your
local Emergency Department immediately
Followup Instructions:
Please follow-up wiht gastroenterology in [**2-9**] weeks. You can
make an appointment by calling ([**Telephone/Fax (1) 2233**].
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16365**], in 2 weeks. You
can make an appointment by calling ([**Telephone/Fax (1) 43017**]
Completed by:[**2111-7-31**]
|
[
"2851",
"4019",
"2724",
"25000",
"42789"
] |
Admission Date: [**2143-7-4**] Discharge Date: [**2143-7-9**]
Date of Birth: [**2087-7-1**] Sex: M
Service: NEUROLOGY
Allergies:
Ativan
Attending:[**First Name3 (LF) 11344**]
Chief Complaint:
seizures/status epilepticus
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 17122**] is a 56 year old man with a history of infantile
meningitis, MR, epilepsy and recent diagnosis of atrial
fibrillation, pericardial effusion and chronic hyponatremia, who
was admitted after prolonged seizure yesterday.
According to his mother, she called out to him and he did not
respond. Upon finding him, he had convulsive movements of his
left side, with his head deviated to the left. She called 911.
The EMTs administered 5 mg Valium at the home and an additional
5
mg Valium in the ambulance. Nonetheless, his seizures
continued.
The next time his mother saw him, he primarily had intermittent
left gaze deviation and nystagmus. This eventually resolved
with
an additional 5 mg IV Valium. He was then transferred here from
[**Hospital1 18**] [**Location (un) 620**] for further evaluation.
Mr. [**Known lastname 56411**] mother noted that he has had a recent increase in
bowel movements, up to 5-6 per day of foul-smelling stool. She
stated that recent stool cultures were negative for C. diff,
although the ova and parasites evaluation was not yet completed.
Mr. [**Known lastname 17122**] has also had recent difficulties with atrial
fibrillation, pericarditis and pericardial effusion, for which
he
was hospitalized in [**2143-4-21**] and started treatment with
Amiodarone. He has also recently had a elevated TSH, for which
he is to be treated with levothyroxine.
Past Medical History:
-Meningitis as an infant
-Mental retardation
-Seizure disorder
-Hyponatremia of unclear etiology (query anti-epileptics)
-Cardiomyopathy: unknown, though possibly ischemic etiology, EF
30-35% but estimated pcwp < 12 per tte doppler, no CHF sx
-Possible CAD: no prior cath or stress, but upon [**3-/2143**] admit
for aspiration pna and sz, found to have elevated Tn (0.73) and
MB-index, multiple WMAs seen on TTE
-Right atrial mass: seen on [**3-/2143**] TTE, unknown etiology, not
seen on subsequent TTEs
-OSA
Social History:
Pt lives in a group home, smoked 1ppd x 30 yrs. No etoh or
illicit drug use. Mother involved in care.
Family History:
No other family members with seizures.
Physical Exam:
Physical Exam:
General: WN/WD man, agitated, frequently moving around within
his bed, disrobing, unable to maintain focus to answer any
questions or follow any commands, limiting examination.
MS: As above.
CN: Able to follow examiner around room. PERRL. Symmetric
facial movements.
Motor: Moves all extremities against gravity. Formal MRC
testing unable to be performed.
Coordination, Gait, Sensation: Unable to perform.
DTRs: 2 bilateral triceps, biceps, brachioradialis, patellar,
Achilles. Downgoing toes bilaterally.
Pertinent Results:
[**2143-7-9**] 07:30AM BLOOD WBC-6.9 RBC-3.65* Hgb-11.6* Hct-32.9*
MCV-90 MCH-31.7 MCHC-35.1* RDW-17.1* Plt Ct-215
[**2143-7-4**] 09:09PM BLOOD Neuts-66.6 Lymphs-24.8 Monos-6.6 Eos-1.9
Baso-0.1
[**2143-7-9**] 07:30AM BLOOD Glucose-83 UreaN-6 Creat-0.6 Na-136 K-4.0
Cl-99 HCO3-30 AnGap-11
[**2143-7-4**] 09:09PM BLOOD Lipase-40
[**2143-7-5**] 11:07AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2143-7-9**] 07:30AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.7
[**2143-7-4**] 09:09PM BLOOD calTIBC-355 Ferritn-29* TRF-273
[**2143-7-4**] 04:00AM BLOOD TSH-9.5*
[**2143-7-4**] 04:00AM BLOOD Free T4-1.1
[**2143-7-5**] 04:30PM BLOOD Cortsol-20.5*
[**2143-7-9**] 07:30AM BLOOD Phenyto-16.5 Valproa-84
[**2143-7-4**] 04:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
EEG [**2143-7-4**]:
Abnormal EEG due to the mildly slow background and due to
the relatively frequent sharp features and spikes in the right
anterior
quadrant. The first abnormality suggests an encephalopathy, but
some of
the slowing could come from drowsiness. Excessive drowsiness can
also
be the manifestation of an encephalopathy. The sharp features
and
spikes in the right anterior quadrant indicate an area of
potential
epileptogenesis. There were no simple spike or sharp and slow
wave
complexes. There were no areas of prominent focal slowing.
CXR [**2143-7-4**]:
The heart size is normal. Mediastinal position, contour and
width are unremarkable. The lungs are essentially clear. Minimal
atelectasis at the left retrocardiac space is demonstrated. No
sizeable pleural effusion is seen.
TTE [**2143-7-5**]:
The left atrium is mildly dilated. No mass or thrombus is seen
in the right
atrium or right atrial appendage. The estimated right atrial
pressure is [**5-30**]
mmHg. 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 and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2143-5-2**], no
right atrial mass is seen. Review of the prior images suggests
the mass may have been extrinsic to the heart (e.g., liver) and
is more clearly defined on the current study.
Brief Hospital Course:
Neurology: Patient was admitted to epilepsy service after
patient had been admitted with recurrent seizures in context of
infectious diarrhea and possible missed medication dose. Patient
had an EEG on HOD which showed generalized slowing with no
epileptiform discharges, consistent with post-ictal state and
valium use. Patient was also noted to be combative that day and
IV access could not be obtained. Later that evening, he was
noted to be acutely hypotensive with SBP 78/56. Emergent PIV
access was obtained and patient was given IVF NS bolus with only
small improvement in blood pressure before PIV became dislodged.
He was transferred to MICU for sustained hypotension and central
line need. Etiology of his hypotension likely dehydration after
history of diarrhea and decreased oral fluids. In the MICU, the
patient had an [**Year (4 digits) 461**] which showed no worsening in
ejection fraction, no pericardial effusion. He received a PICC
line and anti-epileptic medications were given IV until patient
was more awake to take po. The patient returned [**Hospital Ward Name 121**] 5, the
step-down unit for further monitoring. His blood pressure
remained stable without IVF and he was able to take his Depakote
and dilantin orally with good troughs noted. He continued to
have diarrhea while hospitalized and stool was positive for C.
diff. The patient started on 14 day course of po Vancomycin on
[**2143-7-8**].
Of note, the patient's TSH was noted to be elevated (9.5) and
free T4 noted to be in normal range. The patient's
endocrinologist was contact[**Name (NI) **] and no medication changes were
recommended.
Medications on Admission:
-Amiodarone 200 mg po q day
-Depakote 1000mg po TID
-Dilantin 100 mg/100 mg/200 mg
-Toprol XL 50 mg po q day
-Folate 1mg po BID
-NaCl 2g po TID
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Phenytoin Sodium Extended Oral
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO 1 tab in AM, 1 tab lunch, 2 tabs in the evening for 6 months:
1 tab by mouth in the morning, 1 tab by mouth at lunch and 1 tab
by mouth in the evening.
Disp:*180 Capsule(s)* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
5. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
6. Valproic Acid 250 mg Capsule Sig: Four (4) Capsule PO Q8H
(every 8 hours) for 6 months.
Disp:*370 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
seizure disorder, hypotension
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. Blood pressure, hydration status and
medication compliance should be assessed by VNA. VNA should also
make referral for home health aid/outpatient social worker if
needed.
You have a seizure disorder and should take certain precautions.
You are discouraged from climbing higher than 10 feet. Do not
bathe alone, as some people have drowned in the bath during a
seizure. You are encouraged to take a shower and leave the door
unlocked. There should be no unsupervised swimming; you should
swim with other swimmers who are strong enough to rescue them.
You should wear a helmet when riding a bike or rollerblades. You
should not drive unless they have been seizure free for six
months and your vision has been assessed and cleared for
driving. While there can??????t be a universal rule applicable to
every possible situation and person, older children and adults
also need to take reasonable precautions or restrictions with
more dangerous activities, such as operating heavy machinery and
playing contact sports.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2143-10-7**] 11:30 pm
|
[
"2761",
"42731",
"4280",
"2449",
"3051",
"32723"
] |
Admission Date: [**2141-5-31**] Discharge Date: [**2141-6-1**]
Date of Birth: [**2092-2-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Dicloxacillin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
cerebral aneurysms
Major Surgical or Invasive Procedure:
[**2141-5-31**]: Cerebral Angiogram and stenting of left ICA
History of Present Illness:
49-year-old woman with a history of headache. [**Known firstname 1356**] is a
pleasant neuro ICU nurse who struck her head while at work in
[**2140-6-29**]. She had no loss of consciousness, but developed
persistent occipital headaches. Two weeks post injury, her
headaches continued and she developed nausea. She denied any
visual disturbances or weakness or numbness to her extremities.
She reported to work and a CT scan was done with negative
results. Symptoms continued
and she complained of a "sharp stabbing pain" to her occipital
area . An MRI was done and an AComm aneurysm reported. An
angiogram was performed revealing an Acomm artery aneurysm, SCA
aneurysm and Cavernous carotid aneurysm. On [**2140-9-19**] she
underwent successful coiling of the acomm artery aneurysm. She
then underwent subsequent clipping of her SCA aneurysm at [**Hospital1 2025**].
She returns today for diagnostic angiography and possible
recoiling.
Past Medical History:
Acomm artery aneurysm s/p coiling
SCA aneurysm s/p craniotomy and clipping
Social History:
Married, three children age 16, 17 and 20. Works as an ICU
nurse @ [**Hospital1 18**]. Previously smoked, quit six years ago. 2-3drinks
week.
Family History:
non contributory
Physical Exam:
[**6-1**] nonfocal. bilateral groins c/d/i
Brief Hospital Course:
Pt electively presented and underwent a cerebral angiogram under
general anesthesia. Her AComm artery and SCA aneurysms were
stable without recannulization. The left ICA cavernous aneurysm
was stable but it was difficult to confirm whether it was truely
cavernous vs petrous. Therefore it was decided the best choice
would be to embolize it. She was loaded with Plavix 600mg and
Integrillin 15mg and a stent was deployed in the L ICA. Coiling
of the aneurysm was attempted through the stent but aborted due
to stent movement. She was then transferred to the ICU and
successfully extubated. Her 3f left arterial line was removed at
midnight without difficulty. She remained neurologically stable
overnight. Her right arterial sheath was removed at 730am
without difficulty. She remained on flat bedrest until 1530. Her
activity was then slowly increased. Groins remained stable so
she was cleared for discharge.
Medications on Admission:
none
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back pain.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acomm artery aneurysm s/p coiling
SCA aneurysm s/p clipping
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
Followup Instructions:
* Dr [**First Name (STitle) **] will see you in one month. If you have any questions
or issues please call [**Telephone/Fax (1) 1669**].
Completed by:[**2141-6-1**]
|
[
"V1582"
] |
Admission Date: [**2132-8-2**] Discharge Date: [**2132-8-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
shortness of breath, change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt was an 89 yo male with htn, hyperlipidemia, recent penile
surgery for penile cancer who presented to OSH with confusion,
chest pain and shortness of breath. Patient wasmunable to
provide a good history. Per family patient went to urologist's
office the day prior to admission and was in no acute distress
at that time. The day of admission, one of his daughters noted
him to be more confused, pulling at things. He was taken to
[**Hospital3 7569**]. ECG wtih STE V2-V5 and Na 115 and he was
transferred to [**Hospital1 18**] for further mgmt.
.
In the ED here, Na 118, STE V2-V5, I, L, bedside echo with small
pericardial effusion. Pt had been started on heparin earlier at
[**Location (un) **] given concern for ACS and this was stopped after the
echo. He received 600mg plavix in ED.
.
On ROS, pt had temp to 101, 1 day PTA. per family has had poor
PO intake for several days PTA.
Past Medical History:
penile cancer, s/p surgery
h/o back pain
HTN
Hyperchol
Social History:
Lives with daugher. Previous cigar smoker quit 15 yrs ago.
social etoh beer.
Family History:
non-contributory
Physical Exam:
VS: PE T 97 BP 106/60 HR 69 RR 26 O2 95%2L
General: 89 yo male in mild respiratory distress sitting up in
bed, intermittently writhing as if in pain,pulling at clothes,
reaching for objects in the air, diaphoretic.
HEENT: distended neck veins, use of accessory respiratory
muscles. PERRL. MMM.
Heart: RR in 60's, pericardial friction rub. When patient was
placed in the supine position for further cardiac examination,
he became extremely cyanotic from the mid chest cephalad and
seemed to be syncopal with marked respiratory distress that
improved with return to seated position.
Lungs: CTAB, decreased at bases, no crackles
Abdomen: soft, NT, ND
Ext: No edema/cyanosis/clubbing
Neuro: A&O to place and time. Patient seems to have lucent
moments and then speaks in gibberish for several moments,
pulling at lines and clothing.
Pertinent Results:
[**2132-8-2**] diff: Neuts-85* Bands-4 Lymphs-7* Monos-3 Eos-0 Baso-0
Atyps-0 Metas-1* Myelos-0
[**2132-8-2**] CBC: WBC-15.9* RBC-4.20* Hgb-12.4* Hct-34.6* MCV-82
MCH-29.4 MCHC-35.7* RDW-14.8 Plt Ct-285
[**2132-8-2**] PT-18.7* PTT-92.6* INR(PT)-1.8*
[**2132-8-2**] UreaN-31* Creat-1.3* Na-118* K-3.8 Cl-81* HCO3-21*
AnGap-20
[**2132-8-2**] BLOOD Na-114*
.
CE trends:
[**2132-8-2**] 07:15PM BLOOD CK(CPK)-263*
[**2132-8-2**] 07:15PM BLOOD CK-MB-17* MB Indx-6.5* cTropnT-0.11*
[**2132-8-2**] 11:10PM BLOOD CK-MB-18* MB Indx-6.4* cTropnT-0.12*
[**2132-8-3**] 09:11AM BLOOD CK-MB-35* MB Indx-3.0 cTropnT-0.24*
[**2132-8-4**] 04:02AM BLOOD CK-MB-52* MB Indx-1.0 cTropnT-0.31*
.
[**2132-8-4**] 04:02AM BLOOD TSH-2.0
[**2132-8-4**] 02:06PM BLOOD Osmolal-303
[**2132-8-3**] 09:22AM BLOOD Type-[**Last Name (un) **] pO2-31* pCO2-63* pH-7.05*
calTCO2-19* Base XS--15
[**2132-8-3**] 04:16PM BLOOD Lactate-4.6*
.
CTA CHEST W&W/O C &RECONS [**2132-8-2**] 7:34 PM- IMPRESSION:
1. No evidence for pulmonary embolus. Moderate sized bilateral
pleural effusions with bibasilar subsegmental atelectasis.
2. Contrast refluxing down the hepatic veins suggesting right
heart failure.
3. Pleural calcifications suggest prior asbestos exposure.
.
ECHO Study Date of [**2132-8-2**]
Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal(LVEF>55%). Due to suboptimal technical
quality, a focal wall motion
abnormality cannot be fully excluded. The right ventricular
cavity is markedly dilated. Free wall motion could not be
adequately assessed (apical function is preserved). There is an
anterior space which most likely represents a fat pad.
.
ECG Study Date of [**2132-8-2**] 6:49:30 PM
Sinus rhythm. Prolonged QTc interval. Inferolateral ST segment
elevations of uncertain etiology. Clinical correlation is
suggested.
Brief Hospital Course:
89 yo M with HTN, CAD admitted with mental status changes,
hyponatremia and diffuse STE on ECG.
.
1. Hyponatremia - It is unclear why the patient presented with
such marked hyponatremia, likely, it was secondary to chronic
overuse of HCTZ. The sodium was corrected with hypertonic saline
to the 130's over the course of 36-48 hours, although the
patient's mental status did not improve.
.
2. STE - possibly due to myopericarditis and less likely due to
ACS as no focal wma on limited ECho, no q waves on ECG, and CK
and trop only marginally elevated over the course of 16 hours.
Picture more consistent with pericarditis/myocarditis especially
given pericardial effusion, friction rub, positional chest pain
s/s possible infective prodrome. The patient was started on high
dose NSAID's for presumed myopericarditis, however, it was d/c'd
after 1 dose s/s acute renal failure.
.
3. CAD - noted on CT. ASA was started, statin continued.
4. PUMP - EF of >55%. small ASD.
5. Dyspnea - unclear why pt has bilateral pleural effusions.
With respiratory distress, did not respond to several doses of
lasix indicating prerenal failure s/s decreased perfusion.
Distress with reclining resembles an SVC syndrome with plethora
and cyanosis within seconds. First official read of CTA chest
did not find a PE or evidence of SVC syndrome, but on review of
the TTE it seems that there was moderate right ventricular
dilation which may indicate that there is a PE, however no
indication on CTA. Patient was started on low dose lovanox.
.
6 Renal Failure - unclear baseline creatinine, however failure
was s/s to an ATN of either rhabdomyolasis vs. hypoperfusion. Cr
rose as high as 3.6. IVF were given and urine output improved
mildly.
.
7. Coagulopathy - INR 1.8 likely due to nutritional deficiency.
.
8. S/p penile surgery - No records of surgery. On exam pt had
recent surgery wound with resection of part of penis and opening
in the middle, by urology, this is a reconstructed urethra.
Foley was placed by urology.
.
9. CMO - the patient was made CMO by the family on [**2132-8-5**]. The
patient had several episodes of severe respiratory distress with
two runs of SVT controlled with lopressor and amiodarone. He was
admitted DNR/DNI, but with multisystem organ failure and
significant respiratory distress, the option of MICU transfer
for aggressive management versus CMO was discussed at length
with the patient's family and they felt that it would be the
patient's wishes to be made CMO. On [**2132-8-5**], the patient was
transferred from the CCU to the floor on a morphine drip and
expired on [**2132-8-6**].
Medications on Admission:
Gemfibrozil 600 once daily
Proscar 5 mg daily
triametrene/hctz 37.5/25 daily
Lipitor 10 daily
Gabapentin 900 tid
aricept 10 mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
None
|
[
"2761",
"5849",
"42789",
"41401",
"4019"
] |
Admission Date: [**2179-11-13**] Discharge Date: [**2179-12-15**]
Date of Birth: [**2133-1-26**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
direct admit for work up of pulmonary nodules
Major Surgical or Invasive Procedure:
None
History of Present Illness:
*
Mrs. [**Known lastname **] is a 46 yo female with a h/o myocardial infarction
([**4-12**] s/p stents now on ASA/[**Month/Year (2) **]) who is s/p matched unrelated
allogeneic BMT for acute monocytic leukemia 3 years ago who
presents for work-up of pulmonary nodules found on CT scan at
OSH. Mrs. [**Known lastname **] was diagnosed with M4 AML in 05/[**2175**]. She was
initially treated with daunorubicin, Ara-c and etoposide. She
was then referred to [**Hospital 4415**] for further
evaluation, where she received further induction on chemotherapy
with daunorubicin and cytarabine in 07/[**2175**]. She underwent a MUD
transplant on [**2176-10-4**]. Her transplant course was complicated
by grade 1 acute graft versus host disease of the skin as well
as acute renal failure. Reportedly, following her transplant,
she developed chronic graft versus host disease of the GI tract,
lungs and eyes.
*
Mrs. [**Known lastname **] was in remission but her course has been complicated
by GVHD of the skin (scleroderma reaction). She has been
treated for this with Rituxan and more recently with
Pentostatin. Recently, her most noticable complaint has been
progressively worsening dyspnea on exertion. She was admitted
for this in [**State 1727**] one month ago and has felt to have a component
of diastolic heart dysfuntion with an elevated BNP in the 400's.
PFT's performed at that time revealed a significant obstructive
defect with mininal response to bronchodilators felt consistent
with interstitial lung disease. Since this time, she notes that
her symptoms have been worsening with increasing more rapidly.
Now, she becomes SOB walking approximately 100ft or climbing [**4-14**]
steps. In addition, over the past 3-4 days, she notes that she
has been coughing up brown-rust colored sputum. She has also
developed some pain on
deep inspiration at her left costal margin.
*
Her oncologist at [**Hospital1 18**] (Dr. [**First Name (STitle) 1557**] referred her to see a
pulmonologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]) at [**Hospital1 336**] the day prior to
admission. A CT of her chest was performed showing bilateral
pulmonary nodules. Because of these findings, there was concern
for Aspergillus, and she was subsequently referred to [**Hospital1 18**]
given the majority of her care is under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]. The
patient decided that she would come in the following morning.
*
At the time of admission, the denies any fevers, chills, change
in weight or appetite over the past several months. She reports
persistent nausea as well as bouts of constipation interspersed
with diarrhea. She has also had a persistent ulceration in her
right upper buccal mucosa which has not healed despite a course
of famvir and oral diflucan. She additionally has been followed
for persistent conjunctivitis believed to be ocular GVHD. She
reports a sensation of facial pressure but denies any nasal
drainage, visual or hearing
changes, headache, dizziness, or any focal neurologic symptoms.
Past Medical History:
1) Acute monomyelocytic leukemia s/p allo-MUD transplant 3 years
ago as above.
2) CAD: s/p MI and stentx2 one year ago in [**State 1727**].
3) GVHD: mostly cutaneous, questionably ocular.
4) Intersitial lung disease
5) Diastolic heart dysfunction
Social History:
Lives in [**State 1727**], smoked 1 PPD x 30 years but quit in [**4-12**] after
having MI, denies any ETOH or drug abuse.
Family History:
NC
Physical Exam:
VS: WT 133lbs, T 98.7, HR 98, RR 16, BP 130/84, O2 Sat 94% RA
GEN: comfortable, very cushinghoid appearance.
HEENT: PERRL, mild bilateral scleral injection sparing the [**Doctor First Name 2281**],
oropharynx significant for a 2cm ulceration with minimal whitish
exudate in the left upper buccal mucosa.
NECK: +buffalo hump, supple, no LAD.
CV: RRR, no m,r,g
RESP: bilateral late expiratory wheezes in the lower lung zones,
otherwise CTA, poor aeration
ABD: Obese, firm, non-tender, no appreciable HSM.
EXT: lower extremities show scant proximal muscle mass, 1+ pedal
edema to above the ankle bilaterally.
SKIN: erythematous serginious rash involving the upper
extremities and upper chest.
NEURO: CN II-XII intact bilat, decreased sensation on the left
UE and left LE
Pertinent Results:
[**2179-11-13**] 11:53AM WBC-2.3* RBC-3.56* HGB-11.8* HCT-35.2*
MCV-99* MCH-33.0* MCHC-33.4 RDW-15.1
[**2179-11-13**] 11:53AM NEUTS-49* BANDS-5 LYMPHS-3* MONOS-32* EOS-0
BASOS-0 ATYPS-0 METAS-8* MYELOS-3* NUC RBCS-1*
[**2179-11-13**] 11:53AM PLT SMR-NORMAL PLT COUNT-269
[**2179-11-13**] 11:53AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2179-11-13**] 11:53AM GLUCOSE-247* UREA N-42* CREAT-1.0 SODIUM-136
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17
[**2179-11-13**] 11:53AM ALBUMIN-3.6 CALCIUM-9.4 PHOSPHATE-2.2*
MAGNESIUM-1.9
[**2179-11-13**] 11:53AM PT-12.0 PTT-21.7* INR(PT)-0.9
[**2179-11-13**] 11:53AM ALBUMIN-3.6 CALCIUM-9.4 PHOSPHATE-2.2*
MAGNESIUM-1.9
[**2179-11-13**] 11:53AM GRAN CT-1476
*
CT Scan [**2179-11-12**] @ OSH (no report available): multiple bilateral
pulmonary nodules, 2 in the left upper lobe (approximately 3
cm), one in the left lower lobe possibly with cavitation.
Brief Hospital Course:
*
Mrs. [**Known lastname **] is a 46 yo female 3 years s/p matched related
allogeneic BMT AML now severely immunosuppressed, who presented
with multiple bilateral pulmonary nodules in the setting of
persitently worsening dyspnea on exertion and brown-rust colored
sputum.
*
1) PULMONARY NODULES: The patient was significantly
immunocompromised on predisone, cellcept, prograf, and
pentostatin. Therefore, opportunistic infections were
considered on admission. Mrs. [**Known lastname **] was initially started on
Ambisome for empiric coverage of fungal infection such as
aspergillus. She was also started on levofloxacin. She was
taken for VATS on [**2179-11-15**] for biopsy of the lung nodules seen on
chest CT. A bronchoscopy with lavage was also performed during
the procedure. The tissue biopsy obtained during VATS was
negative; however, the BAL was positive for Aspergillus. Her
antifungal regimen was changed from Ambisome to Voriconazole and
Caspofungin. The levofloxacin was later discontinued. Follow
up CT scans of the chest showed findings consistent with
invasive aspergillosis.
*
2) PLEURITIC PAIN: Throughout her admission, the patient
continued to complain of right sided pleuritic pain. The
patient also has chronic pain on top of this acute pain for
which she takes a very low dose of MSIR as an outpatient. She
was started on MS contin 15 mg PO BID, which was later titrated
up to 30 mg PO BID. The pain service was consulted and
recommended starting a lidoderm patch as well as neurontin.
These recommendations were implemented. The acute pleuritic
pain was on the same side of the VATS, so it was thought to be
post-procedural pain, possibly from nerve injury. She also had
an effusion and pleural thickening, so it may have been pain due
to pleural inflammation related to the VATS. A CTA was performed
on [**11-28**] which was negative for pulmonary embolism. The
Pulmonary Service was consulted and their impression was that
her pleuritic pain was due to post-procedural pleural
inflammation. They recommended starting NSAIDS for
anti-inflammatory effect. The patient was started on Ibuprofen
400 mg PO BID and her pain significantly improved. A
thoracentesis was considered to remove fluid from her effusion;
however, it was decided that there was an insignificant amount
of fluid for the procedure to be performed safely.
*
3) MUCOSAL ULCER: The patient had an oral ulcer on admission,
which was thought to be secondary to graft vs. host disease. At
one point, this ulcer became worse and appeared to have an
exudate. There was some concern for was concern for spreading
infection, which may have been involving her sinuses. A sinus
CT was obtained and was negative with exception of mucosal
thickening. She was already on antifungal coverage for
aspergillus. ID was also consulted. She was followed
radiographically with another sinus CT which was unchanged. The
appearance of the ulcer gradually improved.
*
4) EDEMA: The patient had swelling in her left upper and
bilateral lower extremities. She had been net positive since
admission (up 10 pounds), therefore likely it was thought to be
due to fluid overload. There was also concern for CHF given the
patient had an MI in [**4-12**], and there was no echo on file since
[**11-11**]. A TTE was performed [**11-21**] and revealed normal EF. The
lower extremity edema was likely due to GVHD. She was given
gentle diuresis. A left upper extremity doppler U/S was also
performed for the finding of unilateral upper extremity edema.
This study was positive for a left IJ clot. This was reportedly
chronic, and has been followed with serial U/S in the past. She
was not anticoagulated due to her high risk for bleeding given
cavitary lung nodules due to invasive aspergillus.
*
5) ERYTHEMATOUS LEFT FOREARM RASH: During her hospitalization,
the patient had redness on her left forearm. This was
concerning for cellulitis. She was started on vancomycin and
the rash resolved. Vanco was discontinued [**11-29**].
*
6) CAD: The patient has a history of MI in [**2179-4-10**]. She was
stented at that time and was put on [**Year (4 digits) **] and Aspirin. During
this admission, the patient needed to be taken off of these
medications so she could have surgical procedures performed.
Cardiology was contact[**Name (NI) **] to see if the aspirin and [**Name (NI) **] could
be held. Cardiology stated that holding the aspirin and [**Name (NI) 4532**]
temporarily would would be reasonable, given the stents have
likely had time to re-epithelialize over the last 6 months. She
was continued on her beta-blocker. Her aspirin was restarted on
[**11-30**]. The [**Month/Year (2) 4532**] will be restarted at a later time.
*
7) ACCESS: A right IJ was placed during the VATS procdure on
[**11-14**]. Later, a Hickman catheter was placed on [**11-28**] and the
right IJ was removed.
*
8) RML PNEUMONIA: Later in her hospital course, a chest x-ray
was performed showing a RML pneumonia. She was restarted on
levofloxacin and Flagyl was added for presumed aspiration
pneumonia. On [**11-30**], the patient had had increased secretions
and poor O2 saturation. A repeat CXR was performed and showed a
worsening RML pneumonia. Antibiotics were continued and she was
started albuterol and atrovent nebulizers. Humidified air and
chest PT were used to break up secretions.
*
9) RESPIRATORY DISTRESS: On [**11-30**], the patient desatted to the
mid 80's on 1 liter O2 via nasal cannula. After titrating her
O2 up to 5-6 liters via NC, her sats improved to the mid 90's.
She was now having more difficulty moving her secretions. Over
the next 48 hours, she had several more episodes of
desaturation. She was started on albuterol and atrovent nebs,
as well as humidified air and chest PT to break up secretions.
Eventually, the patient had episode of desaturation requiring
100% non-rebreather to maintain saturation in the mid 90's. At
this point in her hospital course, she was transferred to the
ICU for further managment.
*
ICU course:
Mrs. [**Known lastname **] was admitted to the [**Hospital Unit Name 153**] for respiratory distress
with an increasing O2 requirement, felt to be secondary to an
aspiration event. In the [**Hospital Unit Name 153**], she was unable to intubated
because of significant upper airway anatomical obstruction from
her GvHD, so an emergent tracheostomy was performed.
1.)Respiratory failure -- Multiple factors were felt to
contribute, including aspiration, GvHD/capillary leak syndrome,
invasive aspergillois, and decreased chest wall compliance (from
GvHD/anasarca/obesity). For aspiration, she was intially
treated with piperacillin/tazobactam, though this was stopped
because of thrombocytopenia and vancomycin. For GvHD, her
mycophenylate and tacrolimus were continued, and for
aspergilossis, her caspofungin and voriconazole were continued,
and for chest wall compliance, a gentle diuresis was effected.
On this regimen, her oxygenation and ventilation gradually
improved and she was switched to pressure support ventilation,
that was gradually weaned down.
2.)Hypotension -- On admission to the [**Hospital Unit Name 153**], Mrs. [**Known lastname **] was
hypotensive, with numerous factors influencing her blood
pressure. In addition to possible sepsis, she was also felt to
be intravascularly dry despite massive total body volume
overload. In addition, sedation and high pressures of
mechanical ventilation played a role. Initially on
phenylephrine, norepinephrine was added. With antibiotics,
stress dose steroids, and decreasing sedation/positive pressure,
these were both weaned off, and she was able to maintain
adequate pressures on her own.
3.)Thrombocytopenia -- This developed in the midst of her [**Hospital Unit Name 153**]
course. The most likely etiologies, piperacillin/tazobactam and
lansoprazole were stopped, as were all heparing products (and a
HIT Ig was sent). Within a few days her platelets began to
climb again.
Eventually, the patient was unable to be weaned off the
ventilator. She had severe third-spacing, and after a family
discussion, she was made comfort measures only. She passed away
with her family at her bedside.
Medications on Admission:
predisone 30mg once daily, Bactrim DS three times a
week, CellCept [**Pager number **] mg b.i.d., Prograf five milligrams, one
milligrams in the a.m., 1.5 mg in the p.m., Nexium 40 mg b.i.d.,
metoprolol 100 mg t.i.d., [**Pager number **] 75 mg daily, Zocor 40 mg daily,
aspirin 81 mg daily, lisinopril five milligrams daily, Lasix 20
mg daily, Famvir 500 mg t.i.d., folic acid one milligram a day,
and Ambien 30 mg q.h.s., morphine sulfate for pain 15 mg p.r.n.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory distress
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
"5070"
] |
Admission Date: [**2189-10-27**] Discharge Date: [**2189-11-11**]
Date of Birth: [**2138-8-27**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
right total hip arthroplasty
History of Present Illness:
The patient is a 51-year-old gentleman with a history
significant for CML s/p bone marrow transplant and chronic GVHD
was referred for right hip pain.
Orthopedically, he has severe progressive right hip avascular
necrosis related to longstanding prednisone therapy for a
matched unrelated donor bone marrow transplant in [**2182**] for
chronic myelogenous leukemia. The patient has suffered from
chronic graft versus host disease, typically oral and in the eye
as well.
He has been off and on large doses of prednisone as well as
CellCept. He had a contralateral left total hip replacement in
[**2188**] at [**Hospital 50878**], which was complicated by a flareup of
his
GVH. He has had a right total knee replacement in [**2186**] and a
left total knee replacement in [**2187**] again at [**Location (un) 511**] Medical
Center. All of these have been related to avascular necrosis
secondary to prednisone therapy. At this point, he is interested
in a right total hip replacement. He states that the pain is
presently [**10-26**] in the right hip with activity. He
intermittently uses a cane. The pain has markedly
worsened in the past 2 months, and he has noted decreased range
of motion as well. This all severely limits his ability to
remain active and gainfully employed as a commercial real estate
salesman in [**Doctor Last Name **].
Past Medical History:
Past Surgical History: Left herniorrhaphy, left total hip, left
total knee, and right total knee.
Current Medical Problems: Chronic graft versus host disease;
chronic myelogenous leukemia, chronic low back pain, avascular
necrosis of femoral heads and supracondylar femurs.
Social History:
Commercial real estate salesman, does not smoke,
does not drink, and tries to exercise 10-15 minutes a day as
pain
allows.
Family History:
non-contributory
Physical Exam:
Thin white male, 5 feet, 156 pounds. Has
an antalgic gait favoring the right side. He has a normal knee,
foot, and ankle exam. His lower extremities are equal in length.
He has markedly-diminished range of motion through the right hip
with no remaining internal or external rotation, can only abduct
20 degrees, and flex to about 85 degrees. He has good vascular
inflows bilaterally with 5/5 strength.
Pertinent Results:
[**2189-10-27**] 06:37PM GLUCOSE-158* UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-21* ANION GAP-13
[**2189-10-27**] 06:37PM CALCIUM-8.3* PHOSPHATE-3.0
[**2189-10-27**] 06:37PM WBC-8.4 RBC-3.68* HGB-11.7*# HCT-33.2* MCV-90
MCH-31.7 MCHC-35.2* RDW-14.6
[**2189-10-27**] 06:37PM PLT COUNT-152
Brief Hospital Course:
51 year-old patient with PMH chronic GVHD and CML, underwent
right total hip arthroplasty on [**2189-10-28**] for right hip AVN. The
patient tolerated the procedure well. His postoperative course
was complicated by a GVHD exacerbation and by anemia.
Neurologic: Pain was initially managed with a morphine PCA
followed by oral Percocet
Respiratory: The patient's oxygen saturations gradually improved
and at the time of discharge they were weaned to room air.
Cardiovascular: The patient had no cardiac issues. He did have
some occasional low blood pressures early in his postoperative
course but these resolved after several transfusions.
Hematologic: The patient's hematocrit dropped to a low of 22
from 33, however after a transfusion it stabilized and was
stable at 27.7 at discharge. The patient was also started on
iron. Lovenox was started for DVT prophylaxis on post-operative
day number one.
Infectious Disease: The patient was given 48 hours of
Vancomycin for postoperative surgical prophylaxis.
Fluids/Electrolytes/Nutrition: The patient??????s electrolytes were
checked on post-operative day number one and were within normal
limits. He/she was tolerating a regular diet at discharge. The
Foley was removed on post-op day number 2.
Orthopedic: The patient worked with physical therapy and had a
achieved good ROM and was able to ambulate with minimal assist
at discharge, while still being compliant with the strict
restriction on 30% WB. The wound appeared clean, dry, and
intact, however, there was some increasing serous drainage
likely from a liquefying hematoma.
Medications on Admission:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MONDAY/WEDNESDAY/FRIDAY ().
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
for 3 weeks.
8. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q 24H (Every
24 Hours).
9. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. Triazolam 0.75 mg QHS
11. Prednisone 10 mg PO QAM
12. Prednisone 5 mg PO QPM
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MONDAY/WEDNESDAY/FRIDAY ().
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
8. Enoxaparin 40 mg/0.4mL Syringe Sig: Forty (40) Subcutaneous
DAILY (Daily) for 3 weeks.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q 24H (Every
24 Hours).
13. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
14. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
15. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for if patient is still awake at
0200.
16. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
18. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
19. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for pruririts.
Discharge Disposition:
Extended Care
Facility:
St. [**Doctor Last Name 11042**]
Discharge Diagnosis:
right hip avascular necrosis
Discharge Condition:
good
Discharge Instructions:
1) Please keep wound covered with dry sterile dressing. OK to
shower. Do not bathe.
2) Please continue taking all medications as taken prior to this
hospitalization. Please also complete full course of lovenox to
prevent blood clot, colace to prevent constipation, and percocet
for pain.
3) Do not drive or operate machinery while taking percocet.
4) Please follow-up with Dr. [**Last Name (STitle) **] as directed. Call doctor
sooner if you devlop fevers, shaking chills, or increasing wound
redness, drainage, or pain not controlled by pain medications.
Physical Therapy:
Activity: ambulate with assist tid
Pneumatic boots
Right lower extremity: Partial weight bearing
50% WB right lower extremity x 6 weeks, posterior hip
precautions (no adduction/internal rotation), *****PARTIAL
WEIGHT BEARING IS ESSENTIAL
Treatments Frequency:
Site: right hip
Type: Surgical
Dressing: Gauze - dry
Comment: please change daily and cover with dsd (abd with paper
tape)
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2189-11-3**] 1:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 10657**] Date/Time:[**2189-11-13**]
10:00
|
[
"4019",
"2449"
] |
Admission Date: [**2131-7-21**] Discharge Date: [**2131-7-23**]
Date of Birth: [**2060-3-3**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Vision loss.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The pt. is a 71 year-old right-handed gentleman who presented
with acute onset right-sided visual loss.
He was in his usual state of health until 8:30 this evening when
he developed the acute onset of right-sided visual loss. His
daughter called an ophthalmologist who lives in the neighborhood
who came to assess the pt. He apparently diagnosed a right
hemianopia and advised calling EMS over concern for stroke. The
pt was transported via EMS to [**Hospital1 18**] ED. Code Stroke was called
on arrival (10:13pm), the Neurology resident was at bedside by
10:15pm. NIHSS was performed immediately and was 2 (for
complete hemianopia). Blood was drawn and he was taken
emergently for CT scan of the head. This revealed no ICH. The
risks and benefits of IV tPA were discussed with the pt by the
Stroke Fellow. It was decided to administer tPA given the
potential disability caused by this deficit. IV bolus of tPA
(based on wt of 70kg) was administered at 11:18pm.
The pt otherwise offered no complaints. He did state, however,
that all night last night and until roughly 11:30am, he was
experiencing palpitations, which he has been known to experience
in the past.
The pt denied headache, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denied difficulties producing or comprehending
speech. Denied focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denied difficulty with
gait.
On review of systems, the pt denied recent fever or chills. No
night sweats or recent weight loss or gain. Denied cough,
shortness of breath. Denied chest pain or tightness. 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:
-paroxysmal atrial fibrillation
-asthma
-BPH
Social History:
Pt is from [**Country 532**] and is here visiting his daughter. [**Name (NI) **] is a
virologist (MD, PhD). No history of tobacco, alcohol, illicit
drug use.
Family History:
No history of strokes, but there is a history of CAD and MI.
Physical Exam:
Vitals: T: 97.1F P: 69 R: 16 BP: 177/93 SaO2: 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no JVD or carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. 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. There was no apraxia or neglect.
-cranial nerves: Olfaction not tested. PERRL 3 to 2mm and
brisk. On confrontation, there is a complete right visual field
hemianopia in the right eye and more of a crescenteric right
visual field deficit in the left eye (i.e. it is noncongruous).
There is no ptosis bilaterally. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages. EOMI without nystagmus.
Normal saccades. Facial sensation intact to pinprick. No facial
droop, facial musculature symmetric. Hearing intact to
finger-rub bilaterally. Palate elevates symmetrically. [**6-1**]
strength in trapezii and SCM bilaterally. Tongue protrudes in
midline.
-motor: Normal bulk, tone throughout. Strength was full
throughout. No pronator drift bilaterally. No adventitious
movements noted.
-sensory: No deficits to light touch throughout. No extinction
to DSS.
-coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Pertinent Results:
[**2131-7-20**] 10:30PM BLOOD WBC-9.5 RBC-4.92 Hgb-14.7 Hct-42.6 MCV-87
MCH-29.9 MCHC-34.6 RDW-13.1 Plt Ct-279
[**2131-7-20**] 10:30PM BLOOD PT-11.3 PTT-21.4* INR(PT)-1.0
[**2131-7-20**] 10:30PM BLOOD Glucose-168* UreaN-31* Creat-1.2 Na-141
K-4.9 Cl-106 HCO3-25 AnGap-15
[**2131-7-21**] 07:41AM BLOOD ALT-27 AST-24 LD(LDH)-221 CK(CPK)-74
AlkPhos-62 Amylase-56 TotBili-1.0
[**2131-7-21**] 07:41AM BLOOD Lipase-51
[**2131-7-21**] 07:41AM BLOOD Albumin-4.0 Calcium-8.9 Phos-3.4 Mg-2.2
Cholest-189
[**2131-7-21**] 07:41AM BLOOD Triglyc-82 HDL-53 CHOL/HD-3.6 LDLcalc-120
[**2131-7-21**] 07:41AM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE
BRAIN MRI:
There is subtle signal abnormalities seen in the medial left
occipital lobe which is only visualized on the diffusion images
without corresponding abnormalities on the ADC map or on the
FLAIR or T2-weighted images. These findings are suspicious for
an acute infarct. Clinical correlation and followup examination
are recommended. There is mild prominence of sulci. Subtle
periventricular hyperintensities are noted due to small vessel
disease. There is no midline shift or hydrocephalus. Mucosal
thickening is seen in both maxillary sinuses.
IMPRESSION: Subtle diffusion abnormality in the medial left
occipital lobe suspicious for an early infarct. Consider
clinical correlation and followup.
MRA OF THE HEAD:
Head MRA demonstrates normal flow signal within the arteries of
anterior and posterior circulation. Normal flow signal is seen
in both posterior cerebral arteries.
IMPRESSION: Normal MRA of the head.
TTE:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue velocity imaging demonstrates an E/e' <8
suggesting a normal left ventricular filling pressure (<12mmHg).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is no pericardial effusion.
IMPRESSION: No cardiac source of embolus other history of PAF
found. However, transthoracic echo not adequate to assess for
atrial thrombus.
Carotid Ultrasound: Prelim read was no significant stenosis
bilaterally.
Brief Hospital Course:
1. Left occipital stroke: Exam on presentation was notable for a
noncongruous right homonymous hemianopia. Due to the potential
disability derived from this deficit, the decision was made to
give the pt IV tPA in the emergency department. He was
therefore admitted to the ICU for observation 24 hours.
Unfortunately, his deficits did not resolve. MRI demonstrated
an area of restricted diffusion in the left occipital lobe. MRA
of the brain was normal. Etiology was felt to be cardioembolic
given paroxysmal atrial fibrillation. He was started on
warfarin. TTE demonstrated no thrombus. Carotid ultrasonography
was normal. He was found to be hyperlipidemic and was started
on atrovastatin. He was also found to have an elevated glycated
hemoglobin and fasting glucose. This should be followed-up with
his PCP on his return to [**Country 532**].
2. Paroxysmal atrial fibrillation: This was felt to be the
etiology of the stroke. He was started on warfarin. He was
also continued on sotalol.
3. Hyperlipidemia: The pt was found to have elevated total
cholesterol and LDL. he was started on 10mg of atorvastatin
daily.
4. Diabetes Mellitus: The pt was found to have an elevated
glycated hemoglobin and fasting serum glucose. This should be
followed-up with his PCP on his return to [**Country 532**].
5. Asthma: The pt was continued on albuterol.
6. BPH: The pt was continued on tamsulosin.
Medications on Admission:
-sotalol
-tamsulosin
-albuterol
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
3. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Outpatient [**Name (NI) **] Work
PT, INR.
Discharge Disposition:
Home
Discharge Diagnosis:
-left occipital stroke
-paroxysmal atrial fibrillation
-hyperlipidemia
-type 2 diabetes mellitus
Discharge Condition:
Stable. Neurologic examination notable for right homonymous
hemianopia.
Discharge Instructions:
Please take all medications as prescribed. Please follow-up with
your primary care doctor upon your return to [**Country 532**]. Please
have your INR checked on Thursday so that adjustments can be
made to your coumadin dose as needed. If you experience
worsening vision, difficulties with speech, weakness, numbness
or other concerning symptoms, please return to the emergency
department for evaluation.
Followup Instructions:
Please follow-up with your primary care doctor upon your return
to [**Country 532**].
Please have your INR checked on Thursday so that adjustments can
be made to your coumadin dose as needed.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"42731",
"25000",
"49390"
] |
Admission Date: [**2123-12-13**] Discharge Date: [**2123-12-23**]
Date of Birth: [**2053-3-31**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin / Flomax / Hydrochlorothiazide / Biaxin / Atenolol
/ Lisinopril / Levaquin / Ativan
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Nausea, vomiting, abdominal pain.
Major Surgical or Invasive Procedure:
Paracentesis [**2123-12-14**] and [**2123-12-15**].
Stripping of clot from port [**2123-12-16**].
Paracentesis [**2123-12-23**].
History of Present Illness:
Patient is a 70 Y M with Stage IV colon cancer and extensive
portal vein thrombosis who presents from the ER with severe
nausea and vomiting. He began modified FOLFIRI on [**12-8**], and
after he experienced severe nausea and vomiting. He was unable
to take anything PO and went to the ER on [**12-10**] where he
received fluids, antiemetics, and felt well enough to go home.
Since that time, he has had continued nausea and non-bilious
vomiting where he is barely able to keep down water. He has
also had full body shakes without fever or chills. He notes
inceased abdominal girth and a 6lb weight gain over the past
week. He notes difficulty urinating but no urinary incontinance
or hematuria. He has [**10-28**] pain in his abdomen that is worse
with inspiration but decreases to [**1-28**] with PO morphine. Vitals
in the ER: Afebrile 98 148/87 16 95% RA; he received 2L NS, IV
morphine, Zofran and was transfered to the floor for further
management.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss.
Denies blurry vision, diplopia, loss of vision, photophobia.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain or tightness, palpitations, lower extremity
edema. Denies cough, shortness of breath, or wheezes. Denies
diarrhea, constipation, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies arthralgias
or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY: He presented in [**4-/2122**] with abdominal pain.
He had a cecal cancer with no evidence of metastatic disease by
CT. At the time of open colectomy, there was evidence of
miliary
studding and he underwent resection of at least one metastatic
macroscopically visible omental nodule. FOLFOX chemotherapy was
begun in [**7-/2122**] because of symptomatic left lower quadrant pain
related to disease progression. We switched to an every
three-week basis in [**1-/2123**] because of myelosuppression,
especially thrombocytopenia. A repeat CT after four courses
showed slight progression. He had restless legs that was felt
to
represent oxaliplatin toxicity and he was subsequently switched
to short-term infusional 5-FU and leucovorin according to the De
Gramont schedule in 07/[**2122**]. CTs since then have shown
gradually
progressive disease. His last CT scan two weeks ago showed
increasing ascites and the decision was made to discontinue 5-FU
and leucovorin and proceed with FOLFIRI. He received C1 D1 of
modified folfiri on [**2123-12-8**].
.
Other Past Medical History:
1) Hypertension
2) Hyperlipidemia
3) Osteoarthritis
4) Extensive portal vein thrombosis extending up the right
hepatic vein on Lovenox since [**2123-9-9**]
5) BPH
6) s/p tonsillectomy
7) s/p traumatic finger amputation of left hand at age 4
8) Nephrolithiasis
Social History:
Lives with his wife. [**Name (NI) **] 2 sons who live nearby and nine
grandchildren. Works 6 days a week as a furniture maker along
with his son. Denies tobacco or ETOH use.
Family History:
Mother had lung cancer. No other family history of malignancy.
Physical Exam:
ADMISSION EXAM:
VS: T 98.2 bp 139/71 HR 96 RR 16 SaO2 97 RA
GEN: Elderly man in NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP dry and
without lesion
NECK: Supple, no JVD appreciated
CV: Reg rate and rhythm, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: very firm and distended but no rebound or guarging, minimal
tenderness, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ DP/PT bilaterally
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits
PSYCH: appropriate
Pertinent Results:
ADMISSION LABS:
[**2123-12-13**] 01:36PM LACTATE-1.2
[**2123-12-13**] 01:30PM GLUCOSE-118* UREA N-22* CREAT-0.9 SODIUM-137
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14
[**2123-12-13**] 01:30PM ALT(SGPT)-39 AST(SGOT)-24 ALK PHOS-84 TOT
BILI-1.1
[**2123-12-13**] 01:30PM LIPASE-23
[**2123-12-13**] 01:30PM CALCIUM-8.5 PHOSPHATE-2.9 MAGNESIUM-2.5
[**2123-12-13**] 01:30PM WBC-5.4 RBC-4.12* HGB-11.9* HCT-36.6* MCV-89
MCH-29.0 MCHC-32.6 RDW-16.9*
[**2123-12-13**] 01:30PM NEUTS-88.2* LYMPHS-9.5* MONOS-0.7* EOS-1.2
BASOS-0.3
[**2123-12-13**] 01:30PM PLT COUNT-168
.
[**2123-12-13**] CXR: FINDINGS: As compared to the previous examination,
there is no relevant change in extent of the known bilateral
pleural effusions. The effusions are better appreciated on the
lateral than on the frontal radiograph. Minimal subsequent areas
of atelectasis but no evidence of pneumonia. Unchanged size of
the cardiac silhouette. Unchanged left Port-A-Cath.
.
[**2123-12-13**] CT abdomen:
1. Interval increase in the abdominal ascites since [**2123-11-29**].
Stable peritoneal metastatic disease.
2. Stable main and left portal vein thrombosis.
3. Bilateral small pleural effusions, now larger.
4. Mild right hydronephrosis, but no obstructing stone seen.
.
[**2123-12-16**] CXR: IMPRESSION: Essentially unchanged left greater
than right small pleural effusions.
.
[**2123-12-17**] LE DOPPLER U/S: IMPRESSION: No evidence of DVT.
.
[**2123-12-17**] KUB: IMPRESSION:
1. Non-obstructive bowel gas pattern.
2. No free air.
.
[**2123-12-17**] U/S ABD: IMPRESSION:
1. Small volume ascites.
2. Right pleural effusion.
.
[**2123-12-17**] CXR: IMPRESSION: Extensive new consolidation in the
right lower lung on the current study subsequently improves.
This could represent the changes of acute aspiration rather than
pneumonia resolving from it. Small-to-moderate bilateral pleural
effusions are unchanged since the prior study. Left lower lobe
atelectasis has improved. Heart size is normal. Infusion port
catheter ends in the mid SVC. No pneumothorax.
.
[**2123-12-18**] ECHO: LVEF>55%. Unremarkable.
.
[**2123-12-18**] UE DOPPLER U/S: IMPRESSION: No evidence of DVT. Right
cephalic vein not visualized.
.
[**2123-12-18**] CTA CHEST: IMPRESSION:
1. Probable subsegmental right middle lobe pulmonary embolus
without evidence of heart strain. No additional pulmonary emboli
are identified, although this study is limited by respiratory
motion artifact.
2. Small ground-glass opacities within the right upper lobe are
likely infectious or inflammatory in etiology.
3. Small-to-moderate bilateral pleural effusions slightly
increased from [**2123-12-13**] CT.
4. Large volume ascites as before.
5. Cholelithiasis without evidence of acute cholecystitis.
.
[**2123-12-19**] CXR: IMPRESSION: Mild to moderately severe consolidation
in the right lower lobe has worsened compared to [**12-18**],
not as severe as on [**12-17**]. The variability suggests
atelectasis is largely responsible, and there is accompanying
small right pleural effusion. Question of pneumoperitoneum was
raised on the interpretation of [**12-18**] study. There is no
evidence of free air either in the abdomen or pleural space.
Upper lungs are clear. Heart size is normal. Pulmonary
vasculature is not engorged.
.
DISCHARGE LABS:
[**2123-12-23**]: WBC 13.7, HB 10.3, HCT 31.3, MCV 91, PLT 257.
[**2123-12-23**]: PT 18.3, PTT 41.4, INR 1.7.
[**2123-12-20**]: Anti-factor Xa (LMWH) level 0.81.
[**2123-12-23**]: GLU 105, BUN 13, CREAT 0.7, NA 141, K 3.9, CL 112, CO2
24.
[**2123-12-19**]: ALT 15, AST 9, LDH 147, ALP 57, T BILI 0.9.
[**2123-12-23**]: ALBUMIN 2.2, Ca 7.0, PHOS 1.9, MG 2.0.
[**2123-12-19**]: GALACTOMANNAN NEGATIVE, BETA GLUCAN 93.
[**2123-12-19**], [**2123-12-20**], [**2123-12-21**]: C. diff toxin x3 NEGATIVE.
Brief Hospital Course:
70yo man with Stage IV colon cancer and portal vein thrombosis
on enoxaparin admitted for severe nausea, vomiting, and
increased ascites. He was transferred to the ICU [**2123-12-17**] for
hypoxia and aspiration pneumonia.
.
# Nausea/vomiting: Due to chemotherapy. KUB showed no
obstruction. Given fosaprepitant, however will avoid this in
the future given his hiccup-reaction to aprepitant in the past.
Anti-emetics PRN.
