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Admission Date: [**2118-4-3**] Discharge Date: [**2118-4-25**]
Date of Birth: [**2062-1-20**] Sex: F
Service: [**Hospital1 **]/MEDICINE
PRIMARY CARE PHYSICIAN: [**Name10 (NameIs) 39752**] [**Name7 (MD) 99173**], M.D.
CHIEF COMPLAINT: Lower gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: This is a 56 year old Greek
female with a history of recurrent gastrointestinal bleeding,
congestive heart failure, coronary artery disease, chronic
obstructive pulmonary disease and other comorbidities, who
presents from her nursing home with maroon stools times ten
to fourteen days and bright red blood per rectum for the past
two days. For the past ten to fourteen days, she has also
had crampy intermittent lower left quadrant pain,
nonexertional shortness of breath and moderate fatigue.
Falling hematocrit necessitated transfusion of two units of
packed red blood cells at [**Hospital6 13846**]
Center where she has been living for four months. She denies
the following: chest pain, syncope, nausea, vomiting,
dysphagia, dysuria or hematuria. She also denies a history
of peptic ulcer disease or gastroesophageal reflux disease.
She does report swelling and erythema of her legs which has
been unchanged for the past six months.
Gastrointestinal bleeding history:
1. [**Month (only) 404**] to [**2117-6-9**], recurrent gastrointestinal bleeds
over these months requiring eighteen transfusions at various
hospitals.
2. [**2117-6-9**], [**Hospital3 **] Hospital. Video endoscopy did
not reveal bleeding, upper endoscopy showed papular
gastropathy but no source of chronic bleeding.
3. [**2117-7-10**], [**Hospital3 **] Hospital. Colonoscopy revealed
a single nonbleeding angiectasia in the transverse colon
which was treated with electrocautery.
4. [**2117-8-9**], [**Hospital3 **] and then transferred to [**Hospital1 1444**] Medical Intensive Care Unit -
Presented at [**Hospital3 **] with bright red blood per
rectum, hematocrit fell from 28.0 to 12.0 and was transferred
four units; transferred to [**Hospital1 188**]. Coumadin and Heparin were held. There was a
bleeding scan positive for bleeding from angiodysplasia of
the cecum or ascending colon past the distal ileocolic
artery. She received interventional radiology embolization
of the right colon. Coumadin and Heparin were restarted
after embolization. In addition, the patient was hypotensive
throughout the admission with blood pressure nadiring at
82/30; her hematocrit on that admission 24.0, INR 2.6; and in
this setting, she had a myocardial infarction with peak CK of
300 and troponin of 34. An echocardiogram showed an ejection
fraction of 40%. In addition, the patient had a
catheterization that showed one vessel disease which seemed
chronic. She was transfused four units at [**Hospital1 346**] for a total of eight. Her
hematocrit stabilized and bleeding was mostly resolved.
5. [**2117-9-9**], [**Hospital1 69**] Medical
Intensive Care Unit. The patient presented with bright red
blood per rectum initially progressing to maroon colored
stools plus intermittent substernal chest pain relieved with
sublingual Nitroglycerin. She was hypotensive to 99/56. Her
electrocardiogram showed 0.[**Street Address(2) 11725**] depressions in
leads II and III. She ruled out for myocardial infarction
and was transfused five units total. Interventional
radiology elected not to embolize due to the risk of
mesenteric ischemia. Coumadin and Heparin were held.
Bleeding resolved.
6. [**2118-2-9**] - The patient presented to [**Hospital6 14430**] with hypotension and malaise. Colonoscopy showed a
continuous area of nonbleeding shallow ulcer of the mucosa
with no stigmata of recent bleeding present in the ascending
colon distal to the cecum, three ulcers next to each other,
largest 1.0 centimeter, nonbleeding internal hemorrhoids as
well.
PAST MEDICAL HISTORY:
1. Gastrointestinal bleeds as above.
2. Status post aortic valve replacement with a St. Jude
valve in [**2113**].
3. Congestive heart failure with transthoracic
echocardiogram on [**2118-3-4**], showing normal left ventricular
systolic function, inability to assess the ejection fraction
due to irregular rhythm although an ejection fraction of 40%
was shown on [**2117-8-25**]. Right ventricle was dilated with
moderately reduced systolic function. Aortic valve
prosthesis was well seated, no aortic insufficiency, 2+
mitral regurgitation, 3+ tricuspid regurgitation, pulmonary
artery pressure 70 mmHg, mitral valve calcified at the
commissures but mobile without stenosis, dilated inferior
vena cava suggestive of elevated right heart diastolic
pressures.
4. Coronary artery disease. The patient is status post
percutaneous transluminal coronary angioplasty in [**2100**]. She
is status post multiple myocardial infarctions. Cardiac
catheterization on [**2117-8-25**], demonstrated 100% proximal right
coronary artery stenosis with diffuse right coronary artery
disease, not felt to repairable by angioplasty or bypass.
Septal inferior artery with 60% occluded, obtuse marginal 60%
occluded and the first diagonal 20% occluded.
5. Hypercholesterolemia.
6. Atrial fibrillation, status post pacemaker placement.
7. History of rheumatic fever.
8. Diabetes mellitus type 2. The patient is now requiring
insulin. History of neuropathy and mild nephropathy.
9. Chronic obstructive pulmonary disease. She requires home
oxygen at three liters since [**2112**].
10. Klebsiella urinary tract infection in [**9-10**].
11. Depression.
PAST SURGICAL HISTORY: As above.
1. Left atrial mass resection [**2113**], nonneoplastic infected
atrial myxoma.
2. Ovarian cyst removal.
3. Cholecystectomy.
ALLERGIES: No adverse reactions, no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Albuterol, ipratropium nebulizers four times a day.
2. Aspirin 81 mg p.o. once daily.
3. Captopril 6.25 mg p.o. three times a day.
4. Digoxin 0.125 mg p.o. once daily.
5. Docusate 100 mg p.o. twice a day.
6. Furosemide 160 mg p.o. twice a day.
7. Gabapentin 100 mg p.o. q.h.s.
8. Metolazone 5 mg p.o. twice a day.
9. Metoprolol 12.5 mg p.o. twice a day.
10. Ocean Spray nasal spray two puffs each naris three times
a day.
11. NPH insulin 26 units subcutaneous q.a.m., 6 units
subcutaneous q.p.m.
12. Protonix 40 mg p.o. once daily.
13. Simvastatin 10 mg p.o. once daily.
14. Spironolactone 25 mg p.o. once daily.
15. Vitamin C 500 mg p.o. twice a day.
16. Warfarin 5 mg p.o. q.h.s.
17. Zinc Sulfate 220 mg p.o. twice a day.
SOCIAL HISTORY: Two to three pack per day smoker since the
age of 14, 70 to 100 pack years total. Quit six years ago.
No alcohol use. Had lived at home with husband until four
months ago when she moved to [**Hospital6 13846**]
Center.
FAMILY HISTORY: Mother with type 2 diabetes mellitus.
PHYSICAL EXAMINATION: Vital signs revealed a temperature
97.6, pulse 89, respiratory rate 20, blood pressure 105/60.
Oxygen saturation 100% on three liters. In general, this is
an elderly female with mild respiratory distress, alert,
cooperative and oriented times three. Cranium was
normocephalic and atraumatic. The pupils are equal, round,
and reactive to light and accommodation. Extraocular
movements are intact. Sclera anicteric. Mucous membranes
are slightly dry, no lymphadenopathy. Difficult to assess
jugular venous distention. Bilateral bibasilar crackles on
auscultation. Irregularly irregular rhythm, S1, mechanical
S2, grade III/VI holosystolic ejection murmur radiating to
the axilla. Large pannus, normoactive bowel sounds, soft,
nontender, nondistended. Stools guaiac positive. No
costovertebral angle tenderness. Extremities - 2+ edema in
the lower extremities bilaterally. Kyphoscoliotic changes.
Cranial nerves II through XII are intact. Strength and
sensation are intact. No rashes.
LABORATORY DATA: On admission, sodium 137, potassium 3.6,
chloride 94, bicarbonate 32, blood urea nitrogen 26,
creatinine 0.7, glucose 107. Calcium 8.1, magnesium 1.4,
albumin 2.8. INR 1.9. Hematocrit 27.6, white blood cell
count 7.6, platelet count 320,000.
Electrocardiogram on admission showed no significant change
since electrocardiogram on [**2117-10-5**], atrial fibrillation,
premature ventricular contractions or aberrant ventricular
conduction, incomplete right bundle branch block, extensive
but nonspecific ST-T wave changes.
Chest x-ray was consistent with congestive heart failure.
The heart is enlarged. Cardiac pacer device is seen and
sternal clips consistent with prior coronary artery bypass
graft.
HOSPITAL COURSE: In the Emergency Department, the
laboratories and studies reported above were obtained. Her
systolic blood pressure dropped to the 80s and she received
intravenous fluids 500cc bolus normal saline and then 100cc
and made 900cc of urine in three hours. She received two
units of packed red blood cells because of her hematocrit.
She also received Levofloxacin and Metronidazole
intravenously for empiric coverage of gastrointestinal
infection. She was admitted to the Medical Intensive Care
Unit. Her anticoagulants were held and her gastrointestinal
bleeding gradually decreased. The colonoscopy was obtained
on [**2118-4-6**], which was normal to the cecum and terminal
ileum. However, ulcers in the hepatic flexure possibly from
ischemia were noted. BICAP cautery was applied to a small
red spot that was considered stigmata of previous bleeding,
no recurrent arteriovenous malformations were seen, however,
prep was very poor. Biopsies were not taken. Dr. [**Last Name (STitle) **]
of gastroenterology was involved in her care. Also in the
Medical Intensive Care Unit, cardiology evaluated the patient
as moderate risks for perioperative and postoperative
complications and made recommendations for intraoperative
management if hemicolectomy was part of her potential
management.
The patient was started on Heparin and transferred out of the
Medical Intensive Care Unit. On the medical floor, the
patient's Heparin was titrated to achieve a goal partial
thromboplastin time between 60 and 80. She did not
experience any more gross blood per rectum. Her stools with
two exceptions were guaiac negative. Her hematocrit
stabilized around 30.0. During the rest of her stay, she
experienced one episode of respiratory distress with a bump
in her troponin level of 7.6 which was believed to be due to
an acute exacerbation of her congestive heart failure.
Pulmonary evaluated the patient on [**2118-4-11**], and reported
moderately severe obstructive airways disease likely due to
emphysematous and moderately severe restrictive lung
dysfunction, low TLC likely due to kyphosis, obesity and
right effusion. Her pulmonary function tests showed the TLC
53% of predictive, FEV1 0.74 which was 34% of predicted, FVC
1.31, FEV1/FVC ratio 74% of predicted. It is believed that
there would be a significant risk of pulmonary problems. [**Name (NI) 6**]
echocardiogram was obtained on [**2118-4-15**]. The left atrium was
moderately dilated, overall left ventricular systolic
function was estimated near normal, left ventricular ejection
fraction greater than 55%, right ventricular cavity was
moderately dilated. It was believed the patient risk of
having colectomy outweighed risk of leaving the patient with
less anticoagulation given her poor cardiopulmonary status.
It was believed that a repeat colonoscopy with biopsy with an
excellent preparation would help us better assess the source
of her bleeding and would aid in the nonoperative management
of future gastrointestinal bleeds. The patient refused the
procedure. The patient's clinical picture continued to
improve with aggressive diuresis. She was transitioned from
Heparin to Warfarin.
CONDITION ON DISCHARGE: Her condition on discharge was
improved.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed.
2. Congestive heart failure.
3. Status post aortic valve replacement.
4. Coronary artery disease.
5. Chronic obstructive pulmonary disease.
6. Atrial fibrillation.
7. Diabetes mellitus type 2.
8. Hypercholesterolemia.
MEDICATIONS ON DISCHARGE:
1. Albuterol inhaler two puffs four times a day.
2. Captopril 6.25 mg p.o. three times a day.
3. Digoxin 0.125 mg p.o. once daily.
4. Furosemide 120 mg p.o. three times a day.
5. Gabapentin 100 mg p.o. q.h.s.
6. Insulin.
7. Ipratropium inhaler two puffs four times a day.
8. Metolazone 5 mg p.o. twice a day.
9. Metoprolol 12.5 mg p.o. twice a day.
10. Pantoprazole 40 mg p.o. once daily.
11. Simvastatin 10 mg p.o. once daily.
12. Spironolactone 25 mg p.o. once daily.
13. Warfarin 2.5 mg p.o. q.h.s.
14. Sulfadem 5 mg p.o. q.h.s. p.r.n.
DISCHARGE STATUS: She will return to her rehabilitation
facility.
[**Doctor First Name 1730**] [**Name8 (MD) 29365**], M.D. [**MD Number(1) 29366**]
Dictated By:[**Last Name (NamePattern1) 9128**]
MEDQUIST36
D: [**2118-4-24**] 10:49
T: [**2118-4-24**] 12:22
JOB#: [**Job Number 99174**]
|
[
"4280",
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"2720"
] |
Admission Date: [**2179-12-15**] Discharge Date: [**2179-12-30**]
Date of Birth: [**2120-12-29**] Sex: F
Service: MEDICINE
Allergies:
Peanut / Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation
Central line placement
History of Present Illness:
The patient is a 58 year old female with a history of HTN and
tobacco use was presented to an OSH ED ([**Hospital3 51058**] ([**Telephone/Fax (1) 86711**]) from her PCPs office with hypotension in the 70s. The
patient is currently intubated, so most information was gained
from the medical records. She presented to her PCPs office with
complaints of 3 days of severe shortness of breath, cough,
congestion, and general malaise. Her symptoms [**Doctor Last Name **] also noted be
associate with subjetive fevers/chills, poor PO intake, and
loose stool. At the OSH ED, she was noted to be hypotensive
76/45, HR 103, T 99.4, satting 86% on RA. She was noted to have
new ARF with Cr to 4.5m Depsite receiving 2L. She was given a
dose of levofloxacin, placed on a NRB, and transfered to the
[**Hospital1 18**] for further manegement.
.
On arrival to the ED, patient's 92/40, HR 100, RR 24, satting
98% on 15L. She remained hypotensive throughout her ED course
with SBPs in the 70s and 80s, and was uptitrated on levo, neo,
and dopamine to maximal doses with continued hypotension. She
recieved an additional 7L of NS. She was given vancoymcyin and
clindamycin with concern of a PCN allergy. With continued
hypoxia with O2 sats to low 80s, she was intubated. No ABG or A
line oculd be placed. The patinet continued to have low O2 sats,
and had her FiO2 increased to 100%, PEEP increased to 15. She as
transfered to the floor for further care.
.
On arrival to the floor, an ABG was checked showing a gas of pH
6.91 pCO2 77 pO2 67 HCO3 17. 2 amps of HCO3 were given and a
HCO3 drip was started. Vasopressin was started. Her pressors
were weened over the course of her first hour, to low levels of
levophed and vasopressin. Her CVP was 15, and fluid
ressusitation was held. With high peak pressures and ? partial
right mainstem intubation, her ET tube was pulled back 1 cm. An
A line was placed, her PEEP increased from 15 to 20. With absent
bowel sounds on exam and marked leukocytosis with a history of
loose stool, flagyl was given. 4g of Ca were given for iCa of
0.7. Paralytics were started. She was placed on droplet
precautions and tamiflu was given. An A line was placed and
oxygention improved
Past Medical History:
Hypertension
Back pain (new since 3 days PTA)
Social History:
The patient is married and has children. Smokes [**11-27**] PPD for many
years. No alcohol or drug use
Family History:
non contributory
Physical Exam:
General Appearance: Intubated, unresponsive, critically ill
Eyes / Conjunctiva: Pupils dilated, unresponsive
Head, Ears, Nose, Throat: Endotracheal tube, OG tube
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, No(t) Bowel sounds present,
Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed, Unresponive, sedated, paralyzed
Pertinent Results:
==================
ADMISSION LABS
==================
[**2179-12-14**] 11:20PM BLOOD WBC-37.4* RBC-3.29* Hgb-10.1* Hct-30.2*
MCV-92 MCH-30.8 MCHC-33.6 RDW-14.3 Plt Ct-346
[**2179-12-14**] 11:20PM BLOOD Neuts-85* Bands-9* Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2179-12-14**] 11:20PM BLOOD PT-12.2 PTT-31.3 INR(PT)-1.0
[**2179-12-14**] 11:20PM BLOOD Glucose-81 UreaN-90* Creat-2.8* Na-135
K-4.9 Cl-104 HCO3-16* AnGap-20
[**2179-12-16**] 04:01AM BLOOD Lipase-12
[**2179-12-14**] 11:20PM BLOOD Calcium-5.7* Phos-4.7* Mg-2.0
[**2179-12-16**] 04:01AM BLOOD Cortsol-38.0*
[**2179-12-15**] 03:26AM BLOOD Type-ART pO2-67* pCO2-77* pH-6.91*
calTCO2-17* Base XS--20
[**2179-12-14**] 11:44PM BLOOD Lactate-1.9
[**2179-12-15**] 03:26AM BLOOD O2 Sat-82
[**2179-12-15**] 03:59AM BLOOD freeCa-0.72*
=============
RADIOLOGY
=============
CHEST X-RAY
CHEST, UPRIGHT PORTABLE AP VIEW: The right IJ catheter
terminates in the
right atrium. Diffuse airspace consolidation, most severely
involving the
right upper and lower lobes is concerning for pneumonia. Left
hilar
lymphadenopathy may be reactive, although an underlying mass
cannot be
excluded.
IMPRESSION:
1. Right IJ catheter terminating in right atrium.
2. Extensive bilateral airspace consolidation and left hilar
lymphadenopathy. As noted on the previous study, this should be
followed to resolution to exclude an underlying mass.
ECHO ([**2179-12-15**])
The estimated right atrial pressure is 10-20mmHg. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). There is a mild resting
left ventricular outflow tract obstruction. The aortic root is
mildly dilated at the sinus level. The aortic valve is not well
seen. There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
CT CHEST ([**2179-12-15**])
IMPRESSION:
1. Dense parenchymal multifocal airspace consolidation, most
compatible with multifocal pneumonia.
2. Distended gallbladder with small amount of pericholecystic
fluid and
gallbladder stone seen in the region of the neck. Mild
mesenteric stranding adjacent to gallbladder tip. Recommend
clinical correlation, and right upper quadrant ultrasound to
exclude possibility of cholecystitis.
3. No discrete fluid collections that would be concerning for
abscess
formation.
4. Mild wall thickening seen in several regions of the colon,
though is more likely secondary to collapsed bowel from
underdistension as no associated mesenteric stranding to suggest
active colitis.
Brief Hospital Course:
# Hypoxia/ARDS/Pneumonia: The patient presented with 3 days of
fever, cough, SOB and congestion. She presented to an OSH
hypoxic and hypotensive. She was given levofloxacin, placed on
a NRB and transferred to [**Hospital1 18**]. IN the ED she continued to be
hypoxic to the low 80's and hypotensive requiring pressors
(levophed, neo, dopamine). She was intubated for respiratory
failure. She was also given Vancomycin, clindamycin and
tamiflu. She was transferred to the ICU for further management.
The patient had a CXR that showed multifocal opacities and was
venilated based on ARDS protocol. The patient's flu came back
negative from the State Lab and tamiflu was d/c. However, blood
cultures from [**Hospital1 15331**] returned with S. pneumo (pan-sensitive)
and he was continued on meropenem/vancomycin. The patient was
eventually narrowed to a 14 day course of levofloxacin. The
sputum cultures have only grown yeast and all blood cultures
remained negative. The patient was aggressively diuresed given
volume overload on a lasix gtt and eventually was able to be
extubated on [**12-25**]. Following extubation, patient did well with
oxygen via nasal canula. It was weaned as tolerated. On
discharge, Mrs. [**Known lastname 86712**] was satting 95% on 2-3L by NC.
.
#Hypotension- On admission the patient was hypotensive and
required pressors including levophed, neo, and dopamine. He
received approx 7L of IVF for hypotension. In the ICU the
patient's pressors were able to be weaned to levophed and
vasopressin overnight. The patient was able to be weaned off
levophed on [**12-18**], but remained on vasopressin intermittently
until [**12-25**] while being diuresed. Aside from one episode of
hypotension while on lasix/ ambien, Mrs.[**Known lastname 86713**] blood
pressure was stable throughout the rest of the admission.
.
# Acute Renal Failure: At the OSH the patient's creatinine was
found to be 4.5. On admission to [**Hospital1 18**] her creatinine was 2.0
and improved with IVF and blood pressure management. It was
likely a combination of pre-renal leading to ATN. The patient's
renal function improved and returned to baseline prior to
discharge
.
# Fevers: Patient with continued fevers throughout her course
likely from pan-sensitive strep pneumo bacteremia isolated at
the OSH hospital. The patient was treated for pneumonia as
above with broad spectrum antibiotics. Her urine cultures
remained negative and only growing yeast. Patient underwent RUQ
that showed some dilation of the CBD, but evaluated by surgery
who did not feel it was the cause of her fevers. She also
underwent MRI of the T/L/S spine that was negative for abscess.
She was continued on levofloxacin for a planned 14 day course.
.
# Nausea/Vomiting: Following extubation, Mrs. [**Known lastname 86712**] had
difficulty tolerating PO's. She had several episodes of nausea
and vomiting. She was evaluated by speech and swallow and there
was no evidence of aspiration. The nausea and vomiting quickly
resolved on its own without further intervention. On discharge
she was tolerating a regular diet.
.
# Weakness: Lower extremity weakness noted once patient
extubated and awake. This was thought to be secondary to
deconditioning. Physical therapy was initiated and her weakness
was improving throughout her admission. By discharge she was
ambulating with a walker though remains significantly
deconditioned.
Medications on Admission:
ASA prn headache
Benicar 20mg daily
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*2*
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: 12 hours on, 12 hours off.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
3. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Tablet(s)
4. incentive spirometry Sig: One (1) use 10 times per hour:
when awake.
Disp:*1 1* Refills:*2*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**11-27**] Inhalation q2hours as needed for shortness of breath or
wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 86714**]Healthcare
Discharge Diagnosis:
Strep Pneumococcus Bacteremia, Pneumonia
Sepsis
ARDS
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were diagnosed with a severe pneumonia. You had a long
course in the ICU requiring intubation and completed a course of
antibiotics. You will not need to take any antibiotics after
discharge.
.
When you came in you had very low blood pressure, thus we did
not give you your blood pressure medication while you were here.
You should discuss this with your primary care physician before
restarting the medication.
.
You should continue to use your incentive spirometry 10 times
per hour while you are awake. This will help with your
oxygenation.
Followup Instructions:
You will be discharged to a rehabilitation facility.
You should follow up with your primary care doctor 2-4 weeks
after discharge from the rehabilitation facility.
Completed by:[**2179-12-30**]
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Admission Date: [**2187-8-20**] Discharge Date: [**2187-9-14**]
Date of Birth: [**2138-5-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Pt is a 49 yo male transferred via med flight from OSH [**Hospital3 **] s/p GSW. Pt was brought directly to the OR.
Major Surgical or Invasive Procedure:
OPERATION:
1.Median sternotomy, multiple cardiac repairs as dictated by Dr.
[**Last Name (STitle) **], repair of right upper lobe parenchymal
laceration, exploratory laparotomy,chromic suturing and Argon
beam coagulation of 4 liver lacerations,abdominal packing, VAC
closure of abdomen.
2. Emergency median sternotomy.
3. Evacuation cardiac tamponade.
4. Repair of bullet injury to the right ventricle free wall.
5. Tricuspid valve replacement with a size 29 [**Company 1543**] Mosaic
tissue valve.
6. Repair of ventricular septal defect caused by the bullet with
Dacron patch.
7. Left ventriculotomy to remove the bullet.
8. Laparotomy and repair liver lacerations and also lung
parenchymal injury by Dr. [**Last Name (STitle) 16471**] as seen in her operation
dictation note.
9. Mediastinal exploration and washout.
10. Mediastinal exploration and closure of the sternotomy.
11.Exploratory laparotomy/reopening of recent laparotomy,
washout of the abdomen and closure, as well as exploration of
the right arm wounds, debridement and packing
12.Exploratory laparotomy and abdominal washout. Abdominal wall
debridement.Liver biopsy. Abdominal wall closure with retention
sutures.
History of Present Illness:
This is a 49-year-old patient who sustained a gunshot injury to
the right chest. He was apparently very unstable in the field
with multiple arrests resuscitated successfully and on reaching
the outside hospital at [**Hospital3 **] he was apparently
reasonably stable. There, further investigations with x-rays
revealed the bullet had traversed through the right
hemithorax(chest tubed placed) across the heart and lodged
itself into the left heart border and he was transferred
emergently to the [**Hospital3 **] Hospital for further exploration
and repair. On arrival to the [**Hospital3 **] Hospital, he was
actively resuscitated to maintain reasonable hemodynamics and
emergency surgery was carried out by [**Last Name (LF) **],[**First Name3 (LF) **] and the
trauma surgeon, Dr. [**Last Name (STitle) 16471**], and initially explored by Dr.
[**Last Name (STitle) **] as well.
Past Medical History:
+ETOH, DM, HTN, ? methadone user, s/p hit by train [**2180**]
Social History:
Heroin addict
Family History:
Non-contributory
Physical Exam:
Admission physical deferred- rushed emergently to O.R.
Pertinent Results:
TEE [**8-23**]
Focused Study for Chest Closure and Ongoing Pressor Requirement:
Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is a
muscular ventricular septal defect (VSD) just below the
prosthetic tricuspid valve with left to right flow. This is
approximately 1 cm superior to the VSD observed on [**2187-8-21**] that
was repaired. The remaining left ventricular segments contract
normally. Right ventricular chamber size and free wall motion
are normal.. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. A bioprosthetic valve
is seen in the tricuspid position. There is a very small
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person
of the results on [**2187-8-23**] at 0830. Following chest closure
overall systolic function was unchanged from prior.
[**2187-8-31**] Chest and ABD CT Scan:
1.Small apical right pneumothorax.
2.Small bilateral pleural effusions with overlying atelectasis;
however,
infection cannot be excluded, especially at the left lung base.
Chest tube in appropriate position.
3.Small fluid collection inferior to the cecum with high density
material
concerning for extravasation of oral contrast. Associated focal
wall
thickening of the cecum which may be due to colitis: infections
or
inflammatory.
3. Wedge-shaped hypodense lesion within segment [**Doctor First Name 690**] of the
liver, likely
representing repaired liver laceration. Small amount of
perihepatic free
fluid.
4. Open anterior abdominal wall wound with a small amount of
fluid or
stranding inferiorly in the anterior abdominal wall.
5. Fractured left 1st and 2nd ribs.
Discharge labs:
[**2187-9-14**] 06:18AM BLOOD WBC-9.5 RBC-2.98* Hgb-8.4* Hct-27.0*
MCV-91 MCH-28.3 MCHC-31.1 RDW-16.5* Plt Ct-381
[**2187-9-14**] 06:18AM BLOOD Glucose-68* UreaN-28* Creat-1.8* Na-126*
K-4.8 Cl-93* HCO3-23 AnGap-15
[**2187-9-13**] 04:51AM BLOOD WBC-10.0 RBC-2.94* Hgb-8.4* Hct-26.8*
MCV-91 MCH-28.4 MCHC-31.2 RDW-16.7* Plt Ct-401
[**2187-9-12**] 05:19AM BLOOD WBC-12.9* RBC-2.99* Hgb-8.6* Hct-26.8*
MCV-90 MCH-28.8 MCHC-32.1 RDW-16.6* Plt Ct-431
[**2187-9-13**] 04:51AM BLOOD Plt Ct-401
[**2187-9-12**] 05:19AM BLOOD Plt Ct-431
[**2187-9-5**] 02:53AM BLOOD PT-15.0* PTT-42.0* INR(PT)-1.4*
[**2187-9-13**] 04:51AM BLOOD Glucose-78 UreaN-30* Creat-2.1* Na-125*
K-4.2 Cl-93* HCO3-25 AnGap-11
[**2187-9-12**] 05:19AM BLOOD Glucose-96 UreaN-34* Creat-2.2* Na-122*
K-4.0 Cl-89* HCO3-23 AnGap-14
[**2187-9-7**] 05:50AM BLOOD ALT-72* AST-131* AlkPhos-108 Amylase-87
TotBili-1.9*
[**2187-9-3**] 02:01AM BLOOD ALT-62* AST-170* LD(LDH)-378* AlkPhos-97
TBili-2.6*
[**2187-9-7**] 05:50AM BLOOD Lipase-49
[**2187-9-1**] 02:07AM BLOOD Lipase-204*
[**2187-9-13**] 04:51AM BLOOD Mg-2.2
[**2187-9-12**] 05:19AM BLOOD Mg-2.1
[**2187-9-5**] 10:58 am STOOL **FINAL REPORT [**2187-9-6**]**
C. difficile DNA amplification assay (Final [**2187-9-6**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay. (Reference
Range-Negative).
[**2187-8-30**] 9:52 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2187-8-31**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2187-9-2**]):
RARE GROWTH Commensal Respiratory Flora.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE
GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 111925**]
[**2187-8-25**].
[**2187-8-25**] 3:12 pm BLOOD CULTURE Source: Line-IJ 2 OF 2.
Blood Culture, Routine (Final [**2187-8-28**]):
SERRATIA MARCESCENS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
353-3223V
[**2187-8-27**].
Anaerobic Bottle Gram Stain (Final [**2187-8-26**]): GRAM
NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2187-8-26**]): GRAM NEGATIVE
ROD(S).
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2187-9-9**] 2:54 PM
Final Report: In comparison with study of [**9-7**], there has been
placement of a left subclavian PICC line that extends to the
lower portion of the SVC. Continued low lung volumes with
bibasilar effusions and atelectasis. No definite pulmonary
edema. Left apical pleural cap again is seen, representing a
loculated, possibly extrapleural fluid collection related to the
recent rib fracture.
Brief Hospital Course:
The patient was admitted from an outside hospital and went
emergently to the OR after sustaining gunshot wound to the
chest. He underwent extensive surgery to
repair trauma sustained to chest. He was brought from the OR
after undergoing Median sternotomy, TVR/VSD closure/RV repair by
Dr. [**Last Name (STitle) **], repair of right upper lobe parenchymal
laceration, exploratory laparotomy, chromic suturing and Argon
beam coagulation of 4 liver lacerations,abdominal packing, VAC
closure of abdomen .Please see multiple operative notes for
further details. He arrived from OR intubated, sedated,
paralyzed on Epi/Levo/vasopressin, open chest. He was bleeding
from his chest tubes and required multiple blood products and
returned to the OR for abd and chest washout, repair of
diaphragmatic bleeder. Returned from OR continued to be
hypotensive, elevated transaminases, chest and abd open and
wound vac in place. He developed Rapid afib and received
amiodarone with good effect. He returned to the OR on POD#2 for
chest closure which he tolerated well. Abdominal wound remained
open and packed. After chest closure pressors were weaned slowly
over the course of several days. On pod# 4 his abd was closed.
His sedation was weaned off, he remained neurologically intact
and his c-spine was cleared by ACS. He spiked fevers and became
bacteremic. He grew Serratia from his blood and STENOTROPHOMONAS
and ENTEROBACTER from sputum on [**8-28**]. He was covered with broad
coverage antibiotics, (vanc, fagyl, cefepime) ID were consulted
and Bactrim was added. He developed drainage upper aspect of abd
wound and was brought back to the OR by ACS. The abd was opened
and packed. He returned a few days later for abd wound closure
but the skin remained open. He was extubated on POD#7 but was
reintubated 3hr later 2nd to resp distress. Left chest tube was
placed for moderate to large effusion. He was again reextubated
on POD#10. Due to his current drug history he was seen by the
acute pain service for management of meds. He continued to
progress slowly and was transitioned off tube feeds, seen by
speech and swallow and cleared to eat regular diet. Appetite is
poor and he is on supplements. His tranaminases have continued
to improve. He developed acute renal failure peak creatinine
2.5. and was therefore gently diuresed. His creat continues to
be above normal. He was noted to have developed a pressure sore
to the back of his head for which he was seen by wound nurse and
place in foam mattress. Chest tubes and PW were remove without
incident. He eventually transitioned to the floor on POD#12. On
the floor he continued to progress. He has remained very weak
and deconditioned. He developed c-diff and was started on PO
Vanco which he had completed. He became hyponatremic which has
been slowly improving and was placed on fluid and free water
restriction and meds were adjusted. He has remained afebrile and
will continue on bactrim until [**9-14**]. The patient was evaluated
by the physical therapy service for assistance with strength and
mobility. At the time of discharge on POD 24 the patient was
requiring max assist and was screened for rehab. He is able to
sit and stand at the bedside he has a continued flat affect
requiring encouragement to partake in physical therapy. All his
wounds are healing well, his abdominal wound has several
retention sutures and a vac in place to assist with wound
healing. He was noted to be lethargic a few days prior to
discharge and pain meds were adjusted, he has tolerated the
adjustment and noted to be less lethargic.
The patient was discharged to [**Location (un) 511**] Sianai in [**Location (un) 86**] in
good condition with appropriate follow up instructions.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Furosemide 20 mg PO BID
7. Heparin 5000 UNIT SC TID
8. Metoprolol Tartrate 12.5 mg PO BID
hold and call HO for SBP<90
HR<55
9. Milk of Magnesia 30 mL PO DAILY:PRN constipation
10. Nystatin Cream 1 Appl TP [**Hospital1 **] groin
11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 0.5 (One half) tablet(s) by mouth
every four (4) hours Disp #*40 Tablet Refills:*0
12. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
13. Ranitidine 150 mg PO DAILY
14. Tizanidine 0.5 mg PO BID:PRN pain
15. Sodium Chloride 1 gm PO TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] at [**Hospital 3278**] Medical Center
Discharge Diagnosis:
1)Gunshot wound to chest with resultant injuries to heart,
diaphragm, lung and liver resulting in massive hemorrhage and
pericardial tamponade.
2)Bleeding from diaphragm.
3)Fascial dehiscence and evisceration
4)Serratia bacteremia
PMH: HTN, DM
Discharge Condition:
Alert and oriented x3 nonfocal
Bed to chair with assist(per PT)full assist-lift(per nursing)
pain managed with oral narcotics
Extremities:warm well perfused-no edema
Abd wound:with VAC, incision-clean
Occiput: pressure ulcer-keep on sponge pillow
Discharge Instructions:
look at your incisions daily
NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and in the evening take
your temperature, these should be written down on the chart
Vab dressing chnage to abdomin q 72hrs (last change [**2187-9-14**])
No driving for one month or while taking narcotics. Do not drive
until follow up with surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon: Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2187-10-16**]
1:00 in the [**Hospital **] medical office building [**Hospital Unit Name **]
Cardiologist:needs referral
Please call to schedule appointments with your:
Acute Care Surgery(ACS): call [**Telephone/Fax (1) 2537**] to schedule f/u appt
in 2 weeks
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 66039**] in [**4-5**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2187-9-14**]
|
[
"5849",
"99592",
"2761",
"2851",
"4019",
"25000",
"42731"
] |
Admission Date: [**2174-3-13**] Discharge Date: [**2174-3-16**]
Date of Birth: [**2093-8-12**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
tongue, lip swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 5239**] is an 80 y/o W w/ h/o asthma and HTN who p/w severe
swelling of tongue, lips, and throat. This began on the morning
of admission; she first noticed that she could not speak. Her
swelling progressed rapidly, so she went to her sister-in-law's
house and had her drive her to [**Hospital1 **] [**Location (un) 620**]. She denies that she
had trouble breathing during this episode. Of note, she has had
a similar experience twice before, once 4 years ago and once 5
years ago. Neither episode was as severe. She has not been able
to identify any trigger (no new foods, no insect or plant
exposure, etc) other than lisinopril, which she has been taking
for 5-6 years.
.
At [**Location (un) 620**], the patient was treated with epinephrine, Benadryl
50 IV, SoluMedrol 125 mg IV, pepcid 20 mg IV, racemic epi, and a
500 cc NS bolus. ENT evaluated her for a possible surgical
airway; laryngoscopy was consistent with angioedema. ENT
recommended observation, d/c'ing lisinopril permanently, and
decadron 12 mg Q8H. Patient was transferred to [**Hospital1 18**] for further
observation.
.
In the ED, she received 2 albuterol nebs and was admitted to
MICU for close observation. There, she was treated overnight
with Decadron 12 q8h, Benadryl 25 once, and Nebs q6h. She had
improved markedly from admission; she now says she is almost
back to normal, though with a little residual swelling. She is
called out to the floor for further management.
.
ROS: She is otherwise in good health. She denies dyspnea
currently, chest pain, palpitations, lightheadedness, dysphagia,
nausea, vomiting, diarrhea, and dysuria. She does report
"coughing twice today."
Past Medical History:
1. Asthma
2. HTN
Social History:
No alcohol, tobacco (quit 40 years ago), drugs. Lives alone but
is completely independent in ADLs, IADLs.
Family History:
NC
Physical Exam:
VS: T97.1 HR99 BP136/57 RR18 O2 96% 3L NC
Gen: Obese woman appearing younger than stated age in NAD.
HEENT: No visible lip or tongue swelling, questionable neck
swelling; OP clear, PERRL, EOMI, neck supple w/o LAD.
CV: RRR, no m/r/g
Resp: End expiratory wheezes. No rales or rhonchi. No stridor.
Abd: soft, NT, ND, +BS
Ext: warm, well-perfused, + 2 DP pulses
NEURO: alert, oriented
Pertinent Results:
OSH: crea: 1.3, BUN: 27, Trop T 0.014 (normal = <0.01)
[**Hospital1 18**] [**3-14**]:
Chem 7:
140 105 30 200
5.0 24 1.3
CK: 93 MB: Notdone Trop-T: <0.01
WBC: 9.2; Hct: 35.5; Plt: 313
Brief Hospital Course:
Ms. [**Known lastname 5239**] is a pleasant 80 year old woman with a history of
hypertension, treated in part with lisinopril, and asthma who
presented with signs and symptoms of angioedema. Her brief
hospital course by problem is as follows:
.
1. Angioedema.
This was attributed to her lisinopril. She was initially
admitted to the MICU for observation, but she never required
airway support and after a day of high-dose steroids she had
improved dramatically. Her care was continued on the floor,
where a taper of her steroids was begun. She was also treated
with famotidine and diphenhydramine. On discharge, she was given
a prescription for a 7-day steroid taper and was instructed to
follow up with an allergist, whose name and number were
provided, as well as her PCP. *** Her PCP may wish to have her
obtain a MedicAlert bracelet. ***
.
2. Asthma.
She had a flare of her asthma on the planned day of discharge,
which necessitated an additional night in the hospital. This
improved with standing albuterol and ipratropium nebulizers q6h
as she uses at home and an inhaled steroid similar to her
outpatient budesonide. At the time of discharge, she was
breathing comfortably and reported that she was at her baseline.
.
3. Hypertension.
She was started on Nifedipine to control her blood pressure,
which had good effect. She was given a prescription for
Nifedipine XL and was instructed not to use ACE inhibitors in
the future.
.
4. Leukocytosis.
She had a brief increase in her WBC count of one day's duration.
She had no signs of infection, and it was believed that this was
due to steroids. It resolved as the steroids were tapered.
.
5. Anemia.
She was at her baseline hematocrit, although the etiology of
this is as yet unknown. She had no evidence of iron, B12, or
folate deficiency, and her stool was negative for occult blood.
.
6. Chronic renal failure.
She has had an elevated creatinine over the last several months,
with a baseline of 1.2 to 1.4. She remained in this range
throughout her hospitalization, although actually improved to
0.9 on discharge. Further evaluation was deferred.
.
7. Prophylaxis: She was given a bowel regimen PRN, pneumoboots
to prevent DVTs, and an insulin sliding scale while she was on
high-dose steroids.
.
8. Code Status: FULL
.
9. Dispo: She was discharged to home.
Medications on Admission:
Lisinopril
Albuterol
Atrovent
Nifedipine
Beclamethasone
lipitor
.
Allergies: shrimp, scallops, salmon (does not know what her
reaction is)
Discharge Medications:
1. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for lip, tongue, or face swelling for
2 weeks.
Disp:*30 Capsule(s)* Refills:*0*
6. Pulmicort 0.5 mg/2 mL Solution for Nebulization Sig: One (1)
INH Inhalation twice a day.
7. Prednisone 10 mg Tablet Sig: AS DIR Tablet PO once a day for
7 days: Take 4 tablets on Day 1; then take 3 tablets on Days 2 &
3; then take 2 tablets on Days 4 & 5; then take 1 tablet on Days
6 & 7; then stop.
Disp:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Angioedema
2. Asthma
3. Acute renal failure
.
Secondary:
1. Hypertension
Discharge Condition:
Good condition, breathing comfortably, ambulating independently,
vital signs stable.
Discharge Instructions:
You have been evaluated for tongue and lip swelling, a condition
known as angioedema. This was most likely due to your ACE
inhibitor, lisinopril. You should avoid taking all ACE
Inhibitors in the future. You have been given a prescription for
a steroid taper; you should complete the entire course of
prednisone even if you feel better. Please take all medications
as directed and please keep all follow-up appointments.
.
If you should develop recurrent swelling, shortness of breath
above your baseline, chest pain, fever/chills, or any other
symptom that is concerning to you, please call your PCP or go to
the nearest hospital emergency department.
Followup Instructions:
An appointment will be made for you with an allergist, Dr.
[**Last Name (STitle) 2603**], to confirm the cause of your symptoms. His office will
contact you to schedule the appointment, but if you have not
heard from them by Friday afternoon ([**3-18**]), please call
[**Telephone/Fax (1) 1723**].
.
Please also call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 19980**] to
schedule an appointment. You should see him in [**12-14**] weeks.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2174-3-16**]
|
[
"40391",
"5849",
"2859",
"2720"
] |
Admission Date: [**2163-2-20**] Discharge Date: [**2163-3-10**]
Date of Birth: [**2115-7-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
worsening pain, weakness, and low grade fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 47 yo F with multiple sclerosis and metastatic
melanoma p/w FTT at home. Known metastatic disease to brain,
spleen, spine. Patient with chronic back pain secondary to
metastatic disease. The patient reports that it has been
difficult to manage at home since around [**Holiday **] when she
discovered the recurrence of the melanoma in her left axilla.
Over the past 1-2 weeks she has had persistent lower back pain
and poor PO intake. She reports low grade fevers to 99 at home
with difficulty sleeping over the last few weeks. Poor PO intake
over last few weeks. She was seen in the Pain [**Hospital 9085**] clinic
and started on oxycontin and oxycodone for her back pain without
much relief. This morning her family felt that it was becoming
too difficult to manage her symptoms at home and felt it was
necessary to bring her to the ED.
.
In the ED, initial vitals were 97.7, HR 130, BP 132/66, RR19,
96% RA. While in the ED, the patient spiked to 102. UA was
negative. Blood and urine cultures were sent. An initial lactate
was 4.0. She received 4L IVF and her lactate improved to 2.3.
She was empirically treated with vancomycin and cefepime. A CT
scan was performed and did not show any drainable abscess from
her left axilla. The patient declined central access.
Past Medical History:
# Metastatic Melamoma - [**2162-2-8**], underwent an excisional
biopsy for what was felt to be a 7.2 thick, [**Doctor Last Name 10834**] level IV,
nonulcerated melanoma with 10 mitoses/m2 on her left shoulder.
There was evidence of lymphovascular invasion and a question of
perineural invasion. She underwent a wide local excision and
left axillary sentinel lymph node biopsy on [**2162-3-12**]
with pathology revealing melanoma in 4 sentinel lymph nodes with
evidence of extracapsular extension. She underwent a completion
left axillary node dissection on [**2162-3-26**] with
pathology showing no melanoma in 3 lymph nodes identified. She
received radiation therapy to the left axilla without
difficulty, completing in [**2162-5-9**]. She was placed on
interferon alpha-1a (Rebif) for multiple sclerosis on [**2162-7-6**]. She presented to Clinic on [**2163-1-26**] with multiple
nodules in the left axilla consistent with recurrence within the
radiation field. Subsequent head MRI showed multiple CNS
metastases. About to begin a phase II clinical trial of
sorafenib + temazolomide therapy for her CNS metastatic
melanoma.
# Multiple Sclerosis - Diagnosed in [**2154**], relapsing/remitting
Social History:
The patient lives with her husband and youngest son (age 17).
She has 2 older children ages 27 (daughter) and 25 (son). She
used to work as a teachers aid. She denies ETOH/smoking/drugs.
Family History:
Father died of heart disease. Mother with hypertension.
Physical Exam:
Vitals - 98.0 141/100 118 17 100% RA
General - ill appearing middle aged female, lying in bed
HEENT - PERRL, dry MM
Neck - supple, no lympadenopathy
CV - tachycardic, regular, no murmur appreciated
Lungs - CTA B/L
Abdomen - soft, non-tender, non-distended
Ext - extensive soft tissue nodularity in the left axilla with
venous congestion. No drainage appreciated.
Neuro - CN 2-12 intact, sensation intact upper and lower
extremities, RLE [**4-13**], LLE 4+/5, RUE/LUE 4+/5
Pertinent Results:
[**2163-2-20**] ADMISSION LABS:
WBC-9.6# RBC-4.70# Hgb-12.9# Hct-38.0# MCV-81* MCH-27.5
MCHC-34.0 RDW-16.7* Plt Ct-131* Neuts-93* Bands-1 Lymphs-0
Monos-2 Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-1*
.
PT-12.0 PTT-29.7 INR(PT)-1.0
.
Glucose-127* UreaN-20 Creat-0.4 Na-136 K-4.2 Cl-99 HCO3-20*
AnGap-21* Calcium-10.0 Phos-4.3 Mg-1.8
.
ALT-13 AST-16 LD(LDH)-595* AlkPhos-119* TotBili-0.5 Albumin-3.6
.
[**2163-2-20**] 03:15PM BLOOD Lactate-4.0*
[**2163-2-20**] 08:50PM BLOOD Lactate-2.3*
.
calTIBC-177* VitB12-1831* Folate-8.1 Ferritn-1401* TRF-136*
.
[**2163-2-20**] 2:00 pm BLOOD CULTURE
**FINAL REPORT [**2163-2-26**]**
Blood Culture, Routine (Final [**2163-2-26**]): NO GROWTH.
.
[**2163-2-20**] 3:05 pm URINE Site: CATHETER
**FINAL REPORT [**2163-2-21**]**
URINE CULTURE (Final [**2163-2-21**]): NO GROWTH.
.
[**2163-2-23**] 6:39 am URINE Source: Catheter.
**FINAL REPORT [**2163-2-24**]**
URINE CULTURE (Final [**2163-2-24**]): NO GROWTH.
.
[**2163-2-23**] 6:39 am BLOOD CULTURE Source: Line-picc.
**FINAL REPORT [**2163-3-1**]**
Blood Culture, Routine (Final [**2163-3-1**]): NO GROWTH.
.
[**2163-2-24**] 9:29 pm BLOOD CULTURE Source: Line-SL PICC.
**FINAL REPORT [**2163-3-2**]**
Blood Culture, Routine (Final [**2163-3-2**]): NO GROWTH.
[**2-20**] CT CHEST/AXILLA
IMPRESSION:
1. No evidence of drainable fluid collection.
2. Extensive metastatic disease, some of which appears stable,
for example in the lungs, however, some of which appears
increased, for example in the vertebral bodies and spleen.
3. Cortical erosion at the T7 level along the posterior
vertebral body. If concern exists for neurologic change or
compromise, consider MRI imaging to help evaluate the soft
tissue encroachment on the thecal sac and/or nerve roots.
.
[**2-20**] EKG
Sinus tachycardia
Normal ECG except for rate
.
[**2163-2-21**]
IMPRESSION: Satisfactory right PICC tip placement in the
proximal SVC.
.
[**2163-2-22**] MRI L Spine
IMPRESSION:
1. Innumerable bony metastatic foci throughout the lumbar spine,
the sacrum, and the visualized ilia.
2. Apparent epidural extension of tumor at the L3-4 level
causing mild canal stenosis.
3. No definite signal abnormality within the distal spinal cord
or nerve roots.
.
[**2163-2-23**] CXR
IMPRESSION: No new pneumonia in the visualized portions of the
lungs. Multiple melanoma metastases as on prior.
.
[**2163-2-25**] MRI C+T Spine
IMPRESSION:
1. Bony metastatic disease. No evidence of cord compression.
2. Intrinsic signal abnormalities within the spinal cord
secondary to multiple sclerosis with a possible enhancing
multiple sclerosis plaque at T7-8 level. No epidural mass seen.
.
[**2163-2-26**] RLE Ultrasound
IMPRESSION: No evidence of DVT within the right lower extremity.
.
[**2163-3-4**] MRI BRAIN
IMPRESSION:
1. Several new enhancing lesions, less than 1 cm, consistent
with further progression of metastatic melanoma.
2. Stable appearance of demyelinating disease.
3. No evidence of edema, mass effect, or hemorrhage.
[**2163-3-5**] 12:00AM BLOOD WBC-3.0* RBC-3.37* Hgb-9.4* Hct-27.7*
MCV-82 MCH-27.8 MCHC-33.8 RDW-18.4* Plt Ct-127*
[**2163-3-4**] 12:00AM BLOOD Glucose-115* UreaN-15 Creat-0.4 Na-140
K-4.1 Cl-100 HCO3-31 AnGap-13
Brief Hospital Course:
MICU COURSE:
The patient was admitted initially to the ICU for pain control
and presuemd septic physiology given tachycardia and elevated
lactate in the ED. She was continued on Vanc and Cefepime for
broad coverage given her left axillary wound and she remained
hemodynamically stable. She was continued on decadron for her
spinal met and dilaudid for pain control. As she remained
stable, she was transfered to OMED on the [**Hospital Ward Name **] for
further care.
OMED COURSE:
47 F w/ metastatic melanoma to lung, liver, brain, severe MS p/w
weakness and FTT.
# Pain Control - Used a tremendous amount of pain medicine (IV
dilaudid after first arriving to floor. Pain service was
consulted. Was initially put in IV dilaudid PCA. Final
acceptable pain regimen was 6-8 mg dilaudid q3h prn, Fentanyl
Patch 150 mcg/hr TP Q72H, methadone 10mg q8h, naproxen 500mg tid
prn, Lidocaine 5% Patch 1 PTCH TD DAILY, Neurontin
100qAM/100qPM/200qHS, and duloxetine 30mg daily. Additionally,
she underwent 5 fractions of palliative XRT to the pelvis and
spine. To counteract the effects of such a large pain medicine,
an aggressive bowel regimen was pursued. Monitored for narcosis
or depressed respiratory rate. Respirations were as low as [**11-20**]
at points, but was never pathological. Pt did deomnstrate some
nocturnal confusion (see below), for which ambien was
discontinued. By time of discharge was stablized on an adequate
regimen with an aggressive bowel regimen given her high dose
narcotics. Extended care facility has been provided with a
complete list.
# Confusion - Briefly noted early during inpatient course.
Initially thought to be most likely a side effect of
medications, but patient has known brain metastases. MRI brain
showed small new mets c/w melanoma, also stable demyelinating
disease. Ambian discontinued and confusion resolved. Rad-onc
was then consulted to evaluated if whole brain radiation vs
cyberknife were appropriate for new metastases. Given that she
was assymptomatic, no further treatment was pursued while
inpatient. If patient does become symptomatic, she's encouraged
to contact radiation oncology as needed.
# Hypertension - No history of this in the past, but pt
persistently hypertensive on the floor (although BPs were taken
in legs because L arm with invasive melanoma, R arm with PICC,
so BP likely overestimated). Hypertension was likely exacerbated
by pain, so emphasized pain control to control BP as well. BPs's
decreased as pain has come under better control but ultimately
required continued metoprolol for BP control, discharged on this
medication.
# Metastatic Melanoma w/ axillary wound - Plan to continue chemo
with TMZ 200mg per m2 at later date, currently not able [**3-12**]
compromised health. Pan Spinal MRI showed intrinsic signal
abnormalities within the spinal cord secondary to multiple
sclerosis, as well as diffuse bony metastatic disease, with no
evidence of cord compression seen. S/p palliative XRT to spine
with great improvement in pain. Wound care was consulted for
axillary wound and followed patient throughout stay.
Continued dexamethasone with taper for CNS mets. Appreciate SW
consult, psych and pall care consults while inpatient.
# Intermittent Fever - Most likely related to malignancy.
Patient presented with fever in ED. Unclear source for an
infection, as CT showed no axillary abscess and all cultures
either negative or with NGTD. CXRs unrevealing for infiltrate.
After ICU stay, patient spiked again early [**2-23**] despite
vanc/cefepime and steroids. Cultures and radiology from that
date were also negative. Patient completed 5 days of vancomycin
and a 7 day course of cefepime that was completed [**2-27**]. No
further antibiotics were given and no further evidence of
infection was found.
# Multiple Sclerosis - Last med was Rebif, d/c'ed in [**Month (only) **],
with no relapses. Previously on Avonex and Tysabri. Followed by
Dr [**Last Name (STitle) 10835**]. Spoke with Dr. [**Last Name (STitle) 10835**], would defer all MS rx at
this time while undergoing chemo; a last ditch option would be
MTX or cyclophosphamide. If undergoing brain XRT may need more
steroids as higher risk for MS relapse, but this is deferred to
outpatient follow-up if patient becomes symptomatic from new
brain metastases.
# Shoulder Pain - Complained of R shoulder pain that began the
day prior to admission following upper extremity physical
therapy. Patient was consistent with muscle strain, which
patient thought was true as well. No [**Last Name (un) 2043**] deformity. EKG not
indicative of cardiac origin. Abdominal exam benign with no
signs of radiating origin. Maintained current pain regimen with
intermittantly complete relief.
# Anxiety - Psych consulted, continued prn BZD. Duloxetine added
for pain control.
# Code - DNR/DNI - discussed with patient at time of admission
Medications on Admission:
Dexamthasone 4mg [**Hospital1 **]
Ambien 10mg PRN
Oxycontin 20mg [**Hospital1 **]
Oxycodone 5mg prn
Neurontin 300mg , uptitrating
Xanax 0.5mg PRN
Fiorinal 50-325-40mg cap 1 cap daily prn headache
Ibuprofen 600mg q8h
compazine 10mg tab q6h prn nausea
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to lower back. please remove for 12hrs in any 24 hr period .
2. Fentanyl 75 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Hydromorphone 2 mg Tablet Sig: 3-4 Tablets PO Q3H (every 3
hours) as needed: please try to give 6mg doses during the day
and 8mg at night .
4. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): hold for oversedation or confusion.
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed.
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
9. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qAM ().
11. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): continue this dosing until [**3-10**], then decrease to 2mg
daily x 1 week, then taper off, or as otherwise instructed by
MD.
12. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea/vomiting/anxiety.
13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea/vomiting.
14. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for bsp <100, hr <50.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) Powder in Packet PO daily ().
20. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day): Hold for loose stools.
21. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H
(every 4 hours) as needed.
22. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
23. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): Can discontinue once patient
is more mobile.
24. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day): hold fpr SBP<105, HR<55 .
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary:
weakness
.
Secondary:
# Metastatic Melanoma - mets to brain, pelvis, femurs, spleen,
adrenals, and spine
# Multiple Sclerosis - Diagnosed in [**2154**], relapsing/remitting
Discharge Condition:
stable, pain under good control
Discharge Instructions:
You were admitted to the hospital with worsening lower back
pain, lower extremity weakness, and low grade fevers at home.
You were initially admitted to our ICU for close observation
because we were worried about an possible infection in your
bloodstream. However, no source for an infection was ever found
and you were then transferred to our oncology floor. You had
some intermittent fevers but again, no infection was found. The
fever may have been related to your malignancy.
.
We did an MRI of your spine which showed diffuse bony metastases
which were likely causing your pain and weakness. Our pain
service consulted and put you on an extensive pain control
regimen which lowered your pain to an acceptable level. We also
called our radiation oncologists, who provided you with a 5
session course of radiation to your spine and pelvis to further
control your pain.
.
At points you were confused, which was likely a side effect of
the large amount of pain medicine you were on. However, since
you have known brain metastases, we imaged your head to assess
for any change. This scan showed a few new small lesions that
were unlikely to be responsible for the confusion. We continued
to treat your cancer with a drug called temozolomide, as well as
with the palliative chemotherapy.
.
Our physical therapists worked with you and determined that you
need to go to rehab to work on regaining your strength.
.
Please take all of your medicines as prescribed. Please keep all
of your outpatient followup appointments. If you experience any
symptoms that disturb you, such as new weakness, fevers,chills,
please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the ER.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10837**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-3-22**]
2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
date/Time:[**2163-3-22**] 2:30
Provider: [**Name10 (NameIs) 10838**] [**Name11 (NameIs) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2163-3-22**] 2:30
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
[
"0389",
"5990"
] |
Admission Date: [**2192-5-26**] Discharge Date: [**2192-5-31**]
Date of Birth: [**2131-1-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
Pulmonary Embolism
Major Surgical or Invasive Procedure:
IVC Filter
History of Present Illness:
Patient is a 61 yo female with PMH of metastatic ovarian CA and
recently diagnosed DVT on lovenox presents with right sided CP
and SOB to [**Hospital1 **] [**Location (un) 620**] found to have a large right pulmonary
artery PE and pulmonary infaract as well as several small PE's
in right lower pulmonary artery as well as left lower lobe. Of
note, she was seen in Heme/onc clinic on [**5-16**] and was found to
have a RLE DVT and was started on lovenox. She received a dose
of pemetrexed on [**5-21**] and was diagnosed with a UTI and started on
ciprofloxacin. The morning of admission, she developed acute
right-sided CP radiating to the right flank and right back with
SOB. She presented to [**Hospital1 **] [**Location (un) 620**] and was found to have
pulmonary as above. She was started on heparin and tranferred
to [**Hospital1 18**] for IVC filter placement.
.
In the ED, T 97.5 BP 94/71 HR 87 R 16 O2 sats O2 sats 99 % on
RA. She received morphine 2 mg IV x1, dilaudid 1 mg IV x 3,
dilaudid 2 mg IV x 1, ciprofloxacin 400 mg IV x1, zofran 4 mg IV
x1 and was started on a heparin drip. She had an IVC filter
placed by interventional radiology. Currently she denies CP and
SOB, and her only complaint is being tired.
.
ROS: Denies fevers, chills, dysuria, hematuria, BRBPR,
hematochezia, melena. She does report being SOB and anxious on
dexamethasone which she was taking before and after her alimta.
Also, she had urinary frequency over the past week prior to
being started ciprofloxacin. Over the past2 months she reports
weight loss and feeling exhausted doing basic ADLs.
Past Medical History:
Onc history:
Advanced ovarian cancer orginally diagnosed in [**2186**] with stage
IIIC, grade III papillary serous ovarian cancer s/p suboptimal
debulking surgery. She received 6 cycles of carboplatin and
taxol in [**2187**], doxil 6 cycles in [**2188**]. Her CA-125 began to
increase and she was then started on 8 more cycles of doxil. She
was then started on tamoxifen. Most recently she was started on
gemcitabine of which she completed 1 cycle last dose on [**4-30**].
She completed radiation on [**4-6**]. Given that she seemed to be
progressing through these therapies she received first dose of
pemetrexed on [**5-21**]. She has mets to lungs, liver, mediastinum,
soft tissue as well as bilateral hydronephrosis
Iron deficiency anemia.
DVT
Colonoscopy in [**2-/2191**] with bleeding rectal mass. Biopsy
inconclusive
Social History:
SH: Lives with husband. [**Name (NI) **] smoking, ETOH, drugs.
.
Family History:
.
FH: Maternal aunt with breast cancer. No family
history of ovarian or colon cancer
Physical Exam:
General Appearance: Thin
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Wheezes : , Rhonchorous: bilateral bases R>L)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
Imaging:
CT head : 1. No acute intracranial process.
2. No evidence of edema to suggest an underlying mass lesion.
However, of note, CT is not as sensitive as MR [**First Name (Titles) **] [**Last Name (Titles) 54340**] of
intracranial metastatic disease.
.
CTA and CT abd/pelvis:
1. LARGE CENTRAL RIGHT MAIN PULMONARY EMBOLI. THERE IS FLOW
DISTAL TO THE LARGE CENTRAL THROMBUS. FAIRLY EXTENSIVE EMBOLI
ARE NOTED IN THE RIGHT LOWER PULMONARY ARTERY AS WELL. Wedge
shaped consolidation in right lower lobe concerning for
infarctionTHERE ARE SMALL LEFT LOWER LOBE PULMONARY ARTERIAL
EMBOLI.
2. FINDINGS CONSISTENT WITH DIFFUSE METASTATIC DISEASE WITH
NUMEROUS METASTASIS THROUGHOUT THE LIVER. MEDIASTINAL AND HILAR
ADENOPATHY AND A LARGE RIGHT LOWER QUADRANT PELVIC MASS.
3. DELAYED EXCRETION WITHIN THE RIGHT KIDNEYS WITH SEVERE
HYDRONEPHROSIS AND CORTICAL THINNING. THE OBSTRUCTION OF THE
RIGHT KIDNEY IS BEING CAUSED BY THE RIGHT LOWER QUADRANT PELVIC
MASS.
4. CHOLELITHIASIS.
5. SIGMOID DIVERTICULOSIS.
6. MILD ANASARCA AND MILD ASCITES
.
CXR [**2192-5-27**] - The cardiac size is within normal limits. Tortuous
aorta is present. Left lung is clear. Some opacities are present
within the right lower lobe which would be more characteristic
for aspiration pneumonia than for pulmonary embolus. The known
pulmonary metastases are not positively identified.
IMPRESSION: Opacities in right lower lobe not particularly
characteristics for pulmonary embolus.
.
[**2192-5-26**] 09:50AM WBC-5.2 RBC-2.76* HGB-8.7* HCT-25.3* MCV-92
MCH-31.4 MCHC-34.3 RDW-16.0*
[**2192-5-26**] 09:50AM NEUTS-93.2* BANDS-0 LYMPHS-5.8* MONOS-0.3*
EOS-0.4 BASOS-0.2
[**2192-5-26**] 09:50AM PLT SMR-NORMAL PLT COUNT-195
[**2192-5-26**] 09:50AM PT-14.2* PTT-70.5* INR(PT)-1.2*
[**2192-5-26**] 09:50AM GLUCOSE-117* UREA N-22* CREAT-1.1 SODIUM-136
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-19* ANION GAP-17
[**2192-5-26**] 09:50AM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-2.3
[**2192-5-26**] 11:30AM URINE RBC-0-2 WBC-[**11-1**]* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2192-5-26**] 11:30AM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2192-5-26**] 11:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.045*
[**2192-5-30**] 05:40AM BLOOD WBC-5.7# RBC-3.11* Hgb-9.5* Hct-27.9*
MCV-90 MCH-30.6 MCHC-34.1 RDW-15.8* Plt Ct-68*
[**2192-5-28**] 06:50AM BLOOD WBC-1.4*# RBC-2.59* Hgb-8.0* Hct-24.4*
MCV-94 MCH-30.9 MCHC-32.8 RDW-15.5 Plt Ct-121*
[**2192-5-31**] 06:45AM BLOOD Neuts-75* Bands-2 Lymphs-11* Monos-11
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2192-5-31**] 06:45AM BLOOD Plt Ct-56*
[**2192-5-28**] 06:50AM BLOOD PT-14.8* PTT-77.9* INR(PT)-1.3*
[**2192-5-26**] 09:50AM BLOOD PT-14.2* PTT-70.5* INR(PT)-1.2*
[**2192-5-26**] 11:03PM BLOOD PTT-60.5*
[**2192-5-31**] 06:45AM BLOOD Glucose-85 UreaN-12 Creat-0.7 Na-136
K-4.0 Cl-104 HCO3-22 AnGap-14
[**2192-5-27**] 05:32AM BLOOD Glucose-91 UreaN-16 Creat-0.8 Na-133
K-4.1 Cl-105 HCO3-18* AnGap-14
[**2192-5-31**] 06:45AM BLOOD Calcium-9.1 Phos-1.9* Mg-2.0
[**2192-5-26**] 09:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.3
[**2192-5-26**] 11:30 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2192-5-28**]**
URINE CULTURE (Final [**2192-5-28**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
A/P: 61 yo female with metastatic ovarian cancer with recently
diagnosed DVT now with large right main pulmonary artery PE and
pulmonary infarct and small bilateral lower lobe PEs despite
anticoagulation with lovenox now s/p IVC filter placement
.
# PE: The patient presented with a large R main pulmonary artery
PE despite lovenox therapy. Upon arrival to [**Hospital1 18**] the pt was
taken to IR for placement of an IVC filter. She was started on a
heparin gtt and transfered to the ICU for monitoring given her
large clot burden. The pt remained HD stable overnight and was
transferred to the medical floor. There she remained stable on
room air. After another 24 hours, she was transitioned back to
lovenox which she will continue indefinitely. She was evaluated
by physical therapy and after several sessions, it was felt that
she was strong enough to return home with continued PT at home.
.
# UTI: The pt was started on cipro on [**5-22**] for UTI, but urine
culture reveals e. coli resistant to cipro. UA still grossly
positive and has hydronephrosis which has been noted in the
past. She was transitioned to ceftriaxone. Concern was given to
the development of pyelonephritis as the pt has known b/l
hydronephrosis. She has no current evidence of systemic toxicity
with no fevers and normal WBC. Her WBC cound dropped briefly to
the neutrapenic range, during which time she was transitioned to
cefepime. After her WBC count recovered with Neupogen and
sensitivities returned she was transitioned to Bactrim to
complete an anticipated 10 day total course.
.
# RUQ pain: The patient was also noted to have a RLL pulmonary
infarct on CTA which was causing her signficant pain with motion
and deep breathing. This was treated with PO dilaudid to good
effect. The pain was improving throughout admission.
.
# Anemia: Known iron deficiency anemia. Her HCT drifted slowly
down during this admission, likely due to Gemzar. She received a
total of 2 units of PRBCs to good effect.
.
# Nausea: Seems to have this at baseline. Ativan with best
effect. Continued home ativan as well as PRN compazine and
zofran
.
# Metastatic ovarian CA: Has widely metastatic disease.
Currently receiving alimta.
She will follow up with her primary oncologist regarding further
treatment.
.
# FEN: regular diet
.
# Code: Spoke with patient and her husband and [**Name2 (NI) 41859**]. The
patient did not have a HCP prior to admission, but identified
her husband as the person who would be her HCP. She was givne
the HCP form to sign. Additionally, we discussed her wishes,
and she said "I haven't hought about this." She knows that "I
would not want to be kept alive dependent on machines." However,
she does say that she would want to give it a try for now. I
explained that is she got intubated that it would most likley be
for worseing of her PE, which would be very grave and she would
likely not recover from this. She "wants to think about it." For
now, she is full code.
.
Medications on Admission:
Medications:
Ciprofloxacin 500 mg PO twice a day (started in [**5-22**])
Enoxaparin 60 mg SC twice a day
Lorazepam 0.5 mg Tablet [**12-14**] Tablet(s) by mouth every 4 hours as
needed for nausea/ insomnia
Folic Acid 0.8 mg PO daily
Iron 325 mg PO every other day
Loperamide [Imodium A-D] 2 mg Tablet 1 Tablet(s) by mouth as
needed for diarrhea
Multivitamin
Omega-3 Fatty Acids [Fish Oil] 1,000 mg Capsule 1 Capsule(s) by
mouth daily
Discharge Medications:
1. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO EVERY OTHER DAY (Every Other Day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold for diarrhea.
Disp:*60 Tablet(s)* Refills:*2*
7. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
8. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pulmonary Embolus
E.coli Urinary tract infection
Metastatic ovarian cancer
Discharge Condition:
All vital signs stable, afebrile, ambulatory
Discharge Instructions:
You were admitted with a clot in your lungs called a pulmonary
embolus. You had a filter placed in your inferior vena cava to
protect you from these in the future. You were started on IV
blood thinners in the hospital and transitioned to the blood
thinner called Lovenox that will be administered by a shot twice
a day. You will continue this medication until your oncologist
says you should stop. The pain on your right side is associated
with the blood clot and should continue to get better. We will
prescribe a medication called Dilaudid for you to take at home
to help the pain.
You were also found to have a urinary tract infection. This was
treated with IV antibiotics intitially and then you switched to
oral antitiotics. You will need to continue to take these
antibiotics (Bactrim or Trimethoprim/Sulfa) for several more
days to finish up treatment.
Please take all your medications as prescribed and make all of
your follow up appointments.
Please call your doctor if you experience any symptoms that are
concerning to you.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2192-6-4**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2192-6-11**] 4:00
Provider: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2192-6-11**] 4:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
|
[
"5990"
] |
Admission Date: [**2187-5-3**] Discharge Date: [**2187-5-7**]
Date of Birth: [**2133-6-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
s/p coronary artery bypass grafting times four (lima-lad,
v-ramus, V-D1, v-RPDA)[**5-3**]
History of Present Illness:
53 yo male with hypertension,
hyperlipidemia, DM, CAD (s/p 2 BMS to RCA in [**2177**]) who is s/p
MVA
in [**2186-11-22**]. He is scheduled to have meniscus repair and
as
part of a preop workup was found to have an abnormal ekg,
followed by abnormal pMIBI and Coronary CTA. The patient
reports
having shortness of breath and shoulder discomfort occurs with
exertion such as taking out the trash or climbing [**1-25**] flights of
stairs. He only notices these symptoms early in the morning. He
has also been experiencing left shoulder discomfort and numbness
which he primarily notices when he is driving in the car. He has
denies any chest pain. He was referred for left heart
catheterization which revealed a 90% proximal LAD lesion
extending back to the LM, a 50% mid-LAD lesion, and a 60% distal
RCA lesion. Cardiac [**Doctor First Name **] was consulted for evaluation for CABG
Past Medical History:
CAD s/p RCA stenting [**2177**]
Diabetes type II
Hypertension
Torn meniscus
Past Surgical History: Appendectomy 30 yrs ago
Social History:
Lives with: Wife, Married, Taxi cab equipment installer. Has 2
children.
Contact for discharge: Wife: [**Telephone/Fax (1) 20957**] [**Doctor First Name 391**]
Tobacco quit [**2162**] - previously smoked 1/2-1 ppd x 25 years
ETOH: Occassional
Family History:
Non-contributory
Physical Exam:
Physical Exam
Pulse: Resp:18 O2 sat:97% RA
B/P Right:106/60 Left:117/62
Height:6'0" Weight:220#
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:cath site Left: 2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2187-5-5**] 02:00PM BLOOD WBC-11.2* RBC-3.38* Hgb-10.9* Hct-30.9*
MCV-92 MCH-32.3* MCHC-35.3* RDW-13.5 Plt Ct-174
[**2187-5-3**] 01:06PM BLOOD PT-13.5* PTT-25.3 INR(PT)-1.1
[**2187-5-6**] 05:11AM BLOOD UreaN-12 Creat-0.7 Na-138 K-4.0 Cl-102
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 20958**], [**Known firstname 20959**] [**Hospital1 18**] [**Numeric Identifier 20960**]
(Complete) Done [**2187-5-3**] at 9:31:26 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2133-6-11**]
Age (years): 53 M Hgt (in): 72
BP (mm Hg): 122/53 Wgt (lb): 215
HR (bpm): 50 BSA (m2): 2.20 m2
Indication: Intraop CABG. Evaluate Wall motion, LVEF, Aortic
Contours, Valves
ICD-9 Codes: 424.0
Test Information
Date/Time: [**2187-5-3**] at 09:31 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine: us 6
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.5 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.9 cm
Left Ventricle - Fractional Shortening: *0.25 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Stroke Volume: 122 ml/beat
Left Ventricle - Cardiac Output: 6.08 L/min
Left Ventricle - Cardiac Index: 2.76 >= 2.0 L/min/M2
Left Ventricle - Peak Resting LVOT gradient: 6 mm Hg <= 10 mm
Hg
Left Ventricle - Lateral Peak E': 0.11 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 6 < 15
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aorta - Arch: 2.6 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 14 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 9 mm Hg
Aortic Valve - LVOT VTI: 32
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: 3.0 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 1.1 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 2.33
Mitral Valve - E Wave deceleration time: 230 ms 140-250 ms
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. No atheroma in ascending aorta. Normal
aortic arch diameter. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
Conclusions
Pre Bypass: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. The right ventricular
cavity is mildly dilated with normal free wall contractility.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen.
Post Bypass: Patient is on phenylepherine infusion, A paced.
Preseved Biventricular funciton. LVEF >55%. Aortic contours
intact. Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2187-5-3**] 17:36
?????? [**2178**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2187-5-4**] Mr.[**Known lastname **] was taken to the operating room and
underwent Coronary bypass grafting x4 (left internal mammary
artery to left anterior descending coronary artery;reverse
saphenous vein single graft from aorta to first diagonal
coronary artery; reverse saphenous vein single graft from aorta
to ramus intermedius coronary artery; as well as reverse
saphenous vein graft from aorta to posterior descending coronary
artery).Cardiopulmonary Bypass Time:82 minutes.Cross Clamp
time=:69 minutes.Please see operative report for further
details. He tolerated the procedure well and was transferred to
the CVICU intubated and sedated. He awoke neurologically intact
and weaned to extubate without difficulty. He weaned off
pressors and was started on Beta-blockers/ASA/Statin and
diuresis. POD#1 he transferred to the step down unit for further
monitoring. Physical Therapy was consulted to evaluate strength
and mobility. The remainder of his postoperative course was
essentially uneventful and on POD 4 he was cleared for discharge
to home. All follow up appointments were advised.
Medications on Admission:
ATENOLOL - 50 mg Tablet 1 Tablet(s) by mouth once a day
FOLIC ACID 1 mg Tablet - 1 Tablet(s) by mouth once a day
GLYBURIDE 5 mg Tablet - 1 Tablet(s) by mouth twice a day
METFORMIN [GLUCOPHAGE XR] 500 mg Tablet Extended Release 24 hr -
1 Tablet(s) by mouth three times a day
OMEGA-3 ACID ETHYL ESTERS [LOVAZA] - (Prescribed by Other
Provider) - 1 gram Capsule - 2 Capsule(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] 160 mg-12.5 mg Tablet
- 1 Tablet(s) by mouth once a day
ASPIRIN 325 mg Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. tramadol 50 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO TID (3 times a day).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2187-5-29**] 2:15
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2187-5-23**] 2:40
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 4606**] in [**3-27**] 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:[**2187-5-7**]
|
[
"41401",
"4019",
"2724",
"25000",
"V4582",
"V1582"
] |
Admission Date: [**2188-10-29**] Discharge Date: [**2188-11-11**]
Date of Birth: [**2116-1-21**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Lipitor / Zocor / Codeine
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate mitral regurgitation noted on perprocedure TTE and
TEE with no disruption of subvalvular apparatus or frank rupture
of the valve leaflets.
3. Pulmonary hypertension
4. Elevated right and left sided filling pressures.
5. Hemodynamic compromise necessitating IABP placement.
6. Successful PTCA and stenting of the LCX with two overlapping
bare metal stents.
History of Present Illness:
Mrs. [**Known lastname 67738**] is a 72 y oF with CAD s/p multiple PCIs, HTN, PVD,
and DMt2 who presented to an OSH with severe chest pain on
[**2188-10-28**]. She describes the pain as a "tightness" in the center
of her chest that she rated as 10 out of 10 on a pain scale.
Onset of pain was while watching television after attending a
relatives funeral. [**Name2 (NI) 1194**] was associated with nausea and shortness
of breath. She denies palpitations, dizziness, diaphoresis,
syncope, recent illness, fever or chills. It is not associated
with position or diet. She states this chest pain is similar to
the chest pain she experienced with her heart attack in [**2185**].
While at home pt took three ntg tablets without relief so she
called EMS.
.
At the OSH she received additional sublingual ntg without relief
and was subsequently placed on ntg drip. EKG was read as
bigeminy and trigeminy. She had Troponin I of 7.[**Street Address(2) 67739**]
depressions in V3-6. She given aspirin and started on heparin
and integrillin drips. She was continued on home plavix and beta
blocker. CXR showed evidence of congestive changes so she was
gently diuresed with lasix. Pt was then transferred to [**Hospital1 18**] for
cardiac catheterization.
.
On presentation to the floor, pt admits that her chest pain has
never completely resolved but that it has been maintained at a
level of 1 out of ten since admission. She denies current
palpitations, shortness of breath, and nausea. On review of
systems, she denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors.
Cardiac review of systems is notable for abscence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope. She admits to exertional calf pain despite prior
interventions. She also admits to increased dyspnea on exertion
over the last year.
.
Patient was admitted to floor and the triggered for chest pain
that was not controlled with nitroglycerin SL or drip. She was
bolused for 500 ml IVF for low blood pressures. Shortly
thereafter, she became acutely hypoxic, and was started on face
make oxygen. She was given 40 mg lasix, 2 mg morphine, and
increased nitroglycerin rate. She diuresed well with the lasix.
.
On arrival to the CCU, she was chest pain free and respiratory
distress was resolved.
Past Medical History:
CAD s/p MI in [**2185**] with c. cath x 2 (see below)
DMt2
PVD s/p bilateral LE arterial stenting
HTN
s/p psoas abscess repair
s/p cholecystectomy
s/p appendectomy
Cardiac Risk Factors: + Diabetes, +Hypertension, + tobacco
Social History:
Pt is a retired x-ray technician. She lives with her husband and
two grandchildren in [**Name (NI) 67740**], MA. Pt admits to an extensive
tobacco history. Pt had quit but recently restarted, smoking [**12-19**]
packs per week. Pt denies any etoh or drug use. Pt currently has
multiple stressors including a son with substance abuse
disorder, a close relative that recently died, a sister recently
diagnosed with [**Name (NI) 309**] body dementia. She is currently raising her
two grandchildren.
Family History:
No known family history of sudden cardiac death or premature
cardiac disease.
Physical Exam:
VS: BP 102/39, HR 87 RR 18 SpO2 94% 2L fsbs 347 wt 108kg
Gen: WDWN elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple; no masses, no LAD; JVP at angle of jaw
CV: distant heart sounds, RR, normal S1, S2. No m/r/g.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
wheezes or rhonchi, mild crackles at bases
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. Cool, capillary refill 3 seconds
Skin: dry, no stasis dermatitis or ulcers
.
Pulses:
Right: Carotid 2+ DP palpable PT palpable
Left: Carotid 2+ DP palpable PT palpable
Pertinent Results:
Cardiac ECHO ([**11-4**]) The right atrium is markedly dilated. 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 mildly depressed (LVEF= 40 %). Right ventricular
chamber size and free wall motion are normal. The aortic valve
is not well seen. There is no aortic valve stenosis. Mitral
valve leaflets are not well seen. Trivial mitral regurgitation
is seen (may be underestimated due to poor technical quality).
The pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Suboptimal image quality. Mildly depressed left
ventricular systolic function. Preserved right ventricular
function.
Compared with the prior study (images reviewed) of [**2188-10-30**],
the severity of mitral regurgitation appears to be reduced, but
image quality is extremely suboptimal. If clinically indicated,
a TEE would better assess the severity of regurgitation.
.
CARDIAC CATH: 1. Selective coronary angiogrpahy in this right
dominant system revealed 2 vessel obstructive coronary disease.
The LMCA had a distal taper. The LAD had an 80% proximal and 80%
mid vessel stenosis. The LCX was subtotally occluded proximally
with TIMI 2 flow. The RCA had ostial dampening with a filling
defect in the proximal stent.
2. Resting hemodynamics revealed low systemic blood pressure and
shock physiology with SBP as low as 50 mmHg up to 118 mmHg with
initiation of a dopamine IV gtt. There was moderate to severe
pulmonary hypertension with PASP of 84 mmHg. There was elevated
right and left sided filling pressures with RVEDP of 21 mmHg and
mean PCWP of 60 (with giant V waves noted). The cardiac index
was preserved at 3.40 l/min/m2 on IV dopamine.
3. Successful PTCA and stenting of the left circumflex with two
overlapping bare metal stents a Microdriver (2.5x24mm) bare
metal stent proximally and a MiniVision (2.5x28mm) bare metal
stent distally. The stents were postdilated with a 2.5mm
balloon. Final angiography demonstrated no angiograghically
apparent dissection, no residual stenosis and TIMI III flow
throughout the vessel (See PTCA comments).
4. Successful placement of an intraortic balloon pump via the
right femoral artery.
Cardiac cath final diagnosis:
1. Two vessel coronary artery disease.
2. Moderate mitral regurgitation noted on perprocedure TTE and
TEE with no disruption of subvalvular apparatus or frank rupture
of the valve leaflets.
3. Pulmonary hypertension
4. Elevated right and left sided filling pressures.
5. Hemodynamic compromise necessitating IABP placement.
6. Successful placement of a 30cc IABP via the right femoral
artery.
7. Successful PTCA and stenting of the LCX with two overlapping
bare metal stents.
Brief Hospital Course:
CARDIOGENIC SHOCK: Patient was admitted to CCU service for
intractable chest pain without ST elevations. Shortly after
admission to the CCU, she developed progressive hypotension and
dyspnea. She was emergently intubated for hypoxia and was
started on dopamine en route to cath lab on [**10-30**]. In the cath
lab, she had two vessel coronary artery disease, moderate mitral
regurgitation, pulmonary hypertension, elevated right and left
sided filling pressures and overall hemodynamic compromise
necessitating IABP placement. She had successful PTCA and
stenting of the left circumflex with two bare metal stents. She
received prednisone due to a history of allergy to contrast dye.
Following IABP placement, she was aggressively diuresed. She
had ventricular ectopy that interfered with IABP function and
required lidocaine and amiodorone for control. She was weaned
off IABP on [**11-4**] and extubated on [**11-5**]. She had significant
blood loss following IABP removal secondary to a failure of
hemostasis. She was transfused 2 U PRBC. Pressures improved
and she was weaned off dopamine and able to be start
antihypertensives.
.
CORONARY ARTERY DISEASE: She had stenting of left circumflex
but has residual disease. She was started on medical management
for her coronoary artery disease including ASA, plavix, statin,
beta-blocker, ACE-inhibitor.
Cardiac surgery evaluated for CABG, but patient decided that she
was not interested in further interventions at this time.
.
VENTRICULAR ECTOPY: Patient had intermittant bigeminal rhythm on
admission that was thought to be reactive to ischemia. Because
IABP was unable to expand during PVCs, this rhythm prevented
IABP augmentation of cardiac output. She was started on
lidocaine on [**11-1**], but developed tachyphylaxis and was changed
to amiodorone on [**11-2**]. She received prednisone due to the
iodine moiety in amiodorone. Amiodorone was stopped on [**11-4**].
.
GI BLEED: Had episode of [**Doctor First Name 21560**] with falling Hct on [**11-7**]. She
was transfused and started on a [**Hospital1 **] PPI. She was seen by GI
consult, but refused endoscopy. She had no further episodes of
bleeding.
- Would recommend oupatient endoscopy if patient is amenable.
.
BACTERMIA: Coag (-) staph in isolated sample, very likely to be
a contaminant. She had an echo without evidence of vegetation.
Patient refused TEE. She was treated with Vanc [**Date range (1) 24218**].
This was stopped following the results of the coagulase test.
Surveilence cultures were negative. She was afebrile with a
normalizing white blood count.
.
ENDOCRINE: She has a history of DM type 2 that resulted in
marked hyperglycemia on prednisone. She was started on an
insulin drip in the ICU. He insulin was reintroduced following
call-out. She required 24 U NPH [**Hospital1 **] when eating minimally, and
takes 36 U at home. On discharge, she was receiving 26 U
insulin [**Hospital1 **].
- Uptitrate as necessary.
.
RENAL: Patient had acute renal failure secondary to cardiogenic
shock and need for aggressive diuresis. Creatinine peaked at
1.9 but returned to baseline of 1.1 on discharge.
.
EPSTAXIS: Patient had nosebleed. She was seen by ENT who packed
left nares. She was treated with 7 days of nafcillin. Packing
was removed on [**11-5**].
Medications on Admission:
lisinopril 40mg po daily
aspirin 81 mg daily
HCTZ 25mg daily
Plavix 75mg daily
Lopressor 25 mg [**Hospital1 **]
Crestor 2.5 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
NPH 36 u [**Hospital1 **]
Novolog 4 u [**Hospital1 **]
Advil 200 mg prn
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take every day for one year.
2. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
5. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation Q4H (every 4 hours) as needed.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Bisacodyl 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily): Hold
SBP<100, HR< 55.
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Six (26) units Subcutaneous twice a day: before breakfast and
dinner.
Disp:*qs 1* Refills:*2*
11. Humalog 100 unit/mL Solution Sig: Four (4) units
Subcutaneous twice a day: before breakfast and dinner.
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
15. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual q 5 minutes x3.
Discharge Disposition:
Extended Care
Facility:
St Josephs [**Hospital 731**] Nursing Home - [**Hospital1 1474**]
Discharge Diagnosis:
Non-ST elevation Myocardial Infarction
Coronary Artery disease
Cardiovascular Shock
Acute blood Loss anemia
Diabetes mellitus Type 2
Acute Renal failure
Hypertension
Peripheral Vascular Disease
Positive MRSA screen
Ventricular Bigeminy
Discharge Condition:
stable
BUN=35
Creat 1.1
K=4.4
hct=28.8
wbc=12.3
Discharge Instructions:
You had a heart attack and received 2 bare metal stents in your
left circumflex artery. You will need to continue Plavix
(Clopodigrel) for the next month, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]. You
also had a bleed in your bowel that has resolved, you have been
started on Omeprazole twice daily to treat this. Your kidneys
were not working very well, they have normalized now.
.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
.
Medication changes:
1. You are on NPH insulin at 30units twice daily, this is lower
than the 36 units that you were taking on admission.
2. Omeprazole was started twice daily for blood in your stools.
3. Your Lisinopril was decreased to 10mg daily
4. Aspirin was increased to 325mg daily
5. Crestor was changed to Pravastatin
6. HCTZ was discontinued
7. Lopressor was changed to Toprol and increased to 75mg daily
8. Albuterol and Atrovent inhalers were added as needed.
.
Please follow up with your primary care provider after you leave
the rehabilitation facility.
Followup Instructions:
Cardiology:
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD
[**Hospital1 **] Healthcare - [**Location (un) **]
15 [**Name (NI) **] Brothers [**Name (NI) **]
[**Name (NI) **]
[**Location **], [**Numeric Identifier 18655**]
Phone: [**Telephone/Fax (1) 8725**]
Fax: [**Telephone/Fax (1) 8719**]
Date/time: [**12-3**] at 12:00pm
.
Primary Care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3314**], MD Phone:([**Telephone/Fax (1) 16005**]
[**Location (un) 1475**] Pk Med Assoc
[**Street Address(2) 14531**]
[**Hospital1 1474**], [**Numeric Identifier 67741**]
Pt has appt to see in late [**Month (only) 1096**].
Completed by:[**2188-11-11**]
|
[
"41071",
"2851",
"5849",
"41401",
"4240",
"4019",
"25000"
] |
Admission Date: [**2146-8-16**] Discharge Date: [**2146-8-23**]
Date of Birth: [**2107-12-30**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 38 year old
female transferred from an outside hospital for acute liver
failure. Per the patient's family and notes, the patient had
a six week illness associated with nausea and vomiting with a
questionable hematemesis and diarrhea as well as occasional
abdominal pain. This had begun shortly after the patient had
eaten seafood out of the home.
The patient was seen by her primary care physician and her
laboratory studies were presumably normal. At that time, she
was treated with Flagyl. The patient was then found by her
boyfriend on the morning of [**2146-8-16**]. There are
conflicting reports as to whether she was confused and
irritable or unresponsive.
The patient was taken to an outside hospital and found to be
unresponsive. She required intubation, with arterial blood
gases revealing a pH of 7.39 and a CO2 of 26, oxygen 607.
Laboratory data were significant for a white blood cell count
of 16.3 with 93% neutrophils, an ammonia of 274, AST 1,919,
ALT 3,926, prothrombin time 19.7, INR 2.46, partial
thromboplastin time within normal limits, total bilirubin
2.1. Repeat ALT six hours later revealed a value of 2,589,
AST 944, CPK 143, MB 15, MB index 10.4.
At the outside hospital, the patient was given Rocephin,
morphine and Protonix. Nasogastric tube aspirate was notable
for heme positive material. A chest x-ray, KUB, head CT and
CT of the abdomen and pelvis were negative for any
abnormalities. At this time, she was transferred to the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Intensive Care Unit for
further management.
At the time of evaluation, the patient was intubated and
sedated. A history of the etiology of the patient's
unresponsiveness was quite unclear. The patient had not had
any alcohol intake for two years, no history of intravenous
drug use, positive tatoos, occasional Tylenol use.
PAST MEDICAL HISTORY: 1. Depression. 2. Anxiety. 3. Low
back pain.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Effexor and Xanax; intrauterine
pregnancy in place.
FAMILY HISTORY: There is no family history of liver disease,
positive history of deep vein thrombosis and pulmonary
embolus.
SOCIAL HISTORY: The patient smokes. She currently lives
with her boyfriend and two children.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 100.7, pulse 130s, blood pressure
137/68. Patient intubated and sedated. No evidence of
scleral icterus, no spider angiomata. Pulmonary: Clear to
auscultation anteriorly. Cardiovascular: Tachycardia.
Abdomen: Hepatomegaly, no splenic tip palpable, no
appreciable fluid wave. Head, eyes, ears, nose and throat:
Large pupils, 7.5 mm bilaterally, equal, round and responsive
to light, however, pupils did deviate to the left.
LABORATORY DATA: Admission white blood cell count was 12,
hematocrit 33.4, platelet count 274,000, differential with
89% neutrophils, 4% lymphocytes, 1% monocytes, 1% atypicals
with evidence of hypersegmented nucleated cells, occasional
teardrops, 1+ target cells, 2+ anisocytosis on smear,
prothrombin time 18.8, INR 2.5, partial thromboplastin time
30.7, sodium 149, potassium 3.1, chloride 118, bicarbonate
18, BUN 25, creatinine 0.5, glucose 193, anion gap 13,
calcium 9.7, phosphorous 0.3, magnesium 2.6, ALT 2,327, AST
756, LD 325, CK 84, alkaline phosphatase 208, albumin 3.3,
amylase 135, lipase 548, total 3.5, troponin 0.6, CPK 84.
Urinalysis revealed trace leukocyte esterase, positive
nitrites with 3 white blood cells, trace blood, 2 red blood
cells, trace protein, 15 ketones. Urine toxicology screen
was positive for benzodiazepines and positive for opiates.
Serum toxicology screen was negative. Arterial blood gases
revealed a pH of 7.5, pO2 327, pCO2 25, oxygen saturation 99.
Right upper quadrant ultrasound revealed normal flow in the
portal vein, hepatic vein and hepatic arteries with normal
liver parenchyma.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit. An electroencephalogram revealed wide
spread encephalopathy in the cortical and subcortial regions.
The patient was given a three to four day course of
n-acetylcysteine for a presumed Tylenol ingestion per family,
as the patient was taking this medication for abdominal pain.
The patient had an ICP monitor placed by the neurosurgical
service to monitor intracranial pressure. The patient was
treated with lactulose for hepatic encephalopathy. The
patient was evaluated by the transplant surgery team for
possible liver transplant, and was added to the liver
transplant list.
On the second day of admission, the patient was placed on
ceftazidime and vancomycin for infectious disease prophylaxis
as she had a persistently elevated white blood cell count as
well as a fever but no identifiable source. An ethics
consult was obtained regarding performing HIV testing for
possible liver transplantation.
The patient did quite well in the Medical Intensive Care
Unit. She received supportive care with proton pump
inhibitor, electrolyte support, blood transfusion, mechanical
ventilation and antibiotics. The the patient liver function
tests continued to trend downward.
The patient was transferred to the medicine service on [**2146-8-20**] after her liver function tests had trended downward.
She had significantly improved encephalopathy. The patient
had been extubated. She did, however, remain with an
elevated white blood cell count of 22.8 and a mild low grade
fever.
The patient was seen by psychiatry, who deemed that she was
not an immediate risk to herself. Further history elicited
possible Tylenol # or Tylenol P.M. ingestion by patient,
however, she did not appear to have any depressed mood. She
does have an outpatient psychiatrist for a history of
"chemical depression".
The patient had an esophagogastroduodenoscopy which showed
esophagitis, multiple small antral ulcers and mild
duodenitis. Her overall condition improved dramatically and
the patient was eventually discharged to home with follow-up
with her primary care physician as well as the Liver Clinic.
CONDITION AT DISCHARGE: Quite stable.
FOLLOW-UP: The patient needs to have scalp sutures removed
from her neurosurgical procedure. She will see her primary
care physician on [**Name9 (PRE) 766**], [**2146-8-29**].
DISCHARGE MEDICATIONS:
Protonix 40 mg p.o.q.d.
Once she leaves the hospital, the patient will be living at
her mother-in-law's house. She appears to have a good social
support system. Her husband and children will also be living
with her. Ultimately, it was thought that Tylenol ingestion,
unintentionally, as well as possible Kava supplement
ingestion chronically led to fulminate hepatic failure, with
resolution with supportive treatment and n-acetylcysteine.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2146-9-15**] 18:06
T: [**2146-9-21**] 15:37
JOB#: [**Job Number 43810**]
|
[
"51881",
"2760"
] |
Admission Date: [**2178-3-4**] Discharge Date: [**2178-3-12**]
Date of Birth: [**2135-1-11**] Sex: M
Service:
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 43 year old white male
weightlifter with a history of a heart murmur since childhood
who presented to an outside hospital one month prior with a
two week history of increasing dyspnea and fatigue. The
patient was having dyspnea on exertion with fatigue over the
past five to six months which has been increasing over the
past two to three weeks. The patient was found to be in
rapid atrial fibrillation at that time. An echocardiogram
performed revealed a large atrioseptal defect with left to
right shunting. The patient was referred to Dr. [**Last Name (Prefixes) **]
for repair of atrioseptal defect and maze procedure. The
patient underwent cardiac catheterization showing an ejection
fraction of 39%, a large secundum atrioseptal defect.
Cardiac echocardiogram data showed right ventricular
enlargement with mild hypokinesis and a possible intracardiac
shunt and small patent foramen ovale or small atrioseptal
defect, left ventricular enlargement with normal wall motion,
ejection fraction of 55%, mild aortic and tricuspid
regurgitation and trace mitral regurgitation.
PAST MEDICAL HISTORY: Significant for hyperlipidemia,
gastroesophageal reflux disease, depression, atrial
fibrillation and atrioseptal defect. The patient has a
history of a left lung nodule.
PAST SURGICAL HISTORY: Significant for left ear cyst removal
20 years ago.
MEDICATIONS:
1. Lopressor 50 mg q. day.
2. Coumadin 5 mg q. day.
3. Digoxin 0.25 q. day.
4. Crestor 20 mg a day.
5. Protonix 40 per day.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Significant for a mother with atrial
fibrillation, two children with atrioseptal defect.
SOCIAL HISTORY: Occupation of the patient is a machinist on
disability, lives by himself in [**Location (un) 47**] [**State 350**]. He
has smoked one pack per day for 26 years. He quit alcohol 16
months ago. Former ethyl alcohol abuse. Former cocaine
abuse, approximately two months ago. Marijuana approximately
20 years ago.
PHYSICAL EXAMINATION: The patient is afebrile with a heart
rate of 88 and atrial fibrillation. Blood pressure was
within normal limits. The patient is a well developed, well
nourished male in no acute distress, appearing younger than
his stated age. The patient is well hydrated with no rash or
lesions. The patient's pupils were equal, round and reactive
to light, normal mucosa, no dentures. The patient's neck was
supple with no jugulovenous distension, no lymphadenopathy
and no thyromegaly. The patient's chest was clear to
auscultation bilaterally. Heart rate was irregular, no
murmurs, rubs or gallops. Normal S1 and S2. Abdomen was
obese, soft, nontender. Normoactive bowel sounds. No
organomegaly. Extremities were warm, well perfused with no
edema. Cranial nerves II through XII were grossly intact.
The patient's pulse examination was 2+ throughout in both
upper and lower extremities. The patient had no auscultated
carotid bruits.
IM[**Last Name (STitle) **]ON: This is a 43 year old male with a large secundum
atrioseptal defect and atrial fibrillation. The patient
presents for repair of a atrioseptal defect by me and Dr. [**Last Name (Prefixes) 2545**].
HOSPITAL COURSE: On [**2178-3-4**], the patient presented to
the hospital. The patient stopped taking Coumadin one week
prior. His INR was 1.0. The patient was started on a
heparin drip. Laboratory data on admission revealed white
count 9.0, hematocrit 44.4, platelet count 301. Sodium 140,
potassium 4.5, chloride 103, bicarbonate 27, BUN 15,
creatinine 1.0, INR was 1.0. ON hospital day the patient was
preopped for aortic valve replacement. The patient was with
heparin at 1000 and Digoxin and Metoprolol. The patient was
afebrile with stable vital signs with atrial fibrillation
rate-controlled. The patient was preopped for atrioseptal
defect and maze procedure. On [**2178-3-5**], the patient
was brought to the Operating Room for a maze procedure and
atrioseptal defect closure with patch. The patient tolerated
the procedure well and was transferred intubated to the
Cardiac Surgery Recovery Unit on epinephrine and Dobutamine
drip. The patient had chest tubes to suction and pacing
wires.
On postoperative day #1, the patient was on a Nitroglycerin
drip and all other drips were weaned. The patient was
extubated and was sating 95% on a 70% facemask. The patient
was in sinus rhythm immediately postoperatively with
Swan-Ganz catheter. The patient's postoperative laboratory
data showed a white count of 14.6 and hematocrit of 32.7 and
platelet count of 196. The patient's chemistries were all
within normal limits. The patient was planned to wean off of
Nitroglycerin and start Metoprolol 12.5, chest x-ray and
discontinue the Swan-Ganz catheter. On postoperative day #2,
the patient was off all drips. The patient was on Lasix 20
b.i.d., Lopressor 12.5 b.i.d., Coumadin of 1. The patient
was in sinus rhythm at 87 with a temperature maximum of
100.6. The patient was on nasal cannula sating 95%. The
patient had a hematocrit of 30.3 and white count of 12.5.
The patient was up out of bed to a chair with physical
therapy. The patient had some strong nonproductive cough.
The patient was transferred to the floor to continue
postoperative care. On postoperative day #3, the patient was
transferred to the Cardiac Surgery Recovery Unit. The
patient was on Aspirin, Lasix 20 b.i.d. and Metoprolol 25
b.i.d. The patient had a temperature maximum of 100.1,
otherwise vital signs were all within normal limits. The
patient had wires removed. The patient was continued on
Coumadin. The patient's hematocrit was stable at 30.3, white
count 12.5. The patient was seen by physical therapy on the
floor and was ambulating without difficulty.
On postoperative day #4, the patient was afebrile, vital
signs were all stable and within normal limits. The patient
was continued on Coumadin with minimal bump in his INR, the
patient's Coumadin was increased to 5 per day. The patient's
hematocrit remained stable at 31.5 and white count dropped to
9.7. On postoperative day #5, the patient continued well,
was afebrile with stable vital signs. Coumadin continued to
be dosed according to INR. On postoperative day #6, the
patient continued his dosing with Coumadin 7.5. The patient
was doing well, was ambulating with physical therapy. The
patient was discharged to home in stable condition,
tolerating a regular diet, PT level was 5.
DISCHARGE INSTRUCTIONS: Plan was for the patient to follow
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 54731**] in one week. The patient was to
follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in one month. The
patient was discharged home with [**Hospital6 407**]
care for Coumadin dosing.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. for seven days.
3. Potassium 10 mEq two capsules p.o. b.i.d. for seven days.
4. Colace 100 mg tablet, one tablet p.o. b.i.d.
5. Zantac 150 mg tablet, one tablet p.o. b.i.d.
6. Aspirin 81 mg tablet, one tablet p.o. q. day.
7. Percocet 1 to 2 tablets p.o. q. 4-6 hours as needed for
pain.
8. Coumadin 5 mg tablet, 1.5 tablets p.o. q. day with level
to be checked by the visiting nurse.
DISCHARGE DIAGNOSIS:
1. Status post repair of atrioseptal defect and maze
procedure.
2. History of atrial fibrillation.
3. History of cocaine abuse.
4. History of tobacco abuse.
5. Gastroesophageal reflux disease.
6. Hyperlipidemia.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 10638**]
MEDQUIST36
D: [**2178-3-16**] 16:48
T: [**2178-3-16**] 17:02
JOB#: [**Job Number 54878**]
|
[
"42731",
"V5861",
"53081",
"2724"
] |
Admission Date: [**2102-9-20**] Discharge Date: [**2102-9-23**]
Date of Birth: [**2031-5-18**] Sex: F
Service: NEUROLOGY
Allergies:
Shellfish / Ace Inhibitors
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
TPA Administration
History of Present Illness:
Pt is a 71 yo woman with h/o DMII, hyperlipidemia, and h/o
episode of right facial numbness who presents as a code stroke
after developing left sided weakness.
She was in her USOH this morning at home when she awoke. She
did
her morning chores. Then at 11 am, she had the acute onset of
"something going over me" in her head. She had no vertigo and
no
rocking feelings. She said it frightened her significantly, but
can't describe this feeling better. She had no blurred or
double
vision with it. No LOC or presyncope. She hit her lifeline and
sat on her steps. EMS found her staring glassy eyed. She noted
that she was having trouble making a good fist in the left. She
also noted that her left leg was not moving well. She had no
HA,
but did have the rishing feeling as described above. She had no
LOC. She was brought in as a Code Stroke and brought to the CT
scanner. A head CT showed no bleeding and CTA showed no obvious
large vessel occlusion as interpreted by the stroke fellow. The
patient refused an MRI due to claustrophobia. On exam, she was
alert and oriented, but had clear LUE and LLE weakness, with
normal right sided weakness. She also had hemibody sensory loss
to temp and PP as well as vib on the left. Her language was
normal. Based on a high clinical suspicion for lacunar
subcortical stroke and after a discussion of risks(6-7% risk of
ICH) and benefits of tpa, then pt and her son agreed to the
infusion. She was given 90 mg tpa per protocol. She tolerated
this well. She had no exclusionary conditions to lysis.
ROS: Patient denies any fever, nausea, vomiting, headache,
dysarthria, dysphagia, dizziness, visual changes, diplopia,
hearing changes, chest pain.
Past Medical History:
1. Diabetes mellitus type 2 diagnosed ten years ago
2. Spinal stenosis and herniated disk status post laminectomies
in [**2081**] and [**2088**], with no significant improvement in symptoms
3. Hypercholesterolemia
4. Hysterectomy in [**2078**]
5. She had right sided facial "numbness" and some unsteadiness
in
[**2098-9-16**] and was seen by neurology in f/u in [**2098-11-16**] without
clear diagnosis and the MRI/A were normal.
6. Angioedema on ACE-I.
Social History:
SOCIAL HISTORY: She has a 30 pack year tobacco history. Now
quit.
Occasional ETOH use. No other drug use. She is separated from
her
husband. [**Name (NI) **] is supportive. Pt is a retired nurse.
Family History:
Mother died in her late 80s from CA. Father with
renal failure. Brothers with lung cancer and bone cancer.
Physical Exam:
Vitals:94, 134/50, 21, 96% on RA
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear
Neck: No Carotid bruits
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect
Orientation: Oriented to person, place, and date
Attention: Attentive to exam and interview
Language: Fluent with good comprehension and repetition. Naming
intact. No dysarthria or paraphasic errors
No apraxia, no neglect
[**Location (un) **] intact
Calculation intact
No extinction to DSS
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to finger movement.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength intact and symmetric, with ? mild left
NLF flattening. Has V1-V3 decrease to LT and PP on the left.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid normal bilaterally. Trap decreased on
left.
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk and tone bilaterally
No tremor
Unable to do full strength exam given tpa infusion urgency, but
pt has 5/5 strength in RUE, and 4+/5 FF on left. Unable to hold
LUE up for 5 seconds. In LEs, holds RLE against resistance for
10
seconds. Unable to lift LLE off of bed.
Left pronator drift
Sensation: Intact to light touch, pinprick, temperature (cold),
vibration throughout right side extremities. On left, has
decreased to LT, PP, vibration, and temp in face(V1-V3), arm and
leg.