- AVOID FOSAPREPITANT AND APREPITANT DUE TO HICCUPS.
.
# Febrile neutropenia: Due to 1st cycle FOLFIRI. Started G-CSF
(Neupogen). Low-grade fever to 100.7F, pan-cultured. Started
on vancomycin/cefepime and metronidazole in setting of low BPs
and hypoxia worrisome for sepsis. C. diff negative. He had
another temp to 101.3 while in the ICU. CXR and CT scan
revealed RLL pneumonia suggesting aspiration.
.
# Aspiration RLL pneumonia and hypoxemic respiratory distress:
Vancomycin stopped. Swallow eval normal; aspiration occurred
during unremitting vomiting. Galactomannan negative. Positive
beta glucan 93, unlikely significant given his clear clinical
course with aspiration pneumonia and resolution with
antibiotics. ID fellow also pointed out that some
medications/antibiotics can falsely elevate beta glucan.
Changed cefepime and metronidazole to amoxicillin/clavulanate at
discharge to complete a ten day course (only three days of
amoxicillin/clavulanate needed).
- F/U cultures.
.
# Metastatic colon cancer with peritoneal carcinomatosis: s/p
modified FOLFIRI x1 cycle [**2123-12-8**]. Paracentesis x2 [**2123-12-14**]
and [**2123-12-15**] drained 3+4L. Acites SAAG consistent with
malignant ascites. Cytology: Atypical cells highly suspicious
for malignancy. He will need to continue chemotherapy, but with
changes to his regimen (dose-reduction vs. FOLFOX) considering
current complications. Family meeting yesterday discussed
treatment options. Mr. [**Known lastname **] seems likely to opt for additional
chemotherapy after rehab. Therapeutic paracentesis repeated
[**2123-12-23**]: 3L drained.
.
# Hiccups: Likely due to diaphragmatic irritation from
peritoneal mets. Avoided metoclopramide due to recent diarrhea.
Mild improvement with chlorpromazine. Starting baclofen.
Could also consider haloperidol or scheduling prochlorperazine.
.
# Mental status changes: Likely due to meds lorazepam and/or
olanzapine plus infection. Per family, Mr. [**Known lastname **] has not
tolerated lorazepam in the past. Tolerating chlorpromazine for
hiccups.
- AVOID BENZODIAZEPINES.
.
# Sinus tachycardia: Due to infection, volume depletion, and
small PE. ECG unremarkable. Cardiac enzymes negative. LE
doppler U/S negative. Already on enoxaparin.
.
# PE: Continue enoxaparin; no changes given the very small size
of the PE, its indeterminant age (no previous CTA), and the
negative UE/LE doppler U/S. Anti-factor Xa level therapeutic at
0.81.
.
# Neutropenia: Due to chemo. Resolved; D/C'd G-CSF (now
leukocytosis from G-CSF). Afebrile. Hypotension and
tachycardia with aspiration pneumonia. Antibiotics as above.
.
# Diarrhea: Likely due to antibiotics. Severe, resolving. C.
diff toxin x3 negative. Guaic stool negative x3. Loperamide
PRN.
.
# Port clot: Angio study and stripping of fibrin sheath done
[**2123-12-16**].
.
# Urethral obstruction: Secondary to BPH and probably
tumor/ascites. Continued outpatient alfuzosin (Uroxatral);
allergy to tamsulosin.
.
# Portal vein thrombosis: SAAG not c/w portal HTN and CT did not
show progression of clot burden. Continued enoxaparin.
.
# Pleural effusions and acute pulmonary edema: Given furosemide
20mg IV x1 in ICU. Weaned off O2.
.
# HTN: [**Last Name (un) **] (formulary substitution) stopped because of
hypotension.
.
# Hypercholesterolemia: Stopped etezimibe and pravastatin based
on family meeting agreement [**2123-12-22**].
.
# Pain (abdomen): Continued PRN morphine. Stopped MSContin due
to well controlled pain. Therapeutic paracentesis x3 ([**2123-12-14**],
[**2123-12-15**], and [**2123-12-23**]).
.
# Hypernatremia: Volume depleted due to diarrhea, recent N/V,
and poor PO intake. Resolved. Stopped IV fluids with new
dyspnea and pulmonary congestion.
.
# FEN: Regular diet, normal swallow eval. IV fluids stopped.
Repleted hypokalemia and hypophosphatemia (worsened from
diarrhea). Metabolic acidosis also due to diarrhea, now
resolved.
.
# GI PPx: PPI. Bowel regimen on hold with diarrhea.
.
# DVT PPx: Enoxaparin for portal vein thrombosis and PE.
.
# Precautions: None.
.
# Full Code.
Medications on Admission:
ALFUZOSIN [UROXATRAL] 10 mg PO once a day
ENOXAPARIN 100 mg/mL Syringe - inject 100 mg SQ [**Hospital1 **]
EZETIMIBE [ZETIA] 10 mg PO once a day
FLUTICASONE 50 mcg Suspension 1 spray nasally PRN congestion
IRBESARTAN [AVAPRO] 300 mg PO once a day
LIDOCAINE-DIPHENHYD-[**Doctor Last Name **]-MAG-[**Doctor Last Name **] [FIRST-MOUTHWASH BLM] 400 mg-400
mg-40 mg-25 mg-200 mg/30mL Mouthwash - Swish and swallow q2-3HR
PRN
MORPHINE 15 mg Extended Release PO BID
MORPHINE 15 mg PO q3-4HR PRN pain
OMEPRAZOLE 20 mg PO Daily
PRAVASTATIN [PRAVACHOL] 80 mg PO once a day
PROCHLORPERAZINE MALEATE 10 mg PO q8HR PRN nausea
ZOLPIDEM [AMBIEN CR] 6.25-12.5 mg Ext Release Multiphase PO qHS.
Zofran PRN
ASPIRIN 81 mg Delayed Release (E.C.) PO once a day
Discharge Medications:
1. alfuzosin 10 mg Extended Release 24 hr PO daily.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
2. fluticasone 50 mcg/Actuation, SIG: One (1) Spray Nasal DAILY
PRN congestion.
3. morphine 15 mg Extended Release PO Q12H.
4. morphine 15-30 mg PO Q4H PRN pain.
5. omeprazole 20 mg PO DAILY.
6. prochlorperazine maleate 10 mg PO Q6H PRN nausea.
7. aspirin 81 mg PO DAILY.
8. enoxaparin 100 mg/mL SC Q12H.
9. ZOFRAN ODT 4-8 mg Rapid Dissolve PO q8HR PRN nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
10. Imodium A-D 2 mg PO q6HR PRN diarrhea x5 days.
11. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] 200-25-400-40mg/30mL
Mouthwash Sig: 30mL Mucous membrane QID PRN pain.
12. zolpidem 6.25-12.5mg PO qHS PRN insomnia.
13. acetaminophen 325-650mg PO Q6H PRN Pain.
14. loperamide 2 mg PO QID PRN Diarrhea.
15. baclofen 10 mg PO Q8H PRN Hiccups.
16. pantoprazole 40 mg PO Q24H.
17. potassium & sodium phosphates 280-160-250 mg Powder in
Packet PO TID: Neutra-phos.
18. Augmentin 875-125 mg PO BID x3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Nausea with vomiting.
Ascites (fluid in the abdomen).
Metastatic colon cancer.
Portal vein thrombosis (blood clot in the abdomen).
Neutropenia (low white blood cell count).
Blocked port (fibrin sheath).
Aspiration pneumonia.
Hiccups.
Altered mental status (acute delirium, confusion).
Pulmonary embolus (blood clot in lung).
Diarrhea.
Hypertension (high blood pressure).
Hypotension (low blood pressure).
Hypokalemia (low potassium level).
Hypophosphatemia (low phosphorous level).
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 for severe nausea, vomiting,
and abdominal pain. The nausea/vomiting was a likely
complication of your recent chemotherapy for metastatic lung
cancer. CT scan of the abdomen showed increased fluid in your
abdomen (ascites) and you underwent a paracentesis (drainage of
fluid from the abdomen). Since you still had pain and fluid in
the abdomen, you underwent a second paracentesis. Both
procedures removed a total of 7 liters of fluid. Nausea and
vomiting worsened despite nausea medication and you then
aspirated some vomit (going down the wind-pipe into the lungs)
causing a severe pneumonia. You had an episode of low blood
pressure and were satrted on IV antibiotics. Because your
oxygen was dangerously low, you were transferred to the
Intensive Care Unit and needed oxygen support for several days.
A CT scan of the chest showed a pulmonary embolus (blood clot in
the lung) in addition to the pneumonia. The blood clot was very
small and its age was unclear. Therefore, you remained on the
current dose of enoxaparin (Lovenox). Your white blood cell
count was low due to chemotherapy and a medication called G-CSF
(Neupogen) was given to help this. You also became temporarily
delirious (confused) because of a dose of lorazepam (Ativan)
given for nausea. You should never take this medication again.
A swallow evaluation was normal. Lastly, you developed severe
diarrhea, possibly from the antibiotics. Tests for infection
were negative. After IV fluids, electrolyte replacement for low
potassium and low phosphorous, and loperamide (Immodium), the
diarrhea improved. You will need to complete a course of
antibiotics for the pneumonia. More fluid from the abdomen
(ascites) was drained the day you left the hospital.
.
MEDICATION CHANGES:
1. Viscous lidocaine/Maalox/diphenhydramine for mouth/throat
pain as needed.
2. Baclofen 10 mg 3x a day as needed for hiccups.
3. Neutra-phos 3x a day for low phosphorous levels. Your
phosphorous levels should be monitored and this can be stopped
when it is normal.
4. Amoxicillin/clavulanate (Augmentin) 2x a day for three days
to complete the antibiotic course for aspiration pneumonia.
5. DO NOT TAKE LORAZEPAM (ATIVAN).
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2124-1-5**] at 1 PM
With: [**Doctor First Name **] [**Last Name (NamePattern5) 21185**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2124-1-5**] at 2:00 PM
With: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"5070",
"2760",
"5119",
"4019",
"2724",
"V5861"
] |
Admission Date: [**2102-7-29**] Discharge Date: [**2102-8-4**]
Date of Birth: [**2057-11-20**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old
female with multiple sclerosis and a history of tracheostomy
and percutaneous endoscopic gastrostomy tube placement in
[**2093**] who developed hematuria one day prior to admission. She
received one dose of Levaquin at home and had a slight fever.
Then, at 10 p.m. one day prior to admission, she became more
lethargic, and her blood pressure dropped to 60/palpable
(usually 130s/90s). Otherwise, no other localizing symptoms.
Between Emergency Medical Service and the Emergency Room, she
received 400 cc of normal saline. On arrival, her blood
pressure was 215/131. The patient became hypoxic with an
oxygen saturation of 80% and a respiratory rate of 20. A
respiratory rate dropped to 26 and became agonal. Attempts
to bag the patient with AMBI bag, but ventilation was
ineffective secondary to no cuff in the trachea.
In the Emergency Room, the tracheostomy was attempted to be
removed; however, this was unsuccessful. It had never been
removed in the past nine years. Breathing was shallow and
rapid. White blood cell count was 36.2. A chest x-ray
revealed no infiltrates seen. An arterial blood gas was
drawn and revealed pH was 7.19, CO2 was 88, and oxygen was
106. The patient's tracheostomy was attached to the
ventilation, and on ventilation the arterial blood gas
improved to a pH of 7.36, CO2 of 50, and oxygen of 318;
however, her blood pressure dropped to the 70s with no
response to wide-open fluids. Peripheral Neo-Synephrine was
then started, and right subclavian catheter was placed. The
subclavian catheter actually went up the left internal
jugular, and so had to be changed over wire, and is currently
correctly positioned. Subsequently, the Neo-Synephrine was
then re-routed to go through the central venous access. An
arterial line was placed on the day of admission as well.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 102.6, blood pressure was 157/115,
heart rate was 97, respiratory rate was 19, and oxygen
saturation was 70%. In general, the patient was trached and
not responding; however, the family reports this was the
patient's bowel sounds. Head, eyes, ears, nose, and throat
examination revealed the mucous membranes were moist. A cut
on the tongue. The neck examination revealed a tracheostomy
with no erythema or exudate. Cardiovascular examination
revealed tachycardia. No murmurs or rubs. Otherwise, a
regular rhythm. Lung examination revealed very shallow quick
breaths and a few scattered bronchial sounds. The abdomen
revealed good bowel sounds and was soft. Distended and
tympanic. The family reports this was the patient's
baseline. Extremity examination revealed extremities were
warm. No decubitus ulcerations. No spontaneous movement of
extremities except eyes closing.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 36.2, hematocrit was 44.4, and platelets were
562. Electrolytes revealed sodium was 131, potassium was
4.6, chloride was 91, bicarbonate was 31, blood urea nitrogen
was 16, creatinine was 0.6, and blood glucose was 155.
Urinalysis revealed large amounts of blood, 500 mg/dL of
protein, and moderate leukocytes, more than 50 red blood
cells, more than 50 white blood cells, a few bacteria, and no
yeast. Microbiology history: In [**2101-10-11**], there was
a urine cultures which grew out Pseudomonas which was
sensitive to everything but ciprofloxacin (which it was
resistant to). It also grew out pan-sensitive enterococcus.
In [**2100**], urine culture grew out pan-sensitive enterococcus.
In [**2099**], urine culture grew out ampicillin-resistant
Escherichia coli, cefuroxime intermediate and Pseudomonas
resistant to ciprofloxacin.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed a left
lower lobe streak ?.
Electrocardiogram revealed no acute ST-T wave changes per
baseline.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. HYPOTENSION ISSUES: Hypotension most likely due to
urosepsis with a urinalysis showing a high white blood cells
and moderate leukocyte esterase with a white blood cell count
of 36.2. The patient was started on phenylephrine drip on
the day of admission ([**7-29**]) which was discontinued later
on during the day due to resolving hypotension.
2. UROSEPSIS ISSUES: The patient was started on ceftazidime
2 g intravenously q.8h. and metronidazole 500 mg
intravenously q.8h. Urinalysis showed signs of urinary tract
infection. Urine culture from the [**7-29**] grew out
enterococcus pan-sensitive to ampicillin, levofloxacin, and
vancomycin. The patient was originally started on vancomycin
to treat enterococcus until these sensitivities came back
from enterococcus being sensitive to ampicillin. Thus,
vancomycin was discontinued on [**8-2**] and ampicillin was
started.
Urosepsis resolving, and the patient was afebrile throughout
her hospital course. White blood cell count dropped to 13.4.
There was a question of a fistula in the urinary system;
however, Urology was consulted and upon the methylene blue
study there was found to be no vesicovaginal fistula.
Additionally, Clostridium difficile was negative times two;
taken from stool cultures.
The patient received a computed tomography of the abdomen and
pelvis with and without contrast which did not show any signs
of free fluid or abscess collection.
3. RESPIRATORY FAILURE ISSUES: The patient was ventilated
on [**7-29**] and [**7-30**] and was then able to be weaned from
the ventilator, and is currently saturating well on an FIO2
of 50% through her tracheostomy.
The patient went to the operating room on [**8-2**] for a
trachea change. A new tracheostomy was put in place, and the
old tracheostomy was removed.
Additionally, sputum from [**7-29**] grew out Pseudomonas
sensitive to everything but ciprofloxacin. Thus, ceftazidime
was to be continued to complete a 14-day course.
The patient received a computed tomography of the trachea
without contrast and with reconstruction prior to going to
the operating room for tracheostomy removal and replacement
with a new tracheostomy.
4. MULTIPLE SCLEROSIS ISSUES: The patient was to continue
Baclofen.
5. ANEMIA ISSUES: The patient's hematocrit was 44.4 on
admission and dropped to 34.8 on the same day of admission;
progressively decreasing to 31.7 on [**8-2**]. No signs of
active bleeding. Negative hemolysis laboratories. Most
likely due to blood draws.
6. HYPONATREMIA ISSUES: The patient's sodium decreased from
133 on admission to dip down to 126 on [**8-1**], but then
increased back up to 132 on [**8-2**]. This was most likely
due to hypovolemia as the patient's sodium level responded to
intravenous infusion of normal saline. Other electrolytes
were repleted as needed; such as phosphate and magnesium.
The patient without to resume tube feeds with ProMod with
fiber.
7. PROPHYLAXIS ISSUES: The patient received prophylactic
care of H2 blockers, subcutaneous heparin, and pneumo boots.
8. CODE STATUS: The patient is full code, and communication
was kept with the husband who visited frequently.
9. ACCESS ISSUES: The patient will also need intravenous
access for continuation of antibiotics at home for the
enterococcus in the urine and the Pseudomonas in the sputum
(i.e. the tracheobronchitis). The patient was to be
evaluated today for a peripherally inserted central catheter
placement to complete a 14-day course of ampicillin for
enterococcus and ceftazidime for Pseudomonas.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: The patient was to be discharged after
peripherally inserted central catheter line placement.
DISCHARGE DIAGNOSES:
1. Respiratory distress with urosepsis enterococcus.
2. Tracheobronchitis Pseudomonas.
SURGICAL INTERVENTIONS: Tracheostomy tube changed in the
operating room on [**8-2**].
MEDICATIONS ON DISCHARGE:
1. Ceftazidime 2 g intravenously q.8h. (for nine days).
2. Ampicillin 1 g intravenously q.6h. (for eleven days).
The patient was to continue all her home medications; which I
have verified with her home nurse that she has refills of
these medications at home.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with her primary care physician as needed.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 9789**]
MEDQUIST36
D: [**2102-8-2**] 16:51
T: [**2102-8-11**] 08:29
JOB#: [**Job Number 106914**]
|
[
"0389",
"5990",
"2761"
] |
Admission Date: [**2104-2-4**] Discharge Date: [**2104-2-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Location (un) 1279**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Cardiac catherization
History of Present Illness:
The patient is an 85 year old gentleman with hypertension who
presented with decompensated heart failure. He originally noted
dyspnea on exertion two months prior to admission. He
experienced shortness of breath after walking one city blood and
experienced mild sporadic chest pain with and without activity.
He also developed bilateral lower extremity edema and vascular
congestion with increased neck veins.
In [**10-17**] patient had an ETT MIBI which showed partially
reversible defects in the area of the PDA and LAD, new since
[**2099**]. EF was 35-45%. In [**2099**] EF had been 50%. MIBI showed
moderate global LV hypokinesis, mild asymm LVH, mild PA HTN.
During that MIBI patient had AVNRT and sinus tachycardia.
Patient presented for elective cath which showed normal
coronaries but the following pressures: RA 32/RV 64/21 PA
72/32, wedge 35. PA sat 46%. CO 2.9 and CI 1.6. Pt was given 100
lasix in lab and put on natrecor drip at 0.01 and milrinone at
0.325. Transfered to CCU. Of note, INR was 1.8, and there was
significant oozing from groin post sheath pull.
Past Medical History:
1) Hypertension
2) s/p open prostatectomy secondary to BPH [**2097**]
3) s/p hernia repair
4) s/p hydrocele repair
Social History:
Married. Quit smoking 15 years ago.
Family History:
No family history of coronary artery disease.
Pertinent Results:
[**2104-2-4**] 11:53PM MAGNESIUM-2.2
[**2104-2-4**] 11:53PM GLUCOSE-147* UREA N-22* CREAT-1.3* SODIUM-142
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-35* ANION GAP-9
[**2104-2-4**] 11:53PM WBC-4.4 RBC-3.19* HGB-10.2* HCT-31.0* MCV-97
MCH-31.9 MCHC-32.8 RDW-15.2
[**2104-2-4**] 11:53PM PLT COUNT-125*
[**2104-2-4**] 09:11PM URINE HOURS-RANDOM TOT PROT-6
[**2104-2-4**] 09:11PM URINE U-PEP-NO PROTEIN
[**2104-2-4**] 03:22PM HIV Ab-NEGATIVE
[**2104-2-4**] 03:22PM PT-16.4* PTT-32.6 INR(PT)-1.7
[**2104-2-4**] 01:15PM ALT(SGPT)-15 AST(SGOT)-22 LD(LDH)-269* ALK
PHOS-93 TOT BILI-1.6*
[**2104-2-4**] 01:15PM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-3.2
MAGNESIUM-1.7 IRON-66 CHOLEST-111
[**2104-2-4**] 01:15PM calTIBC-265 FERRITIN-125 TRF-204
[**2104-2-4**] 01:15PM TRIGLYCER-53 HDL CHOL-54 CHOL/HDL-2.1
LDL(CALC)-46
[**2104-2-4**] 01:15PM TSH-2.6
ECHO [**2104-2-4**]:
Left Atrium - Long Axis Dimension: *5.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.5 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
TR Gradient (+ RA = PASP): *28 mm Hg (nl <= 25 mm Hg)
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate global left ventricular hypokinesis with relative
preservation of apical segments (suggestive of a non-ischemic
myopathy). No masses or thrombi are seen in the left ventricle.
The right ventricular cavity is mildly dilated with moderate
free wall hypokinesis. The aortic root is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. Physiologic mitral regurgitation
is seen (within normal limits). There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
CATH: [**2104-2-4**]
1. Coronary angiography of this right dominant system revealed
no
angiographically apparent flow limiting coronary artery disease.
The
left main coronary artery, LAD, LCX, and RCA had no
angiographically
apparent flow limiting stenoses.
2. Resting hemodynamics were performed. Right sided pressures
were
severely elevated (mean RA pressure was 33 mm Hg and RVEDP was
32 mm
Hg). Pulmonary artery pressures were severely elevated (PA
pressure was
70/28 mm Hg). Left sided pressures were severely elevated (mean
PCW
pressure was 34 mm Hg and LVEDP was 36 mm Hg). Central arterial
pressure was mildly elevated (aortic pressure was 144/95 mm Hg).
Cardiac index was low (at 1.6 L/min/m2). There was no
significant
gradient across the aortic valve upon pullback of the catheter
from the
left ventricle to the ascending aorta.
3. Left ventriculography was not performed secondary to
markedly
elevated filling pressures and two recent determinations of
ejection
fraction.
4. Intermittent atrial fibrillation with rapid ventricular rate
and
sinus tachycardia with frequent PACs were noted.
5. Because of the markedly elevated filling pressures, the
patient was
transferred to the CCU for IV inotropic, vasodilator, and
diuretic
therapy.
FINAL DIAGNOSIS:
1. No angiographically apparent flow limiting coronary artery
disease.
2. Severely elevated right sided filling pressures.
3. Severe pulmonary arterial hypertension.
4. Severely elevated left sided filling pressures.
5. Severely depressed cardiac index.
6. Known moderately to severely depressed left ventricular
systolic
function.
CT ABDOMEN [**2104-2-5**]:
FINDINGS:
CT ABDOMEN W/O IV CONTRAST: There is a small right sided pleural
effusion which is low in density. There is adjacent atelectasis
within the right lower lobe posteriorly, and atelectasis vs
scarring at the left base. There is cardiomegaly. A Swan-Ganz
catheter is in place via a right femoral approach. Within the
right lobe of the liver medially, a 1.6 cm hypodense lesion is
seen. This is incompletely characterized on this noncontrast
examination. The liver, spleen, pancreas, and adrenal glands
appear otherwise unremarkable in contour on this noncontrast
examination. There is density within the right renal hilum near
the upper pole which could represent calcification vs a small
amount of previously excreted contrast related to the patient's
cardiac catheterization. Additional similar areas are seen
within the collecting system of the left kidney. There is a 6 cm
simple cyst arising from the interpolar region of the right
kidney. An additional rounded cystic appearing structure is seen
just superior to this within the right kidney, possibly
representing a hyperdense cyst, although this is incompletely
evaluated on this examination. There is nonspecific stranding
surrounding both kidneys. The aorta is normal in caliber
throughout, with mural calcifications consistent with
atheromatous disease. The aorta is ectatic at the level of the
bifurcation. There is no free interperitoneal air. There is
diffuse stranding throughout the mesentery and subcutaneous soft
tissues, possibly consistent with congestive heart failure.
CT PELVIS W/O IV CONTRAST: There is a small amount of fluid
layering within the pelvis, and between multiple pelvic loops of
bowel. This is low in density consistent with ascites. The
bladder contains a Foley catheter and a small amount of excreted
IV contrast. There is a suggestion of bladder wall thickening at
the bladder base, although the dome of the bladder is
nonthickened. There are surgical sutures in the right groin.
Small amount of stranding surrounding the right common femoral
artery and vein, possibly consistent with puncture at this
location. There is a right common femoral venous line in place.
No expansion of the retroperitoneal structures to indicate
retroperitoneal hematoma. A small fluid collection is seen in
the left groin, in the region of a left fat containing inguinal
hernia. This could also possibly represent an enlarged lymph
node.
BONE WINDOWS: Bone windows demonstrate degenerative changes of
the thoracic and lumbosacral spine without evidence of
suspicious lytic or sclerotic osseous lesions.
IMPRESSION:
1) No evidence of retroperitoneal hematoma. Low density ascites
without evidence of hemoperitoneum.
2) Small right pleural effusion and bibasilar atelectasis vs
consolidation.
3) 1.6 cm hypodense lesion within the right lobe of the liver,
incompletely characterized on this examination. This could be
further evaluated with ultrasound.
4) Simple cyst in the lower pole of the right kidney. An
additional cystic structure within the right kidney could
represent a hyperdense cyst, although it could be further
evaluated with renal ultrasound.
5) Small amount of stranding in the right groin could indicate a
minimal hematoma
Brief Hospital Course:
A/P: 85 year old man with a history of hypertension admitted
with biventricular heart failure.
1) CHF: Cardiac echo showed EF of 30-35% with moderate global
left ventricular hypokinesis and right ventricular hypokinesis
consistent with non ischemic cardiomyopathy (cath was normal).
Most likely tachycardia induced or from chronic hypertension. We
ruled out other causes such as hyperthyroidism, HIV,
hemochromatosis. He was put on milrinone and natrecor. Once the
patient stabilized these medications were discontinued and he
was started on an ACE inhibitor and beta blocker. Patient
developed 2:1 heart block on the beta blocker which was then
discontinued. The patient remained euvolemic on lasix 40 mg
[**Hospital1 **].
2) Cardiac catherization showed normal coronary arteries. The
patient was continued on aspirin.
3) Rhythm: Wide complex regular tachycardia: consistent with
sinus tachycardia with AV delay and frequent PACs and PVCs.
Patient then developed 2:1 heart block and Wenkebach on beta
blocker. Beta blocker was discontinued and a dual chamber
biventricular pacemaker/ ICD was placed. He was then started on
a low-dose beta-blocker without difficulty.
4) Coagulopathy: likely from hepatic congestion from CHF. The
patient received protamine in cath lab.
5) Anemia: Patient had a small post procedure hematoma.
Hematocrit was stable.
6) ARF: secondary to NSAIDs and diuresis.
Medications on Admission:
Hydrochlorothiazide 12.5 mg po daily
Captopril 50 mg po bid
Vitamin E 400 IU daily
Ecotrin 325 mg po daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for 5 doses.
Disp:*5 Tablet(s)* Refills:*0*
3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 2
doses.
Disp:*2 Tablet(s)* Refills:*0*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Keflex 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
days.
Disp:*6 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive heart failure
Complex Wenchebach conduction delay
Discharge Condition:
Stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2104-2-20**] 3:00
Please call [**Telephone/Fax (1) 10548**] to schedule an appointment with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your cardiologist in [**1-17**] weeks.
|
[
"4280",
"42731",
"5849",
"4019"
] |
Admission Date: [**2156-7-6**] Discharge Date: [**2156-7-16**]
Date of Birth: [**2101-8-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Abdominal pain and edema
Major Surgical or Invasive Procedure:
[**2156-7-13**] EGD
History of Present Illness:
54yo M w/ remote h/o of etoh abuse, cirrhosis w/ portal
gastropathy, esophageal varices, htn, dm tranferred from osh for
eval/further treatment of partial thrombosis of superior
mestenteric vein/extra and intrahepatic portal vein and total
occlusion of spenic vein, ?small bowel ischemia and ARF (BUN crt
28/2.1). He initially presented to [**Hospital3 **] on [**7-5**] w/
abdominal pain and non-bloody diarrhea, 1 episode of emesis x1
day. On Saturday he had 1 episode of diarrhea. Sunday he had
another episode of diarrhea followed by acute onset of sharp
abdominal pain. He took a laxative which was followed by an
episode of emesis. He also reports decreased appetite. He then
presented to [**Hospital3 **] Hosp. In their ED with stable vital
signs. Per report a CT abd showed the findings described above
as well as marked small bowel wall thickening, moderate ascites,
diffuse mesenteric fat stranding concerning for ischemia. At the
OSH he was eval. by surgery who recommended serial abd exams. He
was started on IV heparin and zosyn and given IV dilaudid for
pain.
A review of his labs from the OSH were sig for a leukocytosis of
[**Numeric Identifier 7206**] (up to [**Numeric Identifier **]). ASt was 41, alt 49, ldh 257. CE were neg x
2. TB 2.6. AP 93. [**Doctor First Name **] 15. lip 11. A hypercoagulability w/u is
pending at the OSH. An abg showed 7.34/39/66 lactate 1.7. Bld cx
showed NGTD.
ROS: no recent illness, fevers, chills. 30 lbs weight loss over
6months [**2-7**] to diet and excercise p patient. No headaches. N/V
as described above. loose stools x 2days. No dysuria.
Past Medical History:
etoh abuse (quit 20 years ago)
cirrhosis w/ portal gastropathy
esophageal varices grade 1 (seen on egd [**11/2155**])
UGI bleed [**2-7**] superficial gastric ulcer [**2-7**] nsaids (at [**Hospital 79043**] gastritis 3u prbcs)
diabetes
CVA (TIA)
htn
gerd
hiatal hernia
hyperchol
osteoporosis
benign bladder tumor s/p resection
SMV complete & partial portal and hepatic vein thrombosis [**2156-7-6**]
Social History:
no recent tobacco use (quit 10 years prior), h/o etoh abuse
(quit 20 years ago), married with 4 children
Family History:
father w/ cirrhosis [**2-7**] to alcoholism. HTN (mother and father)
Physical Exam:
VS: 99.1 BP 141/71 HR 106 02sat 93 on 4L
GEN: NAD, slight discomfort from new abd distension
HEENT: anticteric sclera, pupils 2mm bilaterally reactive to
light. dry MM.Neck supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, II/VI SEM at the LUSB
PULM: slight bilateral bibasilar rales, lungs sounds distant [**2-7**]
to body habitus
ABD: obese, tenderness throughout the upper quadrants, could not
assess for hsm [**2-7**] to obesity, hypoactive bs
EXT: warm, dry, +2 distal pulses BL, no femoral bruits , no
edema
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated.
+asterixis
Pertinent Results:
STUDIES:
per osh records:
FAST US [**2156-7-5**]: ascites
.
CXR [**2156-7-5**]: low lung volumes. no acute pulmonary process.
calcification of the aorta.
.
CT abd & pelvis w/w/o con [**2156-7-5**] (as paraphrased from report):
1. new partial thrombosis of the SMV and protions of the extra
and intrahepatic portal vein and near TO of the splenic vein
near teh portosplenic confluence. Also, new marked small bowel
wall thickening greates in the RLG w/ small to mod ascites and
diffuse stranding of mesenteric fat. Given these findings
ishcemia should be considered.
2. features c/w cirrhosis
3. small amount of pelvic ascites. miltiple thickened loops of
small bowel in the RLQ.
ECG interpretation [**2156-7-5**]: sinus tach, LAFB, unchanged from
prior
Brief Hospital Course:
He was transferred here to the MICU from [**Hospital6 33**].
Initially, he was on the medical service then transferred to the
surgical service under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**].
Empiric zosyn continued and well as IV fluid given NPO status.
IV Heparin continued. Venous lactate was 4 up from 1.7 at OSH.
Serial abdominal exams were done and notable for a soft,
nodistened, mildly tender abdomen in the epigastric/RUQ area
without guarding/rebound. WBC continued to be elevated at 25.8.
Blood and urine cultures were drawn on [**7-6**] and were negative.
He required 3+L NC 02 and was also tachycardic and tachypneic. A
chest and abd CT were done to r/o PE in setting of thrombosis.
No central or segmental pulmonary embolus was noted. O2
requirements decreased and he was weaned off O2. Lungs remained
clear.
A repeat CT abd was done showing thrombus at the confluence of
the splenic and superior mesenteric veins, extending into the
SMV and many of its tributaries. Thrombus at the origin of the
left portal vein, extending into both left portal vein and right
anterior portal vein. Hepatic veins were not evaluated. Abdomen
remained soft, non-distended and without pain. IR evaluated him
and felt that thrombectomy was not indicated.
A liver doppler U/S was done to further evaluate flow. This
demonstrated patent main and right portal veins. The left portal
vein was not well imaged. Hepatic veins were patent. The splenic
vein and SMV could not be imaged due to bowel gas. Hepatology
was consulted. Dr. [**Last Name (STitle) **] saw him and performed an EGD on [**7-13**]
noting varices at the lower third of the esophagus, polyps in
the pre-pyloric region. Varices were grade II. Recommendations
included checking hepatitis serologies, AFP and monitoring of
platelets while on heparin. A repeat abd/pelvis CTA was
recommended to reassess the thrombi and follow up on the
hypercoagulable labs done at [**Hospital6 33**]. Some of these
labs were still pending at time of discharge. The following was
available: protein C activity 50, hoocysteine 4.6, anti thromb
III 4.6, anti thromb III function 59, protein C antigen Pend,
Protein S antigen Pend, Protein S activity 78, Prothrombin [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) **] pend, cardiolipin IgG Ab pend, and Cardiolipin IgM pend. The
plan was set for a repeat CT to be done in follow up as an
outpatient.
He was transferred out of the MICU where the NG was removed on
[**7-12**]. Diet was gradually advanced and well tolerated. Nutrition
recommended a low sodium diet. He was passing regularly formed
guaiac negative stool. Hcts remained stable and WBC decreased to
normal.
Heparin drip was adjusted to keep ptt's in the 60-80 range.
Coumadin was initiated and INR increased to 2.1 on [**7-15**] (goal
2.0-2.5). He was discharged on coumadin 5mg qd. He had received
5mg [**7-12**] & [**7-13**], 7.5mg on [**7-14**] and 5mg on [**7-15**] with inr becoming
therapeutic.
Of note, ARF resolved. At the OSH creatinine was 2.7. This
decreased to 1.1 upon admission and further trended down to 0.7.
Insulin sliding scale was used for hyperglycemia given that
glucophage was held. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained. Dr. [**Last Name (STitle) **]
recommended glyburide 2.5mg qd with avoidance of metformin given
h/o lactic acidosis.
His PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location (un) 4628**] MA ([**Telephone/Fax (1) 19070**]was
contact[**Name (NI) **] to manage the inr/coumadin. INR was ordered to be
drawn q Monday and Thursday with results fax'd to Dr. [**Last Name (STitle) **].
[**Last Name (un) 1724**]: ace held [**2-7**] renal insuff at OSH. BP ranged between 141/98
to 106/70. HR remained in the mid 80's.
He will f/u with Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**].
Medications on Admission:
Medications at home:
nadolol 40mg qdaily
protonix 40 [**Hospital1 **]
metformin 500mg [**Hospital1 **]
zetia 10mg qdaily
lisinopril 5mg qdaily
mvi dqaily
glucosamine chondroitin
claritin prn
.
Meds on transfer:
heparin gtt
zosyn 2.25g iv q8hrs
riss
dilaudid 1mg iv q3hrs
zofran 4mg iv q4hrs prn
Discharge Medications:
1. Outpatient Lab Work
Twice weekly INR. Monday and Thursday
Fax to [**Telephone/Fax (1) 79044**] Dr. [**Last Name (STitle) **] (tel:[**Telephone/Fax (1) 79044**])
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
5. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Partial thrombosis of smv, portal vein and hepatic vein
alcoholic liver cirrhosis
DM
Discharge Condition:
fair
Discharge Instructions:
Please call Dr.[**Name (NI) 1381**] office [**Telephone/Fax (1) 673**] if any bloody
vomit/stools including black stools, easy bruising, increased
abdominal girth/leg edema, dizziness/weakness,jaundice,
lethargy/confusion or abdominal pain.
Take coumadin as prescribed. You should have INR lab draws
You should use an electric razor to shave
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2156-7-26**]
8:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2156-8-2**] 11:00
Call your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 19070**] to schedule follow
up appt
She will manage your coumadin dosing and INR values (fax #
[**Telephone/Fax (1) 79044**])
Call [**Hospital **] Clinic [**Telephone/Fax (1) 2384**] to schedule an appointment with
a nurse educator and MD
Completed by:[**2156-7-16**]
|
[
"5849",
"25000",
"53081"
] |
Admission Date: [**2160-12-26**] Discharge Date: [**2160-12-27**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
[**2160-12-26**] - Sigmoidoscopy
History of Present Illness:
88F with PMH signficant for DM2, Afib on coumadin, HTN, SSS
s/p pacer, s/p recent hospitalization with discharge [**2160-12-21**] for
PNA, UTI, and new dx of CHF with MR/TR/AR and cardiomegaly
requring hospitalization for diuresis. Pt now brought to ED from
Nursing facility after mental status change (obtundation) and
desaturation/tachypnia. CXR showed dilated LB and CT A/P showed
sigmoid volvulus at descending colon/sigmoid junction with
partial LBO and contrast from 1 week prior swallow study
proximal
to transition point with decompressed bowel distally. [**Name (NI) 1094**] son
at
bedside, who is HCP. Reportedly, pt did not have n/v, denies
f/c,
and + diarrhea.
Past Medical History:
- Atrial fibrillation, s/p pacemaker placement due to atrial
fibrillation without ventricular response, on coumadin
- Hypertension
- Diabetes mellitus type 2
- Hyperlipidemia
- Peripheral vascular disease
- Peptic ulcer disease
- Sick sinus syndrome status-post pacemaker placement
- Glaucoma
- Urinary incontinence
- Skin cancer
Social History:
Patient lives in lives in [**Hospital3 59217**]
community. At baseline she uses a walker for assistance. She has
never smoked, and drinks alcohol rarely.
Family History:
[**Name (NI) **] mother died sudden death at 85 and MGM died at 75 in
sleep. MGM with angina. No significant past medical history on
paternal side.
Physical Exam:
On Admission
Vitals: 97.6, 105, 106/66, 19, 94% CMV (14, TV 500 PEEP 5, 60%
FIO2)
elderly female, somnolent, responsive to voice, touch but at
baseline still with eyes closed; GCS: 5 motor, 3 eyes, verbal
not
assessed as on ventillator
Dry mucous membranes, NC/AT
tachycardic, irregularly irregular
+ rales b/l lung bases
Abd: markedly distended/tympanitic (per son, at her baseline),
with minimal diffuse TTP. Well healed hysterectomy scar, no
palpable masses/bowel loops
Foley in place
+ venous stasis dermatitis RLE > LLE, b/l pedal edema
Pertinent Results:
[**12-26**] CT Abdomen - IMPRESSION:
1. Partial large bowel obstruction, with an organoaxial volvulus
seen at the junction of the descending and sigmoid colon. No
small bowel dilatation. Retention of oral contrast in the cecum
extending to the point of the volvulus. Small amount of contrast
passage beyond the transition point. 2. Moderate cardiomegaly
with chronically collapsed left lower lobe and mild right-sided
pleural effusion.
Brief Hospital Course:
Pt admitted to [**Hospital1 18**] on [**2160-12-26**] with diagnosis of sigmoid
volvulus. PT was DNR/DNI and surgery was declined by family. Pt
was transferred to the ICU. A sigmoidoscopy was done which
showed the pt had autoreduced the volvulus. Pt was in severe
respiratory distress with mechanical ventilation via a face
mask. Pt was made CMO and transferred to the floor after
ventilatory support was withdrawn. Pt expired at 7:45 Am on
[**2160-12-27**].
Medications on Admission:
coumadin 2 qday, glipizide 5 qday, senna 1 tab [**Hospital1 **], colace
100 [**Hospital1 **], brimonide 0.15 % drops [**Hospital1 **], pantoprazole 40 qday,
tylenol prn, MVI 1 tab qday, lisinopril 20 qday, atenolol 25
qday, lasix 40 po bid, dulcolax 10 po qday, Insulin SS,
Potassium
Chloride 40 meq [**Hospital1 **] while on lasix.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Sigmoid Volvulus
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"486",
"42731",
"V5861",
"4019",
"25000",
"V5867",
"2724"
] |
Admission Date: [**2163-11-5**] Discharge Date: [**2163-12-13**]
Date of Birth: [**2140-7-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Moped vs car crash
Major Surgical or Invasive Procedure:
[**2163-11-5**]: Ex-lap, splenectomy, bilat diaphragm repair, liver
packing
[**2163-11-6**]: Left knee washout
[**2163-11-8**]: Takeback for abdomen washout
[**2163-11-18**]: Takeback for ex-lap, LOA, SBR w/ primary anastamosis
[**2163-12-5**]: PICC line placement
History of Present Illness:
22 yo M on [**2163-11-5**] riding scooter was reportedly struck by
motor vehicle and thrown from scooter and was possibly dragged
or run over. He does not remember the events surrounding the
crash, with +LOC on scene w/ recovery soon thereafter. +Helmet.
+ETOH w/BAL=115. GCS 14 with EMS on scene. Brought to [**Hospital1 18**] in
for further care.
Past Medical History:
PMH: [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**]
PSH: Denies
Allergies: NKDA
Social History:
Student at [**University/College 23925**] College & works part-time in a bar. Parents
are closely involved.
Family History:
Noncontributory
Physical Exam:
Upon admission:
PE: T:100 (rectal) P:112 BP:134/60 R:22 POx:100RA
GEN: NAD
HEENT: NC, minor abrasions over face, 3cm R sided occipital
scalp laceration, PERRL, EOMI, no diplopia, R sided periorbital
ecchymosis, no oral blood, + blood in nares, no septal hematoma,
blood in L ear canal, ?hemotympanum
Pertinent Results:
[**2163-11-5**] 10:44AM BLOOD WBC-17.6*# RBC-3.75* Hgb-11.6* Hct-32.1*
MCV-85 MCH-30.9 MCHC-36.1* RDW-13.0 Plt Ct-331
[**2163-11-5**] 04:36AM BLOOD Plt Ct-417
[**2163-11-5**] 04:36AM BLOOD Fibrino-237
[**2163-11-6**] 12:45PM BLOOD VWF AG-171* VWF CoF-219*
[**2163-11-5**] 10:44AM BLOOD Glucose-129* UreaN-12 Creat-0.9 Na-139
K-4.4 Cl-108 HCO3-22 AnGap-13
[**2163-11-5**] 10:44AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.6
[**2163-11-5**] 04:36AM BLOOD ASA-NEG Ethanol-115* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2163-11-5**] 04:50AM BLOOD Glucose-165* Lactate-5.3* Na-142 K-2.9*
Cl-102 calHCO3-19*
CT abdomen [**2163-12-7**]
IMPRESSION:
1. Removal of right upper quadrant pigtail drainage catheter.
2. Resolution of rim-enhancing mid abdominal collection, drained
under CT
guidance on [**2163-11-29**].
3. Pigtail catheter in the left subdiaphragmatic abscess
collection remains
in unchanged position. There is no significant residual
drainable fluid
collection. Injection of air into this catheter demonstrates no
evidence for
fistulous communication with the bowel. There is extensive oral
contrast
retained within the colon adjacent to this site, but no
extraluminal contrast
is appreciated. Overall, these findings suggest no fistulous
communication
between the abscess cavity and the bowel.
4. Multiple foci of high density within the anterior abdominal
wall, of
unclear etiology, are again seen. If there is clinical concern
for fistulous
communication with bowel, further evaluation with either
gastrograffin enema
or CT with rectal contrast could be considered.
5. Diffuse mesenteric inflammatory change, slightly improved.
6. Small bilateral pleural effusions, improved compared to prior
study.
LENIS BLE [**2163-12-7**]
IMPRESSION: No evidence of DVT in the right or left lower
extremity.
UGI Series [**2163-12-5**]
IMPRESSION:
1. Contrast passed freely into the jejunum, without an
obstructive lesion or
extrinsic mass impression within the duodenum.
2. Mild fold thickening of distal duodenum and proximal jejunum,
likely
reflects mild edema.
3. Mild prominent loops of jejunum, may reflect an ileus.
4. No gastroesophageal reflux demonstrated.
[**2163-12-5**] Radiology UGI SGL CONTRAST W/ KUB
Small bowel segments
1. Patchy hemorrhage of muscularis propria without diffuse
infarction.
2. Acute peritonitis, with marked peritoneal fibrinous and
fibrous adhesions.
3. Small old suture reaction in the mesentery.
4. No tumor.
Brief Hospital Course:
He was admitted to the Trauma Service. In the ED, he was noted
to be slightly labile in terms of his blood pressure. He
underwent emergent CT scan imaging from head to toe which
revealed right occipital and temporal bone fractures,
pneumocephalus, and a grade [**3-22**] liver laceration with question
of disruption of the intrahepatic vena cava, as well as there
being a splenic laceration with a hematoma associated with it,
with the laceration graded between 1 and 2, as well as a
bilateral diaphragmatic rupture and left open distal femur
fracture. Subsequently he was taken to the operating room
emergently for exploration with splenectomy and bilateral
diaphragmatic repair. Packing was left over the liver and below
the gallbladder and the patient was then taken to the trauma
surgical intensive care unit where he was monitored closely.
Over the next 48 hours the decision was made for planned
re-exploration of the abdomen and removal of packing with
possible closure to occur on the morning of postoperative day
#3. He was started on cefazolin at this time (continued through
[**2163-11-7**]).
On [**2163-11-6**] he was taken back to the OR by Orthopedics this time
for repair left open distal femur fracture. Procedure included
irrigation/debridement and arthrotomy. There were no
intraoperative complications. He is to remain NWB on the LLE
until cleared by Dr. [**Last Name (STitle) 7376**] at his follow up appointment in 2
weeks after discharge.
On [**2163-11-8**], he received Vanc and Zosyn and was taken back to OR
for washout, removal of packing, placement of two [**Doctor Last Name 406**] drains
(one above dome of liver along right lateral aspect; another
right below the gallbladder), and abdomen closure.
Post-operatively he was returned back to the Trauma ICU where he
was maintained on 100 mcg/hr fentanyl and 50 mcg/kg/min propofol
drips. Sedation was lightened and PCA begun to allow for
extubation. Continued to have 2 chest tubes and 2 JP drains in
place. Vanc and Zosyn were stopped on [**11-9**]. He was extubated on
[**11-9**] and [**2163-11-10**], he was on nasal cannula and noted to be
intact neurologically, off all sedation. Right chest tube was
pulled and he was transferred to the floor on [**11-10**].
CT follow up on [**11-11**] showed no abdominal abscess, small
bibasilar pneumothoraces and pleural effusions. Also showed
diffuse thickened duodenum/prox jejunum. LENIs on [**2163-11-12**]
showed no DVT. [**2163-11-13**] he was noted to be vomiting and ?SBO
considered. He was kept NPO and NG placed with ~1.7L out. TPN
was started on [**2163-11-13**] pending return of bowel function. KUB
was nonspecific and showed no signs of obstruction. ?Cdiff
considered, but Negative x 3. Clamping trials of NG tube
attempted starting [**2163-11-14**]. He was unable to tolerate this as
he would become increasingly symptomatic with continued high NG
outputs when returned to suction.
While on the floor he developed a syndrome of confusion,
new-onset fever, tachy to 150's, and increased WBC. He also had
progressive abdominal tenderness and distention. [**2163-11-14**]
abdominal CT showed mild increased duodenal and jejunal
dilatation, w/ mid SB/jejunal wall thickening and raised
question of ileus vs SBO.
On [**2163-11-18**] he was taken back to OR for suspected obstructive
process. Conducted ex-lap, LOA, and small-bowel resection with
primary anastomosis. He was found to have diffuse adhesive SBO
without strangulation. He was returned to the Trauma ICU.
He would undergo further abdominal CT imaging which revealed
multiple loculated areas of fluid in the abdomen and pelvis with
enhancing peritoneum, including the
splenectomy bed. His symptoms persisted and on [**11-24**] he was taken
to IR where 2 drains were placed.
His nausea and vomiting persisted intermittently; he was trialed
on Reglan and Erythromycin. The NG tube was eventually removed;
his diet was advanced. Initially he was not able to tolerate
oral solids and did have intermittent episodes of nausea and
vomiting. Ultimately he was able to better tolerate an oral diet
without vomiting.
He was noted to have guaiac positive stools and a slight drop in
his hematocrit. He was transfused with 2 units packed cells.
Postoperatively he was started on a PPI. His hematocrit at time
of discharge was 28.
He was evaluated by Physical and Occupational therapy and was
recommended for home with services.
Medications on Admission:
None
Discharge Medications:
1. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*0*
4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
6. 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*
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
8. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
Disp:*1 jar* Refills:*1*
9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO EVERY EVENING.
Disp:*30 Tablet(s)* Refills:*1*
10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
Disp:*1 * Refills:*1*
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
12. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*1*
13. Outpatient [**Name (NI) **] Work
PT/INR
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
s/p Motor vehicle crash
Right occipital and temporal bone fracture
Pneumocephalus
Liver laceration (Grade [**3-22**])
Splenic laceraction (Grade [**1-19**])
Bilateral diaphragmatic rupture
Left open distal femur fracture
Acute blood loss anemia
Discharge Condition:
Hemodynamically stable, tolerating an oral diet, pain adequately
controlled.
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing.
Activity: No heavy lifting of items [**11-2**] pounds until the
follow up appointment with your doctor.
Medications: Resume your home medications. You should take a
stool softener and laxative, Colace and milk of magnesia as
needed for constipation.
Pain medication may make you drowsy. No driving or operating
heavy machinery while taking pain medicine.
You have been prescribed a low dose of Coumadin referred to as
mini dose Coumadin used to prevent development of blood clots.
Followup Instructions:
Follow up next week on Monday [**2163-12-19**] with Dr. [**Last Name (STitle) **], Trauma
Surgery. Call [**Telephone/Fax (1) 6429**] for an appointment. You will need to
arrive at least 1 hour before your appointment to have your
blood drawn in the [**Telephone/Fax (1) **] on [**Location (un) 453**] of the [**Hospital Unit Name **].
Follow up in 2 weeks with Dr. [**Last Name (STitle) 7376**], Orthopedics. Call
[**Telephone/Fax (1) 1228**] for an appointment.
Completed by:[**2163-12-21**]
|
[
"2851",
"5119"
] |
Admission Date: [**2139-8-10**] Discharge Date: [**2139-8-14**]
Date of Birth: [**2111-3-27**] Sex: M
Service: PLASTIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 26411**]
Chief Complaint:
Right brachial plexus injury with poor motor elbow flexion.
Major Surgical or Invasive Procedure:
Right pedicled latissimus transfer for restoration of right
elbow flexion [**8-10**]
History of Present Illness:
28 yo gentleman who suffered traumatic injury one year ago when
he was hit by a train. He has since undergone several orthopedic
procedures for correction of his multiple injuries. On this
occasion, he was admitted for muscle transposition for elbow
flexion.
Past Medical History:
s/p Struck by train on [**2138-5-28**]
-Left tibia fracture
-Pelvic fractures
-Right arm injury (partial internal amputation/radial nerve
palsy/vascular injury)
Social History:
Lives with wife, independent prior to train accident
Family History:
NC
Physical Exam:
Physical Exam:
v/s: AVSS
GEN: extubated
HEENT: MMM, neck is supple
CV: RRR
ABD: soft, NTND, +bs
LIMBS: No LE edema, cyanosis, clubbing
Pertinent Results:
Labs near time of discharge:
[**2139-8-13**] 03:17AM BLOOD WBC-11.5* RBC-3.68* Hgb-11.7* Hct-35.2*
MCV-96 MCH-31.7 MCHC-33.2 RDW-12.5 Plt Ct-241
[**2139-8-13**] 03:17AM BLOOD Glucose-115* UreaN-8 Creat-0.6 Na-138
K-3.7 Cl-105 HCO3-27 AnGap-10
[**2139-8-11**] 01:28PM BLOOD ALT-29 AST-26 LD(LDH)-189 AlkPhos-90
TotBili-0.2
[**2139-8-13**] 03:17AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.0
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
[**2139-8-10**] and had a Right pedicled latissimus transfer for
restoration of right elbow flexion. The patient tolerated the
procedure well however following the procedure he failed the
cuff test, was therefore transferred to the ICU for monitoring.
He stayed in the ICU until POD 3 because of high vent settings
and IV access issues. He was then transferred to the floor once
these issues resolved.
Neuro: Post-operatively, the patient received Dilaudid IV with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient initially had high vent settings which
resolved. He was extubated on POD 3 and was stable from a
pulmonary standpoint; vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley was removed on POD#3. Intake
and output were closely monitored.
ID: Post-operatively, the patient was started on cefepime,
flagyl and levofloxacin for thought that pneumonia may have
caused his high oxygen requirement but was d/c'd home with
Duricef.
Prophylaxis: The patient did not receive prophylaxis as he has a
heparin allergy.
At the time of discharge on POD#4, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
percocet
cialis
neurontin
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Please take while taking your narcotic pain medication to
prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
3. Cefadroxil 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 10 days.
Disp:*20 Capsule(s)* Refills:*1*
4. Cialis Oral
5. Percocet 10-325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain: Please do not drive or operate
heavy machinery.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right brachial plexus injury with poor motor elbow flexion.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had surgery on [**8-10**] for a Latissimus dorsi muscle flap to
your right elbow.
-Activity as tolerated
-Splint to right upper extremity x 4 weeks, try to minimize
shoulder movement.
-Steri-strips on back (white "bandaid-like" material) will come
off on their own.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take prescription pain medications for pain not relieved by
tylenol.
3. Take your antibiotic as prescribed.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softerner if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
welling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness,swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] sometime next week. To
make an appointment please call ([**Telephone/Fax (1) 26412**].
Please go to the following appointments:
[**2139-10-13**] at 7:40am: ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
[**2139-10-13**] 8:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
|
[
"51881"
] |
Admission Date: [**2189-7-10**] Discharge Date: [**2189-7-17**]
Date of Birth: [**2138-9-16**] Sex: F
Service: MEDICINE
Allergies:
Somatostatin / Compazine / Dilaudid / Meperidine / Percocet /
Bactrim / Fentanyl / OxyContin / Paxil / Demerol / Droperidol /
Lactose / Barium Sulfate / Iodine-Iodine Containing /
Pantoprazole / Omeprazole / Codeine / Sulfa (Sulfonamide
Antibiotics) / tramadol / IV Dye, Iodine Containing Contrast
Media / Lovenox
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
dehydration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 93451**] is a 50yo F with complicated PMH including sclerosing
mesenteritis who presents from home with dizziness and decreased
UOP x 1 day. She initially came to [**Hospital1 **] today to be seen by the IV
access team due to redness and swelling in the R groin after
exchange of her CVL a few days ago. She made herself NPO at 630
this AM in case she required any intervention for her line.
Of note, multiple recent admissions, most recently [**Date range (1) 93571**]
for ?SBO. Ultimately, it was felt that her increased pain was
"multifactorial from both physical and emotional pain." Her
G-tube and fem line for TPN were both re-placed that admission.
For insurance/financial reasons, pt was unable to get home fluid
boluses, although did continue her usual TPN. She is able to
take a small amount of po at baseline.
In the ED, initial VS were: T97, HR 83, BP 83/50, RR 18, 98% RA
In the ED, she was given 3.5L NS and pressures were in the
80s-low 90s. Baseline pressure per OMR 110s. FSG 60 in ED, but
came up with D5W.
On arrival to the MICU, patient's VS BP 122/89, HR 76, RR 18,
100% RA.
Past Medical History:
-Sclerosing mesenteritis (dx'd in [**2172**], s/p multiple abdominal
surgeries, including placement of decompressive G-tube)
-recurrent SBO
-chronic GI dysmotility
-IBS
-NSAID-related gastritis and UGI bleed
-Hep C (transmitted via transfusion in [**2172**])
-recurrent DVTs (most recently in the R subclavian vein
[**2188-6-19**], not on lovenox at the time)
-anemia
-mitral valve prolapse
-migraine HAs w/ visual aura
-asthma
-nocturnal benign myoclonus
-chronic tachycardia (HR in the 120s)
-depression
-osteopenia
-GERD
-esophagitis
-recurrent UTIs
-sebaceous cysts
.
PAST SURGICAL HISTORY: 23 abdominal surgeries
-including multiple LOAs
-colonic decompressions
-SBRs - parts of duodenum, entire ileum
-repair of incisional hernias
-appendectomy
-open CCY
-G-tube placement [**2183**]
-extraction of duodenal bezoar
-multiple port-a-cath placements and removals
-L hemi-thyroidectomy
-breast reduction and multiple breast lumpectomies
-tooth extractions
-b/l knee arthroscopies
-b/l ankle reconstructions
-c-section
Social History:
Lives in [**Location 5110**] with husband, has two sons and a cat. No
smoking history, no alcohol use. Previously worked as a computer
programmer but has been on disability since [**2169**]. Her husband is
also chronically ill.
Family History:
- Mother with myelofibrosis, [**Name (NI) 2320**], breast CA age 30, died at 61
- Father with [**Name2 (NI) 2320**], HTN, MI s/p CABG, aortic aneurysm died at 75
- Brother with glioblastoma multiformans, died 46
- Sister lupus, bowel obstruction, breast cancer mets to brain
- two sons w/ celiac, one with JRA
Physical Exam:
PHYSICAL EXAM ON ADMISSION
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, hypoactive bowel sounds. G-tube
with brown-green output, site dressed. Diffuse tenderness to
light touch.
Ext: Warm, well perfused
Skin: R groin CVL insertion site clean, intact. There is some
erythema and induration medial to the line that is tender to
light palpation.
Pertinent Results:
CXR: Spinal stimulator device is redemonstrated in unchanged
position. The heart size is normal. The mediastinal and hilar
contours are unremarkable. The pulmonary vascularity is within
normal limits.
There is minimal atelectasis in the left lung base. No focal
consolidation, pleural effusion or pneumothorax is visualized.
IMPRESSION: Minimal atelectasis in the left lung base.
[**2189-7-11**] 05:00AM BLOOD WBC-3.0* RBC-3.18* Hgb-9.0* Hct-28.0*
MCV-88 MCH-28.4 MCHC-32.3 RDW-16.3* Plt Ct-135*
[**2189-7-10**] 03:00PM BLOOD WBC-5.6# RBC-3.94*# Hgb-10.9* Hct-34.5*
MCV-88 MCH-27.7 MCHC-31.7 RDW-16.6* Plt Ct-195
[**2189-7-11**] 12:18PM BLOOD Na-141 K-4.0 Cl-111*
[**2189-7-11**] 05:00AM BLOOD Glucose-84 UreaN-17 Creat-0.6 Na-142
K-3.2* Cl-111* HCO3-21* AnGap-13
[**2189-7-10**] 03:00PM BLOOD Albumin-3.8
Brief Hospital Course:
Ms. [**Known lastname 93451**] is a 50yo F with complicated PMH including sclerosing
mesenteritis who presents from home with dizziness and decreased
UOP x 1 day found to have systolic BP in the 80s in the setting
of being unable to recieve IVF boluses as prescribed and no po
intake for > 12 hours.
# Hypovolemic hypotension: the patient has not used her home IV
fluids for some time because of insurance issues. On day of
admission she held her PO intake in case she needed a procedure
for R femoral venous catheter. These 2 events led to her
hypotension. She was admitted to the ICU and quickly recovered
w/ aggressive IVF. Infection on differential but less likely;
blood and urine cultures were negative, no empiric abx were
given.
# R groin pain: has a femoral venous catheter for home TPN.
Given pain from tunnelled site the patient had the catheter
re-tunnelled during this hospitalization.
# Chronic pain: on morphine suppositories, increased on recent
admission from 20mg q6h to 25mg q6h. Patient reports no relief
with this increase. She states honestly that if she continues to
uptitrate it without relief, she may discontinue altogether
because she sees no purpose in taking higher doses of an
ineffective opioid. She was treated with IV dilaudid 1mg doses
while in house for additional pain control; it was noted that
she was not admitted for any acute pain issues and therefore her
home narcotics are not to be changed for discharge. We would
recommend she continue outpatient pain mgmt and have an
established narcotics contract. Patient was discharged with a
script for morphine suppositories as the script that her pain
management doctor had sent was lost in the mail.
INACTIVE ISSUES:
# Abdominal pain, sclerosing mesenteritis: Pt followed by Dr.
[**Last Name (STitle) 79**] as well as Pain Mangement.
- Continued home regimen: gabapentin, morphine PR
- Gets monthly Lupron injections
# Depression/anxiety: Likely contributing to chonic pain per
medical and SW assesment last admission. Pt endorsing worsening
of her depression and frustration with multiple
hospitalizations.
- Con't home meds: Lamotrigine, Abilify, trazodone, lorazepam
- Clonidine patch held
- seen by psychiatry and social work
# Migraines: continude home Butorphanol and Sumatriptan.
# anemia: Pt currently above baseline Hct (29-32).
- Continued home ferrous sulfate.
# Hypothroidsim: Continued home levothyroxine
# Code: DNR DNI(confirmed)
Medications on Admission:
Meds (per d/c summary [**2189-7-7**]):
1. ARIPiprazole *NF* 2 mg Oral daily Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
please dispense liquid form! thanks
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 900 mg PO Q8H
4. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QTUES
5. Ferrous Sulfate (Liquid) 300 mg PO DAILY
6. LaMOTrigine 75 mg PO DAILY
7. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Misoprostol 200 mcg PO QIDPCHS
10. Octreotide Acetate 100 mcg SC Q8H
11. pilocarpine HCl *NF* 10 mg Oral [**Hospital1 **] Reason for Ordering:
Wish to maintain preadmission medication while hospitalized, as
there is no acceptable substitute drug product available on
formulary.
12. Senna 1 TAB PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. traZODONE 150 mg PO HS:PRN insomnia
15. Sumatriptan Succinate 6 mg SC Q4H:PRN migraine headache
please give first injection at onset of headache. can give
second injection 4 hours later. NO MORE THAN 2 INJECTIONS PER
DAY
16. butorphanol tartrate *NF* 10 mg/mL NU QID:PRN headache
* Patient Taking Own Meds *
17. Lorazepam 1 mg PO HS:PRN sleep
18. DiphenhydrAMINE 12.5 mg PO Q6H:PRN itching
19. Leuprolide Acetate 3.75 mg IM QMONTH Duration: 1 Doses
20. Promethazine 25 mg PR Q6H:PRN nausea
21. Polyethylene Glycol 17 g PO DAILY
22. Enoxaparin Sodium 40 mg SC DAILY
23. Morphine Sulfate 25 mg PR Q6H
hold for sedation, RR<12
Discharge Medications:
1. aripiprazole 1 mg/mL Solution [**Hospital1 **]: Two (2) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
3. gabapentin 300 mg Capsule [**Hospital1 **]: Three (3) Capsule PO Q8H
(every 8 hours).
4. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Hospital1 **]: One (1)
PO DAILY (Daily).
5. lamotrigine 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
6. levothyroxine 88 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. misoprostol 200 mcg Tablet [**Hospital1 **]: One (1) Tablet PO QIDPCHS (4
times a day (after meals and at bedtime)).
8. octreotide acetate 100 mcg/mL Solution [**Hospital1 **]: One (1)
Injection Q8H (every 8 hours).
9. pilocarpine HCl 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
10. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
11. cholecalciferol (vitamin D3) 1,000 unit Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
12. trazodone 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
13. sumatriptan succinate 6 mg/0.5 mL Solution [**Hospital1 **]: One (1)
Subcutaneous X2 PRN as needed for migraine.
14. diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: 0.5 Capsule PO Q6H
(every 6 hours) as needed for itching.
15. polyethylene glycol 3350 17 gram Powder in Packet [**Hospital1 **]: One
(1) Powder in Packet PO DAILY (Daily).
16. butorphanol tartrate 10 mg/mL Spray, Non-Aerosol [**Hospital1 **]: One
(1) Spray Nasal Q4H (every 4 hours) as needed.
17. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
18. ethanol (ethyl alcohol) 98 % Solution [**Last Name (STitle) **]: One (1) ML
Injection DAILY (Daily).
19. morphine 20 mg Suppository [**Last Name (STitle) **]: One (1) Rectal every six
(6) hours as needed for pain.
Disp:*40 tabs* Refills:*0*
20. morphine 5 mg Suppository [**Last Name (STitle) **]: One (1) Rectal every six (6)
hours.
Disp:*40 tabs* Refills:*2*
21. zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime).
Disp:*10 Tablet(s)* Refills:*0*
22. enoxaparin 40 mg/0.4 mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous
DAILY (Daily).
23. TPN
See attached order
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Hypotension
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you developed low blood pressure after
not eating in preparation for a [**Hospital1 **] procedure. Your blood
pressure improved with IV fluids.
During this admission your IV catheter in the femoral vein was
re-tunnelled.
During this admission you were seen by social work and
psychiatry.
Your home medications remain the same.
Followup Instructions:
Department: PAIN MANAGEMENT CENTER
When: MONDAY [**2189-7-27**] at 11:10 AM
With: [**Last Name (NamePattern4) **],MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2189-7-28**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2189-7-29**] at 10:10 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"2859",
"4240",
"49390",
"53081",
"311",
"2449"
] |
Admission Date: [**2100-11-5**] Discharge Date: [**2100-11-10**]
Date of Birth: [**2057-7-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Acute alcohol withdrawal.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
43M with history of alcohol abuse, schizophrenia and depression
who presents from [**Hospital1 **] with alcohol withdrawl. The
history was obtained from the medical record, as the patient is
unable to provide any history. The patient initially presented
to St. [**Hospital **] hospital with alcohol intoxication with a serum
alcohol level of 450. He was treated with Ativan and reached
sobriety and subsequently transferred to [**Hospital3 8063**] on
[**2100-11-2**] under a Section 12 for suicidal ideation and hearing
voices. He was started on zyprexa and a standing lorazepam
taper for symptoms of alcohol withdrawl. Over the last two days,
the patient has become increasingly tremulous with altered
mental status. It appears that he received a total of 17mg of
lorazepam over the past two days. His last drink was on the
morning of [**2100-11-4**].
.
In the ED, the patient was minimally responsive, hypertensive to
166/109 and tachycardic to 115. He was started on IVF and given
a total of 25mg of IV Valium. Head CT was negative and tox
screen was positive for benzos. He is admitted to the MICU for
frequent CIWA scale assessments and poor mental status.
Past Medical History:
1. Alcohol dependence, drinks one gallon vodka daily
2. Schizophrenia, followed at [**Location (un) 8973**] Clinic but not
currently taking his meds, history of multiple admissions
3. Depression
4. HTN
5. Opioid and cocaine abuse, last smoked crack cocaine 2 months
ago
Social History:
Lives with wife. They have three grown children (ages
23,22,21). Patient has been on SSDI for the past 11 years due to
mental illness. Drinks 1 gallon of vodka daily for years. Had
five years of sobriety between [**2089**] and [**2094**] to save his
marriage. Occasionally uses cocaine, last smoked crack cocaine
two months ago. Rarely abuses Klonopin and Vicodin, but "very
seldom", last in [**2099-12-19**].
Family History:
Non-contributory.
Physical Exam:
Vitals: T 95.0 BP 159/107 HR 112 RR 18 100% RA
Gen: somnolent but arousable to voice, follows some commands,
mumbling somewhat incoherently
HEENT: pupils 2mm and minimally reactive bilaterally, nystagmus
on lateral gaze, dry mucous membranes with some dried blood
Neck: no LAD, no JVD
Lung: coarse upper airway sounds, no wheezing or rales
Cor: tachycardic, regular rhythm, no murmurs appreciated
Abd: soft, NTND, NABS
Ext: warm and well-perfused, no edema
Neuro: somnolent, but arouses to voice, oriented x 1.5 (name,
[**2099**]), moves all extremities, follows some commands
Pertinent Results:
[**2100-11-5**] 02:00AM BLOOD WBC-4.3 RBC-3.77* Hgb-11.9* Hct-33.7*
MCV-89 MCH-31.5 MCHC-35.3* RDW-14.2 Plt Ct-152
[**2100-11-5**] 02:00AM BLOOD Neuts-69.2 Lymphs-24.9 Monos-4.7 Eos-0.9
Baso-0.3
[**2100-11-5**] 02:00AM BLOOD Plt Ct-152
[**2100-11-5**] 02:00AM BLOOD Glucose-103 UreaN-10 Creat-0.9 Na-141
K-3.4 Cl-103 HCO3-25 AnGap-16
[**2100-11-5**] 02:00AM BLOOD ALT-27 AST-38 AlkPhos-98 Amylase-184*
TotBili-0.2
[**2100-11-5**] 02:00AM BLOOD Lipase-40
[**2100-11-5**] 02:00AM BLOOD Albumin-4.0
[**2100-11-6**] 04:04AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.2*
[**2100-11-6**] 04:04AM BLOOD TSH-5.5*
[**2100-11-7**] 04:21AM BLOOD Free T4-0.5*
[**2100-11-6**] 04:04AM BLOOD VitB12-642 Folate-8.3
[**2100-11-5**] 02:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-POS Tricycl-NEG
RPR(STS):
.
ECG [**2100-11-5**]: Sinus tachycardia. ST-T wave flattening in lead II
and T wave inversion in leads III and aVF. Delayed precordial R
wave progression. Active inferior ischemic process cannot be
excluded.
.
CT head [**2100-11-5**]: No intracranial hemorrhage.
Brief Hospital Course:
A/P: A 43yoM with history of alcohol abuse, HTN, schizophrenia
and depression who is admitted to MICU from [**Hospital3 8063**]
(section 12) with acute alcohol withdrawal.
.
1. Alcohol withdrawal: The patient's last drink was reported as
approximately 24 hrs prior to admission, although this would
have been during his admission to [**Hospital3 8063**]. He was
maintained on CIWA scale and give valium 10mg prn for CIWA scale
or autonomic signs of withdrawal. Since the Pt. was unreliable
on the CIWA scale, he was given valium for autonomic/objective
signs of withdrawal. Amylase elevation is likely related to
alcoholism rather than pancreatitis. Pt. was seen by Psychiatry
and was treated with valium and haldol (for h/o schizophrenia).
Pt. was treated with thiamine, folate, and initially fluid
resuscitated with D5NS, and then transitioned to regular diet.
Patient discharged in stable condition without any signs of
ongoing withdrawl.
.
2. HTN: History of HTN, was acutely hypertensive on admission,
likely related to acute alcohol withdrawal. Withdrawal symptoms
were treated with valium as above. Pt. was started on clonidine
patch, which maintained normotension.
.
3. Substance abuse: Pt has h/o polysubstance abuse including
alcohol, cocaine and opiates, and tested positive for alcohol
and barbiturates on this admission. Was seen by Social Work and
Substance Abuse counseling.
.
4. Schizophrenia/Depression: Schizophrenia previously treated
with Seroquel and Zyprexa. On transfer to [**Name (NI) **], pt had +
suicidal ideation and + auditory hallucinations. Pt. was seen
by psychiatry and treated with haldol [**Hospital1 **] and PRN:TID for
agitation. Daily ECGs were monitored while Pt. was on haldol.
B12 and folate levels were normal. Pt. had a 1:1 sitter around
the clock due to suicidal ideation.
.
5. Hypothyroidism: Pt. found to have low T4 and elevated TSH,
consistent with hypothyroidism. Started on 75mcg levothyroxine.
Will need follow up TSH check in [**5-26**] weeks. Please ensure that
patient has follow up with his PCP regarding this issue.
.
[**2100-11-19**] Addendum *** patient had abnormal TFT's, specifically a
free T4 that was low at 0.6 and a normal TSH of ~3.5. The DDX
for this is sick thyroid versus secondary ( central
hypothyroidism). As the patient TFT's were measureed when he
was ill, I suspect this is from sick thyroid. Nonetheless, he
will require repeat TFT's in [**12-20**] months to ensure normalization.
He should NOT be on thyroid replacement therapy yet.
This discharge summary states that he was discharged on
levothyroxine though the d/c meds do not list levoqthyroxine.
His page 1 also does not list it.
6. FEN: Electrolytes were aggresively followed & repleted in
order to decrease seizure/arrhythmia risk. Pt. was fed a
regular diet.
.
7. PPX: Heparin SQ. PPI.
.
8. Dispo: Pt. spent 3 days in MICU, and was tranferred to a
medical service on [**2100-11-8**].
Medications on Admission:
Clonidine
Discharge Medications:
Clonidine TTS 1 Patch 1 PTCH TD QFRI
Acetaminophen 325-650 mg PO Q4-6H:PRN
Thiamine HCl 100 mg PO DAILY
Folic Acid 1 mg PO DAILY
Citalopram Hydrobromide 5 mg PO DAILY
Haloperidol 5 mg PO BID
Diazepam 5-10 mg PO Q4-6H:PRN prn for CIWA > 10
Discharge Disposition:
Extended Care
Facility:
Bornwood psychiatric facilty
Discharge Diagnosis:
acute alcohol withdrawal
Discharge Condition:
stable
Completed by:[**2100-11-10**]
|
[
"4019",
"2449"
] |
Admission Date: [**2135-9-28**] Discharge Date: [**2135-10-1**]
Date of Birth: [**2099-2-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Cerebellar mass
Major Surgical or Invasive Procedure:
Sub-Occipital Craniotomy with EVD placement
History of Present Illness:
Ms. [**Known lastname **] is a 36-year-old woman with a history of metastatic
breast cancer who presented for re-resection of a cerebellar
lesion. Initially, she had resection of a right cerebellar
metastasis, which was followed by Cyberknife stereotactic
radiosurgery. She has now developed since 4 weeks new symptoms
of ataxia and the latest MRI scan from today shows a large
irregularly contrast enhancing mass in the right cerebellar
hemisphere growing into the tentorial notch and also starting to
compress the fourth ventricle.
Past Medical History:
[**2130**] - breast CA
[**2131**] - mastectomy, radiation
[**2132**] - reconstruction of breast
[**2133-9-26**] - left oophorectomy
Social History:
married, has 2 children 4 and 6 years old, sister is a nurse
practitioner
Family History:
father died of lymphoma at age 50, 4 year old child has
medullablastoma
Physical Exam:
VITAL SIGNS: Blood pressure was 104/61, pulse of 53,
respirations of 10.
CARDIOVASCULAR: She had regular rate and rhythm, no murmurs,
gallops, or rubs.
LUNGS: Clear to auscultation bilaterally.
NEUROLOGIC:
HEENT: Well-healing right posterior fossa scar that the hair has
grown
over.
Eyes: Pupils equal, round, and reactive to light. Extraocular
movements were intact. Visual fields were full. There was no
nystagmus.
Mouth: Tongue was midline. Palate elevated symmetrically.
Neck was soft and supple. Cranial nerves II through VII, IX
through XII were intact.
Motor was [**4-30**] bilaterally, normal tone, no drift.
Sensation was intact to light touch, temperature, and vibration
throughout. Cerebellar: She had normal appendicular
coordination except in the right hand
where she had some slight clumsiness with finger tapping and
finger-nose-finger, but rapid alternating movements were intact.
She had good foot tapping and heel-knee-shin bilaterally. She
had negative Romberg, was able toe tandem and heel walk quite
well.
Pertinent Results:
Pathology: no tumor cell identified.
MRI Wand study [**2135-9-28**]:
1. Wand protocol study, re-demonstrating the right cerebellar
heterogeneously enhancing lesion, for surgical planning.
2. Interval improvement in the mass effect in the cerebellum and
improvement in the size of the fourth ventricle, which now
appears normal.
Postop MR HEAD W & W/O CONTRAST [**2135-9-30**] 12:19 AM
FINDINGS: Again identified is an ovoid enhancing mass in the
right cerebellar hemisphere. This measures approximately 32 x 20
x 16 mm. There is now a new right cerebellar hemisphere
resection cavity extending to the posterior margin of this mass.
There is a small posterior fossa subdural fluid collection with
enhancement, presumably related to the recent surgery. Again
identified is edema extending into the pons. This appears to
have reduced somewhat since the brain MR [**First Name (Titles) **] [**2135-9-23**].
There has been no increase in posterior fossa mass effect since
[**9-28**].
CONCLUSION: Status post suboccipital craniectomy and resection
of the posterior margin of the right cerebellar hemispheric
tumor.
[**2135-9-28**] 11:26AM WBC-8.1 RBC-4.12* HGB-15.0 HCT-40.4 MCV-98
MCH-36.4* MCHC-37.1* RDW-15.5
[**2135-9-28**] 04:13PM GLUCOSE-122* UREA N-15 CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16
[**2135-9-28**] 04:13PM CALCIUM-10.2 PHOSPHATE-4.1 MAGNESIUM-2.1
[**2135-9-28**] 04:13PM WBC-11.6* RBC-4.05* HGB-14.5 HCT-41.3
MCV-102* MCH-35.7* MCHC-35.0 RDW-14.8
[**2135-9-28**] 04:13PM PLT COUNT-255
[**2135-9-28**] 04:13PM PT-12.8 PTT-18.7* INR(PT)-1.1
[**2135-9-28**] 12:40PM TYPE-ART PO2-288* PCO2-33* PH-7.50* TOTAL
CO2-27 BASE XS-3 INTUBATED-INTUBATED
[**2135-9-28**] 12:40PM GLUCOSE-136* LACTATE-3.6* NA+-133* K+-3.4*
CL--95*
[**2135-9-28**] 12:40PM HGB-15.2 calcHCT-46
[**2135-9-28**] 12:40PM freeCa-1.08*
[**2135-9-28**] 11:26AM WBC-8.1 RBC-4.12* HGB-15.0 HCT-40.4 MCV-98
MCH-36.4* MCHC-37.1* RDW-15.5
[**2135-9-28**] 11:26AM PLT COUNT-225
[**2135-9-28**] 11:26AM PT-12.6 PTT-20.2* INR(PT)-1.1
[**2135-9-28**] 11:26AM FIBRINOGE-161
[**2135-9-28**] 10:06AM TYPE-ART PO2-327* PCO2-27* PH-7.56* TOTAL
CO2-25 BASE XS-3
[**2135-9-28**] 10:06AM GLUCOSE-166* LACTATE-2.9* NA+-132* K+-3.2*
CL--99*
[**2135-9-28**] 10:06AM HGB-13.4 calcHCT-40
[**2135-9-28**] 10:06AM freeCa-1.14
Brief Hospital Course:
Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a suboccipital craniotomy with resection of
a right cerebellar mass and EVD placement on [**9-28**], which she
tolerated well. She was admitted to the ICU initially, where she
had tight glucose and BP control. She did well and was
transferred to the step down unit on POD#1, and to the floor on
POD#2. Her EVD was removed on POD#3. She was placed on a
dexamethasone taper, which will end on [**10-4**]. Post-op MRI
revealed reduced edema and no increase in posterior fossa mass
effect.
She had no complications and was discharged on POD#3 with
follow-up arranged.
She was instructed to resume her Xeloda on Sunday (1500mg qam
and 1000 mg qpm) and to resume her Lapatinib one week after
surgery.
Medications on Admission:
Celexa 10 mg daily
Lapatinib 1000 mg daily
Lomotil 2.5 mg prn diarrhea
Xeloda 1500 mg qam, 1000 mg qpm for 14 days, then 7 days off.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): While taking narcotics and prn after that.
Disp:*60 Capsule(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): While taking narcotics and prn after that.
Disp:*60 Tablet(s)* Refills:*2*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
4. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO q8h () for
2 doses: On [**10-1**].
Disp:*4 Tablet(s)* Refills:*0*
5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q8h () for 3
doses: On [**10-2**].
Disp:*3 Tablet(s)* Refills:*0*
6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q12h () for
2 doses: On [**10-3**].
Disp:*2 Tablet(s)* Refills:*0*
7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO qd () for 1
doses: On [**10-4**].
Disp:*1 Tablet(s)* Refills:*0*
8. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*3*
10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Cerebellar Brain Mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
Restart your Lapatinib one week after surgery. Restart your
Xeloda on Sunday, [**10-2**].
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Have staples removed at Dr[**Name (NI) 9034**] office on [**10-7**] between
0900-1200
Follow up in Brain tumor clinic on [**2135-10-17**] @4pm
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Date/Time:[**2135-10-14**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4285**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2135-10-14**] 11:30
Completed by:[**2135-10-1**]
|
[
"311"
] |
Unit No: [**Numeric Identifier 69945**]
Admission Date: [**2101-10-27**]
Discharge Date: [**2102-2-1**]
Date of Birth: [**2101-10-27**]
Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: This baby girl was [**Name2 (NI) **] at 25
and 3/7 weeks' gestation to a 32-year-old, gravida 4, para 2,
woman. Her prenatal screens were 0+, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella unknown and GBS unknown.
Past obstetric history was remarkable for delivery at term in
[**2093**] and at 32 weeks for preeclampsia at [**Hospital6 69946**] in [**2095**]. Both children are doing well.
This pregnancy was uneventful until 6 days prior to delivery
when edema and hypertension was noted. The mother was
transferred from [**Hospital6 49731**]. She was given
betamethasone and completed on [**2101-10-22**]. She was
treated here with nifedipine and labetalol and magnesium
sulfate. The decision to deliver was made on [**2101-10-27**], for nonreasurring fetal heart rate tracing.
Cesarean section was performed under spinal anesthesia. The
baby emerged without a cry and respiratory effort and was
intubated immediately in the delivery room on first attempt.
She was given bag and mask ventilation and then was
transferred to the NICU without any incident.
MATERNAL HISTORY: She is a registered nurse working in a
rehabilitation unit. Father is an assistant manager at
central [**State 350**].
NICU PHYSICAL EXAMINATION: Weight 615 g, 10th percentile,
length 30.5 cm, 10th percentile, head circumference 22.5 cm,
10th percentile. Her vital signs were temperature of 98.4,
heart rate 139, respiratory rate 50, blood pressure 72/26
with a mean of 42. She was being well perfused. Soft anterior
fontanel, normal faces, intact palate, mild retraction with
clear breath sounds. No heart murmur. Positive femoral pulses
bilaterally. Nontender and soft abdomen without any
hepatosplenomegaly. Stable hips. No perfusion. Normal tone
and acuity for gestational age.
IMPRESSION: Extreme preterm infant with respiratory distress
related to hyaline membrane disease. A dose of surfactant was
administered. Initial blood glucose was 24 and she was
admitted for further management.
HOSPITAL COURSE: Respiratory: She was intubated in the
delivery room. She was brought to the NICU and given the
first dose of surfactant and another dose of surfactant was
given for continued high respiratory pressures. Her chest x-
ray on admission showed evidence of respiratory distress
syndrome. She was continued on SIMV and intubated for the
first 6 days of life. She received Vitamin A for BPD
prophylaxis.
On day of life #7 she was extubated and put on CPAP which she
continued up to day of life #32. She was changed to nasal
cannula oxygen on 33rd day of life and she continued to be
doing well on nasal cannula until day of life 52.
On day of life 52 she was given a trial of room air. She was
placed back in nasal cannula on DOL #52. She continued in NC
until DOL 90 when she was given another trial of room air which
she failed on day of life 91 and was put back on nasal
cannula oxygen.
So currently she is on 50 cc of oxygen at 100% and she will
be discharged home with oxygen and home oxygen saturation
monitoring.
On examination she has mild subcostal retractions, normal
work of breathing and chest clear to auscultation
bilaterally.
Respiratory medications: She was started on caffeine on day
of life #3 which was discontinued on day of life #56. Her
last chest x-ray was done on [**2102-1-31**], which shows
evidence of chronic lung disease. Her last blood gas was done
on [**2101-1-30**], which is 7.32, 71, 27 and 38.
On day of life #78, she was started on Lasix 2 mg/kg/day
every Monday, Wednesday and Friday for her chronic lung
disease. Her electrolytes have been stable. She will go home
on Lasix 2 mg/kg/day on Monday, Wednesday and Friday. She will
be followed by a Pulmonologist with appointment on [**2-7**]. Mother
was given a letter to take to Motor Vehicles Dept to obtain a
handicapped placard since infant is going home on oxygen.
Cardiovascular: Her initial blood pressure was stable and her
heart rate was in the 150-160 range. Within the first 24
hours of life, a loud 2/6 systolic murmur was heard and an
echocardiogram was done on day of life #1 on [**2101-10-28**], which showed a large ductus arteriosus and a patent
foramen ovale. She was given a treatment of indomethacin 3
doses and after completion of 3 doses the murmur disappeared.
She continued to have stable blood pressures and a repeat
echocardiogram was done on [**2101-11-10**], on day of life
14 shows normal cardiac anatomy with closed ductus
arteriosus.
On day of life 37 an intermittent murmur was noted, [**12-27**] x 6
in its verity and the normal cardiac anatomy was attributable
to be PPS murmur and on discharge physical examination her
heart rate is in the 150-160 range, her blood pressure is
stable and she has normal first and second heart sounds with
a short soft systolic murmur of [**12-27**] x 6 at the left upper
sternal border with no radiation. Her latent rhythm is
regular. She has good peripheral perfusion and brachial and
femoral pulses are positive bilaterally and 2+.
Fluid, electrolytes and nutrition: She was placed NPO
immediately after birth and an immediate arterial and venous
lines were placed and she was started on parenteral
nutrition. On day of life #3 a PICC line was placed on
[**2101-10-30**]. On day of life #8, feeding was started with
breast milk 20 and gradually advanced. She continued to be
advancing good on p.o. versus PG feedings and her PICC line
was discontinued on day of life #22 on [**2101-11-18**].
She reached full feedings on [**2101-11-18**], and then she was
gradually advanced on the calories and she reached breast
milk 26 with NeoSure. Currently she is taking breast milk 26
with NeoSure powder p.o. feedings ad lib. Her last set of
electrolytes were drawn on day of life 94 on [**2102-1-30**], which showed sodium of 137, potassium 5.1, chloride 105
and bicarb of 25. She is also on Monday, Wednesday and Friday
Lasix schedule since day of life #78 and she also received
sodium chloride supplementation from day of life 26-45 for
initial hyponatremia.
Discharge weight 2715g. Discharge length= 44cm. Discharge head
circumference: 34cm.
OF NOTE, IF SHE DOES NOT GAIN WEIGHT OVER NEXT WEEK, WE RECOMMEND
INCREASING TO 28 CALORIES by adding 2 kcal/oz Corn Oil.
GI: Her maximum serum bilirubin was 5.7 and 0.4 on day of
life #1. She was also Coombs positive and so she was started
on phototherapy on day of life #1. She was continued on
phototherapy under double photo lights until day of life 13.
Her last bilirubin was on [**11-12**], on day of life 16,
which was 1.7 and 0.6.
Discharge physical examination showed that she has soft
nondistended abdomen. There is no hepatosplenomegaly. There
is a small umbilical hernia present.
Hematology: The patient's blood type is B+, antibody
positive. A CBC was drawn at birth which showed initial low
ANC which gradually resolved. On day of life #3, she received
her first packed red blood cells transfusion 20 ml/kg/dose in
4 hours for a hematocrit of 39, and on day of life #5, her
hematocrit was 26 and she received another packed red blood
cell transfusion.
On day of life 40 she was started on iron and vitamin E and
on day of life #89, vitamin E was discontinued and she was
changed to multivitamin. Her last CBC was performed on day of
life 87 which shows WBC of 9, hematocrit 29, platelet count
580, 19 neutrophils, 0 bands, 61 lymphocytes. She is currently
receiving ferinsol for anemia of prematurity.
Infectious disease: An initial blood cultures was drawn at
the time of birth and she was started on ampicillin and
gentamicin. Her culture was negative on day of life 48 and
ampicillin and gentamicin were discontinued. She continued to
do well and on day of life 11, due to her initial drops in
the hematocrit and some apneic episodes, another CBC and
blood culture were drawn and she was started on vancomycin
and gentamicin. This culture was also negative and gentamicin
and vancomycin were discontinued after 48 hours.
Neurology: A screening head ultrasound was performed on
[**2101-11-1**], on day of life 5, due to the gestational
age less than 32 weeks. This showed grade 1 germinal matrix
hemorrhage on the right side. Follow-up exam was done on
[**11-9**] which showed subependymal bigerminal matrix
hemorrhage. A repeat exam was done on [**2101-11-25**], which
was normal, and her head ultrasound was done on [**2102-1-31**], which showed normal anatomy and resolution of the right
bigerminal matrix hemorrhage.
Sensory/audiology: Hearing screen passed bilaterally.
Ophthalmology: Eyes were examined most recently on [**2102-1-30**], which showed mature retinal vessels. A follow-up
exam is recommended at 9 months of age.
Psychosocial: [**Hospital6 256**] social
workers are involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **]. Follow-up will be provided
with a social worker and contact number has been provided to
the family.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY CARE PHYSICIAN:
1. Dr. [**Last Name (STitle) 69947**] [**Name (STitle) 69948**], Pediatrician, [**Telephone/Fax (1) 63053**].
She will also be followed by:
Dr. [**Last Name (STitle) 5448**], [**Hospital1 1559**], pulmonologist, f/u appointment on [**2-7**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital1 1559**], ophthalmologist, f/u at 9 months age.
CARE RECOMMENDATIONS:
1. Feeds at discharge: Breast milk with NeoSure powder to make
26 calories, p.o. feedings ad lib. Of note, if she does not gain
weight over next week, would increase to 28 calories with 2
kcal/oz by Corn Oil. Also, of note, NeoSure will be recommended
until 6-9 months of corrected gestational age.
2. If gains weight over next week, would also increase Ferinsol
to 0.5 ml po q day.
3. Second dose of Synagis is due on [**2102-2-13**].
Medications: Lasix 2 mg/kg/day p.o. every Monday, Wednesday
and Friday, ferrous sulfate 2 ml/kg/day, multivitamin 1 ml
p.o. daily.
STATE NEWBORN SCREENING: Newborn screen was sent on the
third day of life on [**2101-10-31**], and a repeat was done
on [**2101-12-11**], [**2102-1-5**], [**2102-1-11**].
The last screen on [**2102-1-17**] was negative.
CAR SEAT POSITION SCREENING: Passed.
IMMUNIZATIONS RECEIVED: She received her 2 months of
vaccines which included HIB, Pneumococcal 7-valent vaccine,
and Pediarix on [**2101-12-31**].
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life),
immunization against influenza is recommended for all
household contacts and out-of-home caregivers.
She has received her first Synagis immunization on [**2102-1-13**], and she will receive another Synagis on [**2102-2-13**], in the pediatrician's office.
FOLLOW UP: Scheduled and recommended. Family will need to
follow-up with Early Intervention, VNA (scheduled for [**2-2**]),
PUlmonologist, Opthalmologist.
The primary care pediatrician has been informed regarding the
discharge status and will follow-up after second or third day
of discharge.
DISCHARGE DIAGNOSIS:
1. Prematurity at 25 and 3/7 weeks'gestation
2. Hyaline membrane disease, resolved
3. r/o sepsis
4. Chronic lung disease
5. Right germinal matrix hemorrhage, resolved
6. Patent ductus arteriosus, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Name8 (MD) 67568**]
MEDQUIST36
D: [**2102-1-31**] 10:28:01
T: [**2102-1-31**] 11:30:55
Job#: [**Job Number 69949**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2194-7-4**] Discharge Date: [**2194-7-11**]
Date of Birth: [**2122-2-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72 year old spanish speaking woman with a history of a
hemorrhagic CVA in [**2164**] s/p craniotomy, hypertension,
hyperlipidemia, admitted to [**Hospital3 **] on [**7-1**] with two
weeks of increased confusion at home, slurred speech and
conversation not making any sense, unsteady gait, weakness, and
substernal chest pain.
.
First presented to LGH [**2194-6-30**] where she was 141/80 p82 rr18
98%RA. She had a positive UA for infxn (Proteus Vulgaris, per
report) and she was given either Levaquin, Rocephin, or [**Name (NI) **]
(unclear). CK was 123, MB 2.3, and TropI 0.03, subsequently
"negative x3." Other labs significant for hypercalcemia at 10.4,
WBC 7.9, Hct 30.8 (normocytic), Plts 425k. Chemistry
unremarkable, Cr 1.1. EKG was non specific with some ST changes
in II. CT of head negative x2 for acute process with
post-operative changes, chronic ischemic changes. Carotid duplex
study pending.
.
Stress test positive for inferior ischemia (? unclear if pt got
the stress test, reports indicate that she was too agitated to
sit still for it). Cathed today and found to have a tight
proximal 90% PDA lesion. 5 French sheath in RFA. On aspirin
only, has not been prescribed plavix. Daughter speaks english
and has signed consent, will come with patient.
Past Medical History:
Cerebral aneurysm s/p cerebral (MCA) hemorrhage in [**2164**], s/p
craniotomy and repair (clip placement) --> anterior temporal
frontal encephalomalacia
Patchy white matter disease changes in the periventricular and
subcortical white matter
HTN
HL
Social History:
lives with her daughter.
non-[**Name2 (NI) 1818**]
non-drinker
Family History:
N/C
Physical Exam:
On admission to ICU:
97.5 183/83 p98 19 98%RA
Large hispanic woman in no distress but with eyes closed and
moaning. Opens her eyes to voice and follows simple commands but
moans or says nonsensical things and dozes back off if not
stimulated. Not in respiratory distress.
Corneas with bilateral cataracts, pupils are constricted, but
EOMI are grossly intact and sclera normal appearing
No jugular distention noted.
CTAB no w/c/r/r noted anteriorly, good air movement
Regular rhythm but tachycardic, no murmurs or gallops are heard.
Bilateral radial and DP's pulses palpable
Abd soft, NT ND, BS hyperactive
No BLE edema
No rashes noted
Pt responsive but not coherently. Opens eyes to commands but
doesn't answer questions appropriately. Pupils constricted to
1-2mm, EOMI grossly intact. No facial droop noted. Dysarthria
unable to be appropriately tested. Spontaneously moving all four
extremities, with normal tone, not rigid.
Pertinent Results:
OSH:
- UA/UCx: >100k Proteus Vulgaris: resistant--amp,
nitrofurantoin, tetracycline, cefuroxime, cefazolin
sensitive--ceftazadime, ceftriaxone, gent, levaquin, pip-tazo,
tobra, bactrim, cefoxitin, [**Name2 (NI) 9847**]
-CARDIAC CATH performed at OSH demonstrated: 90% PDA stenosis
AO 148/76 (106)
LV 156/4,11
AO 157/71 (107)
LV 161/3,10
.
[**2194-7-8**] 3:06 pm URINE Source: Catheter.
**FINAL REPORT [**2194-7-9**]**
URINE CULTURE (Final [**2194-7-9**]): NO GROWTH.
Brief Hospital Course:
# Coronary Artery Disease: The patient was transfered for
cardiac catheterization. Although the patient was found to have
90% PDA lesion, her symptoms and stress test were unclear. It
was thought that the patient could benefit from medication
managment of CAD with ASA, increased statin and addition of
betablocker. Therefore, she did not undergo repeat cardiac
catheterization. Plavix was stopped. If she does develop more
chest pain in the future, she could have further optimization of
anti-anginal medications and then undergo repeat stress testing.
.
# Agitation/Altered Mental Status: Patient became agitated in
the pre cath area and was given multiple doses of haldol. This
agitation was attributed to delirium [**3-11**] UTI. She was
transferred from the CCU to the medicine service on [**2194-7-5**].
She did well with the resolution of her UTI.
.
She was started on nighttime Zyprexa which we should be stopped
in two weeks.
.
#HCT Drop: Thought to be [**3-11**] Groin oozing into her leg. Bedside
doppler was negative for pseudoanneurysm and there were no
bruits on exam. Her HCT stabilized. This was complicated by
iron deficiency anemia, for which she was started on iron with
vitamin C.
.
# Urinary Tract Infection: At the outside hospital prior to
transfer, she was noted to have a Proteus UTI, and was started
on levofloxacin on [**2194-6-30**], switched to ceftriaxone on [**7-1**],
then to ciprofloxacin on [**7-3**], based on culture data. While
here she was treated with ciprofloxacin, initially IV due to
agitation, and later with PO. She completed her course in house
.
# s/p Arthroscopy: Patient had R knee arthroscopy at [**Hospital3 12748**] in [**4-16**] per her daughters. [**Name (NI) **] right knee was
initially noted to be more swollen than the left, but with no
obvious effusion. She was given one dose of vancomycin,
ultimately, her right knee did not appear infected w/o small
amount of suprapatellar swelling but no effusion, warmth or pain
on movement. Vancomycin was discontinued.
Medications on Admission:
Home medications:
Multivitamin
ASA
Lovaza (omega 3 fish oils)
.
MEDICATIONS ON TRANSFER:
Simvastatin
asa 81mg
Plavix 600mg prior to cardiac catheterization
seroquel
Ancef 1g given at 8am ([**7-4**]?) vs Ciprofloxacin
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO QHS (once a day (at bedtime)) for 2 weeks.
Disp:*7 Tablet, Rapid Dissolve(s)* Refills:*0*
10. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
every eight (8) hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of greater [**Location (un) **]
Discharge Diagnosis:
Urinary Tract Infection
Coronary Artery Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for chest pain, and for possible coronary
catheterization. While here you were noted to be confused. You
were found to have a urinary tract infection, and were treated
with the antibiotic ciprofloxacin.
Followup Instructions:
Please arrange to see your primary care doctor within one week
of discharge.
.
PCP [**Name Initial (PRE) 648**]: Tuesday, [**2194-7-15**] @4:15pm
With: Dr. [**First Name8 (NamePattern2) 1399**] [**Last Name (NamePattern1) **]
Location: [**Location (un) 85714**], #204-[**Hospital1 487**] [**Numeric Identifier 85352**]
Phone: ([**2194**]
Department: GASTROENTEROLOGY
When: FRIDAY [**2194-7-25**] at 1:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2194-7-11**]
|
[
"5990",
"5849",
"2851",
"41401",
"4019",
"2724"
] |
Admission Date: [**2120-5-6**] Discharge Date: [**2120-5-14**]
Date of Birth: [**2050-6-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ceclor
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
cc: chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**5-6**]
cabg x3 (LIMA to LAD, SVG to OM, SVG to PDA) [**2120-5-9**]
History of Present Illness:
.
HPI: 69 y/o M [**Month/Day/Year 1818**] w/ CAD, [**Hospital 2754**] transferred from [**Hospital1 3325**] w/ NSTEMI - troponin 2.03 at OSH. Pt. presented to OSH
with retrosternal chest pain, radiating to both arms along w/
HTN on [**2120-4-27**]. At that time, pt. had mild troponin elevation w/
nl EKG. Pt. admitted and had a normal exercise stress test
following this. Plan was for outpt. nuclear stress test.
.
However, on [**2120-5-6**], pt. had recurrent substernal chest pain
radiating to neck and arms. At that time, pt. denies
diaphoresis, no nausea or vomting. No hemoptysis or
hematemesis. Pt. went to [**Hospital3 3583**] ED and ruled in for
NSTEMI w/ troponin of 2.03 and EKG changes. Pt. was started on
nitro and heparin drips, ASA, and was loaded w/ plavix and was
pain free. Pt. transferred to cath lab and found to have 3VD
today
.
.
ROS: no abd. pain, no N/V, no dark or bloody stools, no sig.
weight changes, + back pain (chronic)
Referred to Dr. [**Last Name (STitle) **] for cabg. Given plavix load on [**5-6**],
surgery was delayed for several days.
Past Medical History:
MI
CAD - s/p PCA 8 yrs ago ([**Hospital1 **])
IMI years ago
HTN
Hyperlipidemia
Hyperthyroid
GERD
Back Pain
Mild cerebral palsy
Social History:
Soc: lives w/ wife, 3 sons, current [**Name2 (NI) 1818**] 50 pack yr. history,
he is primary caregiver, no alcohol,
Family History:
Fam: Dad died MI @ 63,
Physical Exam:
PE: T 95.8 BP 129/61 P 77 RR 16 99% RA
Gen: NAD, watching TV
HEENT: no JVD, supple neck
CV: no lifts/heaves, distant heart sounds
Lung: CTAB, no crackles/wheezes
Abd: + BS, soft, NTND
Ext: no c/c/e
5'[**23**]" 70.8 kg
Pertinent Results:
EKG: NSR at 86, nl axis, no ST/T waves changes
.
Cath Findings ([**2120-5-6**]):
Right dominant
LM: no disease
LAD: eccentric 60% proximal
LCX: diffuse OM1 80%
RCA: tortuous diffuse mid 80-90% w/ disease back to ostium
No intervention
.
[**2120-5-12**] 05:53AM BLOOD WBC-13.2* RBC-3.33* Hgb-9.7* Hct-27.6*
MCV-83 MCH-29.1 MCHC-35.1* RDW-13.1 Plt Ct-168
[**2120-5-14**] 07:55AM BLOOD Hct-29.4*
[**2120-5-6**] 12:46PM BLOOD Neuts-68.1 Lymphs-25.3 Monos-4.0 Eos-2.2
Baso-0.4
[**2120-5-12**] 05:53AM BLOOD Plt Ct-168
[**2120-5-14**] 07:55AM BLOOD Glucose-92 UreaN-30* Creat-1.3* Na-141
K-4.7 Cl-104 HCO3-29 AnGap-13
[**2120-5-7**] 07:30AM BLOOD CK(CPK)-91
[**2120-5-6**] 12:46PM BLOOD ALT-32 AST-21 AlkPhos-51 TotBili-0.3
[**2120-5-6**] 09:30PM BLOOD CK-MB-12* MB Indx-8.8* cTropnT-0.41*
[**2120-5-7**] 07:30AM BLOOD CK-MB-NotDone cTropnT-0.30*
[**2120-5-14**] 07:55AM BLOOD Mg-2.4
[**2120-5-6**] 12:46PM BLOOD TSH-1.4
[**2120-5-6**] 12:46PM BLOOD Free T4-1.4
FINAL REPORT
PA AND LATERAL CHEST ON [**5-12**].
HISTORY: Status post CABG. Chest tube removed.
IMPRESSION: PA and lateral chest compared to [**5-7**] through 15:
Small left apical pneumothorax still present. A tiny residual
left pleural
effusion unchanged following removal of left pleural tube. Left
supraclavicular central venous line tip projects over the SVC.
Lower lungs
clear. Cystic scarring and marked right apical pleural
thickening, unchanged
from the pre-operative appearance. No appreciable mediastinal
widening status
post median sternotomy and CABG.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: SUN [**2120-5-12**] 10:32 PM
Procedure Date:[**2120-5-12**]
PRE-BYPASS: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are 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 aortic root. There are simple atheroma in the
ascending aorta. There are complex (>4mm) atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Torn mitral
chordae are present. Trivial mitral regurgitation is seen. There
is no pericardial effusion.
Post CPB:
Preserved biventricular systolic function.
No change in valve structure and function
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
Brief Hospital Course:
A/P: 69 y/o w/ h/o CAD who presented to OSH w/ CP and found to
have NSTEMI s/p cath today w/ diffuse disease who will require
CABG
.
# Cardiac - Pt. w/ NSTEMI by symptoms and enzymes s/p cath today
w/ 3VD who will likely need CABG. CT [**Doctor First Name **]. aware of pt
- will f/u CT [**Doctor First Name **] recs - will check UA/Ctx
- NO Plavix! as pt. possibly going for CABG
- ASA
- BB
- High dose statin
- will trend cardiac enzymes until peak
.
# HTN - Pt. normotensive at this time
- cont. BB, lisinopril, HCTZ
.
# Hyperlipidemia - pt. on zetia and start high dose statin
.
# Hyperthyroidism
- will continue on methimazole
- will check TSH and free T4
.
# GERD - on omemprazole at home
- protonix
.
# Anxiety - pt. w/ lots of anxiety w/ new diagnosis and worried
about wife at home
- will give low dose ativan PRN
- will consult social work
.
# Anemia - will cont. to monitor crit
- check iron studies
.
# F/E/N - cardiac diet, check and replete electrolytes PRN
.
# Proph - heparin SC,
.
# Code: Full
Underwent cabg x3 on [**5-9**] and transferred to the CSRU in stable
condition on neosynephrine and propofol drips.Extubated that
evening and off all drips on POD #1. Some confusion noted.
Transferred to the floor with some improvement in his confusion
on POD #2. No obvious neuro deficit seen and narcotics were
held. Chest tubes were removed on POD #3. Beta blockade was
titrated for better HR and BP control. Foley came out on POD #3
with some continuing confusion, although he was doing well
overall.CVL and pacing wires removed on POD #4 and gentle
diuresis continued. Alert and oriented x3 on POD #5 and cleared
for discharge to home with VNA services. Pt. is to follow up
with providers as per discharge instructions.
Medications on Admission:
Meds at home:
Zetia 10 mg qd
Atenolol 25 mg qd
Lisinopril 40 mg qd
HCTZ 25 mg qd
Omeprazole 20 mg qd
Tapazole 25 mg qd
.
Meds on transfer:
Nitro gtt
Heparin gtt
ASA
Lisinopril
Zetia
Tenormin
Tapazole
HCTZ
Protonix
Plavix
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Methimazole 10 mg Tablet Sig: 2.5 Tablets PO QD ().
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily) for 3 days.
Disp:*6 Capsule, Sustained Release(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
s/p CABGx3(LIMA-LAD, SVG-OM, SVG-PDA)[**5-9**]
PMH: HTN, Hyper thyroid, s/p lung [**Doctor First Name **], s/p T&A, IMI
Discharge Condition:
good
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
No heavy lifting or driving until follow up with surgeon.
Followup Instructions:
wound clinic in 2 weeks'
Dr [**Last Name (STitle) **] in 4 weeks
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-27**] weeks
Completed by:[**2120-6-6**]
|
[
"41071",
"496",
"41401",
"4019",
"2724",
"53081",
"2859"
] |
Admission Date: [**2148-8-3**] Discharge Date: [**2148-9-16**]
Date of Birth: [**2113-5-16**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
fever, neutropenia
Major Surgical or Invasive Procedure:
Lumbar puncture x 3
PICC line placement
Bone Marrow Biopsy x 2
Itrathecal Chemotherapy with Methotrexate
Initiation of radiation therapy to right arm
History of Present Illness:
35 y.o. woman with history of newly diagnosed T cell lymphoma
([**2148-7-4**]) who presented on day 10 status post CHOP. She had been
feeling well during the week prior to admission before having a
temperature of 100.4 on [**8-2**]. At that point she felt tired but
otherwise well without localizing symptoms (shortness of breath,
cough, chest pain, abdominal pain, dysuria, etc...). She awoke
[**8-3**] with a temperature of 102 F with chills as well as dizziness
and "eyes burning." Otherwise she reported constipation
(ongoing) and some mouth sores. These complaints brought her in
to the ED.
.
In the ED temp 102.7, HR 124, BP 98/52, RR 20, O2 Sat 100% RA.
She received Cefepime 2gm IV, vanco 1gm IV, decadron 10mg IV,
and tylenol. She also received 6L IVF. In the ED her lowest
SBP was 86 and after fluid HR improved to 100.
.
On arrival to the floor she reported feeling thirsty as well as
mild abdominal cramping and some mild headache. She denied
photophobia, neck stiffness, SOB, CP, diarrhea. She had just
finished steroid taper and had been on levofloxacin for
suppressive therapy.
Past Medical History:
Peripheral T cell lymphoma: She presented with fevers and
elevated LFT's in the spring of [**2148**]. Bone marrow biopsy at
that time revealed T-cells. Treatments so far include
-high dose steroids [**7-12**]
-Nitrogen Mustard [**7-19**]
-CHOP [**7-25**].
Social History:
She lives with her husband who is her health care power of
attorney and her two and a half year old son. She denies using
tobacco or alcohol. She rents space in a salon where she does
manicures.