Reflexes: B T Br Pa Ankle
Right 2 1 1 2 t
Left 2 1 1 0 t
Toes were downgoing bilaterally
Coordination: Normal on finger-nose-finger, rapid alternating
movements slightly clumsy on left, FFM normal.
Gait: Not tested due to LE weakness.
Pertinent Results:
[**2102-9-20**] 08:29PM CK(CPK)-163*
[**2102-9-20**] 08:29PM CK-MB-3 cTropnT-<0.01
[**2102-9-20**] 11:55AM GLUCOSE-151* UREA N-18 CREAT-0.8 SODIUM-141
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-16
[**2102-9-20**] 11:55AM CK(CPK)-170*
[**2102-9-20**] 11:55AM cTropnT-<0.01
[**2102-9-20**] 11:55AM CK-MB-4
[**2102-9-20**] 11:55AM CALCIUM-9.8 PHOSPHATE-4.0 MAGNESIUM-2.1
[**2102-9-20**] 11:55AM WBC-7.7 RBC-4.14* HGB-12.2 HCT-35.1* MCV-85
MCH-29.5 MCHC-34.8 RDW-14.1
[**2102-9-20**] 11:55AM NEUTS-63.8 LYMPHS-28.7 MONOS-4.6 EOS-2.5
BASOS-0.3
[**2102-9-20**] 11:55AM PLT COUNT-345
[**2102-9-20**] 11:55AM PT-12.2 PTT-27.1 INR(PT)-1.1
CT PERFUSION:
No abnormal areas of perfusion, ___blood flow/blood volume are
noted on the perfusion scan performed.
IMPRESSION:
1. No abnormality noted on the CT perfusion images.
2. Pending reconstructions on CT angiography.
_____reconstructions on the CT angiography are performed.
NON-CONTRAST CT STUDY: The posterior fossa structures are
normal. The
cerebral parenchyma has normal [**Doctor Last Name 352**] and white matter
differentiation. The
ventricles and extra-axial CSF spaces are unremarkable. The
osseous and the
soft tissue structures are normal. There is no evidence of mass
effect, shift
of normally midline structures
CT-Non Contrast s/p TPA: FINDINGS: The posterior fossa
structures are normal. The cerebral parenchyma has normal [**Doctor Last Name 352**]
and white matter differentiation. There is no evidence of
hemorrhage. The ventricles and the extra-axial CSF spaces are
unremarkable. The osseous and the soft tissue structures are
normal.
TEE: The left atrium is normal in size. A right-to-left shunt
across the
interatrial septum is seen at rest. An atrial septal defect is
present air bubble contrast study positive at rest and with
maneuvers). There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review)of [**2098-8-20**], an atrial septal
derfect is now demonstrated.
Brief Hospital Course:
The patient was admitted to the ICU and given TPA within 2 hours
of sx onset. The patient refused MRI to determine localization
of the stroke. Post-TPA CT showed no evidence of ICH.
On the second hospital day, further stroke w/u revealed ASD on
TEE. After administration of constrast, the pt c/o blurred
vision. She was promptly laid supine and evaluated by the
neurological service. It was found that her vision was impaired
relative to her admission baseline, but that the blurriness was
rapidly improving. It was felt that her sx were not due to
stroke/embolus, but rather likely secondary to contrast rxn or
migraine. Her vision returned to baseline by the end of the
second hospital day. She was then transfered to the floor.
On the third hospital day, the pt was cleared for PO of normal
solids and thin liquids by the speech and swallow service. PT/OT
evaluation cleared the patient for D/C to home.
Had small headache and Stat head ct was done to rule out bleed.
Discharged day 4 and antihypertensives held as patient's blood
pressure in adequate range without them and risk of
hypoperfusion significant. Gave notice to patient's PCP and
restarting antihypertensives can be discussed at follow up
wednesday.
Medications on Admission:
Glucotrol 5 daily
Lipitor 40
Glucophage 1500 daily
Avandia 4 daily
Toprol XL 100 daily
Meclizine prn
Ibuprofen 800 tid
Norvasc 2.5 daily
ASA 325 daily
Diovan 80/12.5 daily
Topamax, unknown dose
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
Disp:*30 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*2*
3. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO DAILY (Daily): increase to twice a day
starting [**9-24**].
Disp:*60 Cap(s)* Refills:*2*
5. Pneumococcal 7-[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 24419**] Vacc 16 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ONCE (Once) for 1 doses.
Disp:*1 ML(s)* Refills:*0*
6. Topomax
Continue your topomax as you were taking it prior.
7. Meds
Do not take your anti-hypertensives (toprol, norvasc) until
discussing with your PCP. [**Name10 (NameIs) **] have been holding them in the
hospital and your blood pressure has been fine. You may need to
have them restarted in the future if your blood pressure
increases. This can be discussed with your PCP, [**Name10 (NameIs) **] we have
notified them.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Stroke
Discharge Condition:
Good. Ambulating independtly and cleared for home discharge by
PT.
Discharge Instructions:
Please return to care if you develop any symptoms like those
that brought you to the hospital, blurred vision, chest pain,
shortness of breath, lightheadedness, dizziness, or any other
signs or symptoms of serious illness.
You have had a stroke, but you responded well to TPA and have
only mild deficits. You are on a new medication aggrenox (see
below). You will need to follow up with providers below. If
any symptoms of weakness, numbness, visual changes return, then
contact your PCP immediately or come to the ED.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3511**] [**2102-9-27**] at 10:45AM
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4406**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22205**] Date/Time:[**2102-9-28**]
8:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2102-10-6**] 8:30
[**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2103-1-2**]
9:30
|
[
"25000",
"2720"
] |
Admission Date: [**2128-1-19**] Discharge Date: [**2128-3-23**]
Date of Birth: [**2086-7-18**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2128-1-20**] Cerebral angiogram with coiling
[**2128-1-24**] Cerebral angiogram with angioplasty
[**2128-1-26**] Cerebral angiogram with verapamil injection
[**2128-1-30**] Right Hemicraniectomy
[**2128-2-3**] Trach
[**2128-2-3**] PEG
[**2128-2-5**] Cerebral angiogram with R ICA coiling'
[**2128-2-6**] Cerebral angiogram with verapamil injection
[**2128-2-9**] CEREBRAL ANGIOGRAM
[**2128-2-10**] CEREBRAL ANGIOGRAM WITH VERAPAMIL
[**2128-2-11**] CEREBRAL ANGIOGRAM WITH VERAPAMIL
[**2128-2-11**] PLACEMENT OF LEFT EXTERNAL VENTRICULAR DRAIN
[**2128-2-12**] CEREBRAL ANGIOGRAM WITH VERAPAMIL
[**2128-2-13**] CEREBRAL ANGIOGRAM WITH STENT AND COILING OF RIGHT ICA
[**2128-2-14**] CEREBRAL ANGIOGRAM WITH VERAPAMIL
[**2128-2-23**] Diagnostic angiogram
[**2128-2-24**] Angiogram with coiling of right ICA aneurysm
[**2128-2-27**] Placement of right VP shunt
[**2128-3-2**] Cerebral Angiogram
[**2128-3-10**] IVCF placment
[**2128-3-16**] diagnostic cerebral angiogram
[**2128-3-18**] L VP shunt placement and R cranioplasty
History of Present Illness:
This ia a 41 year old G4P3 right handed female who was
transferred to [**Hospital1 18**] from [**Hospital 27778**] hospital after she
developed a frontal headache the day prior. She was at a store
with her family and the headache intensified over 15 min to
maximal severity and she also developed blurred vision to the
point where she could not see anything. She denied nausea,
vomiting, abnormal movements, loss
of bowel or bladder function. The blurred vision gradually
resolved, but she maintained a headache, and was unable to fall
asleep secondary to her headache.
MRI/MRA imaging was concerning for intracranial hemorrhage with
extention into the ventricles and possible visualization of an
ACOM aneurysm.
Patient estimated that she is 7 weeks pregnant at time of
admission.
Past Medical History:
Asthma
Social History:
She is married and has three children, ages 8/7/3
Family History:
NC
Physical Exam:
On Admission:
T:97.4 BP: 152 /91 HR:60 R18 O2Sats98 RA
Gen: WD/WN, comfortable, NAD.
HEENT: NCNT
Neck: moderately rigid.
Abd: Soft, NT,
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3-2.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-25**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
ON DISCHARGE:
Prefers her eyes closed and prefers to lay on left side
Follows commands on right side to show fingers or wiggle toes
Will nod head appropriately to orientation questions about her
name, location and family questions about names of her husband
and children. Is not orientated to date
Motor: Appears full and spontaneous on RUE and RLE. LLE triple
flexion. LUE + grasp to command.
Pupils are equal bilaterally
On Discharge:
EO to voice. Pupils are equal and reactive but patient typically
refuses. Nonverbal but nods head appropiately to questions. She
follows commands with the right side. RUE/RLE spont and
purposeful. LUE flexion, has begun to show intermitted spont
movement. LLE weak withdrawl to pain. Head incisions are C/D/I
with sutures. Bilateral groin sites remain hard but have been
improving.
In general she is oriented to name / hospital / yr / husbands
name / will be able to relaibly tell you she has pain and where
when directed / she frowns when in pain or sad. She has been
interactive with her children when the visit ie patting her
little ones head when he stood on her right side.
Pertinent Results:
CT HEAD W/O CONTRAST [**2128-1-19**]
Bilateral subarachnoid hemorrhage, small foci of
intraventricular hemorrhage,
MR HEAD W/O CONTRAST [**2128-1-20**]
MRA BRAIN:
There is an apparent small outpouching versus aneurysm directed
posteriorly
(series 4- image 91) in the right supraclinoid ICA measuring
approximately 1 mm. The right MCA bifurcation has a bulbous
appearance, a normal variant. The intracranial vessels are
otherwise unremarkable.
IMPRESSION:
Abnormal signal in the subarachnoid space and in the ventricular
system that may represent hemorrhage or pus. Tiny outpouching
versus aneurysm directed posteriorly in the right supraclinoid
ICA. No other vascular abnormalities are detected.
CTA HEAD W&W/O C & RECONS [**2128-1-21**]
1. New region of acute hemorrhage, with both intra- and
extra-axial
components, immediately adjacent to the right cavernous sinus.
This is in
close proximity to a focal outpouching of the cavernous segment
of the right internal carotid artery.Given the original
presentation, and the lack of other ready explanation, this
finding must be regarded as suspicious for aneurysmal rupture.
There may also be transependymal extension of this hemorrhage
into the lateral ventricles.
2. Possible distal right vertebral artery pseudoaneurysm
corresponding to a focal outpouching as seen on recent
angiography.
3. Decreased extent of subarachnoid hemorrhage overlying the
bilateral
frontoparietal convexities, with no new focus of subarachnoid
blood, other
than above.
4. Prominence of the lateral ventricles, bilaterally, not
significantly
changed.
5. No evidence of subfalcine, uncal or transtentorial herniation
CT Head [**2128-1-22**]:
IMPRESSION:
No significant short-interval changes of the known
intraparenchymal and
subarachnoid hemorrhage. Persistent bilateral intraventricular
hemorrhage in the occipital horns but without developing
hydrocephalus. No definite
evidence of new foci of intracranial hemorrhage. No midline
shift.
CTA Head [**2128-1-24**]:
IMPRESSION:
1. New right middle cerebral artery infarct involving the
temporal lobe as
well as basal ganglia region on the right with decrease in size
of the flow voids, indicative of vasospasm.
2. Blood products are again seen in the right suprasellar region
and adjacent brain along with blood products in the ventricles
and sulci from subarachnoid hemorrhage.
3. A new small infarct is identified in the right cerebellum
since the
previous MRI examination.
4. Other areas of increased signal on diffusion images along the
sulci appear to be secondary to subarachnoid blood.
5. Mild ventriculomegaly with the ventricular size slightly
decreased from
previous MRI examination and stable from CT of [**2128-1-22**].
CT Head [**2128-1-25**]:
IMPRESSION:
1. A focus of hemorrhage by the right cavernous sinus is
unchanged.
2. Persistent but less conspicuous subarachnoid blood within the
right frontal
lobe.
3. Continued blood layering within the occipital horns.
4. A small focus of hemorrhage adjacent to the left cavernous
sinus is not
well visualized on the current exam.
Bil Lower Ext Dopplers [**2128-1-26**]:
IMPRESSION: No evidence of DVT.
CTA Head [**2128-1-28**]:
IMPRESSION:
1. Continued evolution of a large right MCA territorial
infarction, without evidence of hemorrhagic transformation,
midline shift or herniation.
2. Continued retraction of a clot adjacent to the right
cavernous sinus, as well as residual subarachnoid hemorrhage and
intraventricular hemorrhage. No evidence of new hemorrhage.
3. Diffuse vasospasm of the anterior and posterior circulation,
more severe when compared to prior CTA from [**2128-1-21**].
4. Non-visualization of the previously-noted pseudoaneurysm
arising from the V4 segment of the right vetebral artery, which
may have thrombosed in the interim.
5. Persistent small outpouching along the lateral aspect of the
right
cavernous carotid artery, may reflect a tiny cavernous carotid
aneurysm.
6. Newly-developed focal outpouching along the medial aspect of
the right
carotid terminus, which may relate to vasospasm or,
alternatively, may reflect a new pseudoaneurysm, post-procedure.
CT Head [**2128-1-30**]:
IMPRESSION: Interval development of new leftward shift of
midline structures, effacement of the suprasellar cistern, and
early effacement of the quadrigeminal cisterns, concerning for
subfalcine, uncal, and early downward transtentorial herniation.
CT Head [**2128-1-30**]:
Substantial decrease in the degree of leftward shift of normally
midline
structures as well as decreased effacement of the quadrigeminal
plate cistern (indicating improvement of transtentorial
herniation) s/p right
hemicraniectomy. Brain parenchyma has decompressed through this
right sided defect in the calvaria. Unchanged scattered SAH
overlying the right cerebral hemispheric convexity. Small
quantity of hemorrhage in the occipital [**Doctor Last Name 534**] of the left lateral
ventricle is unchanged. No new areas of intracranial hemorrhage.
Diffuse hypodensity in the right MCA and ACA distributions, c/w
evolving infarction, is not signficantly changed.
[**1-31**] CT Head: IMPRESSION: Minimal increase of mass effect since
[**2128-1-30**] with slightly increased effacement of the frontal
and temporal [**Doctor Last Name 534**] of the right lateral ventricle and minimally
increased midline shift.
[**2-2**] Head CTA/P:
IMPRESSION:
1. Marked increased transit time and decreased regional cerebral
blood volume involving the majority of the right cerebral
hemisphere, consistent with infarction. The right basal ganglia
appears spared, consistent with
maintained arterial flow to these deep nuclei via
lenticulostriate arteries, as seen on the CTA portion of the
study.
2. Hypodensity in the mid brain is unchanged compared to CT from
[**2128-1-31**]. Recommend further evaluation of this finding with MR [**First Name (Titles) **] [**Last Name (Titles) 40806**]y
indicated and not contraindicated.
3. Diffuse vasospasm involving the intracranial portion of the
right internal carotid artery and its distal branches. Given the
attenuation in flow to the majority of the right cerebral
hemisphere as seen on CTA, progression of the vasospasm compared
to [**2128-1-28**] is likely.
4. Small outpouchings from the cavernous portion of the right
ICA and right carotid terminus are not significantly changed.
LENIS [**2128-2-4**]:
No DVT to bil lower extremities
Head CT [**2128-2-5**]:
IMPRESSION:
1. Evolving right MCA and ACA territory infarcts, with mild
increase in the diffuse swelling of the right cerebral
hemisphere, with associated increase in the transtentorial
herniation compared to the prior study of [**2128-1-31**]. No evidence
of new hemorrhage.
2. Stable right frontal SAH. Mild decrease in the
intraventricular
hemorrhage. No hydrocephalus.
Head CT [**2128-2-6**]
IMPRESSION:
1. Evolving right MCA/ACA infarct, with stable right hemispheric
swelling and transcranial herniation since the prior study. No
evidence of hemorrhage within the infarct.
2. Stable right frontoparietal SAH and left occipital
intraventricular
hemorrhage. No evidence of hydrocephalus.
CTA HEAD [**2128-2-7**]
No evidence of new hemorrhage.
Vasospasm is improved since the most recent CTA of [**2-2**], but
appears worse than on the catheter angiogram of [**2-6**].
Continued herniation of right hemisphere through the craniectomy
defect.
Evolving right hemisphere infarction.
Head CT [**2128-2-11**]:
Status post right hemicraniectomy with a 2 mm increase in size
of the diameter of the lateral ventricles. No new hemorrhage
noted.
Head CT [**2128-2-11**]:
Proper placement of EVD catheter.
Head CT [**2128-2-12**]:
Improved; decreased swelling, decreased ventricular size.
Lenies [**2-14**]:
IMPRESSION:
1. No evidence of DVT in left lower extremity veins.
2. A 4.7 x 1.9 x 3.1 cm anechoic collection, within the left
medial thigh,
likely represents a seroma, less likely abscess.
CT HEAD [**2-14**]:
IMPRESSION: No new hemorrhage identified. Ventricular size has
slightly
decreased. Diffuse right cerebral abnormalities are again noted.
Post-coiling changes are seen.
Bil Femoral Ultrasound [**2128-2-16**]:
IMPRESSION:
Little interval change to tubular fluid collection within the
medial left
groin for which differential includes old hematoma or seroma.
Interval
development of a small probable hematoma immediately anterior to
the right
common femoral artery and vein in the right inguinal region
measuring
approximately 3 cm. No findings of pseudoaneurysm or AV fistula
bilaterally.
[**2-16**] Xray Hips: FINDINGS: AP view of the pelvis and two views of
each hip. No fracture identified in either hip. No
osteonecrosis. No degenerative changes.
[**2-19**] CT Head with Angiogram -
1. Interval development of marked hydrocephalus and
intraventricular
hemorrhage compared to [**2128-2-14**]. Dr. [**Last Name (STitle) **] discussed this with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 90370**] via telephone on [**2128-2-19**].
2. Continued evolution of large cerebral infarct, with overlying
hyperdensity in a cortical/gyral pattern. This hyperdensity
could represent laminar necrosis or subarachnoid hemorrhage.
3. Apparent narrowing of right M1 segment at the distal aspect
of the stent was not seen on the [**2128-2-14**] angiogram. However,
this finding may be secondary to artifact from the stent.
Vasospasm is otherwise simlar to the [**2128-2-14**] angiogram.
4. Right carotid aneurysm and right A1 segment obscured by
streak artifact
from coil pack.
CXR [**2128-2-24**]
As compared to the previous radiograph, there is no relevant
change. Minimal retrocardiac atelectasis. Normal size of the
cardiac
silhouette. No focal parenchymal opacity suggesting pneumonia.
Normal lung
volumes. No pulmonary edema. No pneumonia
Cerebral Angiogram [**2128-2-24**]
Successful embolization of the known residual supraclinoid /
paraopthalmic aneurysm involving the right internal carotid
artery. The aneurysm is well coiled.
CT head [**2128-2-24**]
1. Similar extent of intraventricular and subarachnoid
hemorrhage.
2. Stable ventriculostomy catheter with stable degree of
hydrocephalus,
predominantly of components of the right lateral ventricle.
3. Similar degree of transcranial herniation.
CXR [**2128-2-28**]
Minor left lower lobe atelectasis.
Satisfactory appearance of medical devices.
CT head [**2128-2-28**]
1. Interval conversion of left ventricular drain to a
ventriculoperitoneal
shunt, no evidence of hemorrhage along the catheter tract.
2. Stable ventricular size, with relative prominence of the
right lateral
ventricle. No interval progression of ventricular dilatation.
3. Extensive right-sided parenchymal edema, though degree of
transcranial
herniation through a large craniotomy defect is slightly
decreased from prior study.
4. Decreased conspicuity of subarachnoid and intraventricular
blood products, with no new focus of hemorrhage identified.
[**2128-2-29**] Bil LE Dopplers
1. No deep vein thrombosis noted in the bilateral lower
extremities.
2. Bilateral groin fluid collection, similar in appearance
though decreased in size compared to [**2128-1-20**] study and likely
represent resolving hematomas or seromas from prior
instrumentation.
[**2128-3-2**] Cerebral Angiogram:
Minimal filling at the base of the R ICA aneurysm
[**2128-3-7**] CT ABD
FINDINGS:
CT ABDOMEN: There is subtotal atelectasis of the left lower lobe
with some
residual aerated lung at the posterior medial left lung base. No
pleural or pericardial effusion.
The liver, spleen, adrenal glands, and pancreas are normal in
appearance. The kidneys enhance and secrete contrast
symmetrically. There is a subcentimeter hypoattenuating lesion
in the lower pole of the left kidney which is too small to
accurately characterize. There is a ventriculostomy catheter
which terminates in the right pelvis. There is no collection
adjacent to the catheter tip. There is a G-tube in the stomach.
The abdominal aorta is normal in caliber. There is no
retroperitoneal lymphadenopathy.
Bowel loops are normal caliber. A normal appendix is seen. There
is no upper abdominal ascites.
CT PELVIS: There is a Foley catheter in a decompressed bladder.
There is a
small amount of air within the bladder likely related to
catheterization.
There is no pelvic ascites.
There are multiple, soft tissue nodular densities in the
anterior abdominal wall and a small amount of gas in the
anterior abdominal wall inferiorly on the right. This is all
likely related to subcutaneous injections.
There is soft tissue ossfication involving the musculature
posterior to the left hip, particularly the obturator internus,
externus and pyriformis. There are stellate shaped areas of
calcification in the bilateral groin anterior to the femoral
vessels. There are no lytic nor blastic bone lesions.
IMPRESSION:
1. No evidence of acute intra-abdominal pathology.
2. Calcification involving the musculature posterior to left hip
may be
related to heterotopic ossification from brain injury.
3. Ossification/calcification anterior the femoral vessels
likely related to prior line placement and subsequent hematomas
seen on Vascular U/S [**2128-2-16**].
[**2128-3-8**] ABD US
The liveR is normal in echogenicity with no focal lesions
present. The portal vein is patent with hepatopetal flow. The
common bile duct measures 2 mm and is normal. The gallbladder
shows no evidence of cholelithiasis or
cholecystitis.
IMPRESSION:
No cholelithiasis or secondary findings of acute cholecystitis.
[**2128-3-9**] ECHO
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. 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.
No vegetation seen (cannot definitively exclude).
[**2128-3-9**] DOPPLERS
IMPRESSION:
New right-sided common femoral and superficial femoral vein
thrombus since
prior US. Findings are consistent with an above-knee DVT.
[**2128-3-10**] CT BRAIN
FINDINGS:
A left ventriculostomy catheter with frontal approach is noted
terminating in the left lateral ventricle, unchanged. In
comparison to [**2128-2-28**] exam, there is notable increase in size
of the ventricles, concerning for faulty catheter drainage.
There is no evidence of acute intracranial hemorrhage, or shift
of normally midline structures. The right cerebral hemisphere
demonstrates edema and continues to herniate through the
craniectomy site, unchanged from prior exam. The [**Doctor Last Name 352**]-white
matter differentiation of the left hemisphere appears preserved.
The basal cisterns are patent.
Right ethmoid opacification is again noted. The remainder of
paranasal
sinuses and mastoid air cells appear well aerated.
IMPRESSION:
In comparison to [**2128-2-28**] exam, there is progressive enlargement
of
ventricles, concerning for impaired catheter drainage. A
heterogeneous
appearance, edema and herniation of the right hemisphere is
unchanged from
prior exam. No evidence of intracranial hemorrhage.
Head CT [**2128-3-16**]:
IMPRESSION: No interval change.
Head CT [**2128-3-17**]:
IMPRESSION: Interval right cranioplasty, with no evidence of
acute
intracranial hemorrhage.
Head CT [**2128-3-18**]:Post right cranioplasty changes with left
ventriculostomy shunt in unchanged position. Ventricles are
stable in size. No evidence of acute intracranial hemorrhage.
Head CT [**2128-3-19**]:
Stable
Brief Hospital Course:
This is a 41 year old female who was 11 weeks pregnant with
history of HTN who presented with headache. Head CT revealed
SAH. She was admitted to neurosurgery and an OB consult was
done.
On [**1-20**], patient was taken to angio where a R vertebral artery
dissection was was found. The artery was coiled and sacrificed
and patient was placed on heparin drip.
On [**1-21**], patient was more lethargic and emergent CTA was done.
She was found to have a new R ICH and heparin drip was
discontinued.
On [**1-22**], patient's exam was improved, more alert, but reported
headache overnight. TCDs were done which showed moderate
vasospasam L MCA and mild vasospasm on bilateral ACAs. A repeat
head CT was done which showed no change from previous scan.
On [**1-23**],fetal ultrasound: Single gestational sac which by size
corresponds with a 5 week pregnancy without yolk sac or fetal
pole or heart beat is identified within this sac. Human
Chorionic Gonadotropin-level 0200-[**Numeric Identifier 90371**] at 1700-[**Numeric Identifier 90372**]. The
patient experienced worsening headache. On exam she was awake
to voice, oriented x to person, place and time, moves all
extremities to command with full motor strength. There was left
asal labial fold flattening and slight left pronator was noted.
On [**1-24**], The patient was noted by nursing to have an acute
desaturation from 95% to 85% after taking pills with liquid due
to decreased mental status. A chest Xray was performed which was
consistent with worsening atelectasis within the left lower and
upper lobes. MR [**First Name (Titles) **] [**Last Name (Titles) **] protocol per neurology, MRI showed R
MCA infarct involving temp lobe and BG, also small R cerebellar
infarct. The patient was electively intubated and taken to
neuroradiology for an Angiogram with angioplasty to Right ICA
and Right MCA. Verapamil to all other arteries.
[**1-25**]: A head CT was performed which was consisted with a focus of
hemorrhage by the right cavernous sinus which was unchanged.
There was persistent but less conspicuous subarachnoid blood
within the right frontal lobe. There was continued blood
layering within the occipital horns. A small focus of hemorrhage
adjacent to the left cavernous sinus is not well visualized on
the current exam. The patient was febrile overnight, there was
concern for chorioamniotis vs septic abortion. OBGYN felt there
was no need for d&c at this time with plans for a ultrasound on
[**1-26**]. The patientcontinued to be intubated due to poor
respiratory status.
[**1-26**] The patient contnues to be intubated on a vasopressor to
keep a goal systolic blood pressure greater than 160, mini BAL
sent and showed no growth, Transvaginal ultrasound was performed
which was consistent with no retained products. Transcranial
doppler with evidence of spasm on left. Angio was completed and
Verapamil was injected throughout.
[**1-27**] her exam remained stable. On [**1-28**] her IV fluids were
decreased as patient was 4L positive, she recieved albumin x2,
CTA head was obtained which was stable but vasospasm was still
noted and significant. She was transfused with one unit PRBC for
a low HCT. On [**1-29**] she remained stable during the day, TCD
improved. Overnight the patient became hypertensive and on [**1-30**]
[**Name6 (MD) 21336**] morning RN noted patients pupils to be irregular and the
Nsurg was called. On exam patient was no longer following
commands on the R side and pupils were asymmetric but appeared
to react. A STAT head CT was done which showed worsening R MCA
infarct with new ACA infarct, new midline shift, and herniation.
Upon arrival to the ICU after CT, her R pupil remained larger
and reactive, but left pupil was nonreactive, no spont R sided
movement, attempted to localize on RUE, LUE extends, BLE
withdrew. Mannitol 100gm was given emergently and NA 23%. She
was taken emergently to the OR for a right sided
hemicraniectomy. A subgaleal drain was placed. Patient returned
to the ICU where her exam remained unchanged except L pupil was
2mm and reactive. A post-op CT was stable. Her SBP was kept
180-200, no mannitol was continued as vasospasm was still a
concern.
On [**1-31**] she remained neurologically stable. Drain output was
minimal therefore it was removed. A head CT was performed which
revealed minimal increase in MLS and mass effect but no
intervention was indicated at this time with stable exam and
risk of vasospasm. On [**2-1**], patient's exam remained unchanged,
her groin sites were softer to touch and no increase in sizes of
hematoma.
On [**2-2**], she was noted to have a downward gaze and was febrile.
EEG was initiated to r/o seizures and Keppra was increased. On
[**2-3**], she remained febrile, TCD showed critical vasospasm on the
R/L MCA and SBP was kept 180-200. Her trach and PEG were placed.
On [**2-4**] she remained stable. On [**2-5**] she underwent a cerebral
angiogram that showed an enlargement of the R ICA aneurysm, she
was then coiled but not fully. She returned to the ICU with a
sheath in place. Blood pressure parameters were liberalized to
140-160, IVF were decreased, and Nicardipine was started. On
[**2-6**], she returned to angio to re-assess vasospasm which
appeared improved, she received verapamil intra-arterially. Her
exam remained stable. Also on [**2-6**] she was trasnfused with 2
units of PRBC's to maintain a hematocrit of 30.
On [**2-7**] her TCD's showed increased velocities and a repeat CTA
of the head showed improvement in the vasospasm. On [**2-8**] the
staples were removed from her drain site, her BP goal was
changed to 120-180 systolic, and she was febrile to 103. On
[**2-9**], she was taken to angio to re-evaluate. The angio showed
the R side had improved but the left side had mild to moderate
vasospasm. At that time, her SBP was kept at 180-200, and her
angio sheath remained for a repeat angio on [**2-10**].
On [**2-10**], she returned to angio which showed mild to moderate
spasm to the left and she received Verapamil to bil ICAs. She
also received a transfusion of one unit for a HCT of 28. Her
sputum culture grew MRSA and she was started on Vancomycin.
On [**2-11**], a Head CT showed an increase in her ventricles and a
Left sided EVD was placed at bedside. Her SBP was relaxed to
120-140 with Nicardipine. Vancomycin was discontinued and Ancef
was started for the drain. She returned to angiogram which
showed moderate to severe spasm and received Verapamil to the
left. Her EVD was dropped to 5 cm. Her SBP was allowed to return
to 170-190. Nimodipine was discontinued. On [**2-12**], her exam
changed- asymmetric pupils and sluggish R sided movement. A head
CT was done which showed improvement. Her EVD was kept at 5 cm.
She returned to angiogram and received additional verapamil (5mg
to the R ICA, 10mg to L ICA), it was also noted that the R ICA
aneurysm appeared larger. Post-angio, her blood pressure was
liberalized to 140-160.
Patient was taken to the Angio suite on [**2-13**] for stent assisted
coiling of her right ICA aneurysm.
In late [**Month (only) 958**] it was noticed that the patient's left lower
extremity ROM is limited most likely due to a seroma in the left
groin. A bilateral femoral ultrasound was done there was no
psuedo aneurysm and normal arterial and venous flow was noted.
An orthopedic consult was obtained for contracture of her left
hip. No surgical intervention indicated.
She developed MRSA in her sputum was treated with Vancomycin for
propholaxis for the EVD and MRSA in her sputum.
Ms [**Known lastname 90373**] EVD an attempt was made to wean her EVD. Her EVD
was raised to 10 but then went back to 5 after oozing from her
EVD site. During the evening, she continued to ooze and a
additional stitch was placed. On [**2-17**], her exam & HCT remained
stable and her EVD was raised to 10. On [**2-18**] her HCT was stable
at 28. Her exam was also stable so the EVD was raised to 15. On
[**2-19**] she continued to tolerated the weaning of the EVD so it was
raised to 20. A repeat CT on this day showed that the patient
had developed hydrocephalus; again the EVD was dropped for
better drainage, we plan to put in a perminant Vertricular
peritoneal shunt. Patient drained was moved on 10cmH20 and
remained stable. She remained neurologically stable.
On [**2-23**] she underwent another diagnositic angiogram that showed
continued enlargement of Right ICA aneurysm, it was coiled. A
repeat CT also showed a new IVH, her SBP parameters were lowered
to 160. On [**2-24**] she underwent an angiogram which showed
enlargement of the existing aneurysm which required more coils.
On [**2-27**] she underwent a VPS with a programable valve set at 0.5.
A follow up CT showed She will undergo a head CT [**2-28**] to evaluate
her ventricular size was stable. Neurologically she slowly
improvd with the more eye opening answering yes/no questions
appropriatly and moving the right side with excellent strenght.
She requires mechancal ventilation so a vented rehab is being
seeked.
On [**2128-2-29**] Screening LE Dopplers showed no DVT.
On [**3-3**] she underwent an angiogram without intervention. This
showed minimal filling at base of aneurysm. Her post-procedure
Hct droped to 20. She was transfused with 2 units of PRBCS and
her Hct raised to 28. Lovenox was initiated instead of Heparin
for DVT prophylaxis with less abdominal injections. She was
intermittently hypopneic with unclear etiology, requiring a
ventilation rate. She had a BAL. Tube feeds were restarted. Her
neurologic status remained relatively unchanged, she required
light stimulus for EO and LUE movement at times.
[**3-4**]: Her hematocrit was stable at 27.3. She remained on CPAP
through the night. On [**3-5**], patient was febrile overnight 101.
Vancomycin was started for 4+ gram positive cocci and yeast
found in bronch specimen. In the morning, exam remained
unchanged, she had minimal eye opening, followed commands on R
side and moves purposefully, wiggles toes on LLE and no movement
of LUE.
From 4/16-4/17she remained stable but continued spiking
temperatures. On [**3-8**], she continued to spike. CSF and UA was
sent. Shunt was tapped and CSF was sent. Results demonstrated
GPC in clusters. Pt left VP shunt was then externalized for
presumed meningitis. ID was consulted prior and recommended
broad spectrum abx / meropenem was initiated. Vancomycin 1.5g
was continued concurrently. She was taken to OR on [**3-9**] and
underwent L EVD placement and removal of VP shunt. A CT brain
was stable.
Fever workup incuding echo (TTE) was negative. Her lower
extremity doppler study was positive for a DVT. An IVCF was
placed on [**2128-3-10**]. CSF was sent again on [**3-11**].
Her exam remained stable [**Date range (1) 90374**]. On [**3-12**] her serum WBC was
3.5 down from 6.1, her Tmax was 101.5 at 08:00.
She underwent a clamping trial of the EVD and ICP's remained
stable. She underwent diagnostic cerebral angiogram on [**2128-3-16**]
which was stable and no intervention was done. On [**3-17**], she was
planned for a cranioplasty on the right side, but her crani site
appeared [**Hospital1 2824**] so she underwent a R cranioplasty and L VP
shunt. Her shunt was programmed at 0.5 and a subdural drain was
placed. Post-op head CT was stable with expected post-op
changes. She had a speech and swallow evaluation and was cleared
for PMV. On [**3-18**] AM a head CT was done to reassess ventricular
size which were stable and her shunt was kept at 0.5.
On [**3-19**], she was uncomfortable and complaining of stomach
discomfort. ACS was asked to assess and everything appeared
fine. Her HCT was 25.1 and was repeated in the afternoon it was
27.
It was also noted that she had no menstrual cycle for two months
and OB/GYN was consulted. A HCG was sent which was less than 5.
On [**3-22**], medicine was consulted for optimal hypertensive
management. They recommended starting a second [**Doctor Last Name 360**] -
Lisinopril to her regimen of Metoprolol 50mg TID. Vancomycin
was d/c'd as she had completed her course.
On [**3-23**], pt was cleared and had a bed at [**Hospital3 **]
Medications on Admission:
ProAir
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Ondansetron 4 mg IV Q8H:PRN nausea
3. HydrALAzine 10 mg IV Q6H:PRN SBP>160
4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 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 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
bronchospasm.
10. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**11-23**]
Tablets PO Q6H (every 6 hours) as needed for headache.
11. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
13. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-23**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
15. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes .
16. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q4H
(every 4 hours) as needed for pain.
17. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
18. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q2HR PRN () as
needed for pain.
19. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash on back.
20. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
21. fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
SUBARACHNOID HEMORRHAGE
BILATERAL VERTEBRAL ARTERY DISSECTION
RIGHT VERTEBRAL ARTERY ANEURYSM
RIGHT ICA ANEURYSM
SPONTANEOUS ABORTION
STREPTOCOCCUS PNEUMONIAE / pneumonia
ACUTE RESPIRATORY FAILURE
RIGHT MCA INFARCT
LEFT HEMIPLEGIA
CEREBRAL ARTERY VASOSPASM / SEVERE
POST-OPERATIVE FEVER
ANEMIA REQUIRING TRANSFUSION
RIGHT ACA INFARCT
CEREBRAL EDEMA
SEVERE INTRACRANIAL HYPERTENSION
MRSA infection (Sputum)
OBSTRUCTIVE HYDROCEPHALUS
BILATERAL FEMORAL ARETERY PSEUDOANEURYSMS
LEFT GROIN/FEMORAL REGION SEROMA
TRANSIENT TRANSAMINITIS
CNS INFECTION/MENINGITIS
DEEP VEIN THROMBOSIS / RIGHT LOWER EXTREMEITY
AMENORRHEA
HYPERTENSION
Discharge Condition:
Mental Status: Will answer yes/no question appropriately by
shaking head
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Followup Instructions:
Follow-Up Appointment Instructions
Have your sutures removed on [**3-31**], you may have those
removed at our office please call [**Telephone/Fax (1) 4296**] for an
appointment or you may have them removed at your rehab facility
??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a MRI/MRA ([**Doctor Last Name **] Protocol) at that time.
PLEASE FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN FOR YOUR BLOOD
PRESSURE AND GENERAL CARE.
Completed by:[**2128-3-23**]
|
[
"5990"
] |
Admission Date: [**2142-3-22**] Discharge Date: [**2142-5-10**]
Date of Birth: [**2096-8-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
altered mental status
liver failure
Major Surgical or Invasive Procedure:
Intubation
Central venous catheter
Radial arterial line
Paracentesis x 3
History of Present Illness:
This is a 45 YOF with history of alcoholic cirrhosis who
presented to [**Hospital3 **] today with altered mental status,
new onset jaundice, hypotension, and renal failure. At [**Hospital1 46**],
her SBP was in the 70s and Cr found to by 6.0 (reportedly new).
She was given 2L IVF and transferred by med-flight to [**Hospital1 18**] for
further care.
.
In our ED she continued to be hypotensive to 70s when dopamine
stopped. A right femoral line was placed given coagulopathy and
dopamine restarted. She was confused and had positive asterixis.
She was given levofloxacin and flagyl. A RUQ U/S was done which
showed sludge in the gall bladder but no stones and normal
hepatopedal blood flow. Vitals when she left the ED on 10 mcg
dopamine, afebrile HR 140 BP 100/60.
.
Upon arrival to the ICU, patient is not able to answer questions
secondary to encephalopathy. history take from husband and
sister. She has never been hospitalized before. She had new
onset of jaundice about 1 week ago. This was associated with
abdonimal distention, weakness, lehtargy. Has been in bed since
Monday. Husband [**Name (NI) 71737**] last alcohol was Monday. Has not eaten
or drank in several days. Today she refused to go in the
ambulance until she took a shower. She locked her self in the
bathroom and fell hitting her left temple and back.
Past Medical History:
Alcohol abuse
Cirrhosis?
GERD
Hypertension
?Seizure
Social History:
Lives in [**Location 71738**] with Husband [**Name (NI) **] and 13 YO son. [**Name (NI) 1403**] as a
bank teller. Drinks [**3-8**] "nips" of vodka per day. Smokes [**12-5**] ppd.
Previously addicted to cocaine (20 years ago) Hisband denies IV
drug use.
Family History:
CAD, HTN, Alcoholism
Physical Exam:
Vitals: T:97.3 BP:128/80 P:118 R:22 SaO2:98% RA
General: Confused, tearful, extremely jaundiced female
HEENT: Small cut above left eye, PERRL, EOMI without nystagmus,
marked scleral icterus noted, MMdry, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs dull at the bases
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, distended, non-tender, normoactive bowel sounds
Extremities: No edema, 2+ radial, DP and PT pulses b/l.
Rectal: good tone, no masses or hemmorhoids. Guiac negative
Skin: echymosis on knees and right flank. Teleangectasis on
chest
Neurologic:
-mental status: Confused
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: withdraws to pain.
+Asterixis
Pertinent Results:
WBC 19.0 with 2% bands, 1% atypicals, 3% myelos
HCT 29.7 with MCV 109
PTT 47.6 INR 2.3
HCO3 20, AG 20
BUN 37 Cr 5.8
.
ABG 7.44/31/76 on RA Lactate 2.0
.
Tylenol 9.6
.
Peripheral smear
PLTs nl count, no clumping, occasional large plt
RBC macrocytic, no central pallor, no schistocytes, occasional
nucleated RBC and retics seen
WBC - leukomoid reaction with PMN predominance, bands,
occasional atypical lymphocytes. No hypersegmented neutrophils
seen
EKG:
poor tracing. sinus. 129 bpm. nl axis and intervals. No st
changes or TWI.
-
Imaging/Studies:
CXR - Lung volumes are somewhat low. The aorta is unfolded.
There is bibasilar atelectasis. There is no evidence of focal
infiltrate or pleural effusion, however left costophrenic angle
is partially obscured by overlying external device. Pulmonary
vascularity is normal.
.
Liver U/S - No prior for comparison. This study is limited due
to portable nature and patient inability to cooperate with
examination. The liver is diffusely echogenic. Gallbladder wall
is thickened, but the gallbladder does not appear distended.
Layering sludge is seen within it. No definite intrahepatic
ductal dilatation is seen. Common bile duct is not dilated.
Portal venous flow is maintained in the appropriate direction.
Brief Hospital Course:
45 YOF with alcoholic hepatitis, respiratory failure, sepsis,
and renal failure.
# Alcohol hepatitis - Patient had long history of alcohol abuse
and positive tylenol level on admission. Bilirubin greater 30 on
admission and discrimanant function 38, MELD 33. She was treated
initially for 48 hours with N acetylcystiene. Liver was enlarged
but no evidence of portal vein thrombosis. She was also started
on solumedrol and transitioned to PO prednisone. Hepatitis
serologies were sent and were negative. EGD revealed no varices.
Gradualt LFT's improved. However, she returned from the ICU and
then developed worsening diarrhea which precipitated hepatorenal
syndrome. She became dehydrated but could not be fluid
resuscitated due to renal failure and resultant hypoxia with
fluid administration, and was therefore transferred back to the
ICU. given her rising MELD, 42 prior to transfer, patient's
family was informed of her poor prognosis. She was made comfort
measures only and subsequently passed away.
# Renal Failure - Initially in renal failure which improved with
volume resucitation. Cr stablilized at around 1.8. Started on
octreatide and midodrine for emipric treatement of hepatorenal
syndrome with improvement of creatine to 1.0. Then, Patient was
then started on lasix and spironolactone. Several days later,
upon transfer to floor, she had newly elevated creatinine.
FEUrea 30, urine Na 33. She also had positive eos and elevated
Vanc level previously. She was started back on HRS protocol, but
suspicion very high for ATN/AIN picture as well. Renal was
consulted and ultimately felt that this was more likely AIN/ATN.
Creatinine gradually improved.
# Respiratory failure: Intially intubated for worsening acidosis
and volume overload. She was diuresed and extubated on [**2142-4-10**].
She initially improved. Then on [**4-16**] had worsening abdominal
distension and had paracentesis of 3L; also had fever to 101,
dyspnea/tachypnea to 30's, increased oxygen requirement with A-a
gradient of 50, tachycardia. ABG was 7.46/22/69, lactate of 3.4.
V/Q was done - negative for PE. LENIs were negative for DVT as
well. Over remainder of hospital course, she continued to have
episodes of tachypnea, hypoxia, tachycardia requiring several
MICU transfers for closer observation and paracentesis PRN. No
obvious etiology of her symptoms was isolated.
# fever/tachycardia: currently afebrile.
- serial paracenteses [**4-9**], /11, /14, /21, /26 have shown no
evidence of SBP
- tapped again 2.5 L on [**4-28**]
- continue fluc
- Blood Cx revealed no growth except 1 bottle presumed
contaminant
# Sepsis/Hypotension: When she was transferred to [**Hospital1 18**], she was
hypotensive to 70's and placed on dopamine and neosynephrine
gtt. A femoral line was placed at the OSH which was switcher to
a left IJ. She was admitted to the MICU and received empiric Abx
including Vanc, Zosyn, Meropenam. Very extensive MICU course
most notable for prolonged pressor-dependent hypotension,
encephalopathy; was treated with steroids for etoh hepatitis;
had multiple therapeutic paracenteses; multiple transfusions;
intubated [**3-24**] for acidosis and altered mental status, extubated
[**4-10**].
# Alcohol abuse/withdrawl - Intially very delerious. History of
seizure. Was treated with IV ativan. Given
multivitamin/folate/thiamine. During the rest of her hospital
course, she received lactulose and had improvement in mental
status.
# esophageal candidiasis: extensive candidiasis seen on EGD
- continue po fluconazole (started [**4-19**]): plan for [**2-4**] wks
course
# Substance abuse: Had been on CIWA scale for EtOH abuse, but
now >3 weeks from last drink so no further ativan needed.
- Social work involved
- Cont thiamine, MVI, folate
# ANEMIA:
- Macrocytic anemia, likely due to alcohol abuse. Hct seems to
have stabilized
- active T&S, guaiac stools
# FEN: S&S passed, on nectar-thick liquids, soft solids.
- post pyloric NJT placed on [**4-26**], restarted TF on [**4-26**]
- post pyloric pulled out and NGT placed on [**4-29**]. TF resumed.
# ACCESS: PIV.
# Ppx: Pneumoboots, PPI, bowel regimen
# Code: Full
# Dispo: pending improved mental status
Medications on Admission:
Atenolol
Oxycodone
Prilosec
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2142-5-12**]
|
[
"5845",
"51881",
"2762",
"4280",
"3051"
] |
Admission Date: [**2107-2-24**] Discharge Date: [**2107-2-26**]
Date of Birth: [**2107-2-24**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient was a 2.68 kilogram
product of a 35 [**3-24**] week gestation to a 31 year-old gravida 2
para 1 woman whose pregnancy was complicated by premature
rupture of membranes two days prior to delivery. There was
no maternal fever or other signs of infection. Mother's
prenatal screen showed a hepatitis B surface antigen negative
status, RPR nonreactive, A positive, antibody negative,
Rubella immune, group B strep unknown status. The mother
received antibiotics approximately six hours prior to
delivery. She was delivered by C section for a breech
presentation. In the Delivery Room the patient had Apgars of
7 and 8. The patient was pale at birth with slightly low
heart rate. She was given facial CPAP and stimulation and
heart rate rapidly rose to normal. The patient was
transferred to the Intensive Care Unit after visiting with
the parents.
PHYSICAL EXAMINATION ON ADMISSION: Pink, active,
nondysmorphic infant. Weight was 2.68 kilograms (75th
percentile), length 45.5 cm (25th to 50th percentile) and
head circumference was 34 cm (90th percentile). Examination
of the skin was unremarkable. HEENT examination was within
normal limits. Examination of the lungs revealed course
breath sounds with moderate retractions bilaterally. Cardiac
examination was with a normal S1 and S2 without murmurs.
Pulses were 2+ and equal bilaterally without delay.
Examination of the abdomen was unremarkable. Neurological
examination was nonfocal and age appropriate. Hips were
unremarkable. There were clicks bilaterally, but no
dislocations or dislocatability. Spine was intact. Anus was
patent. Genitalia was of a normal premature female.
HOSPITAL COURSE: 1. Pulmonary: The patient required
intubation upon admission to the Neonatal Intensive Care Unit
for respiratory distress. X-ray was consistent with either
amniotic fluid aspiration or mild surfactant
deficiency/respiratory
distress syndrome. Because of the mechanical ventilation and
possibility of RDS the patient was given a single dose of
surfactant. She was able to wean to CPAP and room air within
24 hours of birth. There was a soft murmur detected on the
first day of life, but there were no signs of hemodynamically
significant PDA. The rest of the cardiovascular examination
was normal. Heart size is normal on chest x-ray. Murmur
subsequently resolved on exam in the Newborn Nursery.
2. Fluids, electrolytes and nutrition: The patient was
initially maintained NPO on intravenous fluids. She was
started on first hospital day and tolerated these fine. By
the second hospital day was taken full volumes po.
Breastfeeding is going well. She was able to maintain her
temperature in an open crib.
3. ID - Mother had rupture of membranes for over 2 days prior
to delivery but no other significant risk factors for sepsis
than prematurCBCur on adssion showed a hematocrit of
other white count of 17,800. There was 29% polys and 2%
bands. Platelet count was 272,000. After blood cultures were
obtained the patient was started on ampicillin and gentamycin
for a 48 hour rule out. Blood cultures were negative at 48
hours and antibiotics were discontinued.
4. Gastrointestinal: The patient is tolerating breastfeeding
well. Bilirubin was checked on [**2-25**] and was only 3.8/0.2.
5. Neurological: The patient has manifested a normal
neurological examination throughout her hospital stay.
Because of the advanced gestational age there is no need for
a head ultrasound or ophthalmologic screening.
5. Routine health care maintenance: The patient is to be
seen by pediatrician Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 233**] in [**Last Name (un) 38956**]. The patient
has not yet received hepatitis B vaccine.
Hearing screening with automated ABR was performed and passed
in both ears.
The patient also passed car seat testing on [**2107-2-25**].
DISCHARGE DIAGNOSES:
1. RDS.
2. 35 week premature infant.
3. Rule out sepsis.
DISCHARGE DISPOSITION: Transfer to the Newborn Nursery Care
of the [**Location (un) 13248**] Newborn Services and then transfer to home.
FU with Dr. [**First Name (STitle) 233**] planned in 2 days.
DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1877**] 50.466
Dictated By:[**Last Name (NamePattern1) 37102**]
MEDQUIST36
D: [**2107-2-25**] 15:05
T: [**2107-2-25**] 15:09
JOB#: [**Job Number 38957**]
|
[
"V290"
] |
Unit No: [**Numeric Identifier 67428**]
Admission Date: [**2140-4-28**]
Discharge Date: [**2140-5-12**]
Date of Birth: [**2140-4-28**]
Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 10132**] is a 2,175 gram female infant born
at 33-3/7 week gestation. The estimated date of confinement
was [**2140-6-13**]. She was admitted to the Neonatal Intensive
Care Unit for management of prematurity. Baby Girl [**Known lastname 10132**] was
born to a 35 year-old gravida IV, para III, now IV mother.
The prenatal screens include maternal blood type A positive,
antibody negative. RPR nonreactive, HBsAG negative, RI, GBS
unknown. The pregnancy was complicated by placenta accreta
and episodes of bleeding. The mother was admitted to the [**Hospital1 1444**] for an episode of vaginal
bleeding on [**2140-4-1**]. Otherwise the pregnancy had been
progressing well with normal fetal surveys. The mother of the
baby received a complete course of betamethasone.
The infant was delivered on [**4-28**] by cesarean section due to
maternal issues. The mother was placed under general
anesthesia and there were no perinatal sepsis risk factors
present including no maternal fever, no fetal tachycardia and
no rupture of membranes greater than 24 hours. The mother did
not receive infrapartum antibiotics prior to delivery of the
infant.
The infant emerged pink and vigorous with good tone and
spontaneous respiration. Routine neonatal resuscitation was
provided and the Apgars were 9 and 9. The infant was
transferred to the Neonatal Intensive Care Unit for further
management.
PHYSICAL EXAMINATION ON ADMISSION: Includes a weight of
2,175 grams which is the 75th percentile, a length of 47 cm
which is the 75th to 90th percent and a head circumference of
31 cm in the 50th percentile. The infant was active, pale
pink, nondysmorphic with mild to moderate respiratory
distress as demonstrated by grunting. The anterior fontanelle
was level and soft. Ears were normally set. Palate intact.
Clavicles intact. Breath sounds with poor to fair aeration
and grunting. Cardiovascular: Regular rate and rhythm, no
murmur. Peripheral pulses were +2. The abdomen was soft with
positive bowel sounds, no hepatosplenomegaly. GU was normal
preterm female. The anus was patent. No sacral anomalies and
the hips were stable. She appeared pink and well perfused.
Neurologically the baby had symmetrical tone and strength.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY:
The baby initially required intubation and the administration
of 2 doses of surfactant, On day of life 4 ([**2140-5-2**]) she was
extubated to room air and has remained in
room air since that time.
She has mild apnea and bradycardia of prematurity. Her last
event was yesterday [**2140-5-11**]. She is not on any
methylxanthines.
CARDIOVASCULAR: On day of life 1 she had an intermittent
murmur which has persisted and has remained intermittent. She
initially required 2 doses of normal saline for volume
and since that time her blood pressures have remained stable.
FLUID, ELECTROLYTES AND NUTRITION: The infant had 1
dextrostick below 40 (34) which responded well to a D10w
bolus. She has remained euglycemic since that time. In
addition, upon admission the infant was started on IV fluids.
On day of life #3 enteral feedings were initiated and have
progressed to full feeds Similac 24. She has been all P.O.
since Tuesday [**2139-5-11**].
The most recent electrolytes on [**2140-5-4**] (DOL 6) included a
sodium of 142, a potassium of 5.8 which was hemolyzed, a
chloride of 112 and a CO2 of 15.
Her discharge weight is 2275 grams (up 45 grams from the
previous day).
GASTROINTESTINAL ISSUES: The infant was clinically jaundiced
with an initial bilirubin total of 4.8 and a direct of 0.2 on
day of life 1. The peak bilirubin was on day of life 4 at
10.3 with a direct of 0.3. The infant required 4 days of
phototherapy and is presently off phototherapy with a rebound
bilirubin of 7.9 and a direct of 0.3 on [**5-5**].
HEMATOLOGY: No blood typing has been done on this infant. The
initial hematocrit was 38.8 on admission day which was felt
to be related to placenta accreta and the most recent
hematocrit on day of life 3 was 35.8. The infant has not
required any blood product transfusion.
INFECTIOUS DISEASE: The infant had a CBC and blood culture
screening on admission and received 48 hours of antibiotics
which were discontinued following negative blood culture
results. The CBC results were normal.
NEUROLOGY: The infant has maintained a normal neurologic
status and has required no additional neurologic studies.
SENSORY: Audiology: She passed a hearing screen prior to
transfer to [**Hospital3 **]. Given her family history of
hearing loss, whe qill require repeated screenings. The next
should be performed at 6 months of age.
OPHTHALMOLOGY: The patient is not a candidate for
ophthalmological examination as of this time.
PSYCHOSOCIAL: The [**Hospital1 69**] social
workers are involved in with this family and there are no
current issues but if issues arise the social work department
can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transferred to [**Hospital3 **]
level 2 nursery.
NAME OF PRIMARY PEDIATRICIAN: Dr.[**Name (NI) 67429**].
CARE RECOMMENDATIONS:
1. Feeding at discharge: Similiac 24 PO ad lib.
2. Medications: The infant presently is on no medications.
3. Car seat position screening is recommended prior to
discharge from [**Hospital3 **].
4. The initial state newborn screens showed an elevated
17OHP and a repeat newborn screen was sent on [**2140-5-5**] which was normal. A third screen was sent today
[**2140-5-12**].
5. Immunizations: Hepatitis B vaccine #1 on [**2140-5-10**].
6. Immunizations recommended include 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: 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 contact and out of home care-givers.
7. Follow up appointments: (1) An appointment with the
pediatrician is recommended following discharge from
[**Hospital3 **]. (2) Audiology (due to family history
of hearing loss).
DISCHARGE DIAGNOSES:
1. Respiratory distress syndrome, resolved.
2. Sepsis evaluation, ruled-out.
3. Transient hypoglycemia, resolved.
4. Hyperbilirubinemia, resolved.
5. Apnea of prematurity.
6. Mildly elevated 17-OH on initial state screen, resolved.
7. Prematurity.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 67430**]
MEDQUIST36
D: [**2140-5-5**] 12:55:00
T: [**2140-5-5**] 13:51:34
Job#: [**Job Number 67431**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2123-8-19**] Discharge Date: [**2123-8-25**]
Date of Birth: [**2044-3-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
fatigue & weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79yo M with hx of HTN and gout, who presented to [**Hospital1 18**] [**Location (un) 620**]
on [**2123-8-19**] with fatigue & generalized weakness over the past
week. Pt reports having a gout flare about 2wks ago (affecting L
foot) was started on colchicine. Pain persisted and pt began
taking exra colchicine, hoping it would help relieve his pain.
He took an unclear amount (approx 20pills) over a few days. Foot
pain improved. However, he developed nausea & diarrhea with some
abd discomfort, which radiated to his chest. Saw his PCP, [**Name10 (NameIs) 1023**]
started prilosec w/ little improvement. Pt began to feel
progressively more weak. He also notes trouble w/ his balance &
feeling "shaky." No HA or vision changes. No CP/palpitations. +
SOB at baseline. Pt con't to have diarrhea, no blood noted in
stool. Noted decreased UOP ~1wk.
.
OSH course: Cr 12.2, K 6.7, bicarb 11. Pt got bicarb, kayexylate
(60), insulin and D5. Transferred to [**Hospital1 18**] for possible urgent
HD.
Past Medical History:
HTN for at least 20yr
Gout
Glaucoma
Obesity
.
Social History:
Widowed. Lives alone. Supportive son & dtr in area. History of
alcohol abuse (over [**11-24**] pint of vodka for over 30 years); Quit
12yrs ago. 90+ pack year history, quit >25yr ago
Family History:
No family history of renal disease
Physical Exam:
VS: Temp: 96.9 BP: 125/50 HR: 72 RR: 13 O2sat: 97% on RA
general: obese, pleasant, conversant in mild distress
comfortable, NAD
HEENT: PERLLA, EOMI, anicteric, injected sclera, no sinus
tenderness, MMM, op without lesions, jvd not seen, no carotid
bruits
lungs: CTAb/l, though decreased air movement at bases
heart: distant hrt sounds, RR, S1 and S2 wnl, no murmurs, rubs
or gallops appreciated
abdomen: protuberant, +b/s, soft, nt, no masses or
hepatosplenomegaly
extremities: 1+ dependent edema
skin/nails: no rashes/no jaundice/no splinters
neuro: AAOx3. Cn II-XII intact. No asterixis. 5/5 strength
throughout. No sensory deficits to light touch appreciated
Pertinent Results:
Admission Labs:
[**2123-8-19**] 10:36PM BLOOD WBC-6.7 RBC-3.34* Hgb-10.9* Hct-31.8*
MCV-95 MCH-32.7* MCHC-34.5 RDW-13.7 Plt Ct-279
[**2123-8-19**] 10:36PM BLOOD PT-11.8 INR(PT)-1.0
[**2123-8-19**] 10:36PM BLOOD Plt Ct-279
[**2123-8-19**] 10:36PM BLOOD Glucose-106* UreaN-150* Creat-12.6*
Na-131* K-5.3* Cl-98 HCO3-11* AnGap-27*
[**2123-8-19**] 10:36PM BLOOD ALT-12 AST-5 LD(LDH)-192 CK(CPK)-143
AlkPhos-79 Amylase-100 TotBili-0.2
[**2123-8-19**] 10:36PM BLOOD CK-MB-8
[**2123-8-19**] 10:36PM BLOOD cTropnT-0.04*
[**2123-8-19**] 10:36PM BLOOD Albumin-3.6 Calcium-8.5 Phos-12.2*
Mg-3.8* UricAcd-9.4* Iron-156
[**2123-8-19**] 10:36PM BLOOD Ferritn-456*
[**2123-8-19**] 11:34PM BLOOD Type-ART pO2-87 pCO2-34* pH-7.10*
calTCO2-11* Base XS--18 Intubat-NOT INTUBA
[**2123-8-19**] 11:34PM BLOOD Glucose-101 Lactate-0.8 Na-127* K-5.0
Cl-102
[**2123-8-19**] 11:34PM BLOOD freeCa-1.16
CHEST X-RAY ([**2123-8-19**])
No acute cardiopulmonary process
ECG: ([**2123-8-19**])
Sinus rhythm. First degree atrio-ventricular conduction delay.
Borderline
left axis deviation. Non-specific QRS widening. Diffuse
non-diagnostic
repolarization abnormalities. No previous tracing available for
comparison.
Renal ultrasound
1) Markedly limited examination.
2) No hydronephrosis in either kidney.
3) Bilateral hypoechoic renal lesions cannot be adequately
characterized due to technical limitations, although they may
represent cysts.
4) Patent renal arteries and veins bilaterally. Limited Doppler
examination due to technical difficulties.
ECG: ([**2123-8-21**])
Sinus bradycardia. Intraventricular conduction defect. Compared
to prior
tracing of [**2123-8-19**] no change.
ULTRASOUND OF LEFT LOWER EXTREMITY ([**2123-8-25**])
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the left common
femoral, superficial femoral, and popliteal veins were
performed. Normal flow, compressibility, and augmentation were
seen. There was no evidence of intraluminal thrombus.
IMPRESSION: No evidence for deep vein thrombosis in the left
leg.
Brief Hospital Course:
MICU Course
On arrival here, his Cr was 12.6 and K 5.3. Admitted to the ICU
and treated with a bicarb gtt, kayexylate, insuin and D5. Renal
consult was obtained and it was decided to hold off on dialysis
and to treat him medically. He is continued on a bicarb gtt and
started sevelamer. He had a renal ultrasound which was normal.
Patient transfered to regular wards on [**2123-8-22**].
# ARF with hyperphosphatemia: Continued to improve with medical
therapy. Suspect failure was due to combination of chronic renal
failure, dehydration, ace inhibitor and overdose of colchicine.
We continued IV hydration during period of post ATN diuresis and
were able to medically manage elctrolytes with phosphate binders
and potassium replacement. Nephrology team continued to follow
patient and believe he will not require dialysis. Primary care
physician was [**Name (NI) 653**], he will continue to follow patient and
VNA will check electrolytes with results faxed to his office.
Patient will need nephrology follow up locally; will defer this
to PCP.
.
# EKG changes: TWI in precordial noticed shortly after transfer
to wards. These however were not accompanied by increase in
cardiac troponins in spite of renal failure. Changes are most
likley secondary to metabolic disturabance from renal failure
and were attenuated at the time of discharge.
.
# HTN: Once euvolemic, patient became slightly hypertensive but
responded well to Norvasc 5mg po daily. We held lisinopril, HCTZ
and aspirin as these could further worsen renal function in the
acute setting.
.
# Lower extremity edema: Patient developed pitting edema of
lower extremities in a mildly asymetric fashion. Lower
extremitly dopplers were obtained and preliminary read revealed
no thrombus.
.
# anemia: was anemic on admission with unremarkable iron panel.
Would defer further management to primary care physician.
.
# Gout: Patient did not have any more signs of gout flare. Did
not require steroids; would avoid NSAIDS or colchicine in light
of ARF.
.
# Glaucoma: Continue Brimonidine and Lumigan for bilateral
glaucoma.
.
# FEN: Tolerated a renal diet
.
# prophylaxis: DVT ppx with heparin SC and pneumoboots.
.
# Code: Patient requested to code status be DNR/DNI, which was
maintained during entire hospitalization.
Medications on Admission:
colchicine 0.6mg daily
lisinopril 40mg daily
triamteren/hctz 25/50 [**Hospital1 **]
lipitor 80mg daily
Prilosec OTC 20mg daily
ASA 81mg daily
Discharge Medications:
1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H
(every 12 hours).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: Two (2)
puffs Inhalation Q6H (every 6 hours).
Disp:*1 MDI* Refills:*2*
5. Ipratropium Bromide 0.02 % Solution Sig: Two (2) PUFFS
Inhalation Q6H (every 6 hours).
Disp:*1 MDI* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
PRIMARY
1. ACUTE RENAL FAILURE
SECONDARY
1. GOUT
2. HYPERTENSION
Discharge Condition:
Stable, normotensive with improving renal function.
Discharge Instructions:
You were admitted to the hospital because your kidneys began to
fail after you took more gout medicine than what was
recommended. In the hospital, we stopped the medications that
could worsen this situation, began to give you fluids and
corrected the imbalances in the salts of your blood that were
caused by renal failure. You slowly began to improve and now are
showing signs of recovery.
Please do not take any anti-inflammatory medicines (Advil,
Motrin, Aspirin, ect) or any more of your gout medicine,
Colchicine, until you see your primary care doctor.
Please take all medications as prescribed and keep all doctors
[**Name5 (PTitle) 4314**]. If you experience any chest pain, shortness of
breath, nausea, vomiting or diarrhea, stop making urine, feel
confused or develop any other symptom that concerns you, please
seek medical attenditon immediately.
Followup Instructions:
You have a follow up appointment with your primary care
provider, [**Name10 (NameIs) **] [**Last Name (STitle) 36568**] ([**Telephone/Fax (1) 75007**] on Tuesday, [**8-31**] at
10am
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"5849",
"2761",
"2767",
"40390",
"5859",
"2859"
] |
Admission Date: [**2144-6-15**] Discharge Date: [**2144-6-21**]
Date of Birth: [**2103-6-23**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Amoxicillin / Blood-Group Specific Substance
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
41 yo F with DM1, s/p renal transplant in [**2140**], CAD s/p [**Hospital **]
transferred from OSH for DKA.
.
Initially presented to OSH (Southern [**Hospital **] Medical center) with
n/v, altered mental status on [**6-14**] x 2-3 days. Her initial VS
were: T 91.4, BP 82/53, RR 32, O2 sat 95% on RA. Her inital glu
was 1148, AG 36, PH 6.9, bicarb was 4. She was given NS and
started on an insulin gtt and admitted to the ICU. Anion gap at
2PM on day of transfer was 13. Pt arrived with insulin gtt
running. Total amount of fluid she recieved at OSH is unclear.
Pt has history of frequent recurrent DKA episodes with no known
precipitating factors. She states that she stopped taking her
insulin because she was feeling sick from her menses with
diarrhea.
.
Of note, her Creatinine, which runs 0.9- 1.0 at baseline, was
2.1 on admission. Repeat CRT at 2PM on day of transfer was 1.2.
.
She was also initially noted to be in Aflutter and
spontaneuously converted to NSR. Her EKG showed TW-inversions in
lateral leads. Her troponin I was 0.11 on admission and
increased to 12.0. This was felt to be due to demand ischemia by
the OSH ICU team. A cardiology consult was obtained at the OSH
and the pt was started on Lovenox, ASA, Plavix, Integrellin.
.
Recently admitted [**4-25**]/- [**2144-4-26**] to [**Hospital1 18**] for CHF exacerbation
due to dietary non-complaince. She was ruled our for MI by
enzymes x 3.
Past Medical History:
1.ESRD s/p living related donor [**10-31**]
2.Diabetes Mellitus type I with retinopathy, gastroparesis and
neuropathy
3.CAD s/p CABG [**5-2**] (LIMA-LAD, SVG-PDA, OMI-Diag).
(Echo at [**Hospital1 **] [**First Name (Titles) **] [**2143-8-1**] showed mild
symmetric LVH with a normal EF of greater than 55%. There were
subtle apical, anterior, and lateral areas of hypokinesis.
There was also moderate 2+ mitral regurg and moderate pulmonary
artery hypertension. She had a stress test and exercise MIBI in
[**2144-1-1**] that showed reversible defects in the territory
ofthe LAD and left circumflex similar in appearance to a prior
study in [**2142-5-31**]. A normal ejection fraction of 51% was
reported.)
4.PVD s/p bypass fem-[**Doctor Last Name **]
5.CHF EF = 45-50%
6.HTN
7.Chronic ulcers
8. Sarcoidosis
9. Depression
10. Blindness bilaterally. L eye prosthesis.
.
Medications on Admission to OSH:
1. Bactrim double strength one tab every Monday, Wednesday and
Friday.
2. Aspirin 81 mg daily.
3. Prednisone five milligrams daily.
4. Reglan ten milligrams four times a day before meals and at
bedtime.
5. Zoloft 75 mg at bedtime.
6. Sirolimus three milligrams daily.
7. Lopressor 150 mg t.i.d.
8. Plavix 75 mg daily.
9. Ramipril 2.5 mg daily.
10. Tacrolimus two milligrams b.i.d.
11. Insulin Lantus 22 units qhs
12. Humalog insulin sliding scale.
13. Zantac 75 mg b.i.d.
14. Lipitor 80 mg daily.
15. Compazine 20 mg p.o. q. 4h. as needed for nausea.
16. Remeron 15 mg p.o. at bedtime as needed for sleeplessness.
17. Calcium 500 mg b.i.d.
18. Vitamin D 425 mg daily.
19. Fosamax 70 qweek on WEDs
21. Ranitidine 150 [**Hospital1 **]
.
MEDS on TRANSFER:
1. Insulin gtt
2. Integrilin gtt at 1 mcg/kg/min
3. Rocephon 1g IV qd
4. Ranitidine 150mg PO bid
5. Solucortef 100mg IV q8h x 2 doses, then 50mg IV x 1 dose
6. Protonix 40mg qd
7. Lovenox 60mg SC qd
8. Lopressor 5mg IV q6h
9. Prograft 2mg [**Hospital1 **]
10. Ramamune 3mg PO qd
11. ECASA 81mg po qd
12. Plavix 75mg qd
.
Allergies:
Codeine / Amoxicillin
Social History:
Lives with her mother in [**Name (NI) **]. Quit tobacco 3 months ago;
prior, smoked 1/2ppd - 1 ppd for about 15 years. No alcohol or
IVDU.
Family History:
no diabetes
"heart trouble" in father and mother of unknown type
F - MI at 74y/o
M - HTN
Physical Exam:
Physical Exam:
102 154/48 54 40 100%2LNC
GEN: Ill appearing but in in NAD
HEENT: Mucous membranes dry. Lips dry and cracked. OP clear, JVP
8 cm, L eye prosthesis. R eye blind reactive to light.
CV: RR, 4/6 systolic murmur across precordium
Lungs: crackles at bases bilaterally
Abd: S/nd. +BS, minimal tender diffusely, no rebound or guarding
Ext: Trace edema bilaterally. 1+ DP/PT pulses bilaterally.
Neuro: A&OX3.
Pertinent Results:
LABS ON XFER:
.
WBC 24.2 N82 B13 L3
HCT 47.3
MCV: 103
PLT: 442
.
INR 1.03
PTT 32
.
UA: 3+ glucose, 3+ ketones, Neg LE, nitrites
.
Na: 145 Cl: 117 BUN: 19 Glu: 138
K: 4.0 HCO3: 15 CR: 1.3
.
Ca: 8.3 Mg: 1.7 Ph: 1.6
.
CK: 240 TropI 12.15
.
Lipase 399, [**Doctor First Name **] 182
Hcg neg.
.
ABG: 7.38/20/103
[**2144-6-15**] 08:10PM GLUCOSE-55* UREA N-17 CREAT-1.0 SODIUM-147*
POTASSIUM-3.7 CHLORIDE-120* TOTAL CO2-15* ANION GAP-16
[**2144-6-15**] 08:10PM ALT(SGPT)-11 AST(SGOT)-39 CK(CPK)-233* ALK
PHOS-82 TOT BILI-0.2
[**2144-6-15**] 08:10PM CK-MB-19* MB INDX-8.2* cTropnT-0.72*
[**2144-6-15**] 08:10PM CALCIUM-8.5 PHOSPHATE-2.3* MAGNESIUM-1.6
[**2144-6-15**] 08:10PM WBC-20.8*# RBC-3.78* HGB-11.1* HCT-32.6*
MCV-86 MCH-29.5 MCHC-34.2 RDW-13.6
[**2144-6-15**] 08:10PM NEUTS-93.1* BANDS-0 LYMPHS-3.8* MONOS-1.6*
EOS-1.3 BASOS-0.1
[**2144-6-15**] 08:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2144-6-15**] 08:10PM PLT SMR-NORMAL PLT COUNT-287
[**2144-6-15**] 08:10PM PT-12.5 PTT-30.3 INR(PT)-1.0
CMV Viral Load (Final [**2144-6-17**]): CMV DNA not detected.
Performed by PCR.
MRA: 1. No evidence of aortic pathology. 2. Calcified left
common carotid plaque < 50%
Esophagus mucosal biopsy: Active esophagitis with
fibrinopurulent exudate consistent with ulceration. GMS stain
for fungal organisms is negative with satisfactory control. No
viral cytopathic effect identified
Blood Cultures ([**2144-6-16**]): no growth
Brief Hospital Course:
41 year old female with type 1 DM, s/p renal transplant
transferred from OSH with DKA, NSTEMI, possible left lingular
PNA.
.
DKA: secondary to pneumonia and dietary/insulin non-compliance.
AG gap closed with IVF and insulin, and presenting symptoms
resolved [**Last Name (un) **] followed Pt through course.
.
NSTEMI: Pt with h/o CAD s/p CABG [**5-2**]. TropT 0.72 on admission,
trended down to 0.27. EKG at [**Hospital1 18**] unremarkable. Continued ASA,
plavix, BB, statin, acei
.
BACK PAIN: MRA failed to show disection. Diminished with
resolving DKA. Given Morphine Sulfate 2 mg IV Q3-4H:PRN
.
MELENA: in setting of lovenox and integrillin, stopped soon
after admission. Still on aspirin and plavix. EGD showed
erosion in the fundus, esophageal candidiasis, but otherwise
normal egd to second part of the duodenum
.
NEPHROPATHY: s/p cadaveric renal transplant: Creatinine improved
from admission suggests likely prerenal failure. Continue
prednisone/sirolimus/tacrolimus + ACEi + bactrim. Renal
transplant floowed Pt's course.
.
LEUKOCYTOSIS/LEFT LINGULA PNA. R/o infection. Elevated WBCs may
be due to stress-dose steroids started on admission. Blood
cultures negative. Given levofloxacin to cover for
community-acquired PNA.
.
D/N/V: Patient with gastroparesis. No concerning abdominal exam.
Given antiemetics prn and reglan standing
Medications on Admission:
Medications on Admission to OSH:
1. Bactrim double strength one tab every Monday, Wednesday and
Friday.
2. Aspirin 81 mg daily.
3. Prednisone five milligrams daily.
4. Reglan ten milligrams four times a day before meals and at
bedtime.
5. Zoloft 75 mg at bedtime.
6. Sirolimus three milligrams daily.
7. Lopressor 150 mg b.i.d.
8. Plavix 75 mg daily.
9. Ramipril 2.5 mg daily.
10. Tacrolimus two milligrams b.i.d.
11. Insulin Lantus 22 units qhs
12. Humalog insulin sliding scale.
13. Zantac 75 mg b.i.d.
14. Lipitor 80 mg daily.
15. Compazine 20 mg p.o. q. 4h. as needed for nausea.
16. Remeron 15 mg p.o. at bedtime as needed for sleeplessness.
17. Calcium 500 mg b.i.d.
18. Vitamin D 425 mg daily.
19. Fosamax 70 qweek on WEDs
21. Ranitidine 150 [**Hospital1 **]
.
MEDS on TRANSFER:
1. Insulin gtt
2. Integrilin gtt at 1 mcg/kg/min
3. Rocephon 1g IV qd
4. Ranitidine 150mg PO bid
5. Solucortef 100mg IV q8h x 2 doses, then 50mg IV x 1 dose
6. Protonix 40mg qd
7. Lovenox 60mg SC qd
8. Lopressor 5mg IV q6h
9. Prograft 2mg [**Hospital1 **]
10. Ramamune 3mg PO qd
11. ECASA 81mg po qd
12. Plavix 75mg qd
Discharge Medications:
1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
2. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
12. Sertraline HCl 50 mg Tablet Sig: 1.5 Tablets PO QHS (once a
day (at bedtime)).
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
14. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 weeks.
Disp:*21 Tablet(s)* Refills:*0*
15. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
16. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
17. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
18. Outpatient Lab Work
Please check chem 7 panel on [**2144-6-22**]. [**Date Range **] results to Dr. [**First Name8 (NamePattern2) 3122**]
[**Name (STitle) 1860**] at [**Telephone/Fax (1) 434**] (phone [**Telephone/Fax (1) 20422**])
Discharge Disposition:
Home
Discharge Diagnosis:
1. DMI
2. DKA
3. CAD s/p CABG
4. s/p Renal transplant [**2140**]
5. Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
You are discharged to home and should continue all medication as
prescribed. Try soft foods given your swallowing discomfort.
Please call your primary care physician or present to the ER if
you experience chest pain, shortness of breath, bright red blood
from your rectum, black tarry stools, increasing finger stick
glucose measurements or other concerns. Please keep all of your
appointments.
Followup Instructions:
You should have your blood drawn tomorrow to check your
creatinine (kidney function) and the results faxed to Dr. [**First Name8 (NamePattern2) 3122**]
[**Name (STitle) 1860**] [**Telephone/Fax (1) 434**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2144-7-2**] 1:30
You should follow-up with your Cardiologist Dr. [**Last Name (STitle) **] within
1-2 weeks after discharge. Please call [**Telephone/Fax (1) 6197**].
Provider: [**Name Initial (NameIs) **] Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX)
HMFP Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2144-6-30**] 10:20
Provider: [**Name10 (NameIs) **] SACKS, LICSW Where: RA [**Hospital Unit Name **]
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) HMFP Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2144-6-30**] 11:00
You will also need a Colonoscopy in [**7-8**] weeks. You should
follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3815**] (phone number: [**Telephone/Fax (1) 16315**]). You
can schedule this Colonocopy by calling [**Telephone/Fax (1) 463**].
You should also schedule a follow-up appointment with Dr. [**Last Name (STitle) 2262**]
in Nephrology in two weeks. His office number is [**Telephone/Fax (1) 20423**].
|
[
"41071",
"486",
"4280",
"5849",
"V4581",
"4019"
] |
Admission Date: [**2148-6-26**] Discharge Date: [**2148-7-6**]
Date of Birth: [**2106-1-28**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Adhesive Bandage / Dicloxacillin
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
PICC placement
Therapeutic Paracentesis
Colonoscopy
History of Present Illness:
Mr. [**Known lastname 19420**] is a 42 year old male with a history of end stage
liver disease on the [**Known lastname **] list, pulmonary hypertension who
presents from home with fevers and hypotension. Per his mother
he was in his usual state of health until the afternoon of
presentation. He walked around the house this afternoon and
watched tv. She noticed that his forehead was hot at around noon
and took his temperature and it was elevated at 103. He did not
have any specific complaints. Since his most recent
hospitalization for hepatorenal syndrome his only medication
change has been restarting lasix. He had a therapeutic
paracentesis on [**2148-6-18**] with removal of 8.5 liters of fluid. He
has been taking his lactulose as schedule although he had fewer
than normal bowel movements yesterday and so his dose was
increased with good effect today. He has continued on his tube
feeds for supplemental nutrition. He has not had any other
fevers. He has not been complaining of cough, shortness of
breath, nausea, vomiting, abdominal pain, dysuria, hematuria or
leg pain. His lower extremity edema is at baseline. All other
review fo systems negative in detail.
.
In the ED, initial vs were: T: 103.0 P: 140 BP: not detectable
R: 26 O2 sat 93% on RA. He received 4 liters of normal saline
for resuscitation. Lacatate was elevated at 6.7 with normal pH.
His creatinine was 1.8 from baseline of 1.4. WBC count was 12.0
with 14% bands. Total bilirubin was slightly elevated from
baseline at 12.2. He had a CXR which showed very small lung
volumes but no definite acute process. He had a diagnostic
paracentesis without evidence of SBP. He received vancomycin and
ceftriaxone. He received 60 meq of potassium. He had blood and
urine cultures sent. He was transferred to the MICU for further
management.
.
On arrival to the MICU he is confused but has no complaints. He
is alert and talkative.
Past Medical History:
- End Stage Liver Disease [**1-22**] alcohol and hepatitis C. Currently
on the [**Month/Day (2) **] list. Course complicated by recurrent ascites,
SBP, pulmonary hypertension. Currently on the [**Month/Day (2) **] list
(s/p aborted liver [**Month/Day (2) **] given elevated pulmonary pressures
in OR [**2148-2-28**])
- Spontaneous bacterial peritonitis early [**7-27**] on Cipro
prophylaxis
- Grade II esophageal varices
- Recurrent hepatic encephalopathy on vegetarian diet
- Pulmonary hypertension
- Hypothyroidism
- Anxiety disorder
- History of alcohol and IVDU
- Osteoporosis of hip and spine per pt
- Anemia with history of guaiac positive stool
Social History:
He lives with his mother. Remote history of smoking [**12-23**] ppd.
Quit drinking 11 years ago. Prior history of IVDU as a teenager.
Family History:
Mother with diabetes and hypertension. Father with rheumatic
heart disease.
Physical Exam:
In MICU:
Vitals: T: 98.3 BP: 88/41 P: 118 R: 18 O2: 98% on RA
General: Alert, oriented to [**Hospital1 18**], not time
HEENT: Sclera icteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, + fluid wave, no rebound
tenderness or guarding
GU: foley draining dark urine
Ext: warm, well perfused, unable to appreciate pulses, 3+ lower
extremity edema, + clubbing, no cyanosis
Neurologic: + asterixis
Skin: + jaundice
Rectal: Guaiac negative in emergency room
On the floor:
Physical Exam:
Vitals: T: 97.3 BP:105/70 P:78 R:18 O2: 93% RA
General: Alert and Oriented x 3, Conversant with some mild
slowing of speech. Ill appearing. NAD
HEENT: Sclera Icteric, MMM, oropharynx clear, Dobhoff placed
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Distended with tense ascites, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, impressive
umbilical hernia.
Ext: warm, well perfused, 3+ pitting edema to the knees
bilateral lower extremity.
Skin: Stasis dermatitis bilateral lower extremity. Jaundiced.
Neuro: CN II-XII intact, +Asterixis
Pertinent Results:
[**2148-6-26**] 07:00PM BLOOD WBC-12.0*# RBC-2.80* Hgb-8.6* Hct-25.9*
MCV-93 MCH-30.6 MCHC-33.0 RDW-22.5* Plt Ct-64*
[**2148-6-26**] 07:00PM BLOOD Neuts-72* Bands-14* Lymphs-2* Monos-12*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2148-6-27**] 02:38AM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-1+
Macrocy-2+ Microcy-3+ Polychr-OCCASIONAL Ovalocy-1+ Schisto-1+
Burr-2+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 24904**]
[**2148-6-26**] 08:22PM BLOOD PT-27.5* PTT-48.6* INR(PT)-2.7*
[**2148-6-26**] 07:00PM BLOOD Glucose-100 UreaN-28* Creat-1.8* Na-137
K-2.9* Cl-95* HCO3-25 AnGap-20
[**2148-6-27**] 02:38AM BLOOD Calcium-8.3* Phos-2.0* Mg-1.8
[**2148-6-26**] 07:00PM BLOOD ALT-17 AST-78* CK(CPK)-675* AlkPhos-131*
TotBili-12.2* Albumin-3.3* Lipase-80* Ammonia-48*
[**2148-6-27**] 03:26AM BLOOD Temp-38.2 pO2-28* pCO2-46* pH-7.37
calTCO2-26
[**2148-6-26**] 07:13PM BLOOD Lactate-6.7*
.
Microbiology:
[**2148-6-26**]: PERITONEAL CULTURE: No Growth.
[**2148-6-26**] 7:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN = Sensitive , MIC OF <=0.12 MCG/ML.
ENTEROCOCCUS SP..
ISOLATE SENT TO [**Hospital1 4534**] LABORATORIES FOR FURTHER
IDENTIFICATION
[**2148-7-1**].
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
SENSITIVE TO Daptomycin (MIC: 0.5MCG/ML).
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 16 R
CLINDAMYCIN----------- S
DAPTOMYCIN------------ S
ERYTHROMYCIN----------<=0.25 S
LINEZOLID------------- 2 S
PENICILLIN G----------<=0.06 S 8 R
VANCOMYCIN------------ <=1 S I
Anaerobic Bottle Gram Stain (Final [**2148-6-27**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19840**] #[**Numeric Identifier 77608**] AT 0740, [**2148-6-27**].
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final [**2148-6-27**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
.
URINE CULTURE (Final [**2148-6-28**]): NO GROWTH.
.
Imaging:
[**2148-6-26**] CXR: Low lung volumes without definite acute process.
.
[**2148-6-27**] CXR: An AP portable supine chest radiograph is compared
to [**2148-6-26**]. Nasogastric tube terminates within the stomach,
as before. The lung volumes are overall improved, but remain
low. The cardiomediastinal contours are stable. There are no
focal areas of consolidation
.
[**2148-6-27**] Lower Extremity Doppler: 1) No DVT. 2) Left-sided
medial popliteal fossa ([**Hospital Ward Name 4675**]) cyst.
.
[**2148-6-27**] Abd Ultrasound: 1. Hepatopetal and patent main portal
vein.
2. Cirrhotic liver with gallbladder wall edema and distention.
This might be related to third spacing, chronic liver disease,
and enteric status--please correlate clinically as to whether
there is abdominal pain which may be attributable to the
gallbladder.
.
[**2148-6-27**] TTE: No valvular vegetations seen. Mild symmetric left
ventricular hypertrophy with preserved global and regional
systolic function. Borderline right ventricular systolic
function. Mild to moderate mitral regurgitation. Mild pulmonary
hypertension.
.
[**2148-7-3**] TEE: The left atrium is normal in cavity size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). 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
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: Mild mitral regurgitation with normal valve
morphology.
.
[**2148-7-3**] CT abd/pelvis:
1. Large volume abdominal ascites, similar in appearance to
study from [**1-2**], 09.
2. Mildly distended gallbladder containing innumerable stones,
but no
gallbladder wall thickening to suggest acute cholecystitis. If
this is a
concern nuclear medicine hepatobiliary scan would likely be the
best test.
3. Air in the nondependent portion of the bladder, would
recommend
correlation with recent Foley instrumentation.
4. No bowel obstruction or small bowel abnormality. Mild colonic
ileus with
fluid, which could reflect diarrhea.
.
Brief Hospital Course:
42 year old male with a history of end stage liver disease on
the [**Month (only) **] list, pulmonary hypertension who presents from
home with fevers and hypotension.
Sepsis with Group B strep and Enterococcus Avium: Unclear
etiology. Patient presents with fevers, tachycardia, hypotension
in the setting of end stage liver disease. WBC count of 12.0
with 14% bands. Urinalysis negative. No evidence of SBP on
paracentesis. Urine culture negative. Blood cultures with 4/4
bottles GPC initially. He initially received 5 liters of normal
saline for reuscitation and this was switched to albumin and
blood in the MICU. He was started on vancomycin and ceftriaxone
in the emergency room and this was switched to vancomycin and
cefipime. He never required pressors or central line placement.
His blood pressures improved to 100s systolic which is his
baseline. He continued to have poor urine output 20-30 cc/hr
and was treated with albumin. Lactate was initially elevated at
6.7 and this trended down to normal. When cultures grew Group B
Streptococcus, cefipime was discontinued and he was receiving
only vancomycin via PICC line. On [**2148-7-2**], blood cultures were
also preliminarily growing Enterococcus avium, a rare organism
found predominantly in the GI tract. TEE was negative for
vegitations. CT abdomen/pelvis was negative. Colonoscopy was
negative and no source of GI etiology of bacteremia was found.
Because the enterococcus organism had only intermediate
sensitivity to vancomycin, Mr. [**Known lastname 19420**] was switched to linezolid
600mg [**Hospital1 **] for a one month course (until [**2148-8-2**]). One month
course was recommended by ID since no etiology of bacteremia had
been found. He will follow up with ID on [**2148-7-22**]. Platelet
counts must be followed as linezolid can cause thrombocytopenia
after 2 weeks. He will have weekly CBC's checked. He will
follow up in hepatology [**Date Range **] clinic on [**2148-7-10**].
EKG Changes: No complaints of chest pain or shortness of breath.
Likely related to demand in the setting of profound tachycardia
and hypotension. His CKs were elevated on presentation with
flat MBs and troponins. Repeat EKG was improved. CKs trended
down. During colonoscopy, Mr. [**Known lastname 19420**] had runs of SVT with no
electrolyte changes. He was monitored overnight after
colonoscopy and had no further telemetry events.
Hepatorenal Syndrome: Recent admission for acceleration of
hepatorenal syndrome requiring octreotide and midodrine with Cr
of 3.8. He had mild worsening creatine likely secondary to
hyperperfusion in the setting of infection. No evidence of GI
bleeding or peritonitis. He was given daily albumin 1 gram/kg
for 72 hours and continued on octreotide and midodrine. His
diuretics were held throughout hospitalization. Post
paracentesis 50grams of albumin was given. On discharge,
creatinine was 1.2. Mr. [**Known lastname 19420**] had not been discharged on
diuretics, but was later called on the day of discharge and told
to restart diuretics.
Pulmonary Hypertension: Pulmonary artery pressures on recent TTE
were 35 mmHg but recent right heart catherization with mean PA
pressures of 33 with PCWP 16. Of concern was the finding of mild
RV dilitation. His case was considered carefully by the
[**Known lastname **] committee and he is currently listed for [**Known lastname **].
He was continued on iloprost.
Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse
and hepatitis C. Currently on [**Known lastname **] list. No evidence of
SBP on paracentesis from emergency room. He was encephalopathic
on arrival but this has improved with IV hydration. He was
continued on lactulose, rifaximin, midodrine and octreotide.
His diuretics were held during hospitalization. Ciprofloxacin
was restarted after cefepime was stopped.
Anemia: Baseline hematocrit in mid 20s. On admission his
hematocrit was stable at 25.9 but this decreased to 18 on
hospital day two after 5 L IVF without signs of active bleeding.
He received two units of packed red blood cells with stable
hct. His stools were guaiac negative. He was continued on his
home PPI.
Hypothroidism: He was continued on synthroid.
Code Status: Full.
Communication: [**Name (NI) **] [**Name (NI) 19420**] (mother, health care proxy)
[**Telephone/Fax (1) 77606**], [**Telephone/Fax (1) 77607**]
Disposition: pending clinical improvement
Medications on Admission:
Clotrimazole 10 mg Troche 5X/DAY (5 Times a Day).
Ursodiol 600 mg daily
Miconazole Nitrate powder TID
Levothyroxine 88 mcg daily
Rifaximin 400 mg TID
Simethicone 80 mg QID
Zinc Sulfate 220 mg daily
Cholecalciferol 800 mg daily
Calcium Carbonate 1250 mg daily
Omeprazole 20 mg daily
Iloprost 10 mcg/mL nebulization Q4H
Ciprofloxacin 500 mg daily
Midodrine 10mg TID
Lactulose 30-60mL QID (> 6 BMs per day)
Octreotide 100 mcg Q8H
Codeine Sulfate 15-30 mg PO Q12H:PRN
Lasix 40 mg daily
Magnesium Oxide 400 mg [**Hospital1 **]
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
five times a day.
2. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Iloprost 10 mcg/mL Solution for Nebulization Sig: One (1)
inh Inhalation every four (4) hours.
12. Midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. Codeine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q12H PRN as
needed for pain.
14. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO QID (4 times
a day): titrate to 6+ BM's per day.
15. Octreotide Acetate 100 mcg/mL Solution Sig: One (1)
injection Injection Q8H (every 8 hours).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
17. Linezolid 600 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 28 days: Please continue until [**2148-8-2**].
Disp:*56 Tablet(s)* Refills:*0*
18. Outpatient Lab Work
Please check CBC, Chem 10, ALT, AST, [**Name (NI) 3539**], INR, PT, PTT on
Monday, [**2148-7-8**]
PATIENT WAS INSTRUCTED TO RESTART LASIX 40MG DAILY VIA
TELEPHONE, POST-DISCHARGE ON [**2148-7-6**].
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Sepsis
2. Hepatorenal Syndrome
3. Hepatic encephalopaty
SECONDARY DIAGNOSES:
1. Pulmonary Hypertension
2. End Stage Liver Disease secondary to ETOH abuse and Hepatitis
C
Discharge Condition:
Mental Status back to baseline per mother. Afebrile. Systolic
Blood pressures 90's to 100's. Other vital signs stable.
Discharge Instructions:
You were admitted to [**Hospital1 **] hospital on [**2148-6-26**]
with fevers and low blood pressure. You were in the medical
intensive care unit, where you received albumin and blood
products. You had bacteria growing in your blood so you were
started on antibiotics. You are on linezolid, and you will need
to continue this antibiotic until [**2148-8-2**].
Ultrasound pictures of your calves and abdomen were taken. There
was no evidence of a clot. We also did an echocardiogram of
your heart, which showed not clots on your heart valves.
We took cultures of your urine and the fluid in your abdomen,
but there was no bacteria growing in either of these yet. On
the chest X-ray, there was no sign of pneumonia. There was no
source in your GI tract when we did a CT scan, so we did a
colonoscopy to take a closer look. It is unclear what the source
of the bacteria in your blood is at this point.
While you were in the hospital, there were some changes on your
EKG (heart tracing). We tested your heart enzymes, which showed
that you were not having a heart attack, and your EKG changes
resolved when repeated. You had some abnormal rhythm on the
heart monitor while you had your colonoscopy, but it resolved.
Your kidney function was somewhat decreased while you were in
the hospital. It is now resolved. Your kidney failure is due
to your liver failure.
You are currently on the liver [**Month/Day/Year **] list.
The following changes have been made in your medications:
-START taking ciprofloxacin 500mg every 24 hours.
-START taking linezolid 600mg twice a day until [**2148-8-2**].
You will have outpatient lab work done every week.
You should continue tube feedings via bridled nasal tube. VNA
services will assist you with tube feedings. Continue a low
protein, vegetarian diet. Continue to take in less than 2 grams
of sodium per day.
You must take daily weights. If you gain >3 lbs weight over a
few days, you must call your doctor.
Please return to the ER or call your doctor if you experience a
change in mental status, confusion, dizziness, shortness of
breath, weight gain, chest pain, fevers/chills, abdominal pain,
or any other symptoms that are concerning to you.
Followup Instructions:
You have the following appointments:
1. Provider: [**Name10 (NameIs) **] [**Hospital **] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2148-7-10**] 11:40am
2. PCP [**Name Initial (PRE) 2169**]: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (an associate of Dr. [**First Name (STitle) 6330**]
[**Telephone/Fax (1) 46571**]. You have an appointment scheduled [**2148-7-9**]
at 11:10am.
|
[
"2859",
"2449"
] |
Admission Date: [**2137-10-19**] Discharge Date: [**2137-10-29**]
Date of Birth: [**2066-1-22**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycodone
Attending:[**First Name3 (LF) 11839**]
Chief Complaint:
Worsening jaundice, pneumonia
Major Surgical or Invasive Procedure:
ERCP on [**2137-10-17**] with stent placement
History of Present Illness:
PCP [**Name Initial (PRE) 7274**]: [**Name10 (NameIs) **],[**Name11 (NameIs) **]
Location: [**Location (un) **]-[**Location (un) **] PRIMARY CARE
Address: [**Street Address(2) **] STUITE 212, [**Location (un) **],[**Numeric Identifier 40624**]
Phone: [**Telephone/Fax (1) 13266**]
Fax: [**Telephone/Fax (1) 67271**]
71F with PMH of colon CA s/p partial colectomy in [**5-/2137**], on
chemotherapy
since [**Month (only) 216**], who recently developed acute cholecystitis and
underwent a CCY [**2137-10-14**]. Post-op course complicated by increased
LFT's. She was sent here for ERCP on [**2137-10-17**]. ERCP performed,
showing CBD stones. Sphincterotomy was deferred due to
coagulopathy (elevated INR to 1.8), but biliary stent was placed
successfully. The patient was transferred back to the [**Hospital1 3325**]. However, since returning her LFTs had not improved,
was sent to [**Hospital1 18**] on [**2137-10-19**] for possible repeat ERCP.
Additionally, her coagulopathy has persisted, for unclear
reasons. Bilirubin 4->6, AST/ALT elevated, alk phos normal.
She has also been mildly anemic but no overt signs of bleeding.
Dr. [**Last Name (STitle) 63834**] (surgeon) and her oncologist did not feel these
abnormalities were related to her surgery or chemotherapy.
Thus, she returns for further evaluation. Of note, she was
diagnosed with a LUL PNA, and broadened to Vanco/Zosyn for
possible biliary infection plus HCAP. She has also been given 2
units FFP for her coagulopathy and possible need for repeat
ERCP, as well as 2 units PRBCs. She did have a ? rectal temp of
102.
On admission she complains of fatigue/weakness and shortness of
breath with cough. The nebulizers help, though the albuterol
makes her shaky. She endorses a recent BM with flatus.
Review of systems: 10 point ROS negative except as listed above
Past Medical History:
Colon cancer, stage IIIb on adjuvant chemo with FOLFOX-6
Partial colectomy [**6-3**]
s/p CCY [**2137-10-16**]
Hypertension
Social History:
Indpendent, cares for a blind child. No recent tobacco or
alcohol use
Family History:
Sister with history of [**Name (NI) 87245**] [**Doctor First Name **] na ddeceased of a
stroke
Father also history of a myeloproliferative disorder.
Physical Exam:
VS: T 98.4, BP 136/76, HR 94, RR 22, 93% 3L
Gen: thin, jaundiced, tired appearintg
HEENT: EOMI, icteric sclera, MM dry
Neck: supple no LAD
Heart: RRR no m/r/g
Lung: bibasilar fine crackles with poor effort. No clear wheeze
Abd: distended, soft diffusely TTP, no rebound or guarding, + BS
Ext: warm and well perfused
Skin: jaundiced
Neuro: no focal deficits grossly
Pertinent Results:
CXR [**10-16**]: No acute processes
CXR [**10-19**]: LUL airspace opacity, atelectasis of bases
RUQ US [**10-16**]: cholelithiasis with mild dilated CBD. Small amount
free fluid.
CT ABD [**10-16**]: Acute cholecystitis, diverticulosis
WBC 4.1, Hct 36.6, Plt 189
Neut: 66, Band 5
INR 1.29, PTT 29.1
Na 1326, K 3.2, BUN 3, Cr 0.79, Ca 8.6, T bili 4.9->6.4, D bili
2.9, Alk phos 105, AST 111->92, ALT 118->108
[**Month/Year (2) **] cx [**10-17**]: NGTD
Urine cx [**10-18**]: Negative
-
urine and [**Month/Year (2) **] cultures: [**2137-10-28**] no growth, final results
pending on discharge.
-
Labs on discharge:
[**2137-10-29**] 07:05AM [**Month/Day/Year 3143**] WBC-10.7 RBC-4.89 Hgb-11.7* Hct-36.9
MCV-76* MCH-24.0* MCHC-31.8 RDW-22.8* Plt Ct-564*
[**2137-10-29**] 07:05AM [**Month/Day/Year 3143**] Glucose-149* UreaN-17 Creat-1.1 Na-136
K-4.8 Cl-101 HCO3-24 AnGap-16
[**2137-10-29**] 07:05AM [**Month/Day/Year 3143**] ALT-26 AST-36 LD(LDH)-257* AlkPhos-190*
TotBili-0.8
[**2137-10-28**] 05:13AM [**Month/Day/Year 3143**] proBNP-415*
[**2137-10-29**] 07:05AM [**Month/Day/Year 3143**] Calcium-9.7 Phos-4.0 Mg-2.1
CHEST CTA [**2137-11-22**]:No evidence for pulmonary embolus.
No mediastinal, hilar, axillary or internal mammary adenopathy.
There is a left-sided Port-A-Cath, its tip is identified within
the SVC.
There is a small pericardial effusion measuring maximum
thickness anteriorly
of 5 mm (series 2, image 35).
There are small bilateral pleural effusions.
Evaluation of the lung parenchyma demonstrates marked thickening
of the
interlobular septae with ground glass change identified within
the superior
segments of the right lower lobe (series 2, image 21), distal
segment of the
right middle lobe (series 2, image 25) and within the superior
segment of the
lingula (series 2, image 31). Inflammatory scarring is also
identified within
the superior segment of the left upper lobe. This is actually
unchanged when
compared to chest radiograph from [**2137-10-24**].
Findings most likely represent intercurrent infection. Other
differentials
include edema, and less likely hemorrhage. No pulmonary masses
or nodules.
Evaluation of the upper abdomen demonstrates pneumobilia within
the left lobe
of the liver with surgical clips identified in the gallbladder
fossa, and
plastic stent is noted in a decompressed CBD.
CT OSSEOUS SKELETON:
Evaluation of the bony skeleton shows multilevel degenerative
changes in the
dorsal spine with relative osteopenia of the bony skeleton
without osseous
destructive lesion.
IMPRESSION:
1.Negative study for CTPA.
2.Bilateral hazy ground-glass change consistent with
intercurrent infection or
resolving pulmonary edema. 3.Small bilateral effusions.
RUQ U/S [**2137-10-29**]:FINDINGS: There are no focal hepatic lesions.
There is pneumobilia
predominantly in the left lower lobe, as expected after ERCP.
Patient is
status post cholecystectomy with surgical clips and minimal
amount of fluid in
the gallbladder fossa. There is no intra- or extra-hepatic
biliary duct
dilatation with the common hepatic duct measuring 4 and the
common bile duct
measuring 7 mm. A biliary stent is seen in the common bile duct.
There is no
evidence of common bile duct stones, however evaluation with
ultrasound is
limited. The pancreas is only partially visualized secondary to
overlying
bowel gas, but appears normal. The portal vein is patent with
normal
hepatopetal flow. The right kidney measures 9.6 cm, the left
kidney measures
10.1 cm. The abdominal aorta is normal. There is no free fluid.
IMPRESSION:
No evidence of intra- or extra-hepatic biliary dilatation.
CXR [**2137-10-28**]
FINDINGS: In comparison with the study of [**10-24**], there is some
decrease in the
opacification in the right mid and lower lung zones, most likely
representing
some decreasing atelectasis in a patient with improved degree of
inspiration.
Pulmonary vascularity is essentially within normal at this time.
Central
catheter remains in place.
Brief Hospital Course:
71 yr/o F w/ stage IIIb colon Ca s/p partial colectomy in [**Month (only) 116**]
[**2137**], on adjuvant chemo since [**Month (only) **] who recently underwent a lap
chole and ERCP for cholecystitis with CBD stones presented with
increase in liver function tests, LUL opacity concerning HAP,
and fever. Early on admission was transfered from floor to ICU
for tachypnea and hypoxia.
.
# Tachypnea with hypoxia: likely [**2-26**] to fluid overload based on
CXR which showed vascular congestion and diffuse bilateral
opacities and exam with anterior crackles/wheezing and abdominal
rounding; also may be due to underlying PNA however it was
difficult see definite opacity in LUL described at OSH due to
volume overloaded on initial examination.
DX: BNP 6219, CE negative x 1, Sputum Cx contaminated, urine
legionella antigen is negative. Treated with nitro ointment TP
0.25 in to venodilate and reduce preload/afterload. Patient was
aggressively diuresed with furesomide with electrolytes repleted
as needed. Treated with Vanco/Zosyn/Cipro for emperic Tx of HAP
(total 8 day course, continued through [**10-25**]). Given
Xopenex/ipratropium nebs. Tachypnea with hypoxia improved
throughout ICU stay. She was transferred to [**Hospital1 **], and 8 day
course of empiric therapy completed. She conitued diureses with
oral furesomide with continued negative fluid balance and
electrolyte monitoring. Respiratory status significantly
improved but patient still slightly tachypneac after walking. O2
sats after walking did decrease to 88% and patient is discharged
with 2 lit O2 per NC as needed for activity.A CTA was done and
there was no evidence a pulmonary embolus. Pulmonary was also
consulted and agreed that sob most likely secondary to edema an
drecommended to continue diureses. Of note , patient received
[**Hospital1 **] products at [**Hospital3 3583**] prioir to transfer, exact
timing is not clear , however, the diagnosis of TRALI is a
possibilty that is currently being investigated at [**Hospital1 **].
# Transaminitis with elevated Tbili: Likely [**2-26**] to recent CBD
stones with bypass stent by ERCP on [**10-17**]. Improved with
stenting. Repeat ruq u/s prior to duscharge showed that th eCBD
was patent and no evidence of obstruction. Repeat ERCP planned
for [**2137-11-28**].
.
#Diarrhea: Pt did develop diarhhea during hospital course. C
Diffx3 were negative. Diarrhea did improve with cessation of
antibiotics. A low lactose and low residue diet is recommeded ,
repeat stool cultures should be done if diarhhea persists.
.
# Right portacath: Was removed and a left was placed [**2137-10-22**] due
to problems drawing [**Name2 (NI) **]. New portacath works well when
patient is lying flat.
.
#Thrombocytosis: Plt count was in normal range until two days
prior to discharge. A repeat work-up for an infectious process
was done and non-revealing. Patinet did note that she has a
history of thrombocytosis that was never investigated or treated
. She also has a family history significant for
myeloproliferative disorders. If plts remain high a work-up
should be done. Pateint was on a low dose aspirin at home and
should continue. Other cell counts remained stable an dpt di
drequire repeat [**Name2 (NI) **] transfusions during hospiatl course.