Family History:
Father has a history of benign adrenal mass and skin cancers
removed. Her mother has hyperparathyroidism and hypertension.
Physical Exam:
ADMISSION EXAM:
T 98.6, HR 104, BP 96/58, 97% RA RR23
Gen: well appearing NAD
HEENT: MM dry. palor. JVP 6cm. mild mucositis. No photophobia
or nuchal rig
Cards: RRR no murmurs. physio split S2.
Resp: nl effort. CTAB
Abd: BS+ mildly tender diffusely. no rebound or guarding. Mild
RUQ tenderness. soft. no masses.
Ext: good pulses. no edema. no rashes.
.
ON DISCHARGE:
Patient afebrile two days. Vital signs all stable and within
normal limits except for continued sinus tachycardia. At time
of discharge she no longer had visible mucositis. No longer
right upper quadrant tenderness. Over course of hospitalization
she had interval development of right wrist drop and decreased
sensation in webspace of right hand. Strength 5/5 in all other
extremities and muscle groups.
Pertinent Results:
LABORATORY VALUES
------------------
Admission Labs([**2148-8-3**])
WBC-0.8*# RBC-3.32* Hgb-9.2* Hct-27.5* MCV-83 MCH-27.8 MCHC-33.5
RDW-16.1* Plt Ct-185
---PMNs-52,Bnds-2,L-39,Mono-2,Eos-2,Atyp-3*,NRBC-1*
PT-15.9* PTT-33.8 INR(PT)-1.4*
Glucose-195* UreaN-15 Creat-0.8 Na-135 K-4.5 Cl-101 HCO3-23
AnGap-16
ALT-67* AST-51* AlkPhos-282* TotBili-1.4
Calcium-9.0 Phos-3.0 Mg-1.9
Lactate-2.6*
BLOOD CULTURES:
URINE STUDIES:
Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 Blood-NEG Nitrite-NEG
Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0
Leuks-NEG RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-0-2
ADMISSION CXR:
PORTABLE AP CHEST, ONE VIEW: Patient is in relative lordotic
positioning.
Cardiomediastinal and hilar contours are normal. The lungs are
clear without focal consolidation or pulmonary edema. There is
no pleural effusion or pneumothorax. Osseous structures are
unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 35 yo woman with peripheral T-cell lymphoma
admitted for neutropenic fevers and hypotension between her
first and second cycle of CHOP.
.
1. T cell non-Hodgkins lymphoma. Despite fever patient was able
to proceed to her second cycle of CHOP as scheduled on [**2148-8-13**]
during this admission. She tolerated it well. Because of bone
marrow infarcts during her last cycle G-CSF was held and her
counts dropped. She later was treated with G-CSF and her counts
improved. However, her fevers returned and all her cultures were
negative. Given concern for advancing disease given continued
fevers and no signs of infection she had a series of LP's. The
second and third LP showed atypical cells that likely
represented CNS disease. Therefore she was started on [**Hospital1 **] and
IT methotrexate with high dose methotrexate on day 10. She
tolerated these therapies well with only some GI toxicity and
mild mucositis after the methotrexate. After receiving high
dose methotrexate she again began to have fevers and chills
leading to another infectious work-up which was negative except
for an enterococcal bacteremia (see below). She also had
slightly elevated liver enzymes so repeat MRI of the abdomen was
obtained and showed no focal involvement of the liver. She
ended up on broad spectrum antimicrobials for fevers as her
neutropenia reached its nadir. At the same time work up of her
right radial nerve palsy (see below) led to suspicion of
progressive neurologic disease despite previous chemotherapy.
Thus as she began to recover from her nadir with the help of
G-CSF the plan was made to start steroid therapy for her
suspected continued neurologic disease and proceed to IT AraC
and ESHAP. The patient defervesced on steroid therapy and the
plan was made to continue to IT Ara C in a few days and ESHAP in
approximately a week of discharge.
.
2.) Fever: On presentation there were no localizing symptoms on
imaging or testing so her fevers were thought to be
non-infectious and probably due to bone marrow infarcts vs drug
fever vs continued disease activity. Thus she proceeded onto
her second cycle of CHOP. After the fevers did not resolve
after her second cycle of CHOP an additional fever work up was
initiated which revealed likely CNS involvement of her
lymphoma(see above). Her brain MR was negative for focal
findings but additional work up with lumbar punctures revealed
CNS disease and required additional treatment with [**Hospital1 **] and
intrathecal methotrexate on day 1 and high dose methotrexate on
day 10. After high dose methotrexate she again became febrile
and thus yet another infectious work up was initiated. This
revealed an enterococcal urinary tract infection for which she
was treated with vancomycin and then ampicillin after
sensitivities returned. She never defervesced and as she became
more neutropenic her coverage was broadened to include broad
spectrum antibiotics as well as fungal coverage. Despite this
coverage she continued to be febrile. As her cytopenias
resolved and a high suspicion of progressive neurologic lymphoma
arose her antimicrobials were eventually decreased to
levofloxacin and voriconazole, which she continued on discharge.
At this point progressive lymphoma was considered the most
likely etiology of her fevers but she was continued on
antimicrobials given the inability to completely rule out
infection. Her fevers only resolved with the initiation of
steroid therapy two days before discharge.
.
3.) Hypotension: She was admitted to the [**Hospital Unit Name 153**] on presentation
with hypotension as well as fever. She was treated empirically
on admission with vancomycin and cefepime IV and remained
hemodynamically stable overnight. Her blood pressure responded
to fluid bolus of 1L NS. A cortisol stim test was WNL on
[**2148-8-6**]. It is unclear if the hypotension was due to sepsis of
some infecting organism or some other etiology. This did not
recur.
.
4.) Bone marrow infarction: Around day +10 from her first cycle
of CHOP and while on treatment with G-CSF she developed rapidly
rising LDH, severe bony pain, and fever. This was believed to be
due to BM infarcts. She received supportive care with fluids,
analgesia with a Dilaudid PCA, and fever control. She was easily
weaned from the PCA once the pain passed. Her counts prior to
her second cycle of CHOP were stable. The main complication of
this was urinary retention requiring the placement of a Foley
catheter. Her second cycle of CHOP was a reduced dose. She was
continued on Morphine SR for continued bone pain throughout her
hospitalization and with this the pain was well managed. She
was discharged on this medication.
.
5 HSV Active oral lesions on admission. Received 7 days of
therapeutic dosing of acyclovir. She was reduced to prophylaxis
dose and maintained on that dose without complications
thereafter.
.
6.)Neurologic symptoms: She had UMN signs on the left early in
admission and later weakness and LMN signs of right wrist and
hand with decreased extension of her fingers. Neurology was
consulted and recommended imaging, but MRI of brain, spine, and
brachial plexus on both sides were essentially WNL. Two LP's
were obtained the first of which was normal and the second of
which showed atypical cells. The left arm recovered during the
second cycle of CHOP. The right arm problems started abound
the time [**Hospital1 **] was started. She was also having intense pain in
her right arm at this time. Consideration was given to an
inflammatory process vs a chemo induced or paraneoplastic
neuropathy but no clear etiology was found. Because of no
improvement in the right arm symptoms with treatment with [**Hospital1 **]
and high dose Methotrexate, Neuro-oncology was consulted and
diagnosed a right radial nerve palsy. Neuro-onc suspected
neoplastic involvement of the nerve and MRI of the right arm did
demonstrate this. Thus, radiation oncology was consulted and
began XRT to the lesion in the right arm as the treating team
proceeded to the more aggressive strategy of IT AraC and ESHAP.
The patient had received only a few sessions of XRT at discharge
and no interval change in right radial nerve palsy though in
regards to function and pain it was much improved with use of a
soft splint.
.
7.) Right Upper Quadrant tenderness. Started acutely during the
second cycle of CHOP and resolved for the most part within two
days. There was a concomitant elevation in alk phos, LDH, and
GGT. CT on [**8-14**] showed possible GB wall edema. US on [**2148-8-16**] was
essentially normal. LFT improved since spike on [**2148-8-14**].
Ultimately it was believed that this was due to liver
involvement by lymphoma, which was a component of her original
presentation. A further workup revealed a normal liver MR and
her LFT's resolved.
.
8.) Right pleural effusion: This was found incidentally on
imaging and pulmonology was consulted and performed a
pleurocentesis on [**2148-8-18**]. Final results revealed normal fluid
and this was resolved on her next CT scan.
.
9.) Bilateral neuropathic pain in lower extremities: This may
have been due to lymphoma versus side effects of vincristine.
The pain responded well to gabapentin and amitriptyline therapy
and she was discharged on these medications.
.
10.) Hemorrhoids: The patient had dealt with hemorrhoids in the
past. These flared with some incidents of diarrhea during her
[**Hospital1 **] chemotherapy and had large inflamed hemorrhoids. Given
cytopenias were worsening these were observed and managed with
[**Last Name (un) **] baths and steroid cream with good improvement particularly
as diarrhea resolved.
.
11.) Mucositis: Had some mild mucositis during HD methotrexate
therapy. This was managed with topical cares with good results.
.
12.) Access: The patient initially had a right sided PICC line
that developed pain and poor function. This was removed. A
right upper extremity ultrasound on [**2148-8-22**] revealed a right
cephalic vein thrombosis with no extension of time. She
received local therapies for pain and this resolved. A left
sided PICC was then placed that functioned well for the
remainder of the hospitalization and was present on discharge.
.
13.) Prophylaxis: Patient received her inhaled Pentamadine on
[**2148-9-9**] for PCP [**Name Initial (PRE) 1102**]. She ambulated for DVT prophylaxis.
She remained on her home PPI throughout the hospitalization.
Antimicrobial prophylaxis was acyclovir as described above. She
never received antibacterial prophylaxis as she was always was
on treatment doses of antibiotics for fevers when she became
neutropenic.
.
The patient was maintained on a neutropenic diet. She was full
code.
Medications on Admission:
Levofloxacin 500 daily
Zofran prn
Pantoprazole 40 daily
Senna
Allopurinol 100 daily
Ativan prn
Prednisone taper
Hydroxyzine 25 q4h prn
Colace 100 [**Hospital1 **]
Pentamidine Qmonth
Discharge Medications:
1. Saline flush
5-10 cc saline flush to each lumen of PICC daily
2. heparin flush
10 Units/CC; 3-5 CC flush to each lumen daily after normal
saline flush
3. Dressing changes
Dressing change of PICC site weekly and PRN per critical care
protocol
4. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
6. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
7. 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*
8. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO every eight (8) hours.
Disp:*90 Tablet Sustained Release(s)* Refills:*0*
9. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
11. Oral Wound Care Products Gel in Packet Sig: One (1) ML
Mucous membrane TID (3 times a day) as needed.
12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 1 weeks: Please taper as instructed in the
outpatient BMT area. .
Disp:*14 Tablet(s)* Refills:*0*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
14. Pentamidine 300 mg Recon Soln Sig: One (1) dose Inhalation
once a month: last dose on [**2148-9-9**].
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnosis:
--------------------
T-cell lymphoma
Neutropenic fever
Discharge Condition:
Good, afebrile, tolerating PO's
Discharge Instructions:
You were admitted to the hospital for very high fevers. Your
fevers were thought most likely related your lymphoma and your
recent chemotherapy. You were found to have a urinary tract
infection for which you received adequate treatment. We still
thought it was most likely you had your fevers due to your
underlying lymphoma. While you were admitted to the hospital,
you also had severe bone pain which was controlled with narcotic
pain medication and also thought due to your lymphoma. This pain
improved significantly while you were in the hospital.
.
In the hospital you also had problems with nerve pain, which was
thought due to your chemotherapy and possibly your lymphoma as
well. You also had paralysis of one nerve and a scan of this
area revealed involvement of your lymphoma. We put you on
several medications for nerve pain with some improvement and you
were also started on radiation therapy to attempt to help your
nerve recover from the lymphoma involvement. You also received
high dose methotrexate for your central nervous system disease.
You tolerated this well with only some mouth sores as side
effects. You were always able to tolerate food by mouth. You
will also start intrathecal AraC therapy with Dr. [**Last Name (STitle) 724**] from
neurology. This will be arranged in the next week.
.
We have made the following changes to your medications. You
have been started on GABAPENTIN, MS CONTIN, and AMITRYPTYLINE to
help manage your nerve pain. Your ALLOPURINOL and ONDANSETRON
(ZOFRAN) have been stopped. You have also been started on
DEXAMETHASONE to help manage your fevers and help your nerve
recover.
.
Please keep all follow up appointments as these are important to
maintaining your health.
.
Please seek immediate medical attention if you develop fevers >
100.4, shaking chills, night sweats, shortness of breath, chest
pain, abdominal pain, worsening or changing bone pain.
Followup Instructions:
You have a CT/PET scan scheduled for this Wednesday [**2148-9-18**] at
11:10 this will take place on [**Hospital Ward Name 23**] 4 at the [**Hospital Ward Name 516**].
.
You have an appointment with the ophthalmologist [**Name6 (MD) 6131**] [**Name8 (MD) **],
MD on [**2148-9-18**] at 12:45 pm to assess for ocular involvement of
your lymphoma. Her office can be reached at [**Telephone/Fax (1) 253**].
.
After your ophthalmology appointment please report to the
outpatient area of the BMT floor for evaluation by Dr. [**Last Name (STitle) **],
you will also be coordinated to receive your IT chemo from Dr.
[**Last Name (STitle) 724**] at some point in that afternoon.
|
[
"5990",
"5119",
"4280"
] |
Admission Date: [**2110-10-6**] Discharge Date: [**2110-10-12**]
Date of Birth: [**2044-8-19**] Sex: F
Service: CCU
CHIEF COMPLAINT: This is a transfer from [**Hospital 8**] Hospital
for a catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a 66 year old
female with a past medical history of hypercholesterolemia
and 50 years of tobacco use who presented to the outside
hospital with intense substernal chest discomfort for greater
than four hours and chest heaviness, after she vomited. It
did not radiate. She had mild diaphoresis. At the outside
hospital, EKG showed impressive anterior and lateral ST
elevations. The patient was given aspirin, beta blocker,
Nitroglycerin and heparin with relief of her symptoms. She
was transferred to [**Hospital1 69**] for
catheterization.
Angiography revealed 20% ostial left middle coronary artery
lesion, 99% mid left anterior descending lesion involving a
diagonal branch and ulcerated 70% right coronary artery
lesion. At this time, a stent was placed in the mid left
anterior descending with restoration of flow, TIMI-II flow in
the diagonal 2 branch. The patient was transferred to the
Intensive Care Unit pain free.
PAST MEDICAL HISTORY:
1. Increased hypercholesterolemia.
2. Breast cancer status post right mastectomy 24 years ago.
ALLERGIES: None.
MEDICATIONS: None.
SOCIAL HISTORY: Positive for tobacco, one pack per day
times 50 years. No alcohol. Lives with husband, two sons,
daughter, granddaughter and great-grandchildren. She is
retired.
FAMILY HISTORY: Mother with history of myocardial
infarction at age 50 years old. Father with history of
diabetes mellitus.
PHYSICAL EXAMINATION: Vital signs were 98.2 F.; rate 86;
pressure 126/80; 97% on two liters nasal cannula. Alert and
oriented pleasant female in no acute distress. HEENT:
Anicteric. Mucous membranes were moist. Neck with no
jugular venous pressure or bruit auscultated. Cardiovascular
is S1, S2 normal. No murmurs, rubs or gallops; regular rate.
Respiratory is clear to auscultation anteriorly and
laterally; scattered expiratory wheeze. Abdomen soft,
nontender, nondistended. Extremities with no cyanosis,
clubbing or edema.
LABORATORY: EKG obtained at outside hospital was sinus
tachycardia, 116, with left axis deviation; [**Street Address(2) 2915**]
elevations in I, AVL and 5 to [**Street Address(2) 53659**] elevations in
V2 through V6.
LABORATORY: On admission, white blood cell count 12.3,
hematocrit 39.9, platelets 209, INR 1.1. Chem 7 with 135
sodium, potassium 4.3, BUN and creatinine 13 and 0.5.
Liver function enzymes were normal.
CK peak at 1255.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for management of acute anterolateral myocardial
infarction status post left anterior descending stent
placement.
1. CARDIOVASCULAR: The patient continued on 18 hours of
Integrilin post catheterization and was started on aspirin
325, Plavix 75 and beta blocker titrated up per blood
pressure. EKG post catheterization showed persistent ST
elevation with assumption of probable significant
micro-vascular disease in addition to the patient's known
left anterior descending stenosis. Continued with statin
therapy in lieu of normal liver function enzymes.
Echocardiogram was obtained to assess pump function status.
In catheterization, wedge was 22, right atrial pressure 12.
Echocardiogram revealed an ejection fraction of 25% with
small apical left ventricular aneurysm and apical akinesis.
A heparin drip was initiated at the termination of
Integrilin. An ACE inhibitor was also initiated secondary to
decreased remodeling. The patient continued on heparin
throughout her hospital course and transitioned to Coumadin 5
mg p.o. q. day with goal INR of 2.0 to 3.0.
At the time of discharge, the patient's blood pressure was
normotensive on Zestril 2.5 q. day, Toprol XL, as well as
aspirin and Plavix. For her rhythm, the patient was continued
on Telemetry without dysrhythmias noted.
The patient will follow-up with Electrophysiology Service for
signal average ECG following large interior lateral
myocardial infarction.
Due to persistent ST elevation and right coronary artery
stenosis of 70%, the patient returned to catheterization on
hospital day
Dictation ended.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Last Name (NamePattern1) 972**]
MEDQUIST36
D: [**2110-10-12**] 11:29
T: [**2110-10-12**] 17:10
JOB#: [**Job Number 53660**]
|
[
"5990",
"496",
"41401",
"2720"
] |
Admission Date: [**2110-11-4**] Discharge Date: [**2111-1-7**]
Date of Birth: [**2041-5-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ativan / Piperacillin Sodium/Tazobactam
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
[**2110-11-7**] PROCEDURE PERFORMED:
1. Bronchoscopy.
2. Flexible esophagoscopy.
3. Right posterior thoracotomy with creation of [**Last Name (un) 72968**]
window and primary suture repair of esophagogastric
leak.
[**2110-12-22**] PROCEDURE: Left thoracentesis, ultrasound of the
chest.
[**2110-12-24**] PROCEDURES PERFORMED:
1. Tracheostomy.
2. Bronchoscopy with aspiration of secretions.
3. Esophagogastroduodenoscopy.
History of Present Illness:
Mr. [**Known lastname **] is a 69-year-old gentleman now almost 3 months after
[**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy complicated by leak. He has required 1
prior re-operation for anastomotic dehiscence. This was repaired
primarily, and he has had a long convalescence with both a small
esophagogastric fistula as well as a pancreatic fistula. Most
recently, he was re-admitted from rehab with a white count of
20,000 and a fever to 102 with bilious drainage from his
residual chest tube. CT
scan suggested undrained collection up near the anastomosis,
with moth-eaten bone in the posterior ribs. This suggested a
possible osteomyelitis or a sequestrum. As the tube was not
providing definitive drainage, I recommended creation of a
posterior [**Last Name (un) 72968**] window, and the patient agreed to proceed.
Past Medical History:
1. Invasive CA of GE junction, Barrett's esoph s/p remote
fundoplication (20 yrs ago @[**Hospital1 **])
2. Open CCK
3. Diverticulitis
4. Benign colon polyps
5. B/L cataracts
Social History:
Mr. [**Known lastname **] is a retired groundskeeper for [**University/College **].
Family History:
non contributory
Physical Exam:
Pt Expired [**2111-1-7**]
Pertinent Results:
Autopsy results pending
Brief Hospital Course:
Mr. [**Known lastname **] is well-known to the thoracic service. He returned
from rehab after spiking a temp of 102. Pt was admitted to the
thoracic surgery service on [**2110-11-4**] with a complicated hospital
course after which the pt expired on [**2111-1-7**]. On [**11-4**] empyema
tube fell out and was replaced. On [**2110-11-7**] pt went to the
operating room for bronchoscopy, flexible esophagoscopy, and
right posterior thoracotomy with creation of [**Last Name (un) 72148**] window and
primary suture repair of esophagogastric leak. On [**2110-12-24**] pt
underwent a tracheostomy, bronchoscopy with aspiration of
secretions and esophagogastroduodenoscopy. During his hospital
course the pt was placed on multiple antibiotic regimens due to
spiking fevers, diarrhea, and multiple positive cultures from
blood, wounds, sputum and drainage. He remained ventilator
dependant and was eventually fitted with a tracheostomy tube for
comfort. The pt received tube feeds through a jejunostomy
feeding tube. Hypercalcemia was present throughout most of his
hospital course for which he was followed closely by the
endocrine service. Calcitonin was ultimately given with good
effect in decreasing free calcium levels although the etiology
of the hypercalcaemia was never discovered. Renal function was
variable as monitored by BUN and Cr levels. Antibiotics were
renally dosed and adjusted as necessary for renal function. The
pt continued to require large volumes of both crystalloid and
colloid to maintain appropriate cardiodynamics and eventually
was placed on pressors. On [**2111-1-7**] during a family meeting, in
light of respiratory failure, acute renal failure, and
decreasing cardiac function, it was decided to withdraw
vasopressor support and make the pt comfort measures only. After
pressors were withdrawn, the pt expired within hours.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest as late complication of esophagectomy
Discharge Condition:
none
Discharge Instructions:
none
Followup Instructions:
none
|
[
"51881",
"5849",
"2859",
"42789"
] |
Admission Date: [**2117-2-23**] Discharge Date: [**2117-3-9**]
Date of Birth: [**2044-10-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Transfer from [**Hospital1 **] [**Location (un) 620**] for transfusion reaction, diarrhea x 2
months
Major Surgical or Invasive Procedure:
EGD/Colonoscopy [**2-24**]
PICC line placement
History of Present Illness:
Patient is a 72 year-old female with a past medical history of
gout, hypothyroidism, recent diagnosis of iron deficiency anemia
who presented to the MICU yesterday from [**Hospital1 **] [**Location (un) 620**] after
becomeing hypoxic and hyptensive during a blood transfusion.
Patient reports that in [**Month (only) 1096**] during a routine physical, Hct
was found to be 25 from roughly 34-40, WBC count in the 20s,
platelets of 650. This prompted a hematology workup for
malignancy. Bone marrow biopsy was done and per [**Hospital1 **] [**Location (un) 620**] d/c
summary did not show any primary hematologic malignancy and was
"most suggestive of iron deficiency anemia" with reactive
leukocytosis and thrombocytosis. She was then started on Fe
pills. Simultaneously, around the beginning of [**Month (only) **], she
began to notice diarrhea, described as one loose bowel movement
per day along with intermittent vomiting, associated with 15
pound weight loss, decreased appetite and PO intake. She had a
CT Scan of her abdomen/pelvis ordered by her PCP last week,
which showed "thickening of the wall of the terminal ileum
consistent with acute inflammation and associated mildly
enlarged mesenteric lymph nodes."
.
She was scheduled to undergo an outpatient EGD/colonoscopy on
[**2-24**]. She saw her PCP on this date, who was concerned about her
presenting complaint of SOB, and thus sent her to the day clinic
for transfusion of 2 units prior to the procedures for
persistent anemia. After receiving Lasix with the first unit of
blood, and became hypotensive with a systolic blood pressure in
the 60's. IV fluids were started and her blood pressure came up;
with systolics in the 100's and hypoxic. She had another CT
Scan abd/pelvis done, which showed new terminal ileitis but also
thickening of the colon wall, Mildly dilated small bowel likely
representing paralytic ileus, reactive enlargement mesenteric
lymph nodes, and pericholecystic fluid. RUQ U/S was done and
showed distended gallbladder as well as wall thickening
representing edema, however, there were no stones or son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign. Cipro/Flagyl was started, then started to
ceftriaxone/flagyl and patient was transferred to the ICU
(secondary to concern for QTc). She was febrile to 102, and
recieved roughly 5 L IVFs, sating 97-99% on 2-3L. In light of
Hct continuing to drop to 21, and the fact that she was a
difficult crossmatch at [**Hospital1 **] [**Location (un) 620**], she was transferred to
[**Hospital1 18**] for transfusion of blood products and crossmatch tests
that could more rapidly be obtained.
.
Upon arrival to [**Hospital1 18**] ICU, Hct dropped 26.2 -> 22.6 ->
transfused 1u PRBC -> 24.2 -> transfused 1u PRBC -> 28.5 without
event. GI was consulted. GI was consulted and an
EGD/colonoscopy was performed today, which showed:
Diverticulosis of the sigmoid colon, descending colon,
transverse colon and ascending colon, and Stricture at the
ascending colon through which the scope could not pass, and
abnormal mucosa in the esophagus, erythema and congestion in the
whole stomach. As patient's clinical status had stabilized,
antibiotics were stopped. She will get MR enterography tomorrow
for visualization of remainder of colon. On transfer, patient
is afebrile, HR 72 128/55, 95% RA.
Past Medical History:
Low back pain
Compression fx
Gout
s/p right knee replacement
s/p right rotator cuff repair
s/p hysterectomy
s/p fall 1 yr ago
Social History:
lives alone, is a retired teacher. smokes [**1-17**] cigarettes per
day. denies EtOH, drugs.
Family History:
father is alcoholic
Physical Exam:
ADMISSION PE:
.
VS: Temp: Afebrile BP:128 / 55 HR: 72 RR: 18 O2sat 95% RA
GEN: pleasant, comfortable, NAD, lying flat in bed as position
best for back pain
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, 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: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII grossly intact.
RECTAL: Guiac negative x 2
.
DISCHARGE PE:
.
O: 98.4 127/60 95 20 99% RA
GEN: pleasant, comfortable, NAD, lying flat in bed
HEENT: PERRL, EOMI, anicteric, MMM,
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, dull pain in upper quadrants b/l, no [**Doctor Last Name **] sign, no
guarding or rebound, +b/s, soft, nt
EXT: no c/c/e; surgical scars on L leg well healed with no
swelling or bruising
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII grossly intact.
Pertinent Results:
ADMISSION LABS:
.
[**2117-2-23**] 06:08AM BLOOD WBC-32.9* RBC-3.27* Hgb-7.9* Hct-26.2*
MCV-80* MCH-24.2* MCHC-30.2* RDW-21.5* Plt Ct-584*
[**2117-2-23**] 06:08AM BLOOD Neuts-98* Bands-0 Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2117-2-23**] 07:30AM BLOOD PT-14.1* PTT-30.5 INR(PT)-1.2*
[**2117-3-2**] 03:52PM BLOOD ESR-92*
[**2117-3-2**] 05:50PM BLOOD ESR-83*
[**2117-2-23**] 06:08AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-140
K-4.0 Cl-108 HCO3-23 AnGap-13
[**2117-2-23**] 06:08AM BLOOD ALT-14 AST-62* LD(LDH)-828* AlkPhos-84
TotBili-0.7
[**2117-2-23**] 06:08AM BLOOD TotProt-4.6* Albumin-2.1* Globuln-2.5
Calcium-7.2* Phos-2.0* Mg-2.3
[**2117-2-23**] 06:08AM BLOOD PEP-NO SPECIFI IgG-1108 IgA-377 IgM-155
IFE-NO MONOCLO
[**2117-3-2**] 11:00AM BLOOD HIV Ab-NEGATIVE
[**2117-3-5**] 05:25AM BLOOD Vanco-16.3
[**2117-2-23**] 06:08AM BLOOD tTG-IgA-8
.
ENDOSCOPY [**2117-2-24**]
Abnormal mucosa in the esophagus (biopsy)
Erythema and congestion in the whole stomach (biopsy, biopsy)
(biopsy)
Otherwise normal EGD to third part of the duodenum
.
COLONOSCOPY [**2117-2-24**]:
Diverticulosis of the sigmoid colon, descending colon,
transverse colon and ascending colon
Stricture at the ascending colon (biopsy)
Erythema and ulceration in the ascending colon (biopsy)
(biopsy)
Grade 1 internal hemorrhoids
The colonoscope was withdrawn and the upper endoscope was used
to reach the stricutred area. This, too, could not be advanced.
As a result the procedure was lengthy and aborted in the
ascending colon at the site of the stricture.
Otherwise normal colonoscopy to ascending colon
.
BIOPSIES:
A. Gastroesophageal junction/z-line: Squamous epithelium,
within normal limits; no glandular tissue present.
B. Body: Corpus mucosa with mild chronic focally active
inflammation; [**Doctor Last Name 6311**] stain negative for organisms with
satisfactory control.
C. Antrum: Chronic inactive gastritis; [**Doctor Last Name 6311**] stain negative
for organisms with satisfactory control.
D. Duodenum: Duodenal mucosa, within normal limits.
E. Ascending colon ulcer: Mild lamina propria fibrosis and
architectural disarray; multiple levels examined; see note.
F. Stricture: Mild lamina propria fibrosis and architectural
disarray; multiple levels examined; see note.
G. Colon, random: Within normal limits.
Note: The changes are nonspecific, but raise the possibility of
healed previous injury.
.
MR ENTEROGRAPHY:
1. Wall thickening, mural edema and hyperemia involving the
cecum, ascending colon and approximately 15-cm segment of the
terminal ileum, almost certainly from Crohn's disease. More
proximal terminal ileum and distal ileum involvement appears
more chronic. Cicatrization in the mid ascending colon with
fixed narrowing as seen on clonoscopy. No phlegmon, abscess or
fistula formation.
2. Ectasia of the infrarenal abdominal aorta and the left common
iliac
artery.
3. Inferior mesenteric-lumbar venous shunting and possible small
venous
malformation in the left upper pelvis.
.
ECHO [**3-3**]:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. No 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. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Brief Hospital Course:
72 year-old female with a history of chornic low back/knee pain,
hypothyroid, 2 months of diarrhea, weight loss, iron-deficiency
anemia, radiographic evidence of ileitis/colitis, initially
presented s/p transfusion reaction, colonsocopy showing
ascending colonic strciture, eneterography consistent with
Crohn's, course complicated by C diff and Coag negative staph
bacteremia.
.
#. Diarrhea, Crohn's, and C. Diff: Patient's history of chronic,
non-bloody diarrhea for 2 months, in conjunction with weight
loss, malabsorption, and lower abdominal cramping likely
indicate Crohn's disease. Patient had multiple CT scans from
[**Hospital1 **] [**Location (un) 620**] which indicated colitis and ilietis. Initial
colonoscopy at [**Hospital1 18**] showed a stricture in the ascending colon
through which the endoscope could not be passed. Biopsies from
the stricutre and imaged parts of the colon showed pathology
consistent with chronic fibrosis. To obtain more detailed
imaging of all sections of the GI tract, MR Enterography was
performed, which showed hyperdensity of contrast and bowel wall
thickening in areas of the colon and terminal ileum, which is
indicative of Crohn's Disease. At around this time, patient's
diarrhea worsened, white blood cell count began to increase, she
began to spike fevers, and C. diff toxin assay returned
positive. She was initiated on a course of PO Vancomycin, began
on [**3-3**], for a total of 2 weeks. Diarrhea was improving back to
her baseline prior to discharge. The GI service felt that once
her course for treatment of C. Diff colitis is complete, she
would begin treatment for presumed inflammatory bowel disease
with Entocort 9 mg daily, to begin on Monday [**3-15**]. The plan is
to perform a repeat colonsocpy after treatment with steroids for
eventual dilation of the stricture. On discharge, she was still
having [**1-17**] loose bowel movements per day, with intermittent
abdominal pain and cramping relieved with defecation. She was
tolerating a low residue diet at the time. She will also be
discharged on a [**Hospital1 **] PPI.
.
#. Coag negative Staph aureus bacteremia: On [**3-3**], blood
cultures drawn on [**3-2**] returned as growing coag negative staph
aureus in [**1-19**] bottles. Patient was started on 7-day course of
IV Vancomycin, completed on [**3-9**]. Survellience cultures had no
growth by the time of discharge. Patient had a PICC line placed
on [**3-2**] and after the blood cultures returned positive, the PICC
line was pulled. TTE showed no evidence of vegetations and she
had no other signs or symptoms of endocarditis. She was
afebrile at the time of discharge.
.
#. Transfusion reaction: Patient experienced an acute hemolytic
reaction while getting transfused at [**Hospital1 **] [**Location (un) 620**] secondary to
inappropriately cross-matched blood. Upon arrival, she was seen
by the blood bank team, who determined that she had an Anti-Fya
antibody in her blood. After appropriate cross-matching, she
received 2 units of PRBCs without a transfusion reaction, and
her hematocrit increased appropriately to a baseline of 28-30.
Per the blood bank team, in the future, Ms. [**Known lastname 23239**] should
receive Fya-antigen negative products for all red cell
transfusions. Approximately 34% of ABO compatible blood will be
Fya-antigen negative. A wallet card and a letter stating the
above will be sent to the patient by the blood bank team.
.
#. Fe deficiency anemia: Patient's iron studies indicated that
she has a likely iron-deficiency anemia in combination with an
anemia of chronic disease. Likely source of the anemia is
Crohn's and subsequent malabsorption in the terminal ileum. She
was maintained on oral iron, and will be discharged on Iron 325
once daily. Her baseline Hematocrits have been 28-30, 29.8 on
the day of discharge.
.
#. Atelectasis/Oxygen Saturation: Patient had several days of
bordeline-low O2 saturations ranging 88-92% on room air on the
several days prior to discharge. These saturations would
increase to 99% on room air when patient was asked to take a
deep breath in. Multiple CXRs indicated that the patient had
bilateral atelectasis, likely secondary to immobility. She had
no other signs or symptoms of pneumonia or pulmonary embolism.
She was repeatedly encouraged to use the incentive spirometer,
even though she seems to be non-compliant with it. Upon
discharge to acute care facility, she will need to be encouraged
both to get out of bed and ambulate and to use the incentive
spirometer.
.
#. Nutritional status: Patient's albumin on admission was 2.1,
likely secondary to malabsorption and protein-losing enteropathy
from chronic inflammatory bowel disease as above. She was not
tolerating POs well upon admission and was maintained on TPN for
several days until the PICC line had to be pulled secondary to
bacteremia (see above). Albumin several days prior to discharge
had improved to 2.4. She was tolerating a low residue diet and
was counseled on foods to avoid that would help to reduce her
symptoms.
.
#. Chronic knee/low back pain: Patient has history of chronic
low back and knee pain, for which she previously took roxicet
while at home. While she was unable to take POs, her pain was
maintained with IV morphine. When she was able to tolerate POs,
she was transitioned to PO morphine 15 q6 as needed. She
repeatedly would ask for IV pain meds and exhibited some
evidence of narcotics dependence. It was explained to her that
she no longer needed IV morphine and thus it would not be given
to her. Patient needs encouragement for physical therapy and
ambulation, even given chronic pain.
.
#. Depression: Patient has had depression for several years, and
has been an ongoign issue. She was continue on Fluoxetine 20 mg
once a day.
.
# Gout: Patient's indomethacin was stopped as she was not in an
acute flare and NSAIDs can contribute to her chronic diarrhea
and anemia. She was continued on Allopurinol.
.
# Hypothyroidism: TSH checked during admission and was WNL.
She was continued on Levothyroxine 50 mcg.
Medications on Admission:
Allopurinol 300mg daily
Indomethacin 75 mg daily
Levothyroxine 50 mcg daily
Prozac 20mg daily
Roxicet PRN
Tylenol PRN
Citracal/VitD daily
MVT daily
Discharge Medications:
1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. calcium citrate-vitamin D3 500 mg(calcium) -400 unit Tablet,
Chewable Sig: One (1) Tablet, Chewable PO once a day.
3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
6. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days: End Date: [**3-15**].
7. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for reflux/abd
discomfort.
9. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
12. budesonide 3 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO once a day: START: [**3-15**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Inflammatory Bowel Disease
Acute Hemolytic transfusion reaction
Clostridium Difficile Colitis
Coagulase Negative Staph Aureus Bacteremia
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 seen in the hospital for both diarrhea and an abnormal
reaction to a transfusion of red blood cells. Your diarrhea was
likely secondary to a chronic process called inflammatory bowel
disease. You will start an anti-inflammatory called entocort
next week. You will also be seeing the Gastrointestinal doctors
within the next few weeks as listed below.
.
While you were in the hospital, you also acquired an infection
called C diff colitis. You will be trated for one more week
with an antibiotic called vancomycin. Once you complete this
antibiotic, you will start the entocort next week.
.
We also found that you had a bacteria in your blood called
coagulase negative staph aureus. We treated you with 7 days of
IV Vancomycin for this infection.
.
Our blood bank doctors discovered that your reaction to the
transfusion was caused by inappropriately cross matched blood.
It was found that you have an antibody in your blood called
Anti-Fya antibody. In the future, you should receive
Fya-antigen negative products for all red cell transfusions. A
wallet card and a letter stating the above will be sent to the
patient by the blood bank team.
.
We made the following changes to your medications:
STOPPED Indomethacin
STOPPED Roxicet
ADDED Ferrous Sulfate twice daily
ADDED Oral Vancomycin every 6 hours for another 7 days
ADDED Entocort once a day to start on Monday [**3-15**]
ADDED Morphine 15 mg every 6 hours as needed for pain
ADDED Pantoprazole 40 mg twice a day
ADDED Simethicone as needed for abdominal bloating and
discomfort
.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2117-3-31**] at 2:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22561**], 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
|
[
"2449",
"311"
] |
Admission Date: [**2142-6-10**] Discharge Date: [**2142-6-14**]
Date of Birth: [**2070-1-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 year old male with Type I diabetes x 30 years complicated by
retinopathy, nephropathy, peripheral neuropathy who presents
with hyperglycemia. Per patient's son, the day prior to
presentation BS was >600. His son thought that he forgot to take
his lantus since there was no blood sugar registered on his
meter that am. He got 18 U humalog and still high at lunch time.
He then received 18 units then at 3:00 pm = 296, BS = 84 at
dinner. Patient then had dinner and had 4U humalog. At bedtime
BS = 121. At 5:10 am he was awoken by a dog barking. He then
called out to his dad to remind him to take his insulin. He
heard him vomiting and surmised that his BS was elevated which
it was. He then called the covering doctor [**First Name (Titles) 1023**] [**Last Name (Titles) 32033**] him to
bring him to the ED. In ED found to have glucose in urine with
ketones and sugar of 630. Received 4L NS, 10 units insulin IV,
started insulin gtt at 7units/hr, increased to 8 units. Also
received azithromycin and ceftriaxone x 1 for ? pulmonary
opacity. Also noted to have acute on chronic renal failure with
Cr 4.2
Past Medical History:
DM I in [**2105**], peripheral neuropathy, retinopathy
HTN
AS
CRI
Spinal spondylosis
Idiopathic dilated CM
BPH
Compression fracture C4-5
Bone cancer in childhood
Social History:
Mr. [**Known lastname 32034**] lives with his son and his son??????s wife and daughter
in [**Name (NI) **]. His son has been very involved in his care since
last [**Month (only) 956**] ([**2139**]). He has another son, two biological
daughters and an adopted daughter. His wife passed away 10yrs
ago. He is a retired cop. He has a 60 pack-year smoking hx, but
quit many years ago. He used to drink ~8 drinks/day, but also
quit some time ago and neither smokes or drinks anymore.
Family History:
Mother- died at 48 of ??????trapped heart?????? , other FH not obtained
Physical Exam:
Physical exam on admission:
Vitals in ED: 97.2, 78, 137/88, 18, 97% RA
Vitals current: afebrile, 143/64, 63, 16, 96% RA
Gen: tanned skin, pleasant, breathing comfortably, NAD
HEENT: PERRL, EOMI, anicteric sclera, MMM, OP clear
Neck: supple, no LAD
Cardiac: RRR, NL S1 and S2, III/VE SEM radiating to carotids
Lungs: CTAB, no W/R/C
Abd: soft, NTND, NABS, no HSM, no rebound or guarding
Ext: warm, 2+ DP pulses, 1+ LE edema
Neuro: A&O x 3, MAE
Pertinent Results:
Laboratory studies on admission
WBC-9.7 RBC-3.73 HCT-32.2 MCV-86 RDW-14.4 PLT COUNT-189
NEUTS-82.3 LYMPHS-13.8 MONOS-1.7 EOS-1.6 BASOS-0.5
GLUCOSE-630 UREA N-86 CREAT-4.2 SODIUM-130 POTASSIUM-6.3
CHLORIDE-91 CK(CPK)-78 CK-MB-NotDone cTropnT-0.03
[**6-11**] EKG: Sinus rhythm. Slight ST-T wave changes with borderline
prolonged QTc interval are non-specific, but clinical
correlation is suggested. Since the previous tracing of [**2142-6-10**]
there is no suggestion of prior inferior wall myocardial
infarction.
Radiology
[**6-10**] CXR: Cardiomegaly with mild fluid overload. Focal hazy
opacity posterior chest, likely representing confluence of
shadows, but early infiltrate cannot be excluded. Background
COPD
[**6-11**] CXR: There is persistent mild enlargement of the cardiac
silhouette. Slighly improved interstitial pulmonary edema,
bibasilar ateletasis.
[**6-12**] Lumbar MRI: Acute compression fracture of L1 vertebra,
unchanged in configuration since [**2141-6-7**] but new since
[**2141-5-28**]. Status post L4 through S1 laminectomy and fusion
procedure with marked enhancing scar tissue at the laminectomy
site and circumferentially within the canal.
Brief Hospital Course:
72 year old male with Type I DM, mod AS, HTN admitted w/ DKA
secondary to med non-compliance. He was initially admitted to
the [**Hospital Unit Name 153**] on an insulin gtt, and was rapidy transitioned back to
lantus and transferred to the general floor for further
management. Summary of hospital course by problem:
1) Diabetic ketoacidosis: Likely secondary to medication
noncompliance, given he had missed a lantus dose. No evidence of
infection (U/A neg, repeat CXR w/o infiltrate). [**Last Name (un) **] followed
the patient throughout his hospital stay, and he was discharged
on his home dose of lantus with an adjusted humalog sliding
scale. His hospital course was notable for a.m. hypoglycemia (FS
60s), asymptomatic. [**Last Name (un) **] felt that this was most likely to
enhanced dietary compliance while in-house, and did not
recommend further changes in his lantus dose. His most recent
HgbA1C was 8.3 [**2142-4-5**]. He will follow-up with [**Last Name (un) **] within 1
week. He will have VNA for further diabetic teaching. His son
agreed to monitor the patient's insulin administration. His last
eye exam was ~ 4 months ago. Given gradually worsening vision
over the last 2-3 months, he will need an outpatient
ophthalmology evaluation.
2) ARF: The patient's Creatinine trended down to 3.4 from 4.2
on admit with hydration, indicating likely pre-renal etiology in
the setting of osmotic diuresis. His baseline Creatinine was the
mid 2s until the last 4 mos when it rose to 3-3.3 (likely
progresion of diabetic nephropathy). His ACEI was held
throughout his hospital stay and will be restarted at the
discretion of his outpatient physician. [**Name10 (NameIs) **] furosemide was
initially held, and then restarted at 1/2 his home dose.
4) HTN: As mentioned above, given acute renal failure, the
patient's ACEI was held. He was continued on a beta-blocker and
amlodipine.
.
5) Anemia: HCT 27.8 on discharge from 34.7 on admit (likely
hemoconcentrated on admission, baseline 28-30). [**3-31**] iron
studies were not consistent iron deficiency, and vitamin B12 and
folate were within normal limits. Given his chronic renal
insufficiency, he would likely benefit from epogen as an
outpatient. He also should have an outpatient colonoscopy.
7) systolic CHF: EF 50-55%, mild pulm edema on CXR. The patient
remainded stable on room air throughout his hospital course. As
mentioned above, his ACEI was held; if his renal failure
presents this from being resumed as an outpatient,
hydralazine/nitrate may be considered.
8) Sciatica: Given reports of sciatica and compression fracture
visualized on recent plain films, his PCP had ordered [**Name Initial (PRE) **] lumbar
MRI, which he had while in-house/ This showed an
acute-to-subacute compression fracture of L1 vertebra, unchanged
in configuration since [**2141-6-7**] but new since [**2141-5-28**].
It also showed marked enhancing scar tissue at L4 through S1
laminectomy/fusion site. He was started continued on calcium and
vitamin D. He was able to ambulate without difficulty and denied
back pain at discharge.
Full Code
Medications on Admission:
Lantus 22 QAM
Humulog SS
Atenolol 50 QAM
Citalopram 40 QHS
Lasix 40 QD
Norvasc 10 QD
ASA 81 QD
Synthroid 250 QD
Lisinopril 40 [**Hospital1 **]
Calcium/Vit D
Ferrous sulfate
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22)
units Subcutaneous at bedtime.
2. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale Subcutaneous qAC and qhs: see attached sheet.
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Calcium 600 + D(3) 600-200 mg-unit Tablet Sig: One (1) Tablet
PO once a day.
9. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
10. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
13. One Touch Ultra System Kit Kit Sig: One (1) Miscell.
as directed.
Disp:*1 kit* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary: Diabetic ketoacidosis
Secondary: acute renal failure, chronic renal failure,
hypertension, type I diabetes (poorly controlled), anemia
Discharge Condition:
Creatinine has stabilized. The patient is ambulating well and is
hemodynamically stable.
Discharge Instructions:
1) Please take your insulin daily; your lantus dose remans 22
units, however your sliding scale with meals and at bedtime has
been adjusted (see attached sheet).
2) Please check your fingersticks before each meal and at
bedtime. If FS <70, drink juice. If persistently >250, call your
primary care physician. [**Name10 (NameIs) 357**] bring the list of fingersticks
with you to your appointment on [**6-19**]. Given your renal failure,
atenolol has been replaced with metoprolol XL (Toprol XL)
3) Your ACE inhibitor (lisinopril) is currently on hold; it will
be restarted at the discretion of your PCP (please discuss this
on your appointment with NP[**MD Number(3) 32035**] [**2142-6-19**]). Your lasix dose has
been decreased to 20 mg daily.
Followup Instructions:
1) Primary Care/Endocrinology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2142-6-19**] 10:00
Date/Time:[**2142-7-5**] 10:00Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2142-9-25**] 8:30
- you should have your creatinine checked at this time to ensure
stability (3.3 on discharge)
- your blood pressure should also be checked, as your lisinopril
has been held.
2) Cardiology
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 6197**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2142-6-19**]
|
[
"5849",
"40391",
"4280",
"2859"
] |
Admission Date: [**2147-11-11**] Discharge Date: [**2147-11-11**]
Date of Birth: [**2082-6-9**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 65 year old pedestrian
who was struck by a car was found asystolic and unresponsive
in the field, full ACLS code was run and he was intubated and
brought to [**Hospital6 **] after return of pulse. At [**Hospital6 54025**] computerized tomography scan of the head,
chest x-ray and pelvis films were done with severe head
injury noted, positive subarachnoid hemorrhage, epidural
parenchymal bleed reported by head computerized tomography
scan. He was given Mannitol and transferred to [**Hospital6 1760**] with stable vital signs
throughout his transit. He was given no sedation or
paralytic at [**Hospital6 **] or in transit.
PAST MEDICAL HISTORY: His only known past medical history is
end stage renal disease on hemodialysis.
MEDICATIONS/ALLERGIES: His medications and allergies are
unknown.
PHYSICAL EXAMINATION: His vital signs on arrival to [**Hospital6 1760**] showed a heartrate of 78,
blood pressure of 220/palpable, respiratory rate 15 by Ambu
bag and oxygen saturation of 100%. On examination he had [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 2611**] coma scale of 4T with decerebrate posturing. He was
intubated and noted to have some emesis in the oral cavity
around his endotracheal tube. His pupils were equal at
approximately 2 mm. Both tympanic membranes were obscured by
wax without any blood noted. His left pinna had a degloving
fresh extensive laceration injury in the posterior aspect of
his head, a lot of soft tissue swelling and lacerations and
obvious depressed skull fracture. He had abrasions of
bilateral temples, though his facies was stable. His trachea
was midline. His lungs were clear. His heart was regular in
rate and rhythm. His abdomen was soft. His pelvis was
stable. He had normal rectal tone and was guaiac negative
with a normal prostate. He had a Foley catheter in place
with clear yellow urine draining from it. He has ecchymosis
and abrasions noted in the right knee as well as abrasions in
his right foot and left hand. On examination of his back,
his spine had no stepoff.
LABORATORY DATA: Laboratory data returned with a white count
of 26.3, plus hematocrit of 29.5 and platelets of 203. His
BUN and creatinine were 45 and 7.2. PT was 14.2 and PTT
33.7, INR 1.3. He had a negative toxicology screen and
amylase of 196, fibrinogen 166. Urinalysis was negative with
the exception of 21 to 50 red blood cells, and an arterial
blood gases that was 7.36/36/350/21/-4. Studies ordered
included a head computerized tomography scan, repeated from
the [**Hospital3 2568**] study, the one done here shows bilateral
subdural hemorrhages with midline shift toward the left side,
herniation and infarcted brain, a left frontal contusion,
depressed skull fractures and a left subarachnoid hemorrhage.
Computerized tomography scan of the neck revealed a C1
fracture with cord compression. Computerized tomography scan
of the chest and abdomen were negative for injury.
HOSPITAL COURSE: Neurosurgery evaluated the patient in the
computerized tomography scanner and in the trauma bay and
determined that his head injury was so extensive as to not be
operable. This was discussed with the patient's family at
length while he was brought up to the Trauma Surgery
Intensive Care Unit. The family understood the severity of
injury and the fact that it was nonsurvivable and shared with
us that the patient would not have wanted to be kept alive in
this state. Therefore, all care was withdrawn and his
endotracheal tube was removed. He expired shortly thereafter
at 10:57 PM on [**2147-11-11**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 14131**]
Dictated By:[**Last Name (NamePattern1) 7589**]
MEDQUIST36
D: [**2147-11-12**] 01:49
T: [**2147-11-14**] 16:22
JOB#: [**Job Number 54026**]
|
[
"40391"
] |
Admission Date: [**2190-12-3**] Discharge Date: [**2190-12-6**]
Date of Birth: [**2134-4-29**] Sex: F
Service: CCU
ADMITTING DIAGNOSIS: Acute anterior MI.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
woman who developed chest pain at approximately 7 p.m. on the
night of admission. She went to the [**Location (un) 47**] emergency
room where she was found to have anterior hyper-acute
T-waves. At that time she was started on a nitroglycerin
drip, Integrilin, aspirin, Plavix, heparin drip. The patient
continued to have chest pain. She was transferred to the
[**Hospital1 69**] for emergent cardiac
catheterization. The cardiac catheterization revealed apical
and inferoapical dyskinesis. The LAD had a distal occlusion
consistent with spontaneous dissection versus local coronary
embolus. Attempts to re-vascularize the LAD were
unsuccessful. The patient was transferred to the CCU for
close monitoring of a myocardial infarction. Upon arrival to
the CCU the patient had 1 to 2 out of 10 chest pain. She
denied palpitations, shortness of breath, nausea or vomiting.
She stated that her chest pain was significantly decreased on
her medical regimen as it had been out 10 out of 10
previously.
PAST MEDICAL HISTORY:
1. Hemachromatosis.
2. GERD.
4. Colon polyps.
MEDICATIONS AT HOME: Zantac, Motrin, multi-vitamin.
ALLERGIES: Penicillin causes a rash. Morphine causes
lightheadedness.
SOCIAL HISTORY: The patient is a nonsmoker. She rarely
drinks alcohol. She lives with her husband and family.
FAMILY HISTORY: No history of coronary artery disease.
PHYSICAL EXAMINATION UPON ADMISSION: The heart rate was 100,
blood pressure 130/74, respiratory rate 14, satting 98% on
two liters by nasal cannula. The patient was in no apparent
distress. She appeared fatigue. The chest was clear to
auscultation anteriorly. Heart had a regular rate and
rhythm. There were no murmurs, rubs or gallops. The abdomen
was soft, nontender, nondistended. Bowel sounds were
present. The extremities were without edema. The dorsalis
pedis pulses were 2+ bilaterally. The right groin had a
sheath in it. The were pupils equal, round and reactive to
light bilaterally. The extraocular muscles intact. The
mucous membranes were moist. There was no jugular venous
distention.
LABORATORIES UPON ADMISSION: An arterial blood gas was
7.35/52/234. Hematocrit 35.
CARDIAC CATHETERIZATION DATA: The cardiac output was 5.2, RA
9, RV 48/11, PA 44/12, wedge 22. The ejection fraction was
calculated at 25-30% with apical and inferoapical dyskinesis.
The LAD had a cut-off distally consistent with spontaneous
dissection.
An EKG pre-procedure showed normal sinus rhythm at a rate of
75. There was normal axis. The intervals were normal.
There were hyper-acute T-waves in leads V2 through V5.
COURSE IN HOSPITAL: The patient was admitted to the cardiac
care unit after unsuccessful re-vascularization with an acute
anterior myocardial infarction. The patient was treated with
aspirin, beta blocker and an ACE inhibitor. A statin was
started. Integrilin was continued for 18 hours. The
patient continued to have chest pain for her first 24 hours
in the hospital. This was treated symptomatically with
Fentanyl and morphine with good effect. After 24 hours the
patient remained pain free in hospital. The CK peaked at 1350.
PUMP: On cardiac catheterization the ejection fraction was
calculated at 20-25% with apical akinesis. The patient
underwent an echo the day after admission, which revealed an
ejection fraction of 40-45% with distal anterior, septal,
apical hypokinesis, akinesis with 1+ mitral regurgitation and
2+ tricuspid regurgitation. There was mild PA systolic
hypertension. The patient remained euvolemic throughout her
stay in the hospital. She should have a follow up echo in 4
to 6 weeks as an outpatient to assess her ejection fraction.
RHYTHM: The patient was maintained on telemetry throughout
her stay in the hospital. For 24 hours after her
presentation she had short runs of NSVT. She was maintained
on a beta blocker. By 24 hours after her event she no longer
had NSVT.
GERD: The patient was maintained on proton pump inhibitor
throughout her stay in the hospital.
At the end the patient was maintained on and tolerated a
cardiac diet.
DISCHARGE DIAGNOSES:
1. Anterior MI, status post unsuccessful re-vascularization
attempt.