Medications on Admission:
Home:
Aspirin not taking
HCTZ 25mg daily
Fluoxetine 40mg daily
Simvastatin 20mg daily
Fish oil supple
Eye drops
TransferL
Zosyn 3.375g IV q8
Vancomycin 1g IV q12
Ranitidine 50mg IV q8
HCTZ 25mg daily
Benadryl 25mg IV q6prn
Tylenol 650-1000mg q6 prn
Lorazepam 1mg q6prn
Milk of Mag
Zofran 4mg IV q6 prn
Reglan 10mg IV q4 prn
Morphine 4mg IV q30 min prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever: limit 2 grams per day.
2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. oxygen
2lit per nasal cannula with exertion as needed to maintain
satutaration 90% or above.
8. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center - [**Location (un) 3320**]
Discharge Diagnosis:
Primary Diagnosis:
heart failure, diastolic
health care associated pneumonia
choledocolithiasis
biliary obstruction
thrombocytosis
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 pneumonia and a biliary
tract obstruction as well as pulmonary edema (fluid in your
lungs).You received a course of broad spectrum antibiotics nad
also diuresed with significant improvement in your shortness of
breath. Evaluation prior to admission your oxygen saturation did
go dowm after activity and therefore we are prescribing oxygen
for you to use as needed.Most likely you will not be needing the
oxygen for a long time. Please take your medications as
directed.
Followup Instructions:
Please follow up with the PCP at the rehab facility. You should
have labs drawn to check a cbc to follow plt count and
electrolytes to asses any need for potassium supplements and
renal function. Your respiratory status and weight should be
followed to titrate furesomide dose.
Department: DIGESTIVE DISEASE CENTER
When: THURSDAY [**2137-11-28**] at 1:30 PM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], 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
If you would like to be set up with a new primary care physician
here at [**Hospital1 18**] after you leave rehab, you can call the Find-A-Doc
line at [**Telephone/Fax (1) 5867**] and someone will be able to help you with
that.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2137-11-6**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
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 [**2137-11-6**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3751**], 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
Please have your oncology records sent to Dr. [**Last Name (STitle) 1852**]. They can
be faxed to [**0-0-**]. Please have this done before your
appointment on [**11-6**].( request to have medical records
transfered to Dr [**Last Name (STitle) 1852**] was faxed to [**Hospital1 **] [**Hospital 87246**] medical
records)
|
[
"486",
"5180",
"4280"
] |
Unit No: [**Numeric Identifier 69859**]
Admission Date: [**2129-8-10**]
Discharge Date: [**2129-10-24**]
Date of Birth: [**2129-8-10**]
Sex: F
Service: NB
REASON FOR ADMISSION:
1. Prematurity (27 and [**5-1**]-week gestation).
2. Respiratory distress syndrome
MATERNAL HISTORY: Mother is a 31-year-old G1/P0-1 with [**Last Name (un) **]
[**2129-11-4**] by IVI dating, PNS: A+, antibody negative,
RPR NR, rubella immune, HBS antigen negative, GBS unknown.
Her prenatal ultrasound scan revealed an intracardiac
echogenic focus in twin A; follow-up scan showed less
prominence of this. Fetal surveys were otherwise within
normal limits. Mother developed cervical dilatation,
effacement and preterm labor at 23 weeks gestation and was
treated with bedrest and magnesium sulfate. She was treated
with betamethasone at the end of [**Month (only) 205**].
DELIVERY COURSE: Baby girl [**Known lastname 69860**] was born as twin I by C-
section for preterm labor with twin pregnancy. She was noted
to be crying after some stimulation. Bulb suction and
supplemental oxygen were given with CPAP. The baby was then
intubated because of inconsistent respiratory effort and
reduced air movement. She was transferred to the NICU in view of
prematurity and RDS.
PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature
96.2 (increased to 97.7 with warming blanket), heart rate
160, respiratory rate 45, blood pressure 45/30 (35), oxygen
saturation 91%, weight 945 grams (25th percentile), length
28.5 cm (75th percentile), head circumference 25.5 (20th
percentile). SKIN: Baby appeared bruised on the right side of
her face, entire right arm and axilla. HEENT: Anterior
fontanelle soft and flat, faces normal,
palate intact. RESPIRATORY: Breath sounds with coarse high-
pitched rhonchi initially, improved after surfactant, mild
retractions. CVS: S1/S2 normal, no murmur, perfusion fair.
ABDOMEN: Soft with no organomegaly. GU: Normal AGA female
with prominent clitoris and labia minora. NEURO: Tone good,
symmetrical exam, hips stable.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
A. RESPIRATORY: The initial respiratory course and chest x-ray
findings were consistent with respiratory distress syndrome. She
was intubated soon after birth and received 2 doses of
surfactant. She was successfully extubated to CPAP on day #2
and subsequently to nasal cannula oxygen by day of life #5.
She remained in nasal cannula oxygen for the subsequent 3 to
4 weeks and has been breathing in room air since day of life
#39. She also had apnea of prematurity needing caffeine.
Caffeine was discontinued on day of life #29. Since then she
has had no significant apnea. At the time of discharge, she
has been comfortably breathing in room air and free of
significant apnea or bradycardia for more than 1 week.
B. CARDIOVASCULAR: She was noted to have an
echocardiographically-confirmed patent ductus arteriosus, for
which she received 1 course of indomethacin. Repeat
echocardiogram on [**8-16**] showed no PDA.
C. FLUIDS, ELECTROLYTES, NUTRITION: She received parenteral
nutrition for the first 5 days of life. Breast milk was
introduced on day of life #6 and gradually advanced to a
maximum of 150 mL/kg/day of breast milk 30 calories per ounce
feed by day of life #20. The caloric supplement was weaned
in keeping with her good weight gain. At the time of
discharge, she is on ad lib p.o. feeds of breast milk
24/Similac 24 and is taking approximately 150 mL/kg/day.
Discharge weight 3000 grams, head circumference 35.5 cm, length
46 cm.
D. GI: No complications. She received phototherapy for
physiologic jaundice exaggerated by prematurity with a
maximum bilirubin of 7.3/0.3 on day of life #9.
E. HEMATOLOGY: No complications. She did not receive any blood
products during her stay.
F. INFECTIOUS DISEASE: She received an initial 48-hour course
of IV antibiotics for sepsis rule out. She did not have any
episodes of proven sepsis. She received hepatitis B immunization
on [**9-9**] and her two-month immunization course including
DTaP/IPV/HepB (pediarix), HIB, and pneumococcus.
G. NEUROLOGY: Cranial ultrasound scan [**8-17**] normal;
[**9-9**] normal.
H. AUDIOLOGY: Passed newborn hearing screen.
I. OPHTHALMOLOGY: She had stage I ROP on the right side
which has gradually resolved. At the time of discharge,
she has immature retinae zone 3 bilaterally. Follow-up
eye exam is scheduled in 3 weeks.
J. PSYCHOSOCIAL: No concerns.
CONDITION ON DISCHARGE: Well.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **];
telephone # ([**Telephone/Fax (1) 69861**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge: Ad lib p.o. feeds of breast milk
24/Similac 24.
2. Medications: Multivitamin 1 mL p.o. once
daily, ferrous sulfate 0.5 mL p.o. once daily.
3. Car seat position screening passed.
4. State newborn screening done on [**2129-8-14**]; [**8-10**], [**2128**]. The latest newborn screening is within normal
limits, and a full report awaited.
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,
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.
FOLLOW-UP APPOINTMENTS SCHEDULED OR RECOMMENDED: With
primary care pediatrician 1 to 2 days following discharge.
DISCHARGE DIAGNOSES:
1. Prematurity (27 and [**5-1**]-week gestation).
2. Respiratory distress syndrome.
3. Apnea of prematurity.
4. Hyperbilirubinemia.
5. Patent ductus arteriosus.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Doctor Last Name 69862**]
MEDQUIST36
D: [**2129-10-24**] 15:55:23
T: [**2129-10-24**] 17:06:38
Job#: [**Job Number 69863**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2101-5-13**] Discharge Date: [**2101-6-7**]
Date of Birth: [**2101-5-13**] Sex: F
Service: Neonatology
HISTORY: The patient, twin girl #1, is the daughter of a 35-
year-old G4, P1, now 3, mother with estimated date of
delivery [**2101-6-18**]. Prenatal labs, A+, antibody negative,
RPR nonreactive, rubella immune, hepatitis B surface antigen
negative. Pregnancy was notable for twin gestation with twin
1, this twin, being intrauterine growth restricted at 3% of
predicted size for gestational age. Twin 2, weight and growth
were within normal limits. The mother did have gestational
diabetes, received insulin during that time. She also had an
endometrial cyst removed at 22 weeks of gestation age. Mother
noticed contractions on [**2101-5-8**] and was admitted to
[**Hospital3 **] Medical Center at that time, without cervical
change, with discharge home on nifedipine, but her increased
up until the time of [**2101-5-12**], her cervix was noted to
be 2 cm and delivery was performed in the morning, due to
preterm labor and twin gestation on [**2101-5-13**].
Baby girl twin 1, had spontaneous cry, with Apgar's of 8 and 9,
and transferred to the NICU for prematurity.
Initial weight was 1,525 grams, which is less than 10 percentile.
Baby girl #1 weight at time of discharge 2100 grams grams, which
is less than 10th percentile. Head circumference is 33cm (25-50%)
and length of 44.5 cm (slightly less than 10%).
PHYSICAL EXAMINATION: In general, the patient is alert,
active, in no apparent distress. HEENT exam shows anterior
fontanelles soft, flat and open. Oropharynx clear with moist,
mucous membranes. Mild eye discharge that is clear.
Cardiovascular exam shows a regular rate and rhythm with normal
S1 and S2 and without murmur. Pulmonary exam shows clear breath
sounds to auscultation bilaterally without grunting, flaring or
retracting. Abdomen is soft, nontender, nondistended, with
positive bowel sounds. Genitourinary exam shows normal female
external genitalia. Extremity exam shows warm and well perfused,
with capillary refill less than 2 seconds. Neurological exam
shows moving all extremities, reactive, with normal neonatal
reflexes, such as grasp and suck.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
RESPIRATORY: Baby twin #1 never required significant respiratory
intervention and was on room air. She also did not have an
significant apnea of prematurity and never necessitated caffeine
treatment.
CARDIOVASCULAR: Baby twin #1, was never hypotensive or
required vasopressor therapy. She has been without murmur
and had stable precordium and heart rates and blood pressure
throughout entirety of stay. Stable and no concerns at this
time.
FLUID, ELECTROLYTES AND NUTRITION: The patient was started on
enteral feeds on day of life 2, and advanced to full feeds by
1 week of age. She was advanced to a maximum of 24
kilocalories per ounce of special care 24. However, since she is
still less than 10th percentile, her calories are being advanced
to 26 cal (all by Enfamil powder) on [**6-7**] on day of discharge.
Her weight should be followed closely (growth curve will be faxed
with discharge summary) and IF she continues to remain below the
10th percentile 2 weeks after discharge, pediatrician should
consider increasing to 28 calories by adding 2 cal/oz of corn
oil.
GI: The baby had a maximum bilirubin of 9.1 on day of life 4,
and underwent phototherapy for approximately 5 days, had a
rebound bilirubin of 5.4/0.3 on day of life 6.
HEMATOLOGY: The patient's initial CBC and differential were
within normal limits. Had a white count of 6.9, hematocrit of
54 and platelets of 317,000. White blood cell differential
was unremarkable for infection, showing 38 neutrophils and 0
bands, 51% lymphocytes. No antibiotics were given or
necessary during duration of stay in NICU.
INFECTIOUS DISEASE: Baby girl twin #1, was treated with a 5
day course of gentamycin eye drops empirically for persistent
eye discharge. Her sister's eye discharge grew methicillin
resistant staphylococcus aureus, which was sensitive to
gentamycin, and this patient was empirically treated with
same antibiotic given similar symptoms. Eye discharge
resolved prior to cessation of antibiotics and is minimal at
this time.
DISCHARGE DIAGNOSES:
1. Prematurity, twin
2. Infant of a diabetic mother
3. Intrauterine growth restriction, still remaining less than
10%
2. Rule out sepsis, resolved.
3. Conjunctivitis, resolved
Recommendations:
1) Feedings at discharge: Enfamil powder 26 cal/oz. As noted
above, infant's weight should be monitored closely and if remains
with fair weight gain, would increase to 28 calories in 2 weeks
by adding 2 calories/oz.
2) Medications:
a) iron supplementation 0.3 ml (25 mg/ml) po q day. Note: iron
is supplementation is recommended for preterm and low birth
weight infants until 12 months CORRECTED AGE
b) Goldine MVI 1ml po q day.
3) car seat screening passed
4) hearing screen passed
5) hepatitis B vaccine given on [**5-31**].
6) newborn screening test on [**5-26**] normal
7) other immunization recommendations: 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 Influenze is recommended
for household contacts and out-of-home caregivers.
8) This infant has not received rotavirus vaccine. The AAP
recommends initial vaccination of preterm infants at or following
discharge from the hospital if they are clinically stable and at
least 6 weeks but fewer than 12 weeks of age.
9) Follow-up appointments:
--pediatrician on Thursday, [**6-8**]--Dr. [**First Name8 (NamePattern2) 1743**] [**First Name8 (NamePattern2) 5846**] [**Last Name (NamePattern1) **]
Pediatrics
--VNA this week
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31759**], MD [**MD Number(1) 43886**]
Dictated By:[**Name8 (MD) 68276**]
MEDQUIST36
D: [**2101-6-3**] 17:14:31
T: [**2101-6-4**] 07:12:19
Job#: [**Job Number 73909**]
|
[
"7742",
"V053"
] |
Admission Date: [**2190-8-12**] Discharge Date: [**2190-9-9**]
Date of Birth: [**2124-11-5**] Sex: M
Service: SURGERY
Allergies:
Phenobarbital / Lopressor / Tegretol / Niacin / Sulfa
(Sulfonamides) / Ciprofloxacin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain, pancreatic head mass
Major Surgical or Invasive Procedure:
s/p pyelorus preserving whipple
History of Present Illness:
65M recent diagnosis of pancreatic head mass following an
admission for abdominal pain. ERCP demonstrated malignant
stricture of distal CBD and pancreatic head mass measuring 2.2 x
1.8cm.
Past Medical History:
PMH: CAD, claudication, melanoma, phlebitis, pericarditis,
ataxia, CVA x3, IDDM2, nephrolithiasis
PSH: CABGx3 4 yrs ago, melanoma resection R leg with LND,
Subclavian artery stents, coronary stent x1, B/L renal artery
stents, b/l iliac stents, R knee surgery, ERCP [**7-6**]
Physical Exam:
Discharge:
Alert and following commands; writing/communicating with
housestaff
EOM full, PERRL, anicteric sclera
Neck supple; well healing trach site w/ trach in place
Chest rhonchi throughout, but no rales, equal BS bilaterally
Heart bradycardic, but regular rhythm, no MRG
Abdomen soft NTND, NABS, Incision CDI
LE trace edema throughout, small 1x1cm ulcer on dorsum of R foot
Pertinent Results:
MICRO:
[**8-15**] and [**8-17**] sputum STAPH AUREUS COAG +.
[**8-15**] and [**8-17**] blood cx NG [**8-20**] blood neg so far
[**8-17**] urine cx NG
[**8-20**] sputum 4+ GPC IN CLUSTERS. 3+ GPR
[**8-22**] CDIFF POSITIVE
[**8-26**] Urine Cx No Growth
.
IMAGING:
[**8-15**] CXR: moderate pulmonary edema. Small bilateral pleural
effusions
TTE: Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (EF 55-60), Mild AS
(AoVA 1.2-1.9cm2). Mild (1+) AR. Trivial MR.
[**8-19**]:New bibasilar confluent lung opacities, in conjunction with
airway secretions, raising the possibility of aspiration
pneumonia, although atelectasis is an additional consideration
Mild hydrostatic pulmonary edema and very small pleural
effusions.
[**8-28**] CT abd: no evid of GOO or JJ obstruction
-------------------
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 147**] SICU-A [**2190-8-19**] SCHED
CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 79599**]
Reason: r/o PE
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with poor oxygenation
REASON FOR THIS EXAMINATION:
r/o PE
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
CTA OF THE CHEST DATED [**2190-8-19**]
INDICATION: Poor oxygenation. Clinical suspicion for pulmonary
embolism.
COMPARISON: Chest CT [**2190-8-2**].
TECHNIQUE: Volumetric, multidetector CT acquisition of the chest
was
performed following intravenous administration of 98 cc of
Optiray. Prior to this contrast-enhanced sequence, a low-dose
unenhanced scan of the chest was performed. Multiplanar
reformation images were submitted for review in conjunction with
axial images.
FINDINGS: Pulmonary vasculature is well opacified with contrast,
and
demonstrates no evidence of an acute pulmonary embolism. The
main pulmonary artery is enlarged measuring 3.4 cm in diameter.
Coronary artery
calcifications are present in the right, left main, left
anterior descending and circumflex arteries, and valvular
calcifications are also demonstrated within the aortic valve.
Heart size is normal.
Enlarging lymph nodes are present within the mediastinum,
including a 1.4 cm lower right paratracheal node, previously
measuring about 8 mm. Additionally, apparently new hilar lymph
nodes have developed. Very small bilateral pleural effusions are
also new.
Within the lungs, there are new dependent areas of confluent
opacification
with air bronchograms, involving the left lower lobe to a
greater degree than the right, and associated with mild degree
of volume loss. Widespread
emphysema is without change.
Within the airways, new secretions have developed within the
trachea and
proximal right main bronchus. A new linear and nodular opacity
has developed at the left lung apex with maximal nodular
component dimension of about 8 mm image 8, series 3).
Additionally, new smoothly marginated septal thickening has
developed diffusely.
Previously reported tiny pulmonary nodules are largely obscured
by the acute lung abnormalities that have developed in the
interval.
No suspicious skeletal lesions are identified.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Enlarged main pulmonary artery suggestive of pulmonary
arterial
hypertension.
3. New bibasilar confluent lung opacities, in conjunction with
airway
secretions, raising the possibility of aspiration pneumonia,
although
atelectasis is an additional consideration.
4. Mild hydrostatic pulmonary edema and very small pleural
effusions.
5. New small nodular opacity at left lung apex, very likely
benign
considering rapid development over a two-week period. Previously
reported
small nodules are not well assessed due to obscuration by acute
lung findings. Please see previous recommendations under prior
report (clip [**Clip Number (Radiology) 79600**]).
6. Coronary artery calcifications and aortic valvular
calcifications.
7. New enlarged mediastinal and hilar lymph nodes, likely
reactive in the
setting of presumed acute aspiration pneumonia. These can be
reassessed at
the time of the previously recommended chest CT.
8. Trace ascites and mild anasarca.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: [**Doctor First Name **] [**2190-8-19**] 4:54 PM
--------------
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 147**] SICU-A [**2190-8-28**] SCHED
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip #
[**Clip Number (Radiology) 79601**]
Reason: ?obstruction: specifically at jej-jejunostomyPO contrast
onl
[**Hospital 93**] MEDICAL CONDITION:
65M s/p pylorus preserving whipple, now bilious output from
NGT.
REASON FOR THIS EXAMINATION:
?obstruction: specifically at jej-jejunostomyPO contrast
only. Please pg [**Numeric Identifier **]
with questions.
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
CT ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION FOR STUDY: Pylorus sparing Whipple, now with bilious
output from
NG tube. Evaluate for obstruction.
TECHNIQUE: Following ingestion of oral contrast, a helical scan
was obtained through the abdomen and pelvis without use of
intravenous contrast material and images reformatted in the
axial, sagittal, and coronal planes.
FINDINGS:
ABDOMEN WITHOUT CONTRAST: Bilateral pleural effusions are
present with
bilateral lower lobe areas of consolidation. Heart is
unremarkable. A small amount of ascitic fluid surrounds the
liver. No focal mass lesions are seen in the liver. The patient
is recently post-surgery and a small amount of air is seen
within the bile ducts in the left lobe of the liver. Surgical
drains are in position around the pancreatic bed. Oral contrast
is located entirely within the stomach and in the proximal small
bowel and stomach is not distended. No extravasation of contrast
is noted. No abnormal dilatation of small bowel is identified.
No abnormal dilatation of the afferent or efferent loops is
identified. The spleen is normal in size. The patient is status
post Whipple resection with atrophy of the body and tail of the
pancreas. A large benign-appearing cyst is present in the
lateral aspect of the left kidney. The right kidney is atrophic.
The adrenal glands are unremarkable.
PELVIS WITH CONTRAST: Visualized large and small bowels in the
pelvis are
unremarkable and not dilated. Extensive vascular calcifications
are noted. No free fluid is seen in the pelvis. No enlarged
deep pelvic nodes or inguinal nodes are identified. Extensive
sigmoid diverticulosis is noted with no definitive evidence for
diverticulitis.
BONE WINDOWS: No suspicious lytic or blastic lesions are seen
within the
skeleton.
The axial, sagittal and coronal reformatted sequences
demonstrate contrast
within the stomach passing out into the proximal small bowel
with no abnormal dilatation of the bowel.
IMPRESSION: No gastric outlet obstruction and no evidence for
obstruction at the jejunojejunostomy site.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: SAT [**2190-8-28**] 8:36 PM
Brief Hospital Course:
[**8-12**]: Extubated in the OR and admitted to ICU postoperatively
following Whipple procedure. Overnight he had episodes of
hypotension requiring IVF boluses, receiving 2L to maintain MAPs
in 60s. Pain controlled with epidural by APS.
[**8-13**]: Swan changed to central line. Started carvedolol 12.5".
[**8-14**]: Hemodynamically stable and clear mental status; pt was
transferred to floor. Platelets 85; HIT panel sent, AC changed
to arixtra.
[**8-15**]: HCT 21, low UOP so pt was transfused 2 units PRBCs. During
transfusion, O2 sats dropped to 80s. Transferred to SICU with
sats 80s on NRB, intubated in SICU, diuresed. Saturations
improved following diuresis. Post transfusion HCT 27. Sputum
cx: staph aureus.
[**8-16**]: Continued on vent -pressure support, diuresis with Lasix
20 iv. HIT neg. Afib w/ RVR with mild hypotension. Amio drip
started after bolus and amio converted to PO/per J tube per
protocol. Vancomycin started.
[**8-17**]: TF started, epidural removed. Afib again with RVR and
hypotension. Cardioversion in ICU (shock x 1, 200J)
w/conversion to SR, repeat afib w RVR overnight - unsuccessful
cardioversion (cardiology involved). Amio and dilt.
[**8-18**]: CXR concerning for bibasilar pneumonia. Sputum positive
for staph aureus; TTE EF 50-55%; cont feeds, replete lytes (keep
K>4.5 and Mg>2.5), sinus rhythm - cont amiodarone IV, hold am
Vanc, insulin qtt
[**8-19**]: Bolused LR 500 for hypotension p carvedolol, CTA for PE
neg
[**8-20**]: Pt began spiking temps, pan Cx, C diff
[**8-21**]: Flagyl/zosyn started emperically, NPH increased, more
alert/awake
[**8-22**]: Blood transfusion and lasix; CDiff pos-> IV flagyl because
J tube blocked
[**8-23**]: J-tube cleared, weaned to 5+5 without difficulty
[**8-25**]: Pt extubated, but reintubated due to respiratory distress,
increased work of breathing, aggitation, PO flagyl converted to
liquid PO vancomycin.
[**8-27**]: Placed open trach after failure to wean
[**8-28**]: Concern for obstruction after bilious emesis x2 and bile
in NGT. CT abdomen negative to GOO or JJ obstruction. NGT
removed. Continued diuresis.
[**8-31**]: Lasix gtt increased to 4 - still unable to get negative
due to tube feeds and meds, converted to PO amiodarone after
evaluation by speech and swallow cleared pt for whole pills,
regular solids and thin liquids while using P-M valve.
[**9-1**]: Allopurinol for gout, bronch neg for
tracheobronchomalasia, Echo normal, started HCTZ to assist
diuresis
[**9-2**]: Diuresis stopped. Volume status euvolemic on exam. Amio
stopped due to asymptomatic bradycardia into 40s. HR up to 60s
and regular. Converted to intermittent IV lasix [**Hospital1 **].
[**9-3**]: Discharged to rehab on ventilator. Wean from vent as
tolerated. Plan to restart coreg at half home dose and titrate
up as blood pressure and pulse allow.
Medications on Admission:
allopurinol 300', xanax prn, amitriptyline 25', amlodipine 5',
wellbutrin 300', buspar 5''', coreg 6.25", pletal 50",
fluoxetine 20', folic acid, Novolog/Lantus insulin (doses
unknown), lisinopril 20', nitroglycerin prn, prilosec 20', KCL
10', zocor 20', temazepam 15', tylenol, aspirin
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
3. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoclopramide 5 mg/5 mL Solution Sig: One (1) PO QID (4
times a day).
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): start [**9-4**] in am and titrate to 6.5mg [**Hospital1 **] as blood
pressure and HR tolerate.
8. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO QID prn as needed
for anxiety.
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Insulin NPH & Regular Human Subcutaneous
11. Acetaminophen 160 mg/5 mL Solution Sig: [**12-23**] PO Q6H (every 6
hours) as needed.
12. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours).
13. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSUN (every Sunday) as needed for htn,
anxiety.
14. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
15. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for gout.
18. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO q3h as needed for
pain.
19. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] [**Location (un) 5583**] MA
Discharge Diagnosis:
pancreatic cancer
Discharge Condition:
stable on ventilator: FIO2 0.4, pressure support 5/peep 5
Discharge Instructions:
You have had major abdominal surgery, Whipple procedure with
feeding jejunostomy. If you develop fevers, chills, abdominal
pain, nausea, vomiting, difficulty breathing, copious
secretions, chest pain, or any other symptom concerning to you,
please call [**Hospital1 18**] or return to the emergency department.
You are being discharged to a rehabilitation facility that will
assist you to wean off the ventilator. You should continue to
receive tube feedings as you have in the hospital. In addition,
you may eat and take pills. Physical therapy should work with
you to improve your strength and stamina. You should get out of
bed to the chair daily with assistance.
We have discontinued some of your home medications in the
hospital. You should arrange to see you primary care physician,
[**Name10 (NameIs) **] that he/she may restart your home medications at the
appropriate time.
You should start coreg 3.25mg po bid on [**9-4**] and titrate up to
your dose prior to you hospitalization as your blood pressure
and heart rate tolerate. Then you may begin restarting your
other anti-hypertensive medications one at a time as your blood
pressure tolerates.
Followup Instructions:
Call to arrange follow up with Dr. [**Last Name (STitle) **] upon discharge from
rehabilitation center. ([**Telephone/Fax (1) 2363**].
Call to arrange follow up with your PCP upon discharge from the
hospital, while at rehabilitation.
|
[
"5845",
"5990",
"2760",
"42731",
"4280",
"4019",
"2859",
"25000",
"V4582",
"V4581"
] |
Admission Date: [**2110-7-24**] Discharge Date: [**2110-8-4**]
Date of Birth: [**2110-7-24**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: Baby girl [**Known lastname **] [**Known lastname 51583**] was
born on [**2110-7-24**] to a 36-year-old mother, [**Name (NI) **], P1, at 33 2/7
weeks gestational age via cesarean section with a birth
weight of 2,125 grams and Apgar scores of eight and eight.
Maternal prenatal screens included O positive, rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, GBS unknown. The pregnancy was essentially
unremarkable until PROM until three days prior to delivery.
The mother received a full course of betamethasone as well as
clindamycin/erythromycin for latency. She was born via a
cesarean section secondary to breech and decelerations.
There was no maternal evaluation of temperature. She had
spontaneous cry in the DR [**Last Name (STitle) **] was given blow-by 02 for delay
of pink-up. She developed occasional grunting in the DR.
PHYSICAL EXAMINATION ON ADMISSION: Weight: 2,125 (50th
percentile). Vital signs: Temperature 98.1, respiratory
rate 50s, pulse 150s, blood pressure 56/29 (37). HEENT: The
anterior fontanelle was open and flat, no cleft lip or
palate. Heart: Regular rate and rhythm. No murmur. Pulses
equal in all four extremities. Lungs: Mild retractions with
occasional grunting. Air exchange fair with slightly short
expiratory phase. Abdomen: Soft, bowel sounds present. No
mass palpable. GU: Normal external female genitalia.
Extremities: Normal tone. Moro symmetrical. No hip click.
HOSPITAL COURSE: 1. RESPIRATORY: The patient originally
had some mild grunting for which she was given some blow-by.
However, she quickly was able to be weaned off of oxygen and
remained on room air throughout her hospitalization. During
this time, she was maintained on a monitor without any
evidence of spells or desaturations.
2. CARDIOVASCULAR: [**Known lastname **] remained stable from a
cardiovascular standpoint without any concerns for
hypotension or bradycardia. She was never noted to have a
murmur present.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: [**Known lastname **] was
originally supported with IV fluids, was able to start
feeding on day of life number two. She did quite well from a
feeding standpoint and quickly advanced to all oral feedings.
At the time of discharge, she had been in-house with over
four days of oral feeding. The mother was feeding with
breast milk both by bottle and breast. Twenty-four hours
prior to discharge, she had taken in approximately 200 cc per
kilogram. Her discharge weight was 2,150, up 25 grams from
birth weight of 2,125.
4. GASTROINTESTINAL: Maximum bilirubin was reached on day
of life number six, noted to be 10.8. From that point on,
trends were all downwards with bilirubin on day of life
number seven of 10.3, day of life number 11 of 9.8. At the
time of discharge, she shows mild facial and chest jaundice
only. The mother's blood type was O positive. No blood
typing on baby was obtained.
5. INFECTIOUS DISEASE: With concerns for PROM and grunting
at delivery, a rule out sepsis was initiated. The patient
received 48 hours of ampicillin and gentamicin with negative
cultures. No additional concerns for infectious issues.
6. NEUROLOGY: No concerns for abnormal neurology
examination. In addition, the patient did not meet criteria
for a screening head ultrasound.
7. SENSORY: 1. Audiology: A hearing screen was performed
with automated auditory brain stem responses, results within
normal limits. 2. Ophthalmology: The patient did not meet
criteria for ROP examination.
8. PSYCHOSOCIAL: A [**Hospital1 18**] social worker was involved with
the family. The contact social worker can be reached at
[**Telephone/Fax (1) 8717**] if there are issues.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1022**] [**Doctor First Name 51584**], [**Telephone/Fax (1) 51585**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: Breast feeding and breast milk by
bottle ad lib.
2. Medications: Poly-Vi-[**Male First Name (un) **] 1 cc p.o. q.d., ferrous sulfate
0.2 cc p.o. q.d.
3. Car seat position screening: Passed times two hours.
4. State newborn screening: Times two sent.
5. Immunizations received: Hepatitis B on [**2110-7-30**].
6. Immunizations recommended: Synagis RSV 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. (2) Born between 32 and 35 weeks with
plans for DayCare during RSV season, with a smoker in the
household or with preschool siblings. (3) With chronic lung
disease.
FOLLOW-UP APPOINTMENTS: The patient is to be seen by PMD on
[**2110-8-5**], already scheduled.
DISCHARGE MEDICATIONS:
1. Prematurity at 33 2/7 weeks.
2. Mild hyperbilirubinemia without need for phototherapy.
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Last Name (NamePattern4) 51114**]
MEDQUIST36
D: [**2110-8-4**] 03:24
T: [**2110-8-4**] 16:17
JOB#: [**Job Number 51586**]
|
[
"7742",
"V290"
] |
Admission Date: [**2163-7-1**] Discharge Date: [**2163-7-5**]
Date of Birth: [**2086-7-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ragweed / Zocor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Coronary artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x 2(LIMA-LAD, SVG-OM) [**7-1**]
History of Present Illness:
This 76 year old white female had a stress test because of
recent fatigue. A catheterization done previously demonstrated
70% distal left main disease, 40% osteal LAD and 30% right
disease with preserved LV function(60%). She was referred for
revascularization.
Past Medical History:
hypercholesterolemia
arthritis
catarct surgeries
Social History:
denies tobacco or ETOH use.
Family History:
No premature cardiac disease
Physical Exam:
ADMISSION: WDWN IN NAD
Cor: SR @76. bp 146/76 rt,131/78LT
Lungs: clear.
Extremeties: no edema. Warm and well perfused. Sym pulses 2+.
Neuro: grossly intact.
Wt:135#, 63" in height.
Pertinent Results:
[**2163-7-5**] 05:25AM BLOOD WBC-7.3 RBC-2.77* Hgb-8.2* Hct-24.5*
MCV-88 MCH-29.6 MCHC-33.5 RDW-13.7 Plt Ct-267
[**2163-7-1**] 12:40PM BLOOD WBC-9.7# RBC-2.32*# Hgb-7.0*# Hct-20.5*#
MCV-88 MCH-30.3 MCHC-34.3 RDW-13.4 Plt Ct-223
[**2163-7-1**] 01:44PM BLOOD PT-15.0* PTT-40.3* INR(PT)-1.3*
[**2163-7-1**] 12:40PM BLOOD PT-16.4* PTT-34.3 INR(PT)-1.5*
[**2163-7-4**] 05:30AM BLOOD Glucose-94 UreaN-22* Creat-0.6 Na-138
K-4.4 Cl-103 HCO3-29 AnGap-10
[**2163-7-2**] 03:47AM BLOOD Glucose-98 UreaN-9 Creat-0.5 Na-136 K-4.3
Cl-106 HCO3-25 AnGap-9
Brief Hospital Course:
[**7-1**] Mrs.[**Known lastname **] went to the operating room and underwent
coronary artery bypass grafting x 2 (Left internal mammary
artery grafted to the left anterior descending/saphenous vein
grafted to obtuse marginal). Please refer to Dr.[**Name (NI) 5572**]
operative report for further details. Cross clamp time=44
minutes. Cardiopulmonary bypass time= 60minutes. She tolerated
the procedure well and was transferred to the CVICU in critical
but stable condition. She weaned and extubated the afternoon of
surgery and pressors weaned off.Betatblockade was begun. She
remained in the CVICU until POD#2 due to complaints of confusion
and nausea related to pain medication. Narcotics were
discontinued and her mental status cleared.All lines and drains
were discontinued in a timely fashion. She was transferred to
the step down unit for further monitoring and progression.
Physical therapy consult and evaluation was performed. The
remainder of her postoperative course was essentially
uneventful. She continued to progress and on POD# 4 she was
cleared by Dr.[**Last Name (STitle) **] for discharge to home with VNA. All follow
up appointments were advised.
Medications on Admission:
Cardizem 30mg QID
Zetia 10mg/D
ASA 81mg/D
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Lipitor 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
hypercholesterolemia
degenerative joint disease
s/p tonsillectomy
s/p catarct surgery
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14522**] in 2 weeks ([**Telephone/Fax (1) 14525**])
[**Hospital Ward Name **] 6 wound clinic in 2 weeks
please call for appointments
Completed by:[**2163-7-5**]
|
[
"41401",
"2720",
"25000",
"412"
] |
Admission Date: [**2191-10-25**] Discharge Date: [**2191-11-4**]
Date of Birth: [**2191-10-25**] Sex: F
Service: NEONATOLOGY
HISTORY OF THE PRESENT ILLNESS: Baby girl [**Known lastname **] was born at
33 and 6/7ths weeks gestation to a 38-year-old G2, P1, now 2
mother.
PRENATAL SCREENS: Blood type O positive, antibody negative,
nonreactive.
ANTEPARTUM HISTORY: History is remarkable for gestational
diabetes mellitus. The diabetes initially was diet
controlled, but later requiring insulin most likely the
result of having started terbutaline therapy.
probable abruption. She did receive one dose of
betamethasone. She was in active labor. She was allow to
deliver vaginally. Intrapartum antibiotic prophylaxis was
started nine hour prior to delivery. It was a normal
spontaneous vaginal delivery. Apgars assigned were 7 and 8
at 1 and 5 minutes respectively.
PHYSICAL EXAMINATION: Examination on admission was
remarkable for a well-appearing preterm infant with stable
vital signs. Facies was normal. Anterior fontanelle was
soft, open, and flat. She had an intact palate. There was
no grunting, flaring, or retracting. Breath sounds were
clear. No murmur was ausculted. Femoral pulses were
present. The abdomen was flat, soft, and nontender. She had
normal premature external genitalia. Hips were stable. She
had normal perfusion. Tone and activity were normal.
Blood glucose on admission was 34. She did receive IV
Dextrose bolus.
HOSPITAL COURSE: By systems.
CARDIOVASCULAR: Upon admission, the patient had stable blood
pressure and heart rate. She did have single, brief
brachycardia event with heart rate down to the 70s on day of
life #6. She has been monitored since and she has had no
further spells.
RESPIRATORY: The patient has remained stable in room air.
She initially had some brief desaturations to the upper 80s
on day of life #1, but these have subsequently resolved.
FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
initially maintained on IV fluids. However, by day of life
#1 she began bottle feeding and oral feeds were slowly
advanced. She never required gavage feeding. Birth weight
was [**2169**] grams. Discharge head circumference was 30 cm. Length
was 44 cm.
GASTROINTESTINAL: As noted above, the patient has been
tolerating PO feeds and never required gavage feeding.
HEMATOLOGY: The patient's initial hematocrit was 44.
Platelet count was 460,000. These have not been rechecked
subsequently. She was started on iron therapy on day of life
#7.
INFECTIOUS DISEASE: Blood culture was sent on admission.
Blood culture remained sterile. She was covered with
Ampicillin and Gentamicin for two days until the results of
the blood cultures were back. The initial white count was
25. Differential was 60 polys, 7 bands.
SENSORY: Audiology. Hearing screen was performed with
auditory brain-stem response. Results were the following:
Passed in both ears.
OPHTHALMOLOGY: The retinae were not examined.
PSYCHOSOCIAL: [**Hospital1 69**] social
worker was involved with the family. The contact social
worker is [**Name (NI) **] [**Last Name (NamePattern1) 36527**]. She can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35852**]. Fax: [**Telephone/Fax (1) 45695**].
Telephone #: [**Telephone/Fax (1) 43116**].
CARE/RECOMMENDATIONS:
1. Feeds at discharge: Breast milk 24 and Enfamil 24. The
patient should be taking 2 ounces every three to four hours.
2. Medications: Fer-In-[**Male First Name (un) **] 0.2 cc PO q.d.
3. Car seat position screening was performed and the baby
passed.
4. [**Name2 (NI) **] newborn screening status: Pending.
5. Hepatitis B vaccination was not given since the patient's
weight was not 2 kilograms at the time of discharge.
6. Synagis RSV 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. #2. Born
between 32 and 35 weeks and plans for day care during RSV
season, with a smoker in the household or with preschool
siblings or #3 with chronic lung disease.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Rule out sepsis.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 44694**]
MEDQUIST36
D: [**2191-11-4**] 15:21
T: [**2191-11-4**] 15:50
JOB#: [**Job Number 45696**]
|
[
"V290"
] |
Admission Date: [**2178-8-11**] Discharge Date: [**2178-8-16**]
Date of Birth: [**2140-10-25**] Sex: M
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is a 37-year-old male with
no significant past medical history who presented with the
sudden onset of left-sided abdominal pain radiating to both
the back and the left scrotum. The patient had noted fever
and nausea and had vomited eight or nine times over the few
The patient contact[**Name (NI) **] his primary care doctor who had him
come into the office, and when the patient was evaluated at
the office a blood pressure of 90/60 was obtained, and the
patient was sent to the Emergency Department.
While in the Emergency Department a urinalysis and CT urogram
with perinephric stranding with pyelonephritis. Since the
patient was hypotensive, he was treated with intravenous
fluids and was seen by Surgery and Urology, and the plan was
to treat the patient with ceftriaxone. Also while in the
Emergency Department, a blood sugar was checked and the
patient's glucose was in the 500s. The diagnosis was
diabetic ketoacidosis, and the patient was sent to the
Medical Intensive Care Unit on an insulin drip.
On further questioning, the patient admitted to symptoms of
polyphagia, polyuria, and polydipsia for the several months
prior to presentation.
PAST MEDICAL HISTORY: None.
MEDICATIONS ON ADMISSION: The patient took Motrin and
Pepto-Bismol.
ALLERGIES: There were no known drug allergies.
SOCIAL HISTORY: The patient works as a correction's officer.
He smokes approximately five to six cigarettes per day for
the last 20 years, occasional alcohol use. No drug use.
FAMILY HISTORY: Family history is positive for diabetes on
the mother's side of the family.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination temperature maximum was 99.7, blood pressure
was 95/54, heart rate was 130, respiratory rate was 20,
saturating 100% on room air. Head, eyes, ears, nose, and
throat revealed pupils were equal, round, and reactive to
light. Extraocular muscles were intact, anicteric. Mucous
membranes were dry. The neck was supple. The chest was
clear to auscultation. The heart was first heart sound and
second heart sound, tachycardic, but regular. The abdomen
was soft and nondistended, mild left lower extremity
tenderness. No rebound. No right-sided tenderness and no
rebound was noted. There was left costovertebral angle
tenderness. Rectal examination was guaiac-negative.
Extremities revealed there was no clubbing, cyanosis or
edema.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission with a white blood cell count of 30.2, hematocrit
of 39.4, and platelets were 192. PT was 17.5, PTT was 36.7,
INR was 2.1. Sodium of 130, potassium of 4.2, chloride
of 94, bicarbonate of 15, blood urea nitrogen of 31,
creatinine of 3.4, blood glucose of 577. Urinalysis was
positive for blood, protein greater than [**Telephone/Fax (1) 43249**] glucose,
and trace ketones.
RADIOLOGY/IMAGING: An echocardiogram was performed that
showed an ejection fraction of 45% to 50% with nonfocal
hypokinesis.
A CT showed no obstruction, and a left renal calculous with
left perinephric fat stranding.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit for management of diabetic
ketoacidosis and urosepsis with nephrolithiasis.
For his diabetes, the patient was maintained on an insulin
drip and treated with fluids. His glucose was monitored, and
the patient was switched from an insulin drip to NPH. While
in the Intensive Care Unit, blood cultures and urine cultures
came back positive for Citrobacter. The patient has
initially been treated with ceftriaxone, and this was
switched to levofloxacin. While on antibiotics, the
patient's hemodynamic status improved. Urology was following
the patient while on the unit. The decision was for no
intervention until the patient was more stable.
On [**8-13**], the patient was transferred to the floor to the
[**Hospital1 **] Service.
1. ENDOCRINE: The patient with new onset diabetes,
presenting with diabetic ketoacidosis. The patient was off
insulin drip and on NPH. [**Last Name (un) **] was consulted and followed
the patient regarding the new onset diabetes and made
recommendations regarding the home dose of NPH and Humalog.
Blood sugars were monitored and adjustments were made
accordingly. The patient received Learning Center training
for glucometer and teaching for insulin administration.
2. GENITOURINARY: While on the floor, the patient still had
not passed his kidney stone. Urology made the decision on
[**8-14**] to take the patient to the operating room for a
possible ureteral stent placement with stone retrieval at
this time. No stent was performed, and the stone was
retrieved. The patient's pain improved dramatically the
following day, and the patient was told to follow up with
Urology in two to four weeks.
For the pyelonephritis, the patient was maintained on the
levofloxacin and is currently completing a 14-day course.
For acute renal failure, the elevated blood urea nitrogen and
creatinine on admission, after the patient received hydration
this resolved with follow-up blood urea nitrogen and
creatinine at blood urea nitrogen of 8 and creatinine of 0.8.
3. CARDIOVASCULAR: While in the Medical Intensive Care Unit
the patient had a echocardiogram showing biventricular
dysfunction thought to be secondary to sepsis. The patient
had a repeat echocardiogram done while on the floor which
showed posterior hypokinesis. While this study was much
improved from the previous one, it was felt that the patient
still would require a follow-up transthoracic echocardiogram
as an outpatient in two weeks.
The patient had blood pressures that ranged in the 120s to
130s/80s to 100s while in the hospital and on the floor, and
the patient may need followup regarding diastolic
hypertension.
4. FLUIDS/ELECTROLYTES/NUTRITION: The patient's
electrolytes were monitored while on the floor, and repletion
of potassium and magnesium were done on an as needed basis.
On the day of discharge, the patient's potassium had
normalized to 4.7.
DISCHARGE DISPOSITION: The patient was discharged on
[**2178-8-16**].
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was discharged to home with
multiple follow-up appointments.
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis.
2. Nephrolithiasis.
3. Urosepsis.
4. Status post ureteral stone removal on [**8-14**].
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 500 mg p.o. for seven days (to complete a
14-day course).
2. Humalog sliding-scale.
3. NPH 14 units at breakfast and 10 units at bedtime.
................ alcohol swabs, insulin syringes, and glucose
tester, and glucometer prescriptions.
DISCHARGE FOLLOWUP:
1. The patient was to follow up with primary care provider
this week to repeat urinalysis and also to check blood
pressure.
2. To follow up with Cardiology for a repeat echocardiogram
scheduled on [**2178-9-1**] at 2 p.m. at the [**Hospital Ward Name 23**] Building
on the seventh floor.
3. The patient is also to follow up with Urology
(Dr. [**Last Name (STitle) 8872**] in two to four weeks. The patient was given
the telephone number to call and make an appointment.
4. The patient was instructed to follow up at [**Last Name (un) **] and to
call the day after his discharge to make an appointment for a
new-patient appointment, classes on nutrition and insulin
adjustments.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Last Name (NamePattern1) 13577**]
MEDQUIST36
D: [**2178-8-16**] 17:23
T: [**2178-8-19**] 08:05
JOB#: [**Job Number **]
cc:[**Last Name (STitle) 43250**]
|
[
"5849",
"5180"
] |
Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**]
Service: [**Company 191**] MEDICI
HISTORY OF PRESENT ILLNESS: This is a 79 year old woman
with a history of atrial fibrillation with rapid ventricular
rate status post pharmacologic conversion and status post
pacemaker for tachy-brady syndrome with congestive heart
failure, diastolic dysfunction, and poorly controlled
hypertension, who presented with shortness of breath. The
patient reports a three to four week history of "a cold" with
cough productive of yellow thick sputum, occasionally blood.
She admits to fevers, chills, which have been intermittent
over the past few weeks but she did not take an actual
temperature. No night sweats. She does admit to shortness
of breath, especially with some severe spells over the last
week. This most recent one prompted an Emergency Room visit.
She also notes decreased appetite, possibly change in weight,
but her clothes are looser than they had been. She reports
good compliance with her home anti-hypertensives, but does
not measure her blood pressures.
She says her diabetes mellitus is borderline diabetes
mellitus but not on any medications nor does she check
fingersticks at home. She denied any chest pain but was with
tachycardia on arrival at the Emergency Room. She received a
dose of Lopressor and Diltiazem in the Emergency Room with
good response. Also, she received 20 of intravenous Lasix,
Nitroglycerin, digoxin and then had a CT scan of her chest
done to evaluate for shortness of breath. She was noted to
have some lymphadenopathy and diffuse nodules worse on the
left than on the right.
PAST MEDICAL HISTORY:
1. Congestive heart failure with diastolic dysfunction.
2. Diabetes mellitus.
3. Coronary artery disease status post an myocardial
infarction.
4. Hypertension with history of uncontrolled blood pressures
in the 200s over 100s.
5. Hyperlipidemia.
6. Atrial fibrillation status post tachy-brady syndrome
status post pacemaker.
7. Chronic renal insufficiency.
8. Arthritis.
9. Recent echocardiogram in [**Month (only) **] showed an ejection
fraction of 60% with mild to moderate mitral regurgitation
and aortic regurgitation, prolonged E wave deceleration,
impaired relaxation, mild pulmonary artery systolic
hypertension.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide 25 mg p.o. q. day.
2. Lisinopril 40 mg p.o. q. day.
3. Amlodipine 10 mg p.o. q. day.
4. Aspirin 325 mg p.o. q. day.
5. Toprol XL 100 mg p.o. q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives with her son. She is divorced.
She works as a cook. She quit tobacco in the 70s but had a
previous 20 pack year history. Alcohol with history of heavy
alcohol abuse but quit 30 to 40 years ago and no other
illicit drugs.
FAMILY HISTORY: Includes mother who died of breast cancer
and an uncle with cancer. Father with history unknown.
PHYSICAL EXAMINATION: On admission, temperature 99.8 F.;
pulse of 129; blood pressure 166/71; respiratory saturation
of 92% on room air; respiratory rate of 20. In general, she
is an elderly woman sitting up, tripoding with moderate
respiratory distress. HEENT: Normocephalic, atraumatic.
Pupils are equal, round and reactive to light on the left;
right side with clouding of her cornea. Neck was supple.
Cardiovascular is tachycardic. Pulmonary examination with
bilateral coarse expiratory wheezes and diffuse crackles
throughout, left greater than right. Abdomen was soft,
nontender, nondistended, active bowel sounds. Extremities
with no cyanosis, clubbing or edema. Neurological
examination: She was alert, oriented and appropriate, and
moving all extremities.
LABORATORY: On admission, white blood cell count 13.6,
hematocrit 34, platelets of 209 and differential with 70%
neutrophils, 15% bands, 12% lymphs. Hematocrit 139,
potassium 3.7, chloride 105, bicarbonate 18, BUN 31,
creatinine 1.7, gap of 16. Glucose of 192.
CK of 240; CK MB of 5, troponin of 0.01. Blood gas with pH
of 7.33, pCO2 of 33, pO2 of 63, lactate of 5.
On admission EKG she had atrial fibrillation with rapid
ventricular response, diffuse ST depression, and then
follow-up EKG had sinus tachycardia at a rate of 112, normal
axis, normal intervals. The ST changes were resolved.
A CT scan showed no evidence of pulmonary embolism, extensive
hilar lymphadenopathy and multiple foci. Areas of nodular
density consistent with metastatic foci. Positive post
obstructive pneumonia.
HOSPITAL COURSE: This is a 78 year old woman with history
of atrial fibrillation with rapid ventricular response,
tachy-brady syndrome, status post pacemaker, with congestive
heart failure, diastolic dysfunction, who presented with
shortness of breath. She was initially admitted to the
Intensive Care Unit for better monitoring.
1. SHORTNESS OF BREATH: The patient was stable oxygen wise
and was treated for pneumonia empirically with initially
Ceftazidine and then switched over to Levofloxacin to
complete a two week course; currently being discharged on day
seven of two weeks. The day after admission the patient had
a bronchoscopy done to evaluate airway disease.
She had evidence of diffuse narrowing of her lower airways
without occlusion. No endobronchial lesions were noted. No
source of hemoptysis, but she had minimal non-purulent
secretions. She did have three sets of samples sent of for
pathology and cytology which eventually, on the day prior to
discharge, returned as highly suspicious for non-small cell
carcinoma. The patient was advised of these findings and
referred to the Thoracic Multi-Disciplinary Oncology Center
for further follow-up and further staging.
The patient is aware of diagnosis as is her family were
advised of condition and the patient defers treatment and
plans for treatment to her physicians as she feels they know
more appropriately what is involved. When asked about her
wishes, she also defers to her son. They are prepared to
continue with the treatment and arrangements have been made
to set up initial visit on day of discharge with Dr. [**Last Name (STitle) **].
Otherwise, the patient's shortness of breath was likely
exacerbated by a post obstructive pneumonia. Eventually,
Flagyl was added on for better anaerobic coverage and the
patient is to complete a ten day course of this. She has
seven more days to go to complete those.
Her shortness of breath improved throughout her stay. She
continued to use her incentive spirometer and eventually was
weaned off nasal cannula and saturating well even with
ambulation. She did not require oxygen for the last four
days of her admission.
2. ESCHERICHIEAE COLI BACTEREMIA AND URINARY TRACT
INFECTION: The patient had a few blood cultures positive for
E. coli at time of admission as were her urine cultures. It
was likely that the patient had a urinary source of her
urinary tract infection but her E. coli was pan sensitive and
the patient was continued on Levofloxacin for her urinary
tract infection and her E. coli bacteremia. Eventually, her
blood cultures remained negative and she will just complete
her course for pneumonia on the Levofloxacin, also covering
for her bacteremia and urinary tract infection.
3. ATRIAL FIBRILLATION: The patient remained in sinus
throughout the rest of her stay. She was continued on her
home regimen of Diltiazem and Lopressor. She was not on
Coumadin secondary to fall risk and a question of compliance,
and otherwise remained stable and asymptomatic. The
patient's elevated troponins on admission were likely
secondary to the demand ischemia secondary to her atrial
fibrillation with rapid ventricular response.
4. CORONARY ARTERY DISEASE: The patient was stable and
continued on her metoprolol although her aspirin was held for
procedures and can be restarted once her work-up for her lung
cancer is completed.
5. DIABETES MELLITUS: She was overall well controlled on a
sliding scale, however, her fingersticks remained between 112
and 130 during the course of her stay with minimal sliding
scale requirements. She will continue at home off
medications but advised to continue with diabetic diet. This
can continue to be followed as an outpatient.
6. HYPERTENSION: She was continued on her
Hydrochlorothiazide, Metoprolol and Diltiazem. She had
fairly good control on this regimen, with occasional episodes
of hypertension throughout the course of her stay which
resolved quickly.
7. CHRONIC RENAL INSUFFICIENCY: Her creatinine was elevated
on admission at 1.7 and back down to her baseline of 1.1 and
1.2 at time of discharge. Likely this was slightly prerenal
dehydration on admission.
CONDITION ON DISCHARGE: Good. The patient is ambulated
with the assistance of walker without difficulty. The
patient is sitting up in a chair without difficulty. The
patient is not requiring oxygen. The patient aware of
diagnosis although unsure if understands complete
complications and associated issues associated with her
diagnosis.
DISCHARGE STATUS: Discharged to home with services.
DISCHARGE DIAGNOSES:
1. Non-small cell carcinoma.
2. Post obstructive pneumonia.
3. Diastolic congestive heart failure.
4. Urinary tract infection.
5. Bacteremia.
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 25 mg p.o. q. day.
2. Levofloxacin 250 mg p.o. q. day times seven more days.
3. Flagyl 500 mg p.o. three times a day times seven more
days.
4. Diltiazem 60 mg p.o. four times a day.
5. Ipratropium MDI, two puffs inhaled four times a day.
6. Toprol XL 100 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with Dr. [**Last Name (STitle) **] in the
Multispecialty Thoracic Clinic at 03:30 on [**4-19**].
2. The patient is to follow-up with her nurse practitioner,
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2114-4-25**].
3. The patient is to follow-up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2114-5-22**].
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2114-4-19**] 11:33
T: [**2114-4-20**] 21:43
JOB#: [**Job Number 10605**]
|
[
"486",
"42731",
"4280",
"5990"
] |
Admission Date: [**2197-11-1**] Discharge Date: [**2197-11-8**]
Date of Birth: [**2121-4-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
witnessed aspiration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 76 year-old female with a history of diabetes,
hyperlipidemia, breast cancer and alzheimers who present with
dyspnea.
.
Of note, history obtained from ED signout and from interview
with covering nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] [**Hospital1 1501**].
.
Patient was at her baseline state of health until she had an
aspiration event at lunchtime on the day of admission. After
that event she was noted to have dropping BP, increasing pulse,
decreasing O2 sat with coughing up of secretions. Suction was
attempted and she was seen by staff physician who started her on
a course of levaquin. She was kept NPO in the evening but
continued to have worsening vitals with O2 desaturations to the
50-60s on 4L. Labs at [**Hospital1 1501**] showed WBC of 9.4. EMS was called at
that point for transport to [**Hospital1 18**] ED.
.
In the ED, vitals were T 98.8 BP 138/77 P 109 R 30s O2. HR
improved to the 70's after 1L of NS. Sats were consistantly 100%
on NRB. Respiratory rates was initially 37, decreased to 22 over
the course of the ED stay. FS was 261. Exam in ED notable for
ronchi and tachypnea. Foley was placed. She was given Vancymycin
1000mg IV and flagyl 500mg IV and admitted to the [**Hospital Unit Name 153**] due to
high oxygen demand. Of note, pt has a guardian who has stated
that pt is DNR/DNI (Documentation in chart), but wants pt to
recieve antibiotic therapy as needed.
.
From report, at baseline pt requires assistance with ADLs and
IADLs. She is alert but confused at baseline. She is non-mobile
at baseline.
Past Medical History:
Breast CA
DM
High cholesterol
Alzheimer's
Espohageal strictures
Social History:
Denies, EtOH, tobacco, drugs
Family History:
N/C
Pertinent Results:
[**2197-11-1**] 08:00PM BLOOD WBC-10.7# RBC-4.07* Hgb-13.4 Hct-40.7
MCV-100* MCH-32.9* MCHC-32.9 RDW-13.2 Plt Ct-281
[**2197-11-4**] 06:30AM BLOOD WBC-9.1 RBC-3.87* Hgb-12.4 Hct-37.5
MCV-97 MCH-32.0 MCHC-33.0 RDW-12.5 Plt Ct-221
[**2197-11-1**] 08:00PM BLOOD PT-12.3 PTT-22.7 INR(PT)-1.1
[**2197-11-1**] 07:50PM BLOOD Glucose-245* UreaN-17 Creat-1.0 Na-143
K-4.4 Cl-104 HCO3-24 AnGap-19
[**2197-11-4**] 06:30AM BLOOD Glucose-123* UreaN-9 Creat-0.8 Na-137
K-3.8 Cl-101 HCO3-24 AnGap-16
[**2197-11-2**] 04:45AM BLOOD ALT-6 AST-17 LD(LDH)-196 AlkPhos-76
TotBili-0.3
[**2197-11-3**] 05:30AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0
AP CHEST: Cardiac enlargement with left ventricular
configuration is redemonstrated. Pulmonary vascularity is
unremarkable and there is no evidence of overt edema or focal
consolidation. There is elevation the left hemidiaphragm with
streaky retrocardiac opacity which likely represents
atelectasis. No pneumothorax or large effusion.
IMPRESSION: No definite pneumonic consolidation or overt edema.
Brief Hospital Course:
1. dyspnea/aspiration pneumonitis -- Initially admitted to the
MICU with hypoxia, dyspnea and hypotension. Empiric
levofloxacin and flagyl were started. She improved rapidly, and
was on room air after transfer to the hospital medicine service.
She underwent swallow evaluation which showed difficulty with
solids, but ability to swallow pureed foods and thin liquids
without overt evidence of aspiration. On the medical [**Hospital1 **], she
continued to spike fevers, so antibiotics were adjusted for
broader empiric coverage with Vancomycin and Zosyn. After
discussion with her primary doctor (Dr. [**Last Name (STitle) 5351**], decision was
made to put her back on levofloxacin and flagyl to avoid having
to place a PICC or MID line if possible. She will be followed
at the [**Hospital3 537**] by Dr. [**Last Name (STitle) 5351**] who I discussed this with.
She has stated that if she feels the need to broaden her
antibiotic coverage again she will do so at the [**Hospital3 537**].
2. Alzheimer's dementia -- Her home medications including
namenda and donepizil were continued.
3. Somnolence - attributed to fever. Olanzapine titrated down
to 2.5 hs only. Valproate level checked - normal. CO2 checked
on blood gas - normal.
Medications on Admission:
Depakote sprinkles 500mg [**Hospital1 **]~
colace 100mg [**Hospital1 **]~
Namenda 10mg [**Hospital1 **]~
protonix 40 [**Hospital1 **]~
Zyprexa 5mg [**Hospital1 **]~
Acetominophen 1000mg q6h (standing)~
Aricept 10mg qhs ~
Levaquin 500 po qday x7 days (started today)~
Acidophillus po tid x7 days~
Senna [**Hospital1 **] prn~
Mylanta q6h prn~
Trazadone 50mg po q6h prn for agitation (Based on discussion
with [**Hospital1 1501**] nurse, not on transfer summary)
Robitussin 50mg q4h prn for cough
Discharge Medications:
1. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule,
Sprinkle PO BID (2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
aspiration pneumonitis
Discharge Condition:
stable, on room air
Discharge Instructions:
Take all medications as prescribed
Followup Instructions:
With Dr. [**Last Name (STitle) 5351**] at [**Hospital3 537**] (arranged).
|
[
"5070",
"5849",
"2859",
"2724",
"25000"
] |
Admission Date: [**2104-9-8**] Discharge Date: [**2104-9-21**]
Date of Birth: [**2104-9-8**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 1683**] is a 2105 gram product of a 35-0/7
week gestation, estimated date of delivery [**2104-10-13**]
born to a 31 year-old gravida II, para I mom with prenatal
screen, blood type A positive, antibody negative, hepatitis B
negative, RPR nonreactive, Rubella immune, GBS unknown. The
pregnancy was uncomplicated. The infant was born via normal
spontaneous vaginal delivery with Apgars of 8 and 9 at one
and five minutes. In the delivery room she was stimulated and
dried.
PHYSICAL EXAMINATION: On admission she was a well appearing
infant, appropriate for gestational age. HEENT: Mild caput
posterior occipital region. Anterior fontanelle open and
flat, palate intact. Red reflex is present bilaterally. Neck
supple. Lungs clear bilaterally. Cardiovascular: Regular rate
and rhythm. No murmur. Femoral pulses 2+ bilaterally. Abdomen
soft with active bowel sounds. No masses or distention. GU:
Normal preterm female, anus patent. Spine is midline, no
dimples. Skin with mongolian spot on buttocks. Hips stable.
Clavicles intact. Neuro: Good tone, normal suck, normal gag.
Weight 2105 grams, 75th percentile. Head circumference 32 cm,
50th percentile. Length 46 cm, 50th percentile. Temperature
98. Heart rate 183, respiratory rate 28, blood pressure 57/26
with a mean of 36. O2 saturation 98% in room air.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: This
infant remained in room air throughout her admission. She had
no documented apneas, bradycardias or desaturations
throughout her hospital stay.
CARDIOVASCULAR: Baby Girl [**Known lastname 1683**] had normal heart rates of
130s to 160s and normal mean blood pressures anywhere from 45
to 44 throughout her hospital stay. There was no evidence of
a murmur.
FLUID, ELECTROLYTES AND NUTRITION: Her discharge weight was
2260 grams. At the time of discharge patient was taking p.o.
ad lib of Similac 24 approximately 130 cc per kilo was her
minimum and she was taking well above that.
GASTROINTESTINAL: This infant was treated with phototherapy
for hyperbilirubinemia. She was treated with double banked
phototherapy begun on hospital day #4 for a peak bilirubin of
14.7/0.4. Her phototherapy was discontinued on hospital day
#8 and her rebound bilirubin was 10.5/0.3.
INFECTIOUS DISEASE: This infant did undergo a rule out sepsis
work up at the time of admission. CBC and blood culture was
obtained. Antibiotics were not started due to the benign
nature of the CBC.
HEMATOLOGY: Most recent hematocrit was 43.7 and that was at
the time of admission.
NEUROLOGY: Appropriate for gestational age neurological
examination. Head ultrasound not indicated for this infant
born at 35 weeks gestational age.
SENSORY: Audiology hearing screen was performed with
automated auditory brain stem responses. This infant did pass
her hearing screen.
OPHTHALMOLOGY: Not indicated in this infant who is greater
than 35 weeks gestational age and did not require oxygen
throughout this hospital admission.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**Doctor First Name 69709**].
Telephone #[**Telephone/Fax (1) 1260**].
CARE RECOMMENDATIONS: Patient to continue on her p.o. ad lib
feeds, Similac 24. Medications: This infant was on no
medications at the time of discharge.
Car seat positioning screening: Pass.
State Newborn Screening: Sent on [**2104-9-11**]. Pimary care
pediatrician to follow up.
Immunizations: She did receive her first hepatitis B vaccine
on [**2104-9-12**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
of 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: 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
and for the first 24 months of the child's live immunization
against influenza is recommended for household contacts and
out of home care-givers.
FOLLOW UP APPOINTMENTS: Infant is to follow up with her
primary care pediatrician, Dr. [**Doctor First Name 69709**].
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Rule out sepsis.
3. Hyperbilirubinemia.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) 62855**]
MEDQUIST36
D: [**2104-9-24**] 10:10:26
T: [**2104-9-24**] 11:47:23
Job#: [**Job Number 69710**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2153-7-2**] Discharge Date: [**2153-7-6**]
Date of Birth: [**2071-9-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
1. Low pulse, noted own pulse to be 30 at home.
Major Surgical or Invasive Procedure:
1. Placement of temporary pacemaker
2. Removal of old pacemaker and insertion of new pacemaker.
History of Present Illness:
81 yom with HTn, a. fib s/p AVN ablation and PPM in [**2144**]
presented to OSH with vertigo 3 days ago discharged with
meclizine. States felt lightheadedness and imbalance with
walking episodes lasting [**1-12**] secs. Today checked pulse and was
36 so went back to ER. At [**Hospital3 **] noted to have HR of
30 and intermittenly [**Hospital3 **] not capturing. Also having [**4-19**] sec
asystolic with dizziness when an one episode of 10 sec. (ECG
with a. fib with complete heart block and escape at a rate of
30, RBBB, nl axis. non conducted [**Month/Year (2) **] spikes). He was
transferred to [**Hospital1 1562**] where he was given 2 units FFP for INR
4.2 and RIJ access was obtained and temp wire placed.
Transferred to [**Hospital1 **] for further f/u.
.
On presentation to [**Hospital1 **], patient denies any complaints. No chest
pain/sob. Denies any furhter lightheadedness/dizziness.
.
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:
PMH:
-HTN
-h/o AFib s/p AVJ ablation
-h/o sinus dysfunction
-s/p pacemaker in [**2144**]
-small infrarenal abdominal aneurysm, followed radiographically,
last measured [**2-/2149**] was ~3cm x 3cm
-Query early Parkinsonism, on no medications
-Benign essential tremor, on no medications
.
PSH:
-Appendectomy
-Tonsillectomy
-PPM
Social History:
SHx: He lives in [**Hospital3 28354**] with his wife. Mr. [**Known lastname 5263**] is a
former 8th grade science teacher. No tobacco use now or ever.
He formerly drank apparently fairly actively, but has not done
so for many years. He also spends much of his time living at
[**Hospital3 **].
Family History:
Father had a [**Hospital3 **], mother died of "old age."
Physical Exam:
PHYSICAL EXAMINATION:
VS: 96.1 BP 134/78 HR 73 RR 20 O2 97%
.
Gen: WDWN elderly male in nad. Oriented x3. Mood, affect
appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
Neck: Supple, RIJ line with temp wire in place.
CV: RR, normal S1, S2. No S4, no S3.
Chest: 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+ Femoral 2+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
Pertinent Results:
[**2153-7-2**] 11:19PM BLOOD WBC-5.7 RBC-3.67* Hgb-11.6*# Hct-32.3*#
MCV-88 MCH-31.6 MCHC-35.9* RDW-12.4 Plt Ct-135*
[**2153-7-6**] 09:05AM BLOOD WBC-6.9 RBC-4.71 Hgb-14.4 Hct-41.0 MCV-87
MCH-30.6 MCHC-35.2* RDW-12.6 Plt Ct-156
[**2153-7-2**] 11:19PM BLOOD PT-24.3* PTT-38.3* INR(PT)-2.4*
[**2153-7-6**] 09:05AM BLOOD PT-15.1* PTT-30.3 INR(PT)-1.3*
[**2153-7-2**] 11:19PM BLOOD Glucose-115* UreaN-15 Creat-0.7 Na-144
K-3.8 Cl-106 HCO3-29 AnGap-13
[**2153-7-6**] 09:05AM BLOOD Glucose-174* UreaN-20 Creat-0.8 Na-137
K-3.7 Cl-100 HCO3-28 AnGap-13
ECG on admission:
Ventricular paced rhythm with underlying atrial fibrillation.
Compared to the previous tracing of [**2152-12-28**] no major change.
CXR [**7-2**]:
AP chest radiograph compared to [**2153-1-5**] show similar
configuration
of a right chest wall pacemaker and leads, which terminate in
the right
atrium and right ventricle x2. Since the last exam, a
transvenous right
ventricular [**Year (4 digits) **] has been placed via a right internal jugular
approah. The
cardiomediastinal contour and pulmonary vascularity are within
normal limits.
No pleural effusion, pneumothorax, or consolidation is detected.
CXR [**7-6**]:
Proper placement of lead, no pneumothorax.
Brief Hospital Course:
1. Rhythm: Pt presented with bradycardia in a rhythm of
complete heart block secondary to his pacemaker not capturing.
He has a history of AVN ablation. Pt was on coumadin at home
and had an initial INR of 2.4. Initial bradycardia was likely
d/t failure to capture, based on OSH ECG, likely problem with
[**Name2 (NI) **] lead. Coumadin was held upon admission and he was given
Vit K twice here. He had received FFP at an outside hospital.
A pacemaker could not be placed until INR was lowered. To
bridge the patient until that time, a temporary pacing wire was
placed in the R IJ by electrophysiology. Settings were Ma/MV
[**5-13**], thres MA 0.3 thres MV 8. It was set to capture at a rate of
50. During his time in the CCU, his rhythm alternated between
pacing by his native pacemaker at a rate of 60, pacing by his
temporary pacemaker at a rate of 50, and some very short
instances when neither [**Month/Day (4) **] sensed or captured. These
instances were seen on tele and lasted a few seconds at most.
He was discharged with the underlying rhythm A. fib with RBBB,
currently paced via new pacemaker at a rate of 60. Per EP,
Cefazolin 2g IV q8 x3, last dose at 8am today, and Cephalexin
500g q8 x 5days for post-procedural prophylaxis. Also restarted
Warfarin 7.5mg x 1 the night before discharge. He will be seen
in coumadin clinic on Monday.
2. HTN: on Diovan 80 mg PO BID and Hctz 25 mg po daily. Will
continue at outpt doses.
3. Physical therapy evaluated patient before discharge and
recommended home follow up. He was set up with home nursing for
dressing changes and PT.
Medications on Admission:
Diovan 80 mg PO BID
Coumadin 5mg daily and 7.5 mg on tuesday
HCTZ 25 tab po daily
Discharge Medications:
1. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 4 days.
Disp:*12 Capsule(s)* Refills:*0*
5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please have INR checked at [**Hospital3 **] on Monday
[**7-9**].
Disp:*30 Tablet(s)* Refills:*2*
6. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous twice
a day for 2 days: Please inject lovenox twice daily as you were
taught in the hospital this Sat [**7-7**] and Sun [**7-8**].
Disp:*4 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
1. Complete heart block secondary to pacemaker malfunction.
Secondary Diagnosis:
1. HTN
2. Afib s/p AVN ablation
3. Benign Tremor
Discharge Condition:
stable, with normal vital signs, eating on his own, with intact
mental status.
Discharge Instructions:
You were admitted to the hospital for a low heart rate which was
due to a problem with your pace maker. Possibly the reason was
from a break in the wire in your heart. You had a temporary
pace maker placed and were monitored in the cardic intensive
care unit.
You then had a procedure to put in a new pacemaker and take out
both the old pacemaker (but not the old wires), and the
temporary pacemaker. The procedure went well and you should
have a regular heart rhythm now.
You will be going home on the medicines you were taking before
admission. You also will take 5 days of antibiotics. And on
Sat and Sun after your discharge, you will give yourself two
Lovenox shots a day.
As for follow up apointments, you should get blood work done on
Monday to check your INR which tells us whether to adjust your
Coumadin dose. You should also follow up with your primary
care doctor [**First Name (Titles) **] [**Last Name (Titles) 2974**] to have an incision check. Lastly you
will set up and appointment with the Cardiology Device Clinic in
late [**Month (only) 216**] or early Septemeber.
Followup Instructions:
1. Lab Work - Mon
2. PCP for incision check - Fri
Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2153-7-11**] 2:30
3. Cardiology Device Clinic - late [**Month (only) **], early [**Month (only) **] (Dr.
[**Last Name (STitle) **]
please call [**Telephone/Fax (1) 2934**] for appointment.
Completed by:[**2153-7-7**]
|
[
"42789",
"4019"
] |
Admission Date: [**2134-2-2**] Discharge Date: [**2134-2-16**]
Date of Birth: [**2055-12-6**] Sex: F
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
VATS on [**2-3**], s/p lung biopsy
History of Present Illness:
77 F w/ presumed ILD presented to [**Hospital1 18**] [**Location (un) 620**] on [**2134-1-27**] w/
sob and transferred to [**Hospital1 **] for lung Bx s/p procedure doing well.
Two wks prior to presentation she had the onset of shortness of
breath and cough after just getting over viral gastroenteritis.
She went to her PCP and was treated with levofloxacin x 7 days.
.
Symptoms continued so she presented to [**Hospital1 **] [**Location (un) 620**] [**1-27**] tachypnea
and hypoxia. Imaging suggested pneumonia and she started
empirically on ceftriaxone and azithromycin. Despite treatment
she developed worsening hypoxia. Given concern for IPF
exacerbation she was started on solumedrol 80 mg IV q.6h and
then q8h with minimal response. On [**2134-1-31**] she and episode of
hypoxia with saturations falling to the mid 80s on 5 liters
requiring a nonrebreather but eventually weaned back down to 2
liters facemask. On [**2134-2-2**] she again had an acute episode of
hypoxia this time requiring BIPAP but responded to diuresis with
lasix.
.
As she had never had a lung bx to definitively dx her disease
she was transferred to [**Hospital1 18**] for VATS lung bx. On arrival she
continued to have a 6L by nasal cannula O2 requirement to
maintain saturations >92%. She was continued on levofloxacin and
steroids despite low suspicion for infectious etiology. Pt
underwent VATS RLL wedge biopsy [**2-3**] which she tolerated well.
She underwent further diuresis and CT was removed [**2-5**].
Past Medical History:
ILD (dx [**8-18**]), followed without sx and imaging.
PVD s/p b/l bbypass 7yrs ago
hyperlipidemia
HTN
GERD
Hysterectomy
Social History:
Lives with husband. 6 children and 10 grandchildren. retired
floral designer. quit smoking 40 yrs ago, after 15 pack year hx.
Family History:
Non-contributory
Physical Exam:
98.1 150/60 98-120 20 98 5L
Gen-NAD
HEENT-PERRL, JVP to 10cm, MMdry
Hrt-RRR nS1S2 3/3 SEM at RUSB, 3/6 SEM at apex
Lungs-fine crackles at left base, coarse crackles at rt base
Abd-soft, NT, ND, no HSM
Extrem-2+ rad and dp pulse on left, absent dp on rt, 1+ LE edema
on left
Neuro-CNII-XII intact, [**4-17**] strengh in UE and LE bilat, distal
sensation intact 2+ DTR at patellae bilat
Skin-no lesions, rt CT site dressing CDI
Pertinent Results:
Pertinent labs: on discharge: WBC 14 (range 14-21 on steroids),
HCT stable at 33.1, plt 269, electrolytes within normal limits
with a BUN 21 and Cr 0.7
.
Work up for anemia revealed IRON-96, calTIBC-268, VitB12-984*,
Folate-14.1, Hapto-198, Ferritn-562*, TRF-206
.
legionella antigen negative, mycoplasma pneumonia antibody IgM
negative, pneumonitis hypersensitivity profile negative,
angiotensin 1 converting enzyme test WNL, ANCA negative
.
BCX/UCX all negative
.
U/A negative but had 21-50 RBC with large blood
.
Studies:
Pathology [**2134-2-3**] s/p VATS
DIAGNOSIS
Lung, right lower lobe, wedge resection:
a. Patchy interstitial fibrosis, moderate to severe, with
honey-comb change, fibroblastic foci, and mild chronic
inflammation, see note.
b. Organizing thrombi.
c. Pleural adhesion.
.
Note: The changes are consistent with usual interstitial
pneumonia (UIP)-reviewed by Dr. [**Last Name (STitle) **]. [**Doctor Last Name **]. Clinical correlation
recommended. Special stains for AFB, PCP, [**Name10 (NameIs) **] fungi are
negative.
.
[**2134-2-4**] AP CXR: FINDINGS: There has been interval worsening of
moderate pulmonary edema on top of her chronic pulmonary
interstitial lung disease. There is no pneumothorax. There is
more right pleural effusion. Cardiomediastinal contour is
obscured by the lung abnormality but is not enlarged.
IMPRESSION: Worsening moderate pulmonary edema.
.
[**2134-2-5**] AP CXR: IMPRESSION: Status post removal of chest tube
without pneumothorax. Decreased pulmonary edema. Stable diffuse
interstitial disease.
.
[**2134-2-10**] PA and lat CXR: PA AND LATERAL VIEWS OF THE CHEST:
Compared to recent prior study the appearance of the diffuse
interstitial abnormality has changed slightly raising the
possibility of superimposed fluid overload, although it is
difficult to assess, and there are no pleural effusions.
Cardiomediastinal contour is unchanged.
IMPRESSION: Change in appearance of diffuse interstitial
abnormality raises the possibility of superimposed fluid
overload.
.
[**2134-2-15**] ECHO TTE: LVEF 60% with grade I diastolic dysfunction.
mild AS, 1+MR, moderate pulmonary hypertension with PASP =46.
Brief Hospital Course:
Ms. [**Known lastname 6692**] is a 78 year old female who was transferred to [**Hospital1 18**]
from an OSH for work up for hypoxia with h/o of presumed ILD.
She came to have a VATS for lung biopsy. She spent two days in
the MICU after the procedure until the chest tube was removed.
She was then transferred to the floor. Brief hospital course is
described by problem list below.
.
# Hypoxia: She was treated at the OSH with antibiotics and
initially continued on them in house. These were subsequently
discontinued as she had no signs of pneumonia on CXR or with her
WBC initially. Pathology from lung biopsy shows UIP/IDL and all
cultures from the tissue were negative including fungal
cultures. Although she used no oxygen before her
hospitalization, she now requires baseline oxygen per nasal
cannula at 3-4L to keep oxygen saturation above 92%. The cause
of the exacerbation is unknown; perhaps related to an infection
prior to hospitalization. She still becomes tachypnic and
hypoxia with ambulation for which she will benefit from
pulmonary rehab. Pulmonology was consulted and they have
recommended a month long prednisone taper (she is currently on
50mg daily), nebulizer treatments with albuterol and atrovent
and, mucomyst PO 600mg TID. In addition, based on data from a
clinical trial, they recommended a 2 week course of enoxaparin
given the high ddimer value and the evidence of thrombus on the
pathology tissue. This may help improve her symptoms. She has
PFTs scheduled for the end of [**Month (only) 958**] ([**2134-3-8**]) and an appointment
the same day with her pulmonologist. (please see appointments
section)
.
# fluid overload: She has no history of heart failure, but did
show some fluid overload on CXR. There was concern that her
tachycardia due to hypoxia (and maybe nebulizer treatments) may
contribute to strain on the heart and some failure. She
presented with a BNP in the 1100s at the OSH adn was 1241 on
admission to [**Hospital1 18**]. She has required occassional light diuresis
with furosemide 10mg IV with good outcome. TTE showed LVEF of
60% with grade I diastolic dysfunction, mild AS, 1+MR and
evidence of pulmonary hypertension with an estimated PASP of 46.
.
# diarrhea: She had some episodes of diarrhea and an elevated
WBC, and therefore, was treated empirically with metronidazole
for 7 days. Subsequent cultures showed she was C diff negative
x3.
.
# leukocytosis: Her WBC bounces between 14 and 21 with no signs
of infections including remaining afebrile, no infiltrates on
CXR, clean u/a, no further diarrhea. This is attributed to the
steroid treatment.
.
# hyperglycemia: She has no history of diabetes. This is likely
attributed to the prednisone. She is currently on humalog with
meals and as a sliding scale. The doses with meals is still
being titrated up to better control her blood glucose. The
insulin doses will need to be decreased and even discontinued as
her prednisone taper ends to avoid hypoglycemia.
.
# HTN/tachycardia: She was admitted on norvasc and diovan.
Given her tachycardia and hypertension in house, she is
currrently controlled on amlodipine 5mg, valsartan 160mg [**Hospital1 **],
metoprolol 25mg [**Hospital1 **] with SBP ranging from 110-130's. She has
still been occassionally tachycardic with ranges in heart rate
from 80-110's likely related to medications and perhaps to her
hypoxia.
.
# dyslipidemia: continue lipitor.
.
# anemia: Hct was stable in the mid to low 30's. Iron studies
suggest chronic disease.
.
# PPX: DVT ppx: was on heparin SC but discontinued while on
enoxaparin for the ILD. She will need to be restarted on
heparin subcutaneous 5000 units TID when her course of
enoxaparin is over ([**2134-2-24**]). She was also started on
alendronate 70mg qTuesdays to protect her bones given all the
steroids. Finally, she was started on PCP [**Name9 (PRE) **] with bactrim DS 1
tab qMonday, Wed, Friday given the lung pathology.
.
# Physical therapy: with assistence only and with a walker.
Physical therapy worked with her for improving her strength,
conditioning and breathing.
.
# CODE: FULL
.
# DISPO: to pulmonary rehab
Medications on Admission:
1. Lipitor 20 mg daily.
2. Norvasc 5 mg daily.
3. Prilosec 20 mg a day.
4. Rhinocort [**12-15**] sprays in each nostril.
5. Aspirin 325 mg daily.
6. Multivitamin daily.
7. Diovan 160 mg b.i.d.
8. Ultracet, (acetaminophen-tramadol 325-37.5 mg) q.6h. p.r.n.
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
13. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
14. Acetylcysteine 10 % (100 mg/mL) Solution Sig: Six Hundred
(600) mg Miscellaneous TID (3 times a day).
15. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days.
16. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 5 days.
17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
19. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
20. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed) as needed for sore throat.
21. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
22. Insulin Lispro (Human) 100 unit/mL Solution Sig: variable
units Subcutaneous ASDIR (AS DIRECTED): ongoing while on
prednisone. may not need after steroid taper ends.
23. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg
Subcutaneous [**Hospital1 **] (2 times a day) for 9 days: last dose in PM on
[**2134-2-24**].
24. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
25. oxygen
please use oxygen per nasal cannula to keep oxygen saturation
above 92%. (currently set at 3-4L)
26. lab work
Patient should have CBC, BUN, Cr, sodium, potassium, chloride,
bicarb and glucose checked every Tuesday and Thursday.
27. finger sticks
Finger sticks should be checked qAC and qhs and covered with the
humalog sliding scale. This can be discontinued when the
insulin is discontinued (at the end of the prednisone taper).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Interstitial lung disease/UIP
Congestive heart failure- diastolic
Diarrhea
HTN
tachycardia
hyperglycemia
.
SECONDARY DIAGNOSIS:
PVD s/p b/l bbypass 7yrs ago
Hyperlipidemia
GERD
Hysterectomy
Discharge Condition:
Stable, oxygenation saturation low 90's on 3-4L of oxygen by
nasal cannula, ambulatory with mild SOB.
Discharge Instructions:
You were diagnosed with lung disease which now requires you to
wear oxygen to help you breath better. You have been prescribed
new medications which will help you to breath better as well.
Please take them as instructed.
.
Please take all medications as prescribed.
.
Please use nasal cannula set at 4L oxygen at rest.
.
Call your PCP or return to the emergency department if you
experience worsening shortness of breath, fevers >101, chills,
coughing up blood, chest pain, diarrhea or any other symptoms
which are concerning to you.
Followup Instructions:
Please followup with your PCP [**Name Initial (PRE) 176**] 1 week of discharge for
further medical management: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3393**]
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB
Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2134-4-5**] 2:00
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**]
[**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2134-4-5**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 5445**] [**Last Name (NamePattern1) 1843**]/DR. [**Last Name (STitle) **]
Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2134-4-5**] 2:30
|
[
"5119",
"4280",
"4168",
"2724",
"4019",
"53081",
"2859",
"42789"
] |
Admission Date: [**2186-3-15**] Discharge Date: [**2186-3-23**]
Date of Birth: [**2121-1-8**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Acute Stroke
Major Surgical or Invasive Procedure:
Cerebral Angiogram
Intraarterial tPA
History of Present Illness:
Pt is a 65 yo Cantonese speaking female w/ PMhx sig for HTN,
GERD, ? ovarian cancer who presents as a transfer from [**Hospital1 **]
[**Location (un) 620**] after receiving IV tPA for code stroke. The patient was
apparently at home taking care of her grandchildren when she
fell to the floor. The time of onset from talking to family was
between 12:00 - 4:00 PM. She was unable to speak but called her
husband on the phone. Eventually she was found and taken to [**Hospital1 **]
[**Location (un) 620**] where she was found to have right face weakness, flaccid
right arm, and difficulty producing language. CT scan showed a
L hyperdense MCA sign. The patient was given IV tPA and
transferred to [**Hospital1 18**]. At [**Hospital1 18**] the patient had a CTA of the
head that showed residual clot in the M2 segment of the L MCA.
She was taken to the angiography suite for intra-arterial tPA
administration. She was deemed to have a near total occlusion
of the L ICA. 15 cc of intra-arterial tPA was administered to
the carotid artery. The patient was then transferred to the ICU
for further management.
Past Medical History:
HTN, GERD, osteoporosis, per family ovary or possibly uterus
removed for cancer.
Social History:
Married. No ETOH/tobacco
Family History:
brother - stroke
Physical Exam:
T 97.0; BP 140/70; P 81; RR ; O2 sat 99%
General: lying in bed, in c-collar
HEENT: NCAT
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: Eyes open, attends to examiner, says "two" in
Cantonese when asked to identify two fingers. States OK to
majority of things stated to her.
Cranial Nerves: PERRL 4->2, EOMI, R LMN facial droop, tongue
midline.
Motor/[**Last Name (un) **]: RUE flaccid, normal tone in all other extremities w/
movement to nailbed pressure.
Reflexes: Bic T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
R toe upgoing.
Pertinent Results:
137 103 16
- - - - - - gluc 134
3.3 25 0.7
CK: 232 MB: 4
ALT: 18 AP: 55 Tbili: 0.4 Alb: 3.9
AST: 31 [**Doctor First Name **]: 114 Lip: 72
WBC 14.2 HCT 33.3 PLT 238
N:90.1 Band:0 L:7.9 M:1.7 E:0.2 Bas:0.1
Hypochr: 1+ Anisocy: 1+ Macrocy: 1+ Microcy: 1+ Polychr:
PT: 12.2 PTT: 27.4 INR: 1.0
CTA - + hyperdensity of L M2 segment of MCA
Carotids: Less than 40% right ICA stenosis. Near-occlusive
lesion of the left mid CCA.
ECHO: No ASD or PFO seen. Normal global and regional
biventricular
systolic function. Mild pulmonary hypertension. EF 55%.
Head [**3-17**]: Continued evolution of left MCA infarct. No evidence
of intracranial hemorrhage or mass effect.
Brief Hospital Course:
Pt is a 65 yo female w/ PMHx sig for HTN, GERD, ? ovarian cancer
p/w acute onset aphasia, R facial weakness, RUE plegia found to
have L MCA occlusion now s/p IV and IA tPA. The patient appears
to have a total Left main carotid occlusion based on the
angiogram. Suspect that the patient had long standing carotid
disease and released an artery to artery embolus. The patient
had no complications of IV tPA and was transferred to the
neurology floor. She was placed on heparin gtt for a presumed
clot in the left common carotid artery, based on angiogram
results, which suggested proximal occlusion. She was
transitioned to coumadin, to remain on for 3 months, at which
point she will get a repeat CTA and be seen in stroke clinic.
TTE showed no source of embolism or thrombus. Carotid U/S showed
less than 40% right ICA stenosis. Near-occlusive lesion of the
left mid CCA.
CTA on admission showed "an abrupt cutoff at the location of
hyperdense clot noted on noncontrast head CT within the M2
portion of the left middle cerebral artery, consistent with
thrombus. Remaining vessels and branches of the circle of [**Location (un) 431**]
appear unremarkable. There is a visible mismatch identified on
perfusion imaging with increased mean transit time and decreased
blood flow with perhaps slightly decreased blood volume noted
within the distribution of the left MCA consistent with an
ischemic penumbra.
Evaluation of the internal carotid and vertebral circulation
reveals a minimal amount of flow identified within the left
internal carotid with retrograde and collateral filling of the
distal segements consistent with a high-grade, more proximally
situated stenosis. Please refer to results from angiogram on
same day for further detail. The right internal carotid and
vertebral system do not display any evidence of flow limiting
stenosis. There is no evidence of AV malformation or aneursymal
dilatation within the anterior and posterior circulations or the
circle of [**Location (un) 431**]"
Hospital course was complicated by orthostatic hypotension,
treated well with midodrine.
At discharge to rehab, she has persistent right face/arm/leg
weakness, at least antigravity and tone is coming back. She will
remain on coumadin and should have frequent INR checks.
Medications on Admission:
Calcium, Nifedipine, Protonix
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): sliding scale.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. CALCIUM 500+D 500-125 mg-unit Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Left middle cerebral artery stroke
Left common carotid occlusion
Orthostatic hypotension
Discharge Condition:
Improved
Discharge Instructions:
You have been started on Coumadin, a blood thinner. The level
of this medication must be checked frequently at Rehab and after
discharge (goal INR [**2-11**]).
Please continue to take all medications as listed below. You
should keep you Return to ED with recurrent or new neurologic
symptoms.
Followup Instructions:
1. Primary Care - Please call Dr.[**Last Name (STitle) 17650**] office prior to
discharge from Rehab ([**Telephone/Fax (1) 104073**]
2. [**Hospital 4038**] Clinic [**Telephone/Fax (1) 1694**]
DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time: Wed [**2186-5-17**] 1:00pm. [**Hospital Ward Name 23**] Building [**Location (un) 858**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2186-3-23**]
|
[
"53081",
"4019"
] |
Admission Date: [**2150-11-9**] Discharge Date: [**2150-11-25**]
Date of Birth: [**2091-5-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Strawberry
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fatigue, Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
"Ms. [**Known lastname **] is a 59 year old woman with rheumatoid arthritis and
multiple myeloma. She presents for scheduled admission for
autologous stem cell transplant. She was diagnosed with MGUS in
[**2129**] and slowly progressed until her disease accelerated in [**2149**]
with nearly 100% involvement of her bone marrow in 7/[**2149**]. She
was treated with combinations of velcade, decadron, cytoxan,
Revlimid from [**8-/2149**] thru [**4-/2150**] with a decrease in
paraproteinemia, but without significant response on bone marrow
biopsies. On [**6-/2150**] she was treated with two pulses of
intermediate dose Cytoxan with a reduction in the burden of BM
disease to 20%. She began the mobilization and harvesting phase
of autologous bone marrow transplant on [**2150-9-10**] with high dose
Cytoxan. 8 bags of peripheral cells were collected prior to
admission to be transfused during transplant."
Her autologous transplant was on [**2150-10-19**].
Her transplant occurred as per protocol with Melphalan
conditioning; and she received supportive consults with
nutrition and social work. When patient became hyperglycemic
while on 20mg IV dexamethasone, she was started on an ISS for a
short time. After her SCT, she had her nadir at D+6. She was
given 4 days of TPN as nutritional supplementation as she was
not eating. Ativan controlled her nausea. Loose stools managed
with cholestyramine and imodium. The day prior to her nadir she
has a fever and LLQ pain, which appeared to be mild
diverticulitis/sigmoiditis on CT scan. CXR was negative, urine
culture was negative. Stem cell culture had no growth. Left
subclavian line had minimal erythema and tenderness. Patient was
covered broadly with aztreonam (PCN allergy), vancomycin, cipro,
and flagyl. Was receiving acyclovir ppx and was started on
fluconazole for esophageal pain on swallowing. Esophageal
symptoms improved quickly after addition of fluconazle. All
symptoms improved with the return of her WBC and abx coverage
was narrowed to cipro and flagyl which were discontinue several
days prior to discharge. Patient spiked to 100.6 on [**2150-11-3**] and
CXR and CT showed ground glass opacity in RLL, suggestive of
PNA. Patient was started on a 7 day course of levofloxacin,
which will be continued as an outpatient. Patient is currently
afebrile and without complaints. Acyclovir and atovaquone were
continued on discharge for PPX."
The patient now returns with chills, fever up to 100.2,
weakness, and nausea. She was admitted for further work up. She
says since her discharge, she has been feeling weak and
dehydrated. She had a fever as high as 101 at the apartment she
was staying. She has continued to have loose stool. She denies
any headache, chest pain, cough, sinus congestion, sore
Past Medical History:
Past Oncologic History:
[**2129**]: Diagnosed with MGUS in [**Location (un) 14336**] at [**Hospital1 13199**] Hospital
[**2134**]: Bone marrow bx at [**Hospital1 13199**]: "adequate core showing all
normal elements without granulomata nor ectopic cells seen."
Plasma cells were "plentiful, many showing cytoplasmic
activity."
[**2143-4-4**]: bone marrow bx: plasma cell dyscrasia with
approximately
20% of atypical plasma cells involving bone marrow. At that time
normal Cr and hematocrit, IgG 1360
[**11-30**]: creatinine 0.6, M-protein 0.2 g/dL
[**2148-3-29**]: creatinine 0.9, hct 32.3, M-protein <0.2 g/dL
[**2149-6-2**]: cr 1.12, hct 33.2, M-protein <0.2 g/dL
[**7-3**]: routine dental x-rays showed new mandible lesion. [**2149-7-22**]
oral biopsy of mandible from tooth #20 area showed extensive
infiltration by monotonous population of intermediate sized
cells
with round eccentrically located nuclei; lesional cells
CD[**Pager number **] positive, kappa restricted, consistent with involvement by
a plasma cell neoplasm.
[**8-2**]: cr 0.88, hct 34.1, M-protein <0.2 g/dL, beta-2
microglobulin was 3.38, IgG 294, IgA <7, IgM <9. Serum free
kappa
1562, free lambda 0.68. Urine with kappa 760 mg/dL and 24 hour
collection revealed kappa light chain of 10.6 grams/24h.
[**2149-8-12**]: skeletal survey negative
[**2149-8-15**]: bone marrow bx: 100% CD138 positive kappa restricted
cells ("sections of the biopsy and clot show a marrow which has
been almost entirely replaced by a population of plasma cells.)
[**2149-9-9**]: started velcade/decadron. With cycle 2 revlimid (15 mg)
added, but was stopped within two weeks because of severe
stomach
cramps. Subsequently continued on velcade/decadron alone.
Velcade
was given at a reduced dose. Also monthly zometa.
[**2150-2-5**]: bone marrow bx: monoclona kappa plasmacytosis comprises
approximately 70-80% total bone marrow cellular elements
[**2150-2-17**]: changed to velcade (increased to 1.3 mg/m2), revlimid
(10 mg daily, 2 weeks on/1 week off), cytoxan (500 mg/m2 D1 and
D8), dexamethasone (10 mg twice weekly). Cycle 4 started
[**2150-4-21**].
[**2150-4-23**]: bone marrow bx: bone marrow involvement by a monoclonal
kappa-restricted plasma cell neoplasm, comprising 70% of marrow
elements
[**2150-4-24**]: last treatment (C4D4); further treatment held
[**2150-4-29**]: skeletal survey negative, panorex no focal lesion
[**2150-5-25**]: bilateral bone marrow biopsy done by Dr. [**Last Name (STitle) 87663**]. Report
not available at this time but per patient, 70% involvement on
one side, 80% on the other
[**6-29**] and [**2150-7-20**] Cytoxan, 2 intermediate dose pulses
[**2150-8-6**] BM bx at Dr.[**Name (NI) 87664**] office showing 20% involvement of
BM by myeloma cells.
.
PAST MEDICAL HISTORY:
1) Rheumatoid arthritis diagnosed in the mid [**2119**]. Rheumatoid
factor negative per patient. She has been treated with multiple
anti-inflammatory agents as well as methotrexate for several
years. However, she has been off any therapy for this for >7
years. Her rheumatologist is Dr. [**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 79**] in [**Hospital1 1559**] MA.
2) Irritable bowel syndrome
3) Lactose intolerance
.
PAST SURGICAL HISTORY:
1) Port a cath placement [**2149-9-25**]
2) Left 2nd and 3rd toe surgery (to fix RA deformity) [**2144**]
3) Left 5th finger surgery (for RA deformity) [**2141**]
4) bilateral breast reduction [**2122**]
Social History:
She worked as a social worker at [**Name (NI) 87665**] extended care long
term acute care hospital. She has been married for 36 years. She
has one son who is 31 years old who has had substance abuse and
mental health issues. She drinks wine daily, smokes [**2-26**]
cigarettes daily (prior [**1-25**] PPD x 25 years), and denies illicit
drug use.
Family History:
There is no history of hematologic disorders. Her mother died of
lung cancer at 55. Her father died of an unclear cancer at 46 -
it may have been mesothelioma or stomach cancer. She has 3
sisters - one of her sisters has osteoarthritis, polymyalgia
rheumatica, and fibromyalgia. The other two sisters are healthy.
Physical Exam:
PHYSICAL EXAM:
Tc 98.8, Tm 101, BP 120/74, HR 102, RR 18, O2 98% RA
Gen: awake, alert, oriented x 3
EENT: EOMI, PERRL, dry mucus membranes with no oral lesions
Neck: supple with no lymphadenopathy
Heart: RRR without audible murmurs
Lungs: clear to auscultation bilaterally with no crackles or
wheeze, slightly decreased breath sounds in the LLL
Abdomen: + BS, soft, non-distended, no tenderness to palaption,
no appreciable hepatosplenomegaly
Extremities: no edema
Skin: + R sided port-a-cath with no erythema surrounding it.
Patient has one slightly erythematous spot on her R shoulder.
Pertinent Results:
LABS:
Admission labs:
[**2150-11-8**] 12:10AM BLOOD WBC-2.9* RBC-2.85* Hgb-9.0* Hct-26.9*
MCV-94 MCH-31.6 MCHC-33.5 RDW-16.2* Plt Ct-52*
[**2150-11-8**] 12:10AM BLOOD Neuts-63 Bands-1 Lymphs-23 Monos-13*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2150-11-8**] 12:10AM BLOOD PT-14.7* PTT-43.3* INR(PT)-1.3*
[**2150-11-8**] 12:10AM BLOOD Glucose-97 UreaN-6 Creat-0.5 Na-138 K-3.8
Cl-104 HCO3-23 AnGap-15
[**2150-11-8**] 12:10AM BLOOD ALT-13 AST-23 LD(LDH)-204 AlkPhos-49
TotBili-0.3
[**2150-11-8**] 12:10AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.9
Infectious work up:
[**2150-11-12**] 05:28PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.1
[**2150-11-12**] 05:28PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG - neg
[**2150-11-12**] 05:28PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM- neg
[**2150-11-12**] 05:28PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA [**Doctor Last Name **]) IGG/IGM- neg
[**2150-11-12**] 05:28PM BLOOD B-GLUCAN- neg
[**2150-11-11**] 10:16AM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-3* Polys-0
Lymphs-83 Monos-14 Atyps-3
[**2150-11-11**] 10:16AM CEREBROSPINAL FLUID (CSF) TotProt-55*
Glucose-56 LD(LDH)-14
[**2150-11-11**] 10:16AM CEREBROSPINAL FLUID (CSF) WBC-7 RBC-4* Polys-0
Lymphs-88 Monos-10 Atyps-2
[**2150-11-13**] 06:56PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-3* Polys-0
Lymphs-75 Monos-25
[**2150-11-13**] 06:56PM CEREBROSPINAL FLUID (CSF) TotProt-51*
Glucose-54
[**2150-11-11**] 10:16AM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
[**2150-11-13**] 06:56PM CEREBROSPINAL FLUID (CSF) HERPES 6 PCR- neg
[**2150-11-13**] 06:56PM CEREBROSPINAL FLUID (CSF) EBV-PCR- neg
[**2150-11-11**] 10:16AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR- neg
[**2150-11-13**] 06:56PM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI
ANTIBODY INDEX FOR CNS INFECTION-PND
[**2150-11-13**] 06:56PM CEREBROSPINAL FLUID (CSF) ARBOVIRUS ANTIBODY
IGM AND IGG-PND
Heme labs:
[**2150-11-20**] 12:00AM BLOOD PEP-AWAITING F IgG-302* IgA-19* IgM-8*
IFE-PND
[**2150-11-16**] 05:40AM BLOOD Ret Aut-1.4
[**2150-11-21**] 12:00AM BLOOD Ret Aut-0.9*
[**2150-11-16**] 05:40AM BLOOD Gran Ct-[**2069**]*
[**2150-11-18**] 12:00AM BLOOD Gran Ct-1520*
IMAGING:
[**11-9**] CT abd/pelvis:
1. Resolution of the previously identified inflammatory changes
involving the sigmoid colon. No evidence for fluid collection.
2. Sigmoid diverticulosis without evidence for diverticulitis.
3. Subcentimeter hypodense lesion in the liver is too small to
characterize
but likely represents a cyst.
[**11-10**] MRI head:
1. No evidence of acute infarct, intracranial hemorrhage, or
space-occupying lesion.
2. No abnormal leptomeningeal or parenchymal enhancement.
3. Bones of the skull and of the visualized cervical vertebrae
show
heterogenously hypointense marrow signal on T1-weighted images,
which likely represents diffuse marrow infiltration by multiple
myeloma
[**11-11**] EEG:
This is an abnormal continuous ICU monitoring study because
of rhythmic and sharply contoured epileptiform discharges which
evolve
in frequency consistent with non-convulsive status epilepticus.
This
abates after administration of lorazepam, then recurred for
about two
hours, and remitted again after lorazepam and levetiracetam.
Toward the
end of the recording, several brief electrographic seizures
recurred.
[**11-11**] CSF flow cytometry:
No CD56 and CD138 double cells are seen.
[**11-19**] MRI neck:
1. Inflammatory change in the left neck posterior to the carotid
sheath at
level II/III. As detailed above, the differential includes
thrombosis of a
jugular venous tributary versus prominent lymph nodes with
adjacent
inflammatory change. There is no focal fluid collection to
suggest abscess.
CT of the neck with contrast could be helpful for further
evaluation, if
feasible. Alternatively, ultrasound could be considered.
2. Mild fat stranding in the submandibular region.
3. Patchy partial opacification of the bilateral mastoid air
cells.
[**11-20**] Neck US:
Normal-appearing lymph nodes throughout the left-sided cervical
soft tissues, which do not appear pathologically enlarged. No
venous
thrombosis seen within the internal jugular vein or adjacent
venous
tributaries.
[**11-23**] EEG:
This is an abnormal continuous ICU monitoring study because
of slow alpha rhythm, mild diffuse background slowing, and brief
bursts
of generalized delta activity. These findings are indicative of
mild to
moderate diffuse cerebral dysfunction, which is etiologically
nonspecific. No electrographic seizures are present
[**11-23**] MRI head:
1. No space-occupying mass lesion, infarction, or hemorrhage.
2. No abnormal leptomeningeal or parenchymal enhancement.
3. Stable heterogeneous T1 hyperintensity within the skull and
upper cervical spine, findings suggestive of marrow infiltration
by multiple myeloma.
[**11-25**] Echo:
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No valvular pathology or pathologic flow identified.
Compared with the prior study (images reviewed) of [**2150-8-27**], the
findings are similar.
Brief Hospital Course:
59 yo woman with rheumatoid arthritis and multiple myeloma now
s/p autoSCT D+22, presenting with weakness, chills and fever to
101.0F. Previous admission for SCT complicated by
diverticulitis/sigmoiditis, esophagitis, and possible pneumonia,
discharged on Levofloxacin, now returning with fever and
dehydration, as well as ongoing diarrhea and AMS.
.
ACTIVE ISSUES:
.
#. AMS, Fever without neutropenia: concern for underlying
infection, concerning for diarrhea and worsening MS. [**First Name (Titles) **] [**Last Name (Titles) 28864**], was oriented X3, but hypersensitive and saying
strange sentences. 24 hours later, patient was drowsy, sensitive
to touch, tremulous, and oriented X 0-1. Neuro exam nonfocal.
Patient with negative microbiologic work up during last hospital
stay, Blood and Urine cultures NGTD from [**11-9**]. CXR without
signs of pathology, abdomen benign. CT abd WNL, diverticulitis
from last admission resolved. Blood cultures drawn. Started on
empiric aztreonam and vancomycin. Head MRI showed no acute
pathology. Neuro consulted and lumbar puncture performed showing
slightly elevated protein and 88% lymphocytes. Patient was given
supportive care. Given change in mental status, patient was
transferred to the [**Hospital Unit Name 153**] and EEG performed suggested patient was
having seizures. Patient was loaded with keppra and dilantin and
seizures had resolved x 4 days prior to transfer out of [**Hospital Unit Name 153**] on
[**2150-11-17**]. Repeat MRI head again did not show any abnormality,
and repeat 24 hr EEG [**Date range (1) **] did no show sign of seizure but
generalized mild slowing. The source of her seizures remains
unclear at this point, though a viral encephalitis is though to
be the most likely etiology. She was continued on Dilantin and
Keppra throughout her course and was followed by neurology. She
will be seen in the neuro clinic for outpatient follow up within
the next month.