2. Ejection fraction of 40-45%.
3. Hemachromatosis.
4. GERD.
5. Colon polyp.
DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d.,
atorvastatin 10 mg p.o. q.h.s., lisinopril 2.5 mg p.o. q.d.,
Toprol XL 25 mg p.o. q.d., nitroglycerin 0.3 mg sublingual
p.r.n. q5 minutes for chest pain.
DISCHARGE FOLLOW UP: The patient is being discharged home.
She will follow up with a cardiologist. She will need to
have a cholesterol panel and a CRP checked in 6 weeks time.
She will also need an echo as an outpatient in 4 to 6 weeks
time.
DISCHARGE CONDITION: Good.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2190-12-5**] 16:31
T: [**2190-12-6**] 11:47
JOB#: [**Job Number 25147**]
|
[
"41401",
"53081"
] |
Admission Date: [**2133-12-17**] Discharge Date: [**2133-12-23**]
Date of Birth: [**2058-12-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
cholangitis
Major Surgical or Invasive Procedure:
ERCP, sphincterotomy
History of Present Illness:
Mr. [**Known lastname **] is a 75 yo M with history of HTN, HL, Hodgkin's
lymphoma (dx [**2121**]) and follicular lymphoma grade II (dx [**2127**]),
s/p chemo and xrt, on IVIG therapy for hypogammaglobulinemia
(last dose [**2133-12-9**]), and paroxysmal afib w/ RVR who presented
yesterday with 36 hours of midepigastric abdominal pain, without
radiation, [**2-6**] in pain scale, worse with deep inspiration.
Denied nausea, vomiting, fever, chills, diarrhea, constipation,
BRBPR, SOB, cough, chest pain, unexplained weight loss,
fatigue/malaise/lethargy, pruritis or jaundice. Does note
decreased appetite, pain not associated with food. Last BM 2
days ago. Patient took percocet x1 and later oxycodone x1, which
helped pain. Notified Dr. [**First Name (STitle) **] who recommended he go to the ED.
.
In ED, VS 99.2 64 203/88 20 98%. Labs showed WBC 6.5, elevated
LFTs (ALT 470, AST 278, AP 189, LDH 278, Tbili 9.8, Dbili7.5).
RUQ US showed gallstones, sludge and a distended gallbladder but
no pericholecystic fluid, CBD dilitation, GB wall thickening,
and was negative Murphies. No history of biliary colic,
cholecystitis, or liver disease. CT chest negative for PE.
Patient was admitted to ACS for monitoring, overnight patient
was hypertensive with SBP in the 180s, got hydralazine 10mg IV
however developed Afib with RVR with HR into the 140s this
morning, BP stable. EKG reportedly with ST depressions, CE
negative (CKMB 3, Trop<0.01). Previous episodes of afib with RVR
attributed to chemotherapy, fevers, volume overload. Patient's
HR was stabilized with diltiazem 10mg x2 and 15mg x1, and
metoprolol 10mg x3. Patient was transferred to the [**Hospital Unit Name 153**] with
plans for ERCP for possible cholangitis, based on LFTs and
elevated bilirubin, however patient is afebrile with a normal
WBC and no CBD dilitation on RUQ US. Afib with RVR attributed to
hepatobiliary process.
.
On arrival to the [**Hospital Unit Name 153**], VS: T 98.2, BP 123/71, HR 53, RR 18, 95%
on RA. Patient without abdominal pain, resting comfortable in
sinus rhythm. Patient has not received any pain medicine either
in the ED or on the floor.
Past Medical History:
1. Hodgkin's Lymphoma (diagnosed [**2121**], relapsed [**2126**] treated
with AVBD c/b Afib w/RVR, bleomycin lung toxicity, PCP
[**Name Initial (PRE) 1064**]) and Non-Hodgkin's (follicular) lymphoma (diagnosed
[**2127**], treated w/rituxan in [**2128**]).
2. Bleomycin toxicity
3. h/o PCP [**Name Initial (PRE) 1064**]
4. Paroxysmal A-Fib: Noted in clinic on day of his first dose of
neupogen, [**2127-3-11**], has been recurrant in setting of pulmonary
edema, chemotherapy, fever.
5. Hypertension
6. Hypercholesterolemia
7. Nephrolithiasis
8. Retinal detachment [**6-/2129**]
9. Peripheral neuropathy
10. psoriasis
11. Hypogammaglobulinemia
.
Onc history:
- Left-sided neck adenopathy biopsied in [**5-/2122**]: Hodgkin
disease with flow cytometry noted for monoclonal B cells which
were CD5 positive,raising the possibility of CLL. This was felt
likely due to
persistence of germinal centers and he was treated for stage IA
lymphocyte [**Doctor First Name **] Hodgkin disease with radiation therapy with a
total dose of 3060 centigrade of modified mantle field with
three
fractions of left neck cone down completed in 09/[**2121**].
- CT on [**2127-1-20**] revealed a left pleural mass with biopsy
consistent with relapsed classical Hodgkin lymphoma status post
ABVD X 6 cycles with complications of neutropenia, necessitating
the use of Neupogen, rapid atrial fibrillation, and bleomycin
toxicity along with PCP [**Name Initial (PRE) 1064**]. Bleomycin was held after
cycle two day one. Cycle six completed on [**2127-7-25**].
- Recurrent adenopathy noted in [**6-/2128**] with waxing and [**Doctor Last Name 688**]
size that was followed over time with a slowly increasing
adenopathy. Excisional biopsy of right neck adenopathy done by
Dr. [**Last Name (STitle) 1837**] on [**2129-3-28**] revealed a follicular lymphoma
grade 2.
- Status post four weeks of Rituxan from [**2129-4-19**] to [**2129-5-10**]
and one dose on [**2129-6-7**] followed by six cycles with Rituxan,
Doxil, and Cytoxan on [**2129-7-8**], [**2129-7-29**], [**2129-8-19**],
[**2129-9-8**], [**2129-10-14**] and [**2129-11-4**]. PET after 2 cycles with
marked improvement. PET scan after 4 cycles with no FDG avidity.
Doxil dose reduced to 25mg/m2 for 5th and 6th cycle due to
hand/foot rash.
- PET scan on [**2130-1-27**] revealed no FDG-avid disease. Treated
with 2 doses of maintenance Rituxan on [**2130-3-31**] and [**2130-4-7**].
- Follow up PET scan on [**2130-5-16**] showed new FDG avid
lymphadenopathy in the left infrarenal paraaortic and iliac
regions, with the largest paraaortic node measuring 30 x 16 mm
and SUVmax of 20.4, felt representing recurrent lymphoma but not
amenable to biopsy. No other new focal FDG uptake in the chest,
abdomen or pelvis.
- Received 1 cycle of ICE on [**2130-5-31**] complicated by fluid
overload and atrial fibrillation and flutter.
- Received 1 cycle of ESHAP on [**2130-6-22**] complicated by
bradycardia and repeat admission for atrial fibrillation.
- Repeat FDG imaging on [**2130-7-20**] continued to show FDG
avidity within the left paraaortic lymph node with SUV max of
11.2. Given prior history of Hodgkin's lymphoma and
non-Hodgkin's lymphoma, he underwent a biopsy by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3748**] from Urology with laparoscopic surgery on [**2130-9-4**]
which did not show any evidence for non-Hodgkin's lymphoma or
Hodgkin's lymphoma.
- Repeat PET scan in [**9-/2130**] revealed resolution of his
lymphadenopathy and FDG avidity with no new areas. Follow up FDG
tumor imaging on [**2130-12-11**] reveals no evidence for
lymphadenopathy or recurrent lymphoma.
- Further treatment with Rituxan held due to recurrent sinus
infections which have been treated extensively with antibiotics
under the guidance of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] from ID. Follow up sinus
CTs finally showed resolution of his infection.
- Last treatment with Rituxan in [**3-/2131**] for 2 doses. Receiving
periodic IVIG for hypogammaglobulinemia, last given [**2132-12-30**].
- Follow up PET scanning in [**4-/2131**] and [**9-/2131**] notable for
enlarging FDG avid subcutaneous lesion in the right posterior
neck and new FDG-avidity in a tiny (3 mm) right level 5 lymph
node. These were followed with examinations and scans and the
right occipital node was increasing in size and proceeded with
FNA on [**2132-7-8**] which was nondiagnostic.
- Biopsy of right occipital mass on [**2132-7-31**] showed follicular
lymphoma, Grade 3A and follicular lymphoma, Grade [**11-30**],
diffuse(Extranodal extension) with concurrent lymphocyte-[**Doctor First Name **]
classical Hodgkin's lymphoma.
- Underwent XRT to right occipital area for total 3600cGy
completing on [**2132-10-1**] as only area of disease.
- PET CT on [**2133-2-4**] shows resolution of numerous previously
seen sites of FDG-avid cervical lymphadenopathy and right
suboccipital tissue nodal tissue with persistence of a 10 x 6 mm
left level IIB node with significant FDG avidity (SUV max 5.4).
Social History:
He lives at home with his wife. They have 2 children and 7
grandchildren. He is a retired telecommunications engineer. No
tobacco or alcohol use.
Family History:
Denies FH of DM, heart disease/MI, stroke, cancer. Thinks father
may have had a thyroid problem.
Physical Exam:
Exam (On admission to [**Hospital Unit Name 153**]):
Vitals: T 98.2, BP 123/71, HR 53, RR 18, 95% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
Skin: jaundiced, psoriatic lesions over shins
Neck: supple, JVP not elevated, no LAD
Lungs: minimal bibasilar rales otherwise clear, no wheezes or
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic
murmur, no rubs, gallops
Abdomen: soft with some firmness in midepigastrium, minimally
tender in mid epigastrium and RUQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. neg
murphys sign.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities
Pertinent Results:
Imaging:
EKG: bradycardic at 57, prolonged QTc 460, otherwise normal
intervals, nonspecific T wave inversion unchanged from 8/[**2132**].
.
[**2133-12-16**] CXR: No signs of pneumonia or CHF.
.
[**2133-12-16**] RUQ US: Distended gallbladder containing stones and
probable tumefactive sludge. Findings are equivocal for acute
cholecystitis given lack of son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. Please
correlate clinically for lab abnormalities or other signs of
acute cholecystitis, and if the concern persists, a HIDA scan
can be obtained for further evaluation.
.
[**2133-12-16**] CTA: 1. No acute pulmonary embolism or thoracic aortic
pathology. 2. Small airways disease. 3. Diffusely dilated upper
thoracic esophagus, likely relates to esophageal dysmotility or
stricture. An esophagram can be performed on a non-emergent
basis for further assessment.
.
[**2133-12-17**] ERCP:
Normal major papilla
Cannulation of the biliary duct was successful and deep after a
guidewire was placed
A small filling defect, compatible with a stone was noted at the
distal bile duct. Otherwise, normal biliary tree
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
A small stone and large amount of pus were extracted
successfully using a balloon.
Otherwise normal ercp to third part of the duodenum
.
[**2133-12-21**]:
Atrial fibrillation with rapid ventricular response. Compared to
the
previous tracing of [**2133-12-21**] sinus rhythm is absent.
TRACING #2
.
Microbiology:
[**2133-12-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2133-12-17**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2133-12-17**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
.
[**2133-12-23**] 01:40PM BLOOD Hct-31.5*
[**2133-12-23**] 06:30AM BLOOD WBC-4.3 RBC-3.15* Hgb-10.3* Hct-29.9*
MCV-95 MCH-32.6* MCHC-34.3 RDW-13.7 Plt Ct-207
[**2133-12-22**] 04:05PM BLOOD Hct-32.7*
[**2133-12-22**] 06:30AM BLOOD WBC-4.1 RBC-3.13* Hgb-10.1* Hct-29.4*
MCV-94 MCH-32.4* MCHC-34.5 RDW-13.8 Plt Ct-177
[**2133-12-21**] 07:05AM BLOOD WBC-4.7 RBC-3.35* Hgb-11.0* Hct-31.2*
MCV-93 MCH-32.9* MCHC-35.3* RDW-13.5 Plt Ct-160
[**2133-12-20**] 07:30PM BLOOD Hct-30.5*
[**2133-12-20**] 07:50AM BLOOD WBC-3.5* RBC-3.31* Hgb-10.8* Hct-31.2*
MCV-94 MCH-32.6* MCHC-34.5 RDW-13.6 Plt Ct-149*
[**2133-12-19**] 09:00AM BLOOD WBC-3.1* RBC-3.21* Hgb-10.6* Hct-30.2*
MCV-94 MCH-33.0* MCHC-35.0 RDW-13.4 Plt Ct-149*
[**2133-12-18**] 04:54AM BLOOD WBC-3.8* RBC-3.31* Hgb-11.0* Hct-31.2*
MCV-94 MCH-33.3* MCHC-35.3* RDW-13.3 Plt Ct-154
[**2133-12-17**] 08:02PM BLOOD WBC-6.1 RBC-3.69* Hgb-12.1* Hct-34.1*
MCV-93 MCH-32.8* MCHC-35.5* RDW-13.1 Plt Ct-154
[**2133-12-16**] 07:50PM BLOOD WBC-6.5 RBC-4.18* Hgb-13.5* Hct-38.6*
MCV-92 MCH-32.3* MCHC-35.0 RDW-12.7 Plt Ct-189
[**2133-12-16**] 07:50PM BLOOD Neuts-82.2* Lymphs-8.0* Monos-6.3 Eos-3.1
Baso-0.4
[**2133-12-18**] 04:54AM BLOOD PT-12.6* PTT-32.9 INR(PT)-1.2*
[**2133-12-17**] 08:02PM BLOOD PT-13.1* PTT-29.7 INR(PT)-1.2*
[**2133-12-23**] 06:30AM BLOOD Glucose-90 UreaN-22* Creat-1.3* Na-140
K-4.0 Cl-103 HCO3-29 AnGap-12
[**2133-12-22**] 06:30AM BLOOD Glucose-97 UreaN-33* Creat-1.3* Na-143
K-3.9 Cl-107 HCO3-29 AnGap-11
[**2133-12-21**] 09:30PM BLOOD UreaN-33* Creat-1.3* Na-140 K-3.6 Cl-103
[**2133-12-21**] 07:05AM BLOOD Glucose-97 UreaN-26* Creat-1.3* Na-141
K-3.8 Cl-104 HCO3-29 AnGap-12
[**2133-12-20**] 07:50AM BLOOD Glucose-100 UreaN-20 Creat-1.3* Na-142
K-3.7 Cl-107 HCO3-28 AnGap-11
[**2133-12-19**] 09:00AM BLOOD Glucose-121* UreaN-19 Creat-1.2 Na-142
K-3.2* Cl-106 HCO3-28 AnGap-11
[**2133-12-18**] 04:54AM BLOOD Glucose-76 UreaN-22* Creat-1.3* Na-141
K-3.5 Cl-105 HCO3-24 AnGap-16
[**2133-12-17**] 08:02PM BLOOD Glucose-88 UreaN-21* Creat-1.2 Na-142
K-3.7 Cl-106 HCO3-23 AnGap-17
[**2133-12-16**] 07:50PM BLOOD Glucose-113* UreaN-28* Creat-1.3* Na-139
K-4.5 Cl-100 HCO3-25 AnGap-19
[**2133-12-23**] 06:30AM BLOOD ALT-239* AST-137* AlkPhos-110
TotBili-3.4*
[**2133-12-22**] 06:30AM BLOOD ALT-216* AST-122* AlkPhos-109
TotBili-3.4*
[**2133-12-21**] 07:05AM BLOOD ALT-212* AST-125* AlkPhos-124
TotBili-5.3*
[**2133-12-20**] 07:50AM BLOOD ALT-172* AST-82* AlkPhos-123 TotBili-5.8*
[**2133-12-19**] 09:00AM BLOOD ALT-183* AST-74* AlkPhos-128 TotBili-6.9*
[**2133-12-18**] 04:54AM BLOOD ALT-235* AST-103* LD(LDH)-155
AlkPhos-140* TotBili-8.6*
[**2133-12-17**] 08:02PM BLOOD ALT-273* AST-125* LD(LDH)-196
AlkPhos-146* TotBili-8.6*
[**2133-12-17**] 09:00AM BLOOD CK(CPK)-58
[**2133-12-16**] 07:50PM BLOOD ALT-470* AST-278* LD(LDH)-278*
AlkPhos-189* TotBili-9.8* DirBili-7.5* IndBili-2.3
[**2133-12-16**] 07:50PM BLOOD Lipase-29
[**2133-12-17**] 08:02PM BLOOD CK-MB-3 cTropnT-<0.01
[**2133-12-17**] 09:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2133-12-21**] 07:05AM BLOOD IgG-537* IgA-95 IgM-19*
Brief Hospital Course:
75 yo M with PMH of HTN, HL, Hodgkin's lymphoma (dx [**2121**]) and
follicular lymphoma grade II (dx [**2127**]), s/p chemo and xrt, on
IVIG therapy for hypogammaglobulinemia, and paroxysmal afib w/
RVR who presented with RUQ/epigastric pain and elevated [**Hospital 13550**]
transferred to [**Hospital Unit Name 153**] for afib with RVR (resolved), found on ERCP
to have cholangitis.
.
# Cholangitis/bile duct obstruction/choledocholithiasis: Patient
presented with new onset epigastric and RUQ abominal pain in the
setting of elevated LFT's and direct hyperbilirubinemia. RUQ US
was non definitive for acute cholecystitis or biliary
obstruction. Patient has been afebrile with a normal WBC, and no
evidence of CBD dilitation. He was started on Unasyn on [**2133-12-17**]
and transferred to the [**Hospital Unit Name 153**] for ERCP during which a
sphincterotomy was performed and 1 small stone and significant
amount of pus were extracted. Per ERCP recommendation, patient
was switched from unasyn to ciprofloxacin 500mg PO x5days. LFTs,
Dbili, WBC trended down steadily. Blood cultures sent and were
negative. Patient remained stable in the ICU without abdominal
pain, diet was advanced as tolerated and patient was transferred
to the floor for further monitoring. ACS did not plan to perform
cholecystectomy in this acute setting and recommended outpatient
clinic follow up in [**1-1**] weeks (appointment scheduled). The
surgical service recommended [**Date Range **] comment on optimization
prior to surgery. The [**Date Range 3242**] service did not feel as though pt
needed any further interventions from the [**Date Range **] perspective
prior to surgery.
.
# Afib w/ RVR: Previous episodes of Afib with RVR attributed to
chemotherapy, fevers, and volume overload. Patient went into
afib with RVR, rate in the 140s, on the night of admission,
thought to be due to infection/cholangitis. He was given
multiple IV doses of diltiazem and metoprolol and converted back
into sinus rhythm prior to arrival to [**Hospital Unit Name 153**]. HR remained in the
50s (normally 50s-60s). BP remained stable throughout episode.
EKG showed some ST depressions (troponin and CKMB negative).
Repeat EKG was unchanged from EKG prior to Afib w/ RVR episode,
no ST depressions. He is managed with metoprolol and ASA 325 at
home, which were continued through the admission. Abdominal pain
was controlled and patient was monitored on telemetry. Pt did
well on the medical floor but had one evening of RVR that
responded to IV metoprolol. Generally, pt's HR is 50's-60's and
sinus. He was discharged on his home regimen of 25mg Toprol XL.
His aspirin was held on the medical floor due to guaiac+ dark
stool, but HCT remained stable. Pt was instructed to have a
repeat CBC at his PCP's office [**2133-12-29**]. If stable, would resume
aspirin at that time.
.
#anemia-normocytic, Likely acute blood loss and consistent with
chronic inflammation. Baseline appeared to be 34-38. Pt was
constipated for several days after ERCP. However, pt then began
to develop very dark brown guaiac positive stool. Pt's heparin
SC and aspirin were discontinued in this setting. ERCP team was
notified and recommended HCT monitoring. Pt's HCT was monitored
closely and remained stable for 5 days (~HCT 30) prior to
discharge. However, pt continued with dark guaiac + stool (no
blood), without any evidence of hemodynamic compromise during
admission. Upon discharge, pt was instructed to continue holding
his ASA and have a repeat HCT drawn on [**12-29**] at his PCP's office.
HCT 31.5 on day of DC.
.
#CKD-baseline appears to be 1.1-1.3. Remained at baseline during
admission.
.
# h/o PCP [**Name Initial (PRE) 11091**]: Continued on Bactrim DS MWF, no symptoms during
admission.
.
# Gout: Continued allopurinol 100 Q daily.
.
# HTN: Continued home lisinopril and metoprolol
.
# Hyperlipidemia: Held home simvastatin given elevated LFTs.
Consider resuming when LFTs normalize/stabilize.
.
# Hypogammaglobulinemia: Stable, managed on IVIG, seen regularly
by Dr. [**First Name (STitle) **]. Last dose on [**2133-12-9**]. Pt to follow up with Dr.
[**First Name (STitle) **] for further care.
.
# Lymphoma: Patient is not currently on a chemo regimen.
Followed by Dr. [**First Name (STitle) **]. Follow up appointment scheduled prior to
DC.
.
# Psoriasis: Patient has mild psoriasis over shins managed at
home with hydrocortisone. Continued hydrocortisone cream.
.
Transitional Issues:
-repeat CBC and LFTs at PCP's office. Restart asa/simvastatin
when able. Pt has f/u scheduled in surgery clinic as well as
PCP, [**Name10 (NameIs) **], and cardiology.
Medications on Admission:
Albuterol prn
Allopurinol 100'
Bactrim DS 3xWeek (MWF)
Lisinopril 5'
Simvastatin 40'
Metoprolol 25'
Omeprazole DR 20'
Cialis 5'
Asa 325
Vitamin B
MV
Glucosamine 750'
Fish oil ''
Folic acid 400'
hydrocortisone cream for psoriasis
Occasional percocet or oxycodone for pain (rare)
IVIG
Discharge Medications:
1. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. B-complex with vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
10. folic acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
11. cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day).
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
14. stop
Please stop your simvastatin and aspirin until instructed to
restart by your PCP
15. Outpatient Lab Work
LFTs, bilirubin and CBC on [**2133-12-29**] at Dr.[**Hospital1 6460**] office.
Discharge Disposition:
Home
Discharge Diagnosis:
choledocholithiasis
cholangitis
transaminitis
afib with RVR
anemia
HTN
history of lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of abdominal pain and were
found to have an infection (cholangitis) and stones in your bile
ducts. For this, you underwent and ERCP that found pus and
stones. You also had a sphincterotomy (area of narrowing was
opened).
.
You also had fast atrial fibrillation while in the ICU. You were
continued on your metoprolol.
.
You also had dark stools and a slight drop in your blood count.
However, your blood count has been stable for 5 days. The GI
doctors did not feel that there were any further interventions
that needed to occur.
.
Medication changes:
1.stop your aspirin until instructed to restart by your PCP
after your blood counts are rechecked.
2.please continue to take cipro and flagyl for 5 more days
3.stop your simvastatin until instructed to restart by your PCP
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Address: [**Location (un) **], [**Apartment Address(1) 8308**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 7318**]
Appt: [**12-29**] at 9am
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2134-1-12**] at 2:00 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/[**Hospital Ward Name 3242**]
When: FRIDAY [**2134-1-8**] at 9:00 AM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], 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: [**Hospital Ward Name 3242**] CHAIRS & ROOMS
When: FRIDAY [**2134-1-8**] at 9:00 AM
Department: CARDIAC SERVICES
When: TUESDAY [**2134-1-19**] at 9:20 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"2851",
"2724",
"42731",
"2720",
"40390",
"5859"
] |
Admission Date: [**2123-10-12**] Discharge Date: [**2123-10-14**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
female with a history of rheumatoid arthritis, hypertension,
and questionable colon cancer who has been ill for months.
The patient has been having multiple syncopal episodes at
home times months. They have been unwitnessed. She
experienced fracture of left arm and right arm during falls.
Earlier this year, worked up at [**Hospital **] Medical Center for
a questionable large gastrointestinal bleed. A colonoscopy
with multiple polyps; unclear if cancer or not. Has been
requiring blood transfusions every three months.
In [**2123-7-19**] the patient was admitted to
[**Hospital3 1196**] status post fall. Had delirium and
a 5[**Hospital 15386**] hospital course there.
Last week, she was treated with ciprofloxacin for a urinary
tract infection. On the night of admission, she was found
passed out on the floor by her nephew who called Emergency
Medical Service. Found the patient with heart rate of 33 and
a blood pressure of 80/palp. Taken to [**Hospital 4068**] Hospital. In
the Emergency Department, blood pressure there was 66/palp,
heart rate was 33, respiratory rate was 22, and 97%. Weight
was 60 kilograms. Electrocardiogram with questionable
complete heart block. Was started on dopamine and intubated
for hypotension. When stabilized, was med-flighted to [**Hospital1 1444**] for further management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Anemia; no clear etiology, requires blood transfusions
every two to three months.
3. Hypothyroidism.
4. Gastroesophageal reflux disease.
5. Colonic polyps; diagnosed at [**University/College **] in [**2122**] (unsure if
cancer).
6. Rheumatoid arthritis.
7. Chronic renal failure.
8. Falls.
ALLERGIES: CODEINE (unknown reaction).
MEDICATIONS ON ADMISSION:
1. Plaquenil 200 mg by mouth once per day.
2. Risperdal 0.5 mg by mouth twice per day.
3. Protonix 40 mg by mouth once per day.
4. Iron sulfate 325 mg by mouth once per day.
5. Synthroid 0.125 mg by mouth once per day.
6. Toprol-XL 50 mg by mouth once per day.
7. Procrit 10,000 units every week.
8. Lasix (unsure of dose).
FAMILY HISTORY: Family history is unknown.
SOCIAL HISTORY: She lives alone but nephew often visits at
night. Health aide during the day.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
temperature was too low to record rectally, her heart rate
was 65, her blood pressure was 109/84, her respiratory rate
was 14, and her oxygen saturation was 97% on ventilator. In
general, lying in bed, minimally responsive to voice. Head,
eyes, ears, nose, and throat examination revealed jugular
venous pressure was flat. The oropharynx was dry.
Cardiovascular examination revealed a regular rate and
rhythm. No murmurs, rubs, or gallops. The lungs were clear
to auscultation bilaterally. The abdomen was soft,
nontender, and nondistended. Bowel sounds were present.
Extremities revealed 1+ lower extremity edema. Neurologic
examination revealed the patient was intubated and sedated.
Responded minimally to voice. Responded to pain.
PERTINENT RADIOLOGY/IMAGING: Bedside echocardiogram revealed
no wall motion abnormalities, normal ejection fraction, no
valvular abnormalities.
An electrocardiogram at the outside hospital showed sinus
bradycardia at 33, left axis deviation, T wave inversions in
III.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
an outside hospital revealed sodium was 134, potassium was
3.5, chloride was 98, bicarbonate was 25, blood urea nitrogen
was 42, creatinine was 2.9, and her blood glucose was 85.
Protein was 5.7. Albumin was 2.6. Calcium was 9. Total
bilirubin was 0.18. Alkaline phosphatase was 108,
alanine-aminotransferase was 34, aspartate aminotransferase
was 29. Creatine kinase was 161. MB was 18. Troponin was
less than 0.01. White blood cell count was 4.4, her
hematocrit was 31, and her platelets were 171. Differential
with neutrophils of 81, lymphocytes of 13, and monocytes of
5.2.
Laboratories at [**Hospital1 69**] revealed
her white blood cell count was 6.6, her hematocrit was 39.8,
and platelets were 211. Differential with neutrophils of
88.7. INR was 1.1. Prothrombin time was 12.9 and partial
thromboplastin time was 37.3. Urinalysis was unremarkable.
Sodium was 134, potassium was 3.2, chloride was 97,
bicarbonate was 23, blood urea nitrogen was 44, creatinine
was 3.1, and blood glucose was 100. Her
alanine-aminotransferase was 31, her aspartate
aminotransferase was 31, alkaline phosphatase was 115, and
her total bilirubin was 0.3. CK/MB was 45. Troponin was
0.13. Calcium was 9.6, magnesium was 2.2, and her phosphate
was 5.1. Arterial blood gas revealed pH of 7.4, PCO2 was 35,
PO2 was 454 on 100% assist control. Total volume 500.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. HYPOTENSION ISSUES: The patient was admitted to the
Coronary Care Unit. Presumably at the time of presentation
we thought that the patient might have been septic as her
numbers were more consistent with a septic physiology as
opposed to a cardiogenic shock physiology.
The patient had an elevated white blood cell count and a left
shift. She was hypothermic and had evidence of a recent
urinary tract infection for which she was being treated.
However, we could not completely exclude a myocardial
infarction given recent ongoing myocardial infarction;
although less likely. Other things on our differential that
we were including were adrenal insufficiency and hypothermia
with which she presented.
A sepsis workup was sent off which included blood cultures,
urine cultures, and sputum culture. The urine culture was
unremarkable. The sputum culture was unremarkable as well as
blood cultures. There was one bottle that showed a likely
contaminant. A chest x-ray showed a left lower lobe
collapse and questionable consolidation. No evidence of
congestive heart failure; thus bringing the likelihood that
the patient was in cardiogenic shock.
The patient had a triple lumen placed for access and
aggressive intravenous fluid hydration. The patient was
started on dopamine and later on was changed to Levophed for
blood pressure support. Despite one pressor, the patient
required pressors for blood pressure support. Hence, we
added on Neo-Synephrine and vasopressin. The patient was
covered with broad-spectrum antibiotics; vancomycin,
levofloxacin, and Flagyl with one dose of gentamicin for a
presumed infection. Cortisol was checked and was
unremarkable. Metoprolol was held. The patient was
eventually stabilized on three pressors with an attempt to
wean off pressors and see if the patient would be able to
maintain her own blood pressure.
A conversation with the family was held, and it was their
wishes that the patient not any have further aggressive
measures or attempts of resuscitation such as pacing,
cardiopulmonary resuscitation, or cardioversion. They did,
in the interim, wish to continue with the intubation and
mechanical support as well as intravenous antibiotics. The
family brought in the health care proxy, ([**Name (NI) **] [**Name (NI) 53995**])
assigned her son [**First Name5 (NamePattern1) **] [**Name (NI) 53995**]) as her decision maker.
Despite out continued efforts in attempts to stabilize the
patient and wean off pressors, the patient was not going to
be able to tolerate being off mechanical ventilation or
pressor support. Per family, the patient was made comfort
measures only and comfortable on a morphine sulfate drip.
The family was at bedside at all times. The patient expired
on [**2123-10-14**] at 12:08 a.m. The family declined
autopsy, and the attending was notified.
The patient was admitted to the Unit from an outside hospital
with an external pacemaker, heart beating at 60, and a blood
pressure of 100/60. Pacing wires were subsequently no longer
needed as the patient's heart rate had returned to a regular
rate without any further need for intervention. The
patient's family had also declined any further cardiac
measures such as external pacing.
2. HYPOTHERMIA ISSUES: Likely secondary to sepsis. We
were unable to record any rectal temperatures. The patient
was started on a warming blanket and concurrent antibiotics;
vancomycin, levofloxacin, and Flagyl with one dose of
gentamicin to treat the possible sepsis. Cortisol was
unremarkable. On the second day of her admission,
temperature was improved.
3. BRADYCARDIA ISSUES: At outside hospital, the patient
was recorded as having sinus bradycardia up to 33. On
admission, her bradycardia has resolved, and she had a
regular rate. Most likely secondary to ischemia and
consequent hypothermia.
4. NON-ST-ELEVATION MYOCARDIAL INFARCTION ISSUES: It was
likely that the patient had a non-ST-elevation myocardial
infarction secondary to demand given her hypotension.
Unlikely acute coronary syndrome. Heparin was held, and the
patient was given supportive measures such a blood pressure
support on three pressors; Levophed, Neo-Synephrine, and
vasopressin.
Given the patient's elevated cardiac enzymes with a troponin
of 0.15 in the setting of renal insufficiency, the troponin
leak was attributed to demand ischemia and not acute coronary
syndrome.
5. CHRONIC RENAL INSUFFICIENCY ISSUES: The patient's
baseline creatinine was unknown, but chronic renal
insufficiency may have been attributed to hypotension or
rheumatoid arthritis. Her electrolytes were followed on a
daily basis, and medications were renally dosed.
6. ANEMIA ISSUES: The patient's hematocrit was followed on
a daily basis. Her hematocrit dropped secondary to large
intravenous fluid hydration and volume given. No evidence of
acute blood loss noted on examination. The patient was
stable.
7. SEIZURE ISSUES: The patient had an episode of seizure.
Her blood sugar was checked and noted to be 37. One ampule
of dextrose 50 was administered and consequent Dilantin
loading was also done. The patient's seizure activity
resolved, and no further seizure activity was noted
throughout the remainder of her stay. Likely etiology was
hypoglycemic seizure.
8. PROPHYLAXIS ISSUES: The patient was maintained on
heparin subcutaneously.
9. CODE STATUS ISSUES: The patient was made do not
resuscitate/do not intubate and subsequently comfort measures
only.
10. ACCESS ISSUES: The patient had a right internal jugular
and left arterial line placed on [**10-12**].
CONDITION AT DISCHARGE: The patient expired on [**2123-10-14**] at 12:08 a.m.
DISCHARGE STATUS: None.
FINAL DIAGNOSES:
1. Hypotension.
2. Hypothermia.
3. Bradycardia.
4. Anemia.
5. Hypothyroidism.
6. Gastroesophageal reflux disease.
7. Colon polyps.
8. Rheumatoid arthritis.
9. Chronic renal failure.
10. Falls.
11. Seizure.
MEDICATIONS ON DISCHARGE: None.
DISCHARGE INSTRUCTIONS/FOLLOWUP: None.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Last Name (NamePattern1) 9622**]
MEDQUIST36
D: [**2124-1-18**] 08:30
T: [**2124-1-18**] 21:00
JOB#: [**Job Number 53996**]
|
[
"0389",
"53081",
"4019",
"2449",
"2859"
] |
Admission Date: [**2137-10-9**] Discharge Date: [**2137-10-23**]
Date of Birth: [**2062-1-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Transfer from [**Hospital3 **]- unresponsive, hypotensive
Major Surgical or Invasive Procedure:
1. Central Line Placement and Removal
2. Tracheostomy
3. PEG placement
4. EGD
5. Colonoscopy
History of Present Illness:
75 y/o female with h/o Breast Ca s/p mastectomy, multiple
episodes of PNA with "lung scaring", with several weeks of cough
and sputum production, saw PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 23**] on Monday, for
cough, SOB, given azithromycin taken for one day before
presentation. At 11 AM on the day before admission patient found
to be in mild resp distress at home by grandson. [**Name (NI) **] that day
found to be in severe resp distress, with confusion and
disorientation. Brought to [**Hospital3 **] for altered mental
status. There found to have resp distress, elevated BNP to 1367,
elevated trop I to 5.62, transient lateral ST depressions, WBC
14.4 with 61% bands, Cr 3.8. Treated with Vanco, Levo, Gent.
Intubated. CT head negative for bleed. Abd CT showed trace
amount of fluid in upper abd, stranding around colon at hepatic
flexure, diverticular disease. Transfered from [**Hospital3 3583**]
on Dopamine by peripheral IV.
.
Here unresponsive, on vent. Blood Gas 7.22/55/414. Right IJ
placed. BP 68/42 off dopamine. Levophed started. Pupils 2mm and
nonreactive. T 99.2. Lactate 3.8. Given Ceftriaxone. WBC 8.3. Cr
3.1. AST/ALT markedly elevated. Ck 260, CK-MB 14, index 5.4,
Trop 0.70. EKG with nonspecific ST/T wave changes in V1, V2. ST
depression in II. Received 3L NS.
Past Medical History:
h/o Breast Ca S/P mastectomy, no chemo or radiation
PNA-last epiosode 6-7 years ago
Interstitial Lung Disease
s/p CCY
Social History:
SOCIAL: Non smoker
Family History:
Unknown
Physical Exam:
Vitals T 95.4 BP 131/83(on levophed) in ED 68/42 off pressors HR
77 RR 20 Sat 100% on CMV 500/20 PEEP 5 FiO2 .50
Tanned appearance. Unarousable, not reactive to sternal rub,
withdraws to noxious stimuli (nailbed pressure)
Pupils 1mm b/l and minimally reactive
No LAD, good carotid pulses
Lungs with crackles b/l over axilla and diffuse rhonchi
Abd, soft, non distended, no masses, minimal bowel sounds
No peripheral edema, 1+ DP pulses, toes upgoing B/L. Absent
reflexes throughout
Pertinent Results:
ADMISSION LABS:
[**2137-10-9**] 03:45AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.4* Hct-31.4*
MCV-90 MCH-30.0 MCHC-33.2 RDW-14.5 Plt Ct-149*
[**2137-10-9**] 03:45AM BLOOD Neuts-83* Bands-8* Lymphs-2* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2137-10-9**] 03:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL
[**2137-10-9**] 01:00PM BLOOD Fibrino-487* D-Dimer-6886*
[**2137-10-9**] 01:00PM BLOOD FDP-40-80
[**2137-10-9**] 03:45AM BLOOD Glucose-268* UreaN-50* Creat-3.1* Na-128*
K-4.2 Cl-93* HCO3-20* AnGap-19
[**2137-10-9**] 03:45AM BLOOD ALT-4675* AST-[**Numeric Identifier 68244**]* CK(CPK)-260*
AlkPhos-117 Amylase-197* TotBili-2.1*
[**2137-10-9**] 03:45AM BLOOD Lipase-114*
[**2137-10-9**] 03:45AM BLOOD CK-MB-14* MB Indx-5.4
[**2137-10-9**] 03:45AM BLOOD cTropnT-0.70*
[**2137-10-9**] 08:25AM BLOOD CK-MB-17* MB Indx-6.4* cTropnT-0.72*
[**2137-10-9**] 03:00PM BLOOD CK-MB-16* MB Indx-7.9* cTropnT-0.63*
[**2137-10-9**] 10:21PM BLOOD CK-MB-14* MB Indx-8.4* cTropnT-0.53*
[**2137-10-10**] 03:56AM BLOOD CK-MB-12* MB Indx-7.1* cTropnT-0.54*
[**2137-10-9**] 03:45AM BLOOD Calcium-7.5* Phos-4.6* Mg-2.0
[**2137-10-9**] 08:25AM BLOOD calTIBC-173* Ferritn-GREATER TH TRF-133*
[**2137-10-9**] 01:00PM BLOOD Ammonia-94*
[**2137-10-9**] 03:45AM BLOOD Cortsol-351.7*
[**2137-10-9**] 08:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2137-10-9**] 01:00PM BLOOD AMA-NEGATIVE Smooth-POSITIVE -
[**2137-10-9**] 03:45AM BLOOD CRP-GREATER TH
[**2137-10-9**] 08:25AM BLOOD HCV Ab-NEGATIVE
[**2137-10-9**] 04:22AM BLOOD Lactate-3.8*
.
ABDOMEN U.S. (PORTABLE) [**2137-10-9**] 1:10 PM
DUPLEX DOPP ABD/PEL PORT; ABDOMEN U.S. (PORTABLE)
Reason: Please assess liver and remainder abdomen, please assess
por
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with sepsis, shock liver
REASON FOR THIS EXAMINATION:
Please assess liver and remainder abdomen, please assess portal
and hepatic veins with doppler flow studies
INDICATION: 75-year-old woman with sepsis and shock liver.
PORTABLE DUPLEX OF THE ABDOMEN: This is a limited study due to
patient's intubated status. The gallbladder is not visualized.
The liver shows normal echogenicity with no focal masses. The
intrahepatic branches of the hepatic artery and hepatic vein are
patent. The main portal vein is patent. The intrahepatic portal
veins are difficult to assess. The pancreas is poorly visualized
but shows no gross abnormality. The right kidney measures 12 cm.
There is a cyst in the superior portion of the right kidney
measuring 1.2 x 1.1 x 1.2 cm. The left kidney measures 12 cm,
and there is a cyst in the mid to upper pole measuring 2.4 x 1.8
x 1.4 cm. The aorta is of normal caliber. The spleen is
unremarkable.
IMPRESSION:
1. Patent main portal vein and hepatic artery and vein. 2.
Bilateral renal cysts.
.
DUPLEX DOPP ABD/PEL PORT [**2137-10-9**] 1:10 PM
DUPLEX DOPP ABD/PEL PORT; ABDOMEN U.S. (PORTABLE)
Reason: Please assess liver and remainder abdomen, please assess
por
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with sepsis, shock liver
REASON FOR THIS EXAMINATION:
Please assess liver and remainder abdomen, please assess portal
and hepatic veins with doppler flow studies
INDICATION: 75-year-old woman with sepsis and shock liver.
PORTABLE DUPLEX OF THE ABDOMEN: This is a limited study due to
patient's intubated status. The gallbladder is not visualized.
The liver shows normal echogenicity with no focal masses. The
intrahepatic branches of the hepatic artery and hepatic vein are
patent. The main portal vein is patent. The intrahepatic portal
veins are difficult to assess. The pancreas is poorly visualized
but shows no gross abnormality. The right kidney measures 12 cm.
There is a cyst in the superior portion of the right kidney
measuring 1.2 x 1.1 x 1.2 cm. The left kidney measures 12 cm,
and there is a cyst in the mid to upper pole measuring 2.4 x 1.8
x 1.4 cm. The aorta is of normal caliber. The spleen is
unremarkable.
IMPRESSION:
1. Patent main portal vein and hepatic artery and vein. 2.
Bilateral renal cysts.
.
CT HEAD W/O CONTRAST [**2137-10-9**] 6:12 AM
CT HEAD W/O CONTRAST
Reason: UNRESPONSIVE. ? ICH
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with unresponsiveness
REASON FOR THIS EXAMINATION:
eval for ICH
CONTRAINDICATIONS for IV CONTRAST: creat
INDICATION: Unresponsiveness.
NONCONTRAST HEAD CT: No prior for comparison. Patient is
markedly tilted within the scanner gantry.
FINDINGS: No hydrocephalus, shift of normally midline
structures, intra- or extra- axial hemorrhage, or acute major
vascular territorial infarct is identified. Lacunar infarcts,
chronic in age, are noted in both basal ganglia and subinsular
cortices reflects chronic microvascular infarction. A few subcm.
areas of low density are noted in the right temporal lobe- these
may represent enlarged sulci v. chronic cortical infarcts.
The patient is intubated. No fractures are seen. There is a
small, probable retention cyst in the right maxillary sinus,
with opacification of a few ethmoid air cells, and mild mucosal
thickening in the frontal sinus. Mastoid air cells are poorly
pneumatized and aerated. Sphenoid sinus shows moderate mucosal
thickening. There is fluid and aerosolized secretions in the
nasopharynx and oropharynx, likely due to intubation.
IMPRESSION: No acute intracranial hemorrhage or mass effect. See
above report for additional findings.
Sinusitis, likely chronic in age.
.
Cardiology Report ECHO Study Date of [**2137-10-10**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function.
BP (mm Hg): 117/67
HR (bpm): 72
Status: Inpatient
Date/Time: [**2137-10-10**] at 09:50
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W052-0:00
Test Location: West MICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.1 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: 3.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: *0.23 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Aorta - Arch: *3.1 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 0.86
Mitral Valve - E Wave Deceleration Time: 255 msec
TR Gradient (+ RA = PASP): *>= 33 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild
global LV
hypokinesis. No resting LVOT gradient.
RIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV
systolic function.
[Intrinsic RV systolic function likely more depressed given the
severity of
TR]. Abnormal septal motion/position consistent with RV
pressure/volume
overload.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter. Mildly
dilated aortic arch.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR. LV inflow
pattern c/w impaired relaxation.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Significant PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is elongated. The right atrium is moderately
dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size
is normal. There is mild global left ventricular hypokinesis.
The right
ventricular cavity is dilated. Right ventricular systolic
function is
borderline normal. [Intrinsic right ventricular systolic
function is likely
more depressed given the severity of tricuspid regurgitation.]
There is
abnormal septal motion/position consistent with right
ventricular
pressure/volume overload. The aortic arch is mildly dilated. The
aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen.
Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
.
GI BLEEDING STUDY [**2137-10-20**]
GI BLEEDING STUDY
Reason: BRBPR AND RLQ PAIN ? SOURCE OF BLEED
RADIOPHARMECEUTICAL DATA:
16.4 mCi Tc-[**Age over 90 **]m RBC ([**2137-10-20**]);
HISTORY: Recent bright red blood per rectum, in the setting of
sepsis and
multiorgan failure in the MICU.
DECISION:
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 minutes
were obtained. A left lateral view of the pelvis was also
obtained.
Blood flow images are unremarkable. The iliac arteries are
ectactic.
Dynamic blood pool images show no definite early bleeding on
images obtained
over 0-60 minutes. Subsequently, after repositioning the patient
over a [**10-6**]
minute period, imaging shows evidence of hemorrhage in the
sigmoid colon over
the subsequent hour.
IMPRESSION: Late dynamic images demonstrating extravasation into
the sigmoid
colon, but no evidence of brisk bleeding within the first hour.
This is most
suggestive of a slow intermittent hemorrhage in the sigmoid
colon. These
findings were discussed with Dr. [**First Name (STitle) **] from the MICU shortly
after the study.
.
EKG
Cardiology Report ECG Study Date of [**2137-10-17**] 8:00:54 PM
Sinus rhythm. Atrial ectopy. There is a late transition which is
probably
normal. Compared to the previous tracing atrial ectopy is now
present.
.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **]
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on WED [**2137-10-23**]
10:10 AM
Name: [**Known lastname **], [**Known firstname **] E Unit No: [**Numeric Identifier 68245**]
Service: Date: [**2137-10-21**]
Date of Birth: [**2062-1-27**] Sex: F
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 19187**]
ASSISTANT: [**Last Name (NamePattern4) **], MD
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Respiratory failure.
OPERATION: Percutaneous gastrostomy tube placement.
INDICATION: Nutrition.
DESCRIPTION OF PROCEDURE: After informed consent was
obtained, under general anesthesia, and with the patient
already on Zosyn for antibiotic prophylaxis, she was placed
at a 45 degrees angle. The gastroscope was inserted into the
oral cavity and passed through the esophagus into the
stomach. The mucosa was entirely normal with no obvious
lesion. The stoma was insufflated. The skin over the left
upper quadrant was palpated and a sharp indentation with 1
finger was seen. The skin was prepped with chlorhexidine and
draped in a typical sterile fashion. 1% lidocaine was used
for local anesthesia. An Angiocath was inserted under direct
vision and a snare was lassoed and pulled back through the
esophagus and into the oral cavity. A 20-French PEG tube was
loaded and pulled back through the oral cavity into the
esophagus and through the abdominal wall. The gastroscope was
reinserted to confirm excellent placement with a mushroom cap
against the abdominal wall cavity. Bolsters were placed at 3
cm to secure the PEG tube.
.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **]
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on WED [**2137-10-23**]
10:41 AM
Name: [**Known lastname **], [**Known firstname **] E
Unit No: [**Numeric Identifier 68245**]
Service:
Date: [**2137-10-22**]
Date of Birth: [**2062-1-27**]
Sex: F
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 19187**]
ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (un) 68246**]
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Respiratory failure.
PROCEDURE: Percutaneous tracheostomy tube placement.
INDICATIONS FOR PROCEDURE: Respiratory failure.
DESCRIPTION OF PROCEDURE: After informed consent was
obtained, under general anesthesia, the patient's neck was
prepped with chlorhexidine, draped in the usual fashion. The
first tracheal ring was identified. Local anesthesia using
1.5 Xylocaine with epinephrine was used to anesthetize the
area. A 2 cm horizontal skin incision was performed using a
scalpel. Using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1356**] clamp we dissected the subcutaneous
tissue until visualizing the tracheal rings. The 18 gauge
needle with an attached syringe with lidocaine in the trachea
was penetrated under bronchoscopic visualization. A guidewire
was inserted through the needle, after which the needle was
withdrawn. A punch dilator was inserted and using a blue
Rhino kit, the trachea was dilated, after which an 8 Portex
tracheostomy tube was inserted. The bronchoscope was
introduced through the tracheostomy tube and midline position
was confirmed with adequate volumes on mechanical ventilator.
The tracheostomy tube was connected to the ventilator and was
secured to the neck with a Velcro skin tie.
.
DISCHARGE LABS:
[**2137-10-23**] 04:40AM BLOOD WBC-15.0* RBC-3.52* Hgb-10.6* Hct-31.1*
MCV-88 MCH-30.2 MCHC-34.2 RDW-15.8* Plt Ct-172
[**2137-10-22**] 03:57AM BLOOD PT-15.2* PTT-33.9 INR(PT)-1.4*
[**2137-10-23**] 04:40AM BLOOD Glucose-104 UreaN-85* Creat-3.7* Na-138
K-3.8 Cl-104 HCO3-24 AnGap-14
[**2137-10-20**] 03:53AM BLOOD ALT-123* AST-21 LD(LDH)-227 AlkPhos-74
Amylase-271* TotBili-0.3
[**2137-10-23**] 04:40AM BLOOD Calcium-8.4 Phos-4.9* Mg-1.9
Brief Hospital Course:
75 y/o female with PMH breast ca s/p R sided mastectomy,
interstitial lung disease, h/o pna, presented w/ 1 week h/o
cough, was intubated at [**Hospital3 **], and transferred to
[**Hospital1 18**] at family's request, septic with hypothermia, hypotensive
on pressors, and with shock liver and renal failure.
.
# Respiratory Failure: She was intubated at [**Hospital3 3583**] for
hypoxic respiratory failure. Her CT scan suggests interstitial
lung disease. ECHO showed normal ejection fractio. She was
intubated from admission on [**2137-10-9**], and had a tracheostomy
placed on [**2137-10-22**]. Susupected cause for decompensation was
underlying pneumonia . Sputum cultures were negative. Viral
Bronchoalveolar lavage showed no increase number of macrophages
or eosinophils. She completed a 14 day course of Vancomycin and
Zosyn for empiric pneumonia. Prednisone 1 mg/kg was given for
treatment of possible cryptogenic organizing pneumonia. Patient
became progressively more hypercapnic and had a respiratory
acidosis soon after trying to wean from Assist /Control
Mechanical Ventilation and placed on PS ventilation. For this
reason, a tracheostomy tube was placed on [**2137-10-22**] (day # 14 of
intubation) with no complications. She tolerated BIPAP with
optimal titration parameters between 15/5 cmH2O. She should
continue Prednisone 1 mg/kg for 4 weeks and her outpatient
Pulmonologist should taper Prednisone to 0.5 mg/kg after this
period to continue for at least 6-8 weeks total. She will need
Mechanical Ventilation at rehab facility.
Current vent settings are BiPAP with pressure support of 10 and
PEEP of 5 with .40 FiO2.
.
# Sepsis: She presented with hypotension, hypothermia (T 95.0 on
admission), leukocytosis with bandemia, end-organ failure (shock
liver c AST/ALT > [**Numeric Identifier 2249**], ARF). Initially required pressors (on
levophed which were discontinued within 24 hours. Likely
etiologies included infectious- PNA considering UA was not
abnormal and a CT scan of the abdomen done at an OSH did not
show abscess , diverticulitis, perforation, mesenteric ischemia.
She was given broad spectrum antibiotics vancomycin and zosyn
to cover infectious etiologies. Urine, sputum, and blood
cultures did not grow out any organisms. She completed a 14 day
course of antibiotics on [**2137-10-23**].
.
# Leukocytosis/C Diff Infection: Patient had an elevated WBC
count of 12 K c 10 % bands on admission . She received full
course of broad spectrum atb. After D # 4 of admission WBC
peaked at [**Numeric Identifier **] despite atb treatment. Two C diff toxin A were
negative but a second C diff toxin B came back positive. She
was started on Flagyl [**2137-10-13**] and should complete a 14 day
course on [**2137-10-26**].
.
# ARF: She has no history of underlying renal disease. She
presented with elevated Cr of 3 which peaked to 7 during
admission. UA showed muddy brown casts. Urine lytes c/w ATN. US
showed normal sized kidneys SHe had oliguria which resolved
with time and her urine output is back to baseline. She had also
received Gentamycin and contrast at the outside hosptial, which
may have contributed. There was no need for dialysis.
Creatinine was 3.6 on discharge , with normal Urine output. She
should continue on phosphate binders until renal function
returns to baseline.
.
# Altered mental status: Presented intubated, non-responsive.
Likely Toxic/metabolic (renal failure with uremia, hepatic
encephalopathy, infectious) vs Medication effect given renal
failure and transaminitis as she received sedating medications
at OSH. She regained responsiveness and was alert and oriented
throughout most of her admission.
.
# Elevated Amylase/Lipase: Amylase/lipase trending up after tube
feeds initiated. Enxymes came back to normal after improvement
of renal function.
.
# Transaminitis: Presented with highly elevated LFT's, Bili,
LDH. Likely due to shock liver. Acetamenophen level not
elevated. Hepatitis serologies, EBV, CMV negative for acute
infection. No evidence of portal vein or hepatic vein
thrombosis on U/S. Anti-SM Ab positive. Enzymes trended down to
normal on discharge.
.
# Metabolic Acidosis: Patient had elevated anion gap on
admission . AFter fluid resuscitation her metabolic acidosis
turned was worsened by respiratory acidosis. Both improved
after treatment of sepsis and lung infection.
.
# Diverticular Bleed: Patient had massive hematochezia on HD #
11. Hc remained stable near 28-32 %.EGD wnl. Lower GI scope with
diverticulosis and evidence of earlier bleeding. She received 2
U PRBC. HCT remained stable during rest of hospitalization.
She should avoid NSAIDs and aspirin. High fiber diet
recommended.
.
# NSTEMI: Pt w/out known h/o cardiac disease. Had demand
ischemia in setting of sepsis, with elevated trop due to renal
failure. Echo showed EF 50% with large LA and diated RV with Mod
TR and Significant PR, PAP 33. ASA was started due to
coagulopathy on admission and later GI bleed. [**Month (only) 116**] start ASA in
th future if no further episodes of bleeding.
.
# Bradycardia: Patient's HR ranged from 40 -60 after sepsis
treated. Patient was never symptomatic. EKG without conduction
abnormalities.