.
#MM s/p SCT: Patient s/p recent autostem cell transplant
(discharged the day prior to this admission), admitted from Hope
Lodge. Continued Atovaquone and Acyclovir prophylaxis, CBC
monitored. She remained pancytopenic for the majority of her
admission, which is unusual for being this far out from a
autoSCT, as one would expect a more robust recovery of counts.
She required 2 units PRBCs and 1 unit plts throughout her stay
to keep hct >21, plts >11. She was also transfused IVIg to help
support her through her presumed viral illness, given that her
Ig counts remained low. Her WBC and Hct began to recover
slightly, however her platelets remained low, prompting some
concern for secondary thrombocytopenia. One possibly etiology
is the dilantin, which she was started on for seizures (see
above). Direct antiplatelet antibody negative, DAT negative.
She was discharged with a plan to follow up with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) **] in clinic the following day for continued care for
her multiple myeloma.
.
# Candidal esophagitis: developed a severe case of candidal
esophagitis that prevented her from taking PO meds or nutrition
for 1-2 days. This resolved upon re-starting fluconazole at
treatment dose.
.
# Tachycardia: persistently in sinus tachycardia throughout her
hospital stay, thought to be due to sympathetic drive given her
illness. Not responsive to fluids. She was also hypertensive to
the systolic 150s. Echocardiogram was normal. She was started
on metoprolol at 12.5 [**Hospital1 **] with improved control of her rate and
pressures.
.
INACTIVE ISSUES:
.
# Nausea: continue prochlorperazine
.
# Pain: continue Oxycodone
.
# Rheumatoid Arthritis: Currently stable.
.
# Bowel Regimen: continue Docusate
.
.
TRANSITION OF CARE ISSUES:
- Needs a follow up dilantin level sometime between [**Date range (1) 87667**]
(5-7 days after last change in dosage)
- Will need to follow up with neurology for further care and
monitoring for her seizures
- Follow up BP and HR control on metoprolol
Medications on Admission:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days: take on [**2150-11-9**], [**2150-11-10**], [**2150-11-11**].
Disp:*3 Tablet(s)* Refills:*0*
2. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
Disp:*30 Cap(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
8. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO Q6H
(every 6 hours) as needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
9. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO once a
day.
Disp:*300 ml* Refills:*2*
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for nausea.
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
3. B complex vitamins Capsule Sig: One (1) Capsule PO once a
day.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
6. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for nausea.
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
9. levetiracetam 100 mg/mL Solution Sig: Five (5) ml (500 mg) PO
BID (2 times a day).
Disp:*300 ml * Refills:*2*
10. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO every AM.
Disp:*30 Capsule(s)* Refills:*2*
11. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. phenytoin 50 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables
PO every PM.
Disp:*45 Tablet, Chewable(s)* Refills:*2*
14. Outpatient Lab Work
Please draw phenytoin (dilantin) level, and please note the time
of the draw and time of last dose.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Multiple myeloma
Autologous transplant status
Non-convulsive status epilepticus
Esophageal candidiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure being involved in your care while you were at
[**Hospital1 18**]. You were admitted to the hospital because of fevers and
confusion. You were sent to the intensive care unit, and it was
found that you were having non-convulsive seizures that caused
you to be confused but not have any jerky movements like typical
seizures. It is still not clear exactly why you had these
seizures, but we believe that they may have been due to a viral
infection, which appears to have gone away. You were started on
two anti-seizure medications (Dilantin and Keppra), and you will
be followed by a neurologist in the epilepsy clinic. You will
also need to have levels of this medication checked in the next
5-7 days.
Your fevers were likely due to a viral infection, perhaps the
same viral infection that caused your seizures. You also had a
severe thrush infection that could have made your fevers worse.
We took many blood and urine cultures, chest xrays, and tests on
your spinal fluid, and no source was ever found.
You will need to follow up very closely in clinic as you
continue to recover from your transplant and this recent
illness.
Medication changes:
START fluconazole 200 mg daily (for thrush)
START levetiracetam (keppra) 500 mg twice daily (anti-seizure)
START phenytoin (dilantin) 100 mg in AM, 75 mg in PM
(anti-seizure)
START metoprolol tartrate 25 mg twice daily (for heart rate and
blood pressure)
Followup Instructions:
Neurology follow up appointment:
This appointment is still in the process of being made. They
will call you once you have an appointment.
Department: BMT/ONCOLOGY UNIT
When: THURSDAY [**2150-11-26**] at 9:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2150-11-26**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BMT CHAIRS & ROOMS
When: THURSDAY [**2150-11-26**] at 9:30 AM
|
[
"2762",
"5990",
"42789"
] |
Admission Date: [**2136-3-31**] Discharge Date: [**2136-4-3**]
Date of Birth: [**2059-6-23**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old
male with a history of hypertension, no known coronary artery
disease who presented with intermittent chest pain times a
few days with walking, swimming, exertion in the sauna.
Would have substernal chest pain, but no radiation that
resolved with rest. The patient awoke on the day of
admission at 5:00 a.m. with constant burning substernal chest
pain with mild to moderate shortness of breath. The patient
woke up from sleep. Positive orthopnea. No palpitations.
No lightheadedness, dizziness or nausea or vomiting. The
patient went to the [**Hospital1 69**].
Electrocardiogram showed 3 to [**Street Address(2) 5366**] elevations in V1
through V6. An emergent cardiac catheterization was
performed and he received two left anterior descending
coronary artery stents, taxes coated. The pain decreased to
2 to 3 out of 10. The patient experienced nausea and
vomiting after receiving cystine and then was sent to the
Cardiac Care Unit for monitoring.
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS:
1. Captopril 50 mg b.i.d.
2. Doxazosin 4 mg q.h.s.
PAST MEDICAL HISTORY:
1. Hypertension.
2. No known coronary artery disease.
3. Gastroesophageal reflux disease.
4. Benign prostatic hypertrophy.
CARDIOVASCULAR RISK FACTORS: No history of diabetes
mellitus. No history of hypercholesterolemia. No family
history.
SOCIAL HISTORY: Retired mechanical design engineer.
Married. Lives in [**Last Name (un) 11209**]. No tobacco. Rare alcohol
use. No intravenous drug use.
FAMILY HISTORY: No coronary artery disease.
PHYSICAL EXAMINATION: Temperature 97.2. Heart rate 58.
Blood pressure 154/80. Respiratory rate 19. Weight 80.5
kilograms. No acute distress. Alert and oriented times
three. JVP approximately 10 cm. Bilateral basilar crackles
a third of the way up. Regular rate with normal S1 and S2.
No S3 or S4. Peripheral pulses dorsalis pedis pulses 2+.
Electrocardiogram [**3-31**] after the catheterization normal
sinus rhythm, normal axis, normal intervals, 2 to [**Street Address(2) 2051**]
elevations in V2, V4, V1 through V4, Qs. No echocardiogram.
Cardiac catheterization showed stenosis of the left anterior
descending coronary artery and received two taxes coated
stents.
LABORATORY: CPK of 135, troponin .14, myoglobin 17, white
blood cell count 6.9, hematocrit 42, platelets 169.
Electrolytes sodium 138, potassium 4.5, chloride 104, BUN 24,
bicarbonate 27, creatinine 1.3, glucose 113, INR 1.0, PTT
24.1. Arterial blood gas 7.39/42/116. Chest x-ray showed no
congestive heart failure or effusions. Hemodynamics right
sided heart catheterization, right atrium 12, right ventricle
40/12, PA 40/16, pulmonary capillary wedge 24, aortic 160/80.
HOSPITAL COURSE: 1. Cardiovascular: The patient following
the placement of the taxes stents was monitored in the
Cardiac Care Unit for two days. The patient was initiated on
aspirin, Plavix and Captopril 25 mg b.i.d. The patient
receive 18 hours worth of Integrilin therapy following the
stent placement and then was discontinued. The patient was
then initiated on Lipitor 40 mg q.d. and became chest pain
free within several hours following the cardiac
catheterization. His peak CK myoglobin was greater then 500
and his peak troponin was greater then 4. After pulling the
cardiac sheath heparin was initiated, because of an
echocardiogram, which showed an EF of approximately 35%,
right and left atrial mild dilatation, left ventricular
hypertrophy symmetric, moderate mild pulmonary artery
hypertension of 35, trace aortic regurgitation, 1+ mitral
regurgitation. There was concern that he may have with a low
EF and a recent myocardial infarction the patient would
benefit from electrophysiology consultation and they have
been notified and he will follow up with them in one week
regarding AICD placement. They have also come to see the
patient prior to discharge. The patient was initiated on
Coumadin 2.5 mg with a goal INR of 2 to 2.5 while the patient
is taking aspirin and Metoprolol to try to prevent any
bleeding computations along with the sort of mild right groin
hematoma that he has. The patient will follow up at [**Hospital3 10400**] regarding his INR. The patient will follow up with
EP on [**4-11**] at 1:00 p.m. regarding AICD placement.
2. Fluid and electrolytes: The patient tolerated a cardiac
diet and was up walking around. The patient was seen by
physical therapy and recommended to undergo cardiac rehab.
DISCHARGE PLAN: To home.
DISCHARGE STATUS: The patient was chest pain free, not short
of breath and able to walk and feed himself without
difficulties.
DISCHARGE DIAGNOSES:
ST elevation myocardial infarction status post left anterior
descending coronary artery stents.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Plavix 75 mg q.d.
3. Atorvastatin 40 mg q.d.
4. Protonix 40 mg q.d.
5. Lisinopril 10 mg q.d.
6. Warfarin 2.5 mg q.h.s.
DISCHARGE PLAN:
1. The patient will follow up with Dr. [**Last Name (STitle) 1266**] on Thursday
regarding his INR goal just to make it therapeutic from 2 to
2.5 for the risk of thrombus within the left ventricular with
an anterior myocardial infarction and low EF.
2. The patient will follow up with
Electrophisiology/Cardiology on Wednesday [**4-11**] at 1:00
p.m. on the [**Location (un) 861**] of the [**Hospital1 **] Building for
possibility of an AICD and a recent myocardial infarction
with low EF.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 26705**]
MEDQUIST36
D: [**2136-4-3**] 01:33
T: [**2136-4-4**] 05:59
JOB#: [**Job Number 101465**]
|
[
"41401",
"4019"
] |
Admission Date: [**2162-11-13**] Discharge Date: [**2162-11-19**]
Date of Birth: [**2108-1-13**] Sex: M
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is a 54 year-old Caucasian
male with no significant past medical history who was
admitted on [**2162-11-13**] for new generalized tonic clonic
admission and noted her husband to be gargling, unresponsive
the hospital he had two additional generalized tonic clonic
seizures and was intubated in the Emergency Department for
airway protection. He had been afebrile prior to admission,
but in the Emergency Department he was febrile to 101 degrees
and hemodynamically stable. Head CT was negative. Chest
further evaluation. He was also noted to have seizure like
activity in his extremities while being transferred to the
In the MICU an LP was performed, which showed the following
results: 1 white blood cell, 171 red blood cells, 10% polys,
2% bands, 63% lymphocytes, 22% monocytes and 3% basophils.
They also noted new petechial rash that was all over the body
except for the face, and were concerned about a possible viral
meningitis. On admission he was started on Acyclovir to cover
for HSV meningitis, which was stopped 24 hours later.
On admission he also had a lactacidosis with a lactate level
of 15 and anion gap metabolic acidosis. This was thought to
be likely secondary to multiple seizures. He also had
lymphocytosis up to 29.3, which was in part, because of seizure
activity and some dehydration. Urine tox and blood tox screens
were negative. Lead level was 3, which was within normal limits.
Blood cultures continue to be negative as well as urine cultures.
Sputum culture on [**2162-11-16**] showed >25 PMNs and less then 10
epis with 4+ gram positive cocci and 3+ gram negative rods.
With his new petechial rash meningococcemia could not be
ruled out and he was started on Ceftriaxone. However, his
rash resolved and he continued to spike fevers. He was found
to have pneumonia by chest x-ray possibly aspiration pneumonia in
etiology. However, he denied cough or excess sputum production.
Mr. [**Known lastname 99083**] was extubated on [**2162-11-15**]. He was transferred to
the medical service for further evaluation.
PAST MEDICAL HISTORY: 1. Nephrolithiasis. 2. Possible
asthma. 3. Gastroesophageal reflux disease. 4. "Liver
disease." Biopsy in 8/99 showed focal mild ductal proliferation,
mild fatty infiltrate and focal nonspecific portal chronic
inflammation possibly consistent with extrahepatic bile duct
obstruction. Peak AST was 140. ALT 240, alkaline phosphatase
408 and T bili 6 in 8/99. He was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
for further evaluation of his liver. Of note, Mr. [**Known lastname 99083**] is
hepatitis B surface antibody positive secondary to vaccination.
Hepatitis A and hepatitis C negative and [**Doctor First Name **] negative. At that
time he had been placed on Actigall and counseled for weight loss
and his liver function tests normalized.
ALLERGIES ON ADMISSION: None.
MEDICATIONS AT HOME: Prilosec, Viagra, Aleve, aspirin, Actigall.
MEDICATIONS ON TRANSFER TO THE MEDICAL FLOOR: Protonix,
Ceftriaxone and Dilantin.
SOCIAL HISTORY: Mr. [**Known lastname 99083**] lives with his wife. [**Name (NI) **] has a
history of alcohol use and still occasionally uses this. He
denies tobacco use. He is a firefighter.
FAMILY HISTORY: Positive for coronary artery disease in
father and brother. Negative for cancer.
HOSPITAL COURSE: As stated above Mr. [**Known lastname 99083**] was admitted to
the MICU from [**2162-11-13**] until [**2162-11-17**] at which time he
was transferred to the [**Hospital1 139**] Medicine Floor on Far 7.
PHYSICAL EXAMINATION ON TRANSFER: Temperature 98.6 though T
max was 103 during the MICU stay. 79% on 2 liters nasal
cannula. In general, he was alert and oriented times three
with slow speech. HEENT pupils are equal, round and reactive
to light. Extraocular muscles are intact. Positive
nystagmus to the right. No oropharyngeal lesions. No
lymphadenopathy. Cardiovascular, regular rate and rhythm.
No murmurs, rubs or gallops. Respiratory, crackles at the
right base and decreased breath sounds at the left base with
mild expiratory wheezing. Abdomen, obese, soft, nontender,
nondistended. Liver could not be appreciated secondary to
obesity. Extremities no edema. Neurological, cranial nerves
II through XII intact. Strength 5 out of 5 bilaterally.
Deep tendon reflexes 2+. Negative Babinski.
LABORATORIES ON ADMISSION: Hematocrit of 51, white count
29.3, platelet 312. Chem 7, sodium 152, potassium 4.1,
chloride 102, bicarb 9, creatinine 1.6, BUN 32, sugar 222,
anion gap 41, PT/INR 1.4, PTT 31.3. Arterial blood gas
showed pH 7.16, CO2 39, oxygen 98 and lactate 15.
LABORATORIES ON TRANSFER: White blood cell count 8.3,
hematocrit 26.6, platelet 143, PT 12.0, PTT 22, INR 1.0.
Chem 7, sodium 144, potassium 3.9, chloride 107, bicarb 28,
BUN 17, creatinine 0.9, sugar 118, LD 797, T bili 0.6, ALT
35, AST 57, alkaline phosphatase 71, T bili 0.7.
HOSPITAL COURSE: 1. Neurological: As stated before Mr.
[**Known lastname 99083**] has never had seizures before, but suffered at least
one at home, two in the ambulance and some epileptic
extremity movement was noted in the MICU. However, CT was
negative for bleed or mass. MRI showed no evidence of infarct,
however, there was some focal abnormalities in the left frontal
lobe and in the right paraventricular region that are
nonspecific. There is also left frontal lesion that could be
secondary to an old lacunar infarct. No signs of demyelinating
disease or encephalitis. There is no abnormal enhancement of the
soft tissue. Electroencephalogram was done on [**2162-11-16**], which
showed global slowing, but no active seizure activity. He was
initially started on Ativan in part, because of the intubation
requiring sedation, but also for seizure control and then was
transitioned to Phenytoin. However, Phenytoin was changed to
Depakote due to liver enzyme abnormalities. As stated before, he
had been placed on 24 hours of Acyclovir for presumed HSV
meningitis, which was discontinued. He also received four
days of meningitis dose Ceftriaxone that was changed to
pneumonia dosed Ceftriaxone. He was followed closely by
neurology and will follow up as an outpatient when he is
discharged.
2. Respiratory: As stated above Mr. [**Known lastname 99083**] was intubated on
[**2162-11-13**] and extubated without problem on [**2162-11-15**].
However, he continued to have fevers and had a chest film
that showed possibly new infiltrate. However, a chest x-ray
was repeated on [**2162-11-18**] and Ceftriaxone was discontinued as
the chest x-ray was negative.
3. Gastrointestinal: Mr. [**Known lastname 99084**] hematocrit on admission
was 51, which was likely secondary to dehydration. However,
his hematocrit continued to drop down to 35 and then below
and a new source of bleeding was evaluated. He was guaiac
negative, however, there seemed to be a new lesion in the mouth
that was actively bleeding, thought to be due to a traumatic
intubation. ENT cauterized the lesion and placed Surgicel on it.
Hematocrit was followed and stabilized at 26 and since has made
some recovery. Furthermore, on [**2162-11-18**] AST, ALT were rising,
which was unusual for Mr. [**Known lastname 99084**] current liver history. Most
recent liver function tests as an outpatient were within normal
limits. Transaminitis may be secondary to Phenytoin, and for
this reason phenytoin was discontinued as previously discussed.
4. Hematology: Hematocrit was closely followed as stated
above. Also some amount of coagulopathy was possibly secondary
to liver dysfunction or DIC was carefully monitored. D-dimer was
greater then [**2161**] and he had a whole body petechial rash. He
received two units of fresh frozen plasma on [**2162-11-14**]. However,
the coagulopathy corrected after hydration.
DISPOSITION: Mr. [**Known lastname 99083**] was full code. He will be discharged to
home to follow up with neurology next month . He will likely
require AED treatment for approximately three to six months. He
should not drive or participate in active firefighting duty
during that time.
MEDICATIONS ON DISCHARGE: Same as home medications plus AED,
Depakote 250 mg po bid through [**11-24**], then 500 mg po bid.
He will follow-up with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in [**Location (un) 99085**] [**Telephone/Fax (1) 8927**]. He will also follow-up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in the neurology clinic. He will have repeat blood
work, including a depakote level, checked on [**2162-11-24**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**]
Dictated By:[**Name8 (MD) 8073**]
MEDQUIST36
D: [**2162-11-18**] 14:47
T: [**2162-11-19**] 06:52
JOB#: [**Job Number 99086**]
|
[
"5070",
"2762",
"53081"
] |
Admission Date: [**2129-7-3**] Discharge Date: [**2129-7-8**]
Service: CCU
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF THE PRESENT ILLNESS: The patient is an
87-year-old female with a history of known coronary artery
disease with three VD, refused CABG in the past,
hypertension, high cholesterol, who presented with acute
onset of shortness of breath and respiratory distress to
[**Hospital **] Hospital. The patient had been in her usual state of
health until 5 am on the day of admission when she developed
sudden shortness of breath. At [**Hospital **] Hospital she was
noted to have a saturation of 84% on a nonrebreather. ABG
showed pH of 7.14, and pO2 of 66. The patient was intubated
with slight improvement at 7.28, 51, and 200. She was then
transferred to [**Hospital1 69**] for
further management. The patient was transferred to [**Hospital1 1444**], where she arrived intubated
on a nitro drip, having already received some Lasix at
[**Location (un) **]. She had received Lasix that resulted in decrease in
her blood pressure to the 140s from the 180s with a good
urine output. Upon arrival in our emergency room she
received 40 mg more of IV Lasix and the ABG at that time
showed 7.36, 50, and 192. Upon arrival to [**Location (un) **], the
patient denied any chest pain, but noted shortness of breath.
Her first CK and troponin were flat.
PAST MEDICAL HISTORY:
1. CAD with three VD. The patient had a catheterization one
year ago that showed as follows: LAD with a 99% proximal
stenosis, circumflex with a 90% discrete proximal stenosis,
RCA with a total occlusion in the proximal segment. The
patient has refused CABG. She had an echocardiogram one year
ago that showed the EF of 15%.
2. High cholesterol.
3. Hypertension.
MEDICATIONS ON ADMISSION: (per report)
1. Nadolol.
2. Lasix.
3. Aspirin.
4. Isordil.
5. Accupril.
6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**].
7. Zocor.
8. Plavix.
After the patient was extubated per her report, the
medications she was taking were as follows:
1. Nadolol 40 q.d.
2. Lasix 40 b.i.d.
3. Isordil 40 t.i.d.
4. Aspirin.
The patient had discontinued Plavix, as well as her ACE
inhibitor and statin.
ALLERGIES: The patient DEVELOPS A SKIN REACTION FROM PLAVIX.
SOCIAL HISTORY: The patient lives alone in [**Location (un) **]; one son
lives nearby and one son lives in [**Name (NI) 531**].
PHYSICAL EXAMINATION: Examination revealed the pulse of 58,
blood pressure 132/65. Vent was at IMV with a rate of 10,
tidal volume of 500, FIO2 of 100% and a PEEP of 5. ABG:
Settings of 7.36, 50, and 192. GENERAL: The patient was
intubated and arousable. HEENT: Pupils equal, round, and
reactive to light; ETT in place, OG in place. NECK: Neck
was supple. LUNGS: Basilar rales anteriorly.
CARDIOVASCULAR: Regular, normal S1 and S2. No murmurs,
rubs, or gallops. ABDOMEN: Soft, nontender, nondistended,
positive bowel sounds. EXTREMITIES: No edema.
NEUROLOGICAL: The patient is intubated and sedated,
arousable and moving all extremities.
LABORATORY DATA: Data on admission revealed the following:
Labs at the outside hospital were significant for a CK of 37,
troponin of less than 0.2, normal CBC and chemistry, lipase
of 347, and amylase of 107. Upon arrival here, white count
was 14.2, hematocrit 37, platelet count 791,000, sodium 134,
potassium 4.4, chloride 99, bicarbonate 26, BUN 25 and
creatinine 1.0 with a glucose of 102, CK 70, troponin 1.8,
INR of 1.7 and PTT of 139. EKG: Normal sinus rhythm at a
rate of 57 with normal axis and normal intervals with Q wave
in three and T-wave flattening in 1, AVL, and V6. Chest
x-ray: ETT tube in place with pulmonary edema and possible
right upper lobe infiltrate.
HOSPITAL COURSE: The patient is an 87-year-old female with
known severe coronary artery disease, who presented with
acute onset of pulmonary edema, hypoxia, and acidosis
requiring intubation at an outside hospital. By arrival to
[**Hospital1 69**] the acidosis and hypoxia
were improved status post intubation and diuresis.
CARDIAC: The patient has known three VD as noted above. She
has refused CABG or catheterization at this time. Heparin
was continued and aspirin was continued. Plavix was not
resumed due to a skin reaction the patient develops with
Plavix.
The CKs and troponins were cycled. She had a peak troponin
of 2.6 on the 27th.
MYOCARDIUM: The patient comes in heart failure, requiring
intubation. She was placed on ACE inhibitor and nitrates.
Initially, she was on a nitroglycerin grip, which was changed
to p.o. nitrates. The CHF improved, status post IV Lasix.
The patient was able to be extubated on the day after
admission without difficulty. She was transferred to the
floor and later that evening, the same day of extubation, she
again developed flash pulmonary edema that was unresponsive
to 120 IV Lasix. The patient required repeat intubation at
that time. She was able to be extubated within 12 hours of
the second extubation. Of note, on the second intubation,
she again had a respiratory acidosis with pH of 7.11. She
was hypoxic with oxygen saturation of 78% on a nonrebreather.
All of these numbers improved after re-intubation. She also
showed some ST depression in 1, 2, AVL, V5 and V6 during that
episode. The CK and troponins did not lump after the
reintubation. The patient was easily extubated the day
following and aggressively diuresed with p.o. and IV Lasix
with a goal of one liter negative daily. By the day of
discharge, the patient was on 80 b.i.d. of p.o. Lasix and she
has been receiving p.r.n. Lasix to keep her a liter negative.
The rales have significantly improved on examination, such
that on the 31st, she just had basilar rales and she was over
one liter and one half negative for her fluid balance. She
was titrated up on her Isordil and Captopril and on Captopril
25 t.i.d. and Isordil 30 t.i.d. on discharge. Medications
were limited based on initial hypotension, which gradually
improved, such that her blood pressures were in the high 90s
to the one teens. Beta-blocker was not restarted due to her
bradycardia in the 50s to 60s. This needs to be resumed by
the patient's primary cardiologist. The patient remained in
normal sinus rhythm with one episode of SVT on telemetry and
no other events.
PULMONARY: The patient arrived intubated for flash pulmonary
edema. The patient was extubated the next day. She
developed flash pulmonary edema again and required
intubation. She was extubated quickly and then her pulmonary
status remained good. She was weaned off O2 and at the time
of discharge the saturations were 95% to 100% on room air.
GASTROINTESTINAL: The patient presented with elevated
Amulase and lipase. These were repeated and came into within
normal limits at our hospital. We did not work this up
further.
INFECTIOUS DISEASE: The patient initially presented with
elevated white count and a question of infiltrate on chest
x-ray. On repeat x-ray this resolved and sputum cultures
were negative for infection.
HEMATOLOGY: The patient had a thrombocytosis most likely
reactive. She was initially on heparin, which was continued
and discontinued several days prior to discharge. She was
continued on aspirin and Plavix. This was discontinued due
to her skin reaction to the Plavix.
DISCHARGE STATUS: The patient has improved CHF at the time
of discharge. The patient is on increased doses of Lasix,
Captopril, and Isordil. Medications will need to be titrated
up per the rehabilitation and per the patient's primary
cardiologist. Beta-blocker ultimately should be
re-administered.
The patient will be discharged to [**Hospital 3058**] rehabilitation
on the following medications:
DISCHARGE MEDICATIONS:
1. Lasix 80 mg p.o. b.i.d.
2. Isordil 30 mg p.o.t.i.d.
3. Captopril 25 p.o.t.i.d.
4. Aspirin 325 p.o.q.d.
5. Colace 100 p.o.b.i.d.
6. Senna and Dulcolax p.r.n.
FOLLOW-UP CARE: The patient needs to followup with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4640**], cardiologist in [**Location (un) **]. Phone #:
[**Telephone/Fax (1) 37180**]. She should followup in one week. The patient
should have her I&Os monitored closely, as well as her
weights with a goal I&O even to negative until she is
adequate diuresed. The BUN, creatinine, and potassium should
be followed given her aggressive diuresis. ACE inhibitor and
Isordil should be titrated up and as tolerated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2129-7-8**] 11:26
T: [**2129-7-8**] 12:07
JOB#: [**Job Number 42103**]
|
[
"4280",
"41401",
"2762",
"42789",
"4019",
"2720"
] |
[**Numeric Identifier 40635**]
Admission Date: [**2124-4-7**] Discharge Date: [**2124-4-12**]
Date of Birth: [**2124-4-7**] Sex: M
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 40636**] #1 was born at
36 weeks gestation by a cesarean section for
pregnancy-induced hypertension and a breech-breech
presentation of twins. The mother is a 37 year-old gravida
positive, antibody negative, rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group B strep unknown.
The pregnancy was complicated by pregnancy-induced
hypertension. This infant emerged requiring vigorous
stimulation, blow-by oxygen and suctioning for copious
amounts of secretions. He developed grunting and retraction
with decreased breath sounds in the delivery room. His
Birth weight was 2,750 grams in the 60th percentile for
gestational age. His length was 48 cm in the 70th percentile
and head circumference was 33.5 cm, in he 70th percentile.
His admission physical examination revealed an active
nondysmorphic preterm infant, anterior fontanelle soft and
flat, palate intact, fair aeration, wet breath sound, no
murmur. Normal pulses. Abdomen soft, three vessel umbilical
cord, no hepatomegaly, normal male genitalia with testes
descended bilaterally. No hip click, sacral dimple and age
appropriate tone and reflexes.
NEONATAL INTENSIVE CARE UNIT BY SYSTEMS:
Respiratory status: He was placed on nasopharyngeal
continuous positive airway pressure soon after admission to
the Neonatal Intensive Care Unit and that was discontinued at
four hours of age. He was weaned to room air where he has
remained since that time. At the time of transfer to newborn
nursery [**4-9**], and subsequently, his respirations were comfortable.
Lung sounds are clear and equal.
Cardiovascular status: He has remained normotensive
throughout his Neonatal Intensive Care Unit stay. He has
normal S1, S2 heart sounds and no murmur. There are no
cardiovascular issues.
Fluid, electrolyte and nutrition status: Enteral feeds were
begun on day of life #1 and advanced without difficulty. He
is eating Enfamil 20 calories per ounce on an ad lib
schedule. His mother plans to breast feed, has been
attempting breast feeding and pumping in addition to giving
formula. His weight has stabilized and at discharge he has begun
to regain weight.
Hematological status: His hematocrit at the time of
admission was 46.8 with platelets of 282,000. He has
received no blood products.
Infectious disease status: He had a blood culture drawn at
the time of admission. He has never required any
antibiotics. The blood culture was negative. His white count at
the time of admission was 18.2 with a differential of 30% polys
and 0 bands.
Social Status: Both mothers have been very involved in the
infant's care during his Neonatal Intensive Care Unit stay.
The infant's condition at discharge is good.
The infant was transferred to the Newborn Nursery for
continuing care on [**2124-4-9**] and discharged home on [**2124-4-12**].
Primary pediatric care will be provided by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 40637**] of
[**Hospital 1411**] Medical Associates, address is [**Doctor Last Name **], [**Location (un) 1411**],
[**Numeric Identifier 40638**], telephone number [**Telephone/Fax (1) 8506**]. Dr.
[**First Name (STitle) 40637**] was updated a few hours prior to the [**Hospital 40639**]
transfer to the Newborn Nursery and subsequently prior to
discharge.
Feedings at discharge are Enfamil 20 calories per ounce or
breast feeding on an ad lib schedule.
Infant is being discharged on no medications, to see Dr [**First Name (STitle) 40637**] on
Friday [**2124-4-14**].`
State screen has been sent, he has passed hearing screen in both
ears, received hepatitis B vaccine, and passed car seat test.
DISCHARGE DIAGNOSIS:
1. Twin #1.
2. Prematurity 36 weeks gestation.
3. Status post transitional respiratory distress.
4. Status post sepsis evaluation.
Dictated By:[**Last Name (NamePattern1) 40640**]
MEDQUIST36
D:
T: [**2124-4-9**] 07:03
JOB#: [**Job Number **]
|
[
"V290",
"V053"
] |
Admission Date: [**2125-11-1**] Discharge Date: [**2125-11-9**]
Date of Birth: [**2054-1-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Metoprolol
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Left hip fracture
Major Surgical or Invasive Procedure:
Open Reduction Internal Fixation of Left Femoral Neck Fracture
History of Present Illness:
HPI: Briefly, this is a 71 yo M with a history of CAD s/p
CABGx4, vascular dementia, ESRD on HD, prior TIAs, and recent
postive stress test, who was transferred to [**Hospital1 18**] after
sustaining a L femoral neck fx after a mechanical fall. ED
workup normal except for hip fx and EKG showing sinus brady with
first degree AV block and inferolateral abnormalities.
Intention for OR to fix hip, but in light of recent stress
results demonstrating reversible inferolateral changes, needs
clearance from cardiac standpoint before OR.
.
This morning, he complains of [**5-10**] pain in his left hip and some
minor discomfort in his lower back. Otherwise, he feels well,
and denies CP and SOB.
.
Review of systems:
(+) Per HPI, + orthopnea (2 pillows, 6-8 months), + chronic LBP
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations, PND, peripheral edema. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
-CAD s/p CABG, [**2114**])
-Positive stress test for reversible defects in lateral and
posterolateral walls, [**2125-10-5**]
-LV Diastolic Dysfunction
-HTN, labile
-Hyperlipidemia
-ESRD, on HD since [**2122**], MWF
-Anemia, secondary to ESRD, baseline hematocrit low 30s
-Hypertensive Encephalopathy
-Vascular Dementia
-Subcortical WMD w/ Brain atrophy
-Sleep apnea
-Osteoarthritis
-Spinal Stenosis
-Peripheral Neuropathy
-Depression
-GERD
-BPH
-Nephrolithiasis
Social History:
-Married with one son, one daughter
-Lives with wife in [**Name (NI) **]
-Independent in ADLs, including ambulation
-Tobacco: quit smoking 20 years ago, smoked approx 3
cigarettes/day for 20-30 years.
-Alcohol: none
-Illicits: none
Family History:
His mother died of a stroke at age 87, dad had brain surgery for
a tumor and died as a result of it. One sister has [**Name2 (NI) 8381**]
disease at 71, and one sister had a massive MI and passed away
in her 60's.
Physical Exam:
Admission Exam:
Vitals: T 97.7 BP 131/92 HR 77 RR 20 O2 96/RA
General: NAD, awake, talkative
HEENT: sclera anicteric, dMM, oropharynx clear
Neck: supple, no JVD, no LAD, * L carotid bruit.
Chest: lungs CTAB, 4-5 cm purple ecchymosis just superior to
left nipple
CV: RRR, no MRG
Abdomen: surgical scars consistent with history; soft, ND/NT, no
HSM, +BS
GU: foley in place, draining yellow urine
Ext: warm, well-perfused, non-palpable distal pulses, no edema
or ulcers
MSK: able to flex and abduct L thigh to 30 deg w/ mild pain.
severe TTP at L hip.
Neuro: AOX3, grossly intact, moving all extremities
Discharge Exam:
Pertinent Results:
Admission Labs:
[**2125-11-1**] 10:05PM BLOOD WBC-6.7 RBC-3.65* Hgb-10.6* Hct-34.7*
MCV-95 MCH-28.9 MCHC-30.4* RDW-20.2* Plt Ct-244
[**2125-11-1**] 10:05PM BLOOD PT-18.2* PTT-26.8 INR(PT)-1.6*
[**2125-11-1**] 10:05PM BLOOD Glucose-87 UreaN-28* Creat-5.7*# Na-142
K-3.8 Cl-103 HCO3-24 AnGap-19
[**2125-11-1**] 10:05PM BLOOD CK(CPK)-41*
[**2125-11-1**] 10:05PM BLOOD CK-MB-3 cTropnT-0.05*
[**2125-11-1**] 10:05PM BLOOD Calcium-8.7 Phos-4.8* Mg-2.3
Discharge Labs:
[**2125-11-8**] 07:30AM BLOOD WBC-5.3 RBC-3.23* Hgb-9.4* Hct-31.0*
MCV-96 MCH-29.2 MCHC-30.4* RDW-21.5* Plt Ct-176
[**2125-11-8**] 07:30AM BLOOD PT-18.2* PTT-27.7 INR(PT)-1.6*
[**2125-11-8**] 07:30AM BLOOD Glucose-101* UreaN-32* Creat-5.3*# Na-134
K-3.6 Cl-91* HCO3-33* AnGap-14
[**2125-11-8**] 07:30AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
Cardiac Labs:
[**2125-11-1**] 10:05PM BLOOD CK-MB-3 cTropnT-0.05*
[**2125-11-2**] 08:50AM BLOOD cTropnT-0.04*
[**2125-11-3**] 10:10AM BLOOD cTropnT-0.08*
[**2125-11-3**] 06:02PM BLOOD CK-MB-5 cTropnT-0.11*
[**2125-11-3**] 10:45PM BLOOD CK-MB-4 cTropnT-0.12*
Relevant Heme:
[**2125-11-3**] 11:00PM BLOOD Lactate-2.9*
[**2125-11-4**] 09:49PM BLOOD Lactate-1.9
[**2125-11-4**] 09:49PM BLOOD Type-[**Last Name (un) **] pH-7.28*
[**2125-11-3**] 10:17AM BLOOD Type-ART pO2-70* pCO2-46* pH-7.40
calTCO2-30 Base XS-2
Chemistries:
ALT AST LD(LDH) CK(CPK) AlkPhos
Amylase TotBili
[**2125-11-4**] 15:00 326* 1604* 1222* 136* 0.4
[**2125-11-7**] 07:30 38 212* 324* 112 0.5
STUDIES:
ECG Study Date of [**2125-11-1**] 9:54:18 PM
Sinus rhythm. Occasional premature atrial contractions. Left
ventricular
hypertrophy. Inferolateral ST-T wave changes most likely related
to left
ventricular hypertrophy. Compared to the previous tracing of
[**2125-5-29**] there is no significant diagnostic change.
CT HEAD W/O CONTRAST Study Date of [**2125-11-1**] 8:54 PM
IMPRESSION: No acute intracranial process.
HIP UNILAT MIN 2 VIEWS LEFT Study Date of [**2125-11-1**] 9:14 PM
IMPRESSION: Fracture of the femoral neck with lateral angulation
of the
femoral head with respect to the femoral neck with possible
impaction of the femoral head. Findings less convincing on
cross-table lateral films. If there is concern for femoral neck
fracture, cross-section imaging may be obtained for
confirmation. Recommend physical examination and clinical
correlation.
CHEST (SINGLE VIEW) Study Date of [**2125-11-6**] 3:56 PM
FINDINGS: In comparison with the study of [**11-4**], there is
continued
substantial enlargement of the cardiac silhouette with
atelectatic changes in the retrocardiac area. There has been the
development of moderate
interstitial edema.
LUNG SCAN Study Date of [**2125-11-6**]
INTERPRETATION:
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views
demonstrate
heterogeneous distribution of tracer bilaterally, compatible
with airways
disease.
Perfusion images in the same 8 views show heterogeneous tracer
distribution, with a defect in the superior segment of the right
lower lobe (best seen on the RPO projection), with a peripheral
rim of preserved tracer, and a matching ventilation defect.
Additionally, a small perfusion defect in the medial left upper
lung (best seen on the LPO projection) has a matching
ventilation defect. There are no mis-matched perfusion defects.
Chest x-ray shows cardiac enlargement, without pleural effusion
or
consolidation. The above findings are consistent with a low
likelihood of pulmonary embolus.
IMPRESSION:
Low likelihood of pulmonary embolus.
Airways disease.
Brief Hospital Course:
Mr. [**Known lastname 4643**] is a 71 yo M with a history of CAD s/p CABGx4,
vascular dementia, ESRD on HD, prior TIAs, and recent postive
stress test, who was transferred to [**Hospital1 18**] after sustaining a L
femoral neck fx after a mechanical fall.
.
ACTIVE ISSUES:
.
#Hip: Mr. [**Known lastname 4643**] was admitted for repair of a left femoral neck
fracture that was diagnosed at an OSH. Given his abnormal
cardiac stress test results at the beginning of Novemeber,
demonstrating a reversible inferolateral abnormality, he was
evaluted by the Cardiology service. They felt that he was
stable for surgery and did not require revascularization prior,
but recommended low-dose Metoprolol (6/25 mg IV BID) for risk
reduction. He underwent ORIF of his left femoral neck fracture
on HD #2. He did well in the immediate post-operative period,
but overnight into HD #3 (POD#1) he developed a new oxygen
requirement of 3L nasal cannula. He had crackles bilaterally
throughout his lungs. Given his history, there was a concern
for a cardiac cause of this change, namely ACS or CHF secondary
to fluid overload. Repeat EKG was negative, CXR did not
demonstrate any evidence of fluid overload or acute process, and
an ABG only demonstrated hypoxemia. Shortly after the return of
these studies, he triggered for hypotension, with a systolic
blood pressure in the 60s. He was managed per protocol, but
given ongoing hypotension, he was transferred to the Medical
Intensive Care Unit for further management.
- Follow-up with Orthopedics in 2 months
- Discharge to rehab with physical therapy
#Hypotension: Due to pt's hypotension he was admitted to MICU.
His hypotension was believed to be due to the metoprolol he
received as patient is known to be very sensitive to this
medication and is now listed as an allergy. BP responded with
IVF. LFT's were elevated after his hypotension and led to shock
liver. LFT's trended back down shortly there after with improved
perfusion and no other intervention. Pt stabilized and
transferred back to the floor. On the floor his blood pressure
remained in the 100-120s systolic and he was able to be taken
off the supplemental oxygen.
#Hypoxia: At baseline, the patient has no oxygen requirement. He
has a 30 pack year smoking history and also has a recent stress
that showed a decreased EF. Given his hip fracture,
immobilization, hypoxia and hypotension, PE was a serious
consideration. V/Q scan was negative. He likely was hypoxic in
the setting of being mildly fluid overloaded on his chronic lung
disease as well as post op atelectasis. He was taken off
supplemental O2 as he improved, and he was 93-95% on room air.
An echocardiogram was not done. He will be seen by Dr. [**Last Name (STitle) 911**] as
an outpatient. Cardiology did not feel as though he needed and
echo inpatient.
#Rash: He developed a rash between the OR and MICU. Possible
causes were chlorhexadine bath for the OR, antibiotics during
surgery, and metoprolol. All possible offending agents were
stopped around the same time. At time of dischargethe rash was
improving.
#CAD: The patient has long-standing CAD, with a history of a
four-vessel CABG in [**2114**] and a recent abnormal stress test.
Given the need for surgery, we held his Plavix, but continued
his home Aggrenox and Statin. Cardiology risk stratified him. We
also started him on Metoprolol in advance of surgery (as
described [**Last Name (un) 8585**]), which was subsequently stopped. He will be seen
by Dr. [**Last Name (STitle) 911**] as an outpatient for his abnormal stress test.
-Continue Plavix
-Continue Aggrenox
-Continue Statin
.
#End Stage Renal Disease: He has long-standing ESRD secondary to
HTN, and is on HD with access via an AV fistula. While in the
hospital, he continued his home Monday-Wednesday-Friday schedule
of HD, with supervision by the Renal team. We also continued
him on his home Cinacalcet and Nephrocaps, and added Sevelamer.
#Diastolic and Systolic Dysfunction: See above workup given O2
requirement.
INACTIVE ISSUES:
#Anemia: He has long-standing anemia, secondary to his ESRD.
His hematocrit at admission was 34. We monitored his hematocrit
regularly, which stayed at or around baseline throughout his
hospitalization. We therefore considered him stable for
discharge from this standpoint.
#Hypertension: He has a history of labile HTN. His blood
pressures were in the 130s on admission, so we did not initiate
any therapy. As explained above, he was triggered for
hypotension, with further management by the MICU.
#Spinal Stenosis: He suffers from chronic lower back pain
secondary to spinal stenosis. We treated him with a Lidocaine
patch, consistent with his outpatient regimen. His pain was
well-controlled, so we considered him stable for discharge from
this standpoint.
#Depression: He has long-standing depression, so we continued
him on his home Citalopram and are discharging him with the same
medication.
#Peripheral Neuropathy: He has long-standing peripheral
neuropathy, so we continued him on his home Gabapentin and are
discharging him with the same medication.
#Benign Prostatic Hypertrophy: He is on Tamulosin at home, but
given that a Foley catheter was placed on admission given his
poor ambulation, we held his Tamulosin. He was without
complaints related to this condition. Because of his hypotension
this medication was held at time of discharge. He also makes
very little urine in the setting of his ESRD.
#GERD: He has long-standing GERD, so we continued him on his
home Pantoprazole and are discharging him with the same
medication and is on PPI at home.
TRANSFER OF CARE: Mr. [**Known lastname 4643**] was discharged to a rehab center
for physical therapy of his hip. He has follow-up with
orthopedics in 2 months and the Cardiology clinic will contact
him with an appointment. There are no tests pending at time of
discharge.
Medications on Admission:
-Simvastatin 40 mg tablet one daily
-Plavix 75 mg tablet one daily ON HOLD
-Aggrenox 200/25 mg capsule one capsule [**Hospital1 **]
-Sevelamer 800 mg tablet TID with meals
-Cinacalcet 30 mg tablet one daily
-Nephrocaps daily
-Lidoderm patch
-Gabapentin 300 mg capsule one daily
-Citalopram 40 mg tablet two daily
-Pantoprazole 40 mg daily
-Tamsulosin 0.4 mg capsule one daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime). Capsule(s)
7. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. citalopram 40 mg Tablet Sig: Two (2) Tablet PO once a day.
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day): Until ambulatory.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q 8H (Every 8
Hours) as needed for pain.
17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
18. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5399**] Nursing Home
Discharge Diagnosis:
Primary: left femoral neck fracture
Secondary:
Coronary Artery Disease
End Stage Renal Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 4643**],
It was our pleasure caring for you at [**Hospital1 827**].
You were admitted after a fall for treatment of your left hip
fracture. You underwent surgery to repair your hip.
You were also seen by our Cardiology Service regarding your
recent abnormal stress test results, and they felt that
catheterization was not required before your procedure.
We also continued you on your regular hemodialysis schedule
while you were here.
You had a period of low blood pressure and low oxygen and
required a few days of monitoring in the ICU. You were stable
and managed back on the general medicine floor prior to
discharge. Your low oxygen was in the setting of having extra
fluid on your lungs, and small breaths after surgery.
The following changes were made to your medications:
-STOPPED Flomax
-STARTED Bowel regimen with docusate, senna, bisacodyl, and
miralax
-STARTED Heparin injections to prevent blood clots
-STARTED Sevelamer for your kidneys
-STARTED lidocaine patches for pain
-STARTED Oxycodone for pain
-STARTED sarna lotion for itchy rash
Followup Instructions:
Name: [**Last Name (LF) 911**], [**First Name7 (NamePattern1) 919**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
*[**Doctor First Name **] from Dr. [**Last Name (STitle) 8586**] office will call you to make an
appointment. You should be seen within 2 weeks. Call the number
above if you dont hear from [**Doctor First Name **] in 2 business days.
Department: ORTHOPEDICS
When: TUESDAY [**2126-1-8**] at 12:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2126-1-8**] at 1 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2125-11-10**]
|
[
"40391",
"5180",
"4280",
"32723",
"53081",
"2724",
"311",
"V4581"
] |
Admission Date: [**2150-8-24**] Discharge Date: [**2150-8-28**]
Date of Birth: [**2108-7-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
N/V x2 days and BG of 737
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
42 yo F with HTN, dyslipidemia, DM1 diagnosed in [**2144**] and
followed at [**Last Name (un) **] with HbA1C [**2146**] of [**8-31**]%, history of missed
appointments and medical non-compliance resulting in multiple
admits for DKA, presented with N/V, fever x3 days and BG >700.
Of note, pt's daughter had recently had viral illness with
similar symptoms. In the [**Name (NI) **], pt was started on insulin drip and
given 6L IV fluids and 500mg levoflox x1. BCx and UCx were sent,
cardiac markers cycled; CXR and U/A were negative. EKG showed
sinus tach. She was transferred to the [**Hospital Unit Name 153**] for further care.
Her AG was closed and she was weaned off the insulin drip, so
she was transferred to the floor.
Past Medical History:
Type I DM: dx [**2144**]; Ab positive; on insulin
DKA x 5
Pancreatitis
Hyperchol
HTN
GERD
Anemia
Tubal ligation
Social History:
Lives with husband and three children. Denies tobacco, EtOH,
drug use.
Family History:
DM (mother)
Physical Exam:
In ED:
96 144 128/74 32 99%RA
Gen: Confused, slurred speech
HEENT: [**Last Name (LF) 3899**], [**First Name3 (LF) **], but minimally reactive; MM very dry
CVS: tachy
Chest: CTA B
Abd: Soft, NT/ND, no HSM
Ext: no c/c/e
Neuro: A&O x2; CN II-XII intact bilat
On floor:
99.3 106/71 83 21 100%RA
Gen: Lying in bed, comfortable, AAOx3
HEENT: PERRL, [**First Name3 (LF) 3899**], MMM
CVS: RRR, no M/R/G
Chest: CTA B
Abd: soft, NT/ND, +BS
Ext: No c/c/e
Neuro: CN II-XII intact bilat, strength 5/5 U/L ext bilat
Pertinent Results:
[**2150-8-24**] 11:28AM BLOOD freeCa-1.16
[**2150-8-24**] 12:38PM BLOOD freeCa-1.12
[**2150-8-24**] 11:28AM BLOOD O2 Sat-98
[**2150-8-24**] 09:45AM BLOOD Glucose-737*
[**2150-8-24**] 10:20AM BLOOD Lactate-2.8* K-3.8
[**2150-8-24**] 10:47AM BLOOD Glucose-445* K-3.7
[**2150-8-24**] 11:28AM BLOOD Lactate-1.1
[**2150-8-24**] 12:44PM BLOOD Lactate-1.3
[**2150-8-24**] 11:28AM BLOOD Type-ART Temp-34.3 Rates-25/ O2-100 O2
Flow-4 pO2-161* pCO2-9* pH-6.97* calHCO3-2* Base XS--29
AADO2-561 REQ O2-90 Intubat-NOT INTUBA Comment-NC
[**2150-8-24**] 12:38PM BLOOD Type-[**Last Name (un) **] pO2-24* pCO2-22* pH-7.09*
calHCO3-7* Base XS--23
[**2150-8-24**] 12:44PM BLOOD Type-ART pO2-162* pCO2-13* pH-7.13*
calHCO3-5* Base XS--22
[**2150-8-24**] 07:20PM BLOOD Type-ART Temp-37.0 Rates-/18 O2 Flow-4
pO2-176* pCO2-24* pH-7.24* calHCO3-11* Base XS--15 Intubat-NOT
INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2150-8-24**] 05:36PM BLOOD %HbA1c-13.1*
[**2150-8-24**] 12:10PM BLOOD Calcium-6.2* Phos-1.2*# Mg-1.5*
[**2150-8-24**] 10:03PM BLOOD Calcium-7.4* Phos-1.7* Mg-2.2
[**2150-8-25**] 11:59PM BLOOD Calcium-7.6* Phos-1.6* Mg-1.5*
[**2150-8-24**] 05:36PM BLOOD CK-MB-4
[**2150-8-25**] 03:51AM BLOOD CK-MB-3 cTropnT-<0.01
[**2150-8-25**] 03:26PM BLOOD CK-MB-4 cTropnT-0.04*
[**2150-8-24**] 10:00AM BLOOD Lipase-36
[**2150-8-24**] 10:00AM BLOOD ALT-16 AST-17 LD(LDH)-233 CK(CPK)-70
AlkPhos-130* Amylase-53 TotBili-0.2
[**2150-8-24**] 05:36PM BLOOD CK(CPK)-137
[**2150-8-25**] 03:26PM BLOOD CK(CPK)-140
[**2150-8-24**] 12:10PM BLOOD Glucose-220* UreaN-19 Creat-0.7 Na-152*
K-3.8 Cl-123* HCO3-6* AnGap-27*
[**2150-8-24**] 10:03PM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-149*
K-3.6 Cl-123* HCO3-13* AnGap-17
[**2150-8-25**] 11:59PM BLOOD Glucose-253* UreaN-5* Creat-0.7 Na-142
K-3.5 Cl-118* HCO3-15* AnGap-13
[**2150-8-24**] 10:00AM BLOOD D-Dimer-348
[**2150-8-24**] 05:36PM BLOOD D-Dimer-501*
[**2150-8-24**] 10:00AM BLOOD PT-16.4* PTT-29.2 INR(PT)-1.7
[**2150-8-25**] 03:51AM BLOOD Plt Ct-191
[**2150-8-24**] 10:00AM BLOOD WBC-35.1*# RBC-3.88* Hgb-11.7* Hct-37.6
MCV-97# MCH-30.1 MCHC-31.0 RDW-12.8 Plt Ct-256#
[**2150-8-24**] 10:00AM BLOOD Neuts-85* Bands-2 Lymphs-8* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-0
[**2150-8-25**] 03:51AM BLOOD WBC-18.9* RBC-3.63* Hgb-10.7* Hct-31.9*
MCV-88# MCH-29.5 MCHC-33.6 RDW-13.6 Plt Ct-191
[**2150-8-25**] 03:51AM BLOOD Neuts-86.1* Lymphs-9.7* Monos-3.8 Eos-0.2
Baso-0.1
LENI: no DVT
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 mildly
depressed. Right ventricular chamber size is normal and free
wall motion appears borderline depressed. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion. Compared with the report of
the prior study (tape unavailable for review) of [**2150-7-17**],
findings are probably similar. Right ventricular systolic
function now appears borderline depressed. Tricuspid
regurgitation may now be more pronounced.
CXR: No acute pulmonary process.
Sinus tachycardia. Diffuse ST-T wave changes with ST segment
elevations suggest
pericarditis. Clinical correlation is suggested. Since the
previous tracing
of [**2150-8-24**] sinus tachycardia rate has decreased and diffuse ST
segment
elevation is now seen.
Brief Hospital Course:
42 yo F w/IDDM h/o non-compliance and mult admits for DKA in the
past, HTN, dyslipidemia, admitted for DKA. Likley precipitated
by noncompliance as well as viral illness, as daughter had
similar symptoms of cough, fever, N/V oneweek prior to
presentation. Pt admitted to ICU initially admitted to the ICU,
then transferred to the floor once stabilized.
1) DKA: As noted, the precipitant of Mrs.[**Last Name (STitle) **] DKA was thought to
ba viral illness and medical NC. She was started on an insulin
drip and aggressively fluid resuscitated in the ED and in the
ICU. [**Last Name (un) **] was consulted for recommendations on treatment and
they continued to follow her hospital course. Her anion gap
closed, the insulin drip was stopped, and she was transferred to
the floor. On transfer, her BG was noted to be high, so her
humalog SS was tightened and glargine was increased [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recs. Electrolytes were followed closely and repleted
aggressively. FS were monitored Q4-6 hrs. A social work consult
was obtained to discuss the importance of compliance with
at-home regimens as well as follow-up.
2) DM1: As noted, Mrs.[**Last Name (STitle) **] has a history of non-compliance since
her diagnosis in [**2144**]. Her insulin regimen was changed to QHS
glargine with humalog sliding scale coverage. Her BG continued
to run high after starting glargine 25 units QHS. She required
38 units of humalog coverage over the following day, so glargine
was increased to 35 units QHS.As the effect of glargine takes
approximately 36 hours to be realized, Mrs.[**Last Name (STitle) **] was instructed to
call in her blood glucose levels to the Nurse [**First Name (Titles) **] [**Last Name (Titles) 26825**] at Josiln
on a daily basis in order to make further medication
adjustments. As well, she is to follow up with the Nurse
Educator on the Wednesday after discharge and has a clinic
appointment at [**Last Name (un) **] with Dr.[**First Name (STitle) 3636**] 3 weeks thereafter.
2) Hypernatremia: Mrs.[**Last Name (STitle) **] [**Name (STitle) **] peaked at 152 with a free water
deficit of 1.8L--half of which was corrected over the first 24hr
with D5 1/2NS @ 150cc/hr (while on insulin drip). Fluids were
d/c'ed when she came to the floor and her sodium came down to
142 on HD#2 and remained within normal range for the remainder
of her course.
3) CVS:
Pump-Mrs.[**Last Name (STitle) **] had 2 echos showing LV hypokinesis and EF 40-45% on
her previous admission [**6-24**] when she presented with CP. At that
time, EKGs showed diffuse ST elevation; cath was clean. It was
thought that she may have had viral pericarditis. Her EKGs on
this presentation again showed diffuse ST-T elevation, no
flipped Ps, but concerning for pericarditis. An echo was done to
evaluate interval improvement in EF. As the EKG seemed
relatively unchanged from prior, there was question as to
whether this was due to a new infection vs. a chronic process
that had not yet resolved. She will likely need repeat echo as
an outpatient for follow-up.
HTN-Mrs.[**Last Name (STitle) **] was normotensive on her outpatient medications of
lopressor and lisinopril.
Ischemia- There was no evidence of acute ischemia. Mrs.[**Last Name (STitle) **] has
multiple RFs for CAD, but cath in [**Month (only) 216**] showed no coronary
disease. EKG showed findings described above, cardiac markers
were cycled. The first 2 sets were negative, the third trop were
slightly elevated to 0.04, likely troponin leak secondary to her
sustained sinus tach that had abated by HD#3.
Tachycardia- On presentation, Mrs.[**Last Name (STitle) **] was noted to be tachycardic
to the 150s. With aggressive fluid resuscitation, this came down
to the 90s-100s. She denied any pain/anxiety, was afebrile, and
euvolemic so her metoprolol was increased to 12.5 [**Hospital1 **] and her HR
remained in the 80s.
4) Anemia: On presentation, Mrs.[**Last Name (STitle) **] HCT was 37.6, after fluid
resuscitation, it decreased to 29.5 and remained stable. On
review of her previous admission in [**Month (only) 216**], her baseline HCT
seems to be around 31-32. There was no evidence of acute blood
loss on this admission. Iron studies were sent, but were not
available at time o discharge. Mrs.[**Last Name (STitle) **] will follow up with
Dr.[**First Name (STitle) 4223**] on [**9-16**], at which time these results may be
addressed.
5) GERD: Mrs.[**Last Name (STitle) **] was treated with protonix 40mg PO QD.
6) FEN: Lytes/fluid resuscitation as above. Mrs.[**Last Name (STitle) **] was on a
cardiac/diabetic diet.
7) Code: full
8) Dispo: Mrs.[**Last Name (STitle) **] was discharged home with follow-up instructions
on BG reporting and appointments at [**Last Name (un) **] and with Dr.[**First Name (STitle) 4223**],
her PCP.
Medications on Admission:
lipitor 20mg QD
lisinopril 5mg QD
metoprolol 12.5mg [**Hospital1 **]
ASA
am: NPH 26 units
Hum 10 units
pm: NPH 24 units
Hum 4 units
HSS coverage
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
Units Subcutaneous at bedtime.
Disp:*900 units* Refills:*2*
8. Humalog 100 unit/mL Solution Sig: sliding scale as directed
Subcutaneous as directed.
Disp:*900 units* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Diabetic ketoacidosis
Type 1 diabetes (Ab +)
Secondary diagnoses:
HTN
Dyslipidemia
GERD
Discharge Condition:
Good.
Discharge Instructions:
Please check your blood glucose levels as directed. Call
([**Telephone/Fax (1) 28500**] and ask to speak with the Nurse on duty to report
your blood sugars and adjust your insulin dosing. Please call
daily. If the level is >300 or <70 please call IMMEDIATELY.
Please call your doctor and return to the hospital for nausea,
vomiting, confusion, lethargy, problems controlling your blood
sugar, or any other concerns you may have.
Please keep your scheduled follow-up appointments (see below for
details). If you are unable to make an appointment, please call
the nubers listed below.
Followup Instructions:
The following appointments at [**Last Name (un) **] have been scheduled for
you:
1) Wed [**9-2**] @ 9am with [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) **], Nurse Educator.
2) [**2150-9-29**] 10am with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**].
Both are at [**Hospital **] Clinic, on the [**Location (un) 551**].
It is very important that you receive follow-up care. If you
cannot make either of these appointments, please call to
re-schedule: ([**Telephone/Fax (1) 20881**]
Please follow-up with Dr.[**First Name (STitle) 4223**] on Wednesday, [**9-16**] at 2pm
at [**Hospital1 7975**] FAMILY PRACTICE. If you cannot make this appointment,
please call ([**Telephone/Fax (1) 13239**] to reschedule.
|
[
"2762",
"2760",
"53081",
"2724",
"4019"
] |
Admission Date: [**2125-9-27**] Discharge Date: [**2125-10-9**]
Date of Birth: [**2054-8-29**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Lactose
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Squamous Cell Carcinoma Left Pyriform Sinus
Major Surgical or Invasive Procedure:
1. Laryngoscopy.
2. Total laryngectomy and partial pharyngectomy.
3. Tracheoesophageal puncture.
4. Right modified radical neck dissection.
History of Present Illness:
The patient is a 71-year-old female with 2 prior known squamous
cell carcinomas involving the head and neck. The first was in
[**2121**]. This was a T3 N2B M0 squamous cell carcinoma of the left
tonsil which was treated with concomitant chemotherapy and
radiation. She did well until recently. In [**Month (only) 216**] of this year,
she was found to have a microinvasive squamous cell carcinoma
staged as T1 N0 M0 which was completely resected from the floor
of mouth. Several weeks after the surgery, she began to develop
odynophagia and clinically was found to have a tumor involving
the medial wall of the left piriform sinus. She underwent an
endoscopy and biopsy which revealed a poorly-differentiated
carcinoma. Given her prior radiation therapy and the
unwillingness of the radiation oncologist to give her primary
definitive radiation as the treatment, the only option was for a
total laryngectomy and partial pharyngectomy.
Past Medical History:
GERD
osteoporosis
tonsil cancer T3N2 treated [**2121**] - tonsilectomy and neck
dissection.
Social History:
Denies current EtOH or smoking
Family History:
Non-contributory
Physical Exam:
At the time of discharge:
VS: Afebrile, VSS
Constitutional: No acute distress, speaking with electrolarynx,
visible stoma.
Neck: Flat - staple lines c/d/i, no erythema or induration.
Stoma with red-rubber catheter at TEP site. Mild crusting around
suture line, moist.
CV: RRR, no murmurs
Resp: CTAB, no wheezes or crackles
Abd: Soft, nondistended, +BS
Ext: Warm, distal pulses palpable bilaterally
Skin: Face, neck and chest is normal
Musculoskeletal: Walking without assistance, normal to gait and
station
Spine, Pelvis and Extremities: Stable
Psychiatric: Normal to judgment, insight, memory, mood and
affect
Pertinent Results:
MICROBIOLOGY
[**2125-10-5**] 8:38 am SWAB Source: left stoma site.
GRAM STAIN (Final [**2125-10-5**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
MRSA SCREEN (Final [**2125-9-30**]): No MRSA isolated.
BARIUM SWALLOW STUDY - POD 11
IMPRESSION: Normal postoperative study demonstrating a
surgically created
tracheoesophageal fistula, without reflux of contrast into the
trachea and
without evidence of additional tracheoesophageal fistulae.
PATHOLOGY:
SPECIMEN SUBMITTED: Total Laryngectomy, Left inferior lateral
margin, Right Neck Level 2A, Right Neck Level 3, Right Neck
Level 4.
Procedure date Tissue received Report Date Diagnosed
by
[**2125-9-27**] [**2125-9-27**] [**2125-10-5**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl
Previous biopsies: [**-9/3293**] MEDIAL WALL LEFT PIRIFORM
SINUS.
[**-9/2116**] CARCINOMA IN SITU ANTERIOR FLOOR OF MOUTH, RIGHT
FLOOR OF
[**Numeric Identifier 80013**] R. LATERAL TONGUE LESION (1 JAR)
DIAGNOSIS:
1. Lymph nodes, neck, right level 2A, excision:
Four lymph nodes with no carcinoma seen (0/4).
2. Lymph nodes, neck, right level 3, excision:
Two lymph nodes with no carcinoma seen (0/2).
3. Lymph nodes, neck, right level 4, excision:
Two lymph nodes with no carcinoma seen (0/2).
4. Hypopharynx, left inferior lateral margin, excision:
Unremarkable squamous mucosa. No carcinoma seen.
5. Larynx, total laryngectomy and partial pharyngectomy:
Invasive poorly differentiated carcinoma. See synoptic report.
MICROSCOPIC
Histologic Type:
Poorly differentiated carcinoma. See note.
Histologic Grade: G3: Poorly differentiated.
EXTENT OF INVASION
Primary Tumor: pT1: Tumor limited to one subsite of
hypopharynx and is 2 cm or less in greatest dimension.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 8.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Uninvolved by tumor:
Distance from closest margin: 3 mm. Specified margin:
Lateral.
Lymphatic (small vessel) Invasion: Not identified.
Venous (large vessel) invasion: Note identified.
Perineural invasion: Present.
Note: Sections of the tumor demonstrate an ulcerated, poorly
differentiated carcinoma composed of nests and sheets of
atypical cells with large pleomorphic nuclei and occasional
prominent nucleoli. Numerous mitotic figures and focal necrosis
are identified. A focus suspicious for a squamous precursor
lesion (carcinoma in situ, slide L) with possible keratinization
is noted. Immunohistochemical staining shows that the tumor
cells are positive for cytokeratin cocktail (AE1/AE3 and CAM
5.2), CK5/6, and p63. Staining for neuroendocrine markers were
repeated and show focal staining with synaptophysin and
chromogranin. These immunophenotypic findings are suggestive of
both squamous and neuroendocrine differentiation. Although a
definite squamous carcinoma in situ component is not identified,
the morphologic and immunophenotypic features are consistent
with an invasive poorly differentiated carcinoma arising at this
site. Selected slides (L and immunohistochemical stains) were
reviewed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 9885**].
CBC
[**2125-9-27**] 02:33PM [**Month/Day/Year 3143**] WBC-6.7 RBC-3.81 Hgb-10.1 Hct-31.1 Plt
Ct-182
[**2125-9-27**] 08:15PM [**Month/Day/Year 3143**] WBC-5.9 RBC-3.92 Hgb-10.4 Hct-31.7 Plt
Ct-115
[**2125-9-28**] 05:35AM [**Month/Day/Year 3143**] WBC-5.1 RBC-3.58 Hgb-9.9 Hct-29.1 Plt
Ct-121
[**2125-10-1**] 02:57AM [**Month/Day/Year 3143**] WBC-4.4 RBC-3.53 Hgb-9.5 Hct-28.2 Plt
Ct-138
[**2125-10-2**] 02:55AM [**Month/Day/Year 3143**] WBC-4.7 RBC-3.62 Hgb-10.0 Hct-29.3 Plt
Ct-151
[**2125-10-8**] 06:35AM [**Month/Day/Year 3143**] WBC-8.6 RBC-3.95 Hgb-10.8 Hct-32.5 Plt
Ct-321
CHEMISTRIES
[**2125-9-27**] 02:33PM [**Month/Day/Year 3143**] Glucose-92 UreaN-8 Creat-0.6 Na-136 K-3.8
Cl-103 HCO3-27 AnGap-10
[**2125-9-28**] 05:35AM [**Month/Day/Year 3143**] Glucose-153* UreaN-5* Creat-0.5 Na-132*
K-4.9 Cl-100 HCO3-25 AnGap-12
[**2125-9-30**] 03:50AM [**Month/Day/Year 3143**] Glucose-117* UreaN-5* Creat-0.4 Na-137
K-3.8 Cl-102 HCO3-23 AnGap-16
[**2125-10-2**] 02:55AM [**Month/Day/Year 3143**] Glucose-121* UreaN-11 Creat-0.4 Na-137
K-3.8 Cl-101 HCO3-27 AnGap-13
[**2125-10-8**] 06:35AM [**Month/Day/Year 3143**] Glucose-121* UreaN-18 Creat-0.6 Na-138
K-4.1 Cl-100 HCO3-29 AnGap-13
Brief Hospital Course:
The patient was admitted to the otolaryngology head and neck
surgery service on [**2125-9-27**] after undergoing a total laryngectomy
and partial pharyngectomy, tracheoesophageal puncture and right
modified radical neck dissection. She tolerated the procedures
well and without complication. She was transferred to the SICU
for immediate post-operative care and remained there until POD 7
at which time she was transferred to the floor for further care.
Neuro: Post-operatively, the patient received Dilaudid IV/PCA
with good effect and adequate pain control. When tube feeds were
started through the red-rubber catheter she was started on
crushed dilauded tabs with good effect. On POD 12 she began PO
clears and took dilaudid PO without problem. She was discharged
on liquid dilaudid for pain that could be taken by mouth or via
her feeding tube.
CV: The patient was stable from a cardiovascular standpoint; she
was on telemetry throughout her stay because of her new
laryngectomy stoma and the concern for desaturations - she did
not have any significant cardiovascular problems. [**Name (NI) **] [**Name2 (NI) **]
pressure and hear rate remained normal throughout her stay.
Pulmonary: The patient emerged from the operating room with a
new laryngectomy stoma. She was breathing on her own and was
transferred to the ICU for [**1-4**] nursing care. She was managed
with q1-2 hour suctioning of her secretions and was noted to
have several brief desaturations to the mid-80s while in the ICU
- extending her stay there for close stoma care and frequent
suctioning. Humidified O2 was placed over her stoma site at all
times and mucus crusting removed as needed. Chest x-rays
post-operatively did not show a pneumothorax. A chest x-ray on
POD 5 showed right sided atelectasis and chest PT was initiated.
The patient was also encouraged to get out to bed to ambulate,
she was seen by PT for the duration of her stay and did not have
any further desaturations. She began stoma care with teaching by
nursing staff and the speech and swallow team, she also began
work with her electrolarynx, which will continue as an
outpatient.
GI/GU: Post-operatively, the patient was given IV fluids and
then started on tube feeds through the red-rubber catheter
through her TEP site on POD 4. The tube was repositioned on POD5
and CXR confirmed its position. She continued on continuous tube
feeds without problem per nutrition recommendations. Her IV
fluids were discontinued on POD 6, her input and output were
continuously monitored. On POD 11 she had a barium swallow study
which did not reveal a leak or fistula, and she was started on
clear liquids, advancing to mechanical softs. She did not
experience any leak and was discharged on mechanical soft diet
with TF supplementation 3x/day.
ID: Post-operatively, the patient was started on IV clindamycin
following the procedure. On POD 8 a swab of her stoma site was
taken which grew 2+ MSSA resistant to clindamycin. She was
switched to ancef at that time. The redness around the stoma
site decreased by the time of her d/c. A MRSA swab was negative.
She was discharged on 10 days of duricef. Throughout her stay
she was afebrile, her temperature was closely watched for signs
of infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. Physical therapy worked with the patient in the ICU
and on the floor to encourage ambulation.
At the time of discharge on POD#12, the patient was doing well,
afebrile with stable vital signs, tolerating a mechanical soft
diet, supplemented with tube feeds, ambulating, voiding without
assistance, and pain was well controlled. While she was
participatory in her laryngectomy stoma care, nursing staff, the
speech and swallow team as well as the ORL/HNS primary team felt
that she was not yet proficient in stoma care to be safe for
discharge home. This in combination with the necessary care of
her feeding tube, and administration of the feeds, warranted a
stay at a rehab facility. The patient will see Dr. [**Last Name (STitle) 1837**]
in follow up in [**7-13**] days.
Medications on Admission:
Fosamax, Anastrozole, Vit D, Prilosec
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q4H
(every 4 hours) as needed for pain.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Hydromorphone 1 mg/mL Liquid Sig: [**2-7**] mL PO Q4H (every 4
hours) as needed for pain for 10 days.
Disp:*200 mL* Refills:*0*
5. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
6. Boost Plus Liquid Sig: One (1) can PO three times a day
for 4 weeks: Please continue diet suplementation as needed until
taking adequate calories by mouth.
Disp:*84 84* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 56223**]
Discharge Diagnosis:
Squamous Cell Carcinoma left pyriform sinus, status post total
laryngectomy
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to [**Hospital3 **] Hospital following a
laryngectomy for squamous cell carcinoma, your inpatient stay
was 12 days during which you had a steady recovery from your
operation and you made significant progress in learning how to
care for your new stoma. You are being discharged to a
[**Hospital 3058**] rehab facility in order to manage the more
complicated aspects of your continuing care - the tube feeds and
your stoma being most relevant.
You have received several print-outs which describe in detail
how to care for your stoma and what you should expect over the
next few months. You should read these carefully and continue
looking at the area with your new mirror as often as possible.
Care for your stoma includes keeping humidified air on it at ALL
TIMES, periodic moistening of the opening with a small amount of
saline and decrusting with forceps as needed to maintain the
airway's diameter. You should be doing this every 2 hours while
you are awake. When you awaken in the morning you will need to
take extra care in the removal of any crusts and use the suction
to bring up any thick mucus at the site. Please do not hesitate
to call the office with any questions about your stoma care. The
sutures at the site will dissolve on their own.
You continue to have a red-rubber catheter through your
tracheal-esophageal puncture site. This is providing nutrition
to you in addition to what you take by mouth. You should keep
this tube in place until your follow up appointment with Dr.
[**Last Name (STitle) 1837**], and should continue to receive feeds through it
while at the rehab and at home. You may slow the rate of feeds
if you are having loose stools. The tube is stitched in place
and the tape marks the level of insertion of the tube. It is
very important that the tube remained taped down with silk tape
to maintain its position. DO NOT REMOVE THE STITCHING AND
REPLACE THE TAPE ONLY WHEN NECESSARY, SECURING IT DOWN SO THAT
IT DOES NOT COME OUT.
You can take a mechanical soft diet by mouth - this means pureed
foods and liquids. You should eat any foods that you have to
chew.
It is important for you and those around you to know that you
cannot breathe from your mouth - you are a DEPENDENT NECK
BREATHER. This means that if anyone needs to place a breathing
tube, it must be done through the neck, the CANNOT place one
from your mouth or nose.
You should return to the ER if:
* You have difficulty breathing through the stoma or cannot
clear secretions at that site.
* 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.
* Please resume all regular home medications and take any new
meds as ordered.
* 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.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 1837**] in his clinic ([**Telephone/Fax (1) 6213**]. You
should see him in the next 7-10 days.
|
[
"5180",
"53081"
] |
Admission Date: [**2169-8-4**] Discharge Date: [**2169-8-7**]
Date of Birth: [**2141-5-5**] Sex: F
Service: MEDICINE
Allergies:
Latex / Biaxin / Protonix / Sulfa (Sulfonamides) / Risperidone /
Linezolid / Clindamycin / Rifampin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
28 yo F with h/o asthma (multiple admission for asthma
exacerbations), bipolar disorder, hypothyroid, anxiety who
presented to ED 1 day after discharge for an asthma
exacerbation, with an asthma exacerbation. She was brought to
the ED by ems in the am [**8-4**] after stating she felt increasingly
SOB since D/C (given 4 albuterol nebs and mag). She also reports
a productive cough with green. Of note, during her last
admission she had a right lingula infiltrate and was treated
with levaquin.
Her initial VS were: 97.5, 108/78, 126, 28, 95 on heliox
She was given 125 IV solumedrol, started on continuous nebs and
heliox. she was also given tylenol and 2mg of iv morphine. She
was then admitted to MICU o/n on heliox.
On arrival to the floors, pt states she still feels SOB on
exertion and states she desats when walking. Pt still having
cough productive of green sputum which she has had unchanged for
the past 1 wk. Pt also c/o chest pain stating her muscles hurt
from working so hard to breathe.
ROS: denies recent fevers, chills, nausea, headache, dizziness.
States she had diarrhea with abd pain x2 this am.
Past Medical History:
Asthma - multiple hospitalizations and intubation
Bipolar disorder
B12 deficiency
Dysmenorrhea
Hypothyroidism
Dermatitis
Mitral valve prolapse
Chronic diarrhea, followed by Dr. [**First Name (STitle) **] [**Name (STitle) **] in GI
PTSD
Depression
Bulimia Nervosa per pt report
s/p appendectomy and cholecystectomy
Social History:
Lives in a respite in [**Location (un) **]. Recently lived with her mother by
her report. Patient denies h/o tobacco or illicit drug use. She
also denies current etoh and denies h/o daily or excessive
drinking. She has had > 15 jobs since she was 18; she loses them
[**3-4**] feeling overwhelmed. Pt now on SSDI due to bipolar d/o.
Family History:
Father and [**Name2 (NI) **] aunt have MS
Mother has depression
Aunt has schizophrenia
Aunt and cousin has asthma
Physical Exam:
Vitals: T 97.6 BP 135/87 HR 125 RR 33 95 on heliox
General: sitting in bed, appears uncomfortable, anxious, face
mask in place. can speak in full sentences, intermit. coughing.
HEENT: oropharynx exam deferred.
Heart: tachycardic, regular rhythm
Lungs: very little air movement throughout, no wheezes
Abd: obese, normal BS,Nt/ND, soft, bruising [**3-4**] to subq hep
Ext: no edema
Skin: no rashes
Pertinent Results:
[**2169-8-4**] 06:36PM WBC-6.7 RBC-4.76 HGB-13.9 HCT-41.3 MCV-87
MCH-29.1 MCHC-33.6 RDW-13.0
[**2169-8-4**] 06:36PM NEUTS-85.9* LYMPHS-11.6* MONOS-2.1 EOS-0.1
BASOS-0.3
[**2169-8-4**] 06:36PM PT-11.8 INR(PT)-1.0
[**2169-8-4**] 06:30PM LACTATE-2.6*
[**2169-8-3**] 05:55AM GLUCOSE-94 UREA N-16 CREAT-0.7 SODIUM-140
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-30 ANION GAP-12
CXR [**2169-8-4**]
FINDINGS: As compared to the previous radiograph from [**2169-7-31**], there is little overall change. Low lung volumes with
moderate elevation of the
diaphragms. Moderate bilateral atelectasis at the lung bases. No
focal
parenchymal opacities suggestive of pneumonia have newly
occurred. There is no evidence of pneumothorax or of pleural
effusion. The size of the cardiac silhouette is unchanged.
Brief Hospital Course:
Pt is a 28 yo w/ severe asthma, discharged [**8-3**] for asthma
exacerbation, returned [**8-4**] w/ asthma exacerbation, transferred
[**8-5**] from MICU to floors on 2L nasal cannula.
.
1. Asthma: Pt. has long h/o asthma w/ severe exacerbation
(intubated once). Per records, there is a element of
anxiety/psychiatric issues as a possible trigger. Pt states she
does had A/C at home so this is not likely to be contributing to
exacerbations. CXR [**2169-8-4**] showed no evidence of infxn but low
lung volumes. Pt was placed on Heliox in ED then transferred to
MICU where she stayed overnight and was then put on 2L oxygen
by nasal cannula and sent to the floors. On the day of
discharge, peak flow was 300. Baseline is 450 and was 280 on
[**7-29**]. Prior to discharge, pt ambulated without O2 and maintained
an O2 saturation of 95%. Prednisone 60mg Daily was started in
hospital and pt was placed on the following taper for discharge:
7 days at 60mg, 7 days at 40mg, 7 days at 20mg, 7 days at 10mg.
Pt was discharged otherwise on all the same medications.
.
2. Recent PNA: during her last exacerbation she was treated with
levaquin. Without fever or evidence of infection on CXR, pt was
not restarted on antibiotics in this hospital stay.
.
3. Bipolar Disorder: Pt stated she felt safe in hospital and did
not want to hurt herself. During the hospital stay, she did
report thinking that the steroids were making her moods
vacillate. Pt was discharged on all her home psych meds.
Medications on Admission:
Medications:
Albuterol INH 2 puffs qid prn
Flonase daily
Advair 500/50mcg 1 puff [**Hospital1 **]
Loratadine 10 mg daily
Levothyroxine 50 mcg daily
Carbamazepine 200 mg [**Hospital1 **]
Fluoxetine 20 mg daily
Naltrexone 50 mg qhs
Thorazine 50 mg [**Hospital1 **] prn anxiety or nausea (taken with benadryl
for muscle mvmt)
Trazodone 200 mg qhs
VitB12 1000 mcg monthly
Ranitidine 150 mg [**Hospital1 **]
atrovent nebs q6hrs
prednisone 50mg qdaily (with taper)
vitamin d
calcium
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Vitamin B-12 1,000 mcg/mL Solution Sig: 1000 (1000) mcg
Injection once a month.
3. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO at bedtime.
4. Chlorpromazine 50 mg Tablet Sig: One (1) Tablet PO twice a
day as needed.
5. Naltrexone 50 mg Tablet Sig: One (1) Tablet PO qhs ().
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
11. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day as needed: to be combined with Advair.
12. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal once a day.
13. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 28 days: Take 3 pills daily for 7 days. Then, 2
pills daily for 7 days. Then 1 pill daily for 7 days. Then
half pill daily for 7 days.
Disp:*46 Tablet(s)* Refills:*0*
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
16. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) PUFFS
Inhalation four times a day as needed.
17. atrovent nebulizer 17 mcg/Actuation Aerosol Sig: One (1) neb
every six (6) hours.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary diagnosis:
Asthma exacerbation
Secondary diagnoses:
Bipolar disorder
PTSD
Discharge Condition:
Good- off of all O2 with O2 Sat 95% ambulating of room air
Discharge Instructions:
You were admitted for an exacerbation of your asthma. While
you were here, you needed oxygen mixed with helium for some time
to help you breathe which was given to you in the ICU. You were
also started on prednisone which you will continue for 1 month
as an outpatient on the taper which is listed on your discharge
medications.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on Friday as below.
Please call her sooner for follow up if you have shortness of
breath, difficulty breathing, chest pain, increased cough or
sputum productions or any other concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8988**], MD Phone:[**Telephone/Fax (1) 4775**]
Date/Time:[**2169-8-11**] 11:00
Please call Dr. [**First Name (STitle) **] for earlier follow-up if you start to
have increasing trouble breathing.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2169-8-7**]
|
[
"2449",
"4240"
] |
Admission Date: [**2149-1-17**] Discharge Date: [**2149-1-19**]
Date of Birth: [**2091-8-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57 yo M with history of metastatic hepatocellular is admitted to
the ICU under the sepsis protocol. He last recieved chemotherapy
last Monday. He presented to the ED with fever to 102.4 and
hypotensive. No source of infection identified so far.According
to him, his baseline BP is 120/80. After 3 L IVF, his blood
pressure was still in low 90s and he was thus enrolled in sepsis
protocol and had RIJ placed. He recieved 4L before transferring
to ICU. He recieved one dose of cefipime initially.He denies
any sick contact. According to him, he had recieved 6 weeks of
adriamycin and had not developed fever after any of those. He
claims that appetite has been good and he has satisfactory oral
intake.
He also complained of right sided pleurtic chest pain that had
been occuring intermittenly for about 2 months. According to
him, it's not a severe pain and it does not radiates. CTA done
in the ED ruled out DVT. He denies leg swelling/recent
travel/recent trauma to the leg.
Past Medical History:
1. hepatitis B(Hep C negative)
2. metastatic hepatocellular carcinoma on weekly adriamycin;
primary oncologist is Dr.[**First Name (STitle) **]
3. hypercholesterolemia
*PCP:[**Last Name (NamePattern4) **]. [**First Name (STitle) **] from [**Hospital3 **] comm health
Social History:
He came here from [**Country 651**] six years ago. Does not
speak English. He is married with two children, age 21 to 24.
He has worked in the restaurant business. He quit smoking
cigarettes seven years ago and does not drink any alcohol
Family History:
no family history of cancer
Physical Exam:
T 96.3 P76 BP100/57 R16 SpO2 100% CVP 6
Gen-NAD, very pleasant
HEENT-anicteric, oral mucosa dry, neck supple, no JVD
CV-RRR, no r/m/g, chest pain reproducible by palpation
resp-CTAB
[**Last Name (un) 103**]-active BS, soft, NT/ND, no HSM
neuro-A+OX3, PERL, CN II-XII intact, move all 4 limbs
skin-unremarkable
extremities-no peripheral edema, DP 1+ b/L, no leg swelling/no
palpable cord
Pertinent Results:
CTA [**2149-1-16**]: No pulmonary embolism. Stable mediastinal
lymphadenopathy.There are no focal consolidations or
pleural effusions. No pericardial effusion.Limited views of the
upper abdomen show multiple large
heterogeneous liver masses. The pancreas and spleen are grossly
unremarkable
RUQ U/S [**2149-1-18**]: The gallbladder is decompressed and there is no
evidence of cholelithiasis or acute cholecystitis. The common
bile duct is not dilated at 4 mm. Limited views of the liver
again show multiple, large heterogeneously echoic liver masses
consistent with the patient's known history of metastatic
disease. No biliary dilatation is seen.
Brief Hospital Course:
57yo with history of hepatocellular carcinoma admitted under
sepsis protocol with ED presentation of fever, hypotension and
pleuritic chest pain
1. Hypotension: He was admitted to the [**Hospital Unit Name 153**] on [**1-17**] under the
sepsis protocol. He last received chemotherapy last Monday. He
presented to the ED with fever to 102.4 and hypotensive with SBP
in the 70's. According to him, his baseline BP is 120/80. After
3 L IVF, his blood pressure was still in low 90s and he was thus
enrolled in the sepsis protocol and had a RIJ placed. He
received 4L before transfer to the [**Hospital Unit Name 153**]. He received one dose of
emperic cefipime initially. He denies any sick contact. On
admission, the pt also complained of right sided pleurtic chest
pain that had been occuring intermittenly for about 2 months.
According to him, it's not a severe pain and it does not
radiates. CTA done in the ED ruled out PE. On transfer to the
[**Hospital Unit Name 153**], the pt continued to receive IV fluids for a total of 5 L.
However, no pressors were ever needed. The pt became afebrile.
No source of infection was ever found. The antibiotics was
initially switched to ceftaz but was later changed to oral
ciprofloxacin but was discontinued since he remained afebrile
and pt is not neutropenic. He got a RUQ ultrasound which was
negative for cholecystitis or cholangitis as there was no ductal
dilation. He had an episode of T 101.2 on transfer to the floor
but remained afebrile without antibiotics for 24 hrs. All of
the cutlures were negative at the time of discharge. Patient
appeared well and wanted to go home. He was discharged with no
antibiotics. His right IJ was removed at the time of discharge.
2. Hepatocellular CA: Patient is getting weekly adriamycin and
will be followed by Dr. [**First Name (STitle) **].
Discharge Medications:
1. Epivir Oral
2. Ativan Oral
3. Compazine 10 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea. Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
hypotension
hepatocellular carcinom
Discharge Condition:
Afebrile, hemodynamically stable, asymptomatic
Discharge Instructions:
Please take all medications as prescribed. Please keep all of
your follow-up appointments including your appointment this
Tuesday [**1-21**] at 9:30am with [**First Name5 (NamePattern1) 14552**] [**Last Name (NamePattern1) **].
Please contact Dr. [**First Name (STitle) **] or a covering physician immediately if
you have fever, nausea/ vomiting pain or other worrisome
symptoms or report directly to the emergency department.
Followup Instructions:
Please keep your appoitment with [**First Name5 (NamePattern1) 14552**] [**Last Name (NamePattern1) **] of [**Last Name (NamePattern1) **]/Onc at
9:30am on [**2149-1-21**].
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] Date/Time:[**2149-1-21**] 9:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2149-1-21**] 9:30
Provider: [**Name Initial (NameIs) **]/Onc Date/Time:[**2149-1-27**] 10:30
Completed by:[**2149-1-20**]
|
[
"0389",
"2720"
] |
Admission Date: [**2140-9-26**] Discharge Date: [**2140-9-28**]
Date of Birth: [**2083-10-9**] Sex: F
Service: MICU ORANG
HISTORY OF PRESENT ILLNESS: This is a 57-year-old female
with history of cirrhosis, sickle cell disease (SC variant),
end stage renal disease, on hemodialysis, hypertension, who
presents with fever during hemodialysis, temperature to 103??????.
The patient subsequently transferred to Emergency Department
where initial temperature 104.8??????. Systolic blood pressure
120-130s, which then dropped to systolic blood pressures of
70s-80s. The patient received a 500 cc normal saline bolus
times one without response in blood pressure and then started
on dopamine drip in the Emergency Department, given concerns
by dialysis staff regarding change in mental status along
with fever. Ms. [**Known lastname 106571**] also received a lumbar puncture and
received 2 gm of ceftriaxone times one. Cerebrospinal fluid
was negative for white blood count and had a normal glucose,
high normal protein. CSF Gram stain pending. Given previous
history of MRSA in her sputum and mss in her peripheral blood
as well as an indwelling hemodialysis catheter, she was also
receiving vancomycin 1 gm intravenous times one. She was
subsequently transferred to MICU and started on vasopressin
and Levophed with the weaning off of the dopamine.
PAST MEDICAL HISTORY:
1. Sickle cell anemia with a baseline hematocrit of 17-21.
2. Pulmonary hypertension, on home 02 at 3 liters nasal
cannula.
3. Cirrhosis secondary to iron overload with a history of
ascites.
4. End stage renal disease, on hemodialysis since [**2140-4-26**]. She has a right tunneled catheter times 2.5 months.
5. Congestive heart failure, [**2140-4-26**], ejection fraction
55% with 1+ mitral regurgitation and 2+ tricuspid
regurgitation. Clean coronary arteries in [**2136**].
6. Atrial fibrillation.
7. Hypertension.
8. Gout.
9. Depression.
10. Reactive airway disease.
11. Status post cholecystectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Celexa 20 mg p.o. once daily
2. Renagel 800 mg p.o. three times a day
3. Epogen at hemodialysis.
4. Keflex 2 tabs p.o. once daily
5. Ursodiol
6. Calcitriol
7. Metoprolol 25 mg p.o. twice a day
8. Amlodipine 5 mg p.o. once daily
9. Hydroxyurea 100 mg p.o. once daily
10. Fentanyl patch
SOCIAL HISTORY: He lives with his daughter. [**Name (NI) **] tobacco or
ethanol use.
PHYSICAL EXAMINATION: On admission, temperature 102.4??????,
pulse 81, blood pressure 99/43, respirations 26, 100% on five
liters. GENERAL: Sleepy but arousable. Intermittently
answering questions, oriented times two, breathing rapidly.
Intermittent grunting. HEENT: Pupils are equal, round, and
reactive to light and accommodation, extraocular movements
are intact, icteric, periorbital and facial edema with
enlarged parotid glands Neck supple. No lymphadenopathy.
Oral mucosa slightly dry. Oropharynx clear. CARDIAC:
Regular rate and rhythm, normal S1-S2. II/VI talk murmur at
apex. PULMONARY: Bibasilar crackles without wheezes or
rhonchi. Abdomen distended, soft, normoactive bowel sounds,
liver five fingerbreadths below the right costal margin,
tender with no rebound or guarding. EXTREMITIES: No
cyanosis, clubbing or edema. Warm with good cap refill back.
No CVA tenderness. No tenderness to percussion of her
kidneys. NEURO: Cranial nerves II through XII grossly
intact and symmetric bilateral, moving all four extremities
equally.
LABORATORY DATA: White blood cell count 5.0, hematocrit
21.5, platelets 200, 71% polys, 7 bands. Sodium 139,
potassium 3.6, chloride 96, bicarbonate 30, BUN 14,
creatinine 2.7, glucose 63, lactate 5.9. ALT 63, AST 143,
LDH 443, alkaline phosphatase 534, amylase 89, total
bilirubin 5.3, lipase 19. PT 14.1, INR 1.4, PTT 53.2.
Urinalysis showed large blood, negative nitrates, 500
protein, trace ketones, small bilirubin, trace leukocyte
esterase, 21-50 red blood cells, 0-2 white blood cells. No
bacteria. There are two epithelial cells. CSF: 0 white
blood cells, 0 red blood cells, total protein 50, glucose 63.
CK 31, CKMB not performed. Troponin T 0.31.
Abdominal ultrasound in the Emergency Department with
markedly enlarged liver with nodular contour and no ascites
noted. Electrocardiogram - normal sinus rhythm at 82 beats
per minute, QRS 0.09, QTC 0.478, PR 0.156, LVH - no ST
changes compared to [**2140-9-20**] although evidence of RV strain.
SUMMARY OF HOSPITAL COURSE:
1. Fevers. Differential diagnosis includes line infection,
intraabdominal process, viral process, pneumonia, although no
evidence of pulmonary infiltrates on chest x-ray, sickle cell
crisis (likely combination of an inciting event plus his
sickle cell crisis). The patient was continued on Vancomycin
and ceftriaxone. Flagyl was added to cover for
intraabdominal and aerobic organisms. Blood cultures that
had been drawn in dialysis came back four out of four blood
cultures positive for Gram positive cocci. Transplant
service was consulted and removed right tunnel catheter on
night of admission. The patient initially received high dose
of steroids for suspected adrenal insufficiency. However,
random cortisol came back at 47.2 and the steroids were
discontinued. An infectious disease consult was obtained.
Per their recommendations, gentamicin was started.
2. Hypotension. Differential diagnosis included septic
which is felt to be most likely cardiogenic, hypovolemic.
Patient was started on Vasopressin and Levophed in the MICU,
as well as dopamine for cardiac stimulation as well as SVR
affect. Dopamine was gradually weaned off. Neo-Synephrine
was added for further pressure support.
Diastolic dysfunction. The patient had a history of
congestive heart failure with an ejection fraction of 55% and
on initial exam there was evidence of fluid overload as well
as on chest x-ray. The patient's beta blocker was held,
however, even her hypotension.
3. Respiratory. Following admission to the MICU, the
patient had to increase oxygen requirement with increased
respiratory effort. She was started on Bi-PAP but did not
tolerate it well and patient was very agitated on the Bi-PAP
despite Versed. The patient was intubated on [**2140-9-27**].
4. Colon. The patient had a tender liver on exam in the
setting of increased LFTs from baseline. The differential
diagnoses includes cholestasis, hemolysis, congestion
secondary to congestive heart failure, and sickle cell
crisis. Given patient's rapidly deteriorating course, we
were unable to obtain an abdominal CAT scan.
5. End stage renal disease. The patient was followed by
renal service during her hospital stay. But, given her
persistent hypotension, dialysis could not be performed
safely.
6. Status. Given the patient's rapidly deteriorating course
despite broad antibiotic coverage and pressure support, a
family meeting was held to discuss the goals of therapy. The
patient's daughter, who was her health care proxy, decided to
remove pressor and ventilator support. Shortly after removal
of pressor and ventilatory support, the patient progressed to
asystole. Time of death 06:55 a.m. [**2140-9-28**]. The patient's
family consented to autopsy.
DR.[**First Name8 (NamePattern2) **] [**Name (STitle) **] 12-838
Dictated By:[**Last Name (NamePattern1) 106572**]
MEDQUIST36
D: [**2140-12-19**] 10:40
T: [**2140-12-19**] 14:30
JOB#: [**Job Number 106573**]
|
[
"40391",
"4280"
] |
Admission Date: [**2118-3-30**] Discharge Date: [**2118-4-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Aspiration pneumonia
Sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]f with recent pna, hypothyroidism, VVI pacer for bradycardia
and AV block awoke on morning of admit with dyspnea. She'd been
increasingly dyspneic over the past 2-3d before admit. She'd had
no chest discomfort, f/c, or significant cough. In the ED, she
was found to have a WBC of 16.8 with 7%bands so was treated with
levofloxacin; her o2 sat was 87% on ra in ED but rebound to 99%
on 2L-nc. She was found to have 4+ bilateral lower extremity
edema. Chest xray in ED was unchanged from prior with densely
calcified pleura due to fibrothorax. She had one meausre of O2
sat of 99% on 2 L. Her BNP in the ED was found to be 5455 (last
BNP was >6000). She was noted to have elevated WBC of 16 with 7
bands and was given dose of levofloxacin. She was HD stable in
the ED however her UOP has been none to minimal. She was given
dose of dexamethasone in the ED for concern of adrenal
insufficiency.
.
She was admitted to the [**Hospital Unit Name 153**] where she received ceftriaxone and
azithromycin and remained stable throughout the day, so was sent
to the floor. Here, she is frustrated over being ill and having
to be in the hospital, so she'd answer few questions, though
denies pain but does say she remains dyspneic.
.
Patient was recently admitted for SOB and weakness in [**1-16**] and
felt dyspnea could be secondary to PNA. Patient did have CT
chest on prior admission that showed pleural calcifications. At
that admission patient was noted to have B/L LE edema with
negative LENI and felt edema secondary to low albumin.
.
She was doing well on the wards until [**4-2**] when she began to be
hypothermic. Though she had been hypothermic in the ICU with
temperatures in the 95 range, she was more so on the floor with
temps in the 93 axillary range with as low as 91. The team
changed her abx from levoquin to vanc/zosyn for broader coverage
on [**4-2**]. She was also given increased lasix on [**4-2**] (recieved 10
PO and 20 IV at noon). Attempts to warm her were unsuccessful.
Approximately 9:30 PM on [**4-2**], she began to become hypotensive
as well with systolics in the 70's. She was given normal saline
boluses 250 x2 with minimal effect and transferred to the ICU.
Past Medical History:
1. Hospitalized 4 years ago for atypical chest pain, no MI
2. Hypothyroidism
3. Anemia, iron deficient
4. VVI Pacemaker [**2116**], for bradycardia and AV block
5. Query seizure disorder
6. s/p pneumothorax after pacemaker.
7. h/o falls
8. recent admission for pna
Social History:
The patient previously owned a flower store in [**Location (un) 669**]. She
lives in [**Location (un) 9226**] [**Hospital3 **] facility. She was
never married, though has a niece and nephew in the area who are
primary supports. She denies tobacco, ETOH, drugs. Her nephew is
her HCP.
Family History:
Non-contributory
Physical Exam:
PE: t 96.7, bp 130/60, hr 76, rr 16, spo2 96%2l
Pt defers exam
Appears non-tox, in NAD
Breathing without accessory muscle use
Neurologically, she can tell me she's at [**Hospital1 **]-hospital, just came
up from the [**Location (un) **] and that she was in an ICU, and that it's
[**2118**]; she's moving all extrm.
Pertinent Results:
[**2118-3-30**] CXR: Overall unchanged appearance of the chest with
densely calcified pleura due to fibrothorax and right upper lobe
pleural-based density. Evaluation of lung parenchyma is somewhat
limited.
.
[**2118-3-30**] ECG:
Technically difficult study
Ventricular pacing
Pacemaker rhythm - no further analysis
Probable dissociated atrial rhythm, rate 60-70 bpm
Since previous tracing, no significant change
.
[**2118-4-2**] CXR: The patient's head is slumped over resulting in
obscuration of the bilateral apices, right worse than left.
There is also significant rotation. The position of her chin
obscures the previously noted pleural-based entity in the right
apex. Of the visualized lung, most of it is obscured by the
underlying fibrothorax previously described. The aerated left
upper lung is clear.
IMPRESSION: Nearly nondiagnostic examination secondary to
multiple limitations detailed above.
.
[**2118-4-3**] CT CHEST: 1. No pulmonary embolism.
2. Extensive diffuse bilateral calcified pleural plaques and
pleural thickening/loculated pleural fluid causes marked volume
loss of both lungs, right greater than left. Again this is
consistent with exposure. There is some concern for underlying
pleural malignancy with evaluation for enhancing pleural mass
limited by the very early timing of IV contrast.
3. Increase in loculated pleural fluid of the medial right lower
chest and mildly so elsewhere.
4. Multifocal opacities of both lungs are probably mostly due to
scarring and atelectasis, slightly increased. Underlying lung
parenchymal infection cannot be excluded.
5. Moderate hiatal hernia.
.
[**2118-3-30**] 04:00AM WBC-16.8*# RBC-3.26* HGB-9.0* HCT-28.2*
MCV-87 MCH-27.8 MCHC-32.0 RDW-18.0*
[**2118-3-30**] 04:00AM NEUTS-72* BANDS-7* LYMPHS-11* MONOS-7 EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2118-3-30**] 04:03AM GLUCOSE-148* LACTATE-1.3 K+-6.2*
[**2118-3-30**] 05:30AM ALBUMIN-3.1* CALCIUM-9.2 PHOSPHATE-4.1
MAGNESIUM-2.4
[**2118-3-30**] 05:30AM GLUCOSE-138* UREA N-24* CREAT-0.8 SODIUM-126*
POTASSIUM-5.3* CHLORIDE-93* TOTAL CO2-28 ANION GAP-10
[**2118-4-4**] 04:13AM BLOOD WBC-5.4 RBC-3.14* Hgb-8.8*# Hct-27.0*
MCV-86 MCH-28.0 MCHC-32.5 RDW-18.1* Plt Ct-233
[**2118-4-4**] 04:13AM BLOOD Plt Ct-233
[**2118-4-4**] 04:13AM BLOOD Glucose-87 UreaN-19 Creat-0.8 Na-139
K-3.8 Cl-105 HCO3-27 AnGap-11
[**2118-4-4**] 04:13AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.2
Brief Hospital Course:
[**Age over 90 **] y/o female admitted for shortness of breath.
Hospitalization complicated by need for ICU care for hypothermia
and sepsis. Sepsis believed secondary to chronic aspiration
leading to pneumonia. Covered broadly for this. With advanced
age discussions had with patient and family of overall goals of
care. All agreed that patient would not want prolonging
measures. Patient stabilized in ICU with volume resucitation
but decision made not to transfer back to ICU if again became
sick. Day after transfer to floor patient again hypothermic.
Further discussions agreed to make patient CMO. Patient made
comfortable, visited by family. Slowly blood pressure trended
down; antibiotics and other medications stopped and patient
given oral and IV morphine in low dose prn. Died peacefully of
cardiac arrest.
Medications on Admission:
Levothyroxine 150 mcg PO DAILY
Ferrous Sulfate 325 PO DAILY
Latanoprost 0.005 % Drops Ophthalmic HS
Dorzolamide-Timolol 2-0.5 % Drops One QAM
Brimonidine 0.15 % Drops Ophthalmic [**Hospital1 **]
Levetiracetam 250 mg One PO QHS
Ibuprofen 400 mg One PO Q8H prn
Aspirin 81 mg One PO DAILY (Daily).
Lasix 10 mg PO once a day
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
aspiration pneumonia, sepsis
Discharge Condition:
Dead
Discharge Instructions:
Diet: Speech/swallow recommending soft solid po diet texture
with thin liquids. Po meds to be given either whole or crushed
in purees, as tolerated.
Followup Instructions:
None
|
[
"5070",
"0389",
"99592",
"2761",
"2449"
] |
Admission Date: [**2136-11-22**] Discharge Date: [**2136-11-23**]
Date of Birth: [**2097-12-31**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine / Vicodin / Penicillins / Sulfa (Sulfonamide
Antibiotics) / Nsaids
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Malaise, vomiting
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Central venous line placement
CVVH
History of Present Illness:
39F s/p gastric bypass surgery with alcoholism, fatty liver
disease, and epilepsy transferred from OSH for further
evaluation and management of fulminant hepatic failure.
According to her fiancee and mother, she has been feeling
fatigue, malaise, and, anorexia for more than a week. She
attributed these symptoms to a virus and was taking tylenol for
symptomatic relief. Her fiancee reports finding a half-empty
bottle of tylenol pills (40 pills missing over a period of 4
days but of unknown strength). She felt as if she had a seizure
2 days prior to admission because she awoke feeling confused
with soreness in her ribs, the way she has felt after prior
seizures (most recently months ago.) She was noted to be
hallucinating on the day prior to admission and asked her
fiancee if he saw black dots. She complained of severe fatigue,
nausea, vomiting and poor appetite. Family denies a history of
psychiatric disease or suicide attempt, and does not feel that
this episode represents a suicidal gesture. No reported fever,
chills, sweats, headache, stiff neck, photophobia, chest pain,
palpitations, shortness of breath, abdominal pain, diarrhea,
hematochezia, melena, jaundice, edema, sick contacts, or recent
travel. Called her upstairs neighbor to request that she call
911. Taken to [**Hospital6 28728**] Center in [**Location (un) **]. On arrival to
the ED, was obtunded and intubated for airway protection. CT
head did not show any evidence of intracranial hemorrhage. CxR
showed LLL infiltrate vs. atelectasis. Labs were notable for WBC
11, Hct 31.4, Plt 23, INR 8.1, Cr 4.3, K 6.3, HCO3 7, AST [**Numeric Identifier **],
ALT 2203, Tbili 6.3, Ca 7.3, CK 5076 ammonia 617, lipase 709,
amylase 459, tylenol level 112ug/ml, ETOH 53mg/dl, and lactate
22.3. Remaining tox screen was negative. Her ABG after
intubation was 6.68/52/352. Was hypotensive and started on
levophed & vasopression. Central line, A-line, and dialysis
catheter were placed. Was started on NAc & bicarb drips,
vanc/cefepime/azithro/flagyl, and lactulose. Given vitamin K 5
mg SC and 2U FFP. Received emergent hemodialysis prior to
transfer.
Past Medical History:
Fatty liver disease diagnosed by biopsy [**4-7**] ([**Hospital **] hospital)
s/p gastric bypass surgery
PUD s/p perforated ulcer repair
calcium nephrolithiasis s/p parathyroidectomy
Epilepsy
Alcoholism
Social History:
Unemployed. Smokes [**2-3**] ppd. Drinks 2 beverages per day but has a
history of alcoholism per family.
Family History:
Father died of complications of alcoholic cirrhosis.
Physical Exam:
Vitals - T 98 BP 129/43 (on levo 0.4 mcg/kg/min & vaso 2.4U/hr)
HR 111 RR 22 02sat 91% on Vt 500 RR 20 PEEP 5 FiO2 0.5
GENERAL: Intubated, sedated
HEENT: icteric sclera, dry MM
NECK: R IJ site c/d/i JVD difficult to assess due to habitus
CARDIAC: reg rate nl S1S2 no m/r/g
LUNGS: diffuse rhonchi anteriorly no wheeze/rales
ABDOMEN: soft obese nontender nondistended
EXT: warm, dry trace pedal edema
NEURO: withdraws to painful stimuli
DERM: scaly dry psoriatic rash over rash and anterior chest
Pertinent Results:
Admission labs:
[**2136-11-22**] 11:38PM WBC-4.0 RBC-2.46* HGB-8.0* HCT-25.2* MCV-102*
MCH-32.5* MCHC-31.7 RDW-21.4*
[**2136-11-22**] 11:38PM NEUTS-75* BANDS-1 LYMPHS-22 MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-3*
[**2136-11-22**] 11:38PM PLT SMR-VERY LOW PLT COUNT-24*
[**2136-11-22**] 11:38PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
SCHISTOCY-OCCASIONAL
[**2136-11-22**] 11:38PM GLUCOSE-102 UREA N-19 CREAT-3.6* SODIUM-133
POTASSIUM-4.3 CHLORIDE-88* TOTAL CO2-11* ANION GAP-38*
[**2136-11-22**] 11:38PM ALBUMIN-2.5* CALCIUM-5.6* PHOSPHATE-10.2*
MAGNESIUM-2.0 IRON-142
[**2136-11-22**] 11:38PM ALT(SGPT)-2187* AST(SGOT)-[**Numeric Identifier **]*
LD(LDH)-8040* ALK PHOS-181* TOT BILI-5.3*
[**2136-11-22**] 11:38PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV
Ab-POSITIVE IgM HAV-NEGATIVE
[**2136-11-22**] 11:38PM AMA-NEGATIVE Smooth-NEGATIVE
[**2136-11-22**] 11:38PM [**Doctor First Name **]-POSITIVE TITER-1:40
[**2136-11-22**] 11:38PM ACETMNPHN-47.6*
[**2136-11-22**] 11:38PM HCV Ab-NEGATIVE
.
Imaging:
CXR: The ET tube is low and at risk of intubating the right main
stem
bronchus. The NG tube passes into the proximal stomach and
should be advanced to more optimal position.
The right internal jugular catheter tip is at the cavoatrial
junction. New
hazy opacification of the left lung due to a combination of left
lung collapse and superimposed pulmonary edema is noted. Dense
consolidation in the periphery of the right lower lobe is
probably due to infection and unchanged. The heart size is
normal. No pneumothorax. This chest radiograph was reported in
conjunction with the follow-up study in
which the ET tube has been withdrawn.
.
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 60%). There is no ventricular septal defect. The right
ventricular cavity is dilated with borderline normal free wall
function. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. No masses or vegetations are seen on the tricuspid
valve, but cannot be fully excluded due to suboptimal image
quality. The estimated pulmonary artery systolic pressure is
normal. No masses or vegetations are seen on the pulmonic valve,
but cannot be fully excluded due to suboptimal image quality.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality; no obvious vegetations;
normal left ventricular ejection fraction
.
CT head:
NON-CONTRAST HEAD CT: There is diffuse obliteration of
[**Doctor Last Name 352**]-white
differentiation consistent with mild diffuse cerebral edema.
Hypodense
appearance of deep [**Doctor Last Name 352**] matter structures in the area of the
basal ganglia and thalamus likely also represents sequela of
diffuse cerebral edema. The basal cistern and suprasellar
cisterns are patent. No lytic or sclerotic bone lesion is seen.
The mastoid air cells and visualized paranasal sinuses are
clear. Visualized orbits are clear. There is crowding of the
foramen magnum, which may represent low lying cerebral tonsils.
IMPRESSION: Diffuse cerebral edema as described above.
.
RUQ US:
1. Technically limited study due to the very echogenic liver
which is
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. The degree
of fatty infiltration limits the ultrasound ability to assess
the hepatic architecture, but no focal lesion is identified. No
biliary dilatation is seen.
2. Patent hepatic vasculature.
3. Minimal ascites.
Brief Hospital Course:
Patient is a 39 yo F who was admitted with fulminant hepatic
failure wtih multisystem organ failure, most attributable to
acetaminophen toxicity. She was continued on NAC gtt and
Hepatology followed. Pt arrived intubated and was ventilated
per ARDSnet protocol. She required 4 pressors to maintian a MAP
>65. She initially was on a bicarb gtt until CVVH was started.
When the CT head returned with cerebral edema, her family
changed her goals of care to comfort. She died on [**2136-11-23**]. No
autopsy was requested by the family; however, her case was
referred to the ME.
Medications on Admission:
calcium
vitamin D
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Fulminant hepatic failure
Acetaminophen overdose
Shock
Acute renal failure
Acute respiratory distress syndrome
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"5845",
"99592",
"78552",
"2762",
"2767",
"3051"
] |
Admission Date: [**2145-12-7**] Discharge Date: [**2145-12-13**]
Date of Birth: [**2081-11-5**] Sex: M
Service: SURGERY
Allergies:
Demerol / Haloperidol / Ativan
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
HCV/HCC here for liver transplant
Major Surgical or Invasive Procedure:
[**2145-12-7**] liver transplant
[**2145-12-10**] L ear helix biopsy
History of Present Illness:
64 y/o male who presented for liver transplant evaluation
and was accepeted and listed. Approximately 20 years ago, he was
noted to have an elevated SGOT during a life insurance physical
and was diagnosed with Hepatitis C. Only recently has the
patient
become more symptomatic with fatigue and pruritus. No chest pain
or difficulty breathing are noted. The patient reports feeling
fatigued.
The patient denies any recent fever or chills, no nausea or
vomiting. Intermittent diarrhea (on lactulose) Patient continues
to have c/o pruritus and has very profound quadricep cramps that
make him jump out of bed. The patient currently sees his
psychiatrist about every two months and attends AA meetings on a
regular basis.
Last food was cheese and crackers at 10AM
.
Past Medical History:
- Bipolar disorder: Diagnosed in [**2129**], past suicide attempt in
the 70s during a manic phase or s/t to drug and alcohol abuse.
Had been stable on Wellbutrin and Lithium since [**29**] and 93
respectively, except for during a trial of IFN therapy in [**2138**]
where hospitalization was required.
- HCV: Genotype unknown. Liver biopsy in [**9-/2144**] showed stage 4
cirrhosis and small well-differentiated hepatocellular
carcinoma. Found to have grade 1 esophageal varices on EGD in
4/[**2143**]. Developed hepatic encephalopathy in [**2142**] requiring
hospitalization at [**Hospital1 2025**], started on lactulose with good effect.
Past treatments include peg interferon and ribavirin in [**2139**].
These meds were discontinued due to suicidal ideation.
- HCC: Recently noted 1.4 cm enhancing lesion on liver imaging,
proved to be small, well-differentialed HCC on bx in [**9-26**].
- Hypothyroidism. On levothyroxine as an outpatient.
-[**2145-12-7**] liver transplant
Social History:
He lives [**Location (un) **] w/ wife, who is a nurse. [**First Name (Titles) **] [**Last Name (Titles) 23165**]
beverage for 30 years. No tobacco use ever.
Family History:
Patient recalls no history of neurologic or autoimmune diseases.
Physical Exam:
VS: 98.2, 75, 133/79, 18, 100% RA
General: appears tired but engages easily in converastion
HEENT: no scleral icterus, MMM,
Card: RRR, II/VI systolic murmur
Lungs: CTA bilaterally
Abd: protuberant but soft, cannot feel liver edge, no hernia,
+ BS
Extr: 1+ pitting edema lower extremities, 2+ DPs
Skin: multiple excoriations, most notable over abdomen and back
of neck. No areas appear infected or actively bleeding
Neuro: No asterixis, A+Ox3
.
Pertinent Results:
[**2145-12-13**] 05:50AM BLOOD WBC-5.6 RBC-3.47* Hgb-11.0* Hct-33.9*
MCV-98 MCH-31.6 MCHC-32.3 RDW-15.1 Plt Ct-88*
[**2145-12-10**] 05:03AM BLOOD PT-11.4 PTT-40.7* INR(PT)-0.9
[**2145-12-13**] 05:50AM BLOOD Glucose-107* UreaN-47* Creat-1.0 Na-137
K-5.4* Cl-105 HCO3-30 AnGap-7*
[**2145-12-13**] 05:50AM BLOOD ALT-221* AST-68* AlkPhos-114 TotBili-0.4
[**2145-12-13**] 05:50AM BLOOD Calcium-7.2* Phos-1.6* Mg-2.2
[**2145-12-13**] 05:50AM BLOOD tacroFK-9.0
Brief Hospital Course:
On [**2145-12-7**], he underwent cadaveric liver transplant. Surgeon
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please refer to operative note for complete
details. Induction immunosuppression was administered. Bile was
produced after vascular and biliary anastomoses. Two drains were
placed. He was transferred to the SICU postop for care and was
extubated without complication. He experienced severe restless
leg syndrome. Psychiatry was consulted with recommendation to
use seroquel (home medication). Seroquel was resumed with
improvement each day. His home dose of Wellbutrin was resumed.
LFTs trended back down and postop day 1 liver duplex was normal.
He remained hemodynamically stable and was transferred out of
the SICU. Diet was advanced and tolerated. His incision had some
erythema that was non-blanching and not warm. This was felt to
be bruising. He inadvertently pulled out one of the JP drains
without complication. The 2nd JP was removed several days later.
Both were non-bilious.
Immunosuppression consisted of cellcept which was well
tolerated, steroids were tapered. He did require intermittent
insulin per sliding scale. NPH was added as well. Prograf was
started on postop day 1. Dose was adjusted to 3mg [**Hospital1 **] for trough
level which stabilized at 9.0.
PT evaluated and recommended a rolling walker and home PT. VNA
services were arranged.
Of note, he was noted to have a chronic non-healing lesion on
his left ear. Dermatology was consulted. A shave biopsy was done
to rule out squamous cell. Sutures were to remain in place for
two weeks. The plan was for the sutures to be removed at f/u
appointment on [**12-23**] in the [**Hospital 1326**] clinic. A dermatology
follow up appointment was to be scheduled with Dr. [**First Name (STitle) **] as an
outpatient.
He was doing well, vitals were stable and was tolerating a
regular diet at time of discharge.
Medications on Admission:
Buproprion 150 SR daily, Cholestyramine 4 gm 1 packet [**Hospital1 **],
Clotrimazole 10 mg troche 5x daily, Clotrimazole cream [**Hospital1 **],
Folic
acid 1 mg daily, Lasix 20 mg daily/PRN swelling, Hydroxyzine 25
mg TID PRN itch, Lactulose 10 gm/15 ml 3 TBSP 3-5x daily PRN
, Levothyroxine 75 mg (dose increase 2 weeks
ago) Protonix 40 mg daily, Compazine 10 mg PRN nausea, Qutiapine
50 mg 1/2-1 tab PRN hs insomnia, Spironolactone 200 mg daily,
Sucralfate 1 gm QID, Provigil 100 mg daily, Ursodiol 600 mg
daily, Vit D2 400 unit capsule 2 caps daily,
Glucosamine/chondroitin 250/200 mg [**Hospital1 **], Mag Oxide 500 mg [**Hospital1 **],
MVI
daily, Thiamine 100 mg daily
Discharge Medications:
1. Lasix 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day for 5
days: Last day of lasix [**12-18**].
Disp:*5 Tablet(s)* Refills:*0*
2. Fluconazole 200 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q24H (every
24 hours).
3. Prednisone 5 mg Tablet [**Month/Year (2) **]: Four (4) Tablet PO DAILY (Daily).
4. Colace 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO twice a day.
5. Levothyroxine 75 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a
day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Quetiapine 25 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO QHS (once a
day (at bedtime)) as needed for agitation/insomnia.
8. Quetiapine 25 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO BID (2 times a
day) as needed for agitation.
9. Valganciclovir 450 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Month/Year (2) **]: One (1)
Tablet PO DAILY (Daily).
11. Mycophenolate Mofetil 500 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO
BID (2 times a day).
12. Bupropion HCl 150 mg Tablet Sustained Release [**Month/Year (2) **]: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
13. Oxycodone 5 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
14. Clotrimazole 1 % Cream [**Month/Year (2) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
15. Tacrolimus 1 mg Capsule [**Hospital1 **]: Three (3) Capsule PO Q12H
(every 12 hours).
16. NPH Insulin Human Recomb 100 unit/mL Suspension [**Hospital1 **]: Ten
(10) units Subcutaneous once a day.
17. NPH Insulin Human Recomb 100 unit/mL Suspension [**Hospital1 **]: Ten
(10) units Subcutaneous at bedtime.
18. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: follow
sliding scale Injection four times a day.
Disp:*1 bottle* Refills:*2*
19. One Touch Ultra System Kit Kit [**Hospital1 **]: One (1)
Miscellaneous four times a day.
Disp:*1 kit* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
HCC/HCV now s/p orthotopic liver transplant
L superior helix: 0.5 x 0.5cm hemorrhaghic crusted erosion
? squamous cell carcinoma vs less likely traumatically
nonhealing lesion. s/p Punch biopsy:
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (
rollimg walker)
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, increased abdominal pain,
increased drainage from the incision or old drain sites
yellowing of skin or eyes or any other concerning symptoms.
Monitor the abdominal incisions for drainage or bleeding. You
may keep them covered if there is drainage but it is safe to
leave them open to air.
You may Clean biopsy site with soap, water, then pad dry every
day for 2 weeks. Cover with a thin layer of vaseline and perform
dressing change every day for 2 weeks.
Followup Instructions:
Left ear suture removal [**12-23**] at Transplant Office follow up
appointment
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2145-12-30**]
2:00
Dermatology follow up appointment with Dr. [**First Name (STitle) **]
([**Telephone/Fax (1) 1971**])-you will receive a call with an appointment for a
full body exam. Dr. [**First Name (STitle) **] will call you with biopsy results.
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-12-23**]
8:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-12-30**]
10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2308**], MD Phone:[**Telephone/Fax (1) 3965**]
Date/Time:[**2145-12-14**] 11:30
Completed by:[**2145-12-13**]
|
[
"2449"
] |
Admission Date: [**2158-7-24**] Discharge Date: [**2158-8-3**]
Date of Birth: [**2094-3-2**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 64-year-old female
with myelodysplastic syndrome and history of cerebrovascular
accident in [**2154**], who was in her usual state of health until
approximately three days prior to admission, when her
daughter noticed that she seemed more lethargic than usual.
On the morning of admission, her mother complained to her of
being awakened by acute chest pain "like knives in her
chest". In addition, her mother described feeling nauseated,
lightheaded, dizzy, and weak. She denied experiencing
diarrhea, vomiting, or any change in appetite. At this time,
she denied experiencing coughing, dysuria.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
99.3, pulse 123, blood pressure 90/50, respirations 24, and
oxygen saturation 94% on 2 liters nasal cannula. In general,
the patient was resting comfortably in bed in no acute
distress. Her oral examination was remarkable for very poor
dentition. She had a periodontal gum lesion on the left
upper gum, with swelling on the hard palate directly opposite
to the lesion on the other side of her teeth. She had tender
submandibular lymphadenopathy. Her lung examination revealed
crackles at the bases bilaterally. Her cardiac examination
revealed tachycardia but was otherwise a regular rhythm. Her
abdominal examination was benign and her neurologic
examination was remarkable for a left eye abduction and was
otherwise intact.
LABORATORY/RADIOLOGIC DATA: ........... showed no growth,
and an HSV-PCR analysis returned negative.
HOSPITAL COURSE: ........... or fluid overload. The patient
showed clinical improvement over two days in the Medical
Intensive Care Unit and returned to the Medicine Floor on
hospital day number ........... ........... precautions.
Received 2 units of packed red blood cells, and received four
bags of platelets prior to lumbar puncture.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 51598**]
MEDQUIST36
D: [**2158-8-3**] 11:22
T: [**2158-8-5**] 13:16
JOB#: [**Job Number 97462**]
|
[
"4280",
"2720"
] |
Admission Date: [**2108-10-16**] Discharge Date: [**2108-11-26**]
Date of Birth: [**2035-8-15**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: On presentatio the patient is an
80 year-old woman found to be in an motor vehicle accident.
She is a restrained driver versus a brick wall. She is awake
and confused at the scene and became obtunded, intubated by
EMS, arrived to [**Hospital1 69**] in
collar, intubated. GCS of 3. Initial systolic blood
pressure of 74, decreased breath sounds on left, left chest
tube was placed. Initial attempt went to the abdomen.
Repeat systolic blood pressure 110, heart rate 78. Chest
x-ray of pelvis. X-ray done, access was obtained,
laboratories sent, Foley and G tube placed, to the Operating
Room for emergent laparotomy. In the Operating Room
difficult to ventilate with decreased systolic blood
pressures. Right chest tube was placed with initial return
of 200 cc of blood.
PHYSICAL EXAMINATION: Intubated, C collar, GCS of 3,
temperature 35.5, heart rate 78, blood pressure 70/palp.
HEENT trachea midline. No JVD. Chest stable. Clear to
auscultation bilaterally. Decreased breath sounds on the
left. Heart regular rate and rhythm. Abdomen soft,
nondistended, positive bowel sounds. FAST examination
negative. Pelvis stable. Extremities no obvious
deformities. Good capillary refill. Back had no step offs.
LABORATORY: White blood cell count 12.2, hematocrit 36.0,
platelets 305, PT 13.9, PTT 33.4, INR 1.3, amylase 69, sodium
138, potassium 4.0, chloride 104, glucose 269. Initial
arterial blood gas 7.08, 91, 72, 29, lactate 4.4, tox screen
was negative. Pelvis x-ray negative for fracture. Chest
x-ray was rotated.
HOSPITAL COURSE: The patient was taken to the Operating Room
for emergent exploratory laparotomy. At the laparotomy the
patient was found to have decreased blood pressure and O2
saturations and increased difficulty of ventilation. A right
chest tube was placed at 200 cc of return of blood. No
obvious abdominal injury on laparotomy. Pericardial window
was performed with drainage of blood. Sternotomy performed.
Cardiothoracic surgery scrubbed for emergent intraop consult
and was found a right atrial tear times three and multiple
right lung lacerations. The laparotomy was performed
initially with suspected left diaphragmatic injury following
low left chest tube placement and hemodynamic instability.
There was no hemoperitoneum found and the patient remained
hypotensive despite volume resuscitation. Right chest tube
was inserted with only 200 cc output. A pericardial window
resulted in diagnosis of tamponade and ongoing pericardial
bleeding. Sternotomy was performed and found massive right
hemothorax, multiple perforations of right atrium. The
incision was extended into the right chest. Dr. [**Last Name (STitle) 70**]
and Dr. [**Last Name (STitle) 519**] then placed her on cardiopulmonary bypass and
primary repair of the atrium and multiple staplings and
oversewing of the right lung parenchyma were performed.
Unable to close any of her wounds primarily. Estimated blood
loss was 5000 cc. The patient received 20 units of red blood
cells, 11 units of fresh frozen platelets, 7 units of
platelets, 2 units of cryoprecipitate, 13,000 cc of
crystalloid with a urine output of 600 cc during the case.
The patient was taken intubated to the Intensive Care Unit in
critical condition. The patient on postoperative day one
required multiple blood products including the Operating [**Apartment Address(1) 45455**] units of blood as well as fresh frozen plasma. She was
maintained on pressors including epi and Levophed as well as
neo. She was covered empirically with Cefuroxime for
potential abdominal and chest infection. Over the next few
days the patient was slowly weaned off of her pressors. She
remained intubated with chest tubes in place. She had an
ophthalmology consult for diffuse orbital swelling. They
recommended eye drops, which were started with no evidence of
ocular trauma found. The patient continued to slowly wean
off of her pressors. By postoperative day number three she
was on smaller amounts of pressors and she was not requiring
any further transfusions. She continued to slowly progress
and on postoperative day number four she went back to the
Operating Room for closure. On the [**12-21**] she
underwent exploratory laparotomy, wash out, partial facial
closure of her abdomen and skin closure of her abdomen. The
thorax was explored and her sternotomy wound was also closed.
She tolerated this relatively well and she continued to wean
off of her pressors over the next few days.
She went back to the Operating Room two days later for
complete closure of her abdomen on the 18th, which she
tolerated well. She was recultured and antibiotics were
again continued. She remained on Cefuroxime. She continued
to slowly wean off her pressors and improved slowly. She had
a negative CT of her head and her C spine. She was started
on Vancomycin for sputum cultures with staph coag positive
from a bronch, which she underwent for worsening chest x-rays
as well as sputum on the 20th. It showed mild secretions
nonpurulent. She continued to slowly improve. Neurosurgery
followed her and there were no acute changes with her
neurological status. She also underwent CT scan with
reconstruction of her TLS, which was done. Plain films
showed a question of a T12 anterior wedge compression
fracture. The patient continued to slowly improve. CT of
her C spine showed compression fractures of T8 through 11.
Her head showed right subdural hematoma, parietal
subarachnoid and a pansinusitis. ENT was consulted for this.
ORL or ENT saw her and recommended maxillary of facial CT for
facial fractures and for nasal spray, which she was started
on. The patient continued to improve and neurosurgery
followed her for her head bleeds. She was treated for
sinusitis. Lines were changed. Chest x-rays were followed.
The patient continued to decrease her pressor requirements.
She slowly improved over the next few weeks.
Other events, neurosurgery noted that her thoracic
compression fractures were probably old and there was no
brace needed. In terms of her neurological examination she
had follow up head CTs with no worsening and they did not
require any further treatment. The patient continued to
improve and infectious disease saw the patient and they
started Vancomycin and continued some Zosyn and she was pan
cultured intermittently for fevers. OMSF saw the patient on
the 24th for a left subcondylar fracture. She had a repeat
CT including all of the mandible and they did not recommend
treatment of the let subcondylar fracture and that was their
recommendation. Furthermore she slowly improved and she was
weaning slowly each day off the Levophed drip and was also at
this point in her course. By CICU day 15 she continued to
improve and was noted to be completely off of all pressors.
Her cultures were growing staph aureus and hip cultures were
negative. She was continued on Zosyn and Vancomycin for a
full course. The patient continued to improve and by the end
of [**Month (only) **] she ended up continuing to do well, but slowly
weaning from the vent. It was clear that she did well on
pressor support, but was not ready to be extubated and she
would require full pressor support wean. On [**11-14**] she
underwent a percutaneous tracheostomy without complications.
She was tolerating tube feeds with a nasogastric feeding
tube. She remained with that. By postoperative day thirty,
twenty six and thirteen the patient continued to do well.
She was intermittently diuresed over the prior two weeks
slowly with bouts of hypotension when the diuresis was too
aggressive. Therefore she was started on po Lasix down her
nasogastric tube and it was decided that she would undergo a
percutaneous placement of a J tube or a PEG, which was done
in interventional radiology in mid [**Month (only) 1096**], which she
tolerated well. She is continuing to wean her pressor
support down to 10, PEEP of 7.5 and does well with this with
only occasional episodes of desaturation, very sporadically
if she has a plug has to be placed on a rate for a short time
and then return to her pressor support wean. Her central
lines were removed. A PICC was placed in interventional
radiology, which is her main access and she continues to do
well on pressor support wean and a slow diuresis with 60 po
Lasix b.i.d.
Now she is currently postop day forty one, thirty seven and
twenty four from her original thoracotomy, laparotomy and
closures, status post her motor vehicle accident with right
atrial tear, pneumothoraces, subarachnoid and subdural
hemorrhages and adult respiratory distress syndrome and is
doing well on the following setting, 50% FIO2, PEEP of 7.5,
pressure support of 10. Her current medications are
Amiodarone, Neutrophos, heparin subQ, NPH, sliding scale
insulin, Lasix 60 mg b.i.d., Fluconazole and Fentanyl prn.
She is on Promote tube feeds at 85 cc an hour. Her current
doses of her medications are Fluconazole 200 mg per PEG q 24
hours times four days, she is currently day two of four.
Furosemide 60 mg per PEG b.i.d., potassium chloride 4
milliequivalents in 100 milliliters per K of less then 4.0,
Fentanyl 10 to 25 mg intravenous q 4 hours prn,
_______________ 2 to 4 mg intravenous q 6 hours prn,
Simethicone 40 to 80 mg po q.i.d. prn, Amiodarone 200 mg po q
day, morphine 2 to 8 mg intravenous q one hour prn,
Neutrophos one packet po t.i.d. hold for phosphorus greater
then 3.5, Albuterol 6 to 10 puffs inhaler q 2 hours prn. NPH
10 units q 12 hours. She gets regular sliding scale insulin,
which is given for 120 to 160 2 units, 160 to 200 4 units,
200 to 240 6 units, 240 to 280 8 units, 280 to 320 10 units,
greater then 300 12 units. Heparin 5000 units subQ q 12
hours, Miconazole powder 2% applied q.i.d. prn to effected
areas, calcium gluconate 2 grams intravenous for calcium less
then 1.1 ionized, magnesium sulfate 2 grams per intravenous
prn magnesium less then 1.5, Lacrilube ointment applied each
eye prn. Promote at 85 cc an hour per her PEG tube.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (STitle) 45456**]
MEDQUIST36
D: [**2108-11-26**] 12:14
T: [**2108-11-26**] 12:28
JOB#: [**Job Number 19685**]
|
[
"42731"
] |
Admission Date: [**2143-12-23**] Discharge Date: [**2143-12-27**]
Date of Birth: [**2063-6-18**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Transfer of care from OSH for STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with PTCA to LAD
History of Present Illness:
Ms. [**Known lastname 46525**] is an 80 year-old woman with a histrory of
hypertension, hyperlipidemia who initially presented to an OSH
and now presents on transfer with a STEMI.
.
Per the OSH records, presented on [**12-22**] with sudden onset
dizziness while sitting down at Bingo. The dizziness was
described as vertiginous. After taking two steps she fell to her
left, down to her hands and knees. EMS was called and she was
taken to an OSH. Her VS were initially stable with a BP of
142/60, HR of 70 and O2 of 98% though this was noted to decrease
to 88%. She was noted to vomit twice. For a possible PNA she was
given CTX.
.
On the day of transfer she had acute onset of SSCP with an ECG
showing ST-elevations in V2-V6. She was given ASA 325mg, 600mg
of plavix and started on a heparin gtt.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain
though she does experience dyspnea on exertion. She cannot sleep
flat but cannot describe why. She denies PND.
Past Medical History:
1. CARDIAC RISK FACTORS:
(-) Diabetes
(+) Dyslipidemia TC 180, TG 174, HDL 48, LDL 104
(+) Hypertension
.
2. CARDIAC HISTORY:
-CABG: None
-PCI: None
-PACING/ICD: None
.
3. OTHER PAST MEDICAL HISTORY:
- Colon polyps
- Osteopenia
- Osteoarthritis
Social History:
-Tobacco history: 25 pack-years Quit smoking: 10 years ago
-ETOH: Denied
-Illicit drugs: Denies
-Lives alone, independent in ambulation.
Family History:
Father died in 70s of unknown cause. Mother died at 77 of heart
disease.
Physical Exam:
VS: T=99.2 BP=130/65 HR=82 RR=20 O2 sat=100% initially on NRB
weaned to mid 90s on 4 liters NC
GENERAL: Lying flat in bed in NAD. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP that was up to ear though patient was
lying flat.
CARDIAC: Irregularly irregular. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: Anteriorly, could not hear obvious crackles.
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: DP by doppler
Pertinent Results:
Laboratory Values:
[**2143-12-23**] 09:15PM BLOOD WBC-9.8 RBC-3.38* Hgb-10.1* Hct-28.5*#
MCV-85 MCH-30.0 MCHC-35.5* RDW-13.0 Plt Ct-163
[**2143-12-24**] 04:04AM BLOOD WBC-11.7* RBC-3.67* Hgb-11.1* Hct-31.1*
MCV-85 MCH-30.4 MCHC-35.8* RDW-12.9 Plt Ct-207
[**2143-12-25**] 04:35AM BLOOD WBC-9.9 RBC-3.75* Hgb-11.1* Hct-31.7*
MCV-84 MCH-29.7 MCHC-35.1* RDW-13.0 Plt Ct-210
[**2143-12-26**] 06:10AM BLOOD WBC-9.2 RBC-3.56* Hgb-10.8* Hct-30.3*
MCV-85 MCH-30.5 MCHC-35.8* RDW-12.9 Plt Ct-257
[**2143-12-27**] 06:15AM BLOOD WBC-8.5 RBC-3.63* Hgb-10.7* Hct-31.1*
MCV-86 MCH-29.5 MCHC-34.5 RDW-12.9 Plt Ct-269
.
[**2143-12-24**] 04:04AM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.2*
[**2143-12-25**] 04:35AM BLOOD PT-12.6 PTT-24.4 INR(PT)-1.1
[**2143-12-24**] 04:04AM BLOOD Glucose-123* UreaN-18 Creat-1.2* Na-140
K-2.9* Cl-99 HCO3-29 AnGap-15
[**2143-12-24**] 01:51PM BLOOD Glucose-159* UreaN-17 Creat-1.2* Na-138
K-3.7 Cl-97 HCO3-31 AnGap-14
[**2143-12-25**] 04:35AM BLOOD Glucose-96 UreaN-22* Creat-1.3* Na-140
K-3.6 Cl-99 HCO3-30 AnGap-15
[**2143-12-26**] 06:10AM BLOOD Glucose-112* UreaN-26* Creat-1.4* Na-138
K-4.2 Cl-100 HCO3-28 AnGap-14
[**2143-12-27**] 06:15AM BLOOD Glucose-96 UreaN-24* Creat-1.4* Na-141
K-4.6 Cl-102 HCO3-30 AnGap-14
.
[**2143-12-23**] 11:26PM BLOOD CK(CPK)-903*
[**2143-12-24**] 04:04AM BLOOD CK(CPK)-1148*
[**2143-12-24**] 01:51PM BLOOD CK(CPK)-735*
[**2143-12-25**] 04:35AM BLOOD ALT-21 AST-46* LD(LDH)-353* CK(CPK)-312*
AlkPhos-55 TotBili-0.9
.
[**2143-12-23**] 11:26PM BLOOD CK-MB-53* MB Indx-5.9 cTropnT-2.71*
[**2143-12-24**] 04:04AM BLOOD CK-MB-76* MB Indx-6.6* cTropnT-4.32*
[**2143-12-24**] 01:51PM BLOOD CK-MB-36* MB Indx-4.9 cTropnT-3.11*
[**2143-12-25**] 04:35AM BLOOD CK-MB-13* MB Indx-4.2 cTropnT-2.21*
.
[**2143-12-24**] 04:04AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.4*
[**2143-12-24**] 01:51PM BLOOD Calcium-9.0 Phos-2.4* Mg-2.1
[**2143-12-25**] 04:35AM BLOOD Albumin-3.4 Calcium-8.7 Phos-3.0 Mg-2.1
[**2143-12-26**] 06:10AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.0 Iron-30
[**2143-12-27**] 06:15AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.2
.
[**2143-12-25**] 04:35AM BLOOD %HbA1c-6.2*
.
Urine studies:
.
[**2143-12-24**] 05:40PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.032
[**2143-12-24**] 05:40PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2143-12-24**] 05:40PM URINE RBC->1000 WBC-[**3-27**] Bacteri-MOD Yeast-NONE
Epi-0-2
.
Imaging/Studies/Interventions:
.
ECG [**12-23**]:
Atrial fibrillation with rapid ventricular response. R wave
reversal in
leads V1-V2 with Q waves through to lead V6 with ST segment
elevation.
Extensive anterior myocardial infarction, probably acute. No
previous tracing
available for comparison. 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
106 0 90 354/434 0 -6 52
.
Cardiac Catheterization:
.
1. Selective coronary angiography of this right-dominant system
revealed
three-vessel coronary artery disease. The LMCA had mild diffuse
disease. The LAD had a 100% distal cut-off suggestive of a
proximal
thrombus with distal embolization. The LCX had a 70% mid-vessel
stenosis. The RCA had an 80% distal stenosis.
2. Limited resting hemodynamics demonstrated markedly elevated
biventricular filling pressures, with an PCWP a-wave of 37mmHg
and an
RVEDP of 16 mmHg. Cardiac output and index were preserved.
3. POBA of mid distal LAD with 2mm balloon.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated right- and left-sided filling pressures
3. Preserved cardiac output.
4. POBA of LAD
.
Atrial fibrillation. Since the previous tracing anterior ST
segment elevation
is less prominent. Tracing is consistent with evolution of
anterior myocardial
infarction. Clinical correlation is suggested.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
95 0 86 374/435 0 -12 50
.
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with mild hypokinesis of
the distal anterior septum and apex. The remaining segments
contract normally (LVEF = 45-50 %). Right ventricular chamber
size and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. Normal mitral valve leaflets with
no mitral regurgitation. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Suboptimal image quality. Mild distal septal and
apical hypokinesis with preserved left ventricular ejection
fraction. Mild pulmonary hypertension.
.
ECG [**12-25**]
Sinus rhythm. Non-diagnostic Q waves in leads I and aVL. RSR'
pattern
in lead V1 with ST segment elevation and T wave inversion with R
wave
regression and ST segment elevation in the remainder of the
precordial leads.
Anteroseptal myocardial infarction, age indeterminate. Since the
previous
tracing of [**2143-12-24**] the rhythm is now sinus. Otherwise, as
previously noted.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 162 84 434/453 34 -8 55
.
CXR [**2143-12-24**]
.
FINDINGS: No previous images. The cardiac silhouette is at the
upper limits
of normal in size and there is mild tortuosity of the aorta and
brachiocephalic vessels. Blunting of the left costophrenic angle
that could
represent pleural fluid or merely thickening. No evidence of
acute focal
pneumonia or vascular congestion.
.
ECG at discharge:
.
Sinus rhythm. ST segment elevation in leads V1-V6 with
development of
Q waves across the precordium. Acute anterior myocardial
infarction with
persistent injury pattern. Compared to the previous tracing of
[**2143-12-26**]
there is no significant change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 164 78 376/418 27 -1 56
Brief Hospital Course:
80 year-old woman with a history of hyperlipidemia and
hypertension, presenting with a STEMI.
.
# CORONARIES. Patient was found to have an STEMI. Her risk
factors included hypertension and hyperlipidemia with LDL >100
on pravastatin 20mg. She reports to have had muscle aches on
atorvastatin and simvastatin. She underwent an emergent cardiac
catheterization upon arrival and was found to have an occluded
LAD lesion which was angiopastied (POBA). Patient also had with
RCA (80% distal stenosis) and LCx (70% mid vessel) disease. She
was continued on aspirin and plavix. Her pravastatin was
increased to 80mg daily. Patient completed treatment with
integrillin. She was also started initially on captopril on HD2
which was changed to Hyzaar 100-25mg prior to discharge. Her
atenolol was changed to metoprolol 25mg [**Hospital1 **] and eventually to
Toprol XL 100mg QD. Throughout the hospital stay, after
catheterization, patient remained free of chest pain and did not
report shortness of breath. A discussion was held with patient
and family regarding further intervention w/ CABG and additional
catheterization. It was decided that no further intervention
will be made.
.
# PUMP: On admission from catheterization lab, patient satting
well though noted to have elevated wedge in lab. Limited
resting hemodynamics demonstrated markedly elevated
biventricular filling pressures, with an PCWP a-wave of 37mmHg
and an
RVEDP of 16 mmHg. Cardiac output and index were preserved. Her
ECHO showed mild regional left ventricular systolic dysfunction
with mild hypokinesis of the distal anterior septum and apex
with an LVEF of 45-50%. On HD2 she received one dose of Lasix
20mg x1 for slight volume overload. Her crackles resolved by
HD#3. Her urine output was > 40cc/hr throughout hospital stay.
.
# RHYTHM. Patient was in atrial fibrillation upon arrival from
OSH. She received a n amiodarone drip which was discontinued on
HD2 as atrial fibrillation was felt to be present due to peri-mi
setting. She received a 5mg IV dose of metoprolol and her
atenolol was changed to low dose metoprolol of 12.5mg [**Hospital1 **]. A
low dose was used for relative hypotension of SBPs in low 100s.
On HD2, patient converted to sinus rhythm. She remained in
sinus rhythm for the remainder of hospitalization. At discharge
patient was prescribed Toprol XL of 100mg QD.
.
For osteoarthritis and osteopenia patient was continued on home
regimen of Salsate and Calcium-Vitamin D. For GI prophyhlaxis,
patient was started on Prilosec. She received Heparin SC for
DVT ppx.
.
Patient was discharged home in a hemodynamically stable
condition free of chest pain or shortness of breath.
Medications on Admission:
1. ATENOLOL - 50MG Tablet [**Hospital1 **]
2. HYZAAR - 100-25MG Tablet - daily
3. NIFEDIPINE - 30MG SR daily
4. PRAVASTATIN - 20 mg daiy
5. SALSALATE - 500 mg Tablet - [**Hospital1 **] PRN
6. CALCIUM-CHOLECALCIFEROL (D3) [CALCIUM 600 + D(3)] - (OTC) -
600
mg (1,500 mg)-200 unit [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcium 500 with Vitamin D 500 (1,250)-200 mg-unit Tablet
Sig: One (1) Tablet PO twice a day.
5. Salsalate 500 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
6. 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:*2*
7. Hyzaar 100-25 mg Tablet Sig: One (1) Tablet PO once a day.
8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Acute on Chronic systolic Congestive Heart Failure
Atrial fibrillation: resolved
Discharge Condition:
stable.
Discharge Instructions:
You had a heart attack that was caused by a blockage in your
coronary arteries. One of these arteries was cleared with a
balloon procedure, there are still [**1-23**] other blockages that will
need to be treated in the future. You had atrial fibrillation
that occurred during your heart attack, this went away and your
heart rhythm is now normal.
New medicines:
1. your Atenolol has been changed to Toprol XL once a day
2. Discontinue your Nifedipine
3. You were started on Plavix and aspirin to prevent blood clots
and further heart attacks.
4. Your Pravastatin was increased to 80 mg daily
5. Prilosec was started to protect your stomach from the Plavix
and aspirin.
.
You will see a new Cardiologist, Dr. [**Last Name (STitle) **] who come to [**Location (un) **].
The office will call you with an appt.
.
Please call Dr. [**Last Name (STitle) 410**] if you have any chest pain, trouble
breathing, cough, swelling, palpitations, dizziness or any other
worrying symptoms.
.
Please weigh yourself every day and call Dr. [**Last Name (STitle) 410**] if your
weight increases more than 3 pounds in 1 day or 6 pounds in 3
days. Please follow a 2000mg sodium diet, information about
congestive heart failure was discussed with you on discharge.
Followup Instructions:
Primary Care:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2144-3-23**] 11:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**], MD Phone: [**Telephone/Fax (1) 1144**] Date/Time: [**1-10**] at 2:30pm.
.
Cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 1144**] Date/Time: the
office will call you with an appt.
Completed by:[**2143-12-28**]
|
[
"41401",
"4280",
"42731",
"5859",
"40390",
"2724"
] |
Admission Date: [**2111-2-16**] Discharge Date: [**2111-2-23**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: This is a 61-year-old female
with history of insulin-dependent diabetes mellitus, status
post multiple admissions for DKA; CAD, status post five-
vessel CABG in [**2103**], chronic renal insufficiency, baseline
creatinine approximately 2; hypertension, pancreatitis,
presenting with nausea and vomiting and three days of blood
sugars in the 800 range with an anion gap of 37. The patient
reports having sudden onset of nausea, vomiting over the
weekend with a glucose approximately 500 associated with
decreased p.o. intake. The patient described mild substernal
chest pain prior to admission on the day of admission that
was similar to her anginal symptoms. Chest pain occurred at
nighttime while sleeping, baseline angina occurs weekly.
According to the patient today, she took sublingual
nitroglycerin times 3 without effect. Denied fever, chills,
shortness of breath, diarrhea, abdominal pain recently
describing a good appetite, but decreased over the past few
days. In the Emergency Department, the patient was given 10
units of insulin and was started on insulin drip at 6 units
an hour, which was then increased to 8. Her blood sugar
range went from 700 to 378. She was transferred to the ICU
for further monitoring. Other laboratory data were notable
for white blood cell count of 13 with 3 bands. Her ICU
course was notable for resolution of her gap acidosis;
however, she developed acute on chronic renal failure with a
rise in her creatinine to 3.3 and her BUN to 64 and elevated
amylase of 564 and lipase of 539, troponin leak of 0.2 with
flat CKs. Currently on transfer, the patient was reporting
some nausea, but without any evidence of vomiting.
Additionally, she noted feeling chest pain since her
admission, which has come and gone and has remained
nonexertional. She states that it is typical of her
"angina," which preceded her admission.
PAST MEDICAL HISTORY: CAD, status post CABG in [**2103**].
CHF with an ejection fraction of 30 percent.
Type 1 diabetes diagnosed in [**2085**], complicated by DKA and
triopathy.
Chronic renal insufficiency. Baseline creatinine from 1.3 to
1.6.
Hypertension.
Carotid stenosis, status post left CEA.
Hyperlipidemia.
Recurrent pancreatitis.
Status post cholecystectomy.
Gastroparesis.
Pelvic fracture.
Anemia.
SOCIAL HISTORY: The patient reports smoking half a pack of
cigarettes a day over the past 30 years. She denies any
alcohol use. She is divorced, has 2 children. Lives at home
with her mother. She works for the IRS.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o. q.d.
2. Lipitor 10 mg p.o. q.d.
3. Lantus 20 units h.s.
4. Lopressor 75 mg p.o. b.i.d.
5. Sublingual nitroglycerin.
6. Os-Cal 500 mg q.d.
7. Protonix 40 mg q.d.
8. Zestril 30 mg p.o. q.d.
9. Hydralazine 50 mg q.d.
10. Lasix 20 mg p.o. b.i.d.
11. Reglan.
12. Sucralfate.
13. Ventolin 40 t.i.d.
14. Calcium carbonate.
15. Imdur 120 mg p.o. q.d.
PHYSICAL EXAMINATION ON TRANSFER: Vital signs stable.
General, no apparent distress. HEENT, dry mucous membranes.
Neck exam, JVP approximately 10 cm at 45 degrees.
Cardiovascular exam, regular rate, S1, S2, 2/6 systolic
murmur heard best at the right upper sternal border.
Pulmonary exam, decreased breath sounds at the bases, no
crackles or wheezing. Abdominal exam benign. Extremity exam
benign. Rectal exam, guaiac-negative brown stool.
HOSPITAL COURSE: DKA. The patient was intermittently on
insulin drip while in the ICU, which was off upon transfer.
Her electrolytes remained within normal limits with
resolution of her gap acidosis. The patient was started on
Glargine and a sliding scale. She tolerated her p.o. intake
without emesis; however, she was intermittently nauseated.
[**Last Name (un) **] consult was obtained given her frequent recent
admissions. The patient was maintained on a Humalog sliding
scale as well as her Lantus dosing. However, the patient was
noncompliant during her hospitalization often times refusing
insulin, and therefore it was very difficult to manage her
sugars appropriately and put her on an adequate regimen upon
discharge.
Infectious disease. The patient had presented with what
appeared to be viral gastroenteritis. She did have evidence
of MRSA in her urine. Therefore, ciprofloxacin was
discontinued. The patient was started on vancomycin, which
was renally dosed given her renal insufficiency.
Acute on chronic renal failure. The patient sees Dr.[**Doctor Last Name 4849**]
as an outpatient for her diabetic nephropathy, who was
informed of her admission without any specific
recommendations about her management. The patient did
receive IV fluids with slow resolution of her renal
insufficiency, and her creatinine slowly began to decrease.
CAD. Episode of chest pain at home and intermittently here
concerning for unstable angina; however, there were
nonspecific EKG changes associated with this. The patient
did have an evidence of troponin leak during her
hospitalization; however, CKs were flat. Her EKG and cardiac
enzymes were unremarkable for active ischemia, and she was
maintained on aspirin, beta-blocker, statin, nitrate. We
were holding her ACE inhibitor in the setting of worsening
renal failure. She was also maintained on hydralazine to
maximize her blood pressure control.
Pump. There was no evidence or signs of heart failure. She
was not maintained on her diuretics or her ACE inhibitor in
the setting of her acute renal failure. Her volume status
appeared to be euvolemic.
Rhythm. Her electrolytes were repleted on a p.r.n. basis.
Hematologic. The patient has a history of anemia. She was
on aspirin. Her hematocrit was 29, was maintained above 30
with transfusion with no evidence of active GI losses. Given
the patient's history of anemia, the patient was instructed
to have an outpatient colonoscopy for further workup as well
as imaging of her abdomen given her chronically ill
appearance and history of poorly controlled diabetes and
concern was for GI malignancy contributing to this anemia as
well as her chronic bouts of DKA and pancreatitis.
DISCHARGE DIAGNOSES: Diabetic ketoacidosis.
Poorly controlled type 1 diabetes complicated by nephropathy,
retinopathy, and neuropathy.
Coronary artery disease, status post coronary artery bypass
graft with unstable angina.
Anemia, guaiac-positive stool.
DISCHARGE STATUS: The patient will be discharged to home
with services.
DISCHARGE CONDITION: The patient is stable, tolerating p.o.
intake with resolution of her symptoms.
SURGICAL/INVASIVE PROCEDURES: The patient had a PICC line
placed during this hospitalization.
RECOMMENDED FOLLOW-UP: The patient will see Dr. [**Last Name (STitle) 1538**] as
an outpatient as well as a visit to the [**Hospital **] Clinic.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d.
3. Atorvastatin 10 mg p.o. q.d.
4. Metoprolol 75 mg p.o. b.i.d.
5. Calcium carbonate 1 tablet q.i.d.
6. Isosorbide mononitrate sustained release 60 mg p.o. q.d.
7. Senna.
8. Nitroglycerin sublingual tablet.
9. Lisinopril 40 mg p.o. q.d.
10. Hydralazine 50 mg p.o. t.i.d.
11. Lantus 10 units subcutaneously at bedtime.
12. Insulin sliding scale.
13. Vancomycin via PICC line, dosed according to renal
function for a total of 10 days.
[**Last Name (LF) **],[**First Name3 (LF) **] 12-AEE
Dictated By:[**Last Name (NamePattern1) 12866**]
MEDQUIST36
D: [**2111-5-20**] 14:01:51
T: [**2111-5-21**] 01:35:23
Job#: [**Job Number **]
|
[
"40391",
"4280",
"5990"
] |
Admission Date: [**2123-10-25**] Discharge Date:
Date of Birth: [**2123-10-25**] Sex: M
Service:
This is an interim dictation from [**2123-11-22**] until [**2123-12-10**].
Baby [**Name (NI) **] [**Known lastname **] is now day of life #45. He is a 25 weeker.
His issues are chronic lung disease, apnea of prematurity and
feeding and growing.
HOSPITAL COURSE:
1. Respiratory: The infant has remained on C-pap throughout
[**11-22**] to [**2123-12-10**]. He was on nasal pharyngeal C-pap at 21-25%
but he was changed to nasal prongs on [**2123-12-8**]. He started a
14 day course of Beclovent which was discontinued when he
went to nasal prongs on [**2123-12-8**]. He also remains on
caffeine. He is at 8.8 mg/kg/day. At times he has 6
secretions but at this point he is doing well on the C-pap
via prongs at 5 on 21%.
2. Fluids, Electrolytes & Nutrition: The infant remains on
full feeds, breast milk 30 with ProMod. He has remained on
this throughout [**11-22**] to [**12-10**]. He is getting q 4 hour
gavage. His last set of electrolytes this week were sodium
of 136, potassium 6, chloride 102, CO2 21 and glucose of 78.
He remains on Vitamin E, Fer-In-[**Male First Name (un) **] and his sodium
supplements were discontinued today.
3. Neurology: He had a head ultrasound on day of life #30
which was normal. He had an eye exam on Wednesday of this
week which was [**2123-12-8**]. On the right he has stage I and on
the left he did not have enough dilatation. This exam will
be repeated in one week.
4. Heme: His last hematocrit was on [**12-7**], hematocrit of 34
with retic of 5. Baby [**Name (NI) **] [**Known lastname 36236**] weight as of today,
[**2123-12-10**], is 1420 gm. He is currently doing quite well.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Last Name (NamePattern4) 36237**]
MEDQUIST36
D: [**2123-12-10**] 18:59
T: [**2123-12-10**] 19:57
JOB#: [**Job Number 36238**]
|
[
"V053"
] |
Admission Date: [**2102-7-13**] Discharge Date: [**2102-7-21**]
Date of Birth: [**2055-7-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Alchohol Withdrawl
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46 yo man with a history of etoh abuse/withdrawl (last admit
[**Date range (1) 23527**]), HCV, and anxiety who was admitted yesterday for etoh
withdrawl requesting detox. This was prompted reportedly by an
altercation with his landlord and he was brought in by his
girlfriend. EtOH level on admit (0810 [**7-13**]) 328. On the medical
floor he was noted to have increasing benzodiazepine
requiriements with increased anxiety and tremulousness. Prior to
transfer he received:
[**7-13**]: diazepam 5mg iv: 1700, 1800, [**2015**], [**2125**], 2120, 2220, 2230
(35mg)
[**7-14**]: diazepam 5mg iv 0000, 0100
diazepam 20mg iv 0130, 0615, 0815, 1000 (90mg)
lorazepam 4mg iv 0200
He notes on interview that he has had etoh withdrawl in the past
with report of seizure. He is asking for '40mg valium every hour
so he can sleep through it'. He notes chest pressure (chronic,
baseline), productive cough (yellow sputum, no blood) also
baseline; denies fevers, chills, SOB, abdominal pain, nausea,
vomitting, constipation, diarrhea, melena, BRBPR, dysuria, leg
pain. During the interview however he experienced 'an anxiety
attack' associated with abdominal pain. He notes last cocaine 4
days prior to admission, 1 line. He notes last drink [**7-12**],
drinks 1L vodka/day, h/o iv cocaine (not recent), tried heroin
age 18, last marijauna 1 week ago. He is currently requesting
inpatient etoh detox. VS prior to transfer: T 99.2 BP 125/103
(125-170/107-131) HR 98 (98-104) RR 20 Sat 98% RA. CIWA
currently 11 ([**9-18**]).
With his last admission he required 20mg po q1-2 hours until
lethargic for the first 36 hours, then was able to be managed
with CIWA. Additionally he was seen by psychiatry on his last
admit and started on zyprexa 5mg qam/7.5mg qpm and buspar 5mg
tid for anxiety. He discontinued these medications on discharge.
He was recommended for psychiatric f/u on d/c which he did not
pursue.
.
Past Medical History:
- EtOH abuse with multiple admissions for w/d
- h/o withdrawl seizures
- Alcoholic Dilated Cardiomyopathy (last [**Hospital1 18**] records indicated
an EF of 40-45% with mild global HK)
- cocaine abuse
- hypothyroidism
- h/o head and neck cancer s/p resection and radiation in [**2093**]
- bilateral cavitary lung lesions; bx demonstrated
Aspergillous fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**]. TB negative. Pt did not comply with course of
anti-fungals, but has no evidence of active infection.
- h/o C. diff colitis, no current diarrhea
- h/o IVDA per OSH records (pt denies)
- HCV (no serologies in OMR)
Social History:
Recently cut down to 5-6 cigs/day, prior to that he smoked 1 ppd
x30 years. Heavy EtOH use; drinks 1 shot of Vodka every 3 hours
(~1 pint per day). Sober x10 years, started drinking again 1.5
yrs ago. +Cocaine abuse. He denies IVDA although history
questionable. Sexually active with his girlfriend. Reports
negative HIV test 2 yrs ago.
Family History:
Mother - CAD. Sister - h/o CVA.
Reports his father was the "[**Location (un) 86**] Strangler," and that he and
his mother changed their names after his arrest, etc.
Physical Exam:
Vitals: Tm 97.6, Tc 96.1, BP 120/80, HR 88, RR 20, sat 98% on
room air
Gen -- calm, interactive, nad, very thin
HEENT -- evidence of well healed remote left radical neck
dissection, op clear, sclera anicteric, no evidence of
lymphadenopathy
Heart -- regular
Lungs -- clear
Abd -- soft, nontender, well healed gastrostomy scar superior to
umbilicus, appropriate bowel sounds
Ext -- no edema, rash or lesion
Pertinent Results:
[**2102-7-18**] 07:45AM BLOOD WBC-6.3 RBC-3.42* Hgb-11.6* Hct-34.9*
MCV-102* MCH-34.0* MCHC-33.4 RDW-15.0 Plt Ct-157#
[**2102-7-14**] 07:15AM BLOOD Plt Smr-LOW Plt Ct-81*
[**2102-7-15**] 05:24AM BLOOD Plt Ct-75*
[**2102-7-16**] 08:20AM BLOOD Plt Ct-83*
[**2102-7-18**] 07:45AM BLOOD Plt Ct-157#
[**2102-7-20**] 06:50AM BLOOD Glucose-100 UreaN-23* Creat-0.9 Na-140
K-4.2 Cl-101 HCO3-29 AnGap-14
[**2102-7-13**] 08:10AM BLOOD cTropnT-<0.01
[**2102-7-13**] 08:30PM BLOOD CK-MB-7 cTropnT-<0.01
[**2102-7-14**] 09:05AM BLOOD CK-MB-5 cTropnT-<0.01
[**2102-7-16**] 08:20AM BLOOD Calcium-10.0 Phos-3.6 Mg-1.6
[**2102-7-17**] 07:25AM BLOOD Calcium-10.5*
[**2102-7-18**] 07:45AM BLOOD Calcium-11.0* Phos-5.3*# Mg-1.6
[**2102-7-20**] 06:50AM BLOOD Calcium-10.2
[**2102-7-14**] 09:05AM BLOOD VitB12-415 Folate-GREATER TH
[**2102-7-19**] 08:10AM BLOOD PTH-12*
[**2102-7-13**] 08:10AM BLOOD ASA-NEG Ethanol-328* Acetmnp-UNABLE TO
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2102-7-19**] 04:30PM BLOOD PARATHYROID HORMONE RELATED PROTEIN-PND
[**2102-7-19**] 04:30PM BLOOD VITAMIN D 25 HYDROXY-PND
[**2102-7-19**] 04:30PM BLOOD VITAMIN D [**1-26**] DIHYDROXY-PND
[**2102-7-19**] 08:20AM BLOOD freeCa-1.30
Brief Hospital Course:
1. alcohol withdrawal -- Mr. [**Known lastname 4223**] required large amounts of
Valium (greater than 100 mg q24 hours) to control his withdrawal
symptoms. He was briefly transferred to the [**Hospital Unit Name 153**] for concerns
about the quantity of his benzodiazepines and possibility of
sedation. However, he did well and 5 days after admission a
taper was initiated 10% per day, discharging to inpatient
psychiatry on 10 mg po Valium q6hours with 5 mg po q3 hours prn,
to continue tapering as tolerated.
2. anxiety -- Mr. [**Known lastname 4223**] complained of severe anxiety
throughout his stay, initially attributed to his withdrawal, but
persisting after withdrawal symptoms resolved. Psychiatry had
been contact[**Name (NI) **] in previous stays, and kindly offered their
advice again. We initiated Buspar 5 mg po qday and 10 mg po
qhs, and increased his olanzipine dose to 7.5 mg po bid with prn
2.5 mg doses q8h.
3. delusional psychosis/impaired judgement -- Psychiatry
consulted regarding Mr. [**Known lastname **] anxiety as well as bizarre
behavior, attempts to leave AMA, and agitation. His behavior
was felt to be potential for harm to self, and he had a Section
12 placed so he could not leave AMA. He will be transferred to
an inpatient psychiatry facility on discharge for further
evaluation and management.
4. hypercalcemia -- Mr. [**Known lastname 4223**] was noted to have Calcium
levels as high as 11.0 during his stay. A PTH was low, and PTH
related peptide and calcitriol/calcidiol levels were pending on
discharge. Given his history of head/neck carcinoma, this is
concerning for hypercalcemia of malignancy. This was explained
to the patient and he will need close follow up for malignancy
workup if his PTH-RP returns elevated, likely starting with a
neck CT scan. Clinically, he has no physical exam evidence of
recurrence.
5. Hypertension -- remained stable on metoprolol and HCTZ.
6. alcoholic dilated cardiomyopathy -- stable, on metoprolol
[**Hospital1 **]. It should be considered to initiate an ace inhibitor in
his case, but the patient refused during this hospitalization
because of previous episodes of hypotension.
Medications on Admission:
- Aspirin 81 mg PO DAILY
- Folic Acid 1 mg DAILY
- Hexavitamin PO DAILY
- Thiamine HCl 100 mg PO DAILY
- Lisinopril 5 mg PO DAILY
- Levothyroxine 75 mcg PO DAILY
- Nicotine 21-14-7 mg/24 hr Patch Daily once a day.
- Digoxin 125 mcg PO once a day
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day) as needed for agitation.
13. Buspirone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
14. Buspirone 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
15. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): taper by 20% per day.
16. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for CIWA>10.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
1. alcohol dependence and withdrawal
2. anxiety
3. acute psychosis
4. hypertension
5. history of probable aspergillosis, stable
6. mild hypercalcemia of unknown cause
Discharge Condition:
medically stable, on Valium taper, with continued acute
psychosis
Discharge Instructions:
You were hospitalized for alcohol withdrawal. You have been
doing well with a benzodiazepine taper. Because of your
symptoms of anxiety and psychosis, we are sending you to an
inpatient psychiatric facility for further evaluation and
treatment.
Followup Instructions:
You should follow up with your primary care physician at [**Name9 (PRE) **]
COMMUNITY HEALTH CENTER [**Telephone/Fax (1) 23520**] for further evaluation and
care after discharge from the psychiatry facility, particularly
for your hypercalcemia. This may be related to several possible
reasons, including a recurrence of your malignancy.
|
[
"4280",
"2875",
"4019",
"2449"
] |
Unit No: [**Numeric Identifier 71567**]
Admission Date: [**2108-2-22**]
Discharge Date: [**2108-3-20**]
Date of Birth: [**2108-2-22**]
Sex: F
Service: NEONATOLOGY
Baby girl [**Known lastname 71568**] was born at 33 3/7 weeks gestation
with birth weight 2255 grams. She was admitted to the NICU
for management of prematurity.
MATERNAL HISTORY: A 33-year-old G1 P0 female, with [**Last Name (un) **] [**2108-4-18**]. Prenatal labs: Blood type O negative (received
RhoGAM x2, thus had anti-Rh antibodies), hepatitis B surface
antigen negative, RPR nonreactive, GC negative, chlamydia
negative, rubella immune, GBS unknown.
Mother's pregnancy was remarkable for: 1. hyperemesis 2.
placement of urgent cerclage due to cervical shortening on
[**2107-11-25**]. By verbal history, spinal anesthesia was
used for the cerclage procedure. The mother developed fever,
increased white count and meningeal symptoms 1 day status
post cerclage placement. 3. Mollaret syndrome: The mother has
a history of recurrent aseptic meningitis in [**2094**], [**2095**] and
[**2106**]. The mother had repeat extensive neurological and
infectious disease evaluation at [**Hospital6 1708**]
in [**2107-11-4**] following onset of meningeal symptoms 1 day
status post cerclage. It is suspected that spinal anesthesia
triggered recurrence of aseptic meningitis in [**2107-11-4**]
based on her history of recurrent aseptic meningitis and
positive PCR for HSV from [**Hospital1 2025**]. The mother has no clinical
symptoms of HSV infection (no genital, oral, or skin
lesions). The mother has no prior treatments for HSV
meningitis. She received 1 dose of Acyclovir during
C-section.
Based on this history and positive PCR for HSV, infectious
disease and neurology consultations at [**Hospital1 756**] did not
recommend treatment of the mother with Acyclovir. By report,
ID consult has no evidence the mother has HSV meningitis and
felt there was no risk of vertical transmission of HSV from
the maternal CSF to the baby.
The mother was noted to have decreased fetal movement on the
night of [**2108-2-20**]. She continued to note decreased fetal
movement when she was evaluated by [**Doctor Last Name 13675**] on [**2108-2-21**].
Biophysical profile was [**7-11**] with reactive NST. Over the
course of [**2108-2-21**] through [**2108-2-22**], there was
persistence of decreased fetal movement. Evaluation on [**2-3**]
1 revealed nonreactive NST and decelerations with spontaneous
contractions. BPP [**3-11**]. Due to change in fetal assessment with
history of decreased fetal movement, the OB team decided to
proceed with C-section delivery. Dr. [**Last Name (STitle) **] requested neonatal
antenatal consultation and for a NICU team to be present for
delivery.
Upon delivery, the infant emerged with poor tone, no
spontaneous respirations, dusky appearance. Initial heart
rate less than 100. The infant was suctioned and then
received bag mask ventilation. The infant's heart rate was
greater than 100, spontaneous cry by 2-3 minutes of life, and
tone, color, reflexes rapidly improved. The infant was stable
in room air, [**Last Name (STitle) **], well-perfused after initial resuscitation.
Apgars were 6 and 9 at one and five minutes, respectively.
Initial physical examination in the delivery room following
resuscitation appeared within normal limits for a 33 week
appropriate gestational age female. Birth weight on admission
was 2255 grams (75%).
PHYSICAL EXAMINATION AT DISCHARGE: Weight 2750 grams
(25-50%), head circumference 33 cm (50%), and length 48 cm
(50-75%). In general, the baby is [**Name2 (NI) **], comfortable in room
air. Anterior fontanel open and flat. Red reflex present
bilaterally. No cleft palate. Mucous membranes moist. The
lungs were clear to auscultation bilaterally with no
retractions. HEART: Regular rate and rhythm, no murmur
appreciated. Strong femoral pulses. ABDOMEN: Soft,
nondistended, nontender, good bowel sounds. No masses
appreciated. BACK: Straight. No [**Hospital1 **] or dimples. Anus
patent. Anal fissure noted at 12 o'clock. GU: Normal female
external genitalia. NEURO: Active and alert with normal tone,
strong suck and grasp. Hips stable.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The baby did not require oxygen throughout her
hospital stay. She has been stable in room air without any
apnea of prematurity. Upon discharge, she is breathing room
air, baseline respiratory rate of 30s to 50s, comfortable.
CARDIOVASCULAR: The baby has been stable throughout
her hospitalization.
FLUIDS, ELECTROLYTES, NUTRITION: Blood sugar was initially low
at 30 on day of life 1. The baby received one [**Name (NI) 44084**] bolus.
Blood sugars have been stable since then. Feeds was started
on day of life 2. Volume was gradually advanced, and calories
were also advanced to a maximum of 26 cal/oz of breast milk.
Two days prior to discharge, calories were dropped to 24
cal/oz of breast milk (with Similac powder). The baby has
been feeding all by mouth more than 96 hours prior to
discharge, getting breast milk 24 cal/oz plus breastfeeding
on demand.
GI: The baby was on phototherapy for a few days with a peak
total bilirubin of 11.8 on day of life 4. The last bilirubin
about a week after discontinuation of phototherapy was 7.5/
0.4 on day of life 13.
The baby has had occasional guaiac positive stools. Physical
exam is notable for an anal fissure at 12:00. The abdominal
exam is benign and the baby is tolerating feeds well.
HEMATOLOGY: The baby's blood type is A negative, Coombs
negative. She never required any transfusions. Admission
hematocrit was 51.5. She remains on ferrous sulfate 2
mg/kg/day.
INFECTIOUS DISEASE: Infectious disease was consulted on [**2108-2-23**] due to the maternal history. They recommended no
treatment.
The baby was treated with erythromycin eye ointment from
[**3-4**] for bilateral eye discharge. The discharge
has resolved and she never had erythema, conjunctivitis, or
swelling around the eyes.
NEUROLOGY: The baby's exam has been within normal limits.
SENSORY: Hearing screening was performed with automated
auditory brain stem responses. The baby passed in both ears
prior to discharge.
OPHTHALMOLOGY: Not examined due to gestational age of 33-3/7.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 38676**], MD. Phone number
[**Telephone/Fax (1) 38248**]. Fax number [**Telephone/Fax (1) 38249**].
CARE/RECOMMENDATIONS:
1. Upon discharge, the baby is feeding breast milk 24
Cal/oz with Similac powder, as well as breastfeeding on
demand.
2. Medications include ferrous sulfate 2 mg/kg/day (25 mg/ml
concentration -- 0.25 ml = 6 mg PO Q24H) and
multivitamins 1 ml PO Q24H.
3. Iron and vitamin D Supplementation:
Iron supplementation is recommended for preterm and low
birthweight infants until 12 months corrected age. All
infants fed predominantly breast milk should receive
vitamin D supplementation at 200 units (may be provided
as a multivitamin preparation) daily until 12 months
corrected age.
4. The baby passed car seat position screening prior to
discharge.
5. The state newborn screen was within normal limits on
[**2108-3-7**].
6. Immunizations received include hepatitis B vaccine on
[**2108-2-26**].
7. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 4 criteria: 1) Born at less
than 32 weeks, 2) Born between 32 and 35 weeks with 2 of
the following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school-age siblings, 3) Chronic lung disease, or 4)
hemodynamically significant CHD.
Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out- of-home
caregivers.
This infant has not received the Rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following discharge
from the hospital if they are clinically stable and at
least 6 weeks but fewer than 12 weeks of age.
8. Follow-up appointment scheduled/recommended: Appointment
with the pediatrician is on [**2108-3-22**]. VNA has been
scheduled.
DISCHARGE DIAGNOSES:
1. Prematurity
2. Hyperbilirubinemia, resolved
3. Transitional hypoglycemia
4. History of guaiac positive stools associated with anal
fissure, no other pathologic etiologies identified
5. Bilateral conjuctivitis, resolved
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name (STitle) 71569**]
MEDQUIST36
D: [**2108-3-19**] 16:48:14
T: [**2108-3-19**] 18:52:37
Job#: [**Job Number 71570**]
|
[
"7742",
"V053"
] |
Admission Date: [**2183-3-6**] Discharge Date: [**2183-3-17**]
Date of Birth: [**2112-8-18**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: Briefly, this is a
70-year-old female with a history of diabetes, coronary
artery disease, and Parkinson's disease who was admitted at
[**Hospital6 204**] on [**2183-2-24**] with progressive
lower extremity weakness. She had an MRI which showed
chronic white matter ischemic changes, possible new small
lesion at the right semiovale. The patient had carotid
Dopplers which revealed obstructive disease and an
echocardiogram which showed a moderate mitral insufficiency.
The patient complained of increasing anginal symptoms as
well.
She underwent a Myoview imaging which revealed anterior and
lateral ischemia. She underwent cardiac catheterization on
[**2183-3-6**] which revealed LM mild plaque, LAD 90% ostial
lesion, LCX 90-95% lesion, RCA 80% lesion, and LV low to
normal EF, 3+ mitral insufficiency.
PAST MEDICAL HISTORY:
1. Parkinson's disease.
2. Cardiac catheterization five years ago.
3. PTCA of the diagonal.
4. History of insulin-dependent diabetes mellitus.
5. Status post CVA.
6. History of spinal stenosis.
7. History of subclavian steel syndrome.
ADMISSION MEDICATIONS:
1. Ecotrin 325 mg p.o. q.d.
2. Lopressor 200 mg p.o. b.i.d.
3. Nitroglycerin 0.6 mg two patches q.a.m.
4. .................... one p.o. b.i.d.
5. Prevacid 30 mg p.o. q.d.
6. Avapro 150 mg p.o. b.i.d.
7. Norvasc 10 mg p.o. q.d.
8. Plavix 75 mg p.o. q.d.
9. Lantus insulin 10 units q.h.s. with a sliding scale.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient was
in no acute distress. Vital signs: The patient was
afebrile. The vital signs were stable. Lungs: The lungs
were clear to auscultation. Heart: Regular rate and rhythm.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2183-3-16**] 11:59
T: [**2183-3-16**] 13:22
JOB#: [**Job Number 14015**]
|
[
"41401",
"4240",
"9971",
"42731",
"412"
] |
Admission Date: [**2140-6-29**] Discharge Date: [**2140-7-4**]
Date of Birth: [**2104-7-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2140-6-30**] Off-Pump Coronary Artery Bypass Graft x 2 (LIMA to LAD, L
radial to diag)
History of Present Illness:
Mr. [**Known lastname **] is a 35 y/o male with h/o CAD s/p multiple stents this
year c/b restensosis. He continued to have recurrent angina and
underwent cardiac cath at OSH which revealed progression of LAD
disease. Coronary disease was not amenable to PCI and was
transferred to [**Hospital1 18**] for surgical revascularization.
Past Medical History:
Coronary Artery Disease s/p stent to prox and mid LAD c/b
subacute stent thrombosis s/p thrombectomy of LAD and stent
[**2140-4-7**], s/p DES to prox LAD [**2140-6-3**], h/o
retroperitoneal/extraperitoneal bleed, Hypertension
Social History:
Biochemist. Denies tobacco and ETOH use.
Family History:
Father with stents at age 65.
Physical Exam:
VS: 66 20 176/98 5'9" 195#
Gen: WDWN male in NAD
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, -bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**6-30**] Echo: The left atrium is normal in size. 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 spontaneous echo contrast or thrombus is seen in
the body of the right atrium or the right atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). There is mild symmetric left ventricular
hypertrophy. Right ventricular chamber size and free wall motion
are normal. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque.
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 pericardial effusion. Post off pump:
Preserved biventricular systolic function. Overall LVEF 55%.
Aortic contour is intact
[**7-4**] CXR: The patient is status post recent median sternotomy
and coronary bypass surgery. Cardiomediastinal contours are
stable in the post-operative period. Minor basilar atelectasis
and small pleural effusions are present. No pneumothorax is
evident.
[**2140-6-29**] 12:45PM BLOOD WBC-6.6 RBC-4.77 Hgb-13.7* Hct-37.8*
MCV-79* MCH-28.8 MCHC-36.4* RDW-13.9 Plt Ct-311
[**2140-7-4**] 09:15AM BLOOD WBC-10.0 RBC-3.28* Hgb-9.3* Hct-26.7*
MCV-82 MCH-28.4 MCHC-34.8 RDW-14.4 Plt Ct-371#
[**2140-6-29**] 12:45PM BLOOD PT-11.7 PTT-23.2 INR(PT)-1.0
[**2140-7-2**] 01:24AM BLOOD PT-13.0 INR(PT)-1.1
[**2140-6-29**] 12:45PM BLOOD Glucose-109* UreaN-12 Creat-1.0 Na-140
K-4.4 Cl-103 HCO3-29 AnGap-12
[**2140-7-3**] 05:20AM BLOOD Glucose-126* UreaN-12 Creat-1.0 Na-142
K-4.0 Cl-105 HCO3-28 AnGap-13
[**2140-7-2**] 01:24AM BLOOD Phos-3.4 Mg-1.9
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] was transferred from OSH for
surgical revascularization of his coronary disease. He underwent
usual pre-operative testing and was brought to the operating
room on [**6-30**] where he had a off-pump coronary artery bypass x 2.
Please see operative report for details. Following surgery he
was transferred to the CSRU for invasive monitoring in stable
condition. Later on op day he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one beta
blocker and diuretics were started and he was gently diuresed
towards his pre-op weight. On post-op day two his chest tubes
were removed and he was then transferred to the SDU for further
care. Epicardial pacing wires were removed the following day.
Physical therapy worked with pt. during post-op period for
strength and mobility. He continued to improve and was ready for
discharge home with services on post operative day 4.
Medications on Admission:
At transfer: Plavix 75mg qd, Aspirin 325mg qd, Zocor 40mg qd,
Lisinopril 5mg qd, Toprol XL 100mg qd, Heparin gtt.
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily) for 3 months.
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day) for 1 weeks.
Disp:*70 ML(s)* Refills:*0*
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 10 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Coronary Artery Disease s/p Off-Pump Coronary Artery Bypass
Graft x 2
PMH: s/p stent to prox and mid LAD c/b subacute stent thrombosis
s/p thrombectomy of LAD and stent [**2140-4-7**], s/p DES to prox LAD
[**2140-6-3**], h/o retroperitoneal/extraperitoneal bleed, Hypertension
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 5874**] in [**12-26**] weeks
Dr. [**Last Name (STitle) 43672**] in [**11-24**] weeks [**Telephone/Fax (1) 6256**]
Wound check [**Hospital Ward Name **] 2 please schedule with RN [**Telephone/Fax (1) 3633**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2140-7-4**]
|
[
"41401",
"V4582",
"4019"
] |
Admission Date: [**2189-5-8**] Discharge Date: [**2189-5-12**]
Date of Birth: [**2126-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Aortic valve replacement (23mm porcine) [**2189-5-8**]
History of Present Illness:
62 year old white male with known aortic stenosis being followed
by serial echocardiograms. He has developed worsening dyspnea
with exertiona and fatigue, leading to surgical intervention on
an elective basis.
Past Medical History:
Critical Aortic Stenosis
hypertension
hypercholesterolemia
HIV positive
diabetes mellitus type 2
Social History:
Occupation: ON DISABILITY CURRENTLY, PREVIOUS ACCOUNTANT
Lives with: ALONE, DIVORCED, HAS ONE GROWN DAUGHTER
Tobacco:DENIES
ETOH: H/O HEAVY ETOH, NOW ONLY SOCIALLY on weekends
Family History:
Mother died age 55 of unknown cause
Physical Exam:
Pulse:59 Resp:16 O2 sat:99% RA
B/P Right:143/71 Left:134/71
Height:5'[**89**]" Weight:195 LBS
General: comfortable
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: systolic, max at R upper
sternal border 3-4/6
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [] Edema Varicosities:
mild
to moderate varicose veins, mostly around L knee area
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left: 2+
Carotid Bruit Right: transmitted murmur Left: -
Pertinent Results:
[**2189-5-12**] 05:34AM BLOOD WBC-8.8 RBC-2.87* Hgb-10.2* Hct-30.3*
MCV-106* MCH-35.7* MCHC-33.8 RDW-14.0 Plt Ct-210
[**2189-5-12**] 05:34AM BLOOD PT-20.1* INR(PT)-1.9*
[**2189-5-12**] 05:34AM BLOOD Glucose-163* UreaN-17 Creat-0.8 Na-139
K-4.0 Cl-105 HCO3-26 AnGap-12
[**Known lastname 17982**],[**Known firstname 198**] [**Medical Record Number 17983**] M 62 [**2126-6-12**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2189-5-9**]
12:53 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2189-5-9**] 12:53 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 17984**]
Reason: PTX
[**Hospital 93**] MEDICAL CONDITION:
62 year old man s/p AVR
REASON FOR THIS EXAMINATION:
PTX
Final Report
HISTORY: AVR, to evaluate for pneumothorax.
FINDINGS: In comparison with the study of [**5-8**], the various
monitoring and
support devices have all been removed. Specifically, no evidence
of
pneumothorax. Decreasing atelectasis at the left base.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: SAT [**2189-5-9**] 2:47 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 17982**], [**Known firstname 198**] [**Hospital1 18**] [**Numeric Identifier 17985**] (Complete)
Done [**2189-5-8**] at 9:07:42 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2126-6-12**]
Age (years): 62 M Hgt (in): 70
BP (mm Hg): 139/60 Wgt (lb): 195
HR (bpm): 80 BSA (m2): 2.07 m2
Indication: Intraoperative TEE for AVR
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2189-5-8**] at 09:07 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW2-: Machine: AW4
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.6 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 70% >= 55%
Left Ventricle - Stroke Volume: 97 ml/beat
Left Ventricle - Cardiac Output: 7.74 L/min
Left Ventricle - Cardiac Index: 3.74 >= 2.0 L/min/M2
Left Ventricle - Peak Resting LVOT gradient: 6 mm Hg <= 10 mm
Hg
Left Ventricle - Peak Inducible LVOT gradient: 9 mm Hg
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.1 cm <= 3.0 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aorta - Arch: 1.9 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *64 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 33 mm Hg
Aortic Valve - LVOT VTI: 38
Aortic Valve - LVOT diam: 1.8 cm
Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 1.2 m/sec
Mitral Valve - Mean Gradient: 3 mm Hg
Mitral Valve - Pressure Half Time: 72 ms
Mitral Valve - MVA (P [**11-21**] T): 3.1 cm2
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 2.00
Mitral Valve - E Wave deceleration time: *292 ms 140-250 ms
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild
symmetric LVH. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Simple atheroma in aortic arch. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Severe AS (area 0.8-1.0cm2). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. [**Male First Name (un) **] of the mitral chordae (normal
variant). No resting LVOT gradient. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE BYPASS The left atrium is moderately dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve is functionally
bicuspid with fusion of the left and non-coronary cusps. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (valve area 0.8cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS There is normal biventricular systolic function. The
mitral regurgitation is somewhat improved - now trace to mild.
There is a bioprosthesis located in the aortic position. It
appears well seated. The leaflets are seen poorly but in limited
trans-gastric images they appear to be functioning normally.
There is a trace to mild jet of perivalvular aortic
regurgitation that is seen. The peak gradient through the aortic
valve is about 60 mmHg with a mean gradient of about 30 mmHg at
a cardiac output of 6 liters per minute. The calculated aortic
valve area is about 1 cm2. These measurements are not within the
expected range for a valve of this size (#23 bioprosthesis).
This issue was brought to Dr.[**Name (NI) 5572**] attention
intraoperatively. The thoracic aorta is intact after
decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2189-5-8**] 14:12
Brief Hospital Course:
Admitted and was brought to the operating room for aortic valve
replacement. The annulus was heavily calcified, see operative
report for further details. He received cefazolin for
perioperative antibiotics. He was transferred to the intensive
care for hemodynamic management. He was weaned from sedation,
awoke neurologically intact and was extubated without
complications. He was transferred to the floor on post
operative day one. He had episodes of rapid atrial fibrillation
that were treated with amiodarone and betablockers. He
continued in atrial fibrillation and beta blockers were
increased for rate control. Coumadin was started due to
continued atrial fibrillation. Physical therapy worked with him
on strength and mobility. On post operative day three he
converted back to normal sinus rhythm. He continued to progress
and was ready for discharge home on post operative day four with
services and plans for coumadin to be followed by [**First Name8 (NamePattern2) 3788**] [**Last Name (NamePattern1) 17986**]
office.
Medications on Admission:
hydrochlorothiazide 25mg/D
lisinopril 20mg/D
Verapamil SR 240mg/D
Abacavir 300mg [**Hospital1 **]
Trizivir 400/100 mg [**Hospital1 **]
Neurontin 600mg TID/300mgHS
Creon 10mg w/meals and HS
MVI
Urea cream
ASA 81mg/D
Lantus 44U Qpam
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:*0*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Creon 20 497 mg (66,400- 20K-75K unit) Capsule, Delayed
Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO
before meals/snacks.
Disp:*270 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
4. Trizivir 300-150-300 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
5. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
6. Neurontin 300 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*0*
7. Novolog Flexpen 100 unit/mL Insulin Pen Sig: per sliding
scale sliding scale Subcutaneous four times a day: per sliding
scale as prescribed by [**Last Name (un) 387**] .
Disp:*qs qs* Refills:*0*
8. Lantus Solostar 300 unit/3 mL Insulin Pen Sig: Forty Four
(44) units Subcutaneous once a day.
Disp:*qs qs* Refills:*0*
9. Kaletra 200-50 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*0*
10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane TID (3 times a day) as needed for teeth brushing
: please rinse before and after brushing teeth .
Disp:*qs ML(s)* Refills:*0*
11. Loperamide 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): with each meal .
Disp:*180 Tablet(s)* Refills:*0*
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing, goal INR 2.0-2.5 for atrial
fibrillation - results to Dr [**Last Name (STitle) 2392**] for further dosing office #
[**Telephone/Fax (1) 5723**]
first draw thrusday [**5-14**]
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 4 days: Decrease dose to 2 pills once a day for 7
days after twice a day dose completed, then decrease dose to 1
pill daily.
Disp:*40 Tablet(s)* Refills:*0*
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA
Discharge Diagnosis:
Aortic Stenosis s/p aortic valve replacement
atrial fibrillation
hypertension
hypercholesterolemia
HIV
Diabetes mellitus type 2
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Please continue to check blood sugars and treat with sliding
scale insulin and lantus, follow up with [**Last Name (un) **] for diabetes
management
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 171**] in [**12-23**] weeks
Dr. [**Last Name (STitle) 2392**] in 1 week ([**Telephone/Fax (1) 5723**])
[**Hospital **] clinic
Wound check [**Hospital Ward Name **] 6, please schedule with RN [**Telephone/Fax (1) 3071**]
PT/INR for coumadin dosing, goal INR 2.0-2.5 for atrial
fibrillation - results to Dr [**Last Name (STitle) 2392**] for further dosing office #
[**Telephone/Fax (1) 5723**]
first draw thrusday [**5-14**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2189-7-1**]
10:40
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2189-6-4**] 10:00
Completed by:[**2189-5-12**]
|
[
"4241",
"9971",
"4019",
"2720",
"V5867",
"42731"
] |
Admission Date: [**2108-3-19**] Discharge Date: [**2108-3-29**]
Date of Birth: [**2048-10-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Suicide attempt, overdose, NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization
Intubation
PICC line placement
History of Present Illness:
Patient is a 59 yo woman with PMH severe depression, migraine
has, recent weight loss w/ negative work up who presents from
[**Hospital3 **] today after suicide attempt, c/b NSTEMI.
Patient initially presented to [**Hospital3 **] on [**2108-3-18**] after
overdosing on pills. She apparently called her grandson stating
that she had taken "45 pills". On evaluation of her pill
bottles, it appears as though she took Zyprexa and Adderall.
She was found minimally responsive by her husband at 2pm on
[**2108-3-18**] who called EMS.
On arrival at [**Hospital1 **], patient was intubated, given charcoal and
NG lavage, and admitted to ICU for managment. On admission, pt
was noted to be tachycardic, but vital signs otherwise stable.
Labs were essentially WNL. Tox screen was negative for benzos,
cocaine, tricyclics, marijuana, opiates, amphetamines, asa,
small amt + of tylenol at 1.7. Initial EKG demonstrated sinus
tachycardia at [**Street Address(2) 65762**] depressions in V1 and diffuse ST
elevations with PR depressions. In terms of her overdose,
poison control was contact[**Name (NI) **] and patient was monitered for
neuroleptic malignant syndrome and anticholinergic effects which
was of concern with her Zyprexa overdose, but did not exhibit
any of these signs. She was otherwise maintained with
supportive care.
Patient was also noted to have Troponin trend from 0.09 night of
admission to 0.03 to 4.5. EKG on 2nd day of hospitalization
demonstrated ST elevations in lateral leads which were more
pronounced than on admission. Patient was not placed on heparin
gtt as it was believed that this troponin elevation was more
likely [**2-9**] strain, as patient had had recent cardiac w/u as
outpt that was negative.
Hospital course otherwise notable for some hypoxia with
borderline O2 sats on 100% FiO2- CXR at that time demonstrated
some evidence of aspiration pna and ?CHF. Pt's WBC also rose to
16. Patient was therefore started on unasyn for broad spectrum
coverage. Patient also developed hypotension, thought ?[**2-9**] pna,
and pt was placed transiently on neosynephrine for BP control,
although was off pressors on transfer to [**Hospital1 **].
Patient was therefore transferred to [**Hospital1 18**] for managment of her
MI and her pulmonary status.
Currently patient is intubated and sedated.
Past Medical History:
(per OSH records):
1.) Depression
2.) Migraine HA
3.) Chronic pain
4.) 100 lb weight loss over past year - pt has undergone
extensive w/u including colonoscopy, GYN exam, HIV test, cardiac
w/u, stool studies, celiac studies negative. Also had abd CT
negative, Chest CT demonstrated LUL nodule which was monitered.
Had recent scan that demonstrated increase in size of LUL nodule
from 3mm->7mm, PET scan in [**12-11**] negative - scheduled to have
repeat Chest CT this month.
Social History:
Patient is married, lives w/ husband and 14 [**Name2 (NI) **] grandson. +
family stress due to death of her son from heroin overdose about
2 years ago. Also has daughter w/ current substance abuse
problems. Remote tobacco history.
Family History:
Unknown
Physical Exam:
Vitals - T 101.8, HR 120, BP 97/68, RR 25-30, O2 95% on
AC/FiO21.0/TV500/RR20/PEEP5
General - intubated, sedated, initially reponded to calling
name, able to squeeze fingers per nurse
[**Last Name (Titles) 4459**] - small pupils b/l minimally reactive
Neck - flat JVP, no noted carotid bruits
CVS - regular rhythm, tachycardic, no noted M/R/G
Lungs - CTA anteriorly, decreased BS at R base, no noted
crackles/rhonci
Abd - hypoactive BS, soft
Ext - no LE edema b/l, 2+ PT pulses b/l
Pertinent Results:
Labs on admission:
[**2108-3-19**] 06:14PM BLOOD WBC-15.7* RBC-4.52 Hgb-14.7 Hct-44.1
MCV-97 MCH-32.4* MCHC-33.3 RDW-13.6 Plt Ct-378
[**2108-3-19**] 06:14PM BLOOD Neuts-84.7* Lymphs-11.2* Monos-3.7 Eos-0
Baso-0.4
[**2108-3-19**] 06:14PM BLOOD PT-11.4 PTT-29.3 INR(PT)-1.0
[**2108-3-19**] 06:14PM BLOOD Glucose-149* UreaN-20 Creat-0.7 Na-145
K-4.4 Cl-115* HCO3-20* AnGap-14
[**2108-3-19**] 06:14PM BLOOD ALT-19 AST-38 LD(LDH)-284* CK(CPK)-206*
AlkPhos-66 Amylase-92 TotBili-0.4
[**2108-3-19**] 06:14PM BLOOD Lipase-19
[**2108-3-19**] 06:14PM BLOOD Albumin-3.4 Calcium-8.5 Phos-3.9 Mg-2.0
[**2108-3-19**] 06:18PM BLOOD Type-[**Last Name (un) **] pO2-65* pCO2-44 pH-7.31*
calHCO3-23 Base XS--4 Intubat-INTUBATED
[**2108-3-19**] 06:18PM BLOOD Lactate-2.4*
[**2108-3-19**] 06:18PM BLOOD freeCa-1.26
.
Cardiac Labs:
[**2108-3-19**] 06:14PM BLOOD ALT-19 AST-38 LD(LDH)-284* CK(CPK)-206*
AlkPhos-66 Amylase-92 TotBili-0.4
[**2108-3-20**] 01:09AM BLOOD CK(CPK)-153*
[**2108-3-20**] 05:41AM BLOOD CK(CPK)-122
[**2108-3-19**] 06:14PM BLOOD CK-MB-31* MB Indx-15.0* cTropnT-1.06*
[**2108-3-20**] 01:09AM BLOOD CK-MB-22* MB Indx-14.4* cTropnT-0.79*
[**2108-3-20**] 05:41AM BLOOD CK-MB-21* MB Indx-17.2* cTropnT-0.67*
.
Other pertinent labs:
[**2108-3-22**] 05:15AM BLOOD Cortsol-23.7*
.
Labs on discharge:
.
Microbiology data:
[**2108-3-19**] Blood culture - 1/4 bottles with Oxacillin sensitive
Staph
[**2108-3-19**] Urine culture - no growth
[**2108-3-19**] Sputum culture - Oxacillin sensitive Staph Aureus
[**2108-3-20**] Sputum culture -
[**3-20**], [**3-22**]: Blood cultures negative
[**3-22**]: sputum culture: 1+ GPC in pairs
[**3-24**]: Blood culture negative to date
.
Imaging:
[**2108-3-19**] CXR:
IMPRESSION:
1. Left lower lobe pulmonary opacity, likely representing
aspiration.
.
[**2108-3-19**] Cardiac catheterization:
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
patent LMCA, LAD that had mild 30% mid vessel lesion, LCx that
was
without obstructive disease and the RCA had a mid vessel 60%
lesion.
2. Left ventriculography was deferred.
3. Hemodynamic assessment showed low normal RAp, elevated PaP
with
marked respiratory variation and normal PCWP. The CI was 2.4.
There was
systemic hypotension with narrow pulse pressure. This was
consistent
with septic shock.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Normal ventricular function.
.
[**2108-3-20**] ECHO:
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed
(ejection fraction 20-30 percent) secondary to extensive apical
akinesis, with contractile function improving toward the base of
the heart. A left ventricular mass/thrombus cannot be excluded.
There is no ventricular septal defect. The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated. Right ventricular systolic function is borderline
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2108-3-21**] CXR: IMPRESSION: Interval improvement of pulmonary
edema. Interval improvement of bibasilar opacities, which may
represent residual changes from aspiration.
.
[**2108-3-22**]: CT Chest with Contrast:
IMPRESSION:
1. Bilateral lower lobe consolidation worrisome for multifocal
pneumonia. Given the distribution, aspiration is also a
consideration. Followup after an appropriate clinical interval
post-treatment is recommended to demonstrate complete
resolution.
2. Bilateral pleural effusions, and interlobular septal
thickening that may suggest fluid overload.
3. 3 mm nodule in the right lower lobe. In the absence of known
primary malignancy, followup in twelve months may be performed,
in the presence of known primary malignancy, followup in three
months is recommended.
.
[**2108-3-26**]: CXR:
There has been interval extubation and removal of the
nasogastric tube. A right PICC line terminates in the lower
superior vena cava. Cardiac and mediastinal contours are within
normal limits. There are bibasilar areas of increased opacity
adjacent to small-to-moderate pleural effusions. The left lower
lobe opacity is slightly improved in the interval. The right
basilar opacity is difficult to compare due to the increasing
effusion and differences in positioning of the patient.
IMPRESSION: Bibasilar consolidation in keeping with history of
aspiration pneumonia with interval improvement in left
retrocardiac area. Small-to-moderate bilateral pleural
effusions.
.
CBC:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2108-3-28**] 08:27AM 8.7 3.69* 12.1 35.8* 97 32.7* 33.7 13.5
393
[**2108-3-28**] 05:15AM 8.2 3.31* 10.7* 32.0* 97 32.3* 33.4 13.6
332
[**2108-3-27**] 08:27AM 6.7 3.06* 10.0* 31.4* 103* 32.6* 31.8
13.7 290
[**2108-3-27**] 06:00AM 8.5 3.46* 11.0* 33.6* 97 31.8 32.7 13.6
352
[**2108-3-26**] 06:10AM 7.6 3.61* 11.5* 35.1* 97 31.9 32.8 13.6
362
[**2108-3-25**] 03:20AM 5.7 3.47* 11.4* 33.5* 97 32.7* 33.9 13.4
308
[**2108-3-24**] 04:15AM 5.6 3.44* 11.1* 33.2* 96 32.3* 33.5 13.8
281
[**2108-3-23**] 05:19AM 7.3 3.38* 11.1* 32.5* 96 32.7* 34.0 13.4
326
[**2108-3-22**] 05:15AM 10.8 3.50* 11.3* 33.6* 96 32.2* 33.5 13.7
284
[**2108-3-21**] 04:53AM 13.5* 3.53*# 11.8*# 34.3* 97#1 33.3* 34.3
13.8 265
.
SMA 7:
RENAL & GLUCOSE Glu BUN Creat Na K Cl HCO3 AnGap
[**2108-3-28**] 08:27AM 92 7 0.5 145 3.3 107 26 15
[**2108-3-28**] 05:15AM 83 7 0.5 143 3.4 108 26 12
[**2108-3-27**] 10:12AM 136 3.9
[**2108-3-27**] 06:00AM 93 7 0.4 144 3.3 110* 26 11
[**2108-3-26**] 06:10AM 86 7 0.5 144 4.1 111* 26 11
[**2108-3-25**] 03:20AM 109 7 0.4 145 3.4 110* 26 12
[**2108-3-24**] 04:15AM 96 7 0.4 142 4.1 108 28 10
[**2108-3-23**] 09:22PM 102 6 0.4 143 3.7 108 27 12
[**2108-3-23**] 05:19AM 131 7 0.3 142 4.2 106 30 10
[**2108-3-22**] 05:15AM 172 7 0.4 140 3.6 106 27 11
.
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2108-3-20**] 05:41AM 21* 17.2* 0.67*1
[**2108-3-20**] 01:09AM 22* 14.4* 0.79*1
[**2108-3-19**] 06:14PM 31* 15.0* 1.06*1
.
Brief Hospital Course:
Assessment/Plan: Patient is 59 yo woman without known cardiac
history, presented to OSH with suicide attempt o/d on zyprexa
and adderall, now intubated w/ pna and course c/b NSTEMI.
.
# Aspiration PNA/MSSA sepsis: The patient was started on levo
([**3-19**]) at admission and then added vanc the following day. Her
sputum and Bcx (1 out of 4) from admission grew out MSSA. The
patient finished 7 day course of levoquin (750mg/day) on [**3-25**]
and was switched to oxacillin on [**3-25**] as BCX came back as MSSA.
The patient will finish 14 day course oxacillin on [**4-2**]. She
was on levophed for septic shock and has been off for >36hours
with SBP in high 80s-100s prior to call-out to the floor.
.
# Respiratory failure: Pt was initially intubated for airway
protection after found unresponsive and subsequently found to
have bilateral pneumonia thought to be [**2-9**] aspiration. The
patient was extubated on [**3-23**] and has required high O2, so
empirically started short-course prednisone (5days) for presumed
COPD exacerbation on [**3-25**].
.
# Cardiac:
A. Ischemia: Patient with flat troponins on initial
presentation to OSH, then trended up. No history of CAD and per
OSH records, had recent cardiac w/u which was negative. EKG on
initial presentation to OSH demonstrates diffuse ST elevation
and PR depression. EKG on day of transfer demonstrates
anterolateral ST elevation with reciprical inferior changes. Pt
went to cath on night of presentation to [**Hospital1 18**] ([**3-19**]) that
demonstrated no significant CAD (30% LAD, 60% RCA), more septic
physiology. The patient was started on ASA. Due to
hypotension, carvedilol was started but never given. Lipitor
was not started as cholesterol was low.
.
B. Pump: Patient appears clinically euvolemia, no hx of CHF.
ECHO [**3-20**] demonstrated LV systolic dysfxn with EF 20-30% [**2-9**]
extensive apical akinesis, also 3+ MR. This was thought to be
stress-induced cardiomyopathy. Will need a BB and ACEI once BP
stable and as BP tolerates. The patient has been auto-diuresing
without needing lasix for all the fluid she received for sepsis.
.
C. Rhythm: Was in sinus tachy on presentation, now in NSR. No
prolongation of intervals on EKG.
.
# Suicide attempt/OD: Per OSH records, pt OD on zyprexa and
adderall. Seen by poison control at OSH - monitered for
neuroleptic malignant syndrome and anticholinergic effects which
were not noted. Tox screen neg at OSH. After extubation, she
was placed on CIWA scale and 1:1 sitter for possible alcoholism
and SI. The patient was also evaluated by psych who recommended
d/cing 1:1 sitter and CIWA as pt was no longer suicidal and had
no previous ETOH abuse. Pt was also started on Remeron per
psych recs. On discharge from unit, pt was not suicidal and
although admits depression and anxiety.
.
# FEN: Started TFs w/ nutrition recs while intubated. Once
extubated, started po diet as tolerated. Repleted lytes K to 4
and mag to 2.
.
# PPX: SC heparin, lansoprazole, colace
.
# Code status: Full
.
Patient was discharged from the ICU onto the floor and remained
without a sitter. Since she was not exhibiting signs of SI to
the psych service, SW or to us, it was felt that reinstituting a
sitter would be seen as punitive. During her stay, patient
expressed remorse for her suicide attempt and plans for
restarting her life. Psychiatry felt that the patient was safe
to discharge home with her attending a day program at [**Hospital 882**]
hospital and in addition to having regular meetings with her
therapist, which she agreed to and was arranged. In addition,
she was discharged with a crisis plan in place which was
explained to the patient.
.
She was continued on IV oxacillin and was changed to Levofloacin
on discharge - since her bacteremia was also succeptible to this
antibiotics. She was prescribed enough Levoquin until [**4-2**] (end
of 14 day course of total antibiotics). She did not spike any
fevers while on the floor and surveillance blood cultures were
negative from [**3-20**] and [**3-22**]. Follow up urine cultures were also
negative.
.
Patient's BP remained in the 80s-90s for much of her stay on the
floor making it difficult to add on BB and ACE-I. On discharge,
her SBP rose to 108. Hence low dose metoprolol was initiated.
She was on ASA on the floor. 20mg lipitor was started on
discharge. (Lipid panel showed LDL of 54 and HDL of 43)
.
During her stay on the floor, she was walked with PT and her
oxygen requirements were weaned down slowly; on discharge
patient was completely off of oxygen and was comfortable. Repeat
CXR on [**3-26**] showed resolution of her pulmonary edema. She
finished a 5 day course of steroids for putative bronchospasm in
the hospital and was maintained on nebulizers.
------
Outstanding issues:
- Patient would likely benefit from starting an ACE-I as an
outpatient.
- Patient was on adderall and topamax as outpatient; these were
discontinued and will not be restarted; In particular, the
adderall may have played a significant part in the drastic
weight loss that the patient has experienced over the past year.
In addition, patient will need basic oncologic screening - in
particular, her pulmonary nodule will need follow up - per
Radiology here at [**Hospital1 **], it was recommended that this nodule be
followed up in [**3-12**] months with repeat CT.
- For her depressed EF, she will need a follow up ECHO,
particularly in the event that she may have a depressed EF due
to myocardial stress
Medications on Admission:
Outside medications (per OSH records):
Percocet 5/325 q6hr PRN
Zyprexa ?2.5mg qd
Prozac 60mg QD
Inderal - recently d/ced
HCTZ - recently d/ced
Topomax
Nexium 40mg QD
Premarin 0.625mg QD
.
Medications on admission:
Unasyn 1.5grams IV q6hr
Versed gtt
Morphine 2mg IV q1hr PRN agitation
Pepcid 20mg IV BID
Heparin SC
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 MDI* Refills:*0*
4. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*16 Tablet(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for constipation.
Disp:*20 Tablet(s)* Refills:*0*
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2
doses.
Disp:*2 Tablet(s)* Refills:*0*
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation four times a day.
Disp:*1 QS* Refills:*2*
10. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a
day.
Disp:*30 tablets* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Suicide attempt/Overdose
2. Depression
3. Respiratory failure
4. Aspiration pneumonia
5. Cardiac marker elevation
6. Hypotension
Discharge Condition:
Good, oxygenating well on room air
Discharge Instructions:
You are discharged to home where you should continue all
medications as prescribed. You will not be taking Topamax or
Adderall any longer. You will follow-up with the [**Hospital1 882**] Day
Program, your psychiatrist, and your primary care physician.
We have given you a crisis plan with phone numbers. If you feel
unsafe or have thoughts of hurting yourself, please seek help
immediately by contacting someone at one of those numbers.
Please alert your primary care physician or present to the ER if
you experience chest pain, shortness of breath, increasing
cough, fevers, chills, night sweats, or other concerns.
You should keep all follow-up appointments.
Followup Instructions:
You have an appointment with the [**Hospital1 882**] Day Program on
Wednesday, [**2108-3-21**] at 10:00am.
You should arrange a follow-up appointment with your outpatient
counselor [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 65763**] for Monday, [**2108-4-2**]. Please call his
office at [**Telephone/Fax (1) 65764**].
You have a follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Tuesday, [**2108-4-3**] at 11:45AM.
[**Telephone/Fax (1) 4475**].
Please call [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NPN at [**Telephone/Fax (1) 65765**] to schedule a
follow-up appointment.
Completed by:[**2108-4-12**]
|
[
"0389",
"41071",
"5070",
"78552",
"2762",
"4280",
"41401"
] |
Admission Date: [**2189-2-18**] Discharge Date: [**2189-3-4**]
Date of Birth: [**2189-2-18**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 30-6/7 weeks
gestational male infant admitted for prematurity.
Maternal history significant for mother being a 28-year-old
G4, P1, now 2, woman with past obstetric history notable for
therapeutic abortion times two in [**2184**] and [**2186**]. Also had
normal spontaneous vaginal delivery in [**2186**] and baby is doing
well.
Past medical history is notable for a motor vehicle accident
followed by prolonged hospital admission of three months.
She is currently on no medications other than prenatal
vitamins. Prenatal screens are as follows: O positive, DAT
negative, RPR nonreactive, Rubella immune, hepatitis B
surface antigen negative, GC negative, Chlamydia negative,
GBS unknown. Pregnancy history is significant for last
menstrual period at [**2188-7-17**] and [**Last Name (un) **] at [**2189-4-23**] and estimated
gestational age of 30-6/7 weeks. Fetal survey was normal.
Pregnancy was complicated by premature rupture of membranes
five days prior to admission on [**2189-2-13**]. The fluid was
clear. A course of betamethasone was started at the time of
rupture. Magnesium sulfate was started as were ampicillin
and erythromycin. Over the next several days it was noted
that the mother had an increasing white blood cell count with
left shift. Therefore, an induction was performed. The
induction led to a vaginal delivery under epidural
anesthesia.
NEONATAL COURSE: Infant was vigorous at delivery. It was
orally and nasally bulb suctioned, dried and free flow oxygen
was provided. Subsequently pink and in minimal distress.
Transported uneventfully to the NICU. The physical
examination was consistent with 30 weeks gestational age.
Birth weight was 1,530 grams, 50-75th percentile. OFC was 29
cm 50th percentile. Length was 42 cm 50-75th percentile.
The anterior fontanelle was soft, open and flat. Baby was
[**Name2 (NI) 43619**] with an intact palate. Neck and mouth were
normal. There was mild occipital caput and mild nasal
flaring. The chest had mild intercostal retractions but good
breath sounds bilaterally with a few scattered crackles. The
patient was well perfused with normal rate and rhythm. The
femoral pulses were normal. S1, S2 were normal as well.
There was no murmur auscultated. The abdomen was soft and
non-distended without organomegaly and no masses. Bowel
sounds were active. The anus was patent and there was a
three vessel umbilical cord noted. The patient had normal
male genitalia with bilaterally descended testes. The CNS
examination revealed active and alert responsive infant with
appropriate tone. He was moving all his limbs symmetrically.
Suck, root and organic grasp were intact. Musculoskeletal
examination was normal as was the integument examination.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: Patient remained stable with normal
blood pressures and with only a few bradycardic spells over
the last 14 days of life. The patient does have a soft
intermittent systolic murmur but otherwise the cardiac
examination has remained within normal limits.
2. Respiratory: He was initially on room air and then by
several hours of age required low flow nasal cannula on which
he remains on day of life 14 corrected to 32 and 6/7 weeks.
The etiology of this is thought to be mild residual resolving
RDS.
3. Fluids, Electrolytes and Nutrition: The patient was
initially maintained NPO on intravenous fluids. As his
respiratory status remained stable, he was advanced to
enteral feeds and weaned off intravenous fluids. He is
currently on 150 cc/kg/day of PE30 plus ProMod with adequate
weight gain. His weight today at the time of transfer was
1805 and that is on day of life 14.
4. Gastroenterology: Patient has tolerated enteral feeds
without difficulty.
5. Hematology: Hematocrit on admission was 49.7. He had
mild physiologic hyperbilirubinemia requiring phototherapy
for several days. The bilirubin peaked at 9.4.
6. Infectious Disease: Initial white count was 5.4 with 27
polys and 0 bands, an ANC of 1,458. Ampicillin and
gentamicin were started empirically soon after birth but were
discontinued after 48 hours of sterile blood cultures.
7. Renal: Patient has had adequate urine output. The
newborn screen will be sent on [**3-5**] along with nutrition labs.
8. Radiology: A head ultrasound was performed on day of
life seven and was within normal limits.
9. Social: The parents have most recently been contact[**Name (NI) **] by
phone and updated. They have as yet not identified a
pediatrician.