.
# Anemia: Normocytic. Iron studies show elevated iron and
ferritin levels, low TIBC.
.
# Nutrition: She has a PEG placed on [**2137-10-22**]. She should get
Nepro full strength @ 30 cc /h.
.
#Communication: Daughter [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **]- H [**Telephone/Fax (1) 68247**], C [**Telephone/Fax (1) 68248**]. The patient has a hearing aid and wears glasses to
comunicate.
Medications on Admission:
Unknown
Discharge Medications:
1. Metronidazole 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID (3
times a day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Prednisone 20 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY
(Daily).
4. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Last Name (STitle) **]: [**5-30**]
Puffs Inhalation Q4H (every 4 hours).
6. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (3) **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
7. Calcium Acetate 667 mg Capsule [**Month/Day (3) **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): can stop once renal function
back to baseline.
8. Insulin Regular Human 100 unit/mL Solution [**Month/Day (3) **]: Insulin by
sliding scale while on Prednisone units Injection QACHS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY
1. Multifactorial Respiratory Distress from etiologies including
idiopathic pulmonary fibrosis, pneumonia, and hypercarbic
respiratory failure requiring tracheostomy
2. Gastrointestinal Bleed
3. C. Diff colitis
4. Malnutrition
5. Sepsis with multiple organ failure, improved
SECONDARY
1. Severe restrictive lung disease
2. Breast Cancer s/p Mastectomy
Discharge Condition:
afebrile, hemodynamically stable, comfortable, with tracheostomy
and PEG
Discharge Instructions:
1. Please take all medications as prescribed
2. Attend all follow-up appointments
3. If you develop fevers, chills, nausea, vomiting,
gastrointestinal bleeding, or any other concerning
signs/symptoms, please contact your provider or report to the
Emergency Department
4. Your prednisone is being tapered - please follow instructions
on medications list
Followup Instructions:
1. Please follow-up with the respiratory care team at rehab
regarding a Passy-Muir valve
2. Please follow up with a pulmonologist for Interstitial lung
disease.
3. Please follow up with primary care doctor.
Completed by:[**2137-10-23**]
|
[
"0389",
"5845",
"51881",
"486",
"2762",
"78552",
"4280",
"99592",
"42789",
"4019"
] |
Admission Date: [**2147-6-19**] Discharge Date: [**2147-7-6**]
Service: SURGERY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Perforated Duodenal Ulcer
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Repair of perforated duodenal ulcer with [**Location (un) **] patch.
3. Small-bowel resection with primary anastomosis.
4. Placement of a feeding jejunostomy tube.
History of Present Illness:
This 83-year-old gentleman who presented with acute onset of
upper abdominal pain with focal peritonitis. A CAT scan was
performed and showed clear-cut free air around the liver with
what looked to be a direct communication into the
duodenum. He was taken to the surgical intensive care unit and
was in surprisingly good physiologic shape but resuscitated
prior to the operation. He was taken to the operating room
within a few hours of the CAT scan.
Past Medical History:
1. HTN
2. AAA repair - 90'
3. BPH
Social History:
Formerly in Army now retired. Smokes 1 ppd but quit 13 years
ago. Occasional EtOH use. no drugs
Lives independently, active
Family History:
Mother had unknown CA. Father had hypertension
Physical Exam:
VS: Afebrile, 80, 135/45, 27, 98% 5L
Gen: Alert, oriented x 3, grimacing in pain.
CV: RRR, no M/R/G
Resp: CTA bilat.
Abd: midline scar from AAA repair; normal to percussion, tender
to epigastric on palpation, soft, no rebound tenderness or
peritoneal signs.
Ext: no edema, +1 pulses bilat.
Pertinent Results:
[**2147-6-19**] 07:35AM BLOOD WBC-9.7 RBC-4.21* Hgb-13.2* Hct-36.4*
MCV-87 MCH-31.4 MCHC-36.3* RDW-13.6 Plt Ct-178
[**2147-6-22**] 05:31AM BLOOD WBC-11.7* RBC-3.43* Hgb-10.8* Hct-30.7*
MCV-89 MCH-31.6 MCHC-35.3* RDW-13.4 Plt Ct-136*
[**2147-6-22**] 05:31AM BLOOD Glucose-117* UreaN-18 Creat-1.2 Na-139
K-4.0 Cl-108 HCO3-25 AnGap-10
[**2147-6-19**] 07:35AM BLOOD ALT-11 AST-22 CK(CPK)-157 AlkPhos-66
Amylase-195* TotBili-0.6
[**2147-6-19**] 07:35AM BLOOD Lipase-263*
[**2147-6-19**] 07:35AM BLOOD cTropnT-<0.01
[**2147-6-22**] 05:31AM BLOOD Calcium-8.1* Phos-2.1* Mg-1.7
.
CHEST (PORTABLE AP) [**2147-6-19**] 8:15 AM
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with abd pain, free air on ct
REASON FOR THIS EXAMINATION:
eval for free air and preop,
INDICATION: 83-year-old man with abdominal pain. Free air on
recent CT, preop.
IMPRESSION:
1. Pneumoperitoneum.
2. Bibasilar atelectasis.
.
CTA ABD W&W/O C & RECONS [**2147-6-19**] 7:39 AM
IMPRESSION:
1. Gastric antral perforation, likely due to underlying ulcer,
with moderate amount of free air within the abdomen and free
fluid.
2. Hutch diverticulum of the urinary bladder containing a small
stone.
3. Uncomplicated small and large bowel containing ventral
hernias as described.
4. Bilateral fat-containing inguinal hernias containing a small
amount of fluid on the left side.
5. Extensive degenerative changes of the aorta and its branches
with intraabdominal thrombus and calcified plaques and small
ulcers. The [**Female First Name (un) 899**] is occluded at its origin. Mild fusiform
dilatation of the left common iliac artery.
6. Diverticulosis without evidence of diverticulitis.
7. Severe degenerative changes of the lumbar spine with
spondylolisthesis grade I at the level of L1-2, L3-4, and L4-5
and compression deformities of L1 and L4, age indeterminate.
.
Cardiology Report ECG Study Date of [**2147-6-19**] 8:26:56 AM
Sinus rhythm. Low QRS voltage in limb leads. Possible inferior
myocardial
infarction. Compared to previous tracing of [**2144-4-18**] no
diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 132 94 [**Telephone/Fax (2) 95527**] -13 26
.
UGI AIR W/KUB [**2147-6-23**] 9:57 AM
IMPRESSION: No evidence of leaks or extravasation of contrast
material through the duodenal patch. The study is limited
because the patient ws uable to turn prone for appropriate
evaluation of the anterior wall.
[**2147-6-26**] 09:21PM BLOOD WBC-10.4 RBC-3.49* Hgb-10.7* Hct-31.5*
MCV-90 MCH-30.7 MCHC-34.0 RDW-14.0 Plt Ct-213#
.
**FINAL REPORT [**2147-6-23**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2147-6-23**]):
POSITIVE BY EIA.
.
[**2147-6-27**] 10:43 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2147-6-28**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2147-6-28**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
CT ABDOMEN W/CONTRAST [**2147-6-29**] 4:38 PM
IMPRESSION:
1. Status post duodenal perforation withsurgical repair and
segmental small bowel resection with post- operative fat
stranding in the upper abdomen and small amount of fluid
anterior to the liver, without evidence of rim- enhancing or
gas-containing focal fluid collection to suggest abscess. No
residual free air.
2. Large bladder diverticulum with air and air in the urinary
bladder. Please correlate clinically with the history of recent
intervention.
3. Diverticulosis.
4. Elevated left hemidiaphragm with bibasilar atelectasis.
5. Gynecomastia.
6. Compression deformities of the lumbar spine as described
above.
.
CHEST (PA & LAT) [**2147-7-5**] 3:19 PM
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with crackles on exam and coughing
REASON FOR THIS EXAMINATION:
? pneumonia, acute process
INDICATION: Crackles on exam and coughing, query pneumonia or
acute process.
CHEST TWO VIEWS: Cardiac size, mediastinal and hilar contours
are unchanged. There is a persistent tortuous aorta that
apparently indents the trachea; the lateral view does not
demonstrate any aneurysmal aortic dilatation.
Cardiophrenic and costophrenic angles are clear. There is no
pneumothorax or pleural effusion. There is mild left basilar
atelectasis. There is persistent elevation of the left
hemidiaphragm. No gross skeletal abnormality.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
He was admitted on [**2147-6-19**] and went to the OR on [**2147-6-19**] for:
1. Exploratory laparotomy.
2. Repair of perforated duodenal ulcer with [**Location (un) **] patch.
3. Small-bowel resection with primary anastomosis.
4. Placement of a feeding jejunostomy tube.
Duodenal Ulcer: He was NPO with IVF and a NGT. The NGT was left
in place and he had a tube study performed on POD 4. This showed
No evidence of leaks or extravasation of contrast material
through the duodenal patch. A CT on [**6-29**] showed no focal fluid
collection to suggest abscess.
His incision was C/D/I. The staples were D/C'd prior to
discharge. The J-tube was secure and in place.
HELICOBACTER PYLORI ANTIBODY TEST was positive and he was
started on Flagyl and Clarithromycin, and Protonix [**Hospital1 **].
Diarrhea: He began having frequent, large loose stool on POD
[**5-12**]. C.diff was checked and was negative x 3. He was volume
depleted due to the severe diarrhea. Once the tubefeedings were
stopped, his diarrhea slowed.
Dehydration: Due to the large volume diarrhea, he had some
dehydration resulting in hypernatremia, hyperchloremia, and a
bump in his BUN/Cr. He continued on IV fluid and his PO intake
increased. Eventually, his diarrhea slowed. Although his C.diff
cultures were negative, we assumed he was positive and the
Flagyl that was started for the H.Pylori seemed to also be
effective for the diarrhea.
Pain: He complained of abdominal pain and was refusing pain meds
including PR Tylenol. Once on a PO diet, he was taking Tylenol
and Oxycodone.
FEN: He was started on clears on POD 5. He was also started on
tubefeedings and these were slowly advanced. He began having
severe diarrhea, possibly related to the tubefeedings. The rate
was slowed and then the tubefeedings were discontinued. His diet
was advanced, but he did not have much of an appetite due to the
diarrhea. We encouraged an increase in his diet and he required
two IV fluid bolus for low urine output and then continuous IV
fluid to correct his dehydration.
His IV fluids were continued while his creatinine improved and
was 1.4 on [**2147-7-5**]. His appetite was poor and calorie counts
revealed <600kcal/day.
We started him on trophic tubefeedings again on POD 15 and
slowly advanced these.
We recommend tubefeeding at 30ml/hr as a supplement to his
regular PO diet. If he is taking in adequate calories,
tubefeedings can be tapered and cycled at night as to not
suppress his appetite.
We also do not want to run the tubefeedings at a high rate as
this may result in his return of diarrhea.
Medications on Admission:
Doxazosin 1'', ASA 325'
Discharge Medications:
1. Outpatient Lab Work
Chem 10;
Creatinine - Adjust Flagyl PRN
2. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO twice a day: Twice a day for two weeks, then switch to
once/day.
4. Acetaminophen 160 mg/5 mL Solution Sig: 320-640 mg PO TID (3
times a day) as needed for pain.
5. Oxycodone 5 mg/5 mL Solution Sig: 1.25 mg PO BID (2 times a
day) as needed for pain.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for BP<100, HR<60 .
7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
8. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily).
9. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
10. Promethazine 25 mg/mL Solution Sig: 12.5 mg Injection Q8H
(every 8 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Center
Discharge Diagnosis:
Perforated Duodenal Ulcer
Multiple enterotomies from dense adhesions to abdominal wall
Diarrhea
Dehydration (Hypernatremia, hyperchloremia)
Malnutrition
Discharge Condition:
Good
Tolerating a Diet
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 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 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) **] in [**2-5**] weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment
Completed by:[**2147-7-6**]
|
[
"2760",
"4019"
] |
Admission Date: [**2187-5-15**] Discharge Date: [**2187-5-22**]
Date of Birth: [**2148-11-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
right lower extremity pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 38 year-old man with a history of recent possible
pulmonary embolism, cellulitis, type I diabetes, renal
insufficiency who presents with 2-3 days of right lower
extremity pain and edema. Says it feels similar to when he last
had cellulitis in [**Month (only) 547**]. Has also noticed increased swelling.
Minimal change in color. Has felt feverish over past few days.
.
No water, insect or animal exposures or bites. No recent
travel. No trauma to the area.
Hospital admission in [**Month (only) 547**] of this year for lower extremity
cellulitis. During this admission, hypoxic respiratory failure
thought to be due to possible PE vs. aspiration pneumonia vs.
hosp acquired pneumonia. Plan is for six months
anti-coagulation.
.
In ER given vancomycin, unasyn for cellultiis, morphine for pain
control, aspirin, NPH 62 units at 4:30 AM. Blood cultures sent.
.
On ROS, reports intermittent shortness of breath associated with
pleuritic chest pain occurring every few days and lasting for a
few minutes. Not associated with wheezing.
Past Medical History:
1. Presumed PE diagnosed in [**2187-2-18**] based on V/Q scan in
setting of infiltrates on CXR, currently on coumadin with plan
for 6 months of treatment--etiology attributed to immobility
secondary to lle swelling/cellulitis
2. Cellulitis
3. Type 1 diabetes,
4. hypercholesterolemia
5. hypertension
6. obesity
7. asthma
8. renal insufficiency
9. chronic tobacco use.
Social History:
He lives in [**Location 686**] with his wife, their 11 year-old son and
two step sons. Currently not smoking, former long history of
smoking. Occasional alcohol, no ivdu.
Family History:
Diabetes
Physical Exam:
VS: Temp:100.1 BP: 136/81 HR:105 RR:16 96%rm airO2sat
.
general: pleasant, discomfort secondary to leg pain, no distress
HEENT: PERLLA, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: obese, nd, +b/s, soft, nt, no masses
extremities: right lower extremity with 2+edema, tender over
tibia, increased area of pigmentation over front of tibia-->area
marked,
left lower extremity with 1+edema, symmetric calor
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout.
vasc: 2+ dp pulses bilaterally
Pertinent Results:
Admit labs;
[**2187-5-14**] 08:40PM WBC-14.8* RBC-4.33* HGB-12.3* HCT-34.1*
MCV-79* MCH-28.3 MCHC-36.1* RDW-14.8
[**2187-5-14**] 08:40PM NEUTS-80.7* LYMPHS-14.7* MONOS-3.4 EOS-1.1
BASOS-0.2
[**2187-5-14**] 08:40PM PLT COUNT-295
.
.
[**2187-5-14**] 08:40PM GLUCOSE-216* UREA N-39* CREAT-2.2* SODIUM-136
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-27 ANION GAP-13
.
[**2187-5-14**] 08:40PM PT-30.0* PTT-34.3 INR(PT)-3.2*
.
Discharge labs:
[**2187-5-22**] 06:50AM BLOOD WBC-10.9 RBC-3.66* Hgb-10.2* Hct-29.4*
MCV-80* MCH-28.0 MCHC-34.8 RDW-14.3 Plt Ct-407
[**2187-5-18**] 07:55PM BLOOD Neuts-71.8* Lymphs-19.1 Monos-7.3 Eos-1.5
Baso-0.3
[**2187-5-22**] 06:50AM BLOOD PT-26.6* PTT-33.3 INR(PT)-2.7*
[**2187-5-22**] 06:50AM BLOOD Glucose-146* UreaN-43* Creat-2.4* Na-138
K-4.7 Cl-100 HCO3-31 AnGap-12
[**2187-5-20**] 04:19AM BLOOD ALT-47* AST-35 AlkPhos-361* TotBili-0.5
..
..
Echo:[**2187-5-21**]
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Transmitral and
tissue Doppler imaging suggests normal diastolic function, and a
normal left ventricular filling pressure (PCWP<12mmHg). The
aortic valve leaflets appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space
which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2187-2-20**], the
findings are consistent with normal diastolic function and
normal left ventricular filling pressures (not fully evaluated
on prior study).
..
v/Q scan:
IMPRESSION: Normal lung perfusion scan. Compared with the
prior study, there is no significant interval change.
..
Tib/fib films:
IMPRESSION: No gas is noted within the soft tissue. Prominent
soft tissue swelling of the calf region is unchanged compared to
the prior study.
..
[**5-20**] CXR: FINDINGS: Comparison is made to the chest CT from
[**2187-2-21**], and plain film radiograph from [**2187-5-19**].
Cardiac silhouette demonstrates left ventricular prominence,
which is stable. The right lung is clear. The left lung
demonstrate some vague opacity in the left retrocardiac region,
however, this may be secondary to atelectasis or due to vessel
crowding from poor inspiratory effort. No definite
consolidation is identified. There are no signs of overt
pulmonary edema.
Brief Hospital Course:
Assessment and Plan: This is a 38 year old man with a history of
recent possible pulmonary embolism, cellulitis, type I diabetes,
renal insufficiency who presentsed with right lower extremity
pain/edema. The following issues were addressed on this
admission:
.
1)Right lower extremity pain/edema: Cellulitis: Patient
maintained on vancomycin/unasyn over the course of his admission
for first 6 days. (Got zosyn instead of unasyn for a few doses
after he spiked and had respiratory decompensation, please see
below). Switched to augmentin and remained afebrile with
improvement of cellulitis over the last two days of admission.
No evidence compartment syndrome other than pain. LENI negative
for dvt (already on coumadin) Anti-fungals maintained
throughout. No evidence of osteo on plain film. To complete 14
day total course of antibiotics, six more days of augmentin.
Patient has appointment in two days with Dr. [**Last Name (STitle) **] for
re-evaluation.
.
2)Fever: on antibiotics, vanc and unasyn on [**5-18**]. Multiple
blood cultures and urine cultures negative. Initially unasyn
broadened to zosyn and then antibiotics switched to augmentin on
HD#6. Afebrile on augmentin x2 days prior to discharge. Likely
from cellulitis. Blood cultures and urine cultures pending at
time of discharge.
.
2)Respiratory: History of OSA and asthma as well as recent
diagnosis of possible PE. Intermittent shortness of breath
reported on admission. Initially stable but patient with
decompensation/desaturation [**5-16**] and again [**5-18**] both in early AM
while sleeping. [**5-18**] event required ICU admission. Also febrile
at this time. Felt to be secondary to not being on his usual
home CPAP. Because of history of prior possible PE, V/Q scan
repeated and demonstrated no PE. Cardiac enzymes cycled and
negative, ECG without concerning changes, cxr unremarkable.
Echo checked and no evidence of heart failure.
.
3)Acute renal failure/CKD stage 3: Patient developed renal
failure in setting of fevere, hypoxia on [**5-18**]. Patient
hypovolemic, likely pre-renal. Ace, hctz held, patietn hydrated
and bp allowed to auto-regulate. patient's creatinine returned
to baseline of low 2's. Continuing to hold ace, hctz through
discharge, to be re-started at discretion of Dr. [**Last Name (STitle) **] and
[**Doctor Last Name 4920**]. Should have repeat chem-10 on [**5-24**]
Consider MRA to look for renal artery stenosis as outpatient.
SPEP/UPEP without concerning abnormalities.
.
4)Alkaline phosphatase elevation: should have repeat testing as
outpatient, no acute pathology noted.
.
5)Possible recent PE: On last admission, decision made to
maintain coumadin x 6 months. Maintained on coumadin throughout,
inr therapeutic. Discharged on 6mg to be taken [**5-22**] and [**5-23**] and
will need repeat INR on [**5-24**]. followed in [**Hospital 2786**]
clinic.
.
6)OSA: Initially not on home CPAP. Placed on home CPAP after
desats and hypoxia resolved. Has machine at home, agrees to
compliance. Will need pulmonary follow-up.
.
7)DM: continued outpatient insulin regimen. Low on AM of [**5-22**]
because patient did not eat full dinner. Knows to decrease
insulin if does not eat. Will take lower dose on [**5-22**] PM to
avoid low in Am. Has follow-up at [**Last Name (un) **] Diabetes.
.
8)Asthma: continued albuterol/atrovent/advair
.
9)Hypertension: continued lisinopril, diltiazem, hctz initially.
With renal failure lisinopril and hctz held and then hydralazine
initiated. Patient discharge [**Male First Name (un) **] diltiazem and hydralazine with
plan to re-initiate ace and hctz at discretion of Dr. [**Last Name (STitle) **]
and Heonig once creatinine re-checked. Off ace and hctz and on
hydralazine BP's generally 150's to 160's.
.
10)Hyperlipidemia: off statin given lft rise during last
hospital admission. Mild lft elevation again here. Needs
repeat lft's as outpatient.
.
11)Smoking cessation: maintained on wellbutrin.
.
GI prophylaxis: protonix
.
DVT prophylaxis:therapeutic on coumadin
.
Code:full throughout
.
Medications on Admission:
1. buproprion 100mg [**Hospital1 **]
2. diltiazem xr 180mg daily
3. advair
4. atrovent
5. albuterol
6. coumadin--varying dose, but currently 10qhs
7. hctz 50
8. lisinopril 40
9. Insulin--nph 62 qam, 52 q pm, sliding scale
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QHS (once a day (at bedtime)).
3. Warfarin 6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
take this dose until you are seen by Dr. [**Last Name (STitle) **].
4. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
Disp:*1 tube* Refills:*2*
5. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
7. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
8. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
unit Subcutaneous once a day: as directed
continue your current insulin dose, 62UNPH in AM and 52U NPH in
PM.
9. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a
day: continue this medication until you are re-started on your
other blood pressure medications.
Disp:*40 Tablet(s)* Refills:*0*
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
12. Outpatient [**Name (NI) **] Work
PT/PTT, Chem-10 to be done on [**2187-5-24**] when you see Dr. [**Last Name (STitle) **].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Cellulitis
2. Respiratory Failure
3. Acute Renal Failure
.
Secondary:
1. Obstructive Sleep Apnea
2. Type II DM with renal complications, controlled
3. CKD stage 3
4. Anemia
5. Hypertension
6. Hyperlipidemia
7. Transaminitis
8. Alkaline phosphatase elevation
9. Asthma
Discharge Condition:
Stable. Tolerating PO, ambulating, using CPAP, breathing well.
Discharge Instructions:
Take all your medications as prescribed. I have changed a
number of your medications. You should not take the
hydrochlorothiazide or lisinopril until you are seen by a
doctor. Instead, you will be taking the hydralazine.
.
For the next two days take 6mg of coumadin each night until you
have your INR checked on Thursday. Make sure to have your INR
checked on Thursday, I have provided you a prescription.
[**Hospital **] clinic will adjust your coumadin appropriately
based on that value. You should also have your creatinine
checked on thursday when you see Dr. [**Last Name (STitle) **].
.
Make sure to use your CPAP as scheduled.
Continue to take your antibiotic as prescribed, Dr. [**Last Name (STitle) **]
will evaluate your cellulitis and may change your antibiotics.
The doctors here noted some swollen lymph glands, make sure Dr.
[**Last Name (STitle) **] follows this up to make sure it resolves. You also
were noted to have blood in your urine, make sure your kidney
doctor knows about this.
Take your insulin as we discussed.
Followup Instructions:
You should schedule an appointment this week with your kidney
doctor, Dr. [**Last Name (STitle) 4920**] at [**Last Name (un) **]. You have the number, call him
Thursday to make an appointment.
.
You must follow up with Dr. [**Last Name (STitle) **] on thursday as below.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-5-24**] 4:40
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-6-21**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-5-24**] 4:40
|
[
"5849",
"40391",
"32723",
"2724",
"3051",
"49390",
"2859",
"V5861",
"V5867"
] |
Admission Date: [**2162-10-23**] Discharge Date: [**2162-10-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1845**]
Chief Complaint:
G tube placement, subdural hematoma in ED
Major Surgical or Invasive Procedure:
IR guided G tube replacement
History of Present Illness:
85 yo M with history of AF on coumadin, CAD, stroke who
presented from the rehab on [**10-23**] for replacement of his G tube.
While in the ER, a small catheter was placed through the ostium.
While the patient was in the ER however, he fell from his bed
and hit his head. An emergent CT was done that showed a small
ICH (9mm right parietal). Thus the patient was admitted to the
ICU for further monitoring and serial neuro checks.
Of note the patient was recently admitted to [**Hospital1 18**] on [**8-26**] for Right Superior MCA embolus CVA and resultant mild L
hemiparesis and bladder CA (high-grade papillary urothelial ca),
underwent transurethral resection, was admitted to [**Hospital Unit Name 153**] with
intubation and CVL placement, G-tube placement by IR [**9-7**],
discharged to rehab. He was discharged on [**9-7**] on a heparin
gtt with plans to transition back to coumadin. The coumadin (for
AF) was stopped prior to the CVA in anticipation of a surgical
procedure.
Past Medical History:
-Hematuria
-Paroxysmal atrial fibrillation, off coumadin ~ 3 weeks prior to
[**2162-8-26**] surgery
-h/o Cerebellar hemorrhage ([**2136**]), s/p craniotomy (staples
present in cranium)
-Vascular disease: Severe stenosis of the left vertebral artery,
approximately 2-3 cm proximal to the vertebrobasilar junction.
40% right ICA stenosis ([**2162-8-27**])
-Alzheimer's dementia, disinhibition and frontal dysfunction per
OMR ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, Neurology, [**2162-8-12**])
-Hypertension
-CAD: angina since [**3-/2151**], fixed perfusion defects in the apical
and apical portion of the anterior wall per Thallium ETT
([**2151-4-7**]) mild regional LV systolic dysfunction with
infero-lateral akinesis per TEE ([**2162-8-27**])
-Secundum Atrial Septal Defect w/ left to right shunt
-Valvular disease: Moderate (2+) MR, mild to moderate [[**12-16**]+] TR
-LVH by EKG & echo
-h/o Anemia, baseline Hct mid-30s
-h/o Pulmonary TB:~[**2110**] in USSR, multiple calcified granulomas
bilat lungs, R>L per CXR, h/o cavitary lung lesion, neg for AFB
by bronchoalveolar lavage ([**2154-9-6**])
-h/o Pulmonary nodule, RLL (superior segment) per CXR & CT scan
-Stage III colon cancer (T3N1):s/p resection, adjuvent
5-FU/leucovorin rx ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD, Oncology)
-h/o Alcohol abuse (quit in [**2160**])
-h/o falls, L Ankle fx ([**6-/2152**]), R ankle injury ([**6-/2153**])
-Back Paincervical radiculopathy & myelopathy, T12 compression
fracture, hemangioma at L2, bulging disk @ L2/3, multilevel
degenerative disk disease
-Cataracts, s/p excision & lens implant o.s.
-Glaucoma
-Wet macular degeneration w/ neovascularization
-GERD
-Giant hemangioma of the liver
-CRF, baseline creatinine 1.1 - 1.3
-h/o Right Renal cyst, CT Scan ([**2162-8-3**])
-h/o ARF ([**8-/2154**])
-h/o bowel obstruction
PSHx:
s/p Transurethral resection of the bladder, c/b CVA ([**2162-8-26**])
s/p Complex cataract surgery with intraocular lens implantation,
o.s. ([**2159-8-27**])
s/p Cystoscopy & random biopsies of the bladder ([**2157-2-11**])
s/p Colonoscopy ([**2156-1-15**])
s/p Cystoscopy and fulguration of bladder tumor ([**2155-9-26**])
s/p RIH repair with mesh plug & patch ([**2155-4-16**])
s/p Colonoscopy ([**2155-1-2**])
s/p Anterior resection of the colon ([**2152-9-5**])
s/p TURP, ? Prostate Ca ([**2147-6-9**])
s/p TURP for BPH, [**2138**]
s/p Posterior fossa craniectomy for a cerebellar hemorrhage
([**2136**])
Social History:
Relationships: [**Name (NI) **] (brother)- Cell: [**Telephone/Fax (1) 107744**], Home:
[**Telephone/Fax (1) 107745**]; [**Doctor First Name **] (neice, [**Name (NI) 2979**] daughter) - Cell:
[**Telephone/Fax (1) 107746**]; [**First Name5 (NamePattern1) 440**] [**Last Name (NamePattern1) 107747**] (neice, and [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) **]), Cell:
([**Telephone/Fax (1) 107748**]; Friend [**Name (NI) 751**]
Social:
Immigrated from [**Country 532**] in [**2134**], at baseline speaks & understands
limited English - translator needed. Positive h/o alcohol abuse,
but per PCP note stopped drinking ~1 year ago. He does not
smoke. Previously employed as a photographer. Brother states
patient is a Holocaust survivor.
Assistive Devices:
Glasses at baseline, upper & lower dentures; no hearing aides,
did not use walker or cane prior to admission.
Functional Status:
Was living independantly in senior housing: elevator & no steps
into building. Had HHA/HM (?) for personal care & cleaning,
three meals delivered to him every day. Supportive brother lives
nearby & does shopping. Out-patient Neurological evaluation (OMR
[**2162-8-12**]) notes abnormal mental status screen, h/o disinhibition
and frontal dysfunction, positive visuospatial signs that may
suggest Alzheimer's Disease. PCP had recently filled out forms
for adult daycare.
Values/Belief: [**Hospital1 **]
Family History:
Both parents died in [**2095**] in the [**Location (un) 25508**] ghetto.
Physical Exam:
VS: t 97.7 BP 158/62 HR 65 rr 18 96% RA
Gen: NAD, sleeping comfortably, awakens to alert, converses with
translator by phone who reports that the patient is alert and
oriented x 3.
HEENT: OP clear, EOMI
Neck: No JVD, no thyromegaly, no LAD
Cor: RRR no m/r/g
Pulm: CTAB, rare wheeze, laying flat, normal respirations
Abd: +BS, NTND, No HSM. G tube replaced by small gauge cathether
Extrem: no c/c/e
Skin: no rashes
Neuro: Left sided facial droop, mild decrease in strength in
left arm, but able to do hand grip bilaterally. Moves all
extremities and withdraws to pain. Preferentially grabs objects
with right hand. No tremor appreciated.
Pertinent Results:
[**2162-10-23**] 09:00PM BLOOD WBC-7.3 RBC-4.80 Hgb-12.8* Hct-38.6*
MCV-80* MCH-26.7* MCHC-33.3 RDW-18.3* Plt Ct-245
[**2162-10-25**] 05:55AM BLOOD WBC-5.3 RBC-4.39* Hgb-11.5* Hct-35.3*
MCV-80* MCH-26.2* MCHC-32.7 RDW-17.4* Plt Ct-215
[**2162-10-23**] 09:00PM BLOOD PT-28.5* PTT-35.9* INR(PT)-2.9*
[**2162-10-25**] 05:55AM BLOOD PT-14.9* PTT-32.7 INR(PT)-1.3*
[**2162-10-23**] 09:00PM BLOOD Glucose-95 UreaN-22* Creat-1.1 Na-141
K-3.6 Cl-101 HCO3-33* AnGap-11
[**2162-10-25**] 05:55AM BLOOD Glucose-87 UreaN-16 Creat-1.1 Na-141
K-3.4 Cl-105 HCO3-27 AnGap-12
[**2162-10-24**] 05:12AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8
CT head w/o contrast ([**2162-10-23**]): 1. Small superficial right
parietal hemorrhage. 2. More hypodense appearance of right MCA
territory infarction. 3. Post-surgical changes in the occipital
region, with prior left cerebellar
resection. 4. Age-related parenchymal atrophy.
CT spine w/o contrast ([**2162-10-23**]): 1. No evidence of fracture or
malalignment. 2. Multilevel degenerative change, most pronounced
at C5-C6.
3. Prior right MCA infarction and occipital post-surgical
changes as well as new right parietal hemorrhage are better
evaluated on concurrent head CT.
Abd XR ([**2162-10-23**]): Contrast injected through the gastric tube
opacifies the stomach without evidence of contrast
extravasation.
CT head w/o contrast ([**2162-10-24**]): No significant change over the
four-hour interval, with no new hemorrhage seen.
CXR ([**2162-10-24**]): Findings most consistent with old granulomatous
disease and
scarring. No acute change.
CT head w/o contrast ([**2162-10-25**]): No significant change over the
preceding interval.
CT head w/o contrast ([**2162-10-25**]): No significant change over the
preceding 18 hours.
Brief Hospital Course:
Intracranial Hemorrhage: While in the ICU, the patient had
serial neuro checks which were normal and reversal of his INR
(2.9-->1.4). En total, he received 3 U FFP, 2 vials of factor
IX, 10 mg Vit K PO and 5 mg vit K IV (ED). In the ICU and on
the floor, the patient continued to have serial neuro checks and
head CTs per neurosurgery team, all of which were normal. At
baseline he has a left facial droop and mildly decreased
strength in his left arm. Given history of previous strokes and
former recommendations not to use coumadin, the patient is being
discharged on no anticoagulation, with recommendation to restart
ASA on [**2162-11-3**] and to defer to PCP and neurosurgery about
restarting coumadin at any point in the future.
G-Tube Placement: In the ED, a small catheter was placed for
patency. Tube feeds were started in the ICU at 15 cc with
concern for abdominal pain. On [**2162-10-25**] he had g-tube
replacement, without complication, and subsequently TF were
restarted. consider giving bolus tube feeds and covering the PEG
with a binder or ACE wrap when not in use to deecrease the risk
of dislodging.
Deconditioning: Unsteady gait and decreased strength, in the
context of period of immobility s/p fall. Patient would venfit
from continued phyical and occupational therapy. Recommend
frequent ambulation with assist and fall precautions, including
low bed and floor padding.
Hypertension: BP control was difficult while in the ED and the
patient was briefly on labetolol gtt. Following restarting his
home hypertensive doses per G-tube, he was hypertensive to 180
requiring 20 mg labetolol IV, metoprolol 25 mg PO and 20 mg
hydral IV. He continued to have systolic blood pressure ranging
160-170s, and his dose of metoprolol was increased from 50mg [**Hospital1 **]
to 50mg TID.
History of embolic stroke [**8-/2162**]: DC summary and notes from
prior admission suggest patient was not to be restarted on
coumadin, but rather asa and heparin gtt. However, restarted on
coumadin at rehab. He is now discharged on no anticoagulation.
He should be restarted on ASA on [**2162-11-3**], with plan to discuss
coumadin recs with PCP and neurosurgery in follow up.
Anemia: normocytic anemia with baseline low 30s, currently
stable.
Insulin: pt on insulin sliding scale, though no history of
diabetes. Insulin was discontinued and his glucose remained
within normal.
Glaucoma: continued drops
Medications on Admission:
1. docusate liquid [**Hospital1 **]
2. brimonidine 0.15 % 1 drop q8
3. latanoprost 0.005 % 1 drop qhs
4. insulin Lispro sliding scale
5. simvastatin 20mg qd
6. ferrous Sulfate 325 qd
7. ipratropium Bromide 0.02 % q6hrs prn
8. albuterol q6 prn
9. metoprolol tartrate 50 [**Hospital1 **]
10. lansoprazole 30 mg qd
11. senna 8.6mg qhs:prn
12. bisacodyl 10mg prn
13. lisinopril 40mg qd
14. acetaminophen 325 q6hrs prn
15. PER NURSING - COUMADIN ?DOSE
16. PER NURSING - LACTULOSE 10MG [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
2. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic Q8H
(every 8 hours).
3. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
4. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
8. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
11. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Intracranial hemorrhage
G tube replacement
Discharge Condition:
Neurologically stable and feeding well through g-tube
replacement
Discharge Instructions:
You were admitted to the hospital on [**2162-10-24**] when you presented
to the ED for replacement of your g-tube. In the ED, you had a
fall, and head CT showed a small intracranial bleed. You were
monitored in the intensive care unit for two days, during which
time the Neurosurgery team followed you. Serial neurologic
exams and head CTs were stable. On [**2162-10-25**] your g-tube was
replaced, without complication.
.
Please continue to take all your medications through the g-tube.
Coumadin and aspirin have been stopped. You should not restart
the coumadin until further discussion with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 39992**]. Please restart the aspirin on [**2162-11-3**].
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 39992**] as
instructed below.
.
Seek medical attention if you have any further falls,
lightheadedness, syncope, weakness, changes in vision, or
difficulties with your feeding tube.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2162-10-27**] 9:45
Provider: [**Name10 (NameIs) 1239**] BRAIN, N.P. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-11-23**]
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-12-7**] 1:00
11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2162-12-7**] 1:30
|
[
"42731",
"4240",
"2859",
"40390",
"5859"
] |
Admission Date: [**2116-3-25**] Discharge Date: [**2116-4-14**]
Date of Birth: [**2116-3-25**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 28082**] was the 2.81 kg product of a 34
[**4-25**] week gestation born to a 22 year old G1 P0 mother.
Prenatal screens were O positive, antibody negative,
hepatitis surface antigen negative, RPR nonreactive, Rubella
immune, GBS unknown, CVS screen negative. This pregnancy was
complicated by a motor vehicle accident on [**2116-1-20**],
increased blood pressures over a 4 week period in [**Month (only) 404**]
through [**Month (only) 956**], anemia on iron, history of low lying
placenta, resolved on last study of [**2116-2-3**].
Maternal medications include Paxil, Protonics and iron. Mother
presented the day prior to delivery with lower abdominal pain
and preterm labor. Mother was allowed to labor. Artificial
rupture of membranes 5 hours prior to delivery for clear
fluid. Maternal anesthesia by epidural. Vaginal delivery and
apgars were 8 and 9.
PHYSICAL EXAM ON ADMISSION: Weight was 2.81 kg, greater than
90th percentile, 46 cm, 50th percentile, 30.5 cm 25th
percentile, pink, resting comfortably, in no distress.
Anterior fontanelle was soft and flat. Palate was intact.
Clavicles are intact. Lungs are clear to apex, equal.
Cardiovascular - regular rate and rhythm, soft 1/6 systolic
murmur. There were 2+ femoral pulses. Abdomen was soft,
positive bowel sounds, no hepatosplenomegaly. GU - normal
female, positive vaginal tag. Hips were stable with no sacral
anomalies. Extremities were pink and well perfused and moves
all extremities well with normal tone.
HISTORY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Has been stable in room air throughout her
hospital course. She had mild apnea and bradycardia of
prematurity, but was not treated with methylxanthines.
Her last documented apnea and bradycardic spell was on [**4-8**].
Cardiovascular: She has been cardiovascularly stable with
normal blood pressures and good perfusion. A murmur has been
auscultated on exam that is [**12-26**] soft systolic along the left
sternal border radiating to the axilla and back. The murmur is
consistent with peripheral pulmonic stenosis. This murmur
should be followed with consideration for a cardiology consult
if persistent.
Fluid/Electrolytes: Birth weight was 2.805 kg. She gradually
advanced to ad lib feedings, taking in adequate amounts. Her
discharge weight was 3125 gms.
GI: Peak bilirubin was on day of life 4 was 13.4/0.3. She did
not require any phototherapy. Her last bilirubin level on
[**3-29**] was 11.8.
Hematology: Hematocrit on admission was 49. She has not
required any blood transfusions during this hospital course.
Infectious Disease: CBC was obtained on admission. CBC was
benign with the exception of a low platelet count of 165.
Repeat platelet count 24 hours later was 213. The infant has
not received any antibiotics during this hospital course. Of
note, she was treated with nystatin powder to her diaper area
for a Monilial rash which was discontinued on [**2115-4-12**].
She continues to receive Criticaid or Desitin for a diaper
dermatitis.
Neurology: Has been appropriate for gestational age.
Psychosocial: Social worker has been involved with the family
and can be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) 59067**]. The telephone
number is [**Telephone/Fax (1) 59068**].
CARE AND RECOMMENDATIONS: Continue ad lib feedings with
Similac with Fe, 20 calories/oz.
MEDICATIONS: None.
CAR SEAT POSITION SCREENING: Initial car seat position
screening test was done on [**4-9**] which was not passed due
to desaturations. A repeat car seat position screening test on
[**4-13**] was passed.
STATE NEWBORN SCREEN: Has been sent per protocol and has
been within normal limits.
IMMUNIZATIONS RECEIVED: Received hepatitis B vaccine on
[**2116-4-1**].
RECOMMENDED IMMUNIZATIONS: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following three criteria - 1) born at less
than 32 weeks, 2) born between 32 and 35 weeks with any of
the two following risk factors - day care during RSV season,
a smoker in the household, neuromuscular disease, airway
abnormalities or school age siblings, or 3) with chronic lung
disease. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of age.
Before this age (and for the first 24 months of the child's
life), immunization against influenza is recommended for
household contacts and out-of-home caregivers.
DISCHARGE DIAGNOSES:
1. Premature infant born at 34 5/7 weeks gestation
2. Apnea of prematurity, resolved
3. Sepsis evaluation, ruled-out
4. Cardiac murmur, suspect peripheral pulmonic stenosis (PPS)
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2116-4-12**] 21:01:15
T: [**2116-4-12**] 21:33:37
Job#: [**Job Number 61144**]
|
[
"V053",
"V290"
] |
Admission Date: [**2105-9-10**] Discharge Date: [**2105-9-19**]
Date of Birth: [**2041-8-2**] Sex: F
Service: Oncology
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 34355**] is a 64 year old
woman with a history of metastatic adenocarcinoma of unknown
primary source (gastrointestinal versus breast). She was
admitted with thrombocytopenia and anemia. She reported
increasing lethargy and ataxia for six to seven days prior to
admission. She denied trauma or falling. She did complain
of headache and blurry vision. The patient was seen in the
hematology/oncology clinic on [**2105-9-10**], where her
platelet count was found to be 26,000 and her hematocrit was
23. A magnetic resonance imaging scan showed a large
subdural hematoma on the left side with positive mass effect,
with a midline shift.
The patient was admitted to the Surgical Intensive Care Unit
and neurosurgery was consulted. They recommended
conservative therapy given her decreased platelet count. Her
peripheral smear showed schistocytes, however,
hematology/oncology felt that it was secondary to
microangiopathic hemolytic anemia and not secondary to
thrombotic thrombocytopenic purpura. In the unit, the
patient was started on Decadron and was transfused to keep
her platelet count above 100,000 and her hematocrit above 30.
She continued to improve neurologically.
Neurosurgery believed that the hematoma would resolve as long
as her platelet count remained above 100,000. The patient
was continued on Keflex for breast cellulitis. Given
resolution of her neurologic deficits, she was transferred to
the hematology/oncology clinic on [**2105-9-13**]. Upon
further questioning, she did report hitting her head on a car
door about one week prior to admission. When examined, she
felt fine this morning except for some slight back pain and
mild epigastric pain. She denies any nausea, vomiting,
diarrhea or fever. She is currently on Xeloda for her
metastatic cancer.
PAST MEDICAL HISTORY: 1. Metastatic adenocarcinoma of
unknown primary to bone. 2. Recent diagnosis of
anemia/thrombocytopenia. 3. Peptic ulcer disease. 4.
Endometriosis. 5. PPD positive.
MEDICATIONS ON ADMISSION: Xeloda 1,500 mg p.o.q.i.d., Keflex
500 mg p.o.q.i.d., Protonix 40 mg p.o.q.d., Decadron 4 mg
i.v.q.6h., fentanyl patch 25 mcg q.72h., Percocet p.r.n.
pain, and Milk of Magnesia.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives in [**Hospital1 1474**] with her
husband. She is a full code. She denies any tobacco or
alcohol use.
FAMILY HISTORY: The patient's mother died at the age of 98.
Her father died at the age of 58 of intestinal cancer. Her
sister died of lung cancer and tuberculosis.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a temperature of 98.3, pulse 78, respiratory
rate 18, blood pressure 129/72 and oxygen saturation 96% in
room air. General: Alert and oriented times three. Head,
eyes, ears, nose and throat: Pupils equal, round, and
reactive to light and accommodation, extraocular movements
intact, anicteric sclerae. Cardiovascular: Regular rate and
rhythm, normal S1 and S2. Pulmonary: Clear to auscultation
bilaterally. Abdomen: Soft, nondistended, positive bowel
sounds, minor epigastric tenderness. Extremities: No
cyanosis, clubbing or edema. Neurologic examination: Alert
and oriented times three, cranial nerves II through XII
intact, finger-to-nose intact, no asterixis, no pronator
drift.
LABORATORY DATA: White blood cell count was 12, hematocrit
28.3, platelet count 84,000, fibrinogen 158, FTP 40 to 80,
d-dimer greater than 2,000, prothrombin time 13.5, partial
thromboplastin time 24.3, INR 1.2, sodium 133, potassium 4.3,
chloride 101, bicarbonate 21, BUN 16, creatinine 0.5, glucose
154, alkaline phosphatase 2,190, calcium 8, phosphorous 2.7
and magnesium 2.1. Repeat head CT on [**2105-9-12**]
showed that the hematoma was unchanged in size.
HOSPITAL COURSE: The patient required multiple blood and
platelet transfusions during the rest of her hospital stay to
keep her platelet count above 100,000 and her hematocrit
above 28. She had a right PICC line placed on [**2105-9-27**], where blood could be drawn easily. The patient
remained neurologically stable throughout the rest of her
hospital stay. Her Decadron was eventually tapered to off at
the time of discharge. On [**2105-9-18**], the patient
had a magnetic resonance imaging scan of the head, which
revealed that the size of the hematoma was again unchanged in
size. She is to return to the bone marrow transplant unit on
[**2105-9-22**] for a blood draw to monitor her hematocrit
and platelet count.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS:
Fluconazole 100 mg p.o.q.d.
Xeloda 1,500 mg p.o.b.i.d.
Fentanyl patch 25 mcg q.72h.
Protonix 40 mg p.o.q.d.
Milk of Magnesia 10 cc p.o.q.d.
Percocet 5/325 mg one to two tablets p.o.q.4-6h.p.r.n. pain.
DISCHARGE INSTRUCTIONS: The patient was instructed to return
to Four South on [**2105-9-22**] for a blood draw to
monitor her hematocrit and platelet count.
PROBLEM LIST:
Metastatic adenocarcinoma of unknown primary to bone.
Recurrent anemia and thrombocytopenia.
Peptic ulcer disease.
Endometriosis.
PPD positive.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 25086**], M.D. [**MD Number(1) 34356**]
Dictated By:[**Last Name (NamePattern1) 7690**]
MEDQUIST36
D: [**2105-9-28**] 10:46
T: [**2105-9-30**] 08:43
JOB#: [**Job Number 34357**]
|
[
"2875"
] |
Admission Date: [**2162-9-20**] Discharge Date: [**2162-10-8**]
Date of Birth: [**2101-1-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted with Abdominal distension and pain for 1 day.
Major Surgical or Invasive Procedure:
Status Post Exploratory Laparotomy
History of Present Illness:
61 yo male with Hepatitis C and no previous abdominal surgery
comes in with complaints of abdominal distension, pain since
last night. Had a couple of bowel movements before 6PM which
were normal. Not passed flatus since. No nausea , no vomiting.
No fever. No previous similar episode. Not had anything to eat
since last night because of the distension and pain.
Past Medical History:
PMH: Hepatitis C, HTN, Seizures, opiod addiction, homeless.
Past Surgical History:Tonsillectomy; Eye surgery as a child for
strabismus, 3rd degree burns on feet
Social History:
Patient is a 61 year old homeless male who admits to 40 year
history of opioid addiction. Was in jail until 3 weeks ago. His
father lives in [**Name (NI) 620**]. Stated that he has been buying suboxone
to manage his addiction but has not seen a primary care provider
in [**Name Initial (PRE) **] long time.
Family History:
Non-contributory.
Physical Exam:
Physical Exam:
Vitals: Time Temp HR BP RR Pox
+ 16:43 98.1 107 177/129mmHg 18 98
Looks uncomfortable. in pain.
Lungs: clear bilateral
Heart: Regular rate and rhythm; no murmurs. No carotid bruit
Abdomen: Distended, tympanitic. generalized tenderness more in
lower abdomen. Guarding and rebound in R lower abdomen and
suprapubic region. No groin or umbilical hernias
Rectal: No masses. Rectum ballooned out with no stool. Prostate
moderately enlarged. Occult blood negative
Brief Hospital Course:
Patient admitted with abdominal pain. Patient taken to the
operating room for exploratory laparotomy a bezoar was found in
the small bowel. Postoperative course was complicated by
delirium, decreased respiratory status and wound infection.
Patient placed on antibiotics, chest x-rays monitored.
Readmitted to ICU on [**9-30**] for abdominal distention, vomiting
black tarry fluid, tachycardia, pain and dropping HCT. NGT
placed for 700 cc of black fluid. [**2162-10-1**] EGD done showing
ulcers in lower third of esophagus. Patient started on PPI
intravenously as well as methadone tid. Bleeding resolved. Pt
was transferred to the floor on [**2162-10-1**]. Pt was doing well and
tolerating regular diet on the floor but continued to spike low
grade fevers, though he did not have a WBC. Infectious disease
was consulted and recommending rescanning his abdomen and
pelvis. CT done on [**2162-10-6**] demonstrated multiple fluid pockets
in the right lower quadrant and left paracolic gutter and
pelvis, which were smaller in size compared to prior imaging.
There was discussion between the surgery team, infectious
disease and interventional radiology regarding drainage of those
fluid collections, and it was determined that the patient would
be discharged on four weeks of oral antibiotics with a follow-up
CT scan in four weeks.
Problems:
1. Opioid Withdrawal - Patient monitored and treated with CIWA
scale. Methadone 10mg po tid now being given with adequate
control.
2. Respiratory status now much improved to 97% on room air.
Chest x-rays confirmed atelectasis and pleural effusion but no
pneumonia. Last chest x-ray was [**10-4**].
3. Abdominal wound - open inferior aspect of incision. Swab
culture confirms enterococcus. Course of ampicillin given for
that. Continue wet-dry dressings looks clean.
4. UGI bleed - Patient recieved one unit of PRBC's, hematocrit
monitored until stable. PPI given.
5. Intraabdominal abscesses - Patient will be discharged on four
weeks of Augmentin and will have a repeat CT scan in four weeks.
Will discharge him to rehab facility that can manage abdominal
wound care and addiction issues. He will follow up with Dr.
[**Last Name (STitle) **] in 3 weeks.
Medications on Admission:
HCTZ 25', Phenytoin 1 "' (not taking it for at least 3 weeks),
Suboxone 8-2mg SL once daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Methadone 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
5. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO three times a day.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
8. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Small Bowel Obstruction
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.
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 [**9-30**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower 48 hours after surgery, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please follow up with your primary care provider [**Last Name (NamePattern4) **] [**12-18**] weeks.
Please follow up with Dr. [**Last Name (STitle) **] in 3 weeks, his office is
located on the [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building [**Location (un) 470**]. Please
call the following number [**Telephone/Fax (1) 2723**] to make an appointment.
Provider: [**Name10 (NameIs) **] SCAN; Phone:[**Telephone/Fax (1) 327**]; Date/Time:[**2162-11-8**]
11:45AM
Location is on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical Center on
the [**Hospital1 **] [**Last Name (Titles) 516**].
|
[
"5119",
"4019",
"3051",
"42731"
] |
Admission Date: [**2141-6-30**] Discharge Date: [**2141-7-5**]
Date of Birth: [**2055-11-20**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Zocor
Attending:[**Name (NI) 9308**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 112282**] is 85M with history of CKD, HTN, HLD, afib on
coumadin, PUD s/p UGIB [**1-/2141**] who is presenting with chest
discomfort. The patient reports that the day prior to
presentation he had acute onset of chest discomfort and nausea.
Also reported having intermittent dry heaves. Reports this his
chest pain last for about two day, with intermittent nausea, but
has since resolved. He had a scheduled appointment with his
nephrologist yesterday and reported his chest pain; he had an
EKG done that showed, as per report, elevation in V1-V2, and
loss of R waves in V1-3. The patient was instructed to go to
the ED; however, he refused and instead went home to take care
of his wife. Of note, the patient is also on coumadin for his
afib; he reports that for one day he was having black diarrhea.
Reports having brown stools mixed with black liquid diarrhea.
Denies any vomiting, but does report having dry heaves as noted
above. Also reports having decreased PO intake over the last
two days.
He later came to the ED today because he told his doctors that [**Name5 (PTitle) **] would. The patient is currently chest pain free.
Of note, the patient had UGIB in 2/[**2140**]. He initially presented
with dizziness and was found to be orthostatic in the setting of
having black stools. His crits remained stable and he never
required a transfusion. The patient had an EGD, which was
notable for erosive gastritis, erosive duodenitis, hiatal
hernia, and duodenal ulcer.
While in the ED, EKG notable for afib at 62, LAD, new loss of R
waves v1-3, old twi v2-4. Labs notable for white count of 16.6,
troponin of 4.39, CKMB 45. Rectal exam notable for brown stool
with some evidence of melena, guiac positive. The patient was
bolused with pantoprazole and started on pantoprazole drip.
Both ASA and heparin were held given possible GIB.
On arrival to the CCU, the patient reports feeling well. No
acute complaints. He denies any chest pain or discomfort.
Denies any trouble breathing or shortness of breath. Denies any
abdominal pain. Reports feeling hungry.
Past Medical History:
HTN
Hypercholesterolemia
BPH
Obesity
Atrial fibrillation on coumadin
[**1-/2141**] - GI bleed at MWH --> erosive gastritis, erosive
duodenitis, hiatal hernia, and duodenal ulcer. Had gastroscopy
but no record of embolization or cauterization.
Social History:
Social history: married, lives with wife. One son and two grand
daughters. The patient is ex-smoker; smoked cigars for 20 years.
Etoh rarely.