DISCHARGE DIAGNOSES:
1. Respiratory distress syndrome.
2. Rule out sepsis.
3. Murmur.
4. Physiologic hyperbilirubinemia.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 44694**]
MEDQUIST36
D: [**2189-3-4**] 15:41
T: [**2189-3-4**] 17:07
JOB#: [**Job Number 49645**]
|
[
"7742"
] |
Unit No: [**Numeric Identifier 74445**]
Admission Date: [**2192-8-3**]
Discharge Date: [**2192-8-11**]
Date of Birth: [**2192-8-3**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 74446**] is the former
2.4 kg product of a 33-6/7 week gestation pregnancy born to a
33-year-old G5, P1, now 2 woman. Prenatal screens, blood type
O positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen positive, group beta
strep status positive. The pregnancy was notable for evolving
pregnancy-induced hypertension. The patient has a past
medical history of chronic hypertension. She was an elective
induction of labor for the concerns for her hypertension. She
delivered by spontaneous vaginal delivery. There was no
maternal fever. There was rupture of membranes with clear
fluid 40 minutes prior to delivery. The mother received
intrapartum antibiotics for greater than 4 hours prior to
delivery. The infant emerged vigorous with Apgars of 9 at 1
minute and 9 at 5 minutes. He was admitted to the Neonatal
Intensive Care Unit for treatment of prematurity.
Anthropometric measurements upon admission to the Neonatal
Intensive Care Unit, weight 2.4 kg, length 45 cm, head
circumference 33 cm, all at the 75% for gestational age.
PHYSICAL EXAMINATION AT DISCHARGE: Weight 2.335 kg. General:
Alert, active infant in no distress. Comfortable
respirations. Skin: Warm and dry. Diaper rash in the perianal
area. Head, Ears, Eyes, Nose, and Throat: Anterior fontanel
open, level and flat. Sutures approximated. Eyes clear.
Symmetric facial features. Palate intact. Chest: Breath
sounds clear and equal. Easy respirations. Cardiovascular:
Regular rate and rhythm. No murmur. Normal S1, S2. Femoral
pulses +2. Abdomen: Soft, nontender, nondistended. No masses.
Cord on and drying. GU: Circumcision healing. Testes
descended bilaterally. Extremities: Moving all well. Hips
stable. Neuro: Vigorous tone and reflexes consistent with
gestational age.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory. This infant has been in room air for his
entire Neonatal Intensive Care Unit admission. He had
rare episodes of oxygen desaturation, usually associated
with discoordination with feeding. At the time of
discharge, he is breathing comfortably with a
respiratory rate of 50-70 breaths per minute.
2. Cardiovascular. This infant has maintained normal heart
rates and blood pressures. No murmurs have been noted.
Baseline heart rate at the time of discharge is 130-150
beats per minute with a recent blood pressure of 80/54
mmHg, mean arterial pressure 64 mmHg.
3. Fluids, electrolytes, and nutrition. This infant was
initially treated with intravenous D10W for
hypoglycemia. Enteral feeds started on day of life #1
and have been well tolerated. The baby has been all
breastfeeding or bottle feeding, not requiring gavage
feedings. Serum electrolytes were normal at 24 hours of
life. Weight on the day of discharge is 2.335 kg. He is
being discharged either breastfeeding or taking Enfamil
20 calorie per ounce formula ad lib.
4. Infectious disease. Due to his prematurity, this infant
was evaluated for sepsis. A complete blood count was
within normal limits. A blood culture was obtained. The
blood culture grew a species of gram-positive rod, later
identified as a bacillus species, thought to be a
contaminant. A repeat blood culture was obtained prior
to starting ampicillin, gentamicin and clindamycin. The
second blood culture obtained prior to starting the
intravenous antibiotics was no growth, and the
antibiotics were discontinued. The baby did develop a
candidal-appearing rash that is being treated with
Critacaid ointment antifungal formulation at the time of
discharge.
5. Hematological. Hematocrit at birth was 52.7%. This
infant did not receive any transfusions of blood
products.
6. Gastrointestinal. Peak serum bilirubin occurred on day
of life #4, total 8.7 mg/dL.
7. Neurological. This infant has maintained a normal
neurological exam during admission. There are no
neurological concerns at the time of discharge.
8. Sensory, audiology. Hearing screening was performed with
automated auditory brainstem responses. This infant
passed in both ears on [**2192-8-10**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **], [**Hospital 392**]
Pediatrics, [**Street Address(2) 50887**], [**Hospital1 392**], [**Numeric Identifier 47974**]. Phone
number [**Telephone/Fax (1) 42643**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding. Ad lib breastfeeding or Enfamil 20 calorie per
ounce formula.
2. Medications. Ferrous sulfate 25 milligrams per ml
dilution, 0.2 ml p.o. once daily. Goldline baby
vitamins, 1 ml p.o. once daily.
3. Iron and vitamin D supplementation.
a. Iron supplementation is recommended for preterm
and low birth weight infants until 12 months corrected
age.
b. All infants fed predominantly breast milk should
receive vitamin D supplementation at 200 international
units (may be provided as a multivitamin preparation)
daily until 12 months corrected age.
4. Car seat position screening was performed. The infant
was observed in his car seat for 90 minutes without any
episodes of bradycardia or oxygen desaturation.
5. State newborn screens were sent on [**8-7**] and
[**2192-8-11**]. No notification of abnormal results
to date.
6. Immunizations. Due to the hepatitis B surface antigen
positive status of the mother, this infant received
hepatitis vaccine and hepatitis B immunoglobulin at the
time of birth.
7. Immunizations recommended.
a. Synagis, RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria: 1) born at less than 32 weeks; 1)
born between 32-35 weeks with 2 of the following:
daycare during RSV season, a smoker in the household,
neuromuscular disease, or hemodynamically-significant
congenital heart disease.
b. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of
age. Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
c. This infant has not received rotavirus vaccine.
The American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks, but fewer than 12 weeks of
age.
8. Follow up appointments recommended.
a. Appointment with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] within 3 days
of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 33-6/7 weeks.
2. Suspicion for sepsis ruled out.
3. Status post circumcision.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 43348**]
MEDQUIST36
D: [**2192-8-11**] 02:02:48
T: [**2192-8-12**] 12:02:20
Job#: [**Job Number 74447**]
|
[
"V053"
] |
Admission Date: [**2143-2-4**] Discharge Date: [**2143-2-11**]
Date of Birth: [**2078-10-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Anterior ST Elevation Myocardial Infarction
Major Surgical or Invasive Procedure:
Intubation
Cypher Stent to proximal LAD
Intra-aortic balloon pump insertion, and removal
History of Present Illness:
The patient is a 64 y.o. male w/ pmh CAD, s/p inferior STEMI in
[**2134**] treated with BMS to left CX with known occluded RCA, who
awoke from sleep at 1am with with crushing substernal chest
pain. The patient called EMS, was transported to [**Hospital1 **], where he was found to have an anterior STEMI. He V-Fib
arrested in the ED, was defibrillated, given amiodarone 300mg,
placed on lidocaine gtt, and intubated. Total code time was
20-30 minutes. He was transferred to [**Hospital1 18**] on lidocaine gtt.
On arrival to [**Hospital1 18**], he received aspirin and plavix, and was
started on heparin and integrellin. He was hypotensive and so
was started on a dopamine drip. Left heart cath at [**Hospital1 18**]
revealed occlusion of prox LAD, LAD w/ 40-50% occlusion, RCA
with total occlusion and with left to right collateralls. He
received a cypher stent to the LAD. The patient had a swan
placed which revealed elevated wedge pressures to 26. He was
given lasix 80mg IV. Patient also became acidotic 7.01 w/
elevated CO2 73. Given his proximal LAD lesion, along with
marginal blood pressures on dopamine, a balloon pump 40cc was
inserted 1:1.
.
patient is intubated and unable to provide ROS.
Cardiac review of systems is notable for chest pain
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS:: Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**2132**]-stent to LCx, rotablator and angioplasty of diagonal
[**2134**]-stent to mid LCx Bx Velocity
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Right toe open fracture.
.
Social History:
unable to obtain, per previous notes denies tobacco, occansional
ETOH
Family History:
unable to obtain
Physical Exam:
VS: T=98.0 BP=89/72 HR=98 RR=...O2 sat=96% FiO2
GENERAL: WDWN male intubated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles 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+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Pertinent Results:
Admission labs:
[**2143-2-4**] 03:45AM WBC-26.9*# RBC-5.25 HGB-16.5 HCT-48.2 MCV-92
MCH-31.5 MCHC-34.3 RDW-13.4
[**2143-2-4**] 03:45AM GLUCOSE-375* UREA N-24* CREAT-1.8*
SODIUM-132* POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-19* ANION GAP-18
[**2143-2-4**] 04:11AM TYPE-ART TIDAL VOL-600 PEEP-10 O2-100
PO2-119* PCO2-60* PH-7.11* TOTAL CO2-20* BASE XS--11 AADO2-550
REQ O2-89 INTUBATED-INTUBATED
Discharge Labs: [**2142-2-10**]
wbc 11.2, Hct 40.6, plts 243
Na 139, K 3.6, Cl 107, HCO3 27, BUN 27, Cr 1.3, glu 109
Cardiac Enzyme trend:
[**2143-2-4**] 03:45AM CK(CPK)-223*
[**2143-2-4**] 03:45AM CK-MB-15* MB INDX-6.7*
[**2143-2-4**] 06:16AM CK-MB-239* MB INDX-11.1* cTropnT-5.15*
[**2143-2-4**] 06:16AM BLOOD CK(CPK)-2153*
[**2143-2-5**] 03:01AM BLOOD CK(CPK)-2742*
[**2143-2-8**] 05:01AM BLOOD CK(CPK)-332*
EKG [**2143-2-4**]:
Sinus rhythm. Left atrial enlargement. Low limb lead voltage.
Prior
anteroseptal myocardial infarction. Compared to the previous
tracing
of [**2134-10-6**] the rate has increased. There is variation in
precordial
lead placement. The previously recorded early precordial R wave
transition is
no longer in evidence. There are now Q waves in leads V1-V2
consistent with
interim anteroseptal infarction. The limb lead voltage has
diminished.
The rate has increased and there are ST-T wave changes. Followup
and clinical
correlation are suggested.
Cardiac Catheterization [**2143-2-4**]:
1. Selective coronary angiography of this right dominant system
revealed
3 vessel disease with an acute proximal LAD lesion. The LMCA
had no
angiographically apparent flow limiting disease. The LAD had an
acute
lesion of 99% stenosis in the proximal segment. The first
diagonal had
80% stenosis. The LCX had 40% hazy stenosis at the mid segment.
The
RCA was chronically totally occluded at the proximal segment and
was
filled by left to right collaterals.
2. Resting hemodynamics demonstrated markedly elevated right
sided
filling pressures (RVEDP 26 mm Hg) and markedly elevated left
sided
filling pressures (PCWP 25 mm Hg). There was mild PA
hypertension (PA
40/27 mm Hg).
3.
4. Stenting of very proximal LAD with Cypher 3x18mm stent
posted to
3.25mm in setting of STEMI.
5. IABP inserted for cardiogenic shock.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Mild diastolic ventricular dysfunction.
3. Acute anterior myocardial infarction, managed by acute ptca.
PTCA of vessel.
Transthoracic Echo [**2143-2-4**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
moderate to severe hypokinesis of the septum. The anterior wall
may be hypokinetic also. The inferolateral wall may be slightly
hypokinetic but suboptimal image quality limits certainty. The
right ventricular cavity is dilated. The aortic root is mildly
dilated at the sinus level. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Symmetric LVH with moderate to severe septal
hypokinesis. The anterior wall is probably hypokinetic but is
not well seen. The RV is dilated and probably hypokinetic but
image quality limits interpretation. No significant valvular
abnormality seen. Large anterior fat pad.
Brief Hospital Course:
64M w/ pmh CAD p/w chest pain, found to have anterior STEMI,
complicated by V-fib arrest s/p defibrillation, now s/p cypher
stent to prox LAD.
.
# ST Elevation Myocardial Infarction: Cardiac catheterization
revealed a totally occluded RCA with Left to right collaterals,
99% stenosis of proximal LAD, and 40% stenosis of LCx. He
receiving a cypher stent to his proximal LAD and was admitted to
the CCU. During catheterization he was hypotensive, requiring a
dopamine drip and an intraaortic balloon pump. He was intubated
prior to arrival at [**Hospital1 18**]. During the catheterization he was
vomiting and concern was raised for aspiration. he was initially
acidotic, with a pH of 7.01 and elevated lactate to 2.9. He was
started on aspirin and plavix and atorvastatin, and his IV
heparin was continued while he was still on the IABP. He
underwent the arctic sun cooling protocol as well. he was also
started on an insulin drip to keep his blood glucose under 180.
Echo on [**2-5**] showed an LVEF of 30% with septal and anterior
hypokinesis. His RV was also dilated. After several days his
blood pressure stabilized and his dopamine was discontinued on
[**2-6**]. His balloon pump was removed [**2-6**]. He was extubated on
[**2142-2-6**]. He was started on carvedilol and lisinopril, which were
initially held given his hypotension. His carvedilol was
switched to metoprolol and he was found to have better rate
control with metoprolol. His enzymes were trended and found to
peak at CK 2742, troponin 5.15. Given his septal and anterior
wall hypokinesis, the patient was bridged with enoxaparin and
started on coumadin. He was started on 5mg coumadin daily from
[**2-5**] to [**2-9**], his INR increased from 1.3 to 2.5. He was then
given 3mg of coumadin on [**2-10**] when his INR was 3.6. His coumadin
was held on [**2-11**]. The plan was to continue anticoagulation with
goal INR [**3-12**] for 3-6 months and to re-evaluate in 1 month with
repeat TTE and cardiac MR. [**Name13 (STitle) **] will be discharged home on the
[**Doctor Last Name **] of Hearts monitor for two weeks, with results followed up
by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Hospital1 18**].
By discharge, his systolic blood pressure was ranging between
100-140, and primarily in the 120s, and heart rate ranging from
60-85.
The patient was instructed to visit his PCP [**Last Name (NamePattern4) **] [**2-12**], and [**2-13**] to
have labs drawn to monitor his INR while on coumadin.
He was also instructed to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] from
the department of Cardiology and Electrophysiology after his
Cardiac MRI is performed.
The patient was also completed a 7 day course of levofloxacin
and flagyl for empiric coverage of aspiration pneumonia.
Medications on Admission:
aspirin
metoprolol
atorvastatin
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. 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. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Outpatient [**Name (NI) **] Work
PT, PTT, INR drawn three times per week.
Results should be sent to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Fax# [**Telephone/Fax (1) 32617**]
Tel# [**Telephone/Fax (1) 4475**]
7. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once daily .
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
primary: ST-elevation myocardial infarction
secondary: hyperlipidemia, hypertension
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because you had a heart
attack. A stent was placed in one of the arteries to your
heart. Medications were started to decrease your risk for
having heart problems in the future.
The following medications were changed in the hospital:
Lisinopril was started
Coumadin was started
Clopidogrel was started
Metoprolol was increased
Atorvastatin was increased
Please continue to take your medications as prescribed.
Please do not take coumadin today, [**2142-2-10**].
.
You should visit Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at his office [**2142-2-11**] and
[**2142-2-12**] to have blood tests drawn, in order to manage the dosing
of your coumadin. Do not restart taking coumadin until [**2-12**],
unless instructed otherwise by Dr. [**Last Name (STitle) **].
.
Because you are taking Coumadin, a medication that thins your
blood, you will need to have your blood tested regularly to make
sure the level is correct. The INR is the name of test for the
coumadin level.
You will also be sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor.
Please wear this for two weeks.
Please return to the emergency room or call 911 if you
experience recurrent chest pain or shortness of breath.
Additionally, seek medical attention for high fevers and chills,
vomiting, or other symptoms that are concerning to you.
Followup Instructions:
The cardiac MRI [**Last Name (NamePattern4) **] will call you to schedule an appointment.
This should be in approximately 1 month. Please be sure this
study is performed before you meet with Dr. [**Last Name (STitle) **].
.
You have an appointment for an ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2143-3-11**] 3:00
.
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 62**]
Friday [**2142-3-21**], at 1pm. This appointment is located
on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building.
Please keep your regularly scheduled appointment on [**2-13**] to
have your blood drawn at Dr.[**Name (NI) 32618**] office. At that time you
should have your INR checked. The level should be [**3-12**] with
adjustment of your comadin as directed by your doctor. You were
given 5mg PO daily from [**2-5**] to [**2-9**], then 3mg on [**2-10**], INR was
3.9 on discharge. Discharged on 2mg to start on [**2-12**] (held for
[**2-11**]).
|
[
"5849",
"51881",
"5070",
"4280",
"41401",
"4019",
"2724",
"2720"
] |
Admission Date: [**2175-4-18**] Discharge Date: [**2175-4-21**]
Date of Birth: [**2098-2-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
hyperglycemia, PE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 77yoM with HTN, hypercholesteremia, pancreatic
cancer (s/p bypass) and renal cell carcinoma who was sent in by
his visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] BS into the 400's over the past
few days. In mid-[**Month (only) 958**] he was started on steroid to help
increase his appetite. He did not check blood sugars but
approximately 2 weeks ago he developed chills and shakes and was
brought to the [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **] where he was found to have a pneumonia
and [**Last Name (NamePattern1) **] blood sugar. He was treated with antibiotics but no
intervention was done for his blood sugars. Since being
discharged his family has been checking his BS and they have
been [**Last Name (NamePattern1) **] and his metformin was increased from 500 [**Hospital1 **] to
850 mg [**Hospital1 **] with 425mg prn by his oncologist Dr. [**Last Name (STitle) **] at [**Hospital1 2025**].
However, he continued to have [**Hospital1 **] BS and was noted to be
more tired with decreased PO intake and dehyration. He was also
sleeping 80% of the time over the last 2 weeks. Last evening his
sugar was in the 500s and this a.m. he was seen by his VNA who
recommended evaluation.
In the ED vitals were 98.8, 75, 150/64, 14, 100% RA. FS 330 and
given 6units SQ insulin and 1L NS. Urine and blood cultures
sent. Received levofloxacin 750 mg IV x 1. EKG with TWI in
inferiolateral leads and cardiac enzymes were sent. The patient
also related some increasing SOB today as well as intermittent
chest discomfort over the past few days, and a CTA was performed
which showed a large pulmonary embolism. Bedside ECHO done by
the ED attending showed some evidence of right heart strain per
the ED resident, but no documentation of this. He was started on
heparin and tranferred to the ICU for monitoring.
Currently the patient has left flank discomfort but no chest
pain or pleuritic pain. Not SOB. + abdominal pain and tenderness
that is chronic for pancreatic cancer. Decreased appetite. No
fevers, chills, nausea, emesis, dysuria, or other symptoms.
Past Medical History:
# Hypertension
# High cholesterol
# GERD on p.m. Zantac
# Status post appendectomy
# Orthostatic hypotension
# Kidney mass - new solid mass in the right kidney concerning
for malignancy, 2.2.3, on [**2174-12-1**]
# DM - increasing BS since [**4-13**] on increasing doses of metformin
# Episode of bright red blood per rectum in [**2169**] requiring
hospitalization at [**Hospital3 **].
# Pancreatic head tumor seen on [**2174-12-1**], pancreatic biopsy
[**2174-12-29**] positive for adenocarcinoma likely of pancreatobiliary
origin. Encases the SMV and SMA and not surgical candidate.
Went to [**Hospital1 2025**] for 2nd opinion who agreed with Dr. [**Last Name (STitle) **].
Admission in [**2-3**] for nausea/emesis and found to have
gastric/small bowel obstruction and underwent surgery (specifics
unclear as history is from son) to relieve obstruction. Had
Gtube for some time but no longer.
# Oncologist [**First Name8 (NamePattern2) 17133**] [**Last Name (NamePattern1) **] at [**Hospital1 2025**]
# ????AFIB ?????? on digoxin
Social History:
Occupation: Worked in construction, retired. Emigrated from
[**Country 38213**] several years ago.
Drugs: denies
Tobacco: 1ppd for 50 yrs, quit [**2171**]
Alcohol: No
Other: Married w/ two sons
Family History:
Brother died of CAD at age 53, sister with diabetes. No colon
cancer, pancreatic, prostate cancer.
Physical Exam:
Tmax: 36.2 ??????C (97.1 ??????F)
Tcurrent: 36.2 ??????C (97.1 ??????F)
HR: 76 (76 - 84) bpm
BP: 137/68(84) {137/68(84) - 148/72(90)} mmHg
RR: 17 (15 - 19) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: Well nourished, No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: RRR, no M/R/G. nl S1, S2
Respiratory / Chest: CTA bilaterally, no wheezes
Abdominal: Soft, Tender: TTP around umbilicus, no rebound or
guarding, no HSM appreciated, scar in midline healed
Extremities: 2+ DP. no calf tenderness
Skin: No rash
Neurologic: A/O x 3
Pertinent Results:
[**2175-4-18**] CTA CHEST:
IMPRESSION:
1. Massive pulmonary embolism with pulmonary emboli noted within
the main, right and left pulmonary artery and their subsegmental
branches. This is associated with the straightening of the
ventricular septum, which suggests increased right heart
pressure.
2. Diffuse panlobular emphysema of both lungs with multiple
bulla.
3. Massive ascites.
4. Enhancing lesion in the liver dome is new compared to prior
abdominal CT and is concerning for metastasis.
Lower ext u/s:[**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of bilateral
common femoral, superficial femoral, and popliteal veins were
performed. There is non- occlusive thrombus formation in the
left deep femoral vein with flow detected around the thrombus.
The remaining vessels are patent. In the right lower extremity,
there is non-occlusive thrombus formation in the superficial
femoral vein. The remaining vessels are patent.
IMPRESSION: Bilateral non-occlusive DVT.
ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. There is borderline
pulmonary artery systolic hypertension. There is a small
pericardial effusion located posterior to the basal
inferolateral segment of the left ventricle. There is a small
amount of fluid anterior to the right ventricle also. There are
no echocardiographic signs of tamponade.
IMPRESSION: Small pericardial effusion located posterior to the
inferolateral wall with some fluid also anterior to the right
ventricle. No echo signs of tamponade. Normal global
biventricular systolic
Brief Hospital Course:
The patient is a 77 y.o.m. with HTN, hypercholesteremia,
pancreatic cancer, renal cell cancer and recent pneumonia who
presents with hyperglycemia and was found to have a pulmonary
embolism.
# Pulmonary embolism ?????? The patient's major risk factor is most
likely malignancy. Given malignancy, large PE, pt was treated
with Lovenox. While awaiting assurance of coverage for long
term lovenox by his insurance, he was started on coumadin, in
the case that the Lovenox was rejected. He received 2 days of
coumadin and had a heightened response to INR 5.3 after only 2
doses of coumadin. When insurance accepted Lovenox treatment,
plan was to discharge on Lovenox [**Hospital1 **], given his supratherapuetic
INR, visting nurses agreed to check his INR at home over then
next 3 days and to start Lovenox only once INR below 3.0.
LENI U/S showed b/l femoral vein thrombus. No IVC filter was
pursued, this was discussed with Dr. [**Last Name (STitle) **], his primary
oncologist.
ECHO showed small pericardial effusions but no tamponade and no
evidence of right heart strain from the PE.
# Hyperglycemia- The was likely in the setting of recent
infection, steroids, worsening pancreatic function. He was on
Lantus while in the ICU with good response. Given the family's
wish to avoid insulin if possible, he was trialed on higher
doses of metformin with good effect. Visiting nurses will
assist family with fsbg checks at home and if persistently
[**Last Name (STitle) **], they understand to discuss with primary care whether
he needs to start Lantus at home.
# Poor appetitie, malnutrition: Steroids were discontinued and
pt given a presription for Megace. Family felt he would eat
better at home and plan to hold off on giving him Megace for
now.
# Pancreatic cancer ?????? Pt will follow up with Dr. [**Last Name (STitle) **] in 5 days.
# HTN ?????? Currently well controlled. Continue home regimen
# Hypercholesteremia ?????? Continued statin
Long term goals: Family decided to transition to DNR/DNI. They
were not prepared to discuss hospice at this time, and felt that
they needed to discuss further with his primary oncologist, Dr.
[**Last Name (STitle) **].
Medications on Admission:
Atenolol 50 mg daily
Norvasc 2.5mg daily
Digoxin 0.125mg daily
Prilosec 20mg daily
Aspirin 81 mg daily
Simvastatin 40 mg daily
Creon 20 mg 2 capsules TID
Lisinopril 5mg daily
Metformin 850mg [**Hospital1 **] and 425 [**Hospital1 **] as needed additional
Zofran 4 mg QID prn
Oxycontin 20 mg [**Hospital1 **]
Oxycodone 1 tab Q4-6H prn
Colace
Senna
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
5. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day) as needed.
6. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
7. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
8. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*1 box* Refills:*8*
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Zofran 8 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
15. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO QAM.
Disp:*30 Tablet(s)* Refills:*0*
16. Metformin 850 mg Tablet Sig: One (1) Tablet PO QPM.
17. Megestrol 400 mg/10 mL Suspension Sig: Four Hundred (400) mg
PO DAILY (Daily).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
deep vein thrombosis in both legs
pulmonary embolism
diabetes mellitus
Discharge Condition:
stable
Discharge Instructions:
Please take the Lovenox shots twice per day, in about 6 weeks
you will need a new prescription, please ask Dr. [**Last Name (STitle) **]. Please
call Dr. [**Last Name (STitle) **] with any shortness of breath, chest pain, bleeding
in your stool, or other concerning symptoms.
Please note the following medication changes:
Restart Metformin twice per day, BUT a new higher dose in the
morning (1000mg, prescription provided) and same dose as prior
at night (850mg).
Start Megace for appetite.
Start Lovenox twice per day.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **] within the next 2 weeks.
Please be sure to check finger sticks glucose at least 2 times
per day, if these are persistently over 250, talk to Dr. [**Last Name (STitle) **] at
the upcoming appointment about starting Lantus insulin.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2175-4-24**]
|
[
"4168",
"2720",
"40390",
"5859"
] |
Admission Date: [**2140-8-19**] Discharge Date: [**2140-8-29**]
Date of Birth: [**2058-12-14**] Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Zocor / aspirin
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
[**2140-8-20**] OPERATIONS PERFORMED:
1. Infrarenal inferior vena cava filter.
2. Coil embolization of branches of the left hypogastric artery.
History of Present Illness:
This is an 81-year-old gentleman with a past medical history of
CAD s/p MI, MDS on cycle 2 Vidaza, anemia, severe COPD baseline
home oxygen 2.5 L , hypertension, hyperlipidemia,also with
bladder cancer status post TURBT and BCG treatment in [**2135**]
presenting with retroperitoneal bleed. He presented to [**Location (un) 620**]
ED this afternoon with left sided abdominal pain radiating to
his left thigh. He had previously been hospitalized there from
[**Date range (1) 3462**] for SOB and tachycardia during which he was found to
have a PE and PNA and discharged to rehab on lovenox bridge to
coumadin and levfloxacin. CT at [**Location (un) 620**] showed active
extravasation on CTA abd/pelvis. HCT 23.9, received 1U PRBC and
10mg vitamin K and transferred to [**Hospital1 18**].
.
On arrival to the ED his VS were T 97.6 HR 122 bp 126/66 RR 20
100% ON 5L NC. HCT at 24.3 from 30.5 on discharge [**2140-8-9**] (after
transfusion). In ED Became hypotensive to 59/44 with 1U PRBC
given, 1 U FFP, improving to 111/50 HR in 100s. ED EKG showed
sinus tachycardia. Increasing pain ? tamponading vs worse
managed with fentanyl boluses. Surgery consulted, noted LLQ/L
groin pain c/w location of RP bleed on CT scan, recommended
consulting interventional radiology for possible intervention
and continued transfusion, resuscitation with plan to follow. IR
consulted for angio,felt risks of angio outweighed benefits of
resuscitation, watching.
On arrival to the MICU patient denied pain. SOB with nasal
canula and atrovent nebulizers given. Tachycardia to 140s. IVF
bolus given. 2 18 guage peripherals in place.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- Retroperitoneal bleed s/p L hypogastric coil embolization
- Removable IVC filter placed [**8-/2140**] (to be removed 6 months
later)
- DVT / PE ([**7-/2140**])
- MDS on Vidaza
- CAD s/p MI
- COPD on 2L NC
- GI bleed [**2132**]
- Bladder ca s/p BCG [**2135**]
- HTN
- HLD
- AAA repair [**2120**]
Social History:
Lives with wife. Retired [**Name2 (NI) 3455**] [**Doctor Last Name 3456**]. Quit tobacco in [**2120**]
with 2-3 ppd hx for over 50 years. No etoh or illicits.
Family History:
No family history of bledding disorders.
Physical Exam:
Admission Physical Exam:
Vitals: T: BP: 144/80 P: 133 R: 18 O2: 96%
General: Alert, oriented, no acute distress,
HEENT: pale Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, dis non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge Physical Exam:
VS Tc 97.8 Tm 98.0 HR 84-101 BP 137/67 (120s-150s/60s-70s) RR
18-20 O2 99-100% 2L NC (home O2 is 2.5 L)
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Diminished air movement, improved from prior, otherwise
clear, no wheezes, rales, ronchi
CV RRR normal S1/S2, distant heart sounds, no mrg
ABD firm abdomen (not rigid) - consistent with exam throughout
the week, NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, pitting edema in hands
improved to baseline, 3+ lower extremity peripheral edema
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions, large ecchymosis on left flank
Pertinent Results:
Admission labs:
[**2140-8-19**] 08:24PM BLOOD WBC-1.5*# RBC-2.51*# Hgb-8.1* Hct-24.3*
MCV-97 MCH-32.4* MCHC-33.4 RDW-19.4* Plt Ct-319
[**2140-8-19**] 08:24PM BLOOD Neuts-71* Bands-0 Lymphs-24 Monos-4 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2140-8-19**] 08:24PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Target-OCCASIONAL Stipple-OCCASIONAL
[**2140-8-19**] 11:13PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Burr-1+ Tear Dr[**Last Name (STitle) 833**]
[**2140-8-19**] 08:24PM BLOOD PT-24.3* PTT-40.8* INR(PT)-2.3*
[**2140-8-19**] 08:24PM BLOOD PT-24.3* PTT-40.8* INR(PT)-2.3*
[**2140-8-20**] 10:15AM BLOOD Fibrino-165*
[**2140-8-19**] 08:24PM BLOOD Glucose-167* UreaN-25* Creat-0.9 Na-137
K-5.0 Cl-103 HCO3-30 AnGap-9
[**2140-8-20**] 04:20AM BLOOD Calcium-7.1* Phos-5.9*# Mg-1.9
[**2140-8-20**] 10:20AM BLOOD Type-ART Temp-36 Rates-/12 Tidal V-500
FiO2-100 pO2-475* pCO2-51* pH-7.37 calTCO2-31* Base XS-3
AADO2-186 REQ O2-40 Intubat-INTUBATED
[**2140-8-20**] 10:20AM BLOOD Type-ART Temp-36 Rates-/12 Tidal V-500
FiO2-100 pO2-475* pCO2-51* pH-7.37 calTCO2-31* Base XS-3
AADO2-186 REQ O2-40 Intubat-INTUBATED
[**2140-8-20**] 10:20AM BLOOD Glucose-129* Lactate-2.0 Na-135 K-4.1
Cl-103 calHCO3-31*
[**2140-8-20**] 10:20AM BLOOD freeCa-0.87*
[**2140-8-19**] 08:42PM BLOOD Hgb-8.2* calcHCT-25
Discharge Labs:
[**2140-8-29**] 07:15AM BLOOD WBC-3.0* RBC-3.33* Hgb-10.6* Hct-33.8*
MCV-101* MCH-31.8 MCHC-31.4 RDW-19.1* Plt Ct-405
[**2140-8-29**] 07:15AM BLOOD PT-13.1* PTT-94.3* INR(PT)-1.2*
[**2140-8-29**] 07:15AM BLOOD Glucose-96 UreaN-17 Creat-0.8 Na-136
K-4.5 Cl-99 HCO3-34* AnGap-8
[**2140-8-29**] 07:15AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0
[**2140-8-21**] 05:33PM BLOOD freeCa-1.12
Studies:
[**2140-8-20**] CHEST PORT. LINE PLACEM
In comparison with the earlier study of this date, there is now
a
right jugular sheath in place without evidence of pneumothorax.
Endotracheal
tube tip lies approximately 8 cm above the carina.
Little overall change in the appearance of the heart and lungs.
[**2140-8-20**] CT ABD & PELVIS W/O CONTRAST
Interval increase of left retroperitoneal hematoma, now with
decompression
into the peritoneal cavity. Small amounts of blood tracking
around the liver,
both paracolic gutters, and into the pelvis.
[**2140-8-20**] CHEST (PORTABLE AP)
In comparison with the study of [**8-13**], there is continued
hyperexpansion of the lungs consistent with chronic pulmonary
disease. There
is associated decrease in markings at the apices with coarse
interstitial
markings in the lower lung zones. The possibility of
supervening pneumonia
would have to be considered in the appropriate clinical setting.
Micro:
[**2140-8-19**] Urine culture, final: negative
[**2140-8-20**] MRSA screen x 2, final: negative
Brief Hospital Course:
81M with CAD s/p MI, severe COPD (home oxygen 2.5 L), HTN, HL,
MDS (on cycle 2 Vidaza), and bladder cancer (s/p TURBT and BCG
treatment in [**2135**] was transferred from [**Hospital1 **] [**Location (un) **] [**2140-8-19**] with
retroperitoneal bleed and is now s/p coil embolizatoin of left
hypogastric artery and IVC filter placement. He remained
hemodynamically stable post-operatively and has was called out
of the CV ICU to the medicine floor.
# Retroperitoneal bleed: Atraumatic bleed in the setting of
anticoagulation for provoked DVT/PE with INR in therapeutic
range of 2.3 at presentation. Initially presented to [**Location (un) 620**]
where CT showed active extravasation on CTA abd/pelvis. HCT
23.9, INR 1.8, received 1U PRBC and 10mg vitamin K and
transferred to [**Hospital1 18**]. Transferred to MICU for hypotension. In
the MICU, IR was consulted and then vascular surgery. Iliac
aneurysm was found and patient transferred to vascular surgery.
He was continuing to have expansion of the RP hematoma. Had CT
scan at 5am on [**8-20**] which showed expansion with decompression of
peritoneal cavity and his hypogastric artery was coil embolized,
achieving hemostasis. The bleeding was not related to his iliac
aneurysm. He was then brought to the CV ICU post-operatively.
Arbitrary transfusion goal of 30 (was in 28 range before this
acute illness due to MDS). Only got 2 units in CV ICU. In total
he was transfused 10 units since arrival to [**Hospital1 18**] (6 peri
operatively) Last transfusion [**2140-8-21**] at 9pm with HCT 25 -> 30.
Throughout his stay in the CVICU, he did not require pressors
and has been hypertensive today with SBP~150. Peripheral access
was obtained in the CV ICU and his cortis was pulled.
Transferred from CV ICU to medicine on [**8-22**] and he remained
hemodynamically stable with stable hematocrit in the 28-33
range.
# PE: Diagnosed [**2140-8-13**] by CTA revealing subsegmental right lower
lobe pulmonary embolus. Was anticoagulated with INR 2.3 on
admission, and is now s/p reversal given RP bleed coil of
hypogastric artery. On heparin drip bridging to coumadin.
Started coumadin 5 mg daily on [**8-26**]. No evidence of bleeding and
stable hematocrits. He had an IVC filter placed [**2140-8-20**] (Cook
Select Filter). He will require a total of 6 months of
anticoagulation and will follow up with his Hematologist for
ongoing management of his DVT/PE. At the time of discahrge he
was satting 99% on his home O2 (2L NC).
# Elevated Bicarb: Bicarb peaked at 43. Likely multifactorial
due to COPD with chronic renal compensation and retention of
bicarb. Also likely component of contraction alkalosis secondary
to aggressive diuresis. Started acetazolamide [**8-25**] through [**8-28**].
Bicarb was 34 at the time of discharge. His HCO3 should continue
to be monitored as long as he is being actively diuresed.
# LE edema: Patient with continued marked lower extremity edema
likely from iatrogenic volume overload due to transfusion of 10U
pRBCs. He was diuresed with Lasix 20mg IV qday for the duration
of his course with marked improvement in his volume overload. He
should continue to have his legs elevated at night and
throughout the day when recumbent in bed. He should also
continue Lasix 40mg PO qday for 3 days. He should have his
electrolytes checked twice daily while receiving Lasix.
# COPD: Patient has a history severe COPD with FEV1 of
approximately 0.7 on 2.5L NC at home. His home medications were
continued and there was no e/o COPD flare on this admission. At
the time of discharge he was satting well on his home O2.
# Ischemic Colitis: Diagnosed [**Hospital1 **] CT [**8-4**], involving
descending/sigmoid colon area. Initially presumed infectious s/p
10 day course cipro/flagyll but in context of atherosclerotic
disease and large volume bleed, ischemic seemed more likely. Pt
was transfused per above and was having normal non bloody BMs at
the time of discharge.
# MDS: He is s/p Vidaza with continued pancytopenia. In
consultation with outpatient oncologist, will hold off on
additional chemotherapy for MDS at this time. He will f/u with
his outpatient Oncologist for ongoing management of MDS.
# Liver and renal hypodensities: seen on CT scan last [**Hospital1 **]
admission likely cysts vs hemangiomas.
- outpatient MRI/renal US to further evaluate
# CAD s/p MI: His home Atorvastatin and Diltiazem were continued
throughout his course. He is allergic to ASA.
# GERD: His home omeprazole 20 mg PO daily was continued.
# Hyperlipidemia: His home Atorvastatin 40mg PO daily was
continued.
# Transitional issues:
- Patient will need IV heparin bridge to Coumadin (INR goal [**1-15**]
for 6 months)
- Will need daily INR checks until therapeutic
- Patient scheduled for follow up with Vascular Surgery (Dr.
[**Last Name (STitle) **]
- Please ensure the patient follows up for interval IVC filter
removal. The filter is a Cook Celect filter.
- Patient scheduled for follow up with [**Name (NI) 3463**] [**Name (NI) 2274**]
- Pt will need his Na, Cl, K, Cr and Mg checked twice daily for
3 days while being diuresed with Lasix.
- Pt will need outpatient MRI/renal US to evaluate liver and
renal hypodensities seen on CT
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from team census.
1. Enoxaparin Sodium 80 mg SC Q12H
2. Warfarin 5 mg PO DAILY16
3. Levofloxacin 500 mg PO Q24H
4. PredniSONE 10 mg po daily Duration: 2 Days
5. PredniSONE 5 mg po daily Duration: 2 Days Start: After 10
mg tapered dose.
6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
7. Albuterol-Ipratropium [**12-14**] PUFF IH Q6H:PRN wheeze
8. Omeprazole 20 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Benzonatate 200 mg PO TID
11. Docusate Sodium 100 mg PO BID
12. Senna 1 TAB PO BID
13. Diltiazem Extended-Release 120 mg PO DAILY
Hold for SBP < 100
14. Atorvastatin 40 mg PO HS
15. Bisacodyl 10 mg PO HS:PRN constipation
16. Ensure *NF* (food supplement, lactose-free) 120 ml Oral [**Hospital1 **]
17. Acidophilus *NF* (L.acidoph &
sali-B.bif-S.therm;<br>lactobacillus acidophilus) 175 mg Oral
[**Hospital1 **]
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Senna 1 TAB PO BID
3. Albuterol-Ipratropium [**12-14**] PUFF IH Q6H:PRN wheeze
4. Benzonatate 200 mg PO TID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
8. Warfarin 5 mg PO DAILY16
9. Heparin IV Sliding Scale
10. Diltiazem Extended-Release 120 mg PO DAILY
Hold for SBP < 100
11. Atorvastatin 40 mg PO HS
12. Acidophilus *NF* (L.acidoph &
sali-B.bif-S.therm;<br>lactobacillus acidophilus) 175 mg Oral
[**Hospital1 **]
13. Bisacodyl 10 mg PO HS:PRN constipation
14. Ensure *NF* (food supplement, lactose-free) 120 ml Oral [**Hospital1 **]
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
- Left Retroperitoneal Hematoma / expanding
- Anemia requiring transfusion
- Pulmonary emobolism / recent
- Left Iliac Artery Aneurysm
Secondary diagnoses: Severe COPD on home O2, coronary artery
disease status post MI, hyperlipidemia, myelodysplastic
syndrome, and bladder cancer status post TURBT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 3457**],
You were admitted to the hospital because you were bleeding
internally (retroperitoneal hemeorrhage). You were given
multiple blood transfusions. You required an endovascular
procedure to stop the bleeding as well as to prevent a future
blood clot in your lungs. Due to the recent blood clots in your
leg and lungs, you were restarted on blood thinners (Heparin and
Coumadin) and you should continue taking Coumadin as prescribed
following discharge. You will need to have your blood drawn
often to determine how much Coumadin you will need to take.
Below are the instructions and expectations following the
procedure:
MEDICATION:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart with pillows
every 2-3 hours throughout the day and 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
ACTIVITIES:
?????? When you go home, you may walk and use 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
?????? 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 THE OFFICE FOR: [**Telephone/Fax (1) 3464**]
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
You will need to have the IVC filter removed after you complete
your course of blood thinners. This should be scheduled through
the office of Dr. [**Last Name (STitle) **] who placed the filter.
Followup Instructions:
You will also need to follow up with vascular surgery (Dr.
[**Last Name (STitle) **] for removal of your IVC filter when you finish
your course of blood thinners (6 months from discharge).
Name: [**Name6 (MD) 3465**] [**Last Name (NamePattern4) 3466**], MD
Specialty: Hematology/Oncology
When: Thursday [**2140-9-1**] at 12:30pm
Location: [**Hospital1 641**]
Address: [**Street Address(2) 3467**], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
This appointment was already scheduled for you to see Dr.
[**First Name (STitle) 3459**].
Department: VASCULAR SURGERY
When: WEDNESDAY [**2140-9-28**] at 2:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3453**], MD
Specialty: Primary Care
Location: [**Location (un) 2274**] [**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 3472**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Completed by:[**2140-8-29**]
|
[
"486",
"2851",
"412",
"41401",
"496",
"4019",
"2724",
"53081"
] |
Admission Date: [**2187-9-19**] Discharge Date: [**2187-9-24**]
Date of Birth: [**2132-5-5**] Sex: M
Service: SURGERY
Allergies:
Sulfonamides / Dapsone / Keflex
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p Motor cycle crash; left sided rib pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 year old male driver; helmeted; s/p motorcycle crash on [**9-5**]
with splenic lac, treated and released for this at [**Hospital1 18**], who
presented to [**Hospital1 18**] on [**2187-9-19**] after being trasferred from area
hospital with decreased Hct from 41 to 30, new splenic hematoma
as well as free fluid. Pt. denies LUQ pain but reports [**Month (only) **] BM's
(last 2 days). +flatus, no n/v, no sob, no fevers/chills.
Past Medical History:
HIV (+)
HTN
PVD
Hayfever
Social History:
quit smoking-- 20pack/yr hx
occ marijuana
no EtOH
Family History:
non-contributory
Physical Exam:
Exam on arrival to ED:
99.8 93 154/85 16 99%RA
Gen: A&Ox3, NAD
Pulm: decreased BS at L base, otherwise CTAB
CVS: RRR, no murmors
Abd: Decreased BS, soft, NT/ND
GU: guiac negative, firm stool non-impacted
Ext: C/C/E
Pertinent Results:
[**2187-9-19**] 06:15PM BLOOD WBC-9.6 RBC-3.19*# Hgb-10.3*# Hct-29.7*#
MCV-93 MCH-32.3* MCHC-34.7 RDW-14.0 Plt Ct-429
[**2187-9-23**] 07:15AM BLOOD Hct-28.4*
[**2187-9-19**] 06:15PM PT-14.0* PTT-24.1 INR(PT)-1.3
[**2187-9-19**] 06:15PM PLT COUNT-429
[**2187-9-19**] 06:15PM NEUTS-76.2* LYMPHS-15.2* MONOS-6.6 EOS-1.4
BASOS-0.6
[**2187-9-19**] 06:15PM WBC-9.6 RBC-3.19*# HGB-10.3*# HCT-29.7*#
MCV-93 MCH-32.3* MCHC-34.7 RDW-14.0
[**2187-9-19**] 06:15PM GLUCOSE-105 UREA N-16 CREAT-0.9 SODIUM-134
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-28 ANION GAP-13
[**2187-9-19**] 10:48PM HCT-27.2*
[**2187-9-21**] Hematocrit 29.2*
[**2187-9-22**] Hematocrit 29.6*
[**2187-9-23**] Hematocrit 28.4*
Brief Hospital Course:
Upon arrival to the emergency department as a transfer from [**Hospital1 **]
[**Name (NI) 620**], pt. was evaluated by the emergency department and
trauma surgery staff. The pt was found to have a hematocrit in
the high 20's and was placed on telemetry, bedrest, NPO and
admitted to the trauma SICU for monitoring. The pt. was stable
on bedrest, NPO and IVF for three days while being monitored in
the [**Last Name (LF) 10115**], [**First Name3 (LF) **] the pt. was transferred to the floor where he
continued to be monitored. After another uneventful day, the
pt.'s diet was advaced, and pt. advanced slowly with his
mobility. By HD#5, Mr. [**Known lastname 10116**] had a benign abdominal exam, no
complaints, and was walking around the floor. He was evaluated
and cleared by physical therapy as safe to go home, and his
hematocrits were stable.
He was discharged home on HD #6, with a scheduled follow-up CT
scan on [**10-8**] and follow up in Trauma Clinic on [**10-9**].
Medications on Admission:
1. Indinavir 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*3 Capsule(s)* Refills:*2*
2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
1. Indinavir 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*3 Capsule(s)* Refills:*2*
2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: 1-4 Tablets PO every four (4)
hours as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
splenic laceration re-bleeding episode
left-sided rib fractures
Discharge Condition:
Good
Discharge Instructions:
-Take your medications as perscribed
-If you have severe abdominal pain, faintness or feeling as if
you are going to pass out, dizziness, unexplained fast heart
rate you need to proceed immediately to the nearest emergency
room and inform them that you may be bleeding internally
-You perscibed medications include narcotic pain medication.
This medication will impair your judgement and motor skills. Do
not drive a car or operated heavy machinery while taking this
medication. Also, please do not partake in any activity that
requires fine motor skills to complete when taking this
medication as it may hinder your ability to complete the
activity safely.
Followup Instructions:
Please follow in trauma clinic on [**10-9**]: call to schedule a time
[**Telephone/Fax (1) 6439**]
You have a CT scan of abdomen/pelvis scheduled on [**2187-10-8**]:
please call [**Telephone/Fax (1) 11**] to schedule a time.
Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2788**] INTERNAL MEDICINE
Date/Time:[**2187-11-21**] 3:30
|
[
"5119",
"4019"
] |
Admission Date: [**2180-2-19**] Discharge Date: [**2180-2-28**]
Date of Birth: [**2117-4-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2180-2-21**] Aortic Valve Replacement with 23mm St. [**Male First Name (un) 923**] mechanical
and Mitral Valve Replacement [**Street Address(2) 12523**]. [**Male First Name (un) 923**] mechanical
History of Present Illness:
62 y/o male with h/o rheumatic heart disease with aortic and
mitral valve stenosis. He also has h/o CAD with LAD stenting in
[**2175**], complete heart block w/ ppm placed in [**2174**] and PAF. Recent
echo showed severe aortic and mitral stenosis with increased
gradients.
Past Medical History:
Rheumatic heart disease, Aortic Stenosis, Mitral Stenosi,
Coronary artery disease s/p stent, Hypertension,
Hypercholesterolemia, PAF, Complete Heart Block s/p pacemaker,
Pneumonia [**2177**]
Social History:
Married lives with his wife and children. He has a daughter who
works at [**Hospital1 18**]. Quit smoking 20 years ago. Social drinker. No
other signficant drug use history.
Family History:
Not contributory
Physical Exam:
VS: 70 irregular 110/78
Gen: NAD
Skin: Venous stasis changes in LE
HEENT: EOMI, PERRL, OP benign
Neck: Supple, FROM -JVD, -carotid bruit
Chest: CTAB -w/r/r
Heart: RRR +murmur
Abd: Soft, NT/ND +BS
Ext: Warm -edema
Neuro: A&O x 3, non-focal
Pertinent Results:
[**2-23**] CXR: In comparison with study of [**2-21**], the patient has
taken a much poorer inspiration. The endotracheal tube and
nasogastric tube have been removed. Swan-Ganz catheter has been
removed and the right IJ sheath remains in place. Atelectatic
changes persist at the left base with blunting of the right
costophrenic angle suggesting pleural fluid in this region.
[**2-21**] Echo: Pre Bypass: Poor transgastric windows and significant
artifact limit this study. The left atrium is moderately
dilated. Smoke is seen in the left atrial appendage. The right
atrium is moderately dilated. The left ventricle is not well
seen. with normal free wall contractility. Estimated LVEF 50%The
ascending aorta is moderately 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. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are severely thickened/deformed.
The mitral valve shows characteristic rheumatic deformity. There
is severe valvular mitral stenosis (area <1.0cm2). Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
Post Bypass: Patient is on epinepherine 0.4 mcg/kg/min,
phenylepherine infusions, V paced. Preserved biventricular
function. LVEF 50-55%. There is a mechanical Aortic valve instu
with normal bileaflet motion. It appears well seated with no
perivalvular leaks and normal washing jets seen. Peak gradient
5, mean gradient 1 mm Hg. There is a mechanical Mitral
prosthesis insitu with a mean gradient 4 mm hg. Bileaflet motion
is normal. No perivalvular leaks seen. Normal washing jets seen
on the mitral prosthesis. Aortic contours intact. TR remains 2+.
Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
[**2-20**] CXR: Moderate cardiomegaly is stable. Lungs are clear and
there is no pleural effusion. Transvenous right atrial and right
ventricular pacer leads follow their expected courses
continuously from the left axillary pacemaker.
[**2180-2-19**] 06:50PM BLOOD WBC-6.7 RBC-4.57* Hgb-13.8* Hct-41.3
MCV-90 MCH-30.2 MCHC-33.4 RDW-12.6 Plt Ct-204
[**2180-2-25**] 06:40AM BLOOD WBC-13.6* RBC-3.29* Hgb-10.1* Hct-29.6*
MCV-90 MCH-30.6 MCHC-34.1 RDW-13.1 Plt Ct-168#
[**2180-2-19**] 06:50PM BLOOD PT-15.6* PTT-27.9 INR(PT)-1.4*
[**2180-2-25**] 01:10PM BLOOD PT-18.6* PTT-59.6* INR(PT)-1.7*
[**2180-2-19**] 06:50PM BLOOD Glucose-166* UreaN-18 Creat-1.0 Na-141
K-4.4 Cl-103 HCO3-30 AnGap-12
[**2180-2-25**] 06:40AM BLOOD Glucose-103 UreaN-24* Creat-1.1 Na-136
K-4.3 Cl-97 HCO3-32 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 12524**] was admitted pre-operatively secondary to being on
Coumadin. Upon admission he was started on Heparin and
appropriately work-up prior to surgery. On [**2-21**] he was brought
to the operating room where he underwent a aortic and mitral
valve replacement. Please see operative report for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Later on op day he was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one he was started on diuretics and gently
diuresed towards his pre-op weight. On post-op day to Coumadin
was initiated with a Heparin bridge for his mechanical valves.
Chest tubes and epicardial pacing wires were removed on this
day. On post-op day three he was transferred to the telemetry
floor for further care. Over the next several days he remained
relatively stable while receiving Coumadin and awaiting his INR
to increase to therapeutic level. On post-op day seven he was
discharged home with the appropriate medications and follow-up
appointments.
[**Doctor First Name **] at Dr. [**Last Name (STitle) 12525**] office will resume coumadin management.
Medications on Admission:
Aspirin 325mg qd, Zocor 80 mg qd, Toprol 50mg qd, Lasix 40mg qd,
Diovan 160mg qd, Coumadin qd (last dose 2/19)
Discharge Medications:
1. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(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. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO ONCE (Once) for 1
doses: 7.5 mg; Check INR [**2-29**] with results to Dr. [**Last Name (STitle) 12525**]
office.
.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Rheumatic Heart Disease/Aortic Stenosis/Mitral Stenosis s/p
Aortic Valve Replacement and Mitral Valve Replacement
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 8499**] will be following your INR and adjusting your
Coumadin accordingly
[**Last Name (NamePattern4) 2138**]p Instructions:
[**Hospital Ward Name 121**] 6 for wound check in 2 weeks
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) 911**] in [**1-30**] weeks
Dr. [**Last Name (STitle) 8499**] in [**12-29**] weeks
Completed by:[**2180-2-28**]
|
[
"41401",
"42731",
"4019",
"2720",
"2859",
"V4582",
"V1582",
"V5861"
] |
Admission Date: [**2144-6-26**] Discharge Date: [**2144-7-2**]
Date of Birth: [**2080-5-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB, chest burning
Major Surgical or Invasive Procedure:
s/p urgent CABG x 2
History of Present Illness:
64yo male with HTN, positive FH for CAD, and heavy tobacco use
reports chest burning for 3-4 days. Associated with SOB and
worsens with exertion. [**6-26**] while walking the dog his symptoms
began and this time was associated with emesis. He took an
aspirin at home and went to an OSH ED. He was treated and
stabilized than transferred to [**Hospital1 18**] for cardiac cath. Cath
revealed sever LM disease:90% stenosis. Dr.[**Last Name (STitle) 914**] was consulted
for an urgent CABG.
Past Medical History:
HTN, ? autoimmune-rashes/hives
Social History:
lives with male partner, positive tobacco hx:30py
Family History:
+ CAD-sister 64yo
Physical Exam:
DISCHARGE EXAM
VS: T: BP: P: RR: O2 SAT=
General:
HEENT:
CVS:
Lungs:
ABD:
Ext:
Wound:
Pertinent Results:
[**2144-7-1**] 05:40AM BLOOD WBC-10.8 RBC-3.04* Hgb-8.4* Hct-25.0*
MCV-82 MCH-27.7 MCHC-33.7 RDW-13.9 Plt Ct-257#
[**2144-6-26**] 07:40PM BLOOD WBC-9.3 RBC-5.04 Hgb-13.7* Hct-41.7
MCV-83 MCH-27.2 MCHC-32.9 RDW-13.0 Plt Ct-357
[**2144-7-1**] 05:40AM BLOOD Glucose-121* UreaN-15 Creat-0.9 Na-131*
K-3.7 Cl-95* HCO3-27 AnGap-13
[**2144-6-26**] 07:40PM BLOOD Glucose-125* UreaN-9 Creat-0.7 Na-136
K-4.0 Cl-103 HCO3-23 AnGap-14
URINE CULTURE (Final [**2144-6-28**]):
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp. [**2144-6-28**] 2:38 pm URINE Source:
Catheter.
**FINAL REPORT [**2144-6-29**]**
URINE CULTURE (Final [**2144-6-29**]): NO GROWTH.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2144-6-30**] 11:52 AM
CHEST (PORTABLE AP)
Reason: ? ptx s/p ct removal
[**Hospital 93**] MEDICAL CONDITION:
64 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? ptx s/p ct removal
INDICATION: 64-year-old man status post CABG and removal of
chest tube, evaluate for pneumothorax.
COMPARISON: [**2144-6-29**].
SINGLE BEDSIDE UPRIGHT VIEW OF THE CHEST: Interval removal of
the Swan-Ganz catheter along with bilateral chest tubes and
mediastinal drain. There is no pneumothorax or pleural effusion.
There are no focal consolidations. Cardiomediastinal silhouette
is unchanged. There is no pulmonary edema.
IMPRESSION: Interval removal of bilateral chest tubes without
appreciable pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**Known firstname 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 1569**] [**Hospital1 18**] [**Numeric Identifier 75070**] (Complete)
Done [**2144-6-27**] at 10:36:46 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2080-5-19**]
Age (years): 64 M Hgt (in): 70
BP (mm Hg): 167/57 Wgt (lb): 151
HR (bpm): 67 BSA (m2): 1.85 m2
Indication: Intraoperative TEE for CABG procedure
ICD-9 Codes: 402.90, 786.05, 786.51, 440.0, 424.1
Test Information
Date/Time: [**2144-6-27**] at 10:36 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Limited Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine: AW2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 40% >= 55%
Aorta - Annulus: 1.8 cm <= 3.0 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Mild regional LV systolic
dysfunction. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+)
AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Mild [1+] TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
No prebypass images as patient crashed on CPB because of severe
hypotension
Post Bypass
Patient is being V paced and receiving an infusion of
phenylephrine.
1. No atrial septal defect is seen by 2D or color Doppler.
2.There is mild symmetric left ventricular hypertrophy.
3.There is mild hypokinesis of the anterior septum and septum.
Overall left ventricular systolic function is mildly
depressed.(LVEF40%).
4.Right ventricular chamber size and free wall motion are
normal.
5.There are simple atheroma in the descending thoracic aorta.
6.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Mild (1+) aortic
regurgitation is seen.
7. The mitral valve appears structurally normal with trivial
mitral regurgitation.
8. Aorta intact post decannulation.
9. Dr. [**Last Name (STitle) 914**] was notified in person of the results on
[**2144-6-27**] at 1130am.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2144-6-27**] 13:19
Brief Hospital Course:
Mr.[**Known lastname **] is a 64yo male with unstable angina who was cathed on
[**6-26**] and discovered to have 90% Left Main disease. Dr. [**Last Name (STitle) 914**]
was contact[**Name (NI) **] for urgent CABG. On [**6-27**] He was taken to the OR
and underwent CABG x2 (SVG->LAD, SVG->OM) with cardiac arrest
after induction. External CPR and internal cardiac massage was
performed. Please refer to OR dictation for further details.
Crossclamp time: 49", cardiopulmonary bypass time:86". The
patient was transferred to the CVICU intubated, requiring
Neosynephrine, Milrinone, and Propofol to optimize blood
pressure and cardiac output. POD#1 all drips but Milrinone were
weaned to off and Mr.[**Known lastname **] was extubated.Over the next 2 days,
Mr.[**Known lastname **] was slowly weaned off the Milrinone and remained
hemodynamically stable. He was transfused one unit of packed
blood cells for acute anemia. Lines and tubes were discontinued
in a timely fashion and he was transferred to the floor on
POD#3. The remainder of his postoperative course was uneventful.
On POD # 5 Mr.[**Known lastname **] was doing well and it was felt he was ready
for discharge to home with VNA services. He has been advised of
follow up visits with Dr.[**Last Name (STitle) 914**] 4 weeks following discharge, as
well as following up with his PCP and Cardiologist 1-2 weeks
following discharge.
Medications on Admission:
Fexofenadine [**Numeric Identifier 75071**]), Hydroxyzine 25(1), Amlodipine 5(1)
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:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
status post Urgent CABG x2 (SVG->LAD/SVG->OM)
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) **] in 1 week ([**Telephone/Fax (1) **]) please call for appointment
Dr [**Last Name (STitle) 9250**] in [**3-8**] weeks ([**Telephone/Fax (1) **]) please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2144-7-2**]
|
[
"41401",
"9971",
"2851",
"4019"
] |
Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-24**]
Date of Birth: [**2095-1-27**] Sex: F
Service: OME
CHIEF COMPLAINT: Fever.
Neutropenia.
Diarrhea.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old woman with
stage 3B gastric carcinoma originally admitted to the O-Med
Medicine Service. The patient is status post subtotal
gastrectomy, as well as 5-Fluoro Uracil two weeks prior to
admission. She presented with subjective fever, diarrhea and
found to be neutropenic. The patient had been diagnosed with
gastric carcinoma in [**2-/2151**] when a work-up for weight loss
and abdominal pain led to a gastrointestinal evaluation. The
patient had a subtotal gastrectomy in [**3-/2151**], which was
complicated by a difficult postoperative course including
sepsis with VRE incubation and small bowel obstruction. The
patient subsequently improved and then had a course of 5-
Fluoro Uracel from [**2151-5-25**] to [**2151-5-28**] as a preclude for
a possible chemoradiation one month later, but since during
the chemotherapy, the patient noted mouth sores with fatigue,
nausea and diarrhea with diarrhea increasing to the point in
the past few days prior to admission that was almost melanic
in color and "smells like blood". On the night prior to
admission, she had a fever of 101 with chills and electively
came to the hospital for further evaluation.
REVIEW OF SYMPTOMS: Positive for shortness of breath, as
well as nausea and upper respiratory problems since the 5-
Fluoro Uracil started, but denied any headache, chest pain,
lightheadedness, abdominal pain or lower extremity edema.
PAST MEDICAL HISTORY: Notable for gastric carcinoma, grade
TIMI Grade III-II with a subtotal gastrectomy in [**3-/2151**] and
a course of 5-Fluoro Uracil. She also had heparin-induced
thrombocytopenia. Positive history of hypertension. She has a
history of polycystic kidney disease and a history of chronic
renal insufficiency.
ALLERGIES: Penicillin which causes anaphylaxis and heparin-
induced thrombocytopenia, as well as nickel sensitivity.
MEDICATIONS PRIOR TO ADMISSION:
1. Atenolol 100 mg b.i.d.
2. Protonix 40 mg q day.
3. Hydralazine 25 mg t.i.d.
4. Compazine p.r.n.
5. Ativan 0.5-1.0 mg p.o. q six hours p.r.n.
6. Oxycodone 5-10 mg p.o. q 4-6 hours p.r.n.
SOCIAL HISTORY: The patient is a registered nurse who worked
at a rehabilitation facility and lives in [**Location 38**]. She has
five children. She denies any ETOH, but has a positive thirty
pack year smoking history. She only quit smoking this year.
FAMILY HISTORY: Negative for any history of malignancy, but
her father had polycystic kidney disease.
PHYSICAL EXAMINATION: Upon admission, her temperature was
98, pulse 58, blood pressure 142/75, respirations 20, 99
percent saturation on room air. General: She looked tired
but was in no apparent distress. HEENT: Notable for some
mild thrush, but moist mucous membranes. Neck had no jugular
venous distension. Lungs were notable for decreased breath
sounds at the bases. Cardiovascular examination was regular
with no murmurs, rubs or gallops. Abdomen was notable for
decreased bowel sounds, but was very soft and nontender. She
had a well healed midline scar. Extremities showed no
evidence of cyanosis, clubbing or edema.
LABORATORY DATA: Initial labs showed the patient's whites
were 6, hematocrit 33.3, platelets 43.
HOSPITAL COURSE: Throughout the course of the next few days
of the patient's hospitalization, her mental status began to
decline. A Neurology consult was called on [**2151-6-12**] after a
head magnetic resonance imaging scan done on [**2151-6-11**]
showed no evidence of any metastatic disease or infarcts;
only evidence of some minimal small vessel ischemic disease.
The patient had two lumbar punctures neither of which
revealed any obvious sources of infection. However, an
electroencephalogram performed was notable for the presence
of nonconvulsive status epilepticus. The patient was
transferred to the Fenard Intensive Care Unit on [**2151-6-14**].
The patient was loaded with both Dilantin, as well as
phenobarbital and Infectious Disease was consulted.
Ultimately, no organism grew out of any of her cultures,
including her cerebrospinal fluid, which was also sent off
for HSV PCR ultimately came back negative. The patient then
received a few days of empiric acyclovir treatment for
possible HSV, though that was discontinued once the results
came back negative. Blood, urine and cerebrospinal fluid
cultures, again, remained negative.
During the hospitalization, the patient was started on
empiric intravenous thiamine at 100 mg q day with possible
suspicion of a possible deficiency in dihydropyrimidine
dehydrogenase, which is an enzyme necessary for metabolism
with 5-Fluoro Uracil and in some published studies, the
patients became encephalopathic with this deficiency and
became encephalopathic after being treated with 5-Fluoro
Uracil. This was done empirically without any Western blots
or protein evidence or enzymatic activity evidence of this
patient to reveal this deficiency.
Over the course of the patient's hospitalization, she did
gradually improve on this treatment of thiamine, Dilantin and
5-Fluoro Uracil. The patient's code status was, after much
discussion with the family, made "Do Not Resuscitate" and "Do
Not Intubate". The plan as of this dictation now is for the
patient to be called to the regular hospital floor and to be
sent home with services. The family and patient indicate that
they do not want rehabilitation placement and would prefer
outpatient physical and occupational therapy via her home
situation. Discharge medications will be dictated as an
addendum to this Discharge Summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 18138**]
Dictated By:[**Doctor Last Name 12733**]
MEDQUIST36
D: [**2151-6-22**] 13:12:57
T: [**2151-6-22**] 14:01:28
Job#: [**Job Number 32195**]
|
[
"4019"
] |
Admission Date: [**2183-4-21**] Discharge Date: [**2183-4-23**]
Date of Birth: [**2121-9-5**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
woman with a history of right internal carotid artery
stenosis of 75 to 80 percent, and left internal carotid
artery stenosis of 65 to 70 percent, and an aneurysm of 3.5
mm from the anterior communicating artery which she had
coiled in [**2183-2-10**]. She comes in now for left internal
carotid artery stent placement for carotid stenosis.
PHYSICAL EXAMINATION: The patient was in no acute distress.
Mental status revealed she was pleasant, cooperative, and
attentive. Cardiovascular examination revealed a regular
rate and rhythm with a 3 plus carotid bruit on the right.
The chest was clear to auscultation with fine crackles at the
base which cleared with cough. The abdomen was soft and
nontender. Extremities revealed no edema. The pulses were
dopplerable. The pupils were equal, round, and reactive to
light. The face was symmetric. Right lip decreased with
smile. The tongue was midline.
SUMMARY OF HOSPITAL COURSE: The patient was admitted status
post left carotid artery stent placement without
intraoperative complications. She was monitored in the
Intensive Care Unit overnight. She had sheaths in place that
were removed on post procedure day one with no groin
hematoma. Her vital signs remained stable. She had no
changes in mental status. She was transferred to the regular
floor on post procedure day one in stable condition.
DISCHARGE DISPOSITION: Discharged to home on post procedure
day two with a prescription for Plavix and aspirin as well as
follow up with Dr. [**Last Name (STitle) 1132**] in two weeks.
CONDITION ON DISCHARGE: Stable at the time of discharge.
Her groin site was clean, dry, and intact.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], MD [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2183-4-23**] 16:54:30
T: [**2183-4-24**] 12:08:08
Job#: [**Job Number 35427**]
|
[
"496",
"41401",
"53081",
"V4581"
] |
Admission Date: [**2121-11-3**] Discharge Date: [**2121-11-5**]
Date of Birth: [**2062-11-28**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname **] [**Known lastname 94080**] is a 58 yo man w/HTN, HLD and DM presenting
following a fall. Mr. [**Known lastname 94080**] works as a bus driver, and was at
work around 6:30 this morning, cleaning off his bus, when he
slipped and fell. He lost consciousness, and is not sure how
long he was down on the ground, but awoke to find his coworkers
and the [**Name (NI) 14356**] standing around him. He was taken to [**Hospital1 **],
where he had a NCHCT which showed a small SDH, R frontal
contusion, and possible small SAH. He was then transferred to
[**Hospital1 18**] for further management. Currently he is
complaining about a [**3-7**] occipital headache, but otherwise has
no weakness, numbness or other concerns.
Past Medical History:
HTN
HLD
DM
Hx of L putamen hemorrhage in [**2109**], with only slight residual R
handed clumsiness.
Social History:
Social Hx: Lives alone in [**Hospital1 **]. Currently works as a bus
driver. No EtOH, no smoking, no illicits.
Family History:
Family Hx: Mother died at age 77, father still living, age 86.
ROS: Per HPI, otherwise negative.
Physical Exam:
On Admission:
T:96.7 BP: 205/98 HR:70 R: 15 O2Sats:98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2->2.5 EOMs
Neck: In C-collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**12-31**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 2.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-1**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger. [**Doctor First Name **] on R slightly
slowed (baseline)
EXAM ON DISCHARGE:
XXXXXXX
Pertinent Results:
Labs on Admission:
[**2121-11-3**] 10:30AM BLOOD WBC-11.4* RBC-4.58* Hgb-14.4 Hct-42.6
MCV-93 MCH-31.5 MCHC-33.9 RDW-16.4* Plt Ct-237
[**2121-11-3**] 10:30AM BLOOD Neuts-81.2* Lymphs-15.3* Monos-2.7
Eos-0.5 Baso-0.3
[**2121-11-3**] 10:30AM BLOOD PT-11.1 PTT-22.0 INR(PT)-0.9
[**2121-11-3**] 10:30AM BLOOD Glucose-155* UreaN-17 Creat-1.2 Na-142
K-3.9 Cl-100 HCO3-28 AnGap-18
[**2121-11-3**] 10:30AM BLOOD CK(CPK)-120
[**2121-11-3**] 10:30AM BLOOD CK-MB-5
[**2121-11-3**] 10:30AM BLOOD cTropnT-0.02*
[**2121-11-4**] 03:37AM BLOOD CK-MB-NotDone
[**2121-11-4**] 03:37AM BLOOD cTropnT-0.02*
[**2121-11-4**] 03:37AM BLOOD Phenyto-6.4*
Labs on Discharge:
XXXXXXXXXX
-------------
IMAGING:
-------------
Head CT [**11-3**]:
stable falx post. subdural hemorrhage extending to the right
sulci,
consistent with a SAH. stable when compared to prior outside
study.
frontal parenchimal contusion , stable. No new focus of
hemorrhage.
Head CT [**11-4**]:
In comparison with the most recent examination, there is mild
decrease in size of the previously described subdural hematoma
along the midline falx with minimal residual subarachnoid
hemorrhage. Unchanged extensive microvascular ischemic disease.
No new lesions are identified.
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] neurosurgery following a fall, in
which he sustained an cerebral contusion. He was admitted to the
ICU for frequent neurochecks, monitoring, and reversal of
aspirin therapy with platelets. In the AM of [**11-4**], he had an
additional NCHCT, in which there was no further extension of
contusion. In this setting, he was transferred from the ICU to
the neurosurgery floor. He was seen and evaluated by the
occupational and physical therapists who determined he would be
safe for disposition to home without additional services. He was
discharged with appropriate follow up on [**2121-11-5**].
Medications on Admission:
Amlodipine 10mg',Clonidine 0.2mg",Lasix 40mg',Glyburide 5mg',
Lisinopril 40mg',Metformin 850mg"',Metoprolol 100mg',Simvastatin
80mg',ASA 325mg
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO TID (3 times a day).
Disp:*150 Capsule(s)* Refills:*0*
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
tSDH, tSAH,
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you were on Aspirin prior to your injury, you may safely
resume taking this one month after your injury.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2121-11-5**]
|
[
"25000",
"4019",
"2724"
] |
Unit No: [**Numeric Identifier 58800**]
Admission Date: [**2187-6-24**]
Discharge Date: [**2187-7-5**]
Date of Birth: [**2109-4-25**]
Sex: M
Service: VSU
ADMISSION DIAGNOSIS: Neck mass.
DISCHARGE DIAGNOSIS: Death.
CHIEF COMPLAINT: This is a 78-year-old male with an
enlarging neck mass.
HISTORY OF PRESENT ILLNESS: This 78-year-old male with a 6-
week history of a sore throat, dysphagia and difficulty
breathing who appeared to have a thyroid mass on exam by his
physician. [**Name10 (NameIs) **] underwent a CT scan with fine needle aspiration
which was indeterminate in an outside hospital and he was
seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who felt that based on the
symptoms of his thyroid mass that it may be a thyroid cancer.
He was therefore booked for an operative thyroidectomy. The
patient was admitted to the hospital on [**4-24**] of [**2187**] for
thyroidectomy.
PAST MEDICAL HISTORY: Past medical history is significant
for peripheral vascular disease, aortic aneurysm, CREST
syndrome, scleroderma, CAD with CHF, paroxysmal atrial
fibrillation, iron deficiency anemia, gout, chronic renal
failure, deep venous thrombosis, asbestosis, hypertension,
hypothyroidism.
PAST SURGICAL HISTORY: Past surgical history is significant
for bilateral femoral to dorsal pedal bypass grafts with
saphenous vein for treatment of bilateral thrombosed
popliteal aneurysms.
MEDICATIONS ON ADMISSION: Aspirin, Synthroid, Lopressor,
Protonix, Lasix, insulin.
ALLERGIES: An allergy to Coumadin as well as a questionable
allergy to heparin.
SOCIAL HISTORY: He is married with 6 children, a retired
electrician, 1 pack per day smoking history for 4 years. He
quit 45 years ago. He rarely drank alcohol.
REVIEW OF SYSTEMS: Significant for occasional shortness of
breath, dyspnea on exertion, otherwise unremarkable.
HOSPITAL COURSE: The patient was admitted to the surgical
service and on [**6-26**], underwent a neck exploration with
biopsy of the central portion of the thyroid and tracheostomy
for an obstructing goiter. That was subsequently revealed to
be lymphoma. On the 31st, he underwent a percutaneous
endoscopic gastrostomy for nutrition. He was seen by
hematology/oncology on [**6-28**] for treatment of his B-cell
lymphoma and he was transferred to the hematology/oncology
service for that. On [**7-3**], however, he underwent a CT scan
for abdominal pain and was found to have a ruptured
retroperitoneal aortic aneurysm. He was emergently taken to
the operating room by Dr. [**Last Name (STitle) 1391**] and he underwent a repair
of a ruptured aortic aneurysm. Postoperatively, he was noted
to have pale bilateral lower extremities. By postoperative
day #1, these were beginning to demarcate at the mid thigh.
At this time, he was intubated in the intensive care unit. He
was taken back to the operating room for bilateral femoral
embolectomies because of progressive ischemia of his
bilateral lower extremities. This happened on [**7-4**].
Postoperatively, however, he had persistent ischemia of both
lower extremities. By [**7-5**], he was respirator-dependent
with rising creatinine kinase. His extremities were
completely demarcated at the mid thigh and given his degree
of progressive renal failure/anuria, hypotension requiring
pressors, respiratory failure requiring ventilator support
and peripheral vascular disease with ischemia of both lower
extremities that was going to require bilateral lower
extremity amputations, his family deemed that they did not
want to pursue any further aggressive treatment options and
the patient was made comfort measures only. The patient
expired on [**7-5**] at 6:50 p.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern4) 25081**]
MEDQUIST36
D: [**2187-7-5**] 21:43:32
T: [**2187-7-5**] 22:08:25
Job#: [**Job Number 58801**]
|
[
"51881",
"4280",
"42731",
"5859"
] |
Admission Date: [**2109-8-5**] Discharge Date: [**2109-8-24**]
Date of Birth: [**2050-4-3**] Sex: M
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
male with end stage renal disease who has been on peritoneal
dialysis since [**2106-7-8**]. The patient was initially
diagnosed with chronic renal failure in [**2095**] after returning
from a trip from abroad and having experienced three days of
anuria. His renal failure was thought to be secondary to an
infection. The patient began hemodialysis on [**11/2099**], but
because of difficulties in obtaining an adequate AVF, his
dialysis was changed to peritoneal dialysis. The patient
also has a history of bladder outlet obstruction with
multiple urethral dilatations previously performed. His
systolic blood pressures at home had been running in the 70s
to 90s. The patient presented to the hospital for a
cadaveric kidney transplant on [**2109-8-5**].
PAST MEDICAL HISTORY:
1. Relative hypotension (70s to 90s systolic blood pressure
for several years)
2. Syncope x2 presumably secondary to hypotension
3. End stage renal disease of unclear etiology, but most
likely infectious
4. Intermittent bladder outlet obstruction, status post
multiple urethral dilatations.
5. Spontaneous bacterial peritonitis in [**2109-4-8**]
6. Gastroesophageal reflux disease
MEDICATIONS:
1. Midodrine 5 mg 3x a day
2. Potassium chloride 10 milliequivalents qd
3. Neurontin 100 once a day
4. Epogen 4000 units twice a week
5. Tagamet prn
6. Tums
7. Nephrocaps
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No history of tobacco use.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.3??????, heart rate 106, blood
pressure 100/60, respiratory rate 18, 94% on room air.
GENERAL: Obese male in no apparent distress.
LUNGS: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm, no murmurs.
ABDOMEN: Obese abdomen, otherwise soft, nontender with
peritoneal dialysis opening.
EXTREMITIES: Warm, no edema. Pulses present bilaterally
throughout.
RECTAL: Guaiac negative.
LABORATORY STUDIES: White blood cell count 8.8, hematocrit
34, platelets 149. Glucose 85, BUN 27, creatinine 9.1.
Sodium 140, potassium 4.3, chloride 101. ALT 28, AST 29, LD1
56, alkaline phosphatase 39, total bilirubin 0.3, albumin
3.4, calcium 9.3, phosphate 6.5, magnesium 1.7.
IMAGING STUDIES: Chest x-ray obtained on [**2109-8-6**] showed a
left IJ Swan-Ganz catheter with the tip in the distal right
pulmonary artery. The chest x-ray also showed satisfactory
position of the endotracheal tube and the right IJ central
line. Cardiomegaly and bilateral atelectasis. Chest x-ray
obtained on [**2109-8-7**] showed continued widened mediastinum,
bilateral atelectasis. Chest x-ray from [**2109-8-9**] showed
stable mild congestive heart failure. Chest x-ray obtained
on [**2109-8-14**] showed cardiac enlargement with evidence of mild
congestive heart failure. The exam also showed patchy
atelectasis at the right lower lobe, but no evidence of
pneumothorax. Chest x-ray obtained on [**2109-8-15**] showed small
right sided pleural effusion, as well as cardiomegaly with
mild congestive heart failure. Ultrasound of the bladder
obtained on [**2109-8-17**] showed multiple clots within the
bladder. The renal transplant ultrasound obtained on
[**2109-8-20**] showed mild hydronephrosis of the transplanted
kidney, echogenic material in the collecting system of
transplanted kidney which was thought to be consistent with
blood clot, as well as mild elevation of the resistive index.
SUMMARY OF HOSPITAL COURSE: On [**2109-8-5**], the patient
underwent cadaveric renal transplant for chronic renal
failure. The procedure was without any complications. Blood
loss was 100 cc. The patient was transferred to the PACU
intubated. Please see the full operative report for detail.
In the PACU, the patient was noted to be hypotensive. In
addition, the patient was noted to have poor urine output
which was thought to be secondary to ischemic damage plus the
hypotension. The patient had a Swan-Ganz catheter placed
which demonstrated hyperdynamic hemodynamics and decreased
systemic vascular resistance. The patient was transferred to
the Surgical Intensive Care Unit for closer monitoring. The
patient remained intubated. The patient was started on renal
dopamine.
On postoperative day 1, the patient continued to have low
urine output but it was slightly improved. The patient
received...
DICTATION ENDS ABRUPTLY
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2109-8-23**] 12:04
T: [**2109-8-23**] 12:10
JOB#: [**Job Number 108625**]
|
[
"2851"
] |
Admission Date: [**2162-2-28**] Discharge Date: [**2162-3-9**]
Date of Birth: [**2120-1-15**] Sex: F
Service: SURGERY
Allergies:
Augmentin
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
1. Open reduction, internal fixation right intertrochanteric hip
fracture with dynamic hip screw.
2. Closed treatment right femoral shaft fracture with
manipulation.
3. Closed treatment right intercondylar, supracondylar femur
fracture with manipulation.
4. Application of uniplanar external fixator.
5. Washout and closure wound over anterior knee, 3 cm in length.
6. Open reduction internal fixation femoral shaft segmental
fracture.
7. Open reduction internal fixation distal femur intra-articular
fracture.
8. Open reduction internal fixation tibial plateau fracture.
9. Open reduction internal fixation ankle fracture.
10. Examination under anesthesia of wrist, all right lower
extremity and right upper extremity.
11. Removal of external fixator.
12. Lateral meniscal attachment and examination under anesthesia
ankle mortise.
History of Present Illness:
42 F restrained driver s/p motor vehicle crash head on collision
with another car, ~30-50 mph, no LOC, +airbags, prolonged
extrication. transportedto [**Hospital1 18**] for further care.
Past Medical History:
Colon CA
PSH: s/p resection for colon CA
Social History:
Has 3 children
Family History:
Noncontributory
Physical Exam:
Upon admission:
HR:110 BP:130/80 Resp:30 O(2)Sat:98% normal
Constitutional: Patient is in severe pain
Head / Eyes: Extraocular muscles intact
ENT / Neck: In c-collar
Chest/Resp: Equal breath sounds without
chest wall tenderness
Cardiovascular: Heart sounds
GI / Abdominal: Soft, Nontender
Musc/Extr/Back: Back is negative\npatient
has a obviously deformed
right proximal femur.\nThere
is a laceration over her
right knee.\nThe ankle is
obviously dislocated on the
right.\nHer dorsalis pedis
pulse is present by Doppler
on the right.\nShe seems to
have decreased sensation on
the right foot dorsum.
Neuro: Speech fluent and can move
all 4 extremities
Pertinent Results:
[**2162-2-28**] 11:37PM GLUCOSE-152* UREA N-6 CREAT-0.4 SODIUM-141
POTASSIUM-4.0 CHLORIDE-115* TOTAL CO2-21* ANION GAP-9
[**2162-2-28**] 11:37PM CALCIUM-7.0* PHOSPHATE-3.1 MAGNESIUM-1.4*
[**2162-2-28**] 11:37PM CALCIUM-7.0* PHOSPHATE-3.1 MAGNESIUM-1.4*
[**2162-2-28**] 11:37PM WBC-6.3# RBC-3.91* HGB-11.4* HCT-32.8* MCV-84
MCH-29.2 MCHC-34.9 RDW-13.9
[**2162-2-28**] 11:37PM PLT COUNT-215#
[**2-28**] Abdominal CT:
1. Acute minimally displaced fracture of the sternal manubrium
with possible minimal associated underlying anterior mediastinal
hematoma. No evidence of acute visceral injury in the abdomen or
pelvis.
2. Mildly displaced right-sided intratrochanteric femur
fracture.
3. Rounded 2.0 x 1.2cm asymmetric hypodense area involving the
left breast, may represent a cyst. However, recommend
correlation with
mammography/ultrasound to exclude a more aggressive lesion.
4. Multiple splenic hypodensities involving the spleen,
non-specific. Differential diagnosis is broad and includes
neoplastic/lymphomatous/metastatic involvement or microabcesses.
Other considerations include sarcoidosis although there are no
findings of sarcoidosis in the chest. Recommend clinical
correlation with history of malignancy (chain sutures in rectal
region, question history of colorectal carcinoma) or
immunocompromise.
5. 9mm incompletely characterized hypoattenuating liver lesion.
Area of nodularity involving the mid aspect of the gallbladder,
non-specific may represent atypical adenomyosis or polyp.
Recommend further evaluation of these findings, in addition to
the splenic lesions, with MRI (preferred) or ultrasound.
6. Subcentimeter hypodensity seen within the interpolar region
of the left kidney, incompletely characterized. Attention at the
aforerecommended MRI/ultrasound.
[**2162-3-5**] MRCP
IMPRESSION:
1. No evidence of bile duct injury.
2. Hepatic steatosis.
3. Multiple, nonspecific T2 hyperintense splenic lesions. Unless
the patient has a known primary malignancy or systemic disease,
this finding is most likely in keeping with benign cysts versus
hamartomas.
[**2162-3-8**] LENIS
IMPRESSION: No evidence of DVT in the left lower extremity.
Brief Hospital Course:
She was admitted to the Trauma service. Orthopedics was
consulted for her lower extremity injuries. She was taken to the
operating room on [**2-28**] & [**3-1**] for washout and repair of her
injuries. Postoepratively she remained in the Trauama ICU and
was dificult to wean for extubation. It was felt that this was
primarily due to large amounts of intravenous narcotics required
to control her pain; 0.1% bupivacaine at 10 mL/hr was infused
with adequate pain control. Neurology was very briefly involved
in her care after consult request per ICU team for her decreased
mental status. This was also felt per Neurology to be a result
of her narcotics and not related to seizures or other
intracranial processes. She eventually was more awake and able
to be weaned and extubated. She was then transferred to the
regular nursing unit.
Her LFT's were noted to be elevated during her stay and a GI
consult was requested. An MRCP was done which was normal. Her
LFT's were trending down during her stay and will need to be
checked weekly while at rehab. Given her history of colon CA a
CEA was checked and was less than 1.0. She has given us
permission to forward these results to her primary
hematologist/oncologist. The GI team recommends that she have an
ECHO at some point as an outpatient.
She did have pain control issues once on the nursing unit and it
was recommended per pain service to add Nortriptyline at HS; she
is also receiving po Dilaudid.
Physical therapy has been working with her regularly and she is
being recommended for acute rehab.
Medications on Admission:
Meds: iron
All: augmentin
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: Thirty (30) MG
Subcutaneous Q12H (every 12 hours).
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
s/p Motor vehicle crash
Injuires:
- Manubrial fracture with retrosternal fluid collection
- Right mid-shaft femur fracture
- Right tibial plateau with lateral split-depression
- Right [**Doctor Last Name 11586**] B bimalleolus equivalent
- Right comminuted talar neck fracture
- Right knee laceration
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid
(platform walker or cane)
Discharge Instructions:
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
-Staples will be removed at your first post-operative visit.
Activity:
-Continue to be touch down weight bearing on your right leg.
-Continue to be non weight bearing on your right wrist and
weight bearing as tolerated on your elbow.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize bone healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Followup Instructions:
It is important that you follow up with your
Hematologist/Oncologist at [**Hospital3 2576**] [**Hospital3 **] upon discharge
from rehab. You will need to call for an appointment. It is
being recommended that you follow up with a liver specialist
within 3 months and this can be arranged through Dr. [**First Name (STitle) 916**].
2 weeks in the [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.
Please call [**Telephone/Fax (1) 1228**] to make this appointment. Clinic held
on Tuesday's.
Follow up in Hand Surgery clinic next Tuesday. Call
[**Telephone/Fax (1) 3009**] to schedule this appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2162-3-9**]
|
[
"2762"
] |
Admission Date: [**2188-10-2**] Discharge Date: [**2188-10-2**]
Date of Birth: [**2161-12-6**] Sex: F
Service: NEUROLOGY
Allergies:
Phenobarbital / Fioricet / Latex
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Right leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
26 year-old right-handed woman with a history of ulcerative
colitis, celiac sprue, migraines presents with right foot and
leg weakness.
.
Pt reports onset of throbbing, right-sided headache [**2188-9-26**], that
got worse with movement, associated with photophobia, and
intermittent visual changes typical of her migraines. There was
no change in headache with lying or sitting. Tylenol and
excedrin improved the headache but did not resolve it. She also
tried demerol for headache but had nausea and vomiting
afterwards. ~Two days ago she developed low grade fever to ~100.
She did not have any change in her UC symptoms. PCP was
concerned for possible meningitis as pt on mild immunosuppresion
for her UC, and sent pt to [**Hospital1 18**] ED for evaluation overnight on
[**2197-9-30**]. Head CT was normal. LP was done without complications,
with opening pressure 16 (while pt still curled in ball), and
was
normal. Other lab work revealed elevated WBC count with left
shift, but no source of infection. Pt was discharged yesterday
morning ([**10-1**]) and was to follow-up with PCP.
.
Pt spent much of day sleeping and relaxing. Then, ~9pm last
night she first noticed some mild pain in her groin "as if I had
pulled a muscle." She then noted that her right foot seemed to
be "uncoordinated" and she couldn't "curl my toes as fast as on
the left foot." The right foot also just seemed generally weak.
She denies tingling, but does report a strange sensation in the
leg from groin to toes. No pain or tenderness, but leg does also
feel cold. Pt called ED, and was told to monitor symptoms, and
if
they progressed to return for evaluation. She then went back to
sleep and awoke ~12:30-1am this morning. At that point her foot
was severely weak, right leg was mildly weak and she had trouble
walking. She therefore decided to return to ED.
.
Also of note, pt reports several episode of tingling. Episode
began with tingling on right side of umbilicus, and spread down
to groin, and around to back and then up the back into the
posterior neck and down right arm to ~elbow. Spread occurred
over seconds, and entire episode lasted ~10 secs. Tingling
occurred 3 times, about 10-15 mins apart. It then occurred for a
4th time ~2:10am, and persisted. It has gradually resolved,
currently she only has some tingling around the right side of
her
umbilicus. Also reports some weakness or "heaviness" of the
right arm, proximally.
.
ROS: +Low-grade fever for several days. No cough, cold sx. Has
baseline diarrhea with 3 BMs/day, unchanged and no incontinence.
No abdominal pain. No dysuria, frequency, hesitancy, or
incontinence. No rashes. No changes in hearing, tinnitus.
+Intermittent visual spots, typical of her migraine aura. No
trouble speaking.
Past Medical History:
1. Ulcerative colitis
2. Celiac sprue
3. Migraines with visual aura. Usually occur with UC flare.
4. h/o febrile seizures
5. Recent TB exposure, negative CXR per pt, on INH
.
All: Phenobarb causes "psychosis"; demerol caused vomiting.
+Wheat allergy due to sprue.
Social History:
Lives with fiancee. Works as office manager at BU for
introductory biology department. Currently studying to get into
vet school. No tobacco, EtOH, drugs.
Family History:
No seizures, migraines. Brother possibly with sprue. Mom
with breast cancer. No strokes.
Physical Exam:
T 100.1 BP 116/62 HR 126 RR 18 O2 sat 99% RA
General: Appears stated age, slightly anxious
HEENT: NC/AT Sclera anicteric. OP clear
Neck: Supple, no meningismus.
Lungs: Clear to auscultation bilaterally
Back: No spinal tenderness.
CV: Tachy, RR, nl S1, S2, no murmur. 2+ carotids without bruit
Abd: Soft, nontender, normoactive bowel sounds
Extr: No edema, good dorsalis pedis pulses bilaterally though
right foot and ankle cooler than left
Rectal: Normal tone, intact sensation
.
Neurologic Examination:
Mental Status: Alert and oriented to person, place and date,
cooperative with exam, normal affect
Attention: Can say months of year backward
Language: Fluent, no dysarthria, no paraphasic errors, naming,
repetition and [**Location (un) 1131**] intact
Fund of knowledge normal
Registration: [**3-20**] items, Recall [**3-20**] items at 3 minutes
No apraxia, No neglect
.
Cranial Nerves: Visual fields are full to finger motion. Optic
fundi show normal discs. Pupils equally round and reactive to
light, 4 to 2 mm bilaterally, brisk. Extraocular movements
intact, no nystagmus. Facial sensation and facial movement
normal
bilaterally. Hearing intact to finger rub bilaterally. Normal
oropharyngeal movement. Tongue midline, no fasciculations.
Sternocleidomastoid and trapezius normal bilaterally.
.
Motor: Normal bulk and tone bilaterally, fasiculations absent in
upper and lower extremities. No tremor. No pronator drift. Full
strength in arms (delts, biceps, triceps, WE, FE, FF)
bilaterally
and in left leg. In right leg, IP, hip abductors, adductors,
quads full strength; hamstring 1; hip extensors, DF, PF, TE, TF,
inversion, eversion 0.
.
Sensation: Absent proprioception at right toe, ankle. Decreased
position sense on skin of right leg, right lower abdomen and
back
but intact on right arm, face and on left. Has dysesthesia to
light touch in same distribution (right leg, abdomen not arm).
Vibration intact at toes. Cold and pin inconsistent, but largely
intact. On back, some increase of cold and pin bilaterally at
mid-thoracic. No saddle anesthesia.
.
Reflexes: B T Br Pa An
Right 1 2 0 2 2
Left 1 2 0 2 2
Toes up R>>L.
.
Coordination is normal on finger-nose-finger, rapid alternating
movements bilaterally, heel to shin on left but unable on right
due to weakness.
Gait: Stands with most of weight on left foot, +Romberg with
falling to right. Walks with circumduction and foot drop on
right.
Pertinent Results:
[**2188-10-2**] 09:40AM GLUCOSE-103 UREA N-6 CREAT-0.7 SODIUM-136
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-20* ANION GAP-17
[**2188-10-2**] 09:40AM CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-1.7
[**2188-10-2**] 09:40AM WBC-10.4 RBC-3.45* HGB-10.9* HCT-30.8* MCV-89
MCH-31.5 MCHC-35.3* RDW-14.8
[**2188-10-2**] 09:40AM PLT COUNT-120*
[**2188-10-2**] 09:40AM PT-14.7* PTT-24.1 INR(PT)-1.5
[**2188-10-2**] 09:40AM FIBRINOGE-410*
[**2188-10-2**] 02:45AM NEUTS-83* BANDS-0 LYMPHS-10* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2188-10-2**] 02:45AM PLT SMR-LOW PLT COUNT-129*
[**2188-10-1**] 01:15AM CEREBROSPINAL FLUID (CSF) PROTEIN-20
GLUCOSE-68
[**2188-10-1**] 01:15AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0
LYMPHS-40 MONOS-60
.
Head CT [**9-30**] 11pm: No bleed, edema, mass effect
.
MRI/MRV BRAIN [**10-2**]
COMPARISON: CT head dated [**2188-9-30**].
MRI BRAIN: There are regions of decreased T1 signal and
increased T2 signal affecting the [**Doctor Last Name 352**] and white matter of the
right anterior frontal lobe, left superomedial parietal lobe,
and left posterior superior frontal lobe. There is
susceptibility artifact present within these regions consistent
with hemorrhagic products. High signal on diffusion-weighted
images is also demonstrated affecting the same areas consistent
with acute infarction. Dural and leptomeningeal pattern
enhancement is demonstrated on the post-gadolinium images with
possible subtle areas of enhancement within the infarcted
regions of the brain as well. There is mass effect producing
slight right to left shift secondary to the right anterior
frontal region of infarction. There is no hydrocephalus. Coronal
postgadolinium images demonstrate a filling defect within the
superior sagittal sinus consistent with thrombosis.
MRV: Absence of flow is demonstrated within the superior
sagittal sinus, left transverse sinus, left sigmoid sinus, and
left internal jugular vein. Flow is demonstrated in the right
transverse sinus, right sigmoid size, right internal jugular
vein, internal cerebral veins, the vein of [**Male First Name (un) 2096**], and the basal
veins of [**Doctor Last Name **], but there is diminished flow signal
demonstrated in the straight sinus.
IMPRESSION:
MRI brain: Multiple areas of acute infarction in the right
anterior frontal lobe, left posterosuperior frontal lobe, and
left superior parietal lobes with hemorrhagic material likely
secondary to venous obstruction from sinus thrombosis.
MRV: Absence of flow signal within the superior sagittal sinus,
left transverse sinus, left sigmoid sinus, and left internal
jugular vein indicating thrombosis or markedly decreased flow.
Also abnormal flow in the straight sinus.
.
MRI C SPINE [**10-2**]:
FINDINGS: No abnormal signal seen within the cord. There is mild
degenerative change and disc protrusion at C5-C6. The alignment
is normal. There is no prevertebral soft tissue swelling.
IMPRESSION: No evidence of cervical cord compression.
.
MRI THORACIC SPINE [**10-2**]:
FINDINGS: The study is limited by motion artifact. Evaluation of
the cord signal is limited secondary to motion artifact with no
definite abnormal signal seen. There is no evidence of cord
compression. The alignment is normal.
Brief Hospital Course:
The patient is a 26 year old woman with a history of UC, sprue,
migraines, and febrile seizures who presented with a history of
HA x6 days, and new right leg weakness. The initial exam was
notable for a flailing right foot, weak right hamstring, but
preserved reflexes. In addition she had paresthesias involving
her R-leg and trunk. MRV showed filling defects in the superior
sagittal sinus, left transverse sinus, left sigmoid sinus, and
left internal jugular vein, indicating venous sinus thrombosis.
MRI showed multiple areas of acute infarction in the right
anterior frontal lobe, left posterosuperior frontal lobe, and
left superior parietal lobes with hemorrhagic material likely
secondary to venous obstruction from the sinus thrombosis. It is
unclear to what extent the sinus thrombosis might have been
aggravated by the LP that was done on [**10-1**].
.
Neuro:
The exam later in am [**10-2**] was remarkable for the following: able
to lift up R-hand, but not arm, no weakness in L-UE; able to
lift up and wiggle toes in LLE, not in RLE. Decreased sensation
to LT in RLE. Partial seizures were observed with rhythmical
shaking in L-hand and L-leg, lasting for seconds. The patient
did not loose consciousness but was inattentive. Pupils equal
and reactive to light (3 to 2mm).
Management was as follows:
- q 30 minute neurochecks
- STAT head CT if neurological status deteriorates
- HOB >45 degrees
- SBP parameters: 120-140
- started heparin gtt (start at 10 am; bolus of 2500 units; then
900units/hr; goal PTT 50-70)
- started mannitol iv; 25 gm q 6hrs after initial bolus of 50gm;
follow serum Osm and Na
- seizure management: patient was loaded on dilantin (1000mg iv;
am [**10-2**]) and continued on 100mg TID.
The results of a hypercoagualable workup (including prot C; prot
S; antithrombin II, homocysteine; cardiolipin Abs; lupus Abs,
factor V Leiden; factor VIII) are pending. These labs were sent
prior to the start of heparin.
The patient was transfered to the Neuro-ICU at [**Hospital1 2025**] for possible
thrombolysis.
.
Cardiovascular:
The patient was monitored on telemetry. She had episodes of
tachycardia (110-150)with a systolic blood pressure of 120-130;
diastolic 60-70.
.
Respiratory:
Supportive O2 was given as needed to keep sO2 >94.
In case the patient is not able to protect her airway she should
be intubated.
.
Gastero-intestinal:
The patient has a history of Uleceratve colitis. Her stools were
guiac positive today, prior to starting heparin. Close
monitoring of Hct neceassary.
PPI and home medications to manage ulcerative colitis were
continued.
.
Haematology:
The patient's Hct prior to starting heparin was 30.8. A repeat
Hct in pm [**10-2**]: 34.2. Her stools were guiac positive.
Hct was monitored q 2hr while on heparin. The patient was typed
and screened. She should be transfused aggressively if needed.
.
ID:
The patient's WBC 10.4; neutro 84%. No source of infection found
so fat. LP ([**10-1**]) negative. No antibiotic therapy has been
started.
.
FEN:
The patient was kept NPO except medications and sips of water.
.
Prophylaxis:
A bowel regimen was started. PPI for GI prophylaxis.
.
Code:
Full
.
.
The attending at [**Hospital1 **]: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
The patient's PCP is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She can be reached at all
times at [**Telephone/Fax (1) 27215**] (mobile phone).
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is the patient's gasteroenterologist at [**Hospital1 112**]. In case
of GI hemorrhage or in case of any other questions, please call
her: [**Telephone/Fax (1) **]-page.
.
.
.
.
Addendum:
16.30: patient with head deviated to the Left, not able to move
R leg and R arm.
.
Heparin was stopped. STAT head CT was obtained showing increased
edema especially in the L hemisphere, midline shift; no increase
in size of ICH.
.
Patient intubated at 17.20 and hyperventilated to keep pCO2
25-30. Sedated on propofol. Extra 50gm of mannitol given.
.
Heparin restarted; PTT 26.8, sub-therapeutic; extra bolus of
2500 units given.
.
Patient then airlifted to [**Hospital1 2025**] for further management.
Medications on Admission:
Pentasa 2000mg, mercaptopurine 75, nexium 45, isoniazid
300, vitamin B6 50, Ca 600, vitamin D.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Five
(5) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Mercaptopurine 50 mg Tablet Sig: 1.5 Tablets PO QD ().
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
7. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Insulin Regular Human 100 unit/mL Solution Sig: Two (2) units
Injection ASDIR (AS DIRECTED).
10. Heparin (Porcine) 2,500 unit/mL Solution Sig: 900units/hr
900units/hr Intravenous infusion: Heparin IV. Initial Bolus:
2500 units IVP; additional bolus given at 17.30. Initial
Infusion Rate: 900 units/hr. Check PTT q6h and call HO. Goal
50-70.
11. Mannitol 20 % Parenteral Solution Sig: One (1) 25gm
Intravenous every six (6) hours: Mannitol 20% 50 gm IV ONCE as
bolus then repeated at 17.30.
Check serum osms and sodium before dosing. Hold for osm >320,
Na>146.
12. propofol gtt
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. venous sinus thrombosis
2. intracranial hemorrhage
3. ulcerative colitis
4. seizures
Discharge Condition:
Serious
Discharge Instructions:
Please follow Hct closely as patient is guiac positive.
Please follow PTT; patient started on heparin gtt.
Please monitor for seizures.
Followup Instructions:
For further information:
The attending at [**Hospital1 **]: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Resident: [**Last Name (NamePattern4) 27216**].
The patient's PCP is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She can be reached at all
times at [**Telephone/Fax (1) 27215**] (mobile phone).
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is the patient's gasteroenterologist at [**Hospital1 112**]. In case
of GI hemorrhage or in case of any other questions, please call
her: [**Telephone/Fax (1) **]-page.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2188-10-2**]
|
[
"51881"
] |
Admission Date: [**2192-3-2**] Discharge Date: [**2192-3-7**]
Date of Birth: [**2110-3-12**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Transfer for consideration for cardiac catheterization
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 81 y.o.f. with h/o MVR and HTN who presented
to [**Hospital **] Hospital on [**2192-2-17**] with acute onset SOB. Per notes
and family, she felt well when going to bed, but later awoke not
feeling well and called EMS. No recent chest pain, palpitations,
shortness of breath prior to the admitting episode, orthopnea,
or PND. According to paramedic run sheet she was in Afib with
RVR at 130 with BP 240/100. She could only speak in three word
sentences with RR in the 30's, temp was 102. She was given lasix
and nebs during transport. Initial EKG at [**Location (un) **] showed sinus
in the 80's with LBBB and LAD, and review of paramedic strip
showed sinus tachycardia rather than Afib (although ED physician
states initial rhythm was afib). She was 89% on 100% O2 with BP
222/66. She was intubated for hypercarbic respiratory failure
and gas on initial intubation was 7.22/72/118. She was given
rocephin and zithromax x 1 and admitted to the ICU. CXR showed
pulmonary edema.
.
Over the course of her ICU stay she was found to have a positive
urine culture treated with cefazolin, and felt to have urosepsis
although no blood cultures were positive. She was hypertensive
and overloaded per notes, and she was diuresed with lasix 80 mg
IV BID. CXR films on disc that came with patient to [**Hospital1 18**] showed
rapid improvement in pulmonary edema after 1-2 days in ICU. ECHO
was performed which showed EF 45% and basilar inferior
aneurysmal formation present on earlier ECHO. She was difficult
to wean from the vent due to tachypnea, hypoxia, and
hypotension. Concern was for LV deterioration causing difficulty
weaning, but repeat ECHO on [**2-23**] was unchanged. Additionally,
there was concern for ischemia or valvular dysfunction during
weaning, but repeat ECHO after 30 min. of spontaneous breathing
trial was also unchanged. A swan-ganz catheter was recommended,
but in the end this was not pursued. Her wean failure was
ultimately felt to be d/t delerium, and she was changed from
versed to propofol and successfully weaned and extubated on
[**2-27**].
.
At some point prior to [**2-23**] her CK peaked at 743 with MB of 11.3
and Trop I 1.05 (ULN 0.4). On [**2-29**] she had a 20-30min episode of
hypotension that resolved on its own, and then again on [**3-2**].
Per nursing, these were in the setting of sitting her upright.
She also had episodes of transient hypoxia, unclear specifics.
On [**2-29**] she developed worsening MS - per daughter-in-law, knew
month after extubation, but since Wednesday has been unable to
recall base orientation.
.
ID was consulted for persistent intermittent fevers during
initial ICU course, but etiology was unclear. She was continued
on treatment for UTI with no other source found, and eventually
these resolved. She had 6 negative blood cultures and a negative
sputum culture. Hematology was consulted for pancytopenia (WBC
11 to 2.8, HCT 40 to 27, and plt 230 to 107) and etiology was
felt to be due to sepsis, and her counts subsequently recovered.
.
Cardiology considered taking her to the cath lab on [**2-28**] to
evaluate for CAD, but felt that she was too unstable to do so,
and therefore was tranferred to BICMC for cardiac
catheterization to assess valve and coronaries.
.
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:
# MVR - St. [**Male First Name (un) 923**] prothesis [**2177**], p/w ruptured papillary muscle
of posterior leaflet in cardiogenic shock, clean coronaries in
cath lab and then taken for emergent MVR
# HTN
# Abif on coumadin
# Hypothyroidism
Social History:
Lives with her husband, takes care of her husband (early
alzheimer's), no limit in function. + tob history. No ETOH.
Family History:
non-contributory
Physical Exam:
VS: T 97.7, BP 114/48, HR 74, RR 24 , O2 98% on 50% cool neb
Gen: WDWN middle aged female in NAD, on face mask. Oriented x 0.
Pleasant, appropriate, follows commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. MM dry.
Neck: Supple without JVP while sitting upright.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. III/VI SEM at RUSB.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at left base
with wheezes.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
On admission to OSH [**1-/2113**]:
WBC 11
HCT 40
INR 2.0
132 97 16
4.1 24 0.9
Initial CK/CKMB/Trop negative
Peak CPK 743, MD 11.3, Trop I 1.05
D-Dimer 0.4
.
Discharge from OSH on [**3-2**]:
WBC 17.1 (14.3 day prior, low of 2.8 on [**2-21**])
HCT 33.8
Cr 0.9, K 2.9
BNP 1722
UA on admit with lg leuks, bact, 32 WBC
Urine culture on admission with >100,000 E.coli, pansensitive
UA on [**3-2**] with 25WBC, mod leuk (inc from none)
Sputum: Mod WBCs, OP flora
Multiple blood cultures at OSH negative (>6 per notes)
Admission labs:
[**2192-3-2**] 11:36PM TYPE-ART PO2-100 PCO2-47* PH-7.49* TOTAL
CO2-37* BASE XS-10
[**2192-3-2**] 11:36PM LACTATE-1.2
[**2192-3-2**] 11:36PM O2 SAT-97
[**2192-3-2**] 09:23PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
[**2192-3-2**] 09:23PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2192-3-2**] 09:23PM URINE RBC->50 WBC-[**5-29**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2192-3-2**] 06:18PM GLUCOSE-138* UREA N-53* CREAT-0.8 SODIUM-145
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-35* ANION GAP-13
[**2192-3-2**] 06:18PM estGFR-Using this
[**2192-3-2**] 06:18PM ALT(SGPT)-30 AST(SGOT)-36 LD(LDH)-538*
CK(CPK)-84 ALK PHOS-104 AMYLASE-43 TOT BILI-1.2
[**2192-3-2**] 06:18PM LIPASE-59
[**2192-3-2**] 06:18PM CK-MB-6 cTropnT-0.04*
[**2192-3-2**] 06:18PM ALBUMIN-3.4 CALCIUM-8.8 PHOSPHATE-4.0
MAGNESIUM-2.0 URIC ACID-10.7*
[**2192-3-2**] 06:18PM VIT B12-1041* FOLATE-17.4
[**2192-3-2**] 06:18PM TSH-4.0
[**2192-3-2**] 06:18PM WBC-15.9* RBC-3.53* HGB-10.2* HCT-31.7*
MCV-90 MCH-29.0 MCHC-32.2 RDW-14.9
[**2192-3-2**] 06:18PM NEUTS-86.9* LYMPHS-8.8* MONOS-3.0 EOS-1.2
BASOS-0.2
[**2192-3-2**] 06:18PM PLT COUNT-387
[**2192-3-2**] 06:18PM PT-13.4 PTT-39.8* INR(PT)-1.1
Discharge labs:
[**2192-3-6**] 08:00AM BLOOD WBC-10.9 RBC-3.64* Hgb-10.6* Hct-33.3*
MCV-91 MCH-29.2 MCHC-31.9 RDW-15.5 Plt Ct-326
[**2192-3-6**] 08:00AM BLOOD Plt Ct-326
[**2192-3-6**] 08:00AM BLOOD PT-16.9* PTT-65.0* INR(PT)-1.5*
[**2192-3-6**] 08:00AM BLOOD Glucose-133* UreaN-31* Creat-0.7 Na-147*
K-3.7 Cl-110* HCO3-28 AnGap-13
[**2192-3-6**] 08:00AM BLOOD CK(CPK)-PND
[**2192-3-2**] 06:18PM BLOOD Lipase-59
[**2192-3-6**] 08:00AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.8
[**2192-3-2**] 06:18PM BLOOD VitB12-1041* Folate-17.4
ECHO: [**3-5**]:
The left atrium is moderately dilated. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Left ventricular
systolic function is hyperdynamic (EF>75%). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. There is moderate to severe
aortic valve stenosis (area 0.8-1.0cm2). Trace aortic
regurgitation is seen. A mechanical mitral valve prosthesis is
present. The transmitral gradient is normal for this prosthesis.
No mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Severe left ventricular hypertrophy with normal
systolic function. Moderate to severe aortic stenosis. Normal
functioning mechanical mitral valve.
CXR: [**3-5**]:
IMPRESSION: Slight improvement in right mid and lower lung
opacities. After resolution of these acute findings, chest CT
may be helpful to evaluate for underlying interstitial lung
disease.
CT Head [**3-3**]
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or acute vascular territorial infarction. The ventricles
and sulci are prominent, most consistent with age-related
atrophy, and there is mild ex vacuo dilatation of the occipital
[**Doctor Last Name 534**] of the left lateral ventricle, most consistent with an area
of chronic encephalomalacia. Note is made of extensive vascular
calcification in the bilateral internal carotid arteries, and
vertebral arteries.
IMPRESSION: No acute intracranial process. No evidence of
intracranial hemorrhage.
Microbiology
[**2192-3-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-negative
[**2192-3-3**] BLOOD CULTURE Blood Culture, Routine-PENDING no
growth to date
[**2192-3-3**] BLOOD CULTURE Blood Culture, Routine-PENDING no
growth to date
[**2192-3-2**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-negative
[**2192-3-2**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.}, vanc
resistant
Brief Hospital Course:
ASSESSMENT AND PLAN
81 y/o F with HTN, MVR, PAF who presented to OSH with hypoxia in
setting of hypertensive urgency and tachycardia. Patient became
hypoxic and hypercarbic was transiently intubated. Possible
urosepsis, demand ischemia in setting severe LVH and
tachycardia, diastolic dysfunction. Course c/b change mental
status after extubation, transferred here for cardiac
catheterization.
.
# CAD
Patient had catheterization in [**2177**] prior to MVR with no
evidence of significant CAD. Her enzyme leak was representative
of demand ischemia in the setting of hypertensive urgency and
tachycardia upon her initial presentation to the outside
hospital. Her ECG's were unchanged upon admission and CK and
troponin remained flat. No evidence of ACS and no cardiac
catheterization was indicated. Continued ASA, Lopressor,
lisinopril.
.
# Pump
ECHO [**3-5**] showed severe LVH, moderate to severe AS, with
diastolic dysfunction with preserved and hyperdynamic EF of 75%.
Patient should have daily weight with goal to keep her
euvolemic, she did not require any furosemide. Started
metoprolol to mantain and lisinopril to mantain heart rate
control. She has been on lisinopril long term, concern of
dropping afterload with ACE in setting AS is more theoretical
than seen clinically. Isordil and HCTZ were discontinued as her
BP was well controlled on current regimen. Her MVR showed no
gradient or evidence of MR. [**Name13 (STitle) **] will need repeat TTE in [**2-23**]
months to evaluate her aortic valve, given that her dyspnea
resolved with no evidence of heart failure a CT surgery
consultation was not indicated.
.
# Rhythm
NSR currently. H/O atrial fibrillation, on coumadin chronically.
Unclear if she was actually in Afib at [**Location (un) **] or just sinus
tachycardia. Heparin was started on admission and coumadin was
initially held in case of any procedures. As now procedures wer
planned coumadin was restared and INR was 2.4 on the day of
discharge; therefore heparin gtt was held. She will need INR
check in 2 days, her goal INR is between 2.5 and 3.5, in
addition to her baby aspirin.
.
# Valves
MVR in [**2177**]. Multiple ECHOs without evidence of MV stenosis or
regurgitation. ECHO at OSH without evidence of HOCM. She will
need INR check in 2 days, her goal INR is between 2.5 and 3.5,
in addition to her baby aspirin.
.
# HTN
Continued lopressor and lisinopril, stopped isordil and HCTZ.
Baseline BP runs 90-100s.
.
# SOB/hypoxia
Had no evidence of PNA, edema, infiltrate on CXR. PE unlikely as
she has been anticoagulated since admission to [**Location (un) **] and on
coumadin prior to that, although unclear what INR was as an
outpatient (2.0 on admission). CT chest without contrast showed
no abnormal findings at OSH. Initial consideration for
orthodeoxyea as O2 sat seemed to worsen with sitting upright,
but on redo of this maneuver, this was not replicated. ? COPD as
pt has tob history and ? COPD on OSH CXR as well as elevated
bicarb which may be due to chronic CO2 retension. Patient was
treated for COPD exacerbation with short 3 days pulse steroids
and nebulizer treatments. Her hypoxia resolved and at discharge
she was saturating 95% on room air. She has underlying COPD and
will need outpatient PFT's to evaluate her lung disease.
.
# VRE UTI
Was initially on Cipro which was changed to linezolid 10 day
course given her VRE.
.
# Mental status change
A&O x 0 at initial presentation which is markedly different than
baseline. Per family, has not been completely normal since
extubation. Etiologies include bleed, stroke, toxic/metabolic.
CT head showed only age related atrophy, RPR, B12 and folate
WNL. This is likely toxic/metabolic encephalopathy secondary to
VRE UTI, she was initially on ciprofloxacin which was not
adequate coverage, once sensitivities returned she was switched
to linezolid. Her mental status improved throughout
hospitalization although she waxes and wanes which is consistent
with resolving delirium, she was alert to person, place, DOB at
time of discharge. Mental status should continue to improve,
recommend to complete course of linezolid, frequent
re-orientation and support of her family.
.
# DM
No history of DM, but came from OSH on ISS. Continue ISS and
follow up with her outpatient PCP [**Name Initial (PRE) **] HgbA1c and consideration
of switch to oral regimen if indicated.
.
# Hypothyroidism: Levothyroxine
.
# Code: Full
.
# Communication: Patient, daughter [**Name (NI) 717**] [**Telephone/Fax (3) 78031**]
Medications on Admission:
MEDICATIONS AT HOME:
Coumadin 5mg daily
Hydrochlorothiazide 25mg daily
Quinipril 20 mg daily
Synthroid 75mcg daily
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 25 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days: needs 7 more days.
11. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
atrial fibrillation
diastolic HF
MVR
hypertension
UTI
aortic stenosis
hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital for shortness of breath likely
due to fast heart rate and high blood pressure and component of
COPD. Also, while you were here, you were found to have a
urinary tract infection.
.
You also had a very high blood pressure when you were admitted
and you were started on a new antihypertensive medication. You
will continue with Lopressor and lisinopril, your HCTZ was
discontinued.
You were started on an antibiotic called Linezolid which you
should continue to take to complete a 10day course.
Followup Instructions:
Please follow up with your outpatient cardiologist Dr. [**First Name (STitle) **]
within the next 2-4 weeks
Please call Dr.[**Name (NI) 78032**] office at [**Telephone/Fax (1) 58624**] to schedule
follow up in next 2-4 weeks
You will need a follow up echocardiogram in [**2-23**] months to
reassess your valve.
|
[
"5990",
"2760",
"4280",
"42731",
"4019",
"V5861",
"2449"
] |
Admission Date: [**2146-5-9**] Discharge Date: [**2146-5-12**]
Date of Birth: [**2093-1-15**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4181**]
Chief Complaint:
Post tonsillectomy Hemorrhage
Major Surgical or Invasive Procedure:
Control/Cauterization of right tonsillar fossa
History of Present Illness:
50yM with carcinoma of right tonsil with metastases to right
neck POD5 s/p right extended tonsillectomy developed profuse
bleeding. Patient was transported to OSH where he was intubated
for airway protection and his oropharynx and nose was packed.
He was then medflighted to [**Hospital1 18**] for further management after
being transfused and volume repleted.
Past Medical History:
Gout
Carcinoma of right tonsil as above
Physical Exam:
Intubated and sedated
Nose: rapid rhino pack in both nares
Oropharynx: copious blood clots. Blood soaked gauze packing
removed. Bleeding site identified in right tonsillar fossa that
was status post unilateral extended tonsillectomy.
Neck: right level 2 and 3 firm [**Doctor First Name **]
Brief Hospital Course:
Patient was taken to the operating [**2146-5-9**]. A slow ooze
was visualized from the right tonsillar fossa which was
cauterized. The patient was then observed intubated overnight
in the surgical ICU. On POD 1 he was successfully extubated and
transferred out to the regular surgical floor. His diet was
advanced to clear liquids and then soft solids which he
tolerated well. He was discharged home on POD3 without further
event.
Medications on Admission:
keflex
roxicet
indomethacin
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*300 ML(s)* Refills:*0*
2. Cepacol 2 mg Lozenge Sig: [**11-21**] Lozenges Mucous membrane Q4H
(every 4 hours) as needed for sore throat.
Disp:*50 Lozenge(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Post tonsillectomy bleed
2) Metastatic tonsil cancer
Discharge Condition:
good
Discharge Instructions:
Soft solid diet for two weeks. Follow up as soon as possible
with Dr. [**Last Name (STitle) 61621**] to co-ordinate your cancer care. Go to your
closest ER immediately if you experience any further bleeding
Followup Instructions:
Call Dr.[**Name (NI) 61622**] office for follow-up appointment as soon as
possible
|
[
"2859"
] |
Admission Date: [**2122-2-4**] Discharge Date: [**2122-2-26**]
Date of Birth: [**2047-8-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Cirrhosis, ESLD, fatigue and malnutrition now s/p liver
transplant
Major Surgical or Invasive Procedure:
[**2122-2-7**]: Paracentesis
[**2122-2-8**]: Paracentesis
[**2122-2-10**]: Paracentesis
[**2122-2-14**]: Liver transplant
History of Present Illness:
74-year-old male from [**Country 4194**] with h/o cirrhosis [**2-9**] to
schistosomiasis treated many years ago with episodes of
encephalopathy, esopageal varices, who has decompensated over
last 6 months currently listed for liver transplant with the
most recent MELD score of 39. He p/w ascites and sob on [**2-4**] to
[**Hospital1 18**].
Paracentesis was performed on [**2-8**] and [**2-8**]. Fluid has been
negative. Dyspnea has improved after para's and diuretics, but
renal function has worsened with creat up to 1.5 from 1.2.
Receiving octreotide/midodrine for HRS. Levaquin and Flagyl were
started for possible aspiration pna as crackles noted on LLL
[**2-9**].
CXR on admit did not show evidence of pna. Rpt cxr [**2-9**] again was
negative for pna. Sputum culture was contaminated. Lactulose and
rifaximin continued for encephalopathy. He has had multiple
BMs/day attributed to lactulose, but a c.diff was sent on [**2-11**]
which was negative. A urine culture was sent on [**2-11**] showing
>100,000 colonies of enterococcus sensitive to vanco.
Past Medical History:
- Cirrhosis h/o variceal bleed in [**10/2116**] s/p banding, thought
[**2-9**] schistosomiasis. Last EGD in [**1-14**] with ligated varices and
gastropathy
- Schistosomiasis on serology IgG, not confirmed on liver
biopsy.
- "Hepatitis" at age 18 characterized by jaundice, abdominal
pain, nausea and vomiting. HAV Ab positive, HBV immunized, HCV
not tested.
- s/p Splenectomy in [**4-14**]
- Pancreatitis
- Benign prostatic hypertrophy
- Aplastic Anemia
- Status post cholecystectomy
Social History:
Patient emigrated from [**Country 4194**] in [**2101**]. Patient lives in MA. He
is married with 4 children. Works as a dishwasher and
maintenance worker. Denies tobacco and drugs. Rare EtOH.
Family History:
Patient had two sisters who died with "cirrhosis" of unknown
etiology. Aunt - diabetes [**Name2 (NI) **]
Physical Exam:
98.1 63 118/66 20 96%RA WT: Gluc 114am.310 at 3pm
(received 6 units humalog)
wife translated for husband
alert, [**Name2 (NI) 27723**]. wife present. very jaundiced. Frail appearing
mmm dry. feeding tube in R nares
neck no jvd, no lad
lungs rales bibasilar (R>L)
cor RRR, no murmurs
Abd very disteneded (ascites, tense). well healed midline scar.
dull on R side. tympanitic over gastric area/LUQ. NT. faint BS
ext 2+ DPs. pitting edema to upper shins bilat.
skin: dry, icteric, warm
M/S: no joint swelling. spine NT. No CVAT
Neuro: A&O, toes down.
Pertinent Results:
Upon Admission: [**2122-2-4**]
WBC-12.0* RBC-3.48* Hgb-12.0* Hct-35.0* MCV-100* MCH-34.4*
MCHC-34.3 RDW-18.4* Plt Ct-198
PT-32.0* PTT-51.5* INR(PT)-3.3*
Glucose-116* UreaN-44* Creat-1.2 Na-137 K-4.6 Cl-111* HCO3-16*
AnGap-15
ALT-110* AST-199* LD(LDH)-345* AlkPhos-324* TotBili-22.8*
Albumin-2.6* Calcium-8.9 Phos-3.1 Mg-2.4
At Dischat=rge: [**2122-2-26**]
WBC-14.6* RBC-2.98* Hgb-9.5* Hct-27.3* MCV-92 MCH-32.0 MCHC-34.9
RDW-16.8* Plt Ct-300
PT-13.3 PTT-24.1 INR(PT)-1.1
Glucose-50* UreaN-22* Creat-0.8 Na-134 K-4.8 Cl-104 HCO3-24
AnGap-11
ALT-32 AST-19 AlkPhos-112 TotBili-1.2
Calcium-7.9* Phos-2.9 Mg-1.4*
Brief Hospital Course:
74 y/o male initially admitted to the hepatology service with
increasing ascites and shortness of breath. He required
paracentesis x 3 and a Dobhoff feeding tube was placed due to
concerns for malnutrition. On [**2122-2-14**]: a liver became available
and he was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for an
orthotopic liver transplant. The surgery was unremarkable, he
received 11 units of FFP, 11 units of packed cells and 2
platelets with an EBL of 1500 cc. The liver made bile on the
table, he was transferred intubated to the SICU.
He received routine induction immunosuppression and was treated
for a recently discovered Vanco sensitive enterococcus in the
urine at the time of transplant. This was subsequently treated
with IV ampicillin for an 8 day course. Subsequent urine culture
was negative.
He was extubated on POD 1 and he was transferred to the regular
surgical floor on POD 3.
He made excellent post op progress, was ambulating with walker
and was tolerating diet with calorie counts being adequete
enough to d/c the Dobhoff and tube feeds as previously ordered.
Both JP drains were removed prior to discharge. He had no
difficulty with voiding once Foley was removed.
He was followed by [**Last Name (un) **], and was initially on insulin, but
they felt for discharge home he could be managed with PO Prandin
and follow-up as an outpatient.
His WBC trended up and he had low grade fever around POD 8. All
cultures were negative, his chest xray was clear and the WBC
started to trend back down.
Liver function improved daily with enzymes WNL by day of
discharge.
Medications on Admission:
cholestyramine 4", lactulose 30qid, nadolol 40', rifaximin
400'", Iron 325', hydrocortisone cr 1% tp qid, clotrimazole 1
troche 5x/day, octreotide 100"', midodrine 5"', flagyl
500"'(started [**2-9**]-Dr. [**Last Name (STitle) 497**] rec stopping [**2-13**]), levofloxacin
250'(started [**2-9**]), bicitra 30ml tid, Nutren 2.0 at 35cc/hr,
insulin ss, lasix 20' (hold per Dr. [**Last Name (STitle) 497**], spironolactone 50mg
qd (stop per Dr.[**Last Name (STitle) 497**])
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p orthotopic liver transplant [**2122-2-14**]
h/o schistosomiasis
cirrhosis
DM
Malnutrition
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medication,
abdominal distension, incision redness/bleeding/drainage,
jaundice, blood sugars over 200s, or any concerns
Labs every Monday and Thursday, fax results to the transplant
clinic at [**Telephone/Fax (1) 697**]
Please check your blood sugars at least twice daily (Fasting and
4PM). Record values and bring to clinic and [**Last Name (un) **] visits
No heavy lifting
No driving if taking narcotic pain medication
You may shower, allow water to run over incision, pat dry, leave
open to air. No tub baths or swimming until notified otherwise
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-3-5**] 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51535**], M.D. Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2122-3-5**] 3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-3-10**] 10:00
[**Hospital **] Clinic for blood sugars: Call for appointment
[**Telephone/Fax (1) 2384**]
Completed by:[**2122-3-3**]
|
[
"5849",
"5990"
] |
Admission Date: [**2108-1-14**] Discharge Date: [**2108-5-12**]
Date of Birth: [**2108-1-14**] Sex: F
Service: Neonatology
HOSPITAL COURSE: This is a 26 and [**5-14**] week baby girl [**Name2 (NI) **]
to a 38-year-old G5, P now 4 mother with maternal labs of A+,
antibody negative, hepatitis B negative, rubella immune, RPR
nonreactive and GBS unknown who had rupture of membranes 6
hours prior to delivery. The baby was [**Name2 (NI) **] by repeat [**Name (NI) **]
section for preterm labor and breech presentation. In the
delivery room, the baby received positive pressure
ventilation as well as intubation and had Apgars of 8 and 8.
She has had a lengthy NICU stay and the hospital course by
system is as follows:
1. Respiratory. The baby was intubated in the delivery room
and received Surfactant, then was extubated to CPAP on day
of life 1, remained on CPAP until day of life 29 when she
was transitioned to nasal cannula until day of life 40 when\
she transitioned to room air. She had some mild
apnea of prematurity and was on caffeine through day of life
52 and has been without apnea and bradycardia since then.
2. Cardiovascular: The baby has a structurally
normal heart with an echocardiogram on [**2108-1-30**]
which revealed a patent foramen ovale as well as mild
left pulmonary artery stenosis or PTS. The baby continues
to have a heart murmur on exam and is cardiovascularly
stable.
3. Fluids, electrolytes and nutrition. The baby initially
was NPO and was started on hyperalimentation, had
umbilical arterial as well as umbilical venous lines. She
started feeds on day of life 3 and remains on
NeoSure 30 for suboptimal wieght gain at the time of
discharge. Over the last 3 days since switching to NeoSure
30 calories per ounce, she has gained at least 20 grams per
day. Renal calculi were noted indidentally on abdominal
ultrasound during a work-up for pyloric stenosis.
Urine oxalate is pending at the time of discharge. She has
been assessed by the CH nephrology service, who recommended
outpatient follow-up following discharge, with no need for
therapeutic intervention until then unless symptoms appear.
4. Gastrointesintal: The baby has been stable with some
reflux, is on Zantac 2 mg/kg per dose q. 8 hours. She had a
feeding team consultation from the [**Hospital3 1810**] who
recognized that she was immature on [**2108-4-26**] and
continued to follow her. They can be re-consulted as an
outpatient if need be if she has difficulty with feeding.
5. Hematology: The baby had hyperbilirubinemia and was on
phototherapy at the beginning of life. Her peak bilirubin
was 3.5 and came off bilirubin lights on day of life 7. Her
most recent hematocrit on DOL 98 34.2. She remains on iron.
6. Infectious disease: She received seven
days of ampicillin and gentamicin and had a negative
lumbar puncture on day of life 4. She has remained off
antibiotics since then.
7. Neurological: Cranial ultrasound on [**1-16**] revealed a
right subependymal cyst. On [**1-25**], she had no IVH. On
[**2-17**], she had no IVH. On [**4-5**] she had a mild
ventricular asymmetry. Mild ventricular
asymmetry is stable on cranial ultrasound on [**5-11**].
8. From an ophthalmologic prospective, the most recent eye
exam on [**2108-4-10**] was immature zone 3 bilaterally and
3 week follow up was recommended with Dr. [**Last Name (STitle) 20756**] and on
[**2108-4-30**] she was mature and follow up in 9 months
was recommended.
Discharge Planning: She has passed 2 car seat positional
respiratory stability tests. She passed her hearing test on [**2108-4-10**]. Her state screen was negative on [**2108-2-25**]. She
received her hepatitis B vaccine on [**2108-2-22**] and then
she received her hepatitis B #2 on [**2108-3-21**] as well as her
two-month immnunization course for polio, diptheria, pertussis,
HIB and Prevnat on [**2108-3-21**]. She also received
Synagis on [**2108-1-27**], [**2108-2-28**], and [**2108-3-31**].
Physical Examination at Discharge: She was afebrile.
Her heart rates were 140s-170s. Her respiratory rates were
30s-60s in room air. She had a blood pressure of 87/37 with a
mean of 54. From a general prospective, she is pale but well
perfused. Her HEENT exam, anterior fontanelle is open and
flat. She has mild dolicocephaly. She has an intact palate and
moist mucous membranes. Her lung exam, clear bilaterally, no
retractions, no increased work of breathing, no crackles, no
wheezes. From a cardiovascular prospective, she has a 2/6
systolic murmur heard best over the left upper sternal
border. She has good bilateral femoral pulses 2+ as well as
distal dorsalis pedis pulses bilaterally. She is well
perfused and has capillary refill of less than 2 seconds.
From an abdominal prospective, her belly is soft. She has
bowel sounds. She has no hepatosplenomegaly and no masses.
Her liver is palpable less than 1 cm below the right costal
margin. From a GU prospective, she has [**Male First Name (un) 33542**] 1 and has
normal external female genitalia. She has no sacral dimple.
From a musculoskeletal prospective, her hips and clavicles
are intact. From a neurologic prospective, she has normal
tone, normal grasp, normal Moro. She can fix with her eye
movements.
Her condition at discharge is stable. Her discharge
disposition is home. Her name of her pediatrician is Dr.
[**Last Name (STitle) 17494**], phone #[**Telephone/Fax (1) 17663**]. I spoke to her today. Her fax
number is [**Telephone/Fax (1) 70877**].
Care recommendations. Feeds at discharge are NeoSure 30 and
would recommend continuing that until 4-6 months, 26 calories
per ounce by concentration and 4 calories per ounce by corn
oil, with weaning if weight gain is appropriate. Her medications
include just Zantac 2 mg/kg per dose q.
8 hours or 6 mg p.o. q. 8 hours.
Iron supplementation is recommended for preterm and low birth
weight babies until 12 months of age, and her car seat should be
positioned in the back seat facing the back, strapped in. Her
newborn screen status is complete.
Synagis RSV prophylaxis should be considered from [**2108-12-8**] through [**2109-3-9**] for infants who meet any of the
following 4 criteria:
1. [**Year (4 digits) **] at less than 32 weeks.
2. [**Year (4 digits) **] between 32-35 weeks with 2 of the following: Day
care during RSV season, a smoker in the household,
neuromuscular disease, airway anomalies, or school age
siblings;
3. Chronic lung disease, or
4. Hemodynamically significant congenital heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers. This infant had not
received Rotavirus vaccine. The American Academy of
Pediatrics recommends initial vaccination of preterm infants
at or following discharge from the hospital if they are
clinically stable and at least 6 weeks but fewer than 12
weeks of age.
Follow up appointments need to be made for ophthalmology in 9
months at 1 year of age. Follow up is also recommended for
nephrology and the mother has information for making that
appointment. Additionally, the feeding team from
[**Hospital3 1810**] has seen the baby and can be of use in
the future as an outpatient as indicated.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Respiratory distress syndrome, resolved
3. Suspected sepsis, resolved
4. Apnea of prematurity, resolved
5. Failure to thrive.
6. Feeding immaturity, resolved
7. Heart murmur secondary to peripheral pulmonic stenosis
8. Renal calculi.
9. Gastroesophageal reflux.
10. Cerebral ventricular asymmetry
Please call if there are any further questions or concerns.
Our phone number here is [**Telephone/Fax (1) 41276**].
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 70878**]
MEDQUIST36
D: [**2108-5-11**] 17:39:56
T: [**2108-5-12**] 10:19:42
Job#: [**Job Number 70879**]
|
[
"7742",
"V053",
"V290"
] |
Admission Date: [**2107-9-22**] Discharge Date: [**2107-10-4**]
Date of Birth: [**2050-5-20**] Sex: F
Service: NEUROLOGY
Allergies:
Nystatin
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
Agitation, auditory hallucinations
Major Surgical or Invasive Procedure:
Lumbar Puncture
Intubation/Extubation
History of Present Illness:
The patient is a 57 year old woman with a history of spastic
paraparesis, hypertension, and autoimmune hepatitis on
azathioprine who presents with a 7 day history of herpes zoster
rash in left V1 distribution on Valtrex for 4 doses, and a 2 day
history of increased agitation and auditory hallucinations.
On Friday evening (7 days PTA), she developed an erythematous,
raised rash on her left forehead and eyelid. She took some
Benadryl thinking the rash may have been an allergy, with no
change in the rash. At the same time she developed a headache
which improved with ibuprofen and the Benadryl. On Monday (4
days PTA), she went to her PCP who diagnosed her with shingles,
and prescribed Valtrex. She took a total of 4 doses of Valtrex.
She was also seen by opthomology as an outpatient given the V1
involvement of her zoster.
On Tuesday night (2 days PTA) around 11 pm, she became very
agitated. Her husband found that she was hearing things that
weren't there and talking to people who weren't in the room. He
reports that she thought she was "talking to friends on the
internet via telepathy." Overnight that night she continued to
be agitated and confused, having conversations with people who
were not there. However, if her husband asked her a question,
she responded appropriately and apparently was aware of her
surroundings and location. She also was having an exaggeration
of her normally spastic movements of her feet. She has never had
any symptoms of agitation like this before, and her husband is
not aware of any recent ingestions or sick contacts. Because of
these symptoms, she was taken to an OSH ED.
On ROS, she did not have any subsequent headaches after the
headache 7 days PTA. One week ago she had an episode of
diarrhea, but did not have any abdominal pain. Five days ago she
vomited up some juice that she was drinking, and did complain of
nausea. They have a vacation home in [**Location (un) 3844**], and the last
time they visited was [**9-4**]; however, she did not complain of any
tick bites or rashes.
She was initially seen at [**Hospital6 1597**] on [**2107-9-21**], where
she was noted to have "uncontrolled movement extremities, also
hearing voices, talking back to them, paranoid." Their
differential was exacerbation of movement disorder, valtrex
induced vs. drug interaction, or HSV encephalitis. UA was
normal. It was dtermined LP was a high risk procedure given her
involunatary movements. She was transferred to [**Hospital1 18**] for
neurological evaluation.
In the [**Hospital1 18**] ED, vitals on admission were temp 99.2, HR 70, bp
132/72, RR 20, SaO2 99%. She was intubated with Rocuronium 60 mg
IV, Etomidate 20 mg IV x1, and started on a Propofol gtt, as she
was unable to lay still for LP or head CT. Neurology was
consulted. LP showed 101 WBC with 76% lymphocytes, Head CT
showed no acute intracranial process, and CXR showed right basal
atelectasis, which in this setting, may be secondary to
aspiration. She was given Ceftriaxone 2 gm IV and Acyclvir 700
mg IV x1, Tylenol 1 gm PO x1, and 2 L NS. She was admitted to
the NeuroICU.
Past Medical History:
-Spastic Paraparesis, CSF negative for HTLV-I/II, VDRL,
oligoclonal bands [**1-10**], seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] in Neurology as
an outpatient
-Hypertension
-Autoimmune hepatitis, s/p liver biopsy [**12-7**], previously [**Doctor First Name **]
and
Anti-Smooth Muscle Ab positive
-Depression
-Fractured vertebrae at age 20
-s/p left ankle arthroscopic surgery/repair
Social History:
She smoked as a teenager but does not currently smoke, has an
occasional glass of wine, and denies illicit drug use. She lives
with her husband in [**Name (NI) 1468**].
Family History:
(per outpatient Neurology note): Her mother died at age 70 and
had taken DES during pregnancy. She also had suffered from
hypertension, high cholesterol, and melanoma. Her father died
at 62 and had a very unsteady gait and [**Last Name **] problem/dementia
when older. Her father also suffered similarly stiff legs with
onset at around age 55, though apparently he was diagnosed as
possibly having "Parkinson's disease". She does not know any
significant history regarding her grandparents other than that
her maternal grandfather died at a young age from a fall. Her
sister is aged 57 and has high blood pressure, high cholesterol,
and gallbladder problems.
Physical Exam:
VS: temp 95.6, bp 118/74, HR 53, RR 14, SaO2 100% on CMV, PEEP
5, PIP 20, Vt 513
Genl: Intubated.
HEENT: Sclerae anicteric, left scleral conjunctival injection,
no nuchal rigidity
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NT, slightly distended abdomen
Ext: Pneumoboots bilaterally
Skin: Crusted erythematous papules on left forehead, eyelid, and
nasal bridge.
Neurologic examination:
Mental status: Does not open eyes on command but does grasp
fingers on command bilaterally, shows 2 fingers. Agitated with
Propfol gtt off.
Cranial Nerves: Pupils 5 mm and sluggishly reactive to light (to
4.5 mm bilaterally). Corneal reflex intact bilaterally. Unable
to assess facial symmetry or tongue protrusion as intubated.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. Moving all 4 extremities against gravity.
Sensation: Withdraws all 4 extremities to nailbed pressure.
Reflexes:
[**Hospital1 **] Tri Br K A
Right 2+ 2+ 2+ 3+ 8 beats clonus
Left 3+ 3+ 3+ 3+ 8 beats clonus
Toe upgoing on the left, downgoing on the right.
Pertinent Results:
[**2107-9-21**] 05:35PM WBC-4.2 RBC-4.18* HGB-13.1 HCT-36.7 MCV-88
MCH-31.4 MCHC-35.8* RDW-14.7
[**2107-9-21**] 05:35PM ALBUMIN-4.4 CALCIUM-10.2 PHOSPHATE-3.9
MAGNESIUM-2.4
[**2107-9-21**] 05:35PM LIPASE-38
[**2107-9-21**] 05:35PM ALT(SGPT)-18 AST(SGOT)-25 ALK PHOS-107 TOT
BILI-0.5
[**2107-9-21**] 05:35PM GLUCOSE-94 UREA N-20 CREAT-0.8 SODIUM-136
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13
[**2107-9-22**] 01:35AM CEREBROSPINAL FLUID (CSF) WBC-101 RBC-12*
POLYS-2 LYMPHS-76 MONOS-19 MACROPHAG-3
[**2107-9-22**] 01:35AM CEREBROSPINAL FLUID (CSF) WBC-87 RBC-16*
POLYS-0 LYMPHS-77 MONOS-17 MACROPHAG-6
[**2107-9-22**] 01:35AM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
[**2107-9-22**] 01:35AM CEREBROSPINAL FLUID (CSF) PROTEIN-76*
GLUCOSE-51
[**2107-9-22**] 10:10AM [**Doctor First Name **]-POSITIVE TITER-1:160 PAT dsDNA-NEGATIVE
[**2107-9-22**] 10:10AM CRP-2.5
[**2107-9-22**] 10:10AM SED RATE-55*
[**2107-10-3**] 03:30PM BLOOD WBC-2.5* RBC-3.67* Hgb-11.3* Hct-32.4*
MCV-88 MCH-30.9 MCHC-35.0 RDW-16.4* Plt Ct-189
[**2107-10-3**] 03:30PM BLOOD Glucose-136* UreaN-9 Creat-1.0 Na-143
K-3.7 Cl-109* HCO3-28 AnGap-10
[**2107-10-3**] 03:30PM BLOOD ALT-23 AST-24 LD(LDH)-237 AlkPhos-88
TotBili-0.2
[**2107-9-25**] 04:15PM BLOOD ANCA-NEGATIVE B
[**2107-9-26**] 07:25PM BLOOD HIV Ab-NEGATIVE
[**2107-9-25**] 04:15PM BLOOD CERULOPLASMIN-35 wnl
[**2107-9-27**] 12:18PM CEREBROSPINAL FLUID (CSF) WBC-30 RBC-1* Polys-0
Lymphs-90 Monos-9 Atyps-1
[**2107-9-27**] 12:18PM CEREBROSPINAL FLUID (CSF) TotProt-54*
Glucose-46
[**2107-9-22**] 01:35AM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
[**2107-9-27**] 10:56AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
[**2107-9-27**] 12:18PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA
(PCR)-Test
EEG [**9-25**]: Normal EEG in the waking and drowsy states. There was
plentiful movement artifact. There were no areas of prominent
focal
slowing, and there were no clearly epileptiform features.
MRI Brain [**9-23**]
IMPRESSION:
1. Subtle enhancement within a slightly enlarged left fifth
cranial nerve,
which can be seen with Lyme disease. The enhancement can also be
seen in
herpes infection but is less typical. No additional areas of
leptomeningeal or
cranial nerve enhancement identified.
2. Cerebral atrophy and nonspecific FLAIR hyperintensities which
likely
represent small vessel ischemic disease.
Brief Hospital Course:
IMPRESSION/PLAN: The patient is a 57 year old woman with a
history of spastic paraparesis, hypertension, and autoimmune
hepatitis on azathioprine who presents with a 7 day history of
herpes zoster rash in the left V1 distribution on Valtrex for 4
doses, and a 2 day history of increased agitation and auditory
hallucinations. Her mental status on admission was significant
for decreased attention and concentration, and agitation. She
was intubated for LP, which showed 101 WBC with 76% lymphocytes
and 12 RBC, and head CT which showed no acute intracranial
process. Extubated [**9-23**]
She most likely has a viral encephalitis, VZV being the most
likely [**Doctor Last Name 360**]. Her symptoms were preceded by herpes zoster in the
V1 distribution, and she was on immunosuppression with
azathioprine which puts her at risk for infection. She has also
recently been to her cabin in [**Last Name (LF) 3844**], [**First Name3 (LF) **] Lyme was tested
and found to be negative. Given her history of autoimmune
disease, she was worked up for vasculitis and SLE causing her
symptoms, also negative. Her initial CSF was not sent for VZV
PCR secondary to lab error so a second LP was performed on [**9-27**].
This was done after several days of treatment with acyclovir
and VZV and HSV were negative. The CSF studies were improved
with a WBC count of 30. As part of her work-up she also had an
MRI showing trigeminal nerve enhanceement and EEG which was
unremarkable. With the improvement in her symptoms and CSF
leukocytosis her acyclovir dose was decreased to (5mg/kg) 250mg
IV q8. On [**9-30**] she had a low grade temperature and small
suspicious vesicle on her face. This was sent for VZV testing
but the sample was not adequate. With help from ID, her
acyclovir dose was increased to 10mg/kg. She continued to
improve over the weekend and her dose was changed back to 5mg/kg
on [**10-3**]. She is due to complete a 21 day course of IV acyclovir
at 250mg IV q8. Day 1 is [**2107-9-23**].
-Ophtho consulted: No evidence of herpes zoster ophthalmicus, no
corneal involvement, will need ophtho follow up as outpatient
- Psychiatry consulted to help manage her psychosis - she was
initially started on seroquel with minimal effect. She was then
changed to zyprexa and as the dose was titrated up, she has an
improvement in her symptoms. Most of her delusions and
hallucinations are centered around her husband hurting or
abusing other people. Social work and psychiatry, as well as
the primary team, feel these thoughts are not based in any
reality after talking to several family members and friends.
- Cards - Her BP meds were initially held but gradually
restarted as her BP's trended upward. She has been
hemodynamically stable throughout admission.
- FEN/GI:-LFTs normal -Holding Azathioprine for now as do not
want to immunosuppress during infection, Has liver follow up as
outpatient. She will require IVF while on Acyclovir
7. PPx: Heparin SC tid, Pneumoboots, Tylenol prn, RISS, Colace,
Famotidine 20 IV q12
Medications on Admission:
Azathioprine 50 mg daily
Toprol XL 100 mg daily
Norvasc 5 mg daily
Celexa 20 mg qAM, 10 mg qPM
Valtrex (started [**2107-9-19**], stopped [**2107-9-20**])
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Injection TID (3 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO QPM (once a day
(in the evening)).
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for hallucination.
10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) cap PO
DAILY (Daily).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
15. Olanzapine 2.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
16. Acyclovir Sodium 500 mg Recon Soln Sig: 0.5 Recon Soln
Intravenous Q8H (every 8 hours) as needed for meningitis: 250mg
q8.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
VZV Encephalitis
Discharge Condition:
Improved
Discharge Instructions:
Please follow-up with neurology and GI as arranged. Because of
the severity of your infection, you will need to complete 21
days total of IV antiviral therapy. If you do not finish this
course you would be at risk of not fully treating the infection.
All your symptoms may not be cleared by the time the therapy is
completed but should continue to improve after you are done. If
you have any new symptoms, please call the hospital and ask for
the on call neurologist.
Followup Instructions:
Neurology: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 396**] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 1040**]
Date/Time:[**2107-11-4**] 4:00. [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital1 18**] [**Hospital Ward Name 516**].
Gastroenterologist Dr [**First Name (STitle) 679**]: Thursday [**11-10**] at 10:15, at [**Last Name (NamePattern1) 12939**] #8A
After discharge from rehab, call your PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2671**]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 26774**] to arrange a follow up appointment.
|
[
"5180",
"4019",
"311"
] |
Admission Date: [**2160-5-21**] Discharge Date: [**2160-6-6**]
Date of Birth: [**2100-4-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Cardiogenic shock in setting of dilated cardiomyopathy and rapid
Atrial flutter
Major Surgical or Invasive Procedure:
-s/p Atrial Flutter ablation
-s/p Swan-Ganz catheter placement
-s/p impella device
-s/p intubation
-s/p CVVH
-s/p tunneled line placement for HD
History of Present Illness:
60 yo M with dilated cardiomyopathy (EF 15%) and poor past
medical compliance who presented to OSH on [**5-20**] with SOB, LE
edema and chest congestion. In the ED he was found to be in AF
with RVR (150 bpm) and hypotensive. He was given lopressor,
adenosine and verapamil in the ED but did not convert, so he was
cardioverted electrically and returned to sinus rhythm.
.
Pt was in his usual state of health until one year ago when his
second round of lithotripsy was cancelled because of
tachycardia. On follow-up, his HR was 80-90 bpm, but he did not
follow up with the echo and ETT that were ordered. About two
weeks prior to this admission he began feeling short of breath
and "congested", which he attributed to his allergies. His
family notes that he began cutting back on his gardening and did
not feel able to dog-sit for his daughter. [**Name (NI) **] was seen by a
physician for his "allergies" and was prescribed a steroid
inhaler and ordered a cardiac echo. Echo on [**2160-5-16**] showed EF 15%
and WMAs. He then followed up with his PCP for continued SOB and
EKG showed narrow complex tachycardia at 150-160 with poor
R-wave progression, and he was sent to the ED.
.
In the OSH ED, he also received lasix and antibiotics as
empirical treatment for ? pneumonia. He deteriorated overnight
and required intubation and pressors (dobutamine and dopamine).
He also received solu-medrol for ? COPD flare. A right IJ was
placed.
On review of systems, he notes cough productive of brown-colored
phlegm but no hemoptysis or hematemesis. He also notes pedal
edema and orthopnea. He denies any prior history of stroke, TIA,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains. 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,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
.
Initial data from OSH:
- ABG 7.1/42/69 -> 7.28/39/402
- Troponin 0.07
- BNP 4,511 -> 11,455
- Blood cx pending
- no evidence of pneumothorax
- CBC 10.5 > 44.4 < 164
- Chem: 136 | 102 | 29 / 150
4.4 | 22 | 0.92 \
- Ca 9.1, Mg 1.7, P 3.4
- TSH 2.82
Past Medical History:
- COPD
- Rheumatoid Arthritis
- nephrolithiasis s/p lithotripsy x1. was scheduled for a second
round but developed tachycardia and procedure was cancelled
- "No other GI issues of colitis" per chart
- "No h/o thyroid, stroke or MI" per chart
- cholecystectomy
Social History:
Married, retired firefighter. Has children.
- Smoking: extensive history; recently cut down to 1/2 ppd, 2
weeks ago cut down to 1/day. was using nicorette gum at home,
per chart.
- EtOH: Occasional.
Family History:
- Father with DM2
Physical Exam:
PHYSICAL EXAMINATION:
VS: T= 98.6 BP= 123/54 HR= 85 RR= 18 O2 sat= 99% on RA
GENERAL: WDWN male, intubated and sedated.
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not visible due to bandages.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities. No accessory muscle use.
Crackles and rhonchi bilaterally at bases.
ABDOMEN: Soft, non-distended. No HSM.
EXTREMITIES: Trace pedal edema. No c/c. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
Pertinent Results:
[**2160-6-6**] 06:02AM BLOOD WBC-11.4* RBC-2.44* Hgb-7.8* Hct-24.7*
MCV-101* MCH-32.0 MCHC-31.6 RDW-17.6* Plt Ct-124*
[**2160-6-4**] 04:22AM BLOOD Neuts-87.7* Lymphs-6.4* Monos-4.1 Eos-1.7
Baso-0.2
[**2160-6-6**] 06:02AM BLOOD Plt Ct-124*
[**2160-6-6**] 06:02AM BLOOD Glucose-141* UreaN-84* Creat-7.5*# Na-137
K-4.2 Cl-99 HCO3-28 AnGap-14
[**2160-6-6**] 06:02AM BLOOD ALT-49* AST-40 LD(LDH)-242 AlkPhos-110
TotBili-1.5
[**2160-6-6**] 06:02AM BLOOD Calcium-8.2* Phos-4.9* Mg-2.4
[**2160-5-21**] 04:59PM BLOOD %HbA1c-6.0*
[**2160-5-21**] 04:59PM BLOOD Triglyc-58 HDL-27 CHOL/HD-4.1 LDLcalc-73
[**2160-5-21**] 04:59PM BLOOD TSH-0.89
[**2160-6-6**] 06:02AM BLOOD Digoxin-2.3*
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2160-6-5**]):
Feces negative for C.difficile toxin A & B by EIA.
Brief Hospital Course:
This is a 60 year-old gentleman with dilated cardiomyopathy (EF
15%) who was admitted in cardiogenic shock and rapid Aflutter
now s/p AF ablation and s/p impella device, s/p dialysis for ATN
and s/p self-extubation.
.
PUMP: Mr. [**Known lastname 37557**] was transferred from an outside hospital in
cardiogenic shock in the setting of dilated cardiomyopathy with
EF 15% on echo and Aflutter with rapid ventricular response. He
was transferred with dopamine and dobutamine for hemodynamic
support and was stable on these pressors. An echocardiogram on
arrival to [**Hospital1 18**] showed LVEF 10%, ASD with L->R shunt, LV
dilation, RV dilation, RV severe global free wall hypokinesis.
On the day after admission, he was switched to phenylephrine and
milrinone and an impella device was placed in the cath lab for
left ventricular support. A swan-ganz catheter was also placed
for hemodynamic monitoring. Initial fick numbers were
5.7/2.9/1103 on the Impella device. In addition, he was started
on prednisone 40mg daily for the possibility of giant cell
myositis underlying his dilated cardiomyopathy, but this was
stopped after two days as his CO improved with the impella
device, the low likelihood of myositis in this clinical
scenario. In addition, due to initial concern that he might
deteriorate and require cardiac transplantation, he was tested
for Hep A,B,C and CMV Abs which were all negative. An
echocardiogram was repeated after the impella device was placed
and showed mild decrease in LV size and mildly improved LV
function to 10-20% EF. Another echo on [**5-25**] showed continued
improvement in systolic function with EF 40%, and the impella
was removed. Pressors were weaned off on the following day, and
another echo showed EF 30-35% and improved RV free wall motion.
Another echo on [**5-27**] during AF/flutter showed overall improving
LV function but significantly impaired SV during beats following
short diastolic filling times, with an EF ranging from 20-40%
depending on diastolic filling time. Rate control therefore
became his primary goal, as described below. Phenylephrine was
required initially to accomodate the higher doses of metoprolol,
but was discontinued on [**6-2**], after which he remained
hemodynamically stable both in NSR and occasional AFib without
pressors.
.
He was initially volume overloaded and was gently diuresed for
preload reduction and relief of his pulmonary edema, but
required pressors for hemodynamic support. He initially
responded well to lasix, but as his renal function deteriorated,
he required diuril to maintain urine output. On [**5-23**], it was
determined that he had ATN (see renal section below), and on
[**5-24**] his urine output dropped significantly despite lasix and
diuril. CVVH was started on [**5-26**], which was transitioned to
intermittent HD through a temporary R IJ line and ultimately a
tunneled line was placed by IR for HD on [**6-5**].
.
RHYTHM: His initial EKGs from OSH showed likely Afib vs Aflutter
with 2:1 block that was refractory to lopressor, adenosine,
verapamil and converted with DCCV. He remained tachycardic
(120-140) for the first day of admission and underwent ablation
on [**5-23**] for atrial flutter. This initially reverted him to
sinus rhythm which significantly improved his hemodynamics, and
he was able to come off pressors. The following day, he
spontaneously restarted rapid AF/flutter to 170. He was
electrically cardioverted and started on digoxin, metoprolol,
and procainamide (given limited options for antiarrhythmics in
the setting of liver and renal failure), and returned to sinus
rhythm. The procainamide and digoxin were stopped two days
later due to worsening hepatic and renal function. He reverted
to AF again the following day, and his metoprolol was titrated
up to 100 mg tid since his CO was found to be highly dependent
on diastolic filling time on echo. Amiodarone was considered but
it was decided that his LFTs were still too high to accomodate
amiodarone. He continued to switch spontaneously between AF and
NSR multiple times over the subsequent several days, as his LFTs
slowly began to normalize. On [**5-30**] he was loaded again with
digoxin for improved rate control. He was initially
anticoagulated with heparin IV but this was discontinued on
[**6-2**], after 48 hrs of NSR due to thrombocytopenia. He had short
episodes of AFib on [**6-3**] and [**6-4**] which lasted for 90 min and 5
hours, respectively and both resolved spontaneously without
symptoms hemodynamic consequences and requiring no pressors.
.
CORONARIES: He has no known history of CAD, no previous
diagnostic workup, no Q waves on EKG. However, given smoking
history and initial [**Location (un) 1131**] of regional wall-motion
abnormalities on echo, the dilated cardiomyopathy was first
thought to be ischemic in etiology. His cardiac enzymes peaked
on the day of admission with CK 316 at OSH, and likely
represented cardiac strain in setting of tachycardia and pump
failure. EKG did not suggest acute ischemic changes. He was kept
on aspirin and statin, and a beta blocker was added when his
hemodynamics stabilized. Daily EKGs showed no ischemic changes.
On discharge, he was restarted on atorvastatin at a low dose
given his recent shock liver.
.
ARF: Baseline Cre <1.0. In the setting of cardiogenic shock, his
creatinine peaked at 9.7 on [**5-26**]. His FeUrea was 53%, suggesting
Acute Tubular Necrosis, likely related to hypoperfusion in
setting of cardiogenic shock. His urine output steadily
decreased as his renal function worsened, despite a lasix drip
and diuril. On [**5-24**] it was decided that he would likely require
dialysis and/or filtration. He was started on CVVH on [**5-26**]. CVVH
was initially through a groin line, which was changed to an
IR-guided R IJ line on [**5-30**]. A tunneled line was planned but not
placed because of persistant leukocytosis concerning for
bacteremia. His urine output decreased to <100cc per day for the
duration of his CVVH treatment, but his electrolyte balances
were normalized. HD was started on [**6-2**] and a tunneled line was
placed on [**6-5**] for long-term HD treatment.
.
Respiratory failure: Intubated at OSH for respiratory distress,
stable on low settings (FiO2 40%, PEEP 5) with good O2Sat.
Thought to be pulmonary edema in setting of heart failure
exacerbation. Likely not related to COPD given mild history and
no CO2 retention on OSH gases. Likely not PNA given afebrile and
negative CXR read and normal initial WBC on OSH admission. The
antibiotics and stress-dose steroids that were started in the
OSH were discontinued on admission. He initially required
increased FiO2 to 60% on the morning after admission, but his
blood gas results improved with diuresis and the FiO2 was
returned to 40% the following day. Daily CXRs showed worsening
atalectasis and pulmonary edema as his urine output declined
during his worsening renal function. He was initially sedated
with propafol at the OSH but was switched to fentanyl and
midazolam soon after admission. He started to be weaned off of
sedation on [**5-26**] and over the course of several days became more
responsive. He ultimately self-extubated on [**5-29**] and maintained
stable respiratory function since then.
.
Metabolic acidosis: His pH at the OSH 7.10. On admission, his pH
was 7.32. This was thought to most likely represent resolving
lactic acidosis in setting of cardiogenic shock. His acidosis
continued to improve with better oxygenation after diuresis, but
this improvement was limited by his declining urine output in
the setting of ATN. Once dialysis was initiated, his acidosis
continued to resolve.
.
Leukocytosis: On initial presentation to the OSH, his WBC was
10, which increased to 40.2 the following day, in the setting of
cardiogenic shock, electrical cardioversion and steroids. On
arrival to our hospital, his WBC was 24.2. This initial
leukocytosis was thought to be multifactorial, likely resulting
from acute demargination in setting of shock and electrical
cardioversion as well as steroid-induced leukocytosis. Of note,
he was afebrile during his entire hospital course. CXR on
admission showed likely retrocardiac atalectasis but not PNA.
Given isolated finding of high WBC, this was not thought to
represent sepsis and was not treated with antibiotics. Steroids
were also stopped on admission. However, by day 3 his WBC had
climbed to 29, and he was pan-cultured. On [**5-26**] his WBC peaked
at 46.2. One of four blood culture tubes showed
coagulase-negative staphylococci, most likely representing
contamination, but vancomycin was started to treat possible
bacteremia. [**12-14**] sputum cultures showed budding yeast with
pseudohyphae, likely representing colonization. This rise in WBC
was also in the context of a brief resumption of steroids for ?
giant cell myocarditis, as well as another electrical
cardioversion the day before, and therefore may have also
represented a combination of steroid-induced leukocytosis and
stress demargination. On [**5-27**] his WBC began to trend down
rapidly, falling from 46.2 to 28.7. He was noted to have RUQ
pain at this time on exam, but RUQ U/S and KUB were unrevealing.
The prednisone was stopped on [**5-27**] and vancomycin was redosed
for dialysis. On [**5-28**] he had a bowel movement and C.diff was
sent, which returned negative. His vancomycin was stopped at
this time. His WBC rose again on [**5-29**] to 32.3 and blood cultures
were re-sent but antiobiotics were not re-started and he
continued to be afebrile. WBC began to trend down again the
following morning, but remained chronically elevated in the 20s.
CXRs continued to show no evolving infiltrate. A heme/onc
consult was obtained and suggested that the leukocytosis was
likely reactive and not indicative of acute infection. Beginning
on [**6-4**], the WBC count began to trend down below 20, to 11 on
the day of discharge.
.
Transaminitis: His peak ALT was 3884 and AST 5088, on admission.
This was thought to represent shock liver in the setting of
hypoperfusion. With stabilization of hemodynamics, his LFTs
began to decrease steadily and normalized by the end of his ICU
stay.
.
Thrombocytopenia: On admission, platelet count was 107 and INR
was elevated at 2.8. The etiology for this initial
thrombocytopenia and coagulopathy was unclear. In the setting of
multi-organ ischemia and shock, there was initial concern for
DIC, and thrombin time was also elevated, but DIC labs showed no
elevated fibrinogen or FDP, and both the platelet count and
coagulopathy resolved over several days, likely related to
resolving hepatic function. However, the thrombocytopenia
recurred on [**5-23**] after placement of the impella device, along
with a dropping hematocrit, thought to be related to hemolysis
by the device. Both platelet count and hematocrit recovered and
stabilized at Hct 29-32 and PLT 112-128 after removal of the
device on [**5-25**]. On [**6-1**] the platelet count and hematocrit
dropped again, to 78 and 27.4, respectively. A heme/onc consult
was obtained and suggested that the low platelet count was
likely related to his initial shock and slow bone marrow
response, and was not consistent with heparin-induced
thrombocytopenia. By discharge, the platelet count had recovered
to 129,000.
.
Mental Status Changes: As sedation was weaned off, he became
responsive to verbal commands and became increasingly
communicative. However, he remained oriented only to person. It
is thought that his poor mental status was likely related to
decreased metabolism/excretion of his sedating drugs in the
setting of hepatic and renal failure. He was found to have some
weakness of R foot dorsiflexion and proximal R arm extension but
no other focal or lateralizing neurological deficits, and these
were thought to represent mild deconditioning. By discharge, the
proximal R arm weakness had improved substantially and
dorsiflexion had improved mildly. He continued to have
difficulty with swallowing which required NG tube for feeding.
.
RUQ Pain: While he was recovering from sedation, it was noted on
exam that he withdrew from deep palpation of the abdominal RUQ.
KUB and RUQ U/S were obtained and did not show any acute
hepatobiliary or intestinal processes. Therefore, the tenderness
was likely related to inflammation/reperfusion resulting from
shock liver. His RUQ tenderness had resolved by discharge.
.
COPD: There was no acute flare during his stay. He was continued
on his home ipratropium.
.
PROPHYLAXIS: DVT prophylaxis was covered by IV heparin regimen
for arrhythmia. Heparin was briefly discontinued due to concern
about HIT but was resumed after a heme/onc consult confirmed
that no HIT criteria had been met. He was maintained on a bowel
regimen of senna and colace, and also received suppositories to
facilitate bowel movements.
He was a FULL CODE during his entire stay in the ICU.
Medications on Admission:
MEDICATIONS ON TRANSFER:
Dopamine 20 mcg/kg/min
Dobutamine 5 mcg/kg/min
ASA 325 mg NG daily
Simvastatin 40 mg NG daily
Lovenox 80 mg sq [**Hospital1 **]
Ceftriaxone 1g IV daily
azithromycin 500 mg IV daily
Solu-Medrol 60 mg IV q8h
Albuterol/Atrovent q6h
Flovent 110 2 [**Hospital1 **]
Insulin ssi
Pantoprazole 40 mg IV daily
chlorhexidine [**Hospital1 **]
.
HOME MEDS:
ASA 81 mg daily
Sulfasalazine 500 mg [**Hospital1 **]
Peroxicam 20 mg daily
fluticasone nasal spray
albuterol inhaler
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
Disp:*1 * Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*90 Tablet(s)* Refills:*2*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a week.
Disp:*12 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary: Cardiogenic shock
Secondary:
Dilated cardiomyopathy
Atrial flutter with rapid ventricular response
Atrial fibrillation with rapid ventricular response
Shock liver
Reactive leukocytosis
Acute tubular necrosis
Discharge Condition:
Improved. Vital signs were stable. Cardiogenic shock and shock
liver resolved by discharge. ATN and altered mental status much
improved, with likely resolutiong over time at the time of
discharge.
Discharge Instructions:
You were admitted to the hospital because of dangerously low
blood pressures that occured because of a dangerous heart rhythm
as well as heart failure. We gave you medications to increase
your blood pressure, and for a few days you had a device placed
in your heart to help pump blood. Your heart eventually
recovered, but you will need to follow up with a cardiologist.
You continued to have occasional dangerous rhythms, so you had a
catheter ablation procedure which eliminated the most dangerous
rhythm you were experiencing. However, you continue to have
occasional irregular rhythms, which we are controlling with
long-term medications. The low blood pressures also caused some
damage to your liver and kidney. Your liver has likely recovered
completely, but your kidneys have not. You have been receiving
dialysis because of your kidney failure. Your kidneys have
improved slightly, but will have to be followed up after you
leave the hospital to see if your kidneys will continue to
improve. You had a high white blood cell count but no infection,
and you are anemic. These will most likely resolve over time,
but you should follow up with your primary care physician to
monitor these changes. At this time, you still have some
weakness including in your swallowing muscles, and you should
not eat anything without supervision for now. Your nutrition
will be through the tube in your nose until you regain good
swallowing function. You do have some coronary artery disease as
well, for which you should continue taking aspirin and
atorvastatin every day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases > 3
lbs.
Adhere to a maximum of 2 gm sodium per day diet.
Medication changes:
START taking atorvastatin 20mg daily
START taking metoprolol 100mg three times each day
START taking warfarin 5mg daily
START taking digoxin 0.125mg once a week
START taking calcium acetate 667 mg daily
CONTINUE taking aspirin 81mg daily
Use the atrovent inhaler once every 6 hours for wheezing
Please see a doctor if you have palpitations, feel lightheaded
or faint, have chest pain, shortness of breath, swelling of your
ankles, weight gain of more than 3lbs in a day, or cough up
blood in your sputum.
Followup Instructions:
You have an appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8051**] on
Thursday, [**6-19**] at 11:30 AM
You should follow up with Dr. [**First Name (STitle) 437**], a cardiologist who
specializes in heart failure. You will be contact[**Name (NI) **] by Dr. [**Name (NI) 10875**] office. If you don't hear from them in the next week,
please call them at [**Telephone/Fax (1) 62**] to arrange an appointment one
month after discharge.
|
[
"42731",
"5845",
"51881",
"2761",
"4280",
"2875",
"496",
"2859",
"3051"
] |
Admission Date: [**2163-5-13**] Discharge Date: [**2163-5-24**]
Date of Birth: [**2108-6-7**] Sex:
Service:
CHIEF COMPLAINT: Urticaria/diabetes. Question of insulin
allergy.
HISTORY OF PRESENT ILLNESS: Elective admission for a 54-year-
old male with history of insulin-dependent diabetes x 20
years and urticaria, now to be evaluated for persistent
urticaria with labile blood sugars x several months. The
patient had been on NPH x 20 years. However, in [**2162-10-9**], he reports fairly abrupt onset of urticarial reactions
he described as daily and co-relating with his insulin
administration. No reactions around the site of where the
syringe was introduced into the body. No shortness of
breath/tongue swelling/wheezing during these episodes. Over
the last several months, has changed insulin regimens without
any improvement in urticaria. Recently has been seen by Dr.
[**Last Name (STitle) 2603**] from Allergy, and started on Medrol, which resulted in
elevated blood sugars. The patient now being admitted for
improved blood sugar control in the setting of steroids and
management of urticaria to determine if remedies can be made
to the question of insulin allergy. Operational workup thus
far has shown specific IgG antibody negative on multiple
insulin regimens. Otherwise, he reports being in his usual
state of health. No fevers/chills/nausea or vomiting. No
chest pain, shortness of breath or palpitations. No sick
contacts. [**Name (NI) **] other rashes. No insect bites. No
detergents/cologne or clothing changes. No abdominal pain.
No changes in bowel/bladder habits. Of note, urticaria is
described as encompassing the whole body.
PAST MEDICAL HISTORY: Hypertension.
Insulin-dependent diabetes x 20 years.
Urticaria as per HPI.
CAD status post PCI in [**2162-5-9**] at outside hospital.
Cataract surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. NovoLog insulin 20/30 units subcutaneously t.i.d.
2. Medrol 4 mg p.o. b.i.d.
3. [**Doctor First Name **] 180 mg p.o. t.i.d.
4. Atenolol 25 mg p.o. once a day.
5. Doxepin 10 mg p.o. b.i.d.
6. Hydroxyzine 25 mg p.o. t.i.d.
SOCIAL HISTORY: Remote tobacco history. Lives in [**Hospital1 189**]
with wife. [**Name (NI) **] is a retired fabric worker.
FAMILY HISTORY: Has sons and daughters with diabetes.
PHYSICAL EXAMINATION ON ADMISSION: Afebrile at 97.8, blood
pressure 126/72, pulse of 88, respiratory rate 20, and 97
percent on room air. In general, a well-developed, well-
nourished, Hispanic male, looking very comfortable in no
acute distress, alert and oriented x 3. HEENT: Moist mucous
membranes. Oropharynx clear. Extraocular movements intact.
Cardiovascular: S1, S2, regular. No murmurs, rubs or
gallops appreciated. Pulmonary: Clear to auscultation
bilaterally. Abdominal examination is soft, nontender,
nondistended. Positive bowel sounds. Extremities: No
edema. Skin: No clear rashes/erythema at the time of
admission.
LABORATORY DATA: White count of 7.8, hematocrit 38.8, and
platelet count 163. Chemistries: Sodium 136, potassium 6.1,
chloride 103, bicarbonate 23, BUN 25, creatinine 1.3, glucose
420, calcium 9.6, magnesium 1.7, and phosphorus 3.5. ALT 15,
AST 12, and CPK 2.
HOSPITAL COURSE: Rashes/Urticaria: The patient was
initially admitted under the supervision of Dr. [**Last Name (STitle) 2603**] from
Allergy for further evaluation of the patient's urticarial
skin reactions thought secondary to insulin. In the past, he
had tried multiple insulin regimens and had reported
reactions with all types of insulin. Of note, these
reactions usually were found to be with skin that was quite
erythematous or raised, but without any signs of respiratory
compromise - i.e., there was no laryngeal or tongue swelling
or edema. Initially, the plan was for the patient to be
tapered off of his Medrol dosing and also tapered off
antihistamines. [**Last Name (un) **] was consulted for further help and
management of his diabetes given that his blood sugars are
elevated in the setting of markedly elevated steroid
requirements. During his hospital course initially, the
patient was found to have reactions usually in the evening
and initially thought secondary usually to NPH. There were 1-
2 reactions that he had in the setting of Lantus. His
reactions were somewhat unique for true insulin allergy,
given the fact that there was no local reaction at the site
where the syringe entered the skin. Also of note, he had had
previous IgG antibodies documented as negative when exposed
to insulin. Initially, there was also some question as to
whether patient was truly a type 1 diabetic requiring
insulin. Records from outside hospitals did in fact show
that he has a positive antiGAD antibody and negative C-
peptide antibody, showing that in fact he was type 1 diabetes
and would require insulin for treatment. There ultimately
was a trend towards moving patient towards shorter-acting
insulins and even a, thought about possibly insulin pump.
The patient, at this time was not ready for his pump and at
this point was not felt to be a good candidate, since he was
somewhat unreliable in his self-administration of insulin as
an outpatient. Ultimately, after several days of continued
reactions to largely longer-acting insulins, it was thought
the next step would be to move the patient to the ICU for an
insulin-desensitization trial. He did travel to the ICU
midway through his hospital course and underwent
desensitization with a Regular insulin IV drip, which went
without complications. The protocol was provided by Dr.
[**Last Name (STitle) 2603**] and [**Last Name (un) **]. The patient initially did well following
insulin desensitization, tolerating Regular insulin without
reactions. At this point, longer-acting insulins were held
secondary to fear for potential angioedema type reaction.
However, 1-2 days after his ICU stay, patient had another
reaction, which he thought was secondary to Regular insulin
administration. The reaction was in the evening, although
later on early in the morning, patient received Regular
insulin again without a reaction. Based upon these
circumstances, it was decided to actually perform skin
testing to once and for all determine if patient had true
insulin allergy. After having been abstaining from all
antihistamines x 2 days and using Medrol at higher doses to
mitigate urticarial reactions, patient underwent skin testing
for various insulins. The skin testing results showed that
patient did not have an allergy to insulin after all. If
anything, there was question of potential allergy to Lente
insulin. At this point, it was felt that the reactions could
be characterized as chronic idiopathic urticarial reactions.
The plan at this point was to restart patient on Lantus and a
sliding scale insulin [**First Name8 (NamePattern2) **] [**Last Name (un) 9718**] recommendations.
Meanwhile, he was initiated on a steroid taper and was
started back on antihistamines. The etiology of his
urticaria at this point remains unclear. [**Name2 (NI) **] is due to follow
up with both the [**Hospital 9039**] Clinic and also with either his
local diabetics or with the [**Hospital **] Clinic.
Diabetes: As mentioned above, the patient initially admitted
for question of an insulin allergy and for further assistance
of management of diabetes in the setting of high-dose
steroids. As they imagined, the patient had quite labile
blood sugars in the setting of increased steroids.
Ultimately he was found to be a type 1 diabetic based upon
results of antiGAD antibodies and C-peptide antibodies.
Ultimately, it was felt that patient was not having allergic
reactions to insulin, but rather his urticaria reactions were
chronic and idiopathic. He also may be discharged on Lantus
and short-acting insulin. He has been offered routinely to
follow up with his endocrinologist at [**Hospital1 1774**], Dr. [**Last Name (STitle) 48788**], who
has also been offered to intermittently to follow up with
[**Hospital **] Clinic.
Hypertension: The patient had stable blood pressures during
his hospital course. He will be continued on atenolol 50 mg
p.o. once per day.
CAD: The patient was started on low-dose aspirin 81 mg and
Lipitor, in addition to his beta-blocker, for history of CAD.
Given the fact that he had Q-waves in his EKG, he was ruled
out for MI, but he had no symptoms during his hospital
course.
Transient hyperkalemia: The patient had several episodes of
hyperkalemia, asymptomatic, without ECG changes. He was
given Kayexalate on several occasions. Apparently this has
been a problem in the past. For this reason, an ACE
inhibitor was not started even though the patient has
diabetes.
DISCHARGE DIAGNOSES: Chronic idiopathic urticaria of unclear
etiology.
Type 1 diabetes status post insulin desensitization.
Ruled out for insulin allergy.
Hypertension.
Coronary artery disease.
Hyperkalemia.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Atenolol 50 mg p.o. once a day.
2. Protonix 40 mg p.o. once a day.
3. Lipitor 10 mg p.o. once a day.
4. Aspirin 81 mg p.o. once a day.
5. [**Doctor First Name **] 180 mg p.o. b.i.d.
6. Hydroxyzine 50 mg p.o. q.6h p.r.n.
7. Doxepin 10 mg [**12-10**] capsules p.o. h.s. p.r.n.
8. Lantus 30 units subcutaneous q.p.m.
9. Lispro insulin sliding scale q.4h.
10. Medrol 4 mg p.o. b.i.d. for 3 days to continue until
[**5-26**].
11. Medrol 2 mg p.o. b.i.d. for 1 week to continue from
[**5-27**] to [**6-3**].
12. Medrol 2 mg p.o. once a day to continue from [**6-4**] until [**6-10**].
13. EpiPen to be used p.r.n. only for severe shortness
of breath or wheezing.
FOLLOW UP: To follow up with Dr. [**Last Name (STitle) 2603**] as planned on [**6-2**].
To follow up with PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**6-18**] days.
To follow up with endocrinologist at the [**Hospital3 2358**], Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 48788**].
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern1) 11159**], [**MD Number(1) 11160**]
Dictated By:[**Last Name (NamePattern1) 11267**]
MEDQUIST36
D: [**2163-9-28**] 17:29:42
T: [**2163-9-29**] 02:31:57
Job#: [**Job Number 56145**]
|
[
"2767",
"4019"
] |
Admission Date: [**2148-4-20**] Discharge Date: [**2148-4-28**]
Date of Birth: [**2089-7-12**] Sex: M
Service: CTU
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
male with no known medical or cardiac history who was found
down at a shopping mall. CPR was initiated by a bystander
and the patient was found to be in ventricular fibrillation
arrest. He was then subsequently cardioverted into sinus
rhythm but then went into a recurrent arrhythmia. He was
subsequently shocked again into atrial fibrillation. An
electrocardiogram at the time showed inferior ST segment
elevation as well as some lateral ST segment depression. He
was then loaded on Amiodarone en route to the hospital. He
was transferred to the [**Hospital1 69**]
Cardiac Catheterization Laboratory via the outside hospital
Emergency Department. Head CT was also negative at the
outside hospital. At the catheterization laboratory, he was
found to have a totally occluded right coronary artery with
thrombus which was subsequently stented. Also noted on the
catheterization laboratory report was a 30% discrete proximal
left anterior descending stenosis as well as a discrete 70-80%
hazy appearing left posterior descending artery stenosis. The
patient also had a left dominant system. Also of note, the
resting hemodynamics demonstrated elevated right sided
filling pressures consistent with acute right ventricular
myocardial infarction. Mean right atrial pressure was 20 mmHg and
the mean wedge was 25 mmHg. His cardiac index was depressed as
well.
HOSPITAL COURSE:
1. Inferior ST segment myocardial infarction - As noted, the
patient had an inferior ST segment myocardial infarction with
right ventricular infarction. He underwent stenting of the RCA
acutely, and subsequent repeat atheterization 2 days later
with intervention on the left posterior descending artery lesion.
The patient was started on Aspirin and Plavix during his
admission. He was also started on a beta blocker and was
discharged on 50 mg p.o. twice a day of Metoprolol. An
echocardiogram was also performed which showed an ejection
fraction of greater than 60% and also showed a mildly dilated
left atrium and a moderately dilated right atrium. There was
also noted to be mild symmetric left ventricular hypertrophy but
normal left ventricular cavity size and left ventricular systolic
function was normal. There was 1+ tricuspid regurgitation noted
and moderate pulmonary artery systolic hypertension. Also on the
echocardiogram, it was also read that one could not exclude
mild focal basal and inferior hypokinesis as well as focal
right ventricular wall hypokinesis. The patient did not have
any subsequent ectopy during his hospital stay and his
antiarrhythmics were eventually weaned.
2. Neurologic - As mentioned, the patient had a head CT
performed at the outside hospital which was normal. The
patient also had a CT of the cervical spine performed while
at [**Hospital1 69**] and this did not show
any evidence of fracture or subluxation. Once the patient
was extubated, the patient's neck was cleared clinically.
The patient initially came to the hospital intubated and
sedated as he had arrested. The patient was subsequently
weaned off intubation. During the first few days of his
hospital course, his short term memory was noted to be
impaired, but this improved greatly throughout the remainder of
his hospital course.
3. Staphylococcus epidermidis bacteremia, Oxacillin
resistant - The patient spiked a fever in the early part of
his hospital course and was noted to have fever to
approximately 102. Blood cultures were done and showed three
out of six bottles growing multiple morphologies of
Staphylococcus epidermidis. One of the isolates was noted to
be Oxacillin resistant. The patient was seen by the
infectious disease team in house and was started on
Vancomycin one gram intravenously q12hours. The patient was
eventually discharged with a PICC line and his Vancomycin is
scheduled to be completed on [**2148-5-16**].
4. Elevated liver function tests - The patient was noted to
have elevated liver function tests during his hospital
course. He had a peak AST of 127 and a peak ALT of 118. The
main differential diagnosis was shock liver versus congestive
hepatitis from right ventricular infarct versus possible
statin induced toxicity. The patient had been started on
Lipitor during his hospital course but this was eventually
held due to the rising liver enzymes. A CT of the abdomen
was performed to rule out liver abscess as the patient was
bacteremic from Staphylococcus epidermidis. This did not
show any acute intra-abdominal abnormalities. Also ordered
at the time was a hepatitis panel. The hepatitis surface
antigen was pending at the time of this dictation as well as
hepatitis C antibody. These will be followed up as an
outpatient.
DISCHARGE DIAGNOSES:
1. Inferior ST segment elevated myocardial infarction.
2. Right ventricular infarction.
3. Ventricular fibrillation arrest.
4. Percutaneous transluminal coronary angioplasty and stent
of right coronary artery and left circumflex.
5. Staphylococcus epidermidis bacteremia, Oxacillin
resistant.
6. Elevated liver function tests, question statin toxicity
versus congestive hepatitis.
FOLLOW-UP PLANS: He was scheduled to follow-up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] within four weeks of discharge. He also
has an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3197**] on [**2148-5-7**], as
well as with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] on [**2148-6-17**]. He is also to
follow-up for the Staphylococcus epidermidis bacteremia. In
addition he should follow up with Dr. [**Last Name (STitle) **], his PCP.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. once daily.
2. Plavix 75 mg p.o. once daily.
3. Paxil 20 mg p.o. once daily.
4. Lopressor 50 mg p.o. twice a day.
5. Vancomycin one gram intravenously q12hours for eighteen
days, the course is to end on [**2148-5-16**].
6. Nitroglycerin tablets p.r.n.
The patient is also scheduled to have weekly laboratory draws
to check complete blood count, Chem7, liver function tests
and Vancomycin trough and these laboratory results will be
sent to Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]. He was also discharged on a cardiac
heart healthy diet.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Name8 (MD) 8288**]
MEDQUIST36
D: [**2148-4-29**] 11:05
T: [**2148-4-29**] 19:34
JOB#: [**Job Number 47612**]
|
[
"41401",
"42731"
] |
Admission Date: [**2124-3-29**] Discharge Date: [**2124-4-3**]
Date of Birth: [**2075-8-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion / Diminished exercise tolerance
Major Surgical or Invasive Procedure:
Second time redo (third time heart operation) for mitral valve
replacement with a [**Street Address(2) 7163**]. [**Hospital 923**] Medical mechanical valve and
coronary artery bypass grafting x1 with reverse saphenous vein
graft to the marginal graft.
History of Present Illness:
48 year old gentleman with past medical history signicicant for
triple vessel coronary artery bypass grafting in [**2118-9-9**]
followed by a redo sternotomy with a bioprosthetic mitral valve
replacement in [**2118-11-9**]. In [**2123-9-9**], he developed
dyspnea on exertion with diminished exercise tolerance. An echo
at that time did reveal that his mitral valve bioprosthesis had
begun to degenerate by way of mitral stenosis. Over the winter,
his symptoms have been progressive and worsening prompting a
repeat echocardiogram this [**Month (only) 547**] which showed severe mitral
stenosis and moderate mitral regurugitation. An exercise
tolerance test was positive and a cardiac catheterization
revealed severe three vessel native disease with severe vein
graft disease. The left internal mammary artery had a patent
touch down stent. Given the severity of his disease, he has been
referred for a redo, redo stenotomy with mitral valve
replacement
and coronary artery bypass grafting.
Past Medical History:
Coronary artery disease s/p coronary artery bypass graft x 3
(PCI
and cypher stenting of SVG-OM, LIMA-LAD [**2118-9-9**])
Mitral regurgitation s/p Mitral valve replacement [**11-11**]
Biopresthetic Mitral valve stenosis/regurgitation
Ischemic cardiomyopathy LVEF 40-45% by echo [**2124-3-9**]
Dyslipidemia
Hypertension
Sleep apnea (no c-pap)
Social History:
Race: Caucasian
Last Dental Exam: many yrs ago, edentulous
Lives with: Wife and daughter
Occupation: rug salesman
Tobacco: 30+ pack yr history, currently smoking several cigs/day
ETOH: several beers/week
Family History:
Brothers with CAD (1 underwent CABG, another w/ stents)
Physical Exam:
Pulse: 79 Resp: 16 O2 sat: 99%
B/P Right: 125/90 Left: 134/105
Height: 5'9" Weight: 190 lbs
General: Well-developed male in no acute distress
Skin: Dry [X] intact [X] well-healed sternotomy and right
thoracotomy incision
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur 1-2/6 systolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
[X] healed EVH incision right leg
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ (healing cath site) Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: -
Pertinent Results:
[**2124-3-29**]: TTE
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. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %) with mild
hypokinesis in the mid and apical inferior wma. The right
ventricular cavity is moderately dilated with borderline normal
free wall function. There are focal calcifications in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation.
A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral valve leaflets are thickened. The gradients
are higher than expected for this type of prosthesis. There is
severe valvular mitral stenosis (area <1.0cm2). Moderate to
severe (3+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
Dr. [**Last Name (STitle) **]/[**Doctor First Name **] was notified in person of the results on
Mr.[**Known lastname 58103**] before surgical incision.
Post_Bypass;
Mild global RV hypokinesis.
Mild global LV dysfunction with added focalities in the mid and
apical inferior walls (similar to prebypass)
There is a bileaflet metallic prosthesis in the mitral position,
stable, both leaflets moving, typical washing jets present.
Thoracic aorta is itnact.
Mild TR.
[**2124-4-3**] 05:50AM BLOOD Hct-28.1*
[**2124-4-1**] 07:00AM BLOOD WBC-9.9 RBC-3.28* Hgb-9.9* Hct-28.9*
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.8 Plt Ct-257
[**2124-4-3**] 05:50AM BLOOD UreaN-15 Creat-0.9 K-4.0
[**2124-4-1**] 07:00AM BLOOD Glucose-121* UreaN-17 Creat-1.0 Na-134
K-3.6 Cl-95* HCO3-32 AnGap-11
[**2124-4-3**] 05:50AM BLOOD PT-27.6* INR(PT)-2.7*
[**2124-4-2**] 05:35AM BLOOD PT-31.7* PTT-32.9 INR(PT)-3.2*
[**2124-4-1**] 08:45PM BLOOD PT-22.4* PTT-32.6 INR(PT)-2.1*
[**2124-4-1**] 07:00AM BLOOD PT-21.0* PTT-28.0 INR(PT)-1.9*
[**2124-3-31**] 02:46AM BLOOD PT-15.1* INR(PT)-1.3*
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2124-3-29**] where the patient underwent a second
time redo (third time heart operation) for mitral valve
replacement with a [**Street Address(2) 7163**]. [**Hospital 923**] Medical mechanical valve and
coronary artery bypass grafting x1 with reverse saphenous vein
graft to the marginal graft. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. POD 1
found the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. He was started on
Coumadin on [**2124-3-31**] for his mechanical mitral valve replacement
and anticoagulated for a goal INR 2.5-3.5. By the time of
discharge on POD 5 the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics. The
patient was discharged post operative day 5 in good condition
with appropriate follow up instructions. He is to be followed
by Dr. [**Last Name (STitle) 32255**] for Coumadin dosing and visiting nurses is to draw
INR on [**2124-4-4**] and call results to [**Telephone/Fax (1) 6256**] for goal INR
2.5-3.5. He is to receive 5 mg of Coumadin [**2124-4-3**] prior to
discharge.
Medications on Admission:
Metoprolol Succinate ER 50mg daily
Lisinopril 10mg daily
Buproprion SR 150mg daily
**Plavix 75mg Daily**
Lovaza 1gram TID
Zetia 10mg daily
Tricor 145mg daily
Folic acid
Calcium with vitamin D
Multivitamins
Niacin 500mg TID
Aspirin 325mg daily
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 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:*0*
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for constipation.
Disp:*60 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Warfarin 2 mg Tablet Sig: 1-2 Tablets PO once a day: Goal INR
2.5-3.5 - take as instructed.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Severe prosthetic mitral valve stenosis and recurrent coronary
artery disease, status post coronary artery bypass surgery and
status post mitral valve replacement.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
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
***NO MOTORCYCLE DRIVING FOR 10 WEEKS***
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on at [**Hospital1 **] [**Telephone/Fax (1) 6256**] for wound
check and post-op follow-up
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 12300**] in [**12-11**] weeks
Cardiologist Dr. [**Last Name (STitle) 32255**] in [**12-11**] weeks ([**Telephone/Fax (1) 20259**]
Labs: PT/INR for Coumadin ?????? indication mechanical mitral valve
replacement
Goal INR 2.5-3.5
First draw [**2124-4-4**]
Results to Dr [**Last Name (STitle) 32255**]
phone [**Telephone/Fax (1) 6256**] fax [**Telephone/Fax (1) 31080**]
**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:[**2124-4-3**]
|
[
"4240",
"4019",
"V5861",
"32723",
"V4582",
"2724",
"3051"
] |
Admission Date: [**2175-11-29**] Discharge Date: [**2175-12-11**]
Date of Birth: [**2135-3-24**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old
gentleman with a past medical history significant for
diabetes and hypertension who presented with increasing neck
pain and stiffness for the past three weeks. He had no
history of trauma or falls but did mention that he had a
recent upper respiratory infection just before the neck
symptoms began, and a low-grade temperature for one day.
He said that his neck had simply become stiffer, and there
was decreased range of motion. He had no shooting pain in
the arms, or numbness or weakness, and no headaches.
On the day prior to admission, he decided to go to the
chiropractor due to the pain and underwent a painful
manipulation of his neck and stated immediately afterwards,
he developed a headache. The headache was bifrontal and
bitemporal and was of a pressure nature. He had no
throbbing, and this was not associated with any visual
changes, nausea, slurred speech, or photophobia.
He said he later on at work looked upwards at a shelf and
immediately had the onset of dizziness which he described as
feeling as a swimming feeling. It lasted for about two
minutes. He had no tinnitus or ear pain or fullness, and had
no visual disturbances or slurred speech.
He went to an outside hospital where they did a CBC, CHEM7,
head CT, and LP which were all within normal limits, and the
headache had become progressively worse. He was transferred
to [**Hospital6 256**] for further
management.
PAST MEDICAL HISTORY: Diabetes, hypertension, history of
pancreatitis, obesity, history of disk surgery in the past,
history of motor vehicle accident with brief neck symptoms
seven years prior to admission.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Glyburide, Actos, Lisinopril.
PHYSICAL EXAMINATION: Vital signs: Temperature 96.8, blood
pressure 142/102, heart rate 83, respirations 15, oxygen
saturation 96 percent on room air. General: The patient was
in no acute distress. He appeared comfortable. HEENT:
Oropharynx clear. No scleral icterus or injections. Neck
supple. He had some decreased range of motion and paraspinal
muscle tenderness. No lateral or carotid bruit appreciated.
Lungs: Clear. Heart: Regular, rate, and rhythm. Abdomen:
Soft, nontender, nondistended. Extremities: The patient had
2 plus peripheral pulses. No edema. Neurologic: Awake,
alert, cooperative. Speech fluent with normal content. No
paraphrasic errors. He followed commands well. He was
coherent and gave a detailed history of present illness.
Pupils equal, round and reactive to light. Extraocular
movements full. Cranial nerves II-XII grossly intact.
Strength 5 out of 5 in all muscle groups. Reflexes intact
and symmetric throughout. Sensation intact to light touch.
HOSPITAL COURSE: He was admitted to the Neurosurgery Service
after a CTA. The patient underwent cerebral angiography to rule
out vertebral dissection and was found to have a left internal
carotid artery bifurcation aneurysm that was not amenable to
coiling. The angiogram was done on [**2175-11-30**]. There
were no complications.
The patient was monitored postoperatively for headache and
was taken to the operating room on [**2175-12-5**], for
clipping of a left internal carotid artery bifurcation
aneurysm without intraoperative complications.
Postoperatively the patient's vital signs were stable. He
was afebrile. He was awake and alert and moving all
extremities with no drift. He was following commands.
He had a repeat angiogram on [**2175-12-6**], which showed
good clipping of the aneurysm with no residual. The patient
was complaining of severe headaches and was seen by the
Neurology Service and recommended Ultram.
The patient was transferred to the regular floor on [**2175-12-7**], and was seen also by the Orthopedic Service for
question of bilateral knee pain. Orthopedics recommended
starting NSAIDs as soon as safe from a neurologic surgical
point of view.
The patient's pain improved. The patient actually had his
right knee tapped for to rule out gout and inspection. The
Orthopedic attending felt this was more likely gout and
recommended treating him conservatively with Indomethacin
when able from a Neurosurgery standpoint.
The patient continued to improve neurologically. He with
awake, alert, and oriented times three with full strength.
He had no drift and was following commands. He was
discharged to home on [**2175-12-11**], with follow-up with
Dr. [**Last Name (STitle) 1132**] in two weeks. He is to start Indomethacin in one
week for right knee pain.
His vital signs remained stable. He was afebrile.
DISCHARGE MEDICATIONS: Glyburide 10 mg p.o. daily, Dilantin
150 mg p.o. t.i.d., Tramadol 100 mg p.o. q.6 hours,
Lisinopril 10 p.o. daily, Hydromorphone 2-6 mg p.o. q.4 hours
p.r.n., Colace 100 mg p.o. b.i.d., Pantoprazole 40 p.o.
daily, Zolpidem Tartrate 5-10 mg p.o. q.h.s. p.r.n.,
Pioglitazone 30 mg p.o. daily.
CONDITION ON DISCHARGE: Stable a the time of discharge.
FOLLOW UP: He will follow-up with Dr. [**Last Name (STitle) 1132**] in two weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2175-12-11**] 10:38:45
T: [**2175-12-11**] 11:45:59
Job#: [**Job Number 59969**]
|
[
"25000",
"4019"
] |
Admission Date: [**2144-9-1**] Discharge Date: [**2144-10-1**]
Date of Birth: [**2144-9-1**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] is the 2.77 kg
product of a 37 and [**2-8**] week twin gestation, admitted to the
Neonatal Intensive Care Unit for evaluation of prenatal
diagnosis of possible coarctation and Trisomy-21. Infant was
born to a 32 year-old, Gravida II, Para 0 now II mother.
Prenatal screens AB positive, antibody negative, hepatitis
surface antigen negative. RPR nonreactive. Rubella immune.
GBS positive. Mother had history of infertility,
hyperprolactinemia, treated with Bromocriptine prior to
conception. Pregnancy achieved with the assistance of IVF.
Twin gestation, dichorionic, diamniotic. Prenatal imaging of
twins: Twin A male, no abnormalities except for mild
polyhydramnios. Twin B, female, at 18 weeks noted to have
choroid plexus cyst and intra-cardiac echogenic foci. Follow-
up at 20, 24 and 27 weeks also noted to have moderate
bilateral polyectasis. Most recent scan done by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 55388**] at Diagnostic Ultrasound Associates revealed
bilateral polyectasis, moderate, 4 chamber view of heart also
revealed asymmetry of cardiac ventricles. Could not rule out
coarctation. Parents were counseled regarding potential
diagnosis of Trisomy-21 in twin B and declined amniocentesis
or further evaluation. Family was referred to Dr. [**Last Name (STitle) **],
pediatric urology at [**Hospital3 1810**]. Mother developed
preterm labor at 33 weeks, treated with magnesium sulfate and
betamethasone. Infants were delivered at 37 and [**2-8**] week
gestation by Cesarean section for transverse breech
presentation. Delivery was due to concerns of baby's growth
in utero. Apgars were 8 and 9. Infant was vigorous at birth
with good cry.
PHYSICAL EXAMINATION: On admission, weight was 2.77 kg, 46
cm for length, head circumference 32.5 cm. Infant was pink on
nasal cannula, breathing comfortably. Several features of
Trisomy-21 including epicanthal fold and flattened facies.
Anterior fontanel soft and flat. Red reflex deferred. Ears
small, slightly low set. Palate intact. Respiratory: Breath
sounds clear and equal. Cardiovascular: S1 and S2, normal in
intensity, no murmur. Femoral pulses normal. Abdomen soft
with normal bowel sounds, diastasis rectus, no organomegaly.
Genitourinary: Normal female. Neuro: Tone reduced
diffusely. Head lag. Hips increased laxity noted. Click
unilateral on the right. Extremities: no semian crease
on right. Left with IV in place. Mild clinodactyly.
HOSPITAL COURSE: Respiratory: [**Known lastname **] was admitted to the
Neonatal Intensive Care Unit and placed on nasal cannula
oxygen. For a brief period of time, she was in room air per
cardiology's request for hopes of closing the ductus
arteriosus but the infant was placed back in oxygen with
parameters normalized to be greater than 94%. She currently
remains on nasal cannula oxygen 25 cc flow of 100% oxygen.
Cardiovascular: Initial echocardiogram on [**9-2**] revealed
large PDA with question of bicommissural aortic valve, normal
four chamber heart. Infant presented with a murmur on day of
life #7. She was re-echoed on [**2144-9-18**] for a large PDA, 4 to 5
mm, with bidirectional flow with good biventricular function.
Decision was made to treat with Indomethacin as growth was
limited and the infant still had a respiratory component.
Repeat Echocardiogram on [**9-25**] demonstrated a large
patent ductus arteriosus with continuous left to right flow;
right ventricular dilatation with hypertension with mild
dysfunction and a PFO with bidirectional flow. After much
discussion between cardiology and neonatology, the decision
was made to ligate the infant. Verbal report from the most recent
ECHO on [**2144-10-6**] continues to show large PDA.
Fluids, electrolytes and nutrition: [**Known lastname **] was admitted to
Neonatal Intensive Care Unit. Birth weight was 2.77 kg.
Discharge weight is . She was initially started on 60
cc/kg/day of D-10-W. Enteral feeds were initiated on day of
life #2. She is currently on ad lib feeding schedule, taking
in on average between 100 to 122 cc per kg per day of breast
milk or Similac 28 calories with minimal weight gain. Her
discharge weight is 3240 gm. Laboratory data: She had a TSH on
day of life #4 of 12; free T4 of 1.5.
Gastrointestinal: Peak bilirubin was 8.3 over 0.4. Infant
did not require any intervention. Infant was placed on
prophylactic amoxicillin per renal recommendation prenatally.
Also recommended follow-up VCUG as an outpatient.
Hematology: Hematocrit on admission was 59.2. Infant has not
required any blood transfusions.
Infectious disease: CBC and blood culture were obtained on
admission. CBC was benign. Blood cultures remained negative
at 48 hours. Infant is currently on 20 mg/kg per day of
Amoxicillin for prenatal diagnosis of hydronephrosis.
Neuro: Infant has been appropriate for gestational age.
Infant with Trisomy-21.
Genetics: Chromosomes were sent off to the lab and came back
positive for Trisomy-21.
Orthopedics: she will need Hip US due to breech presentation.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 1810**].
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 37303**], telephone
number [**Telephone/Fax (1) 69545**].
FEEDS AT DISCHARGE: Continue ad lib feeding, breast milk or
Similac 28 calorie.
MEDICATIONS: Amoxicillin 20 mg per kg per day.
IMMUNIZATIONS: Infant received hepatitis B vaccine on [**2144-9-10**].
DISCHARGE DIAGNOSES:
1. 37 and [**2-8**] week twin.
2. Mild respiratory distress.
3. Trisomy-21.
4. Hydronephrosis.
5. Patent ductus arteriosus.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 38354**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2144-9-30**] 23:47:55
T: [**2144-10-1**] 05:42:27
Job#: [**Job Number 69546**]
|
[
"V053",
"V290"
] |
Admission Date: [**2119-11-22**] [**Month/Day/Year **] Date: [**2119-12-8**]
Date of Birth: [**2068-8-7**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Found unresponsive.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
51 yo M with unknown past medical history found down by friends
yesterday AM. History based on chart review is extremely
limited. He was supposedly found unresponsive by his friends at
0800 yesterday AM and they went back to check on him last night
at 2200 and he was still unresponsive. EMS was called and he
was noted to have pinpoint pupils, coffee ground emesis in his
mouth, and coarse respirations. He was given narcan 4 mg IM in
field and taken to [**Hospital **] Hospital. Upon arrival T 99.5 P
113 RR 20 BP 184/111 and sating 94% on RA. He was noted to
"respond to pain but is restless." A handwritten sheet of paper
states he had 1000 cc of [**Location (un) 2452**] urine upon foley insertion and
labs notable for "CK 1000, lactate 3.4, Na 133, WBC 13, + etoh,
tox neg." He received propofol, lidocaine, etomidate,
vecuronium, succinylcholine, ativan, and dilantin 1g. CT head
showed a midbrain hematoma, SAH, and SDH, and was transferred to
[**Hospital1 18**] for further evaluation. He was seen by neurosurgery who
recommended neurology consult.
Past Medical History:
- Recently c/o "migraine-like HA" on left side of face for about
two months. Took unknown med with partial relief.
- History of heavy smoking, cut back recently.
- H/o Emphysema, on some inhaler(s) including albuterol (found
by EMS).
- Borderline hypertension without treatment.
- No prior h/o hospitalization, diabetes, dyslipidemia, no prior
medical complication from EtOH. No known h/o cardiac or
neurologic disease.
Social History:
Patient is visiting from PR, speaks only [**Country 12649**]. Lived at
cousin's house, but left [**2-28**] frequent drunkenness. Still working
at a laundromat in [**Location 17065**]. PCP is [**Name9 (PRE) 1557**] at [**Name9 (PRE) **] Med
Ctr.
Increased EtOH over the past year, up to 24 beers / day on
weekends. Drinks most every day, unsure how much. Moved from
cousin's house to rental with four other people from Central
America [**2-28**] drinking habit. Still smokes, but cut back recently.
No known history of drug abuse.
Family History:
Mom died of colon cancer at 39 years (refused colonoscopy, DRE
at PCP's office). Sister died of breast cancer. Grandfather with
DM, MI. Father (visiting) appears ill/cachectic, but denies Ca
or strokes, etc. Only says "bad circulation" on unknown meds.
Physical Exam:
[**Month/Day (2) **] Examination
Over the course of the admission, his vital signs remained
stable.
Mental status was significant for clarity of cognition - after
transfer to the floor he was clearly able to understand complex
language, instructions and understand complicated information,
all in Spanish. It seems that he cannot understand English. He
was alert, sometime taking a little while to arouse. Although it
is difficult to evaluate his affect fully, he does seem mildly
depressed.
Cranial nerves were significant for impaired eye movement: He
has a vertical skew deviation in mid-position, is able to move
both eyes vertically and can abduct the right eye, without being
able to move the left eye horizontally or adduct the right eye.
There was a left lower motor neuron pattern of facial weakness.
He has an upper motor neuron pattern of weakness on the right,
less so on the left. He can now hold his legs bend against
gravity if the heels are on the bed. He can move both hands with
the left arm antigravity and the right not yet antigravity. The
left hand is clumsy.
He presently cannot sit, let alone stand, without assistance.
Admission Examination
VS: T 98.7 BP 148/95 P 112 RR 18 99% on vent
Gen: lying in bed, intubated, off propofol
HEENT: small superficial abrasion on right forehead and right
upper shoulder.
CV: RRR, no murmurs
Pulm: CTA b/l
Abd: soft, nt, nd
Extr: no edema
Neuro: Eyes closed and unarousable to noxious stimuli. Skew
deviation of eyes with right eye displaced downward. Pupils 1.5
mm and minimally reactive. Does not blink to threat. Corneals
absent. Face appears symmetric. + cough and gag. No
spontaneous movement. Withdraws LUE to noxious, extensor
posturing to RUE noxious stimuli. Withdraws LLE > RLE. Trace
biceps and brachioradialis reflexes, 2+ patellar reflexes b/l,
toes mute
Pertinent Results:
[**2119-12-4**] 06:05AM BLOOD WBC-5.7 RBC-4.17* Hgb-14.1 Hct-42.5
MCV-102* MCH-33.8* MCHC-33.1 RDW-13.2 Plt Ct-369
[**2119-11-22**] 03:24AM BLOOD Neuts-86* Bands-0 Lymphs-8* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2119-12-4**] 06:05AM BLOOD PT-12.1 PTT-29.5 INR(PT)-1.0
[**2119-11-22**] 03:24AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2119-12-3**] 06:50AM BLOOD Glucose-115* UreaN-15 Creat-0.6 Na-140
K-4.2 Cl-103 HCO3-28 AnGap-13
[**2119-12-4**] 06:05AM BLOOD ALT-48* AST-66* LD(LDH)-595* AlkPhos-132*
TotBili-0.4
[**2119-12-3**] 06:50AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.2
[**2119-11-22**]
Sinus tachycardia. Peaked P waves and rightward P axis
consistent with right atrial abnormality. The T waves are tall
and peaked. Clinical correlation is suggested. No previous
tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
112 116 86 324/415 76 64 66
Initial head CT [**2119-11-22**]
There is a 15 x 18 mm intraparenchymal hemorrhage in the
midbrain extending down to the basis pontis, level of lower
middle cerebellar peduncle, with surrounding edema which is
essentially unchanged from the recent exam (13 x 18 mm). This is
associated with hemorrhage within the right quadrigeminal plate
and ambient cistern, subarachnoid hemorrhage in the right
occipital lobe and a 6 mm-thick right temporal extra-axial
hematoma. Also noted are multiple punctate foci of high density
at the [**Doctor Last Name 352**]-white junction in the right frontal lobe (102:52)
and the left frontovertex (102:58-9). While these may represent
cavernous hemangiomas, the presence of multi-compartment
hemorrhage, as well as the edema surrounding edema these foci is
concerning for diffuse axonal injury in the setting of trauma.
There is an incidental likely arachnoid cyst in teh left
posterolateral aspect of the posterior fossa, with minimal mass
effect on the subjacent cerebellar hemisphere. There is an air-
fluid level in the right maxillary sinus. The remaining sinuses
as well as the mastoid air cells are well aerated. No definite
fracture is seen.
IMPRESSION:
1. Midbrain/pontine parenchymal, right occipital subarachnoid
and right
temporal extra-axial hemorrhage, as described above.
2. Foci of high attenuation of the [**Doctor Last Name 352**]-white junction may
represent diffuse axonal injury, although cavernous angiomas are
a possibility.
Repeat Head CT [**2119-12-1**]
1. Hematoma involving the left dorsolateral aspect of the
brainstem at the
pontomesencephalic junction is unchanged from [**2119-11-29**].
2. Right parietal vertex subarachnoid hemorrhage is without
significant change from prior study.
MRI/MRA [**2119-11-22**]
IMPRESSION: 1. Mid brain hemorrhage is identified without
evidence of associated enhancement or abnormal flow voids. 2.
Foci of signal abnormality at the [**Doctor Last Name 352**]-white matter junction in
frontal lobes on diffusion images with two asmall area of blood
products in frontal [**Doctor Last Name 352**]-white matter junction and associated
small subdural hematoma on the right convexity and tentorium as
well as blood products along the subarachnoid space could be
related to trauma. Clinical correlation recommended.
MRA Head:
Head MRA demonstrates normal flow signal in the arteries of
anterior and
posterior circulation without stenosis, occlusion or an aneurysm
greater than 3 mm in size.
IMPRESSION: No significant abnormalities on MRA of the head.
Echocardiography [**2119-11-30**]
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: no obvious vegetations
Non-contrast head CT [**2119-12-1**]
1. Hematoma involving the left dorsolateral aspect of the
brainstem at the pontomesencephalic junction is unchanged from
[**2119-11-29**].
2. Right parietal vertex subarachnoid hemorrhage is without
significant change from prior study.
3. Stable small right frontal epidural hematoma. No new focus of
hemorrhage is noted.
Brief Hospital Course:
Brainstem Hemorrhage
Spontaneous hemorrhage into the medial brainstem with loss of
consciousness and distruption of function of descending motor
tracts and oculomotor control. Hemorrhage dissects into tissue,
resulting in neuropraxic axonal dysfunction, also due to
resulting edema. This can recover, as we have seen in this case.
Structures rostral to the brainstem and arousal nuclei of the
brainstem were largely unaffected, so it was not surprising that
the cognitive outcome in this case would be good. Motor function
improved, presumably with lessened functional disruption of
motor fibers passing into and through basis pontis. Oculomotor
function improved somewhat, but is still dramatically impaired.
Formal angiogram has not been performed in this case, with
vascular imaging at this time relying on MRA. No aneurysmal
dilations were seen (resolution 3 mm), but such an abnormality
may have been etiologic. On follow-up, we will consider again
further evulating cerebral vasculature. It is possible that such
an abnormality might have been singular. Hypertension may have
also contributed. We have commenced antihypertensive treatment.
Respirtory Failure
Owing to respiratory failure, secondary to brainstem hemorrhage,
he was initially intubated, but subsequently breathed well after
tracheostomy then extubation, using tracheal mask with enriched
oxygen between 35 and 50 %.
Nutrition
Difficulty swallow may have both descending control and
brainstem components. PEG tube placement was necessary,
uncomplicated, with subsequent successful at-goal tube feeds.
Cholestatic enzymes were noted sometime after intubation and
cessation of propofol which was attributed to tube feeds. Tube
feeds should now be changed to increased rate with daily hold.
Present rate is at 60 cc, and we would suggest increasing this
slightly for equivalent feeding with a short and lengthening
pause each day, perhaps until a 12 hour on, 12 hour off regimen
is reached. Please check liver function tests.
Cholestasis and Transaminitis
See Nutrition above. Abdominal ultrasound revealed normal
appearances, supporting the hypothesis that cholestatic enzymes
were secondary to tube feeds. See above for recommendations.
Urinary Tract Infection, Bacteremia, Pneumonia
Blood culture grew STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP, and
SPUTUM GRAM and CULTURE revealed HAEMOPHILUS INFLUENZAE,
BETA-LACTAMASE NEGATIVE. UA was dirty without culture. He was
covered by ceftriaxone, which ended at seven days upon
[**Year (4 digits) **].
Hypertension
Blood pressure has been well-controlled. Lisinopril was started.
Medications on Admission:
Albuterol inhaler only.
[**Year (4 digits) **] Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin with minerals Tablet Sig: One (1) Tablet PO
once a day.
4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day) as needed for
lubrication: [**Month (only) 116**] benefit from left eye patch at night.
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
TID (3 times a day).
13. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) as needed for copius secretions: Next
patch due on [**12-9**] afternoon.
14. tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): [**Month (only) 116**] be up-titrated to control back pain (given
immobility).
15. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
16. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
17. HydrALAzine 10 mg IV Q6H:PRN SBP > 160
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
[**Month (only) **] Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
[**Location (un) **] Diagnosis:
Primary
Intracerebral hemorrhage
Secondary
Hypertension
[**Location (un) **] Condition:
Mental Status: Clear and coherent. Unable to speak, but able to
understand complex language and ideas (in Spanish).