Family History:
Family history:
brother with ?testicular cancer, CAD and PVD, mother with breast
cancer, DM,
Physical Exam:
General: pleasant, well appearing gentleman, NAD, laying
comfortably in bed, joking around
HEENT: EOMI, PERRL
neck: supple, no JVD appreciated
CV: irregular, S1, S2, no murmurs/gallops/rubs
lungs: clear to auscultation, no wheezes/rhonchi/crackles
abdomen: soft, nontender, nondistended, +BS
extremities: warm, well perfused, no LE edema, 2+ DP pulses
Neuro: muscle strength and sensation grossly intact
Pertinent Results:
[**2141-6-30**] 12:15PM WBC-16.6* RBC-5.80 HGB-15.3 HCT-47.0 MCV-81*
MCH-26.3* MCHC-32.4 RDW-17.1*
[**2141-6-30**] 12:15PM NEUTS-88* BANDS-0 LYMPHS-7* MONOS-4 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2141-6-30**] 12:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL
ELLIPTOCY-1+
[**2141-6-30**] 12:15PM PLT SMR-VERY HIGH PLT COUNT-850*
[**2141-6-30**] 12:15PM PT-29.8* PTT-45.5* INR(PT)-2.9*
[**2141-6-30**] 12:15PM GLUCOSE-106* UREA N-51* CREAT-1.8* SODIUM-135
POTASSIUM-6.2* CHLORIDE-102 TOTAL CO2-18* ANION GAP-21*
[**2141-6-30**] 12:15PM CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-2.1
[**2141-6-30**] 12:15PM CK-MB-45* MB INDX-6.0
[**2141-6-30**] 12:15PM cTropnT-4.39*
[**2141-6-30**] 12:15PM estGFR-Using this
[**2141-6-30**] 12:29PM HGB-15.2 calcHCT-46
[**2141-6-30**] 12:29PM LACTATE-2.8* K+-5.1
Echo [**7-3**]
The left ventricular cavity size is normal. There is moderate to
severe regional left ventricular systolic dysfunction with near
akineis of the distal 2/3rds of the septum and anterior walls,
distal inferior and lateral walls. The apex is mildly aneurysmal
and dyskinetic. The remaining (basal) segments contract normally
(LVEF = 25 %). No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size is normal with focal
hypokinesis of the apical free wall. The aortic valve leaflets
(3) are mildly thickened. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is
mild-moderate pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Apical left vevntricular aneurysm with regional
systolic dysfunction c/w CAD. No left ventricular thrombi.
Regional right ventricular free wall hypokinesis c/w CAD.
Pulmonary artery hypertension.
Compared with the prior study (images reviewed) of [**2141-6-30**],
the findings are similar.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
[**7-4**] Cardiac perfusion persantine
RADIOPHARMACEUTICAL DATA:
11.0 mCi Tc-[**Age over 90 **]m Sestamibi Rest ([**2141-7-4**]);
29.6 mCi Tc-99m Sestamibi Stress ([**2141-7-4**]);
HISTORY: 85 year old male with hypertension, hyperlipidemia,
permanent atrial
fibrillation and chronic kidney disease who had a recent missed
STEMI.
SUMMARY FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
mg/kg/min.
IMAGING METHOD:
Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi.
Tracer was
injected approximately 45 minutes prior to obtaining the resting
images.
Following resting images and two minutes following intravenous
dipyridamole,
approximately three times the resting dose of Tc-[**Age over 90 **]m sestamibi
was administered
intravenously. Stress images were obtained approximately 30
minutes following
tracer injection.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
Left ventricular cavity size is enlarged with an end diastolic
volume of 143
ml.
Rest and stress perfusion images reveal a focal anteroseptal
wall defect which
shows improvement at rest.
Gated images reveal global hypokinesia.
The calculated left ventricular ejection fraction is 24%.
IMPRESSION:
1- Focal anteroseptal wall defect which shows improvement at
rest suggesting
persantine induced ischemia.
2- Enlarged left ventricular cavity and global hypokinesia.
3- Calculated LVEF of 24%.
Brief Hospital Course:
Mr. [**Known lastname 112282**] is 85M with history of CKD, HTN, HLD, afib on
coumadin, PUD s/p UGIB [**1-/2141**] who is presented with chest pain
and new EKG changes, found to have elevated troponins and guaic
positive stool, with peaked troponins and CK-Mb thought to have
a missed antero-septal MI.
ACUTE ISSUES
#Antero-septal MI: The patient was noted to have chest pain the
day of presentation and was later found to have ST elevations in
V1-2, with loss of R waves in V1-V3 in the setting also having
an elevated troponin. Given the patient's recent UGIB and
concern for current possible GIB, also given downtrending CKMB
and trop suggestive of the back end of an MI cath was deferred.
An ECHO was obtained with h/o regional systolic dysfunction.
After admission to the CCU CK-MB was 45, then downtrended to 40.
Given the patient was chest pain free at this time the infarct
was thought to be completed and there was no angiography
performed. Patient was treated with medical management in house
with metoprolol (atenolol held). ACEI was initially held in the
setting of acute on chronic kidney disease (K at 5.3), but after
normalization captopril added back on to regimen and then
changed to lisinopril. Diuresis was started on [**7-2**] as he
thought to be mildly volume overloaded. During the stay he was
monitored on tele for any arrhythmic complications of MI and any
mechanical complications with close following of his vital signs
and clinical impression. He had an echo on [**7-3**] which showed EF
25% Apical left vevntricular aneurysm with regional systolic
dysfunction c/w CAD. No left ventricular thrombi. Regional right
ventricular free wall hypokinesis c/w CAD. Pulmonary artery
hypertension. Compared with the prior study (images reviewed) of
[**2141-6-30**], the findings were similar. At the beginning of
hospital stay we did treat him for systolic failure with some
lasix and toward the end of hospital stay he had no crackles.
Patient was sent home on metoprolol, an ACE-i, statin, ASA.
While he was here we got stress test MIBI with persantine to see
if there were potential other areas of his heart that could be
interevened on. The results showed Focal anteroseptal wall
defect which shows improvement at rest suggesting
persantine induced ischemia.Enlarged left ventricular cavity and
global hypokinesia. Calculated LVEF of 24% We told him many
times that if he has chest pain to call 911 right away
# rhythm: The patient has history of afib, rate controlled on
atenolol and anticoagulated with couamdin at home. Patient
remained in AF, rate-controlled on metoprolol in house.
Warfarin was initially held as evidence of GI bleed but we
resumed this medication after decreased concern for an active
bleed.
# PUD s/p UGIB: The patient has a history of erosive gastritis,
erosive duodenitis, hiatal hernia, and duodenal ulcer, with UGIB
in 2/[**2140**]. When admitted he was noted to have black stools,
crits were stable and patient has been clinically stable. He had
2 large bore IVs and was satrted on pp-i drip. Patient was
considered stable and pantoprazole was switched to pantoprazole
PO. We sent him home on this medication and told him to follow
up with a GI doctor about it.
# CKD: The patient has history of CKD, baseline creat 1.4-1.6.
On day of discharge his Cr was 1.6, his baseline
#Hyperkalemia: when admitted patient had a K in the 5s. Over the
hospital course his K trended down to the 4s on day of d/c it
was 5. We started him on K-sparing medications like lisinopril
because it is a good medication for post MI patients and told
him to eat a low potassium diet, to avoid potassium [**Doctor First Name **] foods.
Sent pt on very low dose lisinopril (1.125)
#Thrombocytosis: Patient has elevated platlets in the 700s. Our
differential was reactive thrombocytosis vs essential
thrombocytosis. While here the team looked at the smear and saw
lots of platelets, some basophils, looks like possibly
myeloproliferative disorder such as essential thrombocytosis.
Patient is anticoagulated with warfarin adn on an ASA. We felt
this could be followed up in an outpatient setting. This can be
coorindated by [**Doctor First Name 3390**] in outpatient setting
# leukocytosis: The patient was noted to have white count of
16.6 initially, down to 15.5 then down to 10 on [**7-3**]. Most
likely this was a stress response to recent ischemia.
CHRONIC ISSUES
# glaucoma:continued home latanoprost
TRANSITIONAL ISSUES:
-Cards: pt will follow up with cardiologist in outpatient
setting regarding anterior MI and now low EF 25%. Pt came in
with an elevated K in the 5s, K should be followed up in
outpatient setting especially because pt is on an ACE-i. In
outpatient setting may consider starting aldosterone antagonist
at some point, however his K should beb monitored, also may
consider ICD placement after 40 days of MI (in [**Month (only) **]).
-PUD: pt should coordinate GI follow up with [**Month (only) 3390**] in outpatient
setting abotu PUD which seems to be stable
-High platlets: pt should coordinate heme/onc referral with [**Month (only) 3390**]
in outpatient setting to further look into ET
-follow up potassium levels
Medications on Admission:
enalapril 2.5 mg daily
Vitamin D3 1000 units daily
atenolol 50 mg daily
latanoprost 0.005% L eye 1 drop qhs
MVI
Pravastatin 80 mg qhs
Warfarin 5 mg daily
colchicine 0.6 mg [**Hospital1 **] PRN
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Lisinopril 2.5 mg PO DAILY
HOLD SBP<100
RX *lisinopril 2.5 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
5. Colchicine 0.6 mg PO BIDB PRN gout
6. Vitamin D 400 UNIT PO DAILY
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Metoprolol Succinate XL 75 mg PO DAILY
please do not take this medication if your systolic blood
pressure is below 100 or if your heart rate is below 60.
RX *metoprolol succinate 50 mg 1.5 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Warfarin 4 mg PO DAILY16
RX *Coumadin 4 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Outpatient Lab Work
please check INR because patient is on coumadin for Afib. This
should be done on Saturday [**2141-7-8**]. Also please check K
ICD: 427.31
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Priamry: heart attack
Secondary: GI bleed, Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 112282**],
It was a pleasure taking care of you at [**Hospital1 18**]. You came to the
hospital because you had some chest discomfort and were found to
have a heart attack. We did not do any intervention because when
you were here the heart attack was already resolving which means
you likely came in when the heart attack had already almost
passed because you no longer had chest discomfort. We also
didn't do any procedures like place a stent in your heart vessel
because we were concerned you may have had a GI bleed. We
watched you while you were here to make sure you didnt have any
complication from a heart attack and you did great. While you
were here you were also found to have blood in your stool. This
is likely from your known peptic ulcer disease. The GI team came
by to see you and your Hematocrit was stable (that is a marker
for how much you are bleeding). Nothing needed to be done in
terms of the blood in your stool. However we want you to follow
up with your [**Hospital1 3390**] and [**Name Initial (PRE) **] GI doctor about this.
If you feel chest pain please call 911 right away
please get your BLOOD DRAWN on Saturday [**2141-7-8**] for your INR to
be checked.
We made the following changes to your medications:
please STOP atenolol
please START metoprolol - this is a good medication for patients
who have had a heart attack
please START aspirin 81
please START lisinopril 2.5 (this is in place of enalapril)
please START pantoprazole this is for your peptic ulcer disease
We CHANGED your dose of warfarin to 4 (at home it was 5) because
we were initially concerned you may have a GI bleed. We would
like for you to please follow up with your [**Month/Day/Year 3390**], [**Name10 (NameIs) **] [**Last Name (STitle) **] and
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7568**] about titrating this medication.
Followup Instructions:
We recommend a hematology [**Last Name (LF) 5371**], [**First Name3 (LF) **] your [**First Name3 (LF) 3390**], [**Name10 (NameIs) **] look into
your high platelet count. Please discuss this with your [**Name10 (NameIs) 3390**].
[**Name10 (NameIs) 3390**] [**Name Initial (PRE) **]: Friday, [**7-7**] at 9;40am
With:[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 31017**],MD
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 6086**]
Phone: [**Telephone/Fax (1) 31019**]
***Please discuss with your [**Telephone/Fax (1) 3390**] at this visit arranging follow
up care with a new Cardiologist, Hematologist and
Gastroenterologist as a result of your recent hospitalization.
It is recommended from your hosptal team to see these
specialists with in 2 to 4 weeks post hospitalization.
|
[
"41401",
"42731",
"4280",
"V5861",
"40390",
"5859",
"42789",
"2720",
"4168",
"2767"
] |
Admission Date: [**2145-8-1**] Discharge Date: [**2145-8-16**]
Date of Birth: [**2089-6-21**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
nausea, vomiting and gait instability
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 56 year-old woman with a history of
developmental delay, blind and deaf at baseline, with a
Dandy-Walker malformation, who presents with nausea, vomiting
and
gait instability, found to have a new cerebellar infarct on CT
scan. According to her group home, at baseline the patient is
non-verbal, and will occasional communicate with a few hand
signals, but will often spend 4-5 hours during the day sleeping.
At night she will often get up at least once during the night
and
will be found crawling around on the floor, and will have to be
put back to bed. Last night around 1am she was found behaving
similarly, reportedly at her baseline, and was put back to bed.
This morning around 8:30am the worker at her group home went to
wake her up, and found her in bed, covered in vomit. She tried
to get her up to help her go to the bathroom to clean up, and
noticed that she seemed to be leaning to the right when she sat
up. Normally her gait is slightly wide based and she requires
one person to assist her, but this morning she was much more
unstable than usual, and kept falling to the right. The group
home was concerned that she may have had a stroke, so took her
to
an OSH for further evaluation. There she was found to be in
Afib
with RVR for which she was started on a Diltiazem drip, and also
was noted to have a left cerebellar infarct, at which point she
was transferred to [**Hospital1 18**].
Patient unable to answer ROS
Past Medical History:
- Developmental delay, first noted at 9 months. Currently blind
and deaf, minimal communication
- Dandy-Walker malformation
- Hypothyroidism
- Hyperlipidemia
Social History:
Lives in a group home in [**Location (un) 5028**]. HCP is her sister,
[**Name (NI) 803**] [**Name (NI) 33179**] [**Telephone/Fax (1) 85260**].
Family History:
Father died of complications from a brain aneurysm
Physical Exam:
Vitals: T: 99.8 P: 70-133 R: 16 BP: 115/50 SaO2: 98% on RA
General: Awake, will respond to stimuli.
HEENT: NC/AT, clouding of left corneal, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: rapid, irregular
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: Abrasions noted over knees bilaterally
Neurologic:
-Mental Status: [**Last Name (LF) **], [**First Name3 (LF) **] respond to stimuli. Blind and deaf
at baseline, with minimal speech.
-Cranial Nerves: PERRL 3 to 2mm on right. Clouding of cornea
on
left, unable to visualize pupil. Unable to visualize fundi. At
rest eyes deviated down and to the right, however spontaneous
movements noted in all directions. Corneals intact bilaterally,
and squeezes eyes tightly shut with stimuli. No facial
asymmetry, tongue midline, intact gag.
-Motor: Normal bulk, increased tone throughout, with arms flexed
on chest at baseline. Able to hold all limbs antigravity, and
withdraws briskly from painful stimuli.
-Sensory: Withdraws from pinch in all extremities.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was withdrawal bilaterally.
-Gait: Unable to assess. Patient only able to sit with two
person assist, leans consistently to the right.
Pertinent Results:
[**2145-8-1**] 01:55PM WBC-13.4* RBC-5.20 HGB-13.3 HCT-41.0 MCV-79*
MCH-25.6* MCHC-32.5 RDW-14.4
[**2145-8-1**] 01:55PM NEUTS-77* BANDS-11* LYMPHS-8* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2145-8-1**] 01:55PM PLT SMR-NORMAL PLT COUNT-159
[**2145-8-1**] 01:55PM GLUCOSE-139* UREA N-17 CREAT-0.7 SODIUM-145
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-23*
[**2145-8-1**] 01:55PM CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-1.8
[**2145-8-1**] 01:55PM cTropnT-<0.01
[**2145-8-1**] 02:44PM LACTATE-2.9*
[**2145-8-1**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2145-8-1**] 02:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
Imaging:
EKG: Probable atrial flutter or possible fibrillation with rapid
ventricular response
CXR: No definite pulmonary consolidation to suggest aspiration
or
pneumonia
CT head ([**2145-8-1**]): Left cerebellar infarct without evidence of
hemorrhagic
transformation. Large posterior fossa arachnoid cyst
CT head ([**2145-8-2**]): Stable appearance of left cerebellar
hemisphere infarct with hemorrhagic transformation
Echo: The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Brief Hospital Course:
Patient admitted with symptoms of nausea, vomiting and noted
gait instability as per group home. Exam was limited given
patient's baseline inability to
communicate, but is notable for significant truncal instability,
with complete inability to walk, which is new for the patient as
per her facility. The patient had imaging which confirmed a left
cerebellar infarct. Neurosurgery was initially consulted; no
surgical issues were deemed necessary on admission. The patient
was intitally admitted to the neuro ICU for monitoring given the
cerebellar infarct. Given that the patient was in rapid a. fib
on admission, it is believed likely that the stroke was likely
secondary to this. The patient was started on Metoprolol for
rate control of her new onset a. fib. The patient was continued
on her home Aspirin, but anticoagulation for the a. fib was not
started given that a repeat CT head showed minor hemorrhagic
conversion of the infarct as well as the patient being a noted
fall risk at her facility.
During hospitaliztion, patient's Metoprolol was adjusted as she
was becoming bradycardic. However, while on the lower dose of
Metoprolol, she again developed a.fib with RVR with HR into the
140s. She received 5 mg IV Metoprolol pushes for this and
cardiology was consulted. They recommended to continue on dose
of Metoprolol 25 mg [**Hospital1 **] to maintain HR between 50-120.
Medications on Admission:
- ASA 325mg
- Calciferol 100mcg
- Lipitor 10mg
- Prozac 30mg
- Synthroid 75 mcg
- Citrical 630mg [**Hospital1 **]
- Docusate 120mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Fluoxetine 10 mg Capsule [**Hospital1 **]: Three (3) Capsule PO DAILY
(Daily).
3. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
left cerebellar infarct with minor hemorrhagic transformation
a. fib with RVR
developmental delay
Dandy-Walker malformation
Discharge Condition:
Mental Status: unable to assess
Level of Consciousness: unable to fully assess but can be
aroused
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital with nausea, vomiting and increased
gait instabiliy. Imaging of your brain showed that there was a
stroke in the left side of your brain called the cerebellum;
this corresponded with the symptoms you presented with. The
stroke was likely caused by an abnormal heart rhythm called
atrial fibrillation; you were started on a medication called
Metoprolol to help control this heart rhythm and prevent your
heart from beating too fast. You were continued on Aspirin 325
mg daily.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2145-9-10**] 1:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2145-8-16**]
|
[
"2760",
"2724",
"2449",
"42731",
"42789"
] |
Admission Date: [**2113-3-20**] Discharge Date: [**2113-3-27**]
Date of Birth: [**2027-9-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Keflex / Clindamycin / adhesive tape / Gentamicin /
Zosyn / Cefepime
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Hypoxia, Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Chest tube placement
History of Present Illness:
85 y/o F with recent pneumonia, abdominal hernias, CHF, resident
at [**Hospital **] rehab, recent admission to MICU here, now with
worsening respiratory status today at rehab. She was initially
brought in to [**Hospital1 882**], was tachypneic and placed on cpap
initially. She failed cpap and was intubated with etomidate.
X-ray reported whiteout of right lung. Initial pressures 100/50
-> 60s/40s while at [**Hospital1 882**]. She was given 3 L NS, vanc/zosyn,
and placed on levophed/dopamine through RIJ (that was placed at
[**Hospital1 **]). She was transferred for further evaluation. She had a
head CT at the OSH, and read is pending.
.
In the ED, initial vitals were T 102.5, BP 90/52, HR 88, SpO2
99%/CMV 100%/PEEP 8/Vt 400/ RR 22. EKG showed sinus tachycardia
at 135. Her CXR showed a RUL opacity. Patient intubated, sedate
on exam, stool over sheets, multiple abdominal hernias but
abdomen benign. Flagyl was added to the vanco/zosyn given at
[**Hospital1 882**]. Her pressors are levo at 0.4 and dopa at 5. She
received no more IVFs in our ED. She is confirmed full code.
Past Medical History:
# PEA Arrest
# Massive UGIB
# Diastolic CHF
# Atrial Fibrillation s/p Ablation
# Dilated Ascending Aorta
# Osteoporosis
# Hypothyroidism
# Dysphagia for several years with Weight Loss s/p G-tube
placement
# History of PNA requiring VATS pleural effusion drainage and
decortication on the right side
# Diverticulosis/Diverticulitis
# Cerebral Palsy
# Macular degeneration
# Ventral Hernias
# Rosacia
.
Past Surgical History:
# Status post removal of bowel obstruction due to
diverticulitis requiring a temporary colostomy
# Status post surgical repair of a prolapsed uterus
# Status post total hysterectomy
# Status post abdominal surgery secondary to complications of
prolapsed uterus surgery - The patient developed multiple
hernias.
# Status post surgery for exposed keratoses
# Status post G-tube placement
Social History:
Lives alone in [**Location (un) **], recently in MACU at [**Hospital 100**] Rehab. No
tobacco, alcohol, or drug use. Family extremely involved in
care.
Family History:
Non-Contributory
Physical Exam:
Tmax: 38.4 ??????C (101.2 ??????F)
Tcurrent: 38.1 ??????C (100.6 ??????F)
HR: 79 (77 - 128) bpm
BP: 96/57(66) {89/53(63) - 157/73(93)} mmHg
RR: 22 (22 - 24) insp/min
SpO2: 92%
Heart rhythm: 1st AV (First degree AV Block)
Height: 59 Inch
General Appearance: Thin, Diaphoretic
Eyes / Conjunctiva: PERRL, Conjunctiva pale, has cloudy eyes
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical
adenopathy
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: on LUL, Diminished: bilaterally)
Abdominal: Soft, Non-tender, Bowel sounds present, G tube in
place, no erythema, signs of infection
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Musculoskeletal: Muscle wasting
Skin: Cool
Neurologic: Responds to: Noxious stimuli, Movement: Not
assessed, Sedated, Tone: Decreased
Pertinent Results:
Admission Labs:
CBC: WBC-16.6* RBC-3.67* Hgb-11.8* Hct-36.8 MCV-100* MCH-32.2*
MCHC-32.0 RDW-18.0* Plt Ct-313
Diff: Neuts-72* Bands-6* Lymphs-10* Monos-12* Eos-0 Baso-0
Atyps-0 Metas-0 Myelos-0
Coags: PT-14.0* PTT-29.5 INR(PT)-1.2*
Chemistries: Glucose-152* UreaN-35* Creat-0.6 Na-134 K-4.1
Cl-103 HCO3-20* AnGap-15 Albumin-2.5* Calcium-6.8* Phos-3.1
Mg-1.3*
CXR on admission:
1. Endotracheal tube with its tip at the level of the carina.
2. Left airspace opacification consistent with pneumonia.
Recommend
reevaluation following resolution to exclude a hilar mass.
Discharge Labs:
CBC: BLOOD WBC-9.4 RBC-2.98* Hgb-10.1* Hct-29.3* MCV-98
MCH-33.8* MCHC-34.4 RDW-17.7* Plt Ct-285
Diff: Neuts-91.6* Lymphs-4.0* Monos-2.3 Eos-1.8 Baso-0.2
Coags: BLOOD PT-11.8 PTT-29.7 INR(PT)-1.0
Chemistries: BLOOD Glucose-163* UreaN-14 Creat-0.4 Na-138 K-4.5
Cl-96 HCO3-37* AnGap-10
Brief Hospital Course:
85 y/o F with hx of diastolic CHF (LVEF >55%), AF, dysphagia
with a G-tube, recent pneumonia and MICU hospitalization and
type B aortic dissection being medical managed who presents from
rehab with worsening respiratory status, pneumonia and sepsis.
.
# Pneumonia/Sepsis: Patient arrived intubated and sedated and on
norepinephrine and phenylephrine infusions. She was initially
treated empirically with vancomycin, zosyn and flagyl. Her
prior PICC was removed and pressors were weaned. Sputum
cultures grew Klebsiella, and her vancomycin and flagyl was
stopped. She developed a rash and zosyn was suspected, so she
was switched to cefepime. She developed a different rash on
cefepime, so she was switched to meropenem and a new PICC was
placed. She completed an 8 day course of antibiotics (zosyn,
cefepime, meroepenem) for HCAP. A second sputum culture grew
Stenotrophomonas suseceptible to bactrim and she was started on
bactrim DS 2 tabs [**Hospital1 **] with a planned 14 day course, last day
[**2113-4-7**].
# Pneumothorax. She was initially extubated on [**2113-3-24**] without
complications. That night, she became acutely hypoxic and was
emergently reintubated. CXR demonstrated left pneumothorax and
a chest tube was placed by thoracic surgery. Subsequent chest
x-ray showed complete reexpansion. She was extubated again and
the chest tube was removed on [**2113-3-26**] without complication.
.
# Dysphagia/aspiration risk: Patient has had a long history of
dysphagia and receives feeding through a g-tube. She received
oral care q 4 hours, and frequent oral suctioning. Speech and
swallow services was consulted and final recommendations are
attached.
.
# Diarrhea: Patient had diarrhea on arrival and was covered with
IV flagyl. Subsequent stool c. diff antigen was negative x 2 and
flagyl was stopped.
.
# Hypertension: Patient arrived hypotensive and home
antihypertensives were held. As her blood pressure increased,
she was restarted on antihypertensives and was on amlodipine 5mg
PO daily and lisinopril 20mg PO daily on discharge.
.
# Type B Dissection: No further workup. Hypertension was
managed as above.
.
# Atrial Fibrillation: Metoprolol was held throughout this
hospitalization given hypotension and HR < 70. She was
continued on her home aspirin 81mg PO daily. She was not
treated with systemic anticoagulation given h/o GI bleed.
.
# Hypothyroidism: Patient continued home levothyroxine
.
# Macular Degeneration: Patient was continued home eye drops.
.
# Anemia: remained at baseline (~30) throughout this
hospitalization.
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Date Range **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/wheezing.
2. ipratropium bromide 0.02 % Solution [**Date Range **]: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB/wheezing.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Date Range **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. levothyroxine 50 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
5. acetaminophen 325 mg Tablet [**Date Range **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
6. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Date Range **]: One (1)
PO DAILY (Daily).
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Date Range **]: One
(1) Tablet, Chewable PO BID (2 times a day).
8. aspirin 81 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable
PO DAILY (Daily).
9. heparin (porcine) 5,000 unit/mL Solution [**Date Range **]: One (1)
Injection TID (3 times a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet [**Date Range **]: 2.5
Tablets PO DAILY (Daily).
11. senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. lisinopril 20 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY
(Daily).
13. metoprolol tartrate 25 mg Tablet [**Date Range **]: 0.5 Tablet PO BID (2
times a day).
14. bisacodyl 10 mg Suppository [**Date Range **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
15. erythromycin 5 mg/gram (0.5 %) Ointment [**Date Range **]: One (1)
application Ophthalmic QHS (once a day (at bedtime)): use one
ointment or the other - not both.
16. bacitracin-polymyxin B 500-10,000 unit/g Ointment [**Date Range **]: One
(1) Appl Ophthalmic QHS (once a day (at bedtime)): use one
ointment or the other - not both.
17. moxifloxacin 0.5 % Drops [**Date Range **]: One (1) drops Ophthalmic TID
prn () as needed for eye irritation.
18. gatifloxacin 0.3 % Drops [**Date Range **]: One (1) drop Ophthalmic 4 x a
day, M,W,F ().
19. polyvinyl alcohol 1.4 % Drops [**Date Range **]: 1-2 Drops Ophthalmic Q2H
(every 2 hours).
20. docusate sodium 100 mg Capsule [**Date Range **]: One (1) Capsule PO BID
(2 times a day).
21. lorazepam 0.5 mg Tablet [**Date Range **]: [**1-24**] Tablet PO BID (2 times a
day) as needed for anxiety. Tablet(s)
22. amlodipine 5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
23. vancomycin 500 mg Recon Soln [**Month/Day (4) **]: 1.5 Recon Solns
Intravenous Q 12H (Every 12 Hours).
24. cefepime 2 gram Recon Soln [**Month/Day (4) **]: One (1) Recon Soln Injection
Q24H (every 24 hours).
Discharge Medications:
1. aspirin 81 mg Tablet [**Month/Day (4) **]: One (1) Tablet, Chewable PO DAILY
(Daily).
2. acetaminophen 650 mg/20.3 mL Solution [**Month/Day (4) **]: One (1) PO Q6H
(every 6 hours) as needed for fever.
3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Month/Day (4) **]: [**1-22**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
4. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection [**Hospital1 **] (2 times a day).
5. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
QID (4 times a day) as needed for itching.
6. gatifloxacin 0.3 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic QID on
3X/WEEK ().
7. erythromycin 5 mg/gram (0.5 %) Ointment [**Hospital1 **]: One (1) drop
Ophthalmic QHS 3X/WEEK ().
8. moxifloxacin 0.5 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic TID on
4X/WEEK ().
9. bacitracin-polymyxin B 500-10,000 unit/g Ointment [**Hospital1 **]: One
(1) Appl Ophthalmic 4X/WEEK ([**Doctor First Name **],TU,TH,SA).
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Doctor First Name **]: Two (2)
Tablet PO TID (3 times a day) for 12 days: Last day [**2113-4-7**].
11. oxycodone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. amlodipine 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
13. bisacodyl 10 mg Suppository [**Month/Day/Year **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed for CONSTIPATION.
15. nystatin 100,000 unit/mL Suspension [**Month/Day/Year **]: Five (5) ML PO QID
(4 times a day) as needed for THRUSH.
16. lisinopril 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
18. heparin, porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
19. PICC
PICC care per protocol. [**Month (only) 116**] remove if indicated.
20. Palliative Care
Palliative Care consultation
21. insulin sliding scale
please check fingerstick blood glucose qid and administer
insulin lispro (humalog) according to attached sliding scale
22. oral care
1. Remain NPO with PEG feedings only.
2. Oral care every 4 hours with toothbrushes and toothettes
attached to suction with a sterilizing mouthwash & toothpaste.
3. Try a drop of Atropine under her tongue to dry excess
oropharyngeal secretions.
4. Provide Yankauer suctioning as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Klebsiella, Stenotrophomonas Pneumonia
Pneumothorax
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with pneumonia, and were
placed on a ventilator. You were treated with intravenous
antibiotics for 8 days, and oral antibiotics, which you will
continue to take on discharge. After you were taken off the
ventilator, you had a pneumonthorax, or a lung collapse. You
were briefly put back on the ventilator and a chest tube was
placed. The pneumonthorax resolved, and you were taken off the
venilator again and thechest tube was removed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You will be seen by physicians at the MACU at [**Hospital 100**] rehab.
Please arrange follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from the MACU at [**Hospital 100**] Rehab.
Please follow up with the following appointments:
Department: ENDO SUITES
When: WEDNESDAY [**2113-6-14**] at 8:30 AM
Department: DIGESTIVE DISEASE CENTER
When: WEDNESDAY [**2113-6-14**] at 8:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
|
[
"0389",
"78552",
"51881",
"2761",
"42731",
"99592",
"4280",
"2449",
"4019"
] |
Admission Date: [**2189-3-23**] Discharge Date: [**2189-3-26**]
Date of Birth: [**2168-1-28**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
SOB, CP, N/V
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 21 year old woman with a history of DM1 since
age 6, no prior hx of DKA, on an insulin pump, who presents with
shortness of breath and chest pain and admitted to the [**Hospital Unit Name 153**] for
DKA.
She reports that she stopped her insulin pump 2 days ago because
she did not have the proper tubing to attach it. She was
supposed to get something in the mail but has not seen it. She
was taking SC Humalog but only small amounts. She has been
stressed from exams and reports that yesterday she felt that she
had allergies with nasal congestion and a cough that was
occasionally productive of thick green sputum. She felt mildly
feverish but did not take her temperature. Later in the day she
did have chills and felt more short of breath. She stayed up
all night at the library and later in the night developed
non-bloody, non-bilous vomitting x 3. Around 2am she had a
chest pressure that was non-radiating and present on arrival to
the ED at 4/10. She reports fingersticks in the 300s yesterday
(she checked twice) and she was taking minimal insulin. She
took 3 units of Humalog last night. She felt that her abdomen
was distended yesterday. She had 1 episode of small diarrhea
yesterday but otherwise has been having regular bowel movements.
She has not seen an enocrinologist in > 1 year and last doctor
she saw was in [**State 8449**]. She has not established care in
[**Location (un) 86**]. Of note, she recently had a friend pass away [**12-8**] with
a similar presentation and in DKA.
In the ED, initial vs were: T99.4 124 164/100 18 100% RA. She
triggered in the ED for tachycardia in the 130s and tachypnea in
the 30s. ECG showed sinus tach with peaked T waves.
Fingerstick was critically high. She was given 1L/hour of NS
(had received 1.5L so far), 10 units regular insulin. Lytes
came back with K 5.3, bicar < 5 and creatinine 1.4. Anion gap
was 33. K+ 5.6. She was given 7 units of humalog bolus and
started on 7 units/hr humalog gtt. She was given 1mg Ativan for
anxiety. IV access: 2 18 gauge. Vitals prior to transfer: 122
38 168/94 100% on 2L.
On the floor, she feels short of breath. She denies chest,
abdominal pain or other pain. She is tearful.
Past Medical History:
DM type 1, no history of DKA since diagnosis at age 6
Social History:
Originally from [**State 8449**], student at [**University/College 5130**] studying
international business. No tobacco use. Drinks alcohol
socially, had 4 drinks saturday night while going out. Denies
any IVDU. Does not live in the dorms, has a studio apartment.
Family History:
No family history of diabetes or heart disease. Is an only
child, both parents are alive and healthy.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.8 BP: 141/71 P: 133 R: 35 O2: 100% on facemask
General: Alert, oriented, tearful
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Pertinent Labs:
[**2189-3-23**] 07:40AM BLOOD WBC-16.3* RBC-4.32 Hgb-14.3 Hct-46.9
MCV-109* MCH-33.2* MCHC-30.6* RDW-12.5 Plt Ct-338
[**2189-3-23**] 07:40AM BLOOD Glucose-718* UreaN-18 Creat-1.4* Na-133
K-6.3* Cl-95* HCO3-<5*
[**2189-3-26**] 05:35AM BLOOD Glucose-388* UreaN-5* Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-21* AnGap-15
[**2189-3-23**] 09:23AM BLOOD Type-[**Last Name (un) **] pO2-55* pCO2-21* pH-6.91*
calTCO2-5* Base XS--30
[**2189-3-23**] 07:45AM BLOOD K-5.6*
Brief Hospital Course:
1. Diabetic ketoacidosis. Presented in DKA, likely the result of
her not using her insulin pump. In the ICU she was aggressively
fluid resuscitated and placed on an insulin gtt. [**Last Name (un) **] was
consulted. Her transition to [**Hospital1 **] subcutaneous NPH insulin was
complicated by a rise in her venous lactate and brief widening
of her anion gap, so she was restarted on insulin drip briefly
then transitioned back to an increased dose of NPH, then once
daily glargine.
Plan on discharge was to continue with lantus and humalog SS
with [**Last Name (un) **] follow-up. They may reinitiate the insulin pump at a
later date.
2. URI. Presented with cough, nasal congestion, single febrile
episode to 101; no signs of bacterial infection on imaging/labs,
but given initial difficulty coming off insulin drip, patient
was started on 5d course of azithro.
Medications on Admission:
Humalog insulin pump
Discharge Medications:
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
2. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day.
Disp:*qs x1 month units* Refills:*2*
3. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: please see attached sliding scale.
Disp:*qs x1 month units* Refills:*2*
4. insulin syringe-needle,dispos. 1 mL 28 x [**11-30**] Syringe Sig:
One (1) Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diabetic ketoacidosis
2. Diabetes, type I
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 diabetic ketoacidosis
which results from elevated blood sugars.
Given that you do not have your pump supplies available here, we
have started you on subcutaneous insulin regimen which you will
continue until you follow-up with the [**Last Name (un) **].
Followup Instructions:
You have two appointments scheduled at [**Last Name (un) **]:
1. [**2189-4-2**] at 2:30 with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**], NP
2. [**2189-5-1**] at 1:00 with Dr. [**Last Name (STitle) **]
In addition, you should follow-up with the providers at
[**University/College 5130**].
|
[
"V5867"
] |
Admission Date: [**2174-10-9**] Discharge Date: [**2174-10-17**]
Date of Birth: [**2092-9-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2174-10-12**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Diag, SVG to OM, SVG to PDA), Aortic Valve Replacement (23mm St.
[**Male First Name (un) 923**] Epic porcine valve)
History of Present Illness:
This year old white male has known CAD and is followed by his
cardiologist. He underwent a stress test in [**3-5**] which was
positive and then underwent cardiac catheterization which
revealed three vessel disease with moderate aortic stenosis. He
remained stable and a followup catheterization on [**10-7**] revealed
progression of his coronary disease with new occlusive disease
of the right artery. his aortic valve orifice was 1.6 cm2. He
was referred for surgery.
Past Medical History:
Coronary Artery Disease
Aortic Stenosis
Hypertension
Hyperlipidemia
Diabetes Mellitus
Hypothyroidism
Chronic Renal Insufficiency
Benign Prostatic Hypertrophy
h/o Prostate Cancer
s/p Zenker's Divertriculum repair
Social History:
Denies tobacco use. Admits to occasional ETOH use.
Family History:
Brother died from MI at age 53. Father died at 79, was s/p CABG.
Physical Exam:
VSS, alert and oriented
Lungs- slightly decreased BS at bases.
Cor- SR at 62. crisp valve sounds
Abdomen- benign
extremities- warm, trace edema pretibially
EVH wounds clean and dry. Sternum stable.
Pertinent Results:
[**10-12**] Echo: 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. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. There are simple atheroma in the aortic arch. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (area 1.5 cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-29**]+) mitral regurgitation is seen. There was some inflow into
the right atrium which, at first, appeared may represent an
anomalous pulmonary vein. However, furter investigation suggests
that it was simply inferior vena c aval inflow oriented somewhat
differently. There is a trivial/physiologic pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in
the operating room at the time of the study.
POST CPB There is normal biventricular systolic function. A
bioprosthesis is well seated in the aortic position. The
leaflets are not well seen. There is no aortic regurgitation
appreciated. The maximum gradient across the aortic valve is 8
mm Hg with a mean gradient of 4 mm Hg with a cardiac output of 7
liters/minute. The thoracic aorta appears intact. The mitral
regurgitatiion is somewhat improved - now mild.
[**2174-10-17**] 05:25AM BLOOD Hct-26.1*
[**2174-10-16**] 07:20AM BLOOD WBC-9.2 RBC-3.32*# Hgb-10.5*# Hct-29.6*#
MCV-89 MCH-31.6 MCHC-35.5* RDW-16.7* Plt Ct-133*
[**2174-10-17**] 05:25AM BLOOD PT-15.9* INR(PT)-1.4*
[**2174-10-16**] 07:20AM BLOOD PT-13.9* INR(PT)-1.2*
[**2174-10-15**] 06:55AM BLOOD PT-13.2 PTT-25.9 INR(PT)-1.1
[**2174-10-17**] 05:25AM BLOOD UreaN-40* Creat-2.0* K-3.8
[**2174-10-16**] 07:20AM BLOOD Glucose-48* UreaN-39* Creat-2.0* Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
[**2174-10-15**] 06:55AM BLOOD Glucose-37* UreaN-45* Creat-2.0* Na-138
K-4.1 Cl-107 HCO3-23 AnGap-12
[**2174-10-14**] 05:30AM BLOOD Glucose-82 UreaN-39* Creat-1.8* Na-135
K-5.3* Cl-106 HCO3-24 AnGap-10
[**2174-10-13**] 02:36AM BLOOD Glucose-98 UreaN-31* Creat-1.3* Na-138
K-4.2 Cl-111* HCO3-23 AnGap-8
Brief Hospital Course:
Following admission the patient completed his preoperative
workup. This included an echocardiogram which revealed slightly
impaired left ventricular function and moderate aortic stenosis
( [**Location (un) 109**] ~1.1 cm, gradient 35 mmHg). Carotid ultrasound
demonstrated no significant lesions.
On [**10-12**] he was brought to the operating room where he underwent
a coronary artery bypass graft x 4 and aortic valve replacement.
Please see operative report for surgical details. He weaned
from bypass on propofol and phenylephrine in stable condition.
Following surgery he was transferred to the CVICU for invasive
monitoring. He remained stable and was extubated easily after
surgery and weaned from pressor. He was transferred to the
floor on POD 1. Following transfer he developed atrial
fibrillation for which amiodarone was begun. He converted to
sinus rhythm on [**10-16**] and remained there. Coumadin was begun
during his time in atrial fibrillation.
He was ready for discharge home. His creatinine which was
mildly elevated chronically at 1.5, rose to 2 after surgery,
where it remained. This will be rechecked a week after
discharge.
His INR was 1.2 at discharge and he will take 4 mg [**10-17**] and 21.
He will have a PT/INR drawn on [**10-19**] with results sent to Dr.
[**Last Name (STitle) 6051**] for regulation, with a target INR of [**1-29**].5.
Medications on Admission:
Colace 100mg [**Hospital1 **], Protonix 40mg qd, Aspirin 325mg qd, Amlodopine
10mg qd, Levothyroxine 112mcg qd, Lisinopril 10mg qd, Niacin
500mg qd, Zetia 10mg qd, Simvastatin 80mg qd, Atenolol 100mg qd,
HCTZ 25mg qd, Terazosin 5mg qd
Discharge Medications:
1. Influen Tr-Split [**2173**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ASDIR (AS DIRECTED).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
4 weeks.
7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Warfarin 1 mg Tablet Sig: as ordered Tablet PO DAILY
(Daily): INR target 2-2.5.
14. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
17. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
18. Terazosin 5 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p Coronary Artery Bypass Graft x 4
Aortic Stenosis s/p Aortic Valve Replacement
Hypertension
Hyperlipidemia
Diabetes Mellitus
Hypothyroidism
Chronic Renal Insufficiency
Benign Prostatic Hypertrophy
h/o Prostate Cancer
s/p Zenker's Divertriculum repair
paroxysmal atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any redness of or drainage from incisions
report any weight gain greater than 3 pound in a day or 5 pounds
in a weak
report any temperature greater than 100.5
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 1295**] in [**1-30**] weeks
Dr. [**Last Name (STitle) 6051**] in [**12-29**] weeks ([**Telephone/Fax (1) 77748**], also regulating Coumadin
(FAX [**Telephone/Fax (1) 25494**])
Please call to make appointments
Completed by:[**2174-10-17**]
|
[
"41401",
"9971",
"5119",
"4241",
"42731",
"5859",
"25000",
"40390",
"2449",
"V5861",
"2720"
] |
Admission Date: [**2191-5-28**] Discharge Date: [**2191-6-6**]
Date of Birth: [**2125-5-16**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Metoclopramide / Infed / Heparin Agents
Attending:[**First Name3 (LF) 25504**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
[**2191-5-28**]: ultrasound-guided percutaneous cholecystostomy
[**2191-6-2**]: IR guided PICC placement
History of Present Illness:
Pt is a 66 y/o M with PMH significant for ESRD on HD,
compensated liver cirrhosis c/b esophageal varices, poorly
controlled D2M s/p bilateral BTK amputations, AV fistula
infections (VRE and MRSA) and recently diagnosed pancreatic head
mass likely pancreatic adenocarcinoma from EGD brushings was
admitted to the transplant surgery service [**2191-5-28**] ago for
altered mental status which has persisted over his hospital stay
despite abx (IV zosyn) for GNR found in blood (at [**Hospital 100**] Rehab
facility), lactulose.
He was sent to ED from [**Hospital 100**] Rehab where he resides with
altered mental status. Reports from rehab indicate the patient
had a fever and altered mental status first on [**5-25**] and at that
time was started on empiric vanc/zosyn without a source of
infection. Blood cultures sent that day have since yielded GNRs
in [**12-28**] bottles. Reportedly the patient's mental status improved
and he did not have further fevers over the next two days.
Consequently he was sent to [**Hospital1 18**] ED for further evaluation
since his mental status declined again.
On arrival to [**Hospital1 18**] he continued to be somnolent; blood
pressures were marginal with SBP high 80s / low 90s. Notably
the patient last received HD yesterday via his right IJ tunneled
catheter without complications. In the ED he was arousable to
voice but quickly returned to somnolence, he was unable to
answer history questions but denied pain.
.
Since his admission to the transplant service, he has been found
to have a perforated gallbladder on CT abd s/p IR guided
percutaneous chole since he is not a surgical candidate for
cholecystectomy. His CT was also neg for ascitis for tap. Head
CT has been neg for intra-cranial process or bleed. Blood
cultures here have been neg to date. Also, he has persistently
failed speech and swallow evaluations and is NPO for aspiration
risk. He is on tube feeds via Dobhoff.
.
Patient reports an increased sense that he is dying slowly
because his medical condition is deteriorating. He admits to
diffuse non-localized or radiating abdominal pain and chills.
Denies nausea/vomiting, chest pain/SOB. Had diarrhea
(appropriately from the lactulose), no pain/burning with
urination.
Past Medical History:
ESRD from diabetic nephropathy on HD since [**5-/2183**]
Diabetes mellitus type II for over 20 years on insulin
HTN
Hepatitis C genotype 4
Hep B core Ab positive (negative viral load in [**2185**])
Cirrhosis - [**1-26**] HCV, portal hypertensive gastropathy
Ischemic colitis with GIB ([**2180**]), occ BRBPR; known small bowel
AVMs
Small bowel AVMs
Grade I esophageal varices
Chronic anemia
H/o right AV fistula infection
Gastric Antral Vascular Ectasia
S/p penectomy for necrosis [**1-26**] arterial insufficiency
S/p bilat BKA ([**2179**], [**2183**])
H/o IV drug use (heroin), on methadone since [**2159**]
H/o ESBL Klebsiella wound infections
H/o MRSA, VRE and Clostridium difficile
H/o L hand and finger MRSA osteomyelitides
H/o TB (age 15, Rx with PAS/INH x 2 yrs)
H/o line infections w/MSSA, E. fecalis, Pseudomonas and C.
glabrata
Social History:
Born in [**Location (un) 86**] and most recently lived in [**Hospital 100**] Rehab. He has
several brothers/sisters and four children. Worked with
computers. Has history of [**12-26**] ppd smoking for 10 years. Long
time history of IV drug (heroine use) and has been on methadone
since [**2159**]. Denies EtoH and other illicits currently.
Family History:
Several siblings with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Tm:98.7, Tc:96.7, HR:60-70, BP:150/81(110-160/40-80),
RR:18, O2 Sat: 96%RA
GEN: Sick appearing cachetic gentleman lying in bed with feeding
tube in right nostril, no teeth, hypophonic, no acute distress.
Alert, oriented to self but not place (in church) and time
([**Month (only) 404**])
HEENT: Normocephalic, sclera icterus, oropharynx clear, MMM
NECK: No thyromegaly, no lymphadenopathy
CV: Regular rate, normal rhythm, no
murmurs/gallops/regurgitation
PULM: Clear to auscultation bilaterally, mild crackles in the
bases, no wheezing/ronchi, non-labored breathing.
ABD: Soft, decreased bowel sounds, tender to palpation in all
four quadrants, no rebound/guarding
EXT: Bilateral below the need amputation, cool but pulses
palpable in all four extremities. Has 4 fingers on the left.
Nails are dark and clubbed.
SKIN: Difficult to evalaute for spider angioma or palmar
erythema.
NEURO: Alert, interactive, oriented to self but not time or
place. Limited due to inability to follow commands fully.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm:97.7, Tc:93.8, HR:60-70, BP:127/33(110-150/40-80),
RR:18, O2 Sat: 96%RA
GEN: Sick appearing cachetic gentleman lying curled in bed with
feeding tube in right nostril, no teeth, hypophonic, no acute
distress. Opens his eyes with mention of his name but does not
follow commands. Teary.
HEENT: Normocephalic, sclera icterus, oropharynx clear, MMM
NECK: No thyromegaly, no lymphadenopathy
CV: Regular rate, normal rhythm, no
murmurs/gallops/regurgitation
PULM: Clear to auscultation bilaterally, mild crackles in the
bases, no wheezing/ronchi, non-labored breathing.
ABD: Soft, decreased bowel sounds, tender to palpation in all
four quadrants, no rebound/guarding
EXT: Bilateral below the need amputation, cool and non-palpable
pulses in upper extremities. Has 4 fingers on the left. Nails
are dark and clubbed.
SKIN: Difficult to evalaute for spider angioma or palmar
erythema.
NEURO: Opens eyes with mention of name but does not follow
commands.
Pertinent Results:
[**2191-5-28**] 06:21AM BLOOD WBC-13.6*# RBC-3.30* Hgb-10.1* Hct-31.8*
MCV-97 MCH-30.5 MCHC-31.6 RDW-18.0* Plt Ct-162#
[**2191-5-30**] 05:12AM BLOOD WBC-10.3 RBC-2.95* Hgb-8.9* Hct-28.5*
MCV-97 MCH-30.3 MCHC-31.4 RDW-17.4* Plt Ct-146*
[**2191-6-1**] 05:21AM BLOOD WBC-6.4 RBC-3.09* Hgb-9.5* Hct-30.2*
MCV-98 MCH-30.7 MCHC-31.5 RDW-17.2* Plt Ct-136*
[**2191-6-3**] 05:10AM BLOOD WBC-6.7 RBC-3.05* Hgb-9.4* Hct-29.7*
MCV-97 MCH-30.7 MCHC-31.5 RDW-17.5* Plt Ct-163
[**2191-6-4**] 05:45AM BLOOD WBC-7.8 RBC-3.08* Hgb-9.7* Hct-30.0*
MCV-97 MCH-31.4 MCHC-32.2 RDW-17.8* Plt Ct-178
[**2191-6-5**] 06:00AM BLOOD WBC-9.0 RBC-3.47* Hgb-10.7* Hct-33.8*
MCV-97 MCH-30.7 MCHC-31.6 RDW-17.9* Plt Ct-212
[**2191-5-28**] 06:21AM BLOOD Neuts-88.7* Lymphs-8.1* Monos-2.7 Eos-0.2
Baso-0.2
[**2191-5-28**] 06:21AM BLOOD Plt Ct-162#
[**2191-5-30**] 05:12AM BLOOD Plt Ct-146*
[**2191-6-1**] 05:21AM BLOOD Plt Ct-136*
[**2191-6-4**] 05:45AM BLOOD Plt Ct-178
[**2191-6-5**] 06:00AM BLOOD Plt Ct-212
[**2191-5-28**] 06:21AM BLOOD Glucose-192* UreaN-28* Creat-3.1*# Na-140
K-3.4 Cl-100 HCO3-29 AnGap-14
[**2191-5-30**] 05:12AM BLOOD Glucose-70 UreaN-56* Creat-4.6*# Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2191-6-1**] 05:21AM BLOOD Glucose-167* UreaN-40* Creat-4.2*# Na-138
K-4.1 Cl-102 HCO3-23 AnGap-17
[**2191-6-3**] 05:10AM BLOOD Glucose-81 UreaN-29* Creat-3.8* Na-135
K-4.0 Cl-96 HCO3-26 AnGap-17
[**2191-6-3**] 11:00AM BLOOD UreaN-6
[**2191-6-4**] 05:45AM BLOOD Glucose-106* UreaN-17 Creat-2.8* Na-135
K-4.8 Cl-95* HCO3-23 AnGap-22*
[**2191-6-5**] 06:00AM BLOOD Glucose-259* UreaN-30* Creat-4.2*# Na-133
K-5.7* Cl-93* HCO3-23 AnGap-23*
[**2191-6-5**] 02:43PM BLOOD Glucose-307* UreaN-33* Creat-4.8* Na-132*
K-8.1* Cl-92* HCO3-25 AnGap-23*
[**2191-5-28**] 06:21AM BLOOD ALT-19 AST-31 CK(CPK)-78 AlkPhos-119
Amylase-15 TotBili-3.9*
[**2191-5-29**] 01:28AM BLOOD ALT-19 AST-26 LD(LDH)-125 AlkPhos-93
TotBili-1.7*
[**2191-5-28**] 06:21AM BLOOD cTropnT-0.08*
[**2191-5-29**] 01:28AM BLOOD Calcium-9.7 Phos-2.5* Mg-2.1
[**2191-6-3**] 05:10AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.2
[**2191-6-5**] 06:00AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.8*
[**2191-6-5**] 05:21PM BLOOD Calcium-10.1 Phos-4.3 Mg-2.8*
Brief Hospital Course:
The patient is a 66M with cirrhosis and ESRD as well as
pancreatic neoplasm admitted to the surgery service with
perforated cholecystitis as seen on abd CT scan. Broad spectrum
antibiotic coverage (vanc/cefepime/flagyl)was started. He
underwent IR perc cholecystostomy tube placement (8 French
[**Last Name (un) 2823**] catheter) on [**5-28**]. Blood cultures from [**5-28**] isolated staph
coag negative. Bile gram stain were positive for gram negative
rods. Vancomycin was stopped. A 2 week course of flagyl and
cefepime was recommended. Given poor IV access, a right femoral
triple lumen central line was placed. This was removed on [**6-2**]
after a LUE picc was placed. A 28 cm single lumen PICC was
placed via left brachial approach with tip in left subclavian
vein (not SVC). Nephrology followed him and dialyzed him via the
right tunnelled dialysis line on M-W-F schedule. His mental
status wax and waned. On [**6-2**], he was more lethargic and
confused. A lactulose enema was given with slight improvement of
mental status. Speech and swallow evaluation was unable to be
done as patient was confused at that time and could not
participate in evaluation. He was more confused with aphasia
with left arm weakness prompted a non-contrast head CT that
demonstrated no acute process. There was concern that the
Cefepime could be responsible for mental status changes as
Cefepime can cause neuro toxicity as well as Flagyl. Cefepime
was switched to Zosyn on [**6-3**] and Flagyl was d/c'd. His mental
status continued to deteriorate. He passed away on [**6-6**] after a
rapid decline and a change in goals of care to focus on comfort.