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
[**Location (un) **] Instructions:
You came to the hospital after been found unresponsive. This was
attributed to bleeding in your brain, specifically your
brainstem. You were admitted to the hospital for management,
which including placing an airway, feeding tube and controlling
your blood pressure. You are now stable from a medical point of
view, so we would recommend that you now transition to acute
rehabilitation.
Followup Instructions:
Please follow-up with [**Location (un) **]. [**Last Name (STitle) **] and [**Name5 (PTitle) 39380**] in clinic:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Name5 (PTitle) **] Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2120-1-17**] 1:00
Please also see your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehabilitation.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"4019"
] |
Admission Date: [**2129-5-23**] Discharge Date: [**2129-5-27**]
Service: MEDICINE
Allergies:
Sulfur / Loperamide
Attending:[**First Name3 (LF) 6578**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]yo woman with h/o CAD s/p NSTEMI in [**12/2128**] that
was medically managed in setting of melenic stools, HTN,
dyslipidemia, COPD on home oxygen, and CRI admitted with c/o
shortness of breath and left-sided chest pain.
Patient was in her usual state of health yesterday, but she
complained of some subjective dyspnea today at her nursing home.
She was noted to be pale and she c/o pain in her left breast.
She was not given NTG given her low BP but did receive 81mg ASA
x 2 en route to the ED.
In the ED, initial VS were 96.0 70 100/70 22 99% 4L. Soon after
triage, she was noted to be hypotensive to 80/40. She was given
an unclear amount of fluid and her pressures improved to
100s/30s. She was noted to be guaiac positive on exam. EKGs were
concerning for STE in V2 and V3 and the cardiology fellow was
contact[**Name (NI) **]. [**Name2 (NI) 6**] Echo done at the bedside showed newly depressed EF
of 50% as compared to 70% in [**1-29**] as well as possible
anteroseptal hypokinesis. After discussing the matter with the
patient and her daughter, it was decided to pursue medical
management, and she was admitted to the CCU. In addition, UA was
positive and there was a concern for infiltrate on CXR. She
received ceftriaxone and azithromycin as well as albuterol and
atrovent nebs. She was also given 1mg ativan IV.
Past Medical History:
CAD s/p NSTEMI
Hyperlipidemia
HTN
Left MCA in [**1-/2129**] treated with tPA
Dementia
CRI with baseline Cr 1.4
COPD on 2L oxygen at baseline
Anemia with baseline Hct 30
Severe sigmoid diverticulosis (per [**8-30**] colonoscopy)
Hemorrhoids
s/p Appendectomy
s/p bilateral carotid endarterectomy
Hypothyroid
Right breast cancer s/p R mastectomy many ago
Social History:
Alcohol and smoking history not available at this time; per
chart review, she was a previous smoker x 40 pack years. She
lives at [**Hospital1 599**] Senior Living at [**Location (un) 55**]. Her baseline
mental status (per daughter) is essentially no short term
memory; recognizes her children but gets their names wrong. Not
oriented to date.
Family History:
Family history not available at present.
Physical Exam:
VS: T 97.7, BP 101/32->122/67, HR 50->78, RR 17, O2 94-99% on 2L
Gen: Elderly woman in NAD, resp or otherwise. Oriented to
hospital and name, but reports year as [**2052**]. Somewhat nervous.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with flat neck veins.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. +systolic murmur at base. No S4, no S3.
Chest: s/p mastectomy on the right. Resp were unlabored, no
accessory muscle use. No crackles, wheeze, rhonchi.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: Trace LE edema b/l at ankles. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKG demonstrated NSR with normal axis and prolonged QT (480)
with 1-2mm STE in V1-V4 and TWI in I, AVL, and V6; as compared
with prior dated [**2129-2-2**], the QTc has increased from 450 and
the STE in V2 and V3 and no longer upsloping. Of note, EKG done
upon arrival to CCU (at 21:38) demonstrates upsloping ST
elevations in V2 and V3 that are similar in appearance to her
baseline.
2D-ECHOCARDIOGRAM performed on [**2129-5-23**] in ED demonstrated
(PRELIM):
Suboptimal study with focused views. There is symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is low normal (LVEF 50%) with hypokinesis of the basal
anteroseptal and anterior wall. There are three aortic valve
leaflets. Mild (1+) mitral regurgitation is seen. There is a
small pericardial effusion.
IMPRESSION: Mild hypokinesis of basal anteroseptum and anterior
wall consistent with CAD. Overall EF mildly depressed, 50%. Mild
MR. Compared to prior echo dated [**2129-2-3**], the EF is decreased
and the wall motion is new.
CXR [**2129-5-23**]: RLL pneumonia (prelim)
LABORATORY DATA on admission:
Na 130
Cr 1.8
Hct 24
[**2129-5-27**] 06:15AM BLOOD WBC-9.3 RBC-3.95* Hgb-11.8* Hct-36.3
MCV-92 MCH-29.9 MCHC-32.6 RDW-15.3 Plt Ct-321
[**2129-5-23**] 06:35PM BLOOD Neuts-77.6* Lymphs-12.6* Monos-7.1
Eos-2.6 Baso-0.1
[**2129-5-27**] 06:15AM BLOOD Glucose-123* UreaN-21* Creat-1.3* Na-131*
K-4.3 Cl-94* HCO3-27 AnGap-14
[**2129-5-27**] 06:15AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
[**2129-5-27**] 06:15AM BLOOD Vanco-15.4
[**2129-5-24**] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2129-5-24**] 12:05AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2129-5-23**] 06:35PM BLOOD cTropnT-0.04*
Brief Hospital Course:
Mrs. [**Known lastname **] is a [**Age over 90 **] year old female with a PMH significant for
recent NSTEMI admitted after c/o CP and found to have pneumonia.
1. Pneumonia - Found to have a RLL consolidation consistent with
pneumonia. She was treated for healthcare associated pneumonia
with ceftriaxone, doxycycline, and vancomycin. She was treated
with doxycylcine instead of a azithromycin due to her prolonged
QT on admission. She will need to be treated with her antibiotic
regimen for a total of 10 days (currently day 4), and can stop
her antiobitic therapy on [**2129-6-2**]. For the patient's
vancomycin and ceftriaxone, a PICC line was placed.
2.Acute on chronic renal failure - The patient has a baseline
creatinine of 1.4. On admission, her creatinine was 1.8, which
trended down to 1.3 on day of discharge. Likely etiology was
prerenal azotemia with renal function that improved with IV
fluids. Unlikely to be UTI as urine culture was negative. The
patient's lasix was held due on admission, but was restarted on
discharge when her renal function returned to baseline.
Vancomycin was renally dosed at 1 gram Q48H with a random
vancomycin level of 15.4.
3.CAD - Recent NSTEMI that was medically managed due to chronic
guiaic positive stool. The patient's presenting symptoms are
unlikely to represent AMI as she has an unchanged ECG with CEx3
negative. Continue beta blocker, statin, and ASA therapy.
4.COPD - Currently has good O2 sats on 2L nc, which is at her
baseline. Continue advair, budesonide, and atrovent.
5.Prolonged QTc on admission. She is not taking any QT
prolonging drugs, and QT corrected with repeat ECG. She will be
treated with doxycycline instead of macrolide.
6. CHF with diastolic dysfunction. Patient's lasix was held
secondary to acute on chronic renal failure. She was continued
on her beta blocker, and lasix was restarted on admission after
renal function returned to baseline.
7. Anemia - Baseline HCT of 30, with HCT on admission of 24.4.
She received 2 units of PRBC, and on the day of discharge her
HCT was 36.3.
8. Dementia - Patient was disoriented throughout the course of
her stay. Per her records, she is at her baseline.
9. Hypothyroid - Continued on home levothyroxine.
Medications on Admission:
Colace 200mg daily
Budesonide 9mg daily
Furosemide 80mg daily
Levothyroxine 88mcg daily
Omeprazole 20mg daily
Simvastatin 20mg QHS
ASA 325mg daily
Celexa 20mg daily
Tylenol PRN
Bisacodyl PRN
Fleet Enema PRN
Milk of Magnesia PRN
Trazodone 12.5mg QHS PRN
Advair 250/50 [**Hospital1 **]
Atrovent q6h prn
MVI with minerals daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain or elevated temp.
2. Bisacodyl 10 mg Suppository Sig: One (1) 10 mg Rectal once a
day as needed for constipation.
3. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
4. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml
PO once a day as needed for constipation.
5. Trazodone 50 mg Tablet Sig: QTR Tablet PO at bedtime as
needed for insomnia.
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO once a
day.
9. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
11. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Do no crush.
13. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
17. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours).
18. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours).
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
20. Outpatient Lab Work
Vancomycin trough level on [**2129-5-29**] prior to administration of
vancomycin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary - Healthcare associated pneumonia
Secondary
1. CAD s/p NSTEMI
2. Hyperlipidemia
3. Hypertension
4. CVA - Left MCA in [**1-/2129**] treated with tPA
5. Dementia
6. CRI with baseline Cr 1.4
7. COPD on 2L oxygen at baseline
8. Anemia with baseline Hct 30
9. Severe sigmoid diverticulosis (per [**8-30**] colonoscopy)
10. Hemorrhoids
11. Hypothyroid
Discharge Condition:
The patient was discharged in good condition.
Discharge Instructions:
You were admitted for a pneumonia, which is an infection of your
lungs. You are being treated with antibiotics for your
infection. You will need to continue your antibiotics for a
total of 10 days. You can stop your antibiotics on [**2129-6-2**]. The instructions for your antibiotic regimen are:
Ceftriaxone 1 gm IV Q24H
Vancomycin 1 gm IV Q48H
Doxycycline 100 mg PO Q24H
For your intravenous medications, you a PICC line was placed in
your arm. This will need to be kept in place until you finish
your vancomycin and ceftriaxone. After [**2129-6-2**], your PICC
line can be removed.
You will need a blood draw on [**2129-5-29**] PRIOR to your vancomycin
dose administration in order to get a vancomycin level.
Weigh yourself every morning, call your physician if your weight
> 3 lbs.
It is very important that you take all of your medications as
prescribed.
It is very important that you make all of your doctor's
appointments.
If you develop any fevers, chills, sweats, chest pain, or
shortness of breath, go to your local emergency department
immediately.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks after discharge
if possible.
Completed by:[**2129-5-27**]
|
[
"486",
"5849",
"2761",
"5990",
"2449",
"2724",
"40390",
"5859",
"4280",
"496"
] |
Admission Date: [**2192-12-17**] Discharge Date: [**2192-12-26**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**2192-12-18**] Apico-Aortic Conduit(utilizing a 19mm [**Company 1543**]
Freestyle Aortic Root Heart Valve) via Left Thoractomy
History of Present Illness:
86 yo F with critical AS. PMH sig for CABG [**04**] years ago, PPM
placement, and NSTEMI in [**9-3**] with LM DES and aortic
valvuloplasty x 2. Readmitted at OSH for ?ileus/CHF and
transferred to [**Hospital1 **] for surgical eval.
Past Medical History:
Aortic Stenosis
Congestive Heart Failure
Coronary Artery Disease - s/p CABG, s/p Left Main Drug Eluding
Stent, History of NSTEMI
Peripheral Vascular Disease
Cerebrovascular Disease - history of TIA
Bilateral Carotid Disease
Hypertension
Pacemaker in Situ
GERD
History of Lyme Disease
Bilateral Cataract Surgery
Social History:
Retired - worked in resturant. Lives in apartment next to
daughter. [**Name (NI) 1139**] quit > 20 years ago, smoked [**11-28**] cigarettes/
day for 40 years. Denies ETOH.
Family History:
Son deceased at age 42 of myocardial infarction
Physical Exam:
Vitals:
General: WDWN
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2192-12-25**] 04:40AM BLOOD WBC-11.4* RBC-4.10* Hgb-11.8* Hct-34.9*
MCV-85 MCH-28.7 MCHC-33.7 RDW-15.4 Plt Ct-137*
[**2192-12-25**] 04:40AM BLOOD Plt Ct-137*
[**2192-12-23**] 02:09AM BLOOD PT-13.8* PTT-27.7 INR(PT)-1.2*
[**2192-12-26**] 04:50AM BLOOD Glucose-92 UreaN-41* Creat-1.1 Na-138
K-3.4 Cl-102 HCO3-27 AnGap-12
CHEST (PORTABLE AP) [**2192-12-25**] 9:22 AM
CHEST (PORTABLE AP)
Reason: eval ptx with chest tubes clamped
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman s/p apicoaortic conduit
REASON FOR THIS EXAMINATION:
eval ptx with chest tubes clamped
INDICATIONS: 86-year-old woman status post apical aortic conduit
placement. Please evaluate for pneumothorax with chest tubes
clamped.
CHEST, PORTABLE AP: Comparison is made to the prior day. The
configuration of two left-sided chest tubes, a right internal
jugular central venous catheter, and a dual-lead pacemaker/ICD
device is unchanged. There is no evidence for pneumothorax or
effusion. Mild prominence of central pulmonary vessels is
unchanged. Left basilar atelectasis appears improved.
IMPRESSION: No evidence of pneumothorax.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 75681**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75683**] (Complete)
Done [**2192-12-18**] at 11:59:16 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
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: [**2105-12-29**]
Age (years): 86 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Redo AVR
ICD-9 Codes: 402.90, 786.05, 786.51, 799.02, 440.0, V43.3,
424.1, 424.0
Test Information
Date/Time: [**2192-12-18**] at 11:59 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *5.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *103 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 58 mm Hg
Aortic Valve - LVOT pk vel: 0.[**Age over 90 **] m/sec
Aortic Valve - LVOT diam: 1.8 cm
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Severe symmetric LVH. Moderately depressed LVEF.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Mildly dilated ascending aorta. Simple atheroma in
ascending aorta. Normal descending aorta diameter. Complex
(>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Severe AS (AoVA <0.8cm2).
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
(1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pred-CPB: No spontaneous echo contrast is seen in the left
atrial appendage. There is severe symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
moderately depressed (LVEF= 30 - 35 %). with moderate global
free wall hypokinesis. The ascending aorta is mildly dilated.
There are simple atheroma in the ascending aorta. There are
complex (>4mm) atheroma in the descending thoracic aorta. There
is severe aortic valve stenosis (area <0.8cm2). The mitral valve
leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Post-CPB: The patient received a valved conduit from the LV apex
to the descending aorta, on bypass, with continuous VFib. Meds
are Amiodarone infusion and low dose Phenylephrine. A-Paced.
LV fxn is still moderately depressed with EF 30%. There is a
conduit from the LV apex to the descending aorta, with flow
noted. There is considerable reduction in the flow thru the
LVOT. Aorta is intact otherwise. RV systolic fxn mildly to
moderately reduced.
Brief Hospital Course:
She was admitted preoperatively. On [**12-18**] she underwent an
apico-aortic conduit with 19 mm tissue valve. She was
transferred to the ICU in stable condition. She was extubated on
POD #1. She was started on amio and must remain on it for life.
She remained in the ICU for pulmonary toilet. Creatinine bumped
but peaked at 1.9, and has returned to [**Location 213**]. She was
transferred to the floor on POD #6. She had an air leak and her
chest tubes were placed to water seal and then clamped with no
pneumothorax prior to being discontinued. She was ready for
discharge to rehab on POD #8.
Medications on Admission:
ECASA 325, plavix 75, atenolol 50", altace 5, Vytorin [**9-16**],
zantac 300", protonix 40", MVI, lasix 20', Famotidine 20
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for LM stent.
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H
(every 4 hours) as needed.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
200 mg daily x 1 week, then 200 mg daily ongoing for life.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
16. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day for 7
days: 40 [**Hospital1 **] x 7 days then 20 daily as prior to surgery.
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Discharge Disposition:
Extended Care
Facility:
Friendly [**Name2 (NI) **] INC
Discharge Diagnosis:
Aortic Stenosis - s/p Apico-Aortic Conduit
Postoperative Anemia
Coronary Artery Disease - prior CABG
Congestive Heart Failure(Systolic)
Pacemaker in Situ
Hypertension
Peripheral Vascular Disease
Bilateral Carotid Disease
History of TIA
Discharge Condition:
Stable
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**3-2**] weeks, call for appt
Dr. [**Last Name (STitle) 64868**] in [**12-30**] weeks, call for appt
Dr. [**Name (NI) 71003**] in [**12-30**] weeks, call for appt
Completed by:[**2192-12-26**]
|
[
"4241",
"4280",
"9971",
"42731",
"4019",
"2859",
"V4581",
"412"
] |
Admission Date: [**2192-6-21**] Discharge Date: [**2192-7-18**]
Date of Birth: [**2120-7-15**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 71-year-old male
patient with known coronary artery disease, status post
coronary artery bypass graft in [**2184**], now presenting with
unstable angina, ruled in for a non-Q-wave myocardial
infarction. The patient apparently had a 2-day prior history
of chest pain and presented to the Cardiology Service here at
[**Hospital1 69**] for cardiac
catheterization.
PAST MEDICAL HISTORY: (Significant for)
1. Coronary artery disease as noted previously.
2. Hypertension.
3. Hypercholesterolemia.
MEDICATIONS ON ADMISSION: Medications include
hydrochlorothiazide, Aggrastat, captopril, Lipitor,
Lopressor, aspirin, amlodipine.
ALLERGIES: The patient states no known drug allergies.
LABORATORY VALUES ON ADMISSION: A white blood cell count
of 10,000, hematocrit of 39, a platelet count of 241.
Sodium 139, potassium 3.7, chloride 98, bicarbonate 28,
BUN 19, creatinine 1.5.
RADIOLOGY/IMAGING: The patient's cardiac catheterization
which was performed on [**2192-6-21**], revealed left main and
native 3-vessel coronary artery disease as well as
significant in-stent stenosis of two of his vein grafts. It
also showed that his left internal mammary artery graft to
his left anterior descending artery was patent, and the
patient underwent successful percutaneous transluminal
coronary angioplasty of the occluded saphenous vein graft to
the right coronary artery which was occluded. At that time
it was also noted that the patient had moderate left
subclavian stenosis.
HOSPITAL COURSE: The patient was initially seen by
Cardiothoracic Surgery Service who felt the patient was a
significant high risk for redo revascularization procedure.
The patient continued to have chest pain over the next few
days as he was attempting to be managed medically by the
Cardiology Service. For a second opinion, a Cardiothoracic
consultation was obtained by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] who felt that
surgical revascularization was possible. This was initially
scheduled to occur on [**2192-6-25**]; however, this was
postponed for a significant number of days because of a rise
in creatinine after the cardiac catheterization procedure.
The patient remained on the Cardiology Medicine Service and
was managed medically while daily laboratory values were
being evaluated due to rise in creatinine and concern for
worsening renal failure.
On [**2192-7-2**], a Renal Medicine consultation was obtained,
and it was their impression that this was acute on chronic
renal failure possibly from the dye involved with the
catheterization procedure. They felt that there was no
indication for dialysis at that time but to continue to
monitor his BUN and creatinine as well as his potassium. It
was their recommendation to proceed with the cardiac
revascularization thinking that increased cardiac output
would help his renal function.
The patient was taken to the angiography suite on [**2192-7-4**], and underwent renal angiography which demonstrated
moderate right renal artery stenosis without functional flow
limitation. He was taken for this procedure with the hope of
possibly stenting the renal artery. This was something to
benefit the patient; however, since there was no functional
flow limitation, this was not done.
The patient was informed of the high likelihood of requiring
hemodialysis after the cardiac surgical procedure because of
his worsening renal function after cardiac catheterization,
and the patient and his wife both accepted that as a risk in
going into the procedure.
The patient was taken to the operating room on [**2192-7-6**],
where he underwent redo coronary artery bypass graft times
one using a vein to the obtuse marginal, and this was done
off pump.
Postoperatively, the patient was transported from the
operating room to the Cardiothoracic Intensive Care Unit on
nitroglycerin and propofol intravenous drips. The patient
was weaned and extubated from mechanical ventilator on the
night of surgery.
On postoperative day one the patient remained hemodynamically
stable. His pulmonary artery catheter was discontinued as
was his chest tube, and he was transfused 1 unit of packed
red blood cells, and the Renal Service continued to follow
him. On the night of postoperative day one, on [**2192-7-8**], the patient did complain of bilateral arm pain
radiating to his hands with some vague chest discomfort. The
patient was also somewhat hypertensive at that time. He was
placed on nitroglycerin due to possible ischemia as well as
hypertension control. The patient also had an episode of
atrial fibrillation for which he was treated with intravenous
Lopressor.
The patient underwent an urgent echocardiogram to evaluate
for any wall motion abnormalities that may be associated with
this episode of chest pain on [**2192-7-8**], and the
echocardiogram demonstrated normal wall motion with an
ejection fraction of 55%. It was felt the patient did not
need to go to the catheterization laboratory to assess
patency of his graft. The patient remained hemodynamically
stable.
On postoperative day three, [**2192-7-9**], he underwent his
first hemodialysis treatment which he tolerated well with the
exception of an episode of atrial fibrillation which was
treated with intravenous Lopressor, which converted him to
normal sinus rhythm. An Electrophysiology consultation was
obtained on [**2192-7-9**], due to the atrial fibrillation and
the question of whether the patient should be started on
amiodarone was addressed. It was their recommendation that
if he had a further episode of atrial fibrillation to begin
amiodarone. This occurred on the following day, [**2192-7-10**], and amiodarone was started. The patient underwent a
second hemodialysis treatment on [**2192-7-10**], which he
tolerated well.
The patient was transferred out of the Cardiothoracic
Intensive Care Unit to the telemetry floor on [**7-10**], and
remained hemodynamically stable. The patient's had been
followed closely by the Renal Medicine Service over the next
few days, and has gone for his dialysis treatments three
times a week.
The patient was seen by Psychiatry staff on [**2192-7-13**],
for evaluation of depression as well as intermittent period
of delirium. It was their recommendation to discontinue
benzodiazepines as well as other sedating medications and to
continue to manage the patient's metabolic abnormalities as
well as possible. The patient's intermittent mental status
changes resolved and he has been lucid over the next few
days.
On [**2192-7-16**], the patient remained hemodynamically
stable. Rehabilitation screen was requested since it was
apparent that the patient was getting to not needing acute
hospitalization any further.
Today, [**2192-7-17**], the patient went to hemodialysis unit
and due to difficult flow in his left Perm-A-Cath ...........
was instilled, and the catheter has been patent. The patient
was dialyzed today, and he will have a dialysis treatment
once more tomorrow ([**7-18**]) prior to being discharged from
the hospital.
The patient had also been initiated on Coumadin starting,
actually, on [**2192-7-11**], due three postoperative episodes
of atrial fibrillation. His most recent INR was 1.4 on
[**2192-7-16**], and 1.8 today ([**2192-7-17**]). The patient
received 5 mg on [**7-15**], 5 mg on [**7-16**], and 3 mg on
[**7-17**]. His target INR should be 2.5.
Today the patient also complained of some abdominal
discomfort and intermittent nausea. Amylase and lipase were
checked, and his amylase was 102 and lipase was 88. The
patient also claimed that he felt constipated and was
attributing his abdominal complaints to this. His abdomen
was soft, nondistended, minimal tenderness to palpation, and
he had positive bowel sounds and positive flatus.
Physical examination today is as follows: His temperature
is 96.7, his pulse is 68, his respiratory rate is 20. His
blood pressure is 154/70, his oxygen saturation is 96% on
room air. His weight today is 62.5 kg which is below his
preoperative weight of 70 kg. Neurologically, the patient is
alert and oriented, although depressed. His coronary
examination has a regular rate and rhythm. His is in normal
sinus rhythm. His lungs are clear to auscultation
bilaterally. His sternum is stable. His incisions are
clean, dry and intact. His abdomen is soft with positive
bowel sounds.
Most recent laboratory values from [**7-16**] which include a
hematocrit of 31.4. Sodium 129, potassium 5.3, chloride 89,
BUN 137, creatinine 7.3, glucose of 122. Laboratories from
[**7-17**] include an amylase of 102, lipase 88, PT 16.5,
INR 1.8.
MEDICATIONS ON DISCHARGE:
1. Amiodarone 400 mg p.o. b.i.d. until [**2192-7-23**]; then
he is to decrease to 400 mg p.o. q.d. times one week; and
then to 200 mg p.o. q.d.; and then as directed by his primary
care cardiologist.
2. Plavix 75 mg p.o. q.d. times three months.
3. Amaryl 1 mg p.o. q.a.m.
4. Nephrocaps 1 p.o. q.d.
5. Phos-Lo 2 capsules p.o. q.i.d. with meals.
6. Remeron 7.5 mg p.o. q.h.s.
7. Colace 100 mg p.o. b.i.d.
8. Zantac 150 mg p.o. q.d.
9. Aspirin 81 mg p.o. q.d.
10. Norvasc 10 mg p.o. q.d.
11. Dilaudid 2 mg p.o. q.4-6h. p.r.n. for pain.
12. Coumadin 3 mg on [**7-17**] and needs to be titrated daily
for a target INR of 2.5.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) 1537**] in about one month after surgical procedure. His
office number is [**Telephone/Fax (1) 170**]. To follow up with a
nephrologist affiliated with that rehabilitation facility
until he becomes stable to be discharged home. Then the
patient should follow up with his primary care physician, [**Name10 (NameIs) 1023**]
is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to determine further needs for dialysis
and renal medicine followup.
CONDITION AT DISCHARGE: The patient is stable.
DISCHARGE STATUS: To be discharged to rehabilitation
facility.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2192-7-17**] 16:24
T: [**2192-7-17**] 16:29
JOB#: [**Job Number 35359**]
|
[
"41071",
"41401",
"40391",
"9971",
"42731"
] |
Admission Date: [**2110-2-26**] Discharge Date: [**2110-3-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Fever, hypotension, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] M with recent necrotizing cholecystitis s/p brief
percutaneous cholecystotomy drainage, recent MI with CHF, was at
[**Hospital 100**] Rehab with fever 101.5, hypotension to SBP 70s, 7
episodes of diarrhea yesterday. Per his daughter, he has been
more combative with altered mental status at Heb Reb over the
past few days. He had been recuperating at [**Hospital 100**] Rehab using a
walker, was alert, with generalized weakness, but last night
after 7 diarrhea episodes, got out of bed at 7 pm, and at 8 pm,
vitals were 70/40, T100.2. The patient denies pain but states
that he is dizzy. No CP, no SOB, no HA, no neck stiffness, no
N/V, +RUQ abd pain.
.
On [**2110-1-23**], he was discharged from MICU West with necrotizing
cholecystitis in the setting of an MI and CHF, so CCY was not
performed and perc drain was placed instead on [**1-18**]. Patient
pulled out the drain on [**1-22**], and surgery and IR felt that the
tube should not be replaced. Bile culture grew out GNR and Vanc
sensitive Enterococcus. He had been brought to [**Hospital 882**]
Hospital, but was transferred here since his PCP has admitting
privileges here.
.
At [**Hospital1 882**], he was given zosyn and flagyl. In the [**Hospital1 18**] ED, he
was given 250 ml NS x2 with SBP improving from 70s to 100s. He
was also given Ceftazidime for [**4-6**] BCx from [**Hospital1 882**] that grew
out GNR [**2-26**]. US abdomen showed cholelithiasis but no
cholecystitis, and a new left liver lobe 4 cm mass (radiology
read was changed: the word "cystic" was deleted) with internal
flow that does not look like an abscess. C. diff was considered
the most likely cause. Surgery consult felt no acute need for
intervention at this time.
Past Medical History:
1. Coronary artery disease, followed by Dr. [**First Name8 (NamePattern2) **] [**Doctor Last Name 104377**]/p
multiple MIs (3 in [**2087**])
2. s/p MIs
3. Dizziness.
4. H/o deep vein thrombophlebitis with chronic left venous
stasis
5. Status post pulmonary embolism- [**2053**] while he was in [**Country 532**].
6. Cerebrovascular disease.
7. Gallstones and acute cholecystitis [**2093**] with multiple stones
and obstructive jaundice, ERCP failed so had papillotomy
8. Gait disturbance.
9. Gastritis with GI bleeding [**5-7**]
10. Question of prostate cancer.
11. Inguinal hernia on R
12. Hearing loss.
13. Cataracts.
14. Hypothyroidism.
15. Status post herpes zoster ophthalmicus.
16. Hyperlipidemia.
17. R carotid stenosis: 70-80% stenosis distal R carotid, 90%
stenosis of suprabulbar R carotid
18. He had an echocardiogram performed in [**2102**], which showed
moderate ischemic myopathy with an ejection fraction of 45%,
mild mitral and aortic regurgitation, and aortic sclerosis.
Social History:
Married. Daughter who is endocrinologist. Lives in senior
housing. Home health aide twice a day. Former orthopedic
surgeon. No EtOH, no smoking. Mostly only speaks Russian, some
basic English.
Family History:
Unknown
Physical Exam:
VS: 97.4 / 85 / 104/48 / 20 / 100% RA
GEN: Alert, speaks clearly to relatives, yelling occasionally
[**Name (NI) 4459**]: JVD flat, no LAD, dry mm, OP clear
LUNGS: Quiet rales at bases
HEART: Irregularly regular, no m/r/g
ABD: +RUQ tenderness, soft, +BS, ND
EXTR: No c/c/e, 2+ DP bl
NEURO: Would not cooperate with motor exam even when family was
present, but moves all extremities
Pertinent Results:
[**2110-2-26**] RUQ U/S:
1. Distended gallbladder filled with stones and sludge. No
gallbladder wall edema or pericholecysttic fluid to suggest
acute cholecystitis.
.
2. New left liver lobe mass measuring up to 4 cm. MRI or
multiphasic CT is recommended for further evaluation.
.
TTE [**2110-1-18**]
EF 25%
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. There is moderate to severe regional
left ventricular systolic dysfunction with anterior,
antero-septal and apical hypokinesis to akinesis. The basal
inferior wall appears hypokinetic. No masses or thrombi are seen
in the left ventricle. Right ventricular systolic function is
low normal. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (area 0.8-1.19cm2) The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen. The
left ventricular inflow pattern suggests impaired relaxation.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Regional LV systolic dysfunction c/w CAD. Moderate
calcific aortic stenosis. Moderate pulmonary hypertension.
Moderate MR.
.
[**1-16**] CT Abd/Pelvis:
1. Large heterogeneous retroperitoneal mass is most likely a
retroperitoneal sarcoma.
2. Intrahepatic biliary ductal dilation and idstended
gallbladder with wall edema, sludge and stones,
ndpericholecystic fluid/stradning [**Month (only) 116**] be from external
compression by the mass, although given presence of gallstones,
choledocholisthiasis cannot be excluded. Ultrasound is ulikely
to give significant additional details, consider HIDA scan to
assess for cystic duct patency.
3. Pneumobilia. Please correlate with recent instrumentation or
prior sphincterotomy.
4. 3.6-cm exophytic hypodensity arising off the mid left kidney.
Nonemergent further evaluation with ultrasound can be performed
for additional characterization.
5. Small amount of ascites and free fluid in the pelvis.
6. No evidence of pulmonary embolism.
7. Mild-to-moderate congestive heart failure with bilateral
pleural effusions.
.
[**1-17**] GB US: Technically successful placement of 10-French
pigtail catheter within a distended gallbladder. However, it
appears that the gallbladder is filled with stones and gel-like
clot. As such, there is very little drainage emanating from the
pigtail catheter. Specimen was sent for culture and Gram stain.
.
[**1-20**] CXR: Widespread pulmonary opacification which progressed
between [**1-16**] and 17 is stable, accompanied by slightly
larger small right pleural effusion. Heart size is normal. The
progression of findings suggests that the lung abnormalities are
due to edema, though not necessarily cardiogenic. There is no
pneumothorax. In the upper abdomen one can see a dilated colon
and a percutaneous biliary drainage catheter.
.
MRI abdomen:
FINDINGS: There are small bibasilar effusions and atelectasis.
There are multiple heterogeneous, but predominantly T2-
hyperintense, masses and nodules in the liver. These include a
large mass noted recently on ultrasound examination within the
left lobe, which measures 3.4 x 4.7 x 4.3 cm (AP x transverse x
vertical). There is a similar, but somewhat smaller, 3-cm
diameter mass within segment VI, as well as multiple additional
lesions up to 1.6 cm in diameter. All of these liver lesions are
new since a CT performed on [**2110-1-16**].
A large intraluminal heterogeneous mass of 4.8 cm in diameter
occupies the fundus of the gallbladder. There is mass effect on
adjacent dependent stones and sludge which are pushed medially.
One of the gallstones measures 12 mm in diameter, but numerous
others are present which are all less than 5 mm in diameter. A
small amount of residual fluid is present within the gallbladder
fossa. Several sub-5 mm stones are visualized within the common
hepatic and cystic ducts, but there is no intra- or extra-
hepatic biliary ductal dilatation.
A large portacaval mass is similar, to perhaps minimally
increased in size, compared to the earlier CT appearance from
[**2110-1-16**]. The mass measures 4.8 x 6.5 x 4.4 cm (AP x
transverse x vertical). Its contour and location are most
suggestive of a metastatic lymph node, centered at the expected
site of a portcaval node. The pancreas, and the main portal and
splenic veins, are splayed anteriorly by the mass, but the
pancreas parenchyma appears unremarkable. The portocaval mass
abuts the uncinate process, but does not necessarily arise from
it. The spleen is within normal limits. Bilateral simple renal
cysts are unchanged.
Multiplanar reformatted images were helpful in evaluating the
findings.
Brief Hospital Course:
[**Age over 90 **] M with recent necrotizing cholecystitis s/p brief
percutaneous cholecystotomy drainage, recent MI with CHF [**1-8**],
presented with fever 101.5, hypotension with SBP to 70s, 7
episodes of diarrhea, and found to have e coli severe sepsis
most likely from newly found gallbladder cancer and obstruction.
.
# GNR sepsis: [**4-6**] blood cx positive for pan sensitive e coli at
[**Hospital 882**] Hospital. Received zosyn for 8 days (as well as vanc
for 6 days) and now switched to cipro (e coli was pan
sensitive). Plan for 5 more days of cipro for 14 days total
treatment.
.
# Liver mass: Found on MRI to have rapidly enlarging RP/liver
masses with mass near neck of gallbladder. Had Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] review films and case at family's request and agreed
most c/w gallbladder cancer with mets to liver. No good
surgical/medical treatment options. Patient with some c/o pain
and placed on morphine with some relief. Also has had
intermittent jaundice with T bili as high as 4. Will need
monitoring for jaundice and treatment if develops any pruritis
(none here). Urine has been darker as well.
.
# Diarrhea: Likely associated with biliary drainage issue. C
diff toxin assay sent and was negative. Amylase and lipase
negative.
.
# Cardiac ischemia: Has had multiple MIs, recurrent angina, RCA
stenosis. EF 25% after MI in [**1-8**]. EKG shows sinus 90s, LAFB,
frequent PVCs. Has been medically managed on aggrenox,
carvedilol, isosorbide dinitrate, lipitor, but carvedilol,
isosorbide dinitrate held during period of hypotension. Started
on metoprolol with good blood pressure control. Continued
aspirin 81.
.
# Cardiac pump: EF 25%. Has had CHF with pulmonary edema and
effusions on CXR, but euvolemic on exam. Tolerated fluid
resuscitation.
.
# Agitation: Has episodes of yelling in resistance to medical
treatment. Responded well to zyprexa 5 sl and ativan 0.5 prn,
but also needed restraints. On last admission, responded well to
haldol, but had QTc prolongation. Daughter was very concerned to
give antipsychotics to her father, says he has become more
confused and not tolerated well. He seemed to do well with
zyprexa in the evenings, but she requested this being stopped.
Instead gave morphine in the evenings and will plan scheduled
dose of morphine. Patient needs work with his sleep/wake cycle
and does better with Russian speaking sitters than with
restraints. Hope this will improve in more consistent setting.
.
# ARF: Prerenal physiology. Creatinine returned to baseline of
1.
.
# Anemia: Baseline Hct 33, currently at baseline. Has had guaiac
positive stool in past, but is still maintained on aggrenox and
plavix, which are being held. Continue aspirin 81.
.
# Hypothyroidism: Synthroid 75 mcg QD continued per outpatient
regimen.
.
# Hematuria: In episode delirium patient pulled out foley with
balloon up. Had [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 104380**] that improved with CBI. Have
removed foley and though urine is dark (from bili) no longer has
seen blood. Does appear to be spontaneously voiding. Continue
to monitor.
.
# FEN: Patient had swallow eval that recommended nectar
thickened liquids. Family says patient gets such pleasure out
of food, would prefer not to withhold. Can continue to discuss
in rehab.
.
DNR/DNI. Family aware of malignancy and grim prognosis. Would
like to speak with hospice once patient returns to [**Hospital 100**] Rehab.
Medications on Admission:
Aggrenox 1 cap [**Hospital1 **]
Folic acid
Lactobacillus prn
Isosorbide dinitrate 5mg tid
Lipitor 10mg qd
Carvedilol 4.75 mg PO BID
Proscar 5mg qd
Protonix 40mg qd
Synthroid 75mcg qd
Nitroglycerin prn
Plavix 3x/day
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Morphine 10 mg/5 mL Solution Sig: One (1) 2.5 ml PO every six
(6) hours as needed: Please make sure one dose in evening at
bedtime.
8. Morphine 10 mg/5 mL Solution Sig: One (1) 2.5ml PO q2h prn as
needed for pain.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
11. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H PRN ()
as needed for anxiety.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Acetaminophen 160 mg/5 mL Liquid Sig: One (1) 10ml-20ml PO
every four (4) hours as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Gallbladder cancer (most likely) with metastatic disease to
liver
E coli severe sepsis
Prerenal azotemia
Delirium
Discharge Condition:
Fair
Discharge Instructions:
Continue to take your medications as prescribed.
Followup Instructions:
Please schedule regular follow up with physician at [**Hospital 100**]
Rehab. Should be seen in next few days.
|
[
"5849",
"4280",
"41401",
"2449",
"412"
] |
Admission Date: [**2145-4-16**] Discharge Date: [**2145-4-18**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 21822**] is a 32 yo M w/hx of DM type I, ESRD on HD who
presents with shortness of breath and hypoxemia. Patient has
been in usual state of health. On Thursday morning he noticed
he was more short of breath. Went to HD yesterday and completed
session w/o events (w/ 1.6L ultrafiltration). Unfortunately,
yesterday afternoon/evening developed progressive shortness of
breath worst when lying flat. No reported fevers, chills, night
sweats, productive cough or other complaints. No sick contacts,
recent travel. To patient feels similar to previous admission
in [**Month (only) 958**] when he had dyspnea related to volume overload.
.
In the ED, initial vs were: T99.4 HR 98 BP 185/108 RR18 100.
Initial impression was for pulmonary edema in setting of
diastolic dysfunction and hypertensive urgency. Was given oral
medications/home regimen for treatment of BP. CT Chest
performed that excluded PE, and showed stable ground glass
opacities. Read of CT Chest concerning for infection rather
than volume overload, and patient was covered in ED with vanco.
Zosyn held given PCN allergy. Renal contact[**Name (NI) **] who saw patient
and planning HD on arrival to floor.
.
Prior to transfer to the ICU, patient's VS were: HR 91, 153/86
100% NRB, RR 20.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- HTN
- DM I since age 19, seen at [**Last Name (un) **]. Complicated by nephropathy,
gastroparesis, and possibly retinopathy. Recent admissions for
DKA and hypoglycemia.
- ESRD/CKD: thought to be related to HTN and longstanding
diabetes.
Now on hemodialysis T/Th/Sat. Does make urine. Has been listed
on kidney/pancreas transplant wait list since 4/[**2144**].
- Anemia: Thought to be combination of iron deficiency and CKD,
now on epo with dialysis
- Depression
- s/p appendectomy [**7-/2144**]
Social History:
States that he previously drank heavily (30-40 drinks/week) but
has not used alcohol since [**2144-11-14**]. +h/o tobacco use, quit in
[**2142**], relapsed, quit last year and denies tobacco currently.
Denies other drugs. Neg PPD [**2145-2-26**]. Lives with girlfriend.
Family History:
No FH of pancreatitis. Diabetes and heart trouble in
grandfather.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on admission:
[**2145-4-16**] 03:34AM PLT COUNT-299
[**2145-4-16**] 03:34AM NEUTS-64.7 LYMPHS-25.1 MONOS-7.1 EOS-2.4
BASOS-0.7
[**2145-4-16**] 03:34AM WBC-8.1 RBC-3.73* HGB-11.1* HCT-33.1* MCV-89
MCH-29.7 MCHC-33.5 RDW-14.9
[**2145-4-16**] 03:34AM K+-5.1
[**2145-4-16**] 03:34AM COMMENTS-GREEN TOP
[**2145-4-16**] 03:34AM CK-MB-2
[**2145-4-16**] 03:34AM cTropnT-0.24*
[**2145-4-16**] 03:34AM CK(CPK)-187
[**2145-4-16**] 03:34AM GLUCOSE-289* UREA N-19 CREAT-5.9* SODIUM-131*
POTASSIUM-7.8* CHLORIDE-94* TOTAL CO2-29 ANION GAP-16
[**2145-4-16**] 09:00AM URINE RBC-[**3-12**]* WBC-[**3-12**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2145-4-16**] 09:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2145-4-16**] 09:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2145-4-16**] 09:00AM URINE cocaine-NEG amphetmn-NEG
[**2145-4-16**] 09:00AM URINE HOURS-RANDOM
[**2145-4-16**] 11:54AM TYPE-ART PO2-92 PCO2-44 PH-7.47* TOTAL
CO2-33* BASE XS-7
[**2145-4-16**] 12:42PM ALBUMIN-3.4* CALCIUM-9.1 PHOSPHATE-4.2
MAGNESIUM-1.7
[**2145-4-16**] 12:42PM CK-MB-2 cTropnT-0.24*
[**2145-4-16**] 12:42PM LIPASE-19
[**2145-4-16**] 12:42PM ALT(SGPT)-21 AST(SGOT)-22 LD(LDH)-269*
CK(CPK)-74 ALK PHOS-88 TOT BILI-0.3
[**2145-4-16**] 12:42PM GLUCOSE-188* UREA N-18 CREAT-6.9* SODIUM-137
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-30 ANION GAP-14
.
MICROBIOLOGY:
Blood Cx [**4-16**]: NGTD (not final at discharge)
Urine Cx [**4-16**]: Neg
Legionella Urine Ag [**4-16**] Neg
.
IMAGES/STUDIES:
.
CXR [**2145-4-16**]:
PORTABLE UPRIGHT CHEST X-RAY: There is increased opacity in the
bilateral lungs, which appears more severe at the right base.
This is diffuse and nonfocal, and suggests a diffuse airspace
process. There is no pleural effusion. There is no pneumothorax.
The cardiac contour is enlarged and globular, in keeping with
known pericardial effusion. The mediastinal contour is otherwise
unremarkable. The visualized bones and the upper abdomen
demonstrate no acute abnormality.
IMPRESSION:
1. Enlarged cardiac silhouette, in keeping with known
pericardial effusion.
2. New diffuse airspace opacities, which appears more severe
than right. Lack pleural effusions argue against volume
overload, and a diffuse infectious process is considered more
likely. Other etiologies, including hemorrhage, are not
excluded.
.
CTA [**2145-4-16**]:
FINDINGS: The aorta is normal in caliber and configuration, with
no evidence for acute aortic syndrome. There is adequate
opacification of the pulmonary arterial tree, with no evidence
of filling defect to suggest pulmonary embolus. The main
pulmonary artery is again enlarged, suggesting pulmonary artery
hypertension. There is a moderate pericardial effusion, similar
in size to prior study. The heart is otherwise unremarkable.
Prominent prevascular and pretracheal mediastinal nodes are
again noted. In the lungs, there are diffuse ground-glass,
somewhat nodular opacity, seen predominantly in the lower lobes
with relative sparing of the apices. This is improved compared
to [**2145-3-21**]. More consolidative processes at the bases
have improved. While there is slight septal thickening,
suggesting that a component of this may represent pulmonary
edema, the lack of effusion argues against attributing this
strictly to volume overloada, and infectious etiologies remain
strong consideration. The trachea and central airways are patent
to the subsegmental level, without endobronchial lesions
identified. The esophagus appears normal. There is no acute
abnormality identified in the upper abdomen.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. No evidence for acute aortic syndrome or pulmonary embolism.
2. Extensive ground-glass, nodular opacities throughout both
lungs, most predominant in the lower lobes, remain most
concerning for infection. Other diagnostic considerations
include pulmonary edema (given history of renal failure and HTN)
or pulmonary hemorrhage. Findings are improved. There is
prominent pretracheal and prevascular lymph nodes again present,
possibly reactive.
3. Moderate pericardial effusion, stable.
4. Prominent main pulmonary artery, again suggestive of
pulmonary hypertension.
Brief Hospital Course:
Mr. [**Known lastname 21822**] is a 32 y/o M w/ DM, ESRD on HD, HTN who presents
with acute onset dyspnea and hypertensive urgency.
.
# Dyspnea/Hypoxemia:
The patient was admitted to the MICU given his respiratory
distress. The most likely cause was felt to be hypertension
precipitating diastolic dysfunction and pulmonary edema. There
was likely a significant component of volume-overload to this
presentation as blood pressure, respiratory status and oxygen
requirement decreased post-hemodialysis with removal of >3L
fluid. A CTA demonstrated ground glass opacities with possible
infectious etiology so he was initially covered with broad
spectrum antibiotics. Blood cultures negative, urine legoinella
negative, and clinical status improved with fluid removal so
antibiotics stopped on day 2. The patient was weaned rapidly
from non-rebreather to room air post-dialysis, and did not
require supplemental oxygen for the remainder of his
hospitalization.
.
# Malignant Hypertension:
His blood pressure was acutely controlled on a nitroglycerin
drip with rapid transition to control on home medications and
removal of fluid with hemodialysis. Hydralazone was
discontinued, as it was felt that it could be contributing to
his complaints of fatigue and depression. Lisinopril was
titrated up from 20 mg to 30 mg daily, and the remainder of his
antihypertensive medications were continued at home doses.
.
# ESRD:
The renal team was consulted on arrival and hemodialysis was
started on the day of admission with removal of 3.3L of fluid.
The next day 400ml were taken off and hemodialysis was stopped
early due to an episode of chest pain. His home medications were
continued. He received epogen and zemplar with HD.
.
# Type 1 Diabetes Uncontrolled with Complications:
Last A1c 7.5 in [**Month (only) 404**]. The patient was continued on his home
regimen of lantus 15 units daily, and humalog sliding scale.
.
# R-Arm Pain:
Thought to be possibly related to AV Graft as having elevated
venous pressures during session, and some clot retrieved at
start of session. Did thrombose graft and had thrombectomy in
past month. However, the pain was worse with movement and
could also be musculoskeletal. The graft functioned well during
dialysis.
.
# Chest pain:
The patient described left sided chest pain that was worse with
inspiration and reproducible with palpation. EKG was unchanged.
Cardiac enzymes were cycled with normal CK and slightly elevated
but unchanged troponins. This was thought to be due to demand
related ischemia in the setting of ESRD. CTA on admission was
negative for pulmonary embolism.
.
# Failure to thrive/weight loss:
Felt most likely to be secondary to depression. The option of
starting an SSRI was discussed with the patient, and he
declined. He was also followed by social work during this
admission.
Medications on Admission:
Hydralazine 25mg PO TID
Lisinopril 20mg PO qday
Calcium Acetate 667mg tablets - 2 tablets TID with meals -> not
taking
Reglan 5mg PO TID - not eating well so using sporadically
Vitamin D 5,000 IU PO qday x 2 weeks -> not taking currently
Calcitriol 0.25mg daily -> not taking
Amlodipine 10mg PO qday
Toprol XL 200mg PO qday
Laisx 80mg PO qday PO qday
Glargine 15 units SC qAM
Humalog sliding scale as below
< 50 0 15
51 100 0 0 0 0 0
101 150 0 0 0 0 0
151 200 0 0 0 0 0
201 [**Telephone/Fax (2) 40889**]1 300 4 0 4 4 2
301 350 6 0 6 6 4
351 400 8 0 8 8 6
> [**Telephone/Fax (2) 40890**] 8
All insulin doses in units
Discharge Medications:
1. Calcium Acetate 667 mg Tablet [**Telephone/Fax (2) **]: Two (2) Tablet PO three
times a day: with meals.
2. Metoclopramide 10 mg Tablet [**Telephone/Fax (2) **]: 0.5 Tablet PO TID W/ MEALS
().
3. Vitamin D 50,000 unit Capsule [**Telephone/Fax (2) **]: One (1) Capsule PO once a
week.
4. Calcitriol 0.25 mcg Capsule [**Telephone/Fax (2) **]: One (1) Capsule PO once a
day.
5. Amlodipine 5 mg Tablet [**Telephone/Fax (2) **]: Two (2) Tablet PO DAILY (Daily).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
[**Telephone/Fax (2) **]: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Furosemide 40 mg Tablet [**Telephone/Fax (2) **]: Two (2) Tablet PO DAILY (Daily).
8. Lisinopril 30 mg Tablet [**Telephone/Fax (2) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Lantus Solostar 300 unit/3 mL Insulin Pen [**Telephone/Fax (2) **]: Fifteen (15)
units Subcutaneous qAM.
10. Humalog 100 unit/mL Solution [**Telephone/Fax (2) **]: ASDIR Subcutaneous four
times a day: Please follow [**Last Name (un) 387**] sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Pulmonary Edema
Hypertensive Urgency
Diabetes Mellitus Type I - poorly controlled, with complications
ESRD on Hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have severe hypertension, and were admitted to the hospital
for low oxygen. We think that your lungs became filled with
fluid because of an episode of severe hypertension. It is very
important to take all of your blood pressure medications and
continue with dialysis. If you decide to stop either of these
treatments, it is likely that you will become very ill and
possibly die.
.
We made the following changes to your home medications:
-STOP Hydralazine
-INCREASE Lisinopril to 30 mg daily
Please take all of your other medications as prescribed.
Followup Instructions:
Please call your kidney doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 1-2 weeks.
Tel [**Telephone/Fax (1) 673**]
.
Please also call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to see him within [**1-9**]
weeks. Tel [**Telephone/Fax (1) 250**]
.
Department: ADVANCED VASC. CARE CNT
When: WEDNESDAY [**2145-4-21**] 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
Department: TRANSPLANT
When: MONDAY [**2145-7-19**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"V5867",
"311"
] |
Admission Date: [**2119-3-10**] Discharge Date: [**2119-3-21**]
Date of Birth: [**2061-4-22**] Sex: F
Service: MEDICINE
Allergies:
Celebrex / Sulfa (Sulfonamide Antibiotics) / Nafcillin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Left foot ulceration and cellulitis
Major Surgical or Invasive Procedure:
1. Left foot incision and drainage with debridement and
hardware removal.
2. Right foot incision and drainage.
History of Present Illness:
This is a lovely 57-year-old woman with a pmh significant for
DMII, diabetic neuropathy, HTN, hypercholesterolemia, psoriasis,
CAD, CHF, and multiple podiatric interventions for right and
left foot ulcers/osteomyelitis, who was admitted from podiatry
clinic on [**2119-3-10**] for fevers, chills, and expression of pus from
left foot ulcer and started on vanc and zosyn. The patient was
seen in the [**Hospital **] clinic on [**2119-3-9**], where her BP was 94/58. ID has
been following her for recurrent MRSA osteomyelitis and septic
arthritis. She was most recently treated with 6 weeks of
vancomycin, ending in [**2118-7-29**], and then was placed on
suppressive doxycycline. She does have metatarsal hardware in
her R foot, which is thought to be distant from the site of
infection. The patient reports that she has had intermittent
vomiting over the past few months and worsened in the days prior
to admission. She also endorses chills and subjective fevers on
the day of admission. She had hit her foot on the day of her ID
appt which resulted in the wound opening up and bleeding. On
[**3-10**], she had chills, subjective fever and n/v.
.
Of note, the patient notes that she has had DOE with exertion
(for example, walking a flight of stairs) for greater than one
year. She has had acute worsening of her DOE with dyspnea even
with just walking to use the bathroom starting today. She also
has had acute worsening of orthopnea today, even with a slight
decrease in head elevation she has orthopnea. She has been dizzy
and lightheaded when she changes position.
.
She may need to go to the OR with podiatry but they have not yet
committed and they are still following. ID is also following,
last seen on [**3-11**]. Since the night prior to her transfer to the
MICU, the patient has been hypotensive with SBPs in the 80s
(baseline pressures according to patient are in the 90s) and
creatinine up to 3.2 (baseline 1.0). Also felt nauseated last
night and could not eat dinner and mildly febrile this morning
to 100.8. She received 2L NS boluses, CXR, UA, Ucx and Bcx were
sent. Patient is alert and oriented x3, looking well.
.
She did have pna around Xmas, had a recent cxr and was told it
was healed. Was treated with unclear [**Name2 (NI) 621**]. She has previously
been treated for htn.
Past Medical History:
- HTN
- Hypercholesterolemia
- Psoriasis
- CAD, diastolic CHF followed by cardiologist in [**Location (un) 5503**]
(Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **])
- IDDM c/b neuropathy
- B/l Charcot foot deformity; L non-healing wound
- Depression
PAST SURGICAL HISTORY:
- Debridement and hardware removal left foot [**2117-7-20**]
- Left Charcot foot medial and lateral column fusion [**2116-2-25**]
- Left lateral malleolus debridement [**2116**]
- R panmetatarsal head resection [**2114**]
- Ludloff osteotomy of the right foot, Arthroplasty of the
second
digit, Flexor tenotomy of the right second digit [**2113**]
- Left hallux amp [**2112**]
- Right Carpal tunnel release [**2110**]
- b/l oopherectomy [**2118**] (benign masses)
FOREIGN BODIES:
Screws in the first metatarsal of the R foot; pin
in the L midfoot
Social History:
- Lives at home with husband. Currently unemployed. States she
is using a wheelchair but can walk; she uses this bc she is
supposed to stay off of her feet.
- Denies alcohol, tobacco, illicit drug use.
Family History:
Father c DM, CAD, 3V CABG x2, CEAs
Mother stroke
Brother DM
Physical Exam:
Vitals: T: 97 BP: 82/57 P:80 R: 12 O2: 99%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP to jaw and elevated to ear lobes with hepatic
pressure, no LAD
Lungs: Minor bibasilar crackles no wheezes, rales
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
+S3 Abdomen: soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool, 2+ pulses in UE, no LE edema. Feet are bilaterally
wrapped and right is not examined. Left foot has 2cmx2cm
ulcerative lesion on lateral aspect of dorsum of foot which is
frankly purulent (not probed). Toes are cracked, dry with
multiple toes missing.
Skin: psoriasis throughout entire dermis. No open abrasions.
Hemorrhagic/edematous 4cmx3cm on RUE
Neuro: CNs2-12 intact, motor function grossly normal, finger to
nose normal. Gait deferred.
Pertinent Results:
ADMISSION LABS
[**2119-3-9**] 12:15PM BLOOD WBC-11.0# RBC-3.61* Hgb-11.7* Hct-35.7*
MCV-99* MCH-32.4* MCHC-32.7 RDW-13.9 Plt Ct-157#
[**2119-3-9**] 12:15PM BLOOD Neuts-84.2* Lymphs-7.7* Monos-5.4 Eos-2.3
Baso-0.4
[**2119-3-12**] 03:10PM BLOOD PT-14.0* PTT-28.3 INR(PT)-1.3*
[**2119-3-10**] 05:21PM BLOOD Glucose-135* UreaN-34* Creat-1.5* Na-140
K-4.3 Cl-101 HCO3-26 AnGap-17
[**2119-3-9**] 12:15PM BLOOD ALT-13 AST-22 AlkPhos-131* TotBili-0.4
[**2119-3-12**] 03:10PM BLOOD CK(CPK)-22*
[**2119-3-12**] 03:10PM BLOOD CK-MB-1 cTropnT-<0.01
[**2119-3-13**] 04:07AM BLOOD CK-MB-1 cTropnT-<0.01
[**2119-3-10**] 05:21PM BLOOD Calcium-9.7 Phos-3.2 Mg-1.7
PERTINENT RESULTS
[**2119-3-9**] 12:15PM BLOOD ESR-120*
[**2119-3-13**] 04:07AM BLOOD Albumin-2.4* Calcium-8.9 Phos-4.8* Mg-2.4
Iron-31
[**2119-3-13**] 04:07AM BLOOD calTIBC-159* Ferritn-1460* TRF-122*
[**2119-3-9**] 12:15PM BLOOD CRP-122.0*
[**2119-3-12**] 05:36PM BLOOD Lactate-1.1
[**2119-3-13**] 04:41AM BLOOD Lactate-1.3
[**2119-3-12**] 04:44PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2119-3-12**] 04:44PM URINE RBC-5* WBC-12* Bacteri-MOD Yeast-NONE
Epi-2
[**2119-3-12**] 04:44PM URINE Hours-RANDOM UreaN-134 Creat-209 Na-20
K-GREATER TH Cl-<10
[**2119-3-10**] 12:32 pm SWAB Source: left foot. wound culture
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
QUANTITATION NOT AVAILABLE.
GRAM NEGATIVE ROD(S). SPARSE GROWTH. SECOND
MORPHOLOGY.
Echo [**2119-3-10**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
mildly dilated with moderate global hypokinesis. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded (LVEF = 30%). [Intrinsic function is
more depressed given the severity of aortic regurgitation and
mitral regurgitation.] The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Moderate (2+) aortic regurgitation is
seen directed along the interventricular septum The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. IMPRESSION: Suboptimal image quality. Left ventricular
cavity dilation with moderate global hypokinesis c/w diffuse
process (toxin, metabolic, etc.). Right ventricular cavity
dilation with free wall hypokinesis. Moderate aortic
regurgitation. Moderate mitral regurgitation.
Trivial/physiologic pericardial effusion.
If there is a clinical history to suggest endocarditis, a TEE is
suggested.
[**2119-3-16**] 4:00 pm TISSUE BONE LEFT FOOT
GRAM STAIN (Final [**2119-3-16**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2119-3-20**]):
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 67722**]
([**2119-3-10**]).
PROTEUS MIRABILIS. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 67722**]
([**2119-3-10**]).
ANAEROBIC CULTURE (Final [**2119-3-20**]):
ANAEROBIC GRAM POSITIVE COCCUS(I). SPARSE GROWTH.
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
Discharge Labs:
[**2119-3-21**] 06:57AM BLOOD WBC-9.6 RBC-3.14* Hgb-10.2* Hct-29.0*
MCV-92 MCH-32.4* MCHC-35.1* RDW-14.7 Plt Ct-209
[**2119-3-12**] 03:10PM BLOOD Neuts-85.1* Lymphs-7.9* Monos-4.3 Eos-2.4
Baso-0.3
[**2119-3-21**] 06:57AM BLOOD Plt Ct-209
[**2119-3-21**] 06:57AM BLOOD Glucose-111* UreaN-17 Creat-1.0 Na-140
K-3.8 Cl-106 HCO3-26 AnGap-12
[**2119-3-13**] 04:07AM BLOOD ALT-8 AST-17 LD(LDH)-186 AlkPhos-155*
TotBili-0.5
[**2119-3-21**] 06:57AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.7
[**2119-3-13**] 04:07AM BLOOD calTIBC-159* Ferritn-1460* TRF-122*
[**2119-3-9**] 12:15PM BLOOD CRP-122.0*
[**2119-3-20**] 06:15AM BLOOD Vanco-15.2
Brief Hospital Course:
57-year-old woman with DMII, neuropathy, HTN,
hypercholesterolemia, psoriasis, CAD, CHF, and multiple
podiatric interventions for right and left foot
ulcers/osteomyelitis, who was admitted from podiatry clinic on
[**2119-3-10**] for fevers, chills, transferred to the MICU with
pulmonary edema and hypotension likely secondary to acute
exacerbation of systolic heart failure.
.
# Systolic Heart Failure: the patient initially presented to the
MICU with florid signs of fluid overload after receiving bolused
2L. She has an underlying EF 30-35% with moderate MR [**First Name (Titles) **] [**Last Name (Titles) **]
(thus under estimating her EF), which was seen on echo at OSH in
[**Month (only) 216**] and is likely long-standing. She had acute worsening of
DOE and orthopnea and pulmonary edema on CXR, which improved
with diuresis (20mg IV lasix x3 with diuresis of 2L on [**3-13**] in
the MICU). She symptomatically improved although with ongoing
signs of heart failure, with JVD and vascular congestion on CXR
[**3-13**]. The heart failure medications: ACEi, beta blocker,
spironolactone, were initially held in setting of hypotension.
The ACEi and BB restart on [**3-15**] and were well tolerated. Her
ACEi was switched from quinapril 10 mg [**Hospital1 **] to lisinopril 5mg
daily, which should be uptitrated as BP tolerates. Lisinopril
was not uptitrate since her BP was typically in the 100's.
Spironolactone was restarted on [**3-18**] and were well tolerated
until discharge on [**2119-3-21**].
.
# Hypotension: The patient was initially hypotensive with the
likely etiology was initially sepsis [**3-2**] osteomyelitis and then
was exacerbated by 2L fluid boluses, which caused acute
worsening of her systolic HF. Her blood pressure improved after
diuresis of 2L, likely due to improved dynamics with decr
afterload. Her baseline blood pressure remaned in 100-110
systolics, with good mentation and UOP. Coreg, lisinopril, and
spironlactone were restarted per above and she had a stable BP
and stable electrolytes for 5 days prior to discharge.
.
# [**Last Name (un) **]: baseline Cr 1.0, trended up quickly to 3.8 in setting of
CHF exacerbation, likely [**3-2**] poor forward flow. The patient has
improved with diuresis to baseline of 1.0 prior to discharge.
.
# Osteomyelitis: the patient has had a long hx of osteo, and
currently has elevated inflammatory markers with a purulent
ulcerative lesion on her left foot. On admission, iv vancomycin
and zosyn were started per ID recommendations, new left foot
films were taken, and a wound swab was collected, which grew
beta streptococcus group B, gram negative rods (2 morphologies),
corynebacterim species (diphtheroids). She was changed to
meropenem empirically to cover ESBL at time of transfer to the
MICU and vanc by level was continued. The patient was taken for
a I&D of the right foot and I&D of left foot with bone and
mental hardware removal of the left foot. No ESBL grew back and
the patient was restarted Zosyn 4.5 q8 and vancomycin 1gm q24.
See Bone cultures. She will need to complete a total of 8 weeks
(until [**2119-5-11**]) of these antibiotics. Vancomycin trough should
be targeted to 15-20. The patient will need to follow up with
both podiatry and ID.
.
# Anemia: the patient's hct has trended from 44 to 28 since
admission, she was likely hemoconcentrated at presenation as her
baseline hct is in the range of 28. Iron studies c/w ACD.
.
#DM: The patient BS were well controled on a lower than home
dose of lantus 30 units at bedtime and a humalog sliding scale.
.
# Transition Issues:
-The patient should have here electrolytes and a vancomycin
trough check one week after discharge
-The patient should follow up with Podiatry on MONDAY [**4-3**],[**2119**] at 2:10 PM
-The patient should follow up with Infectious Disease on FRIDAY
[**2119-3-31**] at 9:30 AM
Medications on Admission:
HOME MEDICATIONS:
Doxycycline Hyclate 100 mg PO Q12H
Acidophilus *NF* 175 mg Oral daily
Aspirin 81 mg PO/NG DAILY
Nortriptyline 10 mg PO/NG HS
Oxcarbazepine 150 mg PO BID
Citalopram 40 mg PO/NG DAILY
Carvedilol 6.25 mg PO/NG [**Hospital1 **]
Quinapril 10 mg PO/NG [**Hospital1 **]
Simvastatin 20 mg PO/NG QHS
Furosemide 40 mg PO/NG DAILY
Spironolactone 25 mg PO/NG DAILY
Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Lantus
40U
Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Mobic *NF* (meloxicam) 7.5 mg Oral daily
Oxycodone/Apap 5-325mg [**1-30**] tab in am 1 tab qhs
Discharge Medications:
1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day).
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Acidophilus Oral
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours) for 8 weeks:
continue until [**2119-5-11**].
15. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 8 weeks: please titrate
for trough of 15 to 20;
continue until [**2119-5-11**].
16. insulin
Please continue Insulin per attached flowsheet and lantus 30
units every night
Discharge Disposition:
Extended Care
Facility:
Oaks Long Term Care Facility - [**Location (un) 5503**]
Discharge Diagnosis:
Left foot ulceration and bilateral foot cellulitis.
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:
Ms. [**Known lastname 4281**],
It was a pleasure taking care of you a [**Hospital1 827**]. You were admitted from podiatry clinic on
[**2119-3-10**] for fevers, chills, and expression of pus from left foot
ulcer. You were admitted to the ICU due to low blood pressure
and dropping oxygenation. You were aggressively treated and now
doing better. You underwent surgery to remove infected bone and
hardware in your left foot and surgery to reduced the amount of
infection in both feet. You are now doing better after the
surgery. You are to remain NONWEIGHT BEARING to your LEFT FOOT
at all times in a surgical shoe. You can do partial weight
bearing on the right foot. You will need IV antibiotics for a
total of 8 weeks (until [**2119-5-11**]). Please follow up with both
podiatry and infectious disease at the appointment listed below.
You were discharged with new medications. Please take as
directed. You may resume your home medications unless otherwise
instructed.
Keep your dressings clean, dry, and intact. Nursing staff will
perform daily dressing changes. Avoid getting your dressings
wet.
You may resume your normal home diet.
If you develop any of the symptoms listed below or anything else
concerning please see your PCP or go to your nearest emergency
room.
Medication Changes:
Stop taking Oxycodone
Stop taking Mobic
Stop taking doxyclcline
Stop taking quinapril
Reduce your insulin glargine dose to 30 units subcutaneously at
night
Start taking lisinopril 5mg daily
Start taking vancomycin 1 gram IV daily until [**2119-5-11**]
Start taking Zosyn 4.5 g IV every 8 hours until [**2119-5-11**]
Followup Instructions:
Department: INFECTIOUS DISEASE
When: FRIDAY [**2119-3-31**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PODIATRY
When: MONDAY [**2119-4-3**] at 2:10 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"0389",
"5849",
"4280",
"99592",
"V5867",
"4019",
"2720",
"41401",
"311",
"4240"
] |
Admission Date: [**2122-5-7**] Discharge Date: [**2122-5-15**]
Date of Birth: [**2066-8-27**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 55-year-old gentleman
with known coronary disease, status post multiple PCI. The
patient most recently was hospitalized in [**2121-10-27**]
after a positive stress test and catheterization which showed
three vessel disease. At that time, it was thought the
patient would be better served by coronary artery bypass
grafting. The patient reports a history of worsening
exertional angina and now with occasional rest pain, all
relieved by sublingual Nitroglycerin.
PAST MEDICAL HISTORY: Coronary artery disease.
Status post myocardial infarction [**2102**].
Peripheral vascular disease.
Hypertension.
Hypercholesterolemia.
Status post right CEA in [**2114**].
Status post left CEA in [**2113**].
Status post aorto-bifemoral bypass graft in [**2113**].
Status post thrombectomy of the right brachial artery in
[**2108**].
Status post multiple cardiac catheterizations and PCI's.
PREOPERATIVE MEDICATIONS:
1. Lipitor 40 mg p.o. once a day.
2. Plavix 75 mg p.o. once a day.
3. Imdur 120 mg p.o. once a day.
4. Toprol XL 200 mg p.o. once a day.
5. Protonix 40 mg p.o. once a day.
6. Colace.
7. Lisinopril 5 mg p.o. once a day.
8. Aspirin 325 mg p.o. once a day.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2122-5-7**] and taken to the
Operating Room for a coronary artery bypass graft times
three, LIMA to LAD, saphenous vein graft to OM and saphenous
vein graft to ramus with Dr. [**Last Name (STitle) 70**]. Please see operative
note for further details. The patient was transferred to the
Intensive Care Unit in stable condition on Neo-Synephrine,
amiodarone and Propofol. The amiodarone was started in the
Operating Room due to the patient developing ventricular
tachycardia prior to cardiopulmonary bypass. Please see
operative note for full details. Upon arrival to the
Intensive Care Unit, the patient was noted to have several
hours of significant chest tube drainage. At the time of his
admission to the Intensive Care Unit, the patient was noted
to be hypothermic and have mild coagulopathy. Once the
coagulopathy was resolved, chest tube output markedly
decreased and at that time, the patient was noted to have
acute elevation in his filling pressures with a resultant
significant decrease in his systemic blood pressure. It was
felt the patient was noted to be in acute tamponade and the
patient required to have his chest incision opened and his
sternum explored at the bedside. Upon opening the chest and
removing a large amount of clot, the patient's hemodynamics
improved. The patient was taken back to the Operating Room
where the incision was irrigated and all bleeding was
controlled and the patient was transported back to the
Intensive Care Unit in stable condition. Upon returning to
the Intensive Care Unit, the patient had been placed on low
dose milrinone and Levophed infusion. In the Operating Room,
the patient's ejection fraction was noted to be 50 percent.
The patient was weaned and extubated from mechanical
ventilation on postoperative day no. 1 . The patient required
________ for optimal sedation to achieve extubation. The
patient's hemodynamics were good. The milrinone was
discontinued with good hemodynamics. As well, on
postoperative day no. 1, the patient was noted to have
several episodes of atrial fibrillation which continued into
the early morning of postoperative day no. 2. The patient
received boluses of amiodarone and low dose Lopressor. The
patient's chest tubes remained in due to an air leak. On
postoperative day no. 2, the patient's pulmonary artery
catheter was discontinued. The patient was started on
Lopressor and the patient was transferred from the Intensive
Care Unit to the regular part of the hospital. Upon arrival
on the floor, the patient was noted to be in atrial
fibrillation, rate controlled. The patient was also having
several episodes of 4 to 5 beats of nonsustained ventricular
tachycardia. Electrophysiology consultation was obtained.
It was recommended that the patient get an echocardiogram to
assess right ventricular and left ventricular function. As
the patient had normal left ventricular function, the patient
would just be treated with amiodarone and beta blockers. The
patient had an echocardiogram on postoperative day no. 5
which showed an ejection fraction of 45 to 50 percent. No
pericardial effusion, 2 plus mitral regurgitation. The
morning of postoperative day no. 6, the patient converted to
sinus rhythm although intermittently had brief episodes again
of atrial fibrillation. The patient was started on heparin
infusion as well as Coumadin for anti-coagulation. The
patient's chest tube was removed. Post removal, chest x-ray
showed a small left apical pneumothorax with complete
resolution by postoperative day no. 6. By postoperative day
no. 6, the patient had completed a Level 5 of physical
therapy and was able to ambulate 500 feet and climb one
flight of stairs. Electrophysiology Service recommended the
patient be discharged on continued amiodarone and Coumadin
for anticoagulation as well as be discharged home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
of Hearts monitor. On the evening of postoperative day no.
5, the patient was noted to have a fair amount of
serosanguinous drainage from his sternal incision. The
patient was started on Keflex as well. On postoperative day
no. 6, the patient was noted to have a thrombophlebitis of
the left forearm from an old intravenous site. This
progressively got better over the next several days. The
sternal incision never had any erythema and the patient was
never febrile. The drainage decreased over the next several
days and stopped by postoperative day no. 7. The patient
continued on his Keflex and by postoperative day no. 7 he was
cleared for discharge to home.
CONDITION ON DISCHARGE: TMAX 98.7 degrees, pulse 74 in sinus
rhythm, blood pressure 117/52, respiratory rate 20, room air
oxygen saturation 94 percent. Neurologically, the patient is
awake, alert, oriented times three, nonfocal. Heart is
regular rate and rhythm without rub or murmur. Breath sounds
are clear bilaterally. Sternal incision is clean and dry.
There is no erythema. There is no drainage. Sternum is
stable. Abdomen soft and nontender, nondistended. The
patient is tolerating a regular diet and having normal bowel
movements. Lower extremities are warm and well perfused with
trace to 1 plus pitting edema. The right lower extremity
vein harvest site clean and dry without erythema or drainage.
LABORATORY DATA: White blood cell count 8.2, hematocrit
28.7, platelet count 390. Sodium 138, potassium 4.5,
chloride 103, bicarbonate 22, BUN 13, creatinine 1.0, glucose
103. The patient's PT is 16.4, INR of 1.8.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. twice a day.
2. Lasix 20 mg p.o. once a day times 7 days.
3. Potassium chloride 20 mEq p.o. once a day times 7 days.
4. Colace 100 mg p.o. twice a day while taking narcotic pain
medications.
5. Plavix 75 mg p.o. once a day.
6. Lipitor 40 mg p.o. once a day.
7. Enteric-coated Aspirin 81 mg p.o. once a day.
8. Keflex 500 mg p.o. q.i.d. times 7 days.
9. Dilaudid 2 mg Perles 1 to 2, p.o. q.4-6h. p.r.n.
10. Amiodarone 400 mg once a day times one month.
11. Protonix 40 mg p.o. once a day.
12. Coumadin. The patient is to take 2 mg on [**5-15**],
[**5-16**] and [**5-17**]. The patient is to have PT and INR
checked on [**2122-5-18**] with the results called to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1226**] office and further Coumadin dosing and
INR checks are to be per Dr. [**First Name (STitle) **].
The patient is to be discharged to home in stable condition.
The patient is to follow-up with Dr.[**Name (NI) 11574**] office by
phone on [**Last Name (LF) 766**], [**2122-5-18**], and in the office on [**2122-5-22**] at 2:30 p.m. He is to follow-up with Dr. [**Last Name (STitle) **] in
one to two weeks, and he is to follow-up with Dr. [**Last Name (STitle) 70**]
in five to six weeks.
DISCHARGE DIAGNOSES: Coronary artery disease.
Status post coronary artery bypass graft times three.
Postoperative atrial fibrillation.
Postoperative drainage from sternal incision which is
resolved.
Postoperative left forearm thrombophlebitis.
Peripheral vascular disease and hypertension.
Hypercholesterolemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2122-5-15**] 12:46:42
T: [**2122-5-15**] 16:25:00
Job#: [**Job Number 24656**]
|
[
"41401",
"42731",
"4240",
"9971"
] |
Admission Date: [**2139-4-5**] Discharge Date: [**2139-4-18**]
Date of Birth: [**2066-4-30**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Left IJ hemodialysis catheter placement
Right IJ central line placement
History of Present Illness:
The patient is a 72 year old male with a history of CAD s/p CABG
x 2, CHF EF 20%, AFIB, DM2 who presented on [**2139-4-5**] with
worsening DOE x 4 weeks, cough, and increased LE edema. Pt
reports that 4 weeks prior to presentation, he would be able to
climb 10 steps and walk [**1-28**] mile w/o dyspnea - DOE has slowly
progressed such that today not able to walk 20 feet w/o dyspnea.
Denies dyspnea at rest. Pt also states that he had noticed
increased LE edema over past 4 weeks before admission. Finally,
he states he has had a cough productive of white sputum x 4
weeks; worse at night and interferes w/ his ability to sleep.
On presentation, the patient denied any CP, but stated that one
week prior he felt non-radiating sharp substernal CP after
climbing 1 flight of stairs. +dyspnea -diaphoresis, -N/V. He has
been prescribed SL NTG in past, but never has needed it - during
this episode, however, he wished he had it at the time. CP
dissipated after resting for 10 minutes and did not recur.
Does not actively monitor salt intake. Has increased fluid
intake (2-3 L/day now) b/c of sensation of dry mouth when wakes
up. General malaise has resulted in missing some medication
doses. Pt's PCP was going to start him on digoxin for his AF but
the prescription has not been filled b/c of dosing error
(prescribed 0.1 mg every other day). Has been taking tylenol (2
tabs 2-3 times daily) for generally unwell feeling. Has been
seen multiple times by PCP for worsening DOE. Work-up included
CXR ([**3-31**] - no evidence CHF, no infiltrate), echo (EF 20%) and
blood cx to r/o endocarditis (pending).
ROS: + rhinorrhea, decreased appetite. +wt gain, but not sure
how much. Denies orthopnea, PND (but sleeps w/ two pillows for
GERD), fevers, chills, night sweats, change in bowel or bladder
habits, BRBPR, melena, hematuria, visual changes, weakness in
arms or legs. pain in L shoulder w/ movement (longstanding
problem)
Past Medical History:
CAD (CABG [**2109**] AND [**2120**])
CHF w/ EF 20%, diastolic dysfx
AF (dating back to [**2134**])
DM (HBA1c [**2138**] = 7.5)
CRI
GERD
PUD
gout
claudication
s/p CCY
s/p cataract [**Doctor First Name **] [**1-30**]
s/p back surgery
Social History:
Pt is a retired engineer. Lives w/ wife, daughter and
granddaughter. Quit tobacco >15 years ago; 50 pk-yr history.
Social EtOH (2 drinks/week), no illicits. Wife is HCP. Daughter
is cardiac nurse.
Family History:
Noncontributory.
Physical Exam:
T 97.3, BP 103-119/53-70, 87-102, 15-16, 100% RA.
Gen: comfortable appearing man, in bed at 40 degrees, speaking
in complete sentences without dyspnea, NAD
Skin: no rashes, numerous ecchymoses, particularly L forearm,
stasis changes LLE
HEENT: NCAT, PEERLA (3-->2), EOMI, OP clear w/o erythema, neck
supple, no LAD.
CV: JVD above ear @90 degrees, 1+ carotid pulses bilaterally w/o
bruits, irregular rhythm, rate 75-90, III/VI
crescendo-decrescendo murmurSEM, ?gallop, no heave
Resp: decreased BS bilaterally in lower [**1-27**] of lung, bibasilar
crackles in lower [**1-26**] of lungs
Abd: obese, well healed midline incision w/ hernia, +
distention/mildly tense, non-tender.
Ext: 3+ edema LLE, 2+ edema RLL, non-tender to palpation.
Extremities warm. 2+ radial pulses bilaterally. L shoulder: pain
on passive forward flexion; non-tender to palpation.
Pertinent Results:
Admission Labs:
WBC-9.1 RBC-3.10* Hgb-10.6* Hct-31.0* Plt Ct-208 Neuts-86.4*
Bands-0 Lymphs-7.6* Monos-4.7 Eos-0.7 Baso-0.5
PT-20.6* PTT-39.0* INR(PT)-2.0*
Glucose-258* UreaN-84* Creat-2.2* Na-132* K-3.4 Cl-92* HCO3-25
AnGap-18
ALT-32 AST-35 AlkPhos-217* Amylase-50 TotBili-1.5 Lipase-34
proBNP-7947*
Cardiac Enzymes:
[**2139-4-5**] 02:00PM CK(CPK)-85 CK-MB-NotDone cTropnT-0.07*
proBNP-7947*
[**2139-4-5**] 08:10PM CK(CPK)-81 cTropnT-0.07*
[**2139-4-5**] 09:43PM CK(CPK)-81 CK-MB-3 cTropnT-0.08*
[**2139-4-6**] 06:20AM CK(CPK)-78 CK-MB-NotDone cTropnT-0.06*
***
Admission Studies:
ECG Study Date of [**2139-4-5**] 1:14:06 PM
Atrial fibrillation Ventricular premature complexes Consider
prior inferior myocardial infarction Prior anteroseptal
myocardial infarction
Diffuse nonspecific ST-T wave abnormalities Since previous
tracing of [**2136-6-12**], ventricular ectopy and further ST-T wave
changes present
CHEST (PORTABLE AP) [**2139-4-5**] 1:28 PM
SEMI-UPRIGHT AP VIEW OF THE CHEST: Patient is status post median
sternotomy and CABG. The heart is at the upper limits of normal
size. In the interval, there has been upper zone vascular
redistribution, vascular engorgement, and perihilar haziness,
findings all consistent with mild congestive heart failure. The
costophrenic angle is excluded from this study. Small left
pleural effusion is likely present. There is no pneumothorax.
Osseous structures are unchanged.
IMPRESSION: Mild congestive heart failure. Probable small left
pleural effusion.
UNILAT LOWER EXT VEINS LEFT [**2139-4-5**] IMPRESSION: No evidence of
DVT.
***
Other Labs:
[**2139-4-13**] 05:25AM BLOOD ALT-22 AST-35 LD(LDH)-302* AlkPhos-206*
TotBili-1.5
GGT-318*
[**2139-4-5**] 02:00PM BLOOD calTIBC-270 VitB12-595 Ferritn-622*
TRF-208
[**2139-4-10**] 06:20AM BLOOD Folate-12.2 Ferritn-600*
[**2139-4-9**] 06:30AM BLOOD Triglyc-58 HDL-36 CHOL/HD-2.2 LDLcalc-32
[**2139-4-9**] 06:30AM BLOOD Digoxin-0.5*
***
Other Studies:
CHEST (PORTABLE AP) [**2139-4-13**] 7:10 AM
1. Slightly improving interstitial pulmonary edema.
2. Swan-Ganz catheter terminates in the right upper lobar
artery.
RENAL U.S. [**2139-4-9**] 9:55 AM
IMPRESSION: Diminished intrarenal arterial diastolic flow
suggesting chronic small vessel disease. Otherwise, normal renal
ultrasound with no hydronephrosis or evidence for renal artery
stenosis.
ESOPHAGUS [**2139-4-16**] 3:08 PM
During the initial swallows, there was no evidence of
aspiration. However, after consecutive sips of thick dye and the
patient aspirated a small amount. The cough was partially
effective in clearing the aspirated barium.
The motility of the esophagus appears satisfactory. In the
anterior aspect of the distal third of the esophagus there is
some irregularity which was incompletely evaluated in this
study. This should be further evaluated when the patient comes
down tomorrow for a video swallow.
IMPRESSION:
1. Mild aspiration during the study. Recommend evaluation by the
speech and swallow therapist with a video swallow fluoroscopy.
REPEAT BARIUM SWALLOW [**4-17**]:
IMPRESSION: Extrinsic compression upon anterior distal
esophagus. If there
is further clinical concern recommend followup CT exam.
VIDEO SWALLOW: mildly reduced oral control and mild pharyngeal
residue in the valleculae with all consistencies. Pt also had
trace penetration before the swallow with both thin and nectar
thick liquids, but he completely cleared the penetration and no
aspiration was seen during this study. Based on this study, pt
is safe for thin liquids and regular consistency solids. Pt will
need to perform repeat swallows as needed to clear the
pharyngeal residue which he is sensate to, and often coughs in
response to. Spontaneous coughs during this evaluation were
never due to
aspiration.
RECOMMENDATIONS:
1. suggest pt continue with a PO diet of thin liquids and
regular
consistency solids.
2. Pills whole with thin liquids.
3. Continue with esophageal work- up, especially for reflux, as
many of the pt's symptoms may coincide with reflux.
CT CHEST W/O CONTRAST [**2139-4-17**] 9:04 PM:
CT OF THE CHEST WITHOUT IV CONTRAST: There is a left internal
jugular line terminating in the distal SVC. There are extensive
vascular calcifications. There are multiple small mediastinal
lymph nodes. There are multifocal patchy areas of consolidation
in the right upper lobe, left upper lobe, right middle lobe, and
bilateral lower lobes. There is a focal area of calcification at
the dome of the liver. There is an axial type hiatal hernia. No
abnormal masses producing extrinsic compression of the esophagus
are identified. There is no definite esophageal wall thickening
with areas of the mid esophagus that are underfilled and thus
difficult to evaluate for wall thickening.
Bone windows reveal no suspicious lytic or sclerotic lesions.
IMPRESSION:
1. No abnormal masses producing extrinsic compression of the
esophagus are identified. There is no definite wall thickening,
with evaluation of the mid esophagus limited due to under
filling.
2. Small axial type hiatal hernia.
3. Extensive vascular calcifications including dense coronary
artery calcifications in this patient that appears to be status
post CABG.
4. Multiple patchy opacities in the lungs concerning for
multifocal pneumonia. Given this patient's documented aspiration
on the recent barium swallow, this is likely contributory.
Brief Hospital Course:
[**Hospital3 **] Course:
Pt was admitted on [**2139-4-5**] on the [**Hospital1 139**] APG service. He was
fluid overloaded with CHF and was diuresed to be negative 3L,
however in the setting of decompenstated HF, aggressive
diuresis, and initiation of an ACEI, he developed acute renal
failure. Despite discontinuation of all diuretics and
renal-toxic medications, his creatinine continued to rise over
the next two days to 4.2. Additionally, his blood pressures
remained very low (80s-100s SBP), though he was asymptomatic and
not orthostatic. Accordingly, he was transferred to the CCU for
CHF decompensation on [**2139-4-9**].
In the CCU, a central line and swan were placed and the patient
was initially maintained on dopamine and vasopressin. His
initial numbers were : PCW 33 on admission to CCU , PAP 63/29,
CO 4.4, CI 2.07, SVR 855, SVO2 58% --> CO 5.2, CI 2.44 SVR 877,
SvO2 61% off milrinone.
In addition, he had been on milrinone until [**2139-4-13**]. In the CCU,
renal was consulted and CCVH was initiated with HD through a
left IJ line. At the end of his CCU course, the patient was a
total of 3.8 liters negative. On [**2139-4-14**], the day of transfer to
the floor, the patient had diuresed 1 liter the day before on
CVVH and was 200 cc+ until noon with little urine output prior
to transfer on metalazone and lasix 80 mg PO QD.
He was transferred back to the medicine service on [**4-13**].
Diuresis was resumed with lasix and metalozone, with good urine
output and stable creatinine at his baseline.
From a respiratory stand point, Mr. [**Known lastname 100942**] improved
substantially with diuresis; he was able to ambulate without
dyspnea, limited only by deconditioning. His significant lower
extremity edema, however, persisted.
Hospital Course By Issues:
Cardiac:
CHF Exacerbation: The etiology of this exacerbation is not
clear, however might be in part due to increasing fluid intake
and salt indiscretion. While he was ruled out for MI during
this hospitalization, it is possible he previously had an
ischemic event which contributed to this exacerbation
On admission, Mr. [**Known lastname 100942**]' CHF regimen included: furosemide 80 mg
daily, metolazone 5 mg daily, and spironolactone/HCTZ 25/25 mg
daily. He had previously been on a BB but it was discontinued
as he is believed to have pulmonary disease, which was
exacerbated the BB. It could not be determined whether he had
previously been on an ACEI. His outpatient diuretics were
continued, though lasix was change to IV and administered [**Hospital1 **],
and an ACEI was started. In this setting he developed ARF and
was transferred as detailed above to the CCU for tailored
therapy. Furthermore, he was hypotensive (80s-100s SBP), though
he was asymptomatic from this.
His regimen on discharge is lasix and metalozone [**Hospital1 **] and he was
diuresing well to this regimen with stable creatinine. He was
also started on digoxin 0.125 mg daily. As Mr. [**Known lastname 100942**] has an
appointment with the Heart Failure clinic, further modification
of his CHF regimen was deferred. He was not restarted on a BB
given his history of exacerbation of respiratory dyspnea with
atenolol and onset of ARF inconjunction with starting an ACEI
during this hospitalization.
He should have a repeat echocardiogram when he is euvolemic to
assess his actual EF and to guide decisions regarding the need
for AICD.
CAD:
- Mr. [**Known lastname 100942**] has a history of CABG x 2, [**2109**] and [**2120**] and was
ruled out for MI. In [**2131**], cath showed 3VD and occlusion of [**3-30**]
grafts.
- He was continued on ASA and lipitor 80. BB was felt to be
contraindicated given his history of pulmonary exacerbation and
his relative hypotension.
-[**Name2 (NI) **] should follow-up with his cardiologist as an outpatient to
discuss the role for cardiac catheterization when he is
euvolemic for hemodynamic assessment and to evaluate for
ischemic contribution to his worsening CHF.
# Rhythm: AFIB since [**2134**].
-Mr. [**Known lastname 100942**] was monitored on telemetry during his stay - he was
in afib but HR was routinely in the 70s-90s
-he was started on digoxin 0.125 mg daily; it was felt a
beta-blocker was contraindicated as detailed previously.
- He was anticoagulated with heparin gtt while in the CCU then
transitioned to coumadin with a goal INR [**2-27**]
# Acute on chronic renal failure:
- Mr. [**Known lastname 100942**]' Cr rose from his baseline of 2.0 to a peak of 4.1,
but returned to his baseline after CVVH in the CCU. His ARF was
likely multifactorial (low-flow state in the setting of
decompensated CHF, aggressive diuresis, ACEI). Renal US showed
no hydro or renal a stenosis and urine lytes showed a prerenal
state.
- Many of his medications were discontinued in the setting of
ARF and were not restarted at discharge given his CRF. These
include glyburide, metformin, and colchicine.
#. Cough: likely multifactorial - secondary to pulmonary
congestion, related to pneumonia.
-Pneumonia - Sputum culture + for H. influenzae, placed on levo
7 day course (renally adjusted).
-given the history of exacerbation of cough after drinking
fluids, a video swallow was performed which did not demonstrate
aspiration.
#. Elevated alk phos - has had cholecystectomy in past. Likely
related to CHF, especially as level as increased as CHF has
worsened. Unlikely cholestasis or congestion given normal LFTs,
normal bili, and ******normal GGT.
# DM2: discontinued glyburide and metformin given a creatinine
clearance of 35. Started on glargine 8, and RISS. At discharge,
the pt's creatinine had improved and he was restarted on
glargine per Dr.[**Name (NI) 19189**] recs.
# Anemia:
- Baseline Hct 39-40, this month has ranged 28-30.
- Iron studies show chronic disease.
-Started epogen qM,W,F and continued iron supplementation.
.
# Hematuria/UTI
-Urine: no longer grossly bloody after removal of foley, only
[**3-29**] RBCs on microscopic eval of urine --> hematuria resolved. Pt
with UTI treated with levofloxacin.
# Esophageal motility
- Pt was evaluated for possible aspiration and found to not be
aspirating. Additionally, there was a question of something
compressing the anterior distal esophagus. This was further
evaluated with a CT scan which was normal.
# FEN: Placed on low Na, cardiac/DM diet, 1L IVF restriction.
Electrolytes were carefully monitored and repleted prn. Patient
was placed on standing Mg 800 mg [**Hospital1 **].
Medications on Admission:
Warfarin 5 mg M-F, 2.5 mg Sat,Sun
Dipyrimidole 25 mg TID
Glyburide 1.5 mg daily
metformin 1000 [**Hospital1 **]
furosemide 80 mg daily
metolazone 5 mg daily
spironolactone/HCTZ 25/25 mg daily
colchincine 0.6 mg daily
nexium 20 mg daily
vitamin E 400 IU daily
Lipitor 20 mg daily
Medications on transfer from CCU:
ASA 325 mg
Atorvastatin 20 mg PO QD
Heparin gtt
SSI
Lantus 6 units QHS
Levofloxacin 250 mg PO Q24
Metalazone 5 mg PO QD
Lasix 80 mg PO QD
Coumadin 5 mg M-Fri. 2.5 mg Sat-Sun
PPI
Senna
Epo 4000 units MWF
Iron 325 mg PO QD
Discharge Medications:
1. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) mL Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*15 mL* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
[**2139-4-20**]
Serum Digoxin Level, PT, PTT, INR, Chem10, CBC
cc Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
11. Enoxaparin 80 mg/0.8 mL Syringe Sig: 0.7 mL Subcutaneous
Q12H (every 12 hours): Your dose is 70 mg every 12 hours. On
syringe is 80 mg in 0.8 mL. Please administer 0.7 mL.
Disp:*10 syringes* Refills:*2*
12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
13. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA [**Location (un) 270**] East
Discharge Diagnosis:
Primary Diagnoses:
Decompensated Congestive Heart Failure
Acute Renal Failure
Secondary Diagnoses:
Coronary Artery Disease
Atrial Fibrillation
Diabetes Mellitus
Chronic Renal Insufficiency
Anemia
Discharge Condition:
Stable, with less dyspnea and clearer lungs, with renal function
at baseline, but with persistent lower extremity edema.
Discharge Instructions:
You were hospitalized at [**Hospital1 18**] for exacerbation of your
congestive heart failure. The cause of this exacerbation is not
certain, but may be related to increased fluid intake and
excessive salt intake. After trying to remove some of the
excessive fluid with lasix, your kidney function worsened.
Accordingly, you were transferred to the ICU for tailored
therapy including a form of dialysis, to help remove excess
fluid without injurying your kidneys.
During the course of your hospital stay, approximately
****XXXX**** liters of excess fluid was removed. Your weight at
the time of discharge from the hospital was ******.
1. Take all medications as prescribed. Some of your medications
were discontinued (including metformin and colchicine) given
your worsened kidney function. At the moment, your diuretic
regimen (water pills) includes lasix and metalazone; you should
take both medications twice daily. You were started on Epogen
for anemia (low red blood cell counts), digoxin for your heart
failure and atrial fibrillation, and a short course of
levofloxacin for pneumonia. Your coumadin was subtherapeutic at
the time of discharge, so you are receiving lovenox shots until
your coumadin is therapeutic.
2. Keep all appointments with your medical care providers (see
below).
3. You should contact your doctor or return to the hospital if
you:
-notice an increase in your weight of more than 2 lbs (you
should weigh yourself daily)
-notice an increase in leg swelling, or increased shortness of
breath, worsened cough, become short of breat when lying flat,
or frequent awaken in the night short of breath
-chest pain/tightness, palpitations, shortness of breath,
nausea/vomiting, decreased exercise tolerance (becoming short of
breath with less exertion than previously)
-fevers, uncontrollable shaking chills
-lightheadedness, particularly on standing
-coughing up blood, blood in your urine or stools
-any other symptoms that are concerning to you.
Followup Instructions:
1. Heart Failure Clinic: You have an appointment with [**First Name8 (NamePattern2) 1903**]
[**Last Name (NamePattern1) 1904**], NP, on [**2139-4-29**] @ 10:00AM. Located in [**Hospital Ward Name 23**] Clincial
Center. Phone:[**Telephone/Fax (1) 3512**]
2. Primary Care Physician: [**Name10 (NameIs) **] have a follow up appointment with
your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Tuesday [**2144-4-20**]:30 AM (arrive 15 minutes early) at [**Location (un) **]. [**Location (un) **],
[**Telephone/Fax (1) 4775**] .
-you were started on digoxin while in the hospital. The blood
levels of digoxin should be periodically monitored. You have
been given a prescription to have your digoxin level measured on
[**4-20**]. Additionally, laboratory work will be done to assess
your kidney function, electrolytes, and PT/PTT/INR. Dr. [**Last Name (STitle) **]
will follow-up on these results.
3. Cardiology: you have a follow-up appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 120**] on Tuesday [**5-26**] at 8:30 AM in [**Location (un) **], [**Telephone/Fax (1) 8645**]
4. Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 120**], or the staff at the Heart Failure
clinic may wish to repeat an echocardiogram (ultrasound) of your
heart when it is felt that your CHF medication regimen has been
optimized to get a better sense of the actual function of your
heart. Additionally, Dr. [**Last Name (STitle) 120**] may wish to order a cardiac
catheterization as an outpatient to evaluate your coronary
artery disease.
5. Other follow-up appointments currently scheduled:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLOGY-PRIVATE
Date/Time:[**2139-8-4**] 11:00
Provider: [**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2139-9-22**] 10:30
|
[
"5849",
"40391",
"5990",
"42731",
"V4581",
"25000"
] |
Admission Date: [**2148-10-15**] Discharge Date: [**2148-10-18**]
Date of Birth: [**2103-6-23**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Amoxicillin / Blood-Group Specific Substance /
Adhesive Tape
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Left ankle pain
Major Surgical or Invasive Procedure:
[**2148-10-15**]: s/p Open Reduction Internal Fixation of Left
Bimalleolar Fracture.
[**2148-10-15**]: s/p Removal of Hardware, Left Patella.
History of Present Illness:
Ms [**Known lastname 19419**] is a 45 year old female who inverted her left ankle
on [**2148-10-15**] resulting in a left bimalleolar ankle fracture
requiring surgical fixation.
Past Medical History:
CAD
s/p coronary bypass surgery [**5-1**]- LIMA to LAD, SVG to
OM, SVG to Diagonal, and SVG to PDA. SVG to the OM and diagonal
occluded.
Diastolic Heart Failure
Diabetes Mellitus-type I
s/p living-related kidney transplant [**2140-10-31**] (baseline Cr
0.8-1.1 over the last year)
s/p MI
tobacco use
osteoporosis
gastroparesis
s/p right tibial fracture
peripheral [**Year (4 digits) 1106**] disease: s/p right femoropopliteal bypass
and left SFA drug-eluting [**Last Name (LF) **], [**2147-5-2**]
retinopathy- legally blind
s/p left patella open reduction and fixation, [**2147**]
s/p right leg fracture (cast), [**2147**]
s/p left wrist fracture, [**2147**]
s/p fall and intracranial bleed, [**2147**]
s/p cholecystectomy
sarcoid, reported lung nodule
neuropathy
depression
hypertension
blood group specific substance. Blood products (red cells and
platelets) should be leukoreduced.
chronic heel ulcers
hyponatremia
Social History:
-Tobacco history: smokes half a pack per day
-ETOH: none
-Illicit drugs: smokes marijuana several times per week to help
with nausea and appetite
Family History:
There is no history of diabetes or kidney disease. Her father
had an MI at 74 and mother has hypertension. Grandfather had
leukemia and hypertension.
Physical Exam:
Physical examination on admission:
Afebrile with stable vital signs.
No acute distress, Non-toxic.
Alert and Oriented x 3
No lymphadenopathy, Neck has full range of motion.
Pupils equal, reactive to light and extra-ocular motion intact
bilaterally.
Lungs Clear bilaterally.
Cardiac regular rate and rhythm.
Abdomen soft, non-tender, non-distended, + bowel sounds.
Extremities: Neurovascular intact throughout.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2148-10-16**] 06:00AM 3.7* 2.83* 8.2* 27.5* 97#1 29.0 29.8*
13.0 164#
BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct
[**2148-10-16**] 06:00AM 164#
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2148-10-16**] 06:00AM 79 24* 1.0 136 4.9 107 19* 15
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2148-10-16**] 06:00AM 8.6 3.7 1.7
Brief Hospital Course:
Ms [**Known lastname 19419**] is a 45 year old female who inverted her left ankle
on [**2148-10-15**] resulting in a left bimalleolar ankle fracture
requiring surgical fixation. She was admitted to the Orthopedic
service via the emergency room and underwent open reduction
internal fixation of her left ankle and hardware removal of her
left patella without complication. She was transferred to the
recovery room in stable condition and subsequently transferred
to the floor in stable condition. She had adequate pain
management throughout her hospital course. She worked with
physical therapy. The remainder of her hospital course was
uneventful. She is being discharged today in stable condition.
Medications on Admission:
Senna 1 TAB PO BID:PRN Constipation
Multivitamins 1 CAP PO DAILY
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Vitamin D 400 UNIT PO DAILY
Calcium Carbonate 500 mg PO TID
Milk of Magnesia 30 ml PO BID:PRN Constipation
Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO Q6H:PRN
Dyspepsia
Acetaminophen 650 mg PO Q6H
Ipratropium Bromide MDI 2 PUFF IH Q6H coughing
Lisinopril 2.5 mg PO DAILY
Metoclopramide 10 mg PO QIDACHS
Metoprolol Succinate XL 25 mg PO DAILY
PredniSONE 4 mg PO DAILY
Prochlorperazine 25 mg PR Q12H:PRN nausea
Ranitidine 150 mg PO BID
Sirolimus 3 mg PO DAILY
Tacrolimus 2 mg PO Q12H Dose to be admin. at 6am and 6pm
TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
traZODONE 100 mg PO HS
Sulfameth/Trimethoprim SS 1 TAB PO QMOWEFR
Aspirin 325 mg PO DAILY
Atorvastatin 40 mg PO DAILY
BuPROPion 75 mg PO DAILY
Citalopram Hydrobromide 60 mg PO DAILY
Clopidogrel 75 mg PO DAILY
Furosemide 40 mg PO DAILY
Insulin SC Sliding Scale & Fixed Dose
Gabapentin 800 mg PO DAILY
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. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*56 syringe* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: do not operate any motor vehicle or
machinary. do not drink alcohol.
Disp:*90 Tablet(s)* Refills:*0*
4. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):
Please take a 5 pm every day .
5. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: Two (2)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
7. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed for coughing.
15. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea.
16. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
17. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
19. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
20. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
22. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
24. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
25. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
26. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
27. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
28. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
29. Insulin Sliding Scale
Insulin SC Fixed Dose Orders
Bedtime
Glargine : 25 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL 4 oz. Juice and 15 gm crackers
71-150 mg/dL 0Units 0Units 0Units 0Units
151-200 mg/dL 2Units 2Units 2Units 2Units
201-250 mg/dL 4Units 4Units 4Units 4Units
251-300 mg/dL 6Units 6Units 6Units 6Units
301-350 mg/dL 8Units 8Units 8Units 8Units
351-400 mg/dL 10Units 10Units 10Units 10Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Home With Service
Facility:
Southshore VNA
Discharge Diagnosis:
Left Bimalleolar Fracture
Discharge Condition:
Stable
Discharge Instructions:
Keep incision and splint dry to prevent infection. Do not soak
in tub. Sponge bath until your first follow-up appointment.
Continue to be non weight bearing on your left leg. Do not
remove splint. Elevate your left leg to reduce swelling and
pain
Resume your regular diet.
Avoid nicotine products to optimize healing.
Resume your home medications. Take all medications as
instructed.
Continue taking the Lovenox to prevent blood clots.
You have been given narcotic pain medication, which may cause
drowsiness, dizziness, nausea, vomiting and constipation. Do
NOT operate any motor vehicle or machinery while taking narcotic
pain medication. Do drink alcohol while taking narcotic pain
medication. Take a stool softener to prevent constipation.
If you have questions or concerns please call your doctor at
[**Telephone/Fax (1) 1228**].
If your experience fevers greater than 101.2, incisional
drainage, bleeding or redness, nausea, vomiting, calf pain,
chest pain or shortness of breath, then call your doctor or go
to your local emergency room
For your congestive heart failure:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Physical Therapy:
1. Non-weight bearing, left lower extremity
2. Keep splint on left lower extremity until follow up in the
[**Hospital **] clinic.
Treatments Frequency:
1. Keep splint and incision dry.
2. Keep splint on at all times.
3. Elevate left leg to reduce swelling and pain
Followup Instructions:
2 weeks in the Orthopedic office with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.
Please call [**Telephone/Fax (1) 1228**] to make this appoinment.
Completed by:[**2148-10-18**]
|
[
"4280",
"4019",
"V4581"
] |
Admission Date: [**2123-11-10**] Discharge Date: [**2123-11-23**]
Date of Birth: [**2058-1-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Transfer for GIB
Major Surgical or Invasive Procedure:
Abdominal angiogram
EGD
Colonoscopy
GI capsul study
History of Present Illness:
65 year old man with h/o stoke and rheumatic heart disease s/p
mechanical MVR on chronic cooumadin admitted for GIB. One day
prior to admission, he felt lightheaded and his wife took his
blood pressure at home: 70/40. He was admitted to OSH on [**11-7**]
and was found to have a GIB. First there was dark brown stools
that progressed to frank blood. He reportedly had 6 units of
pRBC. His hct was 24 before transfer. INR was 1.9 on admission
and 4.1 on [**11-8**]. 2u FFP was given. Upper and lower endoscopy
was performed on [**11-9**]. EGD was unremarkable. Per wife's report
and progress notes, colonoscopy revealed old blood but no source
of bleeding was found. Colonoscopy was advaced to small bowel
and there is a suspicion that the blood is coming from the small
bowel. He is transferred to Dr.[**Name (NI) 8664**] service for "procedure."
From talking to wife, it seems like there may be an angiography
planned to isolate the bleed.
.
Currently, the patient is hemodynamically stable. He is a poor
historian due to memory loss from a stroke. His wife takes care
of him and reports that he has the mental capacity of a child.
.
He denies chest pain, shortness of breath, abd pain, nausea or
vomit.
Past Medical History:
Cardiac History:
# s/p mechanical mitral valve replacement x 2 for rheumatic
fever
# CVA
# chronic afib s/p ablation and pacemaker
.
Percutaneous coronary intervention: none
.
Pacemaker placed for afib.
.
Other Past History:
# traumatic brain injury
# memory loss from previous stroke
# right inguinal hernia repair
# appendectomy
# tonsillectomy
# adenoidectomy
Social History:
He lives with his wife who takes care of him full time. He has
limited mental capacity and memory since his stroke. He has
remote trivial tobacco history. He does not use alcohol or
illicit drugs. He does not have children. He reports that he was
a dog trainer.
Family History:
NC
Physical Exam:
VS