Medications on Admission:
(per OMR) amylase/lipase/protease 2caps PO TID with meals,
calcium acetate 667mg PO BID, diphenoxylate-atropine 2.5/0.025mg
PO q4h, doxepin 10mg PO qHS, famotidine 20mg PO qHS, folic acid
1mg PO daily, gabapentin 300mg PO daily, lantus 10Units SC qHS,
Humalog 2Units qAM and ISS with meals and at bedtime, methadone
600mg PO BID (per OMR, not verified!), nadolol 20mg PO daily,
opium tincture 6mg PO QID prn diarrhea, Renagel 1600mg PO TID
with meals, vit B12 500mcg PO daily, loperamide 4mg PO QID prn
diarrhea, iron 325mg PO daily
ALLERG: Cephalosporins (itching), Metoclopramide, Infed
Discharge Medications:
paient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
[**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 25507**]
|
[
"40391",
"25000",
"V5867"
] |
Admission Date: [**2132-3-28**] Discharge Date: [**2132-4-9**]
Date of Birth: [**2054-2-21**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Levaquin
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
Hip and patellar fracture
Major Surgical or Invasive Procedure:
ORIF of right patella fx
ORIF of right femoral neck fracture
History of Present Illness:
Briefly, Mr. [**Known lastname 1104**] is a 78 year old male with extensive medical
history, who uses a RLE prosthesis for ambulation s/p R BKA from
PVD, who presents s/p fall when his prosthesis slipped out of
place, found to have R patellar and non-displaced fracture of
the R femoral neck, here for possible orthopedic surgery. His
medical problems notably include CAD s/p CABG in [**2117**], MI [**2123**],
MIBI with fixed and reversible defects in [**2129**], CHF with EF 20%,
PVD s/p R BKA with b/l iliac stents, AAA found to be 5.4 x 5.0
cm on recent abdominal US, paroxysmal atrial fibrillation,
bovine AVR, and CRI, on coumadin for his iliac stents and PAF.
Patient reports that at baseline he is able to walk about 2
blocks, and activity is limited by SOB. He feels SOB getting
out of bed in the morning. He is able to climb a flight of
stairs without difficulty. He denies orthopnea or LE edema. No
recent weight gain.
Past Medical History:
1) CAD s/p CABG [**2117**], MI [**2123**]
2) AS s/p AVR [**2123**] (bovine)
3) PVD s/p R BKA and b/l iliac artery stents
4) Carotid stenosis s/p R CEA
5) h/o C. Diff
6) h/o MRSA
7) CHF class [**Last Name (LF) 1105**], [**First Name3 (LF) **] 30%
8) AAA 5 x 5.4 cm
9) S/P AICD
10) Hypercholesterolemia
11) CRI (baseline approx. 1.3)
12) PAF
Social History:
Lives at home alone, independent. Quite smoking 8 years ago but
50 pack year smoking hx.
Family History:
Non-contributory
Physical Exam:
98.2, 68, 100/48, RR15, 98% on RA
Gen: Cachectic appearing elderly male, resting comfortably in
bed, appearing in pain with movement.
Neck: No JVD.
Cor: RR, normal rate, no m/r/g.
Lungs: CTA b/l.
Abd: NABS, soft, NT/ND
Extr: No c/c/e. R BKA. Swollen, erythematous R knee,
exquisitely tender. Trace PT on the L.
Pertinent Results:
[**3-28**] AP, LATERAL AND SUNRISE VIEWS OF THE PATELLA: No prior
studies are available for comparison. There is a horizontal
fracture through the patella with 1.2 cm of displacement of the
fragments anteriorly. There is a small joint effusion. There are
changes from prior BKA, and extensive [**Month/Year (2) 1106**] calcifications
are present.
IMPRESSION: Horizontal patellar fracture with 1.2 cm of
displacement anteriorly.
[**3-28**] PELVIS AND RIGHT HIP, THREE VIEWS: There is a transverse
lucency through the femoral neck, which may represent a
nondisplaced fracture. No other fractures or dislocations are
identified. Degenerative changes of the SI and hip joints are
noted. There is diffuse demineralization. Extensive [**Month/Year (2) 1106**]
calcifications and iliac stents are noted.
IMPRESSION: Transverse lucency through the femoral neck, which
may represent a nondisplaced fracture.
[**3-28**] CT PELVIS: There is a nondisplaced fracture of the
proximal right femoral neck. No other fractures or dislocations
are identified. There is diffuse osteopenia. There is a small
amount of high attenuation fluid within the right hip joint
space, which may represent a small amount of hemorrhage.
Extensive [**Month/Year (2) 1106**] calcifications are seen as are bilateral
iliac stents. Visualized portions of the pelvis are
unremarkable. Soft tissue structures are within normal limits.
IMPRESSION: Nondisplaced fracture of the right femoral neck.
Brief Hospital Course:
78 year old male with extensive medical history, notably
including CAD s/p CABG in [**2117**], MI [**2123**], MIBI with fixed and
reversible defects in [**2129**], CHF with EF 20%, PVD s/p R BKA with
b/l iliac stents, AAA found to be 5.4 x 5.0 cm on recent
abdominal US, paroxysmal atrial fibrillation, who uses a RLE
prosthesis for ambulation s/p R BKA, who presents s/p mechanical
fall with R patellar and R femoral neck fractures, here for
orthopedic surgery.
1) Ortho: Patient is high risk for surgery, however per ortho,
surgery will not be extensive, could be completed in relatively
short time frame, possibly under spinal anesthesia only.
Awaiting cardiolgy consult for estimate of operative risk given
recent MIBI with reversible defects in all territories, and cath
with 3VD. Patient willing to accept 25-30% chance of operative
mortality. [**Year (4 digits) **] has seen patient and says o.k. for surgery.
Limiting factor may be INR, as still 2.9 with 5 mg Vitamin K.
Another 5 mg given, but may need FFP/platelets, and given EF
30%, would likely need to be done under controlled setting in
ICU in case of respiratory distress. [**Month (only) 116**] defer until tomorrow.
Needs patellar surgery one way or another in order to ever be
able to use prosthesis again.
2) AAA: Seen by [**Month (only) 1106**]. Will try to get CTA during
hospitalization at some point, though not now in setting of
worsened creatinine. [**Month (only) 116**] just be able to get abdominal US.
Appreciate [**Month (only) 1106**] consult. Outpatient repair of AAA.
3) CHF: Class [**Last Name (LF) 1105**], [**First Name3 (LF) **] 20% in past, though 30% on most recent
cath, currently dry on exam, therefore holding lasix. If
patient doesn't go to surgery tonight, will order food and will
likely order lasix then. Also will need lasix with any
FFP/platelets.
-Coumadin for goal INR [**1-10**]
4) PVD: Bilateral iliac stents, on coumadin, therefore once INR
below 2, will have to start heparin drip.
--recheck INR post second dose of vitamin K, if < 2.0, will
start heparin, and d/c prior to surgery
5) A-fib: As above, holding coumadin.
6) CRI: Slightly above baseline. Holding ACE-I.
7) FEN: K borerline therefore holding ACE-I. No fluids. Will
order food if pt. doesn't go to OR.
8) Code: Full.
9) PPx: Heparin drip then transfer to coumadin, senna, colace.
Removed RIJ CVL and placed peripheral IV on [**2132-4-9**]. Hct 29.7 on
discharge. Needs daily Hct and INR. Transfuse Hct<28 and keep
INR [**1-10**].
Medications on Admission:
Coumadin
Lipitor 10 mg daily
Lasix 20 mg alternating with 40 mg
folate
Toprol 25 mg daily
Zestril 2.5 mg daily
Tylenol PRN
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Per slide scale.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-9**] Sprays Nasal
QID (4 times a day) as needed.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust dose to keep INR 2.0-3.0. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Right Patella fracture
Right femoral neck fracture
Post-op anemia
AAA
CHF
ARF
DM
PVD
Discharge Condition:
stable
Discharge Instructions:
Please cont with non-weight bearing left leg. Coumadin for
anti-coagulation goal INR 2.0-3.0. Oral pain medication as
needed. Please keep incision clean/dry. Please call/return if
any fevers, increased discharg from incision, or trouble
breathing.
Please check Hct, coags on arrival.
Check daily Hct. If Hct <28, then transfuse. Last Hct [**2132-4-8**]
29.7.
Followup Instructions:
Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2132-8-4**] 11:00
Follow-up with Dr.[**First Name (STitle) **] 2weeks after discharge, please call this
week for appt. [**Telephone/Fax (1) 1113**]
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-5-28**]
10:00
|
[
"5849",
"4280",
"42731",
"25000",
"41401"
] |
Admission Date: [**2129-3-5**] Discharge Date: [**2129-3-11**]
Date of Birth: [**2046-10-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
transfer from [**Hospital1 1516**] service for diuresis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 82 year-old gentleman with a history of CAD s/p CABG,
systolic HF, and PVD s/p numerous revascularizations who
presented with worsening edema, SOB and LLE cellulitis. Patient
is a poor historian, but per report from wife, he recently
completed an outpatient course of antibiotics (name unknown) and
was noted to have pain and darkening of the L 1st toe over the
last week. No c/o fevers or chills. He has had weight gain over
the past week and has felt SOB at rest and on exertion, with
ankle edema, orthopnea and PND, but no CP. Of note, he was
admitted for CHF exacerbation and similar toe complaints
12/[**2127**].
.
In ED, VS T 96.7, BP 100/39, HR 98, 18, 100%RA. Pt was noted to
be somnolent. Pt received vanco and pip-tazo for dry
gangrene/osteo after two sets of blood cultures were obtained.
He was noted to have an elevated BNP and troponin and admitted
to cardiology for further eval and mgmt. He additionally
received 200cc NS bolus prior to transfer to the floor.
.
On the floor, he was to be started on a lasix gtt for diuresis,
but given SBP in the 80s, he was transferred to the CCU for
closer monitoring for diuresis.
.
On arrival to the CCU, patient is drowsy, but in no acute
distress and denies current foot pain. He currently feels SOB
and has a dry cough. He notes having intermittent palpitations
and lightheadedness in the past, but denies these sx currently.
Also denies abd pain.
Past Medical History:
# CAD: IMI [**2097**] s/p 2V CABG, s/p redo 5V CABG
# Chronic systolic HF: ischemic cardiomyopathy, LVEF 30%
# Atrial fibrillation on coumadin
# DM type 2: c/b peripheral neuropathy
# CKD: baseline creatinine 1.5-2.5
# hyperlipidemia
# HTN
# Anemia: baseline HCT mid 20s
# COPD: no PFTs recently
# PVD: s/p redo fem-fem right to AK-popliteal with 8-mm PFT and
right 2nd toe amputation on [**2123-7-30**]; s/p right femoral
BK-popliteal bypass with PTFE on [**2125-5-30**]. L Fem-[**Doctor Last Name **] w/ PTFE
and 3rd L toe amputation [**9-5**]
# s/p Aortobifemoral bypass graft for abdominal aortic
aneurysm [**2118**]
# colon polyps s/p polypectomy
# internal hemorrhoids
Social History:
Was an officeworker (accountant) for International Harvester.
Lives with his wife in [**Name (NI) 577**]. He denies current tobacco use.
He quit smoking at age 51. He smoked for 40yrs (since age 11),
about three packs per day (120 pack/yr hx). He reports social
drinking, perhaps two cocktails per week when out for dinner. He
denies illegal drug use or prescription drug abuse.
.
Family History:
No significant family hx of cancer or heart disease. Father died
in 70s from MI, had [**Name (NI) 2320**]. One brother had [**Name (NI) 2320**], died in 50s.
Sister died at age 12 of rheumatic fever.
Physical Exam:
VS: T 97.0 BP 119/53 P 92 RR 18 SpO2 100% 2L
GEN: Drowsy, oriented to hospital, year "19..." (best response).
HEENT: NCAT, PERRL, no icterus, MM dry.
NECK: Supple, JVP 15-20cm
CV: Irregular rate and rhythm, nl S1 and S2, no m/r/g
LUNGS: Decreased BS B/L, bibasilar crackles, expiratory wheezes
b/l
ABD: NABS. Soft, distended, NT.
EXT: 3+ pitting edema b/l with erythema of BLE (L >R). Left 1st
toe with dark hematoma & gangrenous skin with blister on dorsum
of toe. Open wound at distal tip is dry and without drainage.
Multiple toe amputations.
PULSES: 1+ DP pulses bilat, PT pulses dopplerable.
Pertinent Results:
[**2129-3-5**] 07:20PM CK(CPK)-44
[**2129-3-5**] 07:20PM CK-MB-NotDone cTropnT-0.21*
[**2129-3-5**] 04:32PM TYPE-ART PO2-73* PCO2-42 PH-7.50* TOTAL
CO2-34* BASE XS-7 INTUBATED-NOT INTUBA
[**2129-3-5**] 04:32PM LACTATE-0.9
[**2129-3-5**] 11:08AM COMMENTS-GREEN TOP
[**2129-3-5**] 11:08AM LACTATE-1.3
[**2129-3-5**] 11:00AM GLUCOSE-80 UREA N-71* CREAT-1.4* SODIUM-135
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-32 ANION GAP-13
[**2129-3-5**] 11:00AM estGFR-Using this
[**2129-3-5**] 11:00AM CK(CPK)-45
[**2129-3-5**] 11:00AM cTropnT-0.23*
[**2129-3-5**] 11:00AM CK-MB-NotDone proBNP-8569*
[**2129-3-5**] 11:00AM WBC-10.4 RBC-3.27* HGB-8.7*# HCT-26.0*
MCV-80* MCH-26.6* MCHC-33.4 RDW-18.3*
[**2129-3-5**] 11:00AM NEUTS-78.2* LYMPHS-10.4* MONOS-6.3 EOS-4.4*
BASOS-0.7
[**2129-3-5**] 11:00AM PLT COUNT-408
[**3-5**] CXR: 1. Retrocardiac opacity is concerning for pneumonia.
Probable small left pleural effusion.
2. Moderate cardiomegaly with no definite pulmonary edema.
[**3-5**] Foot Xray 1. Interval amputation of the left first digit
with irregularity of the amputation site and overlying soft
tissue ulcer. Osteomyelitis cannot be excluded in this location.
2. Increasingly poor visualization of the left fifth MTP joint,
which may be due to disuse osteopenia; however, again
osteomyelitis cannot be excluded.
3. Interval amputation of the right third digit.
Given the severe diffuse background osteopenia, if there is
continued clinical concern for osteomyelitis and it will change
clinical management, an MRI of is recommended.
[**3-7**] Echo: The left and right atrium are moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is mildly dilated. There is severe regional left
ventricular systolic dysfunction with inferior and inferolateral
thinning/akinesis and hypokinesis of the anterior septum and
anterior wall. The apex and remaining segments contract well
(LVEF = 25%).The right ventricular cavity is moderately dilated
with mild free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with cavity
dilation and extensive regional systolic dysfunction c/w
multivessel CAD. Moderate pulmonary arteyr systolic
hypertension. Moderate tricuspid regurgitation. Mildly dilated
ascending aorta.
Compared with the prior study (images reviewed) of [**2128-11-17**],
the left ventricular cavity is slighly larger and anterior and
anteroseptal dysfunction is new c/w interim ischemia.Overall
systolic function is more depressed.
Brief Hospital Course:
A&P: 82 yo male with a hx of CAD s/p CABG, systolic HF, and PVD
presents with acute decompensated HF with LLE cellulitis and
infection of wound in distal forefoot.
.
# Acute on chronic systolic HF, EF 20-30%: Patient presented
with significant volume overload on exam and had a positive
heart failure ROS. BNP elevated to 8569. Unclear precipitant,
but possible etiologies include Na intake, hypertension,
ischemia, or worsening valvular dysfunction. [**Name (NI) 103331**] pt with
120mg IV furosemide and started gtt at 10mg/hr. He diuresed 1-2L
net negative daily and was continued on PO metolazone. Echo was
consistent with worsening EF and interim ischemia. His
lisinopril and carvedilol were continued with careful
observation of BPs. Patient's lasix gtt was uptitrated to
20mg/hr with continued improvement in urine output, hypoxia and
symptoms. His blood pressures improved with diuresis and were
stable.
.
# LLE ulcers and celllulitis: Started on empiric vanc and
pip-tazo per vascular recs. Vascular opted not to intervene
surgically. He remained afebrile with blood cultures negative to
date. At discharge, he was transitioned to TMP-SMX for an
additional 14 days.
.
# Pulmonary opacity: Retrocardiac opacity on CXR concerning for
PNA. Patient had a nonproductive cough, but no fevers. This was
felt to be well covered by his concurrent 7d course of
vancomycin and pip-tazo as mentioned above.
.
# CAD: S/p CABG [**10-5**]. Trop-T currently .23 -> .21 (baseline
troponin .16-.23). MB negative. No new ischemic changes noted on
EKG. Continued on ASA, rosuvastatin, carvedilol.
.
# Atrial Fibrillation: Remained in afib with rate well
controlled. Patient not on warfarin anticoagulation due to
history of bilateral psoas hematomas [**1-6**]. Continued carvedilol
and ASA. Monitored on tele without events.
.
# CKD: Creatinine initially 1.4 (baseline 1.5-2.5). Creatinine
trended up with diuresis but with good urine output however he
was still at his baseline and likely it was falsely low on
admission bc of hypervolemia.
.
# Anemia: Hct 26, with baseline mid 20s. Continue erythopoeitin.
Hct monitored daily.
Medications on Admission:
1. Fluticasone-Salmeterol 250-50 mcg inh [**Hospital1 **]
2. Aspirin 325 mg daily
3. Rosuvastatin 10 mg DAILY
4. Senna 8.6 mg [**Hospital1 **] PRN
5. Docusate Sodium 100 mg [**Hospital1 **]
6. Multivitamin DAILY
7. Insulin Glargine 8 units SC QHS
8. Oxycodone-Acetaminophen 5-325 mg Q8H PRN
9. Carvedilol 3.125 mg [**Hospital1 **]
10. Metolazone 5 mg [**Hospital1 **]
11. Lisinopril 2.5 mg DAILY
12. Trazodone 25 mg QHS PRN
13. Torsemide 80 mg [**Hospital1 **]
14. Epoetin Alfa 4,000 unit SC QMOWEFR
15. Hydroxyzine HCl 25 mg [**Hospital1 **] PRN itching
16. Humalog sliding scale
Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
9. Insulin Glargine 100 unit/mL Cartridge Sig: Eight (8) units
Subcutaneous at bedtime.
10. Insulin Lispro 100 unit/mL Cartridge Sig: as directed per
sliding scale Subcutaneous four times a day.
11. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) unit
Injection QMOWEFR (Monday -Wednesday-Friday).
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for pain.
16. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous once for 1 doses: Administer 6hrs after
last dose received at [**Hospital1 18**].
17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO twice a day for 14 days.
18. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Acute on Chronic Systolic Congestive Heart Failure
2. Peripheral Vascular Disease
3. Hypotension
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital for treatment of your heart
failure. You were given medications to help remove fluid. Upon
your discharge from the hospital, your symptoms were much
improved.
.
We have made the following changes to your medications:
Started bactrim, an antibiotic for your foot infection.
You will receive one more dose of zosyn, an antibiotic for
pneumonia.
Lowered your aspirin dose to 81mg daily due to some mild
bleeding.
.
Please follow-up with your primary cardiologist Dr.[**Name (NI) 17483**]
on [**2129-4-1**] at 9:00am on [**Hospital Ward Name 23**] [**Location (un) 436**].
.
Please follow up with Dr. [**Last Name (STitle) 1391**] as needed for your leg
ulcers.
.
If you develop any of the following, chest pain, shortness of
breath, cough, fever, chills, lightheadness, nausea, vomiting,
or decrease in urine output, please call your doctor or go to
your local emergency room.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L/day
Followup Instructions:
Please follow-up with your primary cardiologist Dr.[**Name (NI) 17483**]
on [**2129-4-1**] at 9:00am on [**Hospital Ward Name 23**] [**Location (un) 436**].
.
Please follow up with Dr. [**Last Name (STitle) 1391**] as needed for your leg
ulcers.
Completed by:[**2129-3-11**]
|
[
"5849",
"486",
"4280",
"40390",
"5859",
"496",
"2724",
"2859",
"42731",
"412",
"V5861"
] |
Admission Date: [**2149-8-23**] Discharge Date: [**2149-9-12**]
Date of Birth: [**2087-8-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Left leg angiography
History of Present Illness:
Mr [**Known lastname **] is a 62 y/o man with PMH notable for s/p renal pancreas
tx, 4-5 days of vomiting with abdominal pain and bloody
diarrhea, fevers (didnt take temp), chills, no ill contacts,
recent travel to [**Name (NI) 1727**] for windjammer (?) trip within past month
but no other travel. He drove himself (the evening of [**8-22**]) to
[**Location (un) **]-wellsely where he was noted to be initially hypotensive
to 94/66 HR 64 resp 20 sat 100% RA, temp 94.9 rectal. He was
given total 2L NS, 4mg iv morphine, 4mg iv zofran and zosyn
3.375gm iv. Abdominal pain mostly over tx pancreas. Temp there
94 initially, placed on bear hugger, temp improved to 97.3 po by
time of transfer. He was ordered for ct abd/pelvis (not sure if
that was done) but had US that prelim showed tx pancreas in rlq,
appears adematous with associated peripancreatic fluid
suggesting pancreatitis, GB mildly distended with dilatation in
common bile duct 8mm, native kidneys atrophic, spleen normal, tx
kidney and left lower quadrant reportedly nl but doppler flow
not done. WBC 20, hct 49.7, plt 311, diff 90 pmn, <10 bands, 7
lymph, [**Doctor First Name **] 1265, lip 3709, albumin 4.6, bicarb <10.
In the ED: initial vitals were: T 98.5 rectal, HR 67, BP 107/50,
RR 20, 100% on RA. He was given 3L NS, D5W with 3 amps bicarb
x1L, solumedrol 500mg iv, solucort 100mg iv, zofran 4mg iv,
prograf 2mg iv, and dilaudid 1mg iv. US of abdomen repeated.
On arrival to the ICU he is sleepy and confused (does not know
where he is or why he is here). He c/o HA, mild photophobia,
meningismus, abdominal pain, no current fevers or chills.
Past Medical History:
* Liver/kidney transplant 10 years ago
* type 1 DM s/p SPK in [**2138**]
- complicated by neuropathy, nephropathy (cr 1.9)
* per his sister, has had difficulty with left foot vascular
supply recently and was referred by his pcp but details unknown
* Hypertension
* Hypercholesterolemia
* s/p esophagectomy in [**2145**] for Barrett's vs esophageal cancer
* h/o TIA
* h/o perineal abscess in [**2147**]
* s/p appy age 11
* h/o R foot Staph infection, reportedly no osteo
* OSA
* Gastroparesis
Social History:
1.5ppd x15yrs quit [**2135**]. Retired. Divorced, no kids. Rare
alcohol, denies drug use.
Family History:
N/C
Physical Exam:
VS: T 97.5 BP 142/111 P 76 RR 11 O2sat 99RA
Gen: A&Ox3, NAD
HEENT: No scleral icterus, MM slightly dry
Heart: RRR, no m/r/g
Lungs: Distant BS bilat with mild bibasilar rales
Abdomen: NABS. Soft, nondistended. Very TTP over RLQ transplant
site with no rebound or guarding. Also with mild RUQ and LLQ
tenderness.
Ext: LLE cool to touch, no palpable DP or PT pulses. Other ext
WWP with 2+ pulses. No edema. No sensation of bilat feet, but
intact on bilat shins.
Pertinent Results:
[**2149-8-23**] 07:00AM BLOOD WBC-17.9* RBC-5.40# Hgb-15.2# Hct-48.7#
MCV-90 MCH-28.2 MCHC-31.2 RDW-14.1 Plt Ct-263#
[**2149-8-23**] 07:00AM BLOOD Neuts-92.5* Lymphs-4.9* Monos-2.3 Eos-0.3
Baso-0.1
[**2149-8-23**] 01:44PM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2*
[**2149-8-23**] 07:00AM BLOOD Glucose-118* UreaN-84* Creat-4.2*# Na-136
K-5.1 Cl-111* HCO3-9* AnGap-21*
[**2149-8-23**] 01:44PM BLOOD ALT-6 AST-8 LD(LDH)-160 CK(CPK)-34*
AlkPhos-135* Amylase-1115* TotBili-0.3
[**2149-8-23**] 07:00AM BLOOD Lipase-4650*
[**2149-8-23**] 07:00AM BLOOD Calcium-9.3 Phos-5.4*# Mg-1.9
[**2149-8-23**] 07:32AM BLOOD tacroFK-7.8
[**2149-8-23**] 07:06AM BLOOD Lactate-1.0
[**2149-8-23**] 07:32AM BLOOD %HbA1c-5.5
[**2149-8-23**] 01:44PM BLOOD Triglyc-196* HDL-12 CHOL/HD-8.8
LDLcalc-55
Abdominal U/S [**8-23**]:
IMPRESSION:
1. Elevated resistive indices in the transplanted kidney within
the left
lower quadrant. This is a nonspecific finding, and can be seen
with chronic
rejection or infection.
2. No hydronephrosis or perinephric fluid collection involving
the
transplanted kidney.
3. Mildly dilated common bile duct, similar in appearance from
[**2148-5-30**]
CT, allowing for differences in modality. If clinically
indicated, this can
be further evaluated with an MRCP.
Lower ext arterial duplex U/S [**8-25**]:
IMPRESSION:
1. Severe flow deficit to the left foot.
2. Normal right ABI.
Pancreas U/S [**8-26**]:
IMPRESSION:
1. Unremarkable appearance of the pancreas transplant, with
preserved flow
throughout.
2. Disorganization and heterogeneity of tissues deep to the left
lower
quadrant kidney transplant, new from the prior study. This
raises the
possibility of a hematoma at this locale, which is not affecting
the kidney in terms of hydronephrosis or mass effect at this
time. A short-term followup scan is advised.
Lower ext vein mapping U/S [**8-26**]:
IMPRESSION: The greater saphenous veins are widely patent
bilaterally, there is minimal focal dilatation at the popliteal
level and the distal calf on the right as well as the popliteal
level and at the level of the ankle on the left.
CXR PA/Lat Preop [**8-26**]:
Mild atelectatic changes are seen at the left base though there
is no evidence of acute pneumonia. Right IJ catheter extends to
the lower portion of the SVC.
Angiogram [**8-29**]:
____________________.
Femoral vascular U/S [**8-29**]:
IMPRESSION: No pseudoaneurysm or fistula.
Brief Hospital Course:
1) Pancreatitis: Patient is s/p pancreas transplant (bladder
anastamosis). APACHE II using patient's initial labs was 26,
which has a roughly 57% mortality. Pancreas U/S at OSH
consistent with acute pancreatitis. Given the coexisting renal
failure, and low urine amylase compared with prior, this was
concerning for graft rejection. CMV serology and viral load were
negative. Unable to biopsy the kidney to assess rejection due to
his heparin drip (see below). He was initially admitted to the
ICU due to altered mental status and a R IJ central line was
placed for administration of anti-thymocyte globulin. His mental
status improved and he was transferred to the floor. The central
line was kept due to inability to obtain reliable peripheral
access, as well as concern for bleeding if removed due to the
heparin drip. He received ___ doses of anti-thymocyte globulin,
as well as __ doses of 500mg IV methylprednisolone, then 1 dose
of 100mg IV methylprednisolone. The latter was converted to
prednisone 40mg x2 days, then 20mg daily. He was also
aggressively volume resuscitated with IV fluids. Over the first
few days, his pain significantly improved, and his diet was
advanced to regular, which was well tolerated. Pancreas U/S at
[**Hospital1 18**] showed resolution of inflammation, and his amylase and
lipase trended down. His tacrolimus was slowly increased to ___
due to lower levels, likely due to holding his calcium channel
blocker. He was also started on valganciclovir and TMP/SMX
prophylaxis. Note that the repeat pancreas U/S showed a possible
hematoma associated with the transplanted kidney. This should be
reassessed with a follow up study.
2) Acute on chronic renal failure: Creatinine was initially 4.2,
while baseline from [**3-10**] was 1.6. Prerenal as well as ATN
suspected, likely ischemic, given muddy brown casts in urine and
patient presented with hypotension. IV fluid resuscitated as
above, with bicarb-containing fluids. His creatinine decreased
to ___ by discharge.
3) Peripheral arterial disease: Coolness of the left foot was
noted while in the ICU, therefore a heparin drip was started and
ASA was resumed. Per patient's sister, this problem may have a
chronic component. Arterial duplex U/S showed no flow in the
left foot. Vein mapping for bypass showed widely patent greater
saphenous veins. He had a left LE angiogram with pre-procedure
hydration with bicarb and mucomyst. The angiogram showed
popliteal occlusion below the knee. Post-cath check on day of
angiogram showed bilateral femoral bruits, although U/S of the
entry site showed no aneurysm or fistula. The foot remained cool
on exam, but without evidence of necrosis.
4) Nongap metabolic acidosis: Initially had an increased gap,
now closed. Likely due to diarrhea on admission that was
self-limited, as well as NS hydration, bicarb loss from pancreas
graft, and renal failure. Bicarb improved with IV fluids
containing bicarb.
5) HTN: Metoprolol increased to 50mg TID with good control.
Calcium channel blocker was held.
On [**2149-9-8**] patient underwent a left above-knee popliteal to
peroneal bypass with
non reverse saphenous vein graft, angioscopy. Post-operative
course was essentially unremarkable.
Neuro: The patient received morphine and oxycodone with good
effect and adequate pain control. When tolerating oral intake,
the patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout this hospitalization.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF.
The patient's diet was advanced when appropriate, which was
tolerated well.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
diltiazem 240 daily
aspirin 325mg daily
atenolol 100mg daily
prednisone 4mg daily
cellcept 1 gm [**Hospital1 **]
prograf 2mg qam, 1mg qpm
botox yearly injection for gastroparesis
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
Complete blood count, Chem 10, tacrolimus level to be drawn
every 2 weeks
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis, Acute on chronic renal failure, below knee
popliteal artery occlusion
Discharge Condition:
Improved
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-5**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and [**Month/Day (3) **] dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
You were found to be iron deficient and anemic you should have
an outpt. colonoscopy to evaluate for polyps.
You also had a low B12 level with anemia, you recieved a vitamin
B12 supplement shot while in the hospital, you should see your
primary care physician to determine if you continue to need
vitamin B12 shots.
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-10-16**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2149-10-9**] 9:45
Completed by:[**2149-9-12**]
|
[
"5845",
"2762",
"40390",
"5859",
"2724",
"32723"
] |
Admission Date: [**2105-11-20**] Discharge Date: [**2105-11-27**]
Date of Birth: [**2044-10-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath, dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2105-11-20**] Redo sternotomy, mitral valve replacement (31mm St.
[**Male First Name (un) 923**] mechanical)
History of Present Illness:
Mr. [**Known lastname 87733**] is a 60 year old male who underwent single
vessel coronary artery bypass to the acute marginal and a mitral
valve repair in [**2097**] at the [**Hospital1 2025**] by Dr. [**Last Name (STitle) **]. Over the last
several months, he has developed worsening dyspnea on exertion
and even shortness of breath at rest. He currently denies chest
pain, orthopnea, PND, pedal edema and syncope. Recent
echocardiogram revealed severe mitral regurgitation with flail
posterior leaflet. Given the above findings, he was referred for
redo operation.
Past Medical History:
Coronary artery disease
Hypercholesterolemia
Hypertension
Osteoarthritis
Gout
Varicose Vein
Past Surgical History:
s/p CABG, MV Repair [**2097**]
Left Hip Pinning at age 13
Social History:
Race: Caucasian
Last Dental Exam: "many years ago"
Lives: Alone
Occupation: Car Sales, currently on disability
Tobacco: Quit 8 years ago, approx 30PYH
ETOH: Rare
Family History:
Father with MI at age 61. Sister with MI at age 59.
Physical Exam:
Pulse: 63 Resp: 18 O2 sat: 100% BP Right: 128/80, Left: 130/85
General: WDWN male in no acute distress
Skin: Warm[x] Dry [x] intact [x]
HEENT: NCAT[x] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] - no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [**3-7**] holosytolic murmur best
heard at apex, left lower sternal border
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema - trace
Varicosities: GSV varicosed left thigh, both lower legs without
significant varicosities
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: None
Pertinent Results:
[**11-20**] Echo: 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. Left ventricular wall thicknesses are
normal. Right ventricular chamber size and free wall motion are
normal. There are focal calcifications in the aortic arch. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. Moderate to
severe (3+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results on Mr.[**Known lastname 87733**] by Dr.[**First Name (STitle) 6507**]
[**Name (STitle) 60351**]: Patient is on epinephrine 0.02mcg/kg/min. Normal
Right ventricular systolic function. LVEF 55%. The mitral
mechanical prosthesis is well placed and stable with
transvalvular gradients (mean of 8mm of Hg) and conveyed by
Dr.[**First Name (STitle) 6507**] to Dr.[**Last Name (STitle) **]. Intact thoracic aorta.
[**2105-11-20**] 02:40PM BLOOD WBC-42.0*# RBC-3.48* Hgb-10.0* Hct-30.9*
MCV-89 MCH-28.8 MCHC-32.4 RDW-14.3 Plt Ct-317
[**2105-11-22**] 04:24AM BLOOD WBC-16.6* RBC-2.93* Hgb-8.4* Hct-25.7*
MCV-88 MCH-28.7 MCHC-32.7 RDW-14.4 Plt Ct-171
[**2105-11-27**] 05:00AM BLOOD WBC-10.7 RBC-2.92* Hgb-8.6* Hct-25.6*
MCV-88 MCH-29.3 MCHC-33.4 RDW-14.7 Plt Ct-270
[**2105-11-20**] 02:40PM BLOOD PT-13.1 PTT-39.6* INR(PT)-1.1
[**2105-11-23**] 12:14PM BLOOD PT-28.8* INR(PT)-2.8*
[**2105-11-24**] 05:15AM BLOOD PT-45.6* PTT-39.0* INR(PT)-4.9*
[**2105-11-24**] 09:20AM BLOOD PT-46.0* INR(PT)-5.0*
[**2105-11-25**] 05:30AM BLOOD PT-33.9* INR(PT)-3.4*
[**2105-11-26**] 05:05AM BLOOD PT-29.1* INR(PT)-2.9*
[**2105-11-27**] 05:00AM BLOOD PT-25.4* INR(PT)-2.4*
[**2105-11-20**] 03:03PM BLOOD UreaN-22* Creat-1.3* Na-142 K-3.9 Cl-115*
HCO3-22 AnGap-9
[**2105-11-27**] 05:00AM BLOOD Glucose-96 UreaN-29* Creat-1.8* Na-138
K-5.1 Cl-105 HCO3-27 AnGap-11
[**2105-11-21**] 01:27AM BLOOD ALT-12 AST-40 LD(LDH)-384* AlkPhos-53
Amylase-42 TotBili-0.4
[**2105-11-24**] 05:15AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 87733**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On [**11-20**] he was brought
directly to the operating room where he underwent a
redo-sternotomy, mitral valve replacement. Please see operative
note for surgical details. Following surgery he was transferred
to the CVICU for invasive monitoring in stable condition. Within
24 hours he was weaned from sedation, awoke neurologically
intact and extubated. On post-operative day one he was started
on beta blockers and diuretics and diuresed towards his pre-op
weight. In addition Coumadin was started and titrated for a goal
INR 3-3.5. He remained in the ICU receiving aggressive pulmonary
toilet for several days and on post-op day three was transferred
to the telemetry floor for further care. He had an episode of
atrial fibrillation and was given additional beta blockers and
started on Amiodarone. His rhythm at discharge was sinus
regular. Chest tubes and epicardial pacing wires were removed
per protocol. Cipro was started for post-op UTI. On post-op day
five he received 2 units of red blood cells for low HCT. His HCT
at discharge was 25. While awaiting a therapeutic INR he worked
with physical therapy for strength and mobility. He was
discharged home with VNA services on post-op day seven with the
appropriate medications and follow-up appointments. Dr.
[**Last Name (STitle) 35055**] will follow his INR and adjust his Coumadin
accordingly.
Medications on Admission:
Aspirin 325 daily
Allopurinol 150 daily
Lovastatin 20 daily
Lisinopril 10 daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take two 200 mg tablets twice daily x 5. Then one 200mg
tablets twice daily x 7 days. Then 1 200mg tablet until stopped
by cardiologist.
Disp:*60 Tablet(s)* Refills:*2*
10. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Goal INR 3-3.5 for mechanical MVR. Dr. [**Last Name (STitle) 35055**] to adjust dose
depending on INR.
Disp:*30 Tablet(s)* Refills:*2*
11. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Mitral regurgitation s/p Mitral valve Replacement
s/p mitral annuloplasty/coronary artery bypass [**2097**]
Hypertension
Hypercholesterolemia
Degenerative joint disease
Gout
s/p left hip pinning
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 2+
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 [**12-17**] at 1PM
Please call to make appointments with:
PCP/Cardiologist:Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35055**] ([**Telephone/Fax (1) 87734**])
**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 mechanicla valve
Goal INR 3-3.5
First draw [**11-29**]
Results to:Dr. [**Last Name (STitle) 35055**] phone:[**Telephone/Fax (1) 87734**]
fax:781-
Completed by:[**2105-11-27**]
|
[
"4240",
"2762",
"5990",
"42731",
"V4581",
"2720",
"4019"
] |
Admission Date: [**2103-12-20**] Discharge Date: [**2103-12-30**]
Date of Birth: [**2032-10-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Positive stress-MIBI
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
71yo M with HTN, Hypercholesterolemia, PVD, +tob and recent IMI
2 weeks ago presents for cardiac evaluation after positive
stress test today. The pt is [**Name (NI) 595**] and speaks little English.
History was obtained through translation via the patient's
daughter. Over the past year the pt has developed increasing
DOE and claudication. He currently developes these symptoms
after walking approximately one block. The claudication is felt
bilaterally and improves with resting. Approximately 2 weeks
prior to admission the patient experienced malaise one evening.
He denies having experienced CP, SOB, jaw pain, L arm pain,
diaphoresis or nausea at the time of his malaise. Two to three
days afterward he was found to have new EKG changes consistent
with an IMI. Approximately one week prior to admission the
patient had an echocardiogram which the patient's daughter said
was abnormal. On the day of admission the patient had an
outpatient stress-MIBI which was abnormal and he was sent to the
ED. The patient remained asymptomatic during his stress-MIBI
and denies having ever experienced CP, jaw pain, or L arm pain
with exertion. In addition, he denies F/C/S, N/V/D, abdominal
pain, melena, hematochezia, recent weight changes, orthopnea,
PND and dysuria.
.
In the ED, the pt had the following VS: T99.5 P60 BP: 159/82
RR22 O2sat: 100% on 2L. Pt was given 325mg ASA x1 and IV
metoprolol 5mg x1 with good response of his BP.
Past Medical History:
1. CAD
2. Hypercholesterolemia
3. HTN
4. PVD
5. Glaucoma
Social History:
Lives w/wife. 50 pack-yr hx, now at 4 cigs/day. EtOH approx 4
drinks/wk
Family History:
No CAD, CVA, DM in family
Physical Exam:
VS: T 99.5 P 69 BP: 150/74 RR 16 O2sat: 98% on RA
Gen: Awake, alert, laying in gurney in NAD.
HEENT: EOMI. PERRL. OP clear w/MMM. No oral lesions.
Neck: Supple. No [**Doctor First Name **]. Unable to appreciate JVP
CV: RRR S1 S2. No m/r/g
Pulm: CTAB
Abd: Soft. NABS. NTND. No masses or hepatomegaly.
Ext: Cool. Unable to palpate DP/PT pulses bilaterally. Femoral
pulses 2+ bilaterally.
Pertinent Results:
STUDIES:
[**2103-12-20**] ED EKG: Sinus, irregular, approx. 60bpm, nl axis, nl
PR, narrow QRS, nl QT, LAE seen in II, TWI in inferior leads,
lateral ST depressions (I, aVL, V4-V6)
.
CXR [**2103-12-20**]: no acute cardiopulmonary process
.
STRESS-MIBI [**2103-12-20**]:
STRESS: Ischemic EKG changes (3-4mm ST depressions) in the
setting of baseline abnormalities without anginal symptoms
.
MIBI:
1. Severe, predominately reversible perfusion defects in the
anterior, septal and apical walls consistent with multivessel
ischemic disease. Fixed perfusion defect at the base of the
inferior wall.
2. Severe global hypokinesis with a calculated ejection
fraction of 27%. Likely post stress ischemic dilation of the
left ventricular cavity.
Brief Hospital Course:
/P: 71yo M with recent silent IMI (cardiac risk factors include
known CAD, PVD, HTN, Hypercholesterolemia, +tob) presents for
evaluation after positive stress test.
.
1. CV:
A. Coronaries: The pt has known CAD with IMI in recent past.
Stress test was positive with reversible perfusion defects in
ant, septal and apical walls consistent with multivessel
ischemia as well as severe global HK.
---Telemetry and ECG in AM
---cycle CE x3 - if pt rules in, will start hep gtt and consider
GP IIB/IIIA inhibitor as well.
---Cath in AM - will d/w cards fellow re: white board.
---ASA 325mg once daily
---supplemental oxygen to obtain SaO2 of 100%
---metoprolol 25mg [**Hospital1 **] titrate up as tolerated
---start captopril 6.25mg TID titrate up as tolerated
---lipitor 80mg QHS - will also obtain lipid panel and LFT in
AM.
---hold Plavix given suggestion of multivessel ischemic disease
on MIBI and possibility of CABG in near future.
---pt is currently pain free, however if he were to develop sx
will start hep gtt and consider GPIIB/IIIA inhibitor as well.
.
B. Pump: The pt has global HK with calculated EF of 27% on
MIBI. This may reflect some element of myocardial stunning
after recent IMI and therefore may recover function with time.
Will aim for afterload reduction for now and follow signs and sx
of CHF.
---transition metoprolol short acting to toprol XL when at a
stable dose
---titrate up ACEI as tolerated.
---daily weights and ins/outs.
.
C. Rhythm: The ECG has some evidence of sinus node dysfunction
and is concerning for wandering pace maker.
---telemetry
---cont. BB as above.
---discuss with cards re: significance of rhythm.
2. Glaucoma: not an active issue, cont. eye drops.
---lumigan gtt
---cosopt gtt
The above hospital course pertains to the patient's stay while
on the medical service. On [**2103-12-25**] the patient was
taken to the OR for a 3 vessel CABG (LIMA to LAD, SVG to OM, SVG
to PDA). The patient tolerated surgery well, was extubated the
night of surgery and was transferred from the CSRU on postop day
one to the regular cardiac hospital floor. On post op day two
the patient's foley was removed and with his chest tubes. On
post op day three the patient's pacing wires were removed. The
patient tolerated a cardiac heart healthy diet, diuresed well
after surgery while his pain was controlled throughout his
hospital stay. The patient was discharged on post op day five.
He will follow up with his PCP [**Name Initial (PRE) 176**] 10 days for medication
adjustment if needed and routine blood work. Additionally, the
patient was cleared by physical therapy and he will be going
home with visiting nursing services to monitor his wounds,
assure medication compliance and check vital signs.
Medications on Admission:
1. Lipitor 10mg QHS
2. ASA 325mg once daily
3. Atenolol 25mg once daily
4. Lumegon gtt for eyes
5. Cosopt gtt for eyes
.
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. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
PVD
CAD
HTN
hypercholesterolemia
Discharge Condition:
stable
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions. You must follow up with a primary care
physician [**Name Initial (PRE) 176**] 10 days for medication adjustment and rountine
laboratories.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Call to schedule
appointment within 1 month
Provider: [**Name10 (NameIs) 3300**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 65529**] Appointment should be
in [**8-12**] days
Provider: [**Name10 (NameIs) **] Appointment should be in [**8-12**] days
|
[
"41401",
"4280",
"2720",
"4019"
] |
Admission Date: [**2191-2-2**] Discharge Date: [**2191-2-3**]
Service: MEDICINE
Allergies:
Sulfasalazine / Percocet
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 year old male with h/o Pagets, CRI, CAD, DM, HTN, CAD
presented from nursing home with concern for tibial plateau
fracture seen on xray at the nursing home. He was transferring
with assistance from the nurses and fell on his knee. He was
given Percocet 5/325 and ativan 0.5 mg this morning to help him
tolerate ambulance transfer which confused him.
.
In the ED, films were done and showed no evidence of fracture.
Then patient desaturated to 70% while sleeping; (per son he is
on oxygen at home only at night); pt placed on NRB and sats came
up to 100%; stayed in 90s off of the NRB. Labwork and EKG
ordered as well as CXR. Then desated to 70s again while lying
flat in bed again. CXR showed large left sided pleural effusion
(has this in past and drained before). EKG wnl. ABG done b/c
became more somnolent pH 7.21/76/104 and was then gave patient
nebulizers, azithromycin, 125mg Solumerol. Labs WBC 11.1 with
89%Neutrophils. Repeat gas: ph:7.00 pCO2:141 pO2:79 HCO3:37.
Discussion was held with the family given the patients desire
for DNR/DNI and the decision was made to do trial of BIPAP to
see if his respiratory status could improve. On BIPAP in the
ED, his repeat ABG demonstrated persistant hypercarbic
respiratory failure.
The patient was then admitted to the MICU for further care.
.
Currently the patient is non-responsive on BIPAP, thus further
history is unable to be obtained.
Past Medical History:
Paget's disease
Chronic kidney disease (most recent Cr 2.5, GFR 28 [**2191-1-28**], Cr
sometimes up to high 3's)
Prostate CA
CHF
Dementia, early
PLeural effusions
DM 2
Anemia of chronic disease
COPD
Social History:
Patient lives at [**Hospital **] [**Hospital **] Nursing Home. Wife was in the
ICU. No smoking, EtoH or IVDU. Has local sons.
Family History:
NC
Physical Exam:
Admission:
GENERAL: patient is somnolent, nonresponsive
HEENT: Pupils are equal, reactive, MMM
CARDIAC: RRR no murmurs
LUNG: Difficult to assess, chest wall rises, minimal air
movement
ABDOMEN: Soft, NT, ND
EXT: Warm, perfused, no edema
NEURO: Not alert or responsive.
Pertinent Results:
[**2191-2-2**] 03:10PM BLOOD WBC-11.1* RBC-4.18* Hgb-11.2* Hct-37.4*
MCV-90 MCH-26.9* MCHC-30.0* RDW-16.2* Plt Ct-294
[**2191-2-2**] 08:42PM BLOOD WBC-19.2*# Hct-37.9*
[**2191-2-2**] 03:10PM BLOOD Neuts-89.3* Lymphs-4.9* Monos-4.1 Eos-1.1
Baso-0.6
[**2191-2-2**] 03:10PM BLOOD Glucose-170* UreaN-40* Creat-2.7* Na-144
K-4.6 Cl-102 HCO3-30 AnGap-17
[**2191-2-2**] 08:42PM BLOOD Glucose-316* UreaN-42* Creat-3.1* Na-141
K-5.9* Cl-102 HCO3-27 AnGap-18
[**2191-2-2**] 08:42PM BLOOD Calcium-9.2 Phos-7.3*# Mg-2.3
[**2191-2-2**] 08:42PM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2191-2-2**] 03:59PM BLOOD pO2-104 pCO2-76* pH-7.21* calTCO2-32*
Base XS-0 Intubat-NOT INTUBA Comment-NON-REBREA
[**2191-2-3**] 06:19AM BLOOD Type-[**Last Name (un) **] pO2-209* pCO2-243* pH-6.77*
calTCO2-40* Base XS--6 Comment-GREEN TOP
[**2191-2-2**] 08:56PM BLOOD Lactate-1.6
[**2191-2-3**] 06:19AM BLOOD Lactate-4.0*
Knee Plain Films:
IMPRESSION:
1. No acute fracture is seen. If clinical concern persists,
consider CT or
MRI to evaluate for occult fracture.
2. Moderate to large right suprapatellar joint effusion.
3. Bilateral degenerative changes at the knees with joint space
narrowing as
well as diffuse osteopenia.
CXR:
IMPRESSION:
1. Interval worsening with now moderate left-sided pleural
effusion. Stable
left basilar opacification, likely representing collapse and
effusion, though
underlying infection is not excluded. Note that patient has had
persistent
collapse since remote examinations dating back to [**2185**].
Correlate with any
history of bronchoscopy.
2. Mild interstitial pulmonary edema.
3. Known Paget's involving the right shoulder.
Brief Hospital Course:
85 yo M with MMP admitted with hypercarbic hypoxic respiratory
failure. Admitted to ICU for trial of BIPAP as patient is
DNR/DNI.
# Hypercarbic and Hypoxic Respiratory Failure:
Patient presented from his nursing home with concern for tibial
plateau fracture seen on xray at the nursing home. He was
transferring with assistance from the nurses and fell on his
knee. He was given Percocet 5/325 and ativan 0.5 mg to help him
tolerate ambulance transfer which confused him. In the ED, films
were done and showed no evidence of fracture. He was evaluated
by ortho and placed in a knee immobilzer. Then patient
desaturated to 70% while sleeping; (per son he is on oxygen at
home only at night). He was placed on NRB and O2 saturations
came up to 100% and remained in the 90s off of the NRB. A CXR
showed a large left sided pleural effusion. His EKG was wnl.
His initial ABG was 7.21/76/104 and was then given nebulizers,
azithromycin, 125mg Solumerol. A repeat gas: showed ph:7.00
pCO2:141 pO2:79 HCO3:37. Discussion was held with the family
given the patients desire for DNR/DNI and the decision was made
to do trial of BIPAP to see if his respiratory status could
improve. On BIPAP in the ED, his repeat ABG demonstrated
persistant hypercarbic respiratory failure. The patient
continued to worsen and reamined non-responsive. He had
worsening hypercarbic respiratory failure without improvement on
BiPAP. After a discussion with the family his BiPAP was removed
and the patient passed with the family at the bedside. The
Medical Examiner and family decline autopsy.
Medications on Admission:
Glipizide 5mg [**Hospital1 **]
Ativan 0.5mg qhs
Zocor 20mg daily
Ocuvite
Casodex 50mg daily
Plavix 75mg daily
Omeprazole 20mg
Tiotropium
Fluticasone [**Hospital1 **]
Spiriva
Insulin regular prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypercapneic respiratory failure
Discharge Condition:
death
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2191-2-3**]
|
[
"51881",
"5070",
"5119",
"496",
"4280",
"25000",
"40390",
"5859",
"41401"
] |
Admission Date: [**2167-5-31**] Discharge Date: [**2167-6-6**]
_----------------------_
Date of Birth: [**2096-12-21**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
gentleman with a past medical history of ethmoid cancer
resected at [**Hospital6 1129**] in [**2162**].
He had a repeat resection here on [**2167-5-22**] by
Ear/Nose/Throat and Neurosurgery. Postoperative course was
uneventful. The patient had no cerebrospinal fluid leak.
He passed a swallow evaluation and was discharged to
rehabilitation on [**2167-5-28**].
He began having mental status changes and seizure activity on
the day of admission. He became unresponsive. He had a
fever to 102 and was transferred here for further management.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Rheumatoid arthritis.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination his temperature was 97.9, blood pressure was
124/55, heart rate was 72, respiratory rate was 20, and
oxygen saturation was 97%. Head, eyes, ears, nose, and
throat examination revealed pupils were equal, round, and
reactive to light. Extraocular movements were full. He had
bilateral orbital edema. His cardiovascular status revealed
a regular rate and rhythm. Normal first heart sounds and
second heart sounds. No murmurs, rubs, or gallops.
Pulmonary examination was clear to auscultation bilaterally.
The abdomen was soft, nontender, and nondistended. No
masses. Extremity examination revealed no clubbing,
cyanosis, or edema. On neurologic examination, he did not
open his eyes. He did grasp hand bilaterally.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed some mild
fluid overload; slightly improved. No infiltrates.
HOSPITAL COURSE: He was seen by the Ophthalmology Service
and ruled out for orbital cellulitis. He had a lumbar
puncture and a magnetic resonance imaging with evidence of an
epidural versus subdural frontal collection.
On [**2167-5-31**] the patient was taken to the operating room
for exploration and drainage of a frontal collection. A
drain was in place, and the patient was monitored in the
Intensive Care Unit postoperatively where he had severe
facial swelling, and his eyes were swollen shut.
Postoperatively, he was awake and following commands. He was
moving all extremities to commands. The fluid collection was
sent for a culture.
He was seen by Infectious Disease Service. He was placed on
vancomycin 1 g q.12h. and ceftazidime 2 g q.8h. for initial
antibiotic coverage. The Gram stain showed gram-positive
cocci and gram-negative rods from the abscess.
The patient had a bone flap removed. Therefore, there was a
skull defect. The patient will require six weeks of
intravenous antibiotic coverage. His drain was removed on
postoperative day four (on [**2167-6-3**]), and he was
transferred to the regular floor after being seen by Physical
Therapy and Occupational Therapy.
He was also re-evaluated by the Swallow Service. He passed
the swallow with some modifications. He needs to be on a
nectar-thick ground solid diet. Pills need to be crushed and
pureed. He needs to maintain aspiration precautions. He
should be full upright for all meals, alternating between
bites and sips, and two to three swallows for each bite and
sip.
His dressing was removed, and his incision was clean, dry,
and intact. He had a peripherally inserted central catheter
line placed on [**2167-6-5**]. He currently continues on
gentamicin 100 mg intravenously q.12h. and ceftazidime 2 g
intravenously q.8h. He was growing Proteus from the culture
from his surgery.
The patient was to be discharged on ceftazidime 2 g
intravenously q.8h. and ciprofloxacin 500 mg p.o. q.12h.;
together for a total of six weeks.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 1906**] at [**Hospital 14852**] in four to six weeks.
2. The patient should also have his staples removed at
rehabilitation in 14 days postoperatively.
3. The patient should also be fitted for a helmet due to the
bone defect once at rehabilitation.
MEDICATIONS ON DISCHARGE: (Medications at the time of
discharge included)
1. Pantoprazole 40 mg p.o. q.24h.
2. Metoprolol 25 mg p.o. twice per day.
3. Sodium chloride nasal spray four times per day as needed.
4. Ceftazidime 2 g intravenously q.8h.
5. Folic acid 1 mg p.o. once per day
6. Gentamicin 100 mg intravenously q.12h. (peak and trough
levels are pending).
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE STATUS: To rehabilitation.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2167-6-5**] 12:00
T: [**2167-6-5**] 12:19
JOB#: [**Job Number 45954**]
|
[
"496"
] |
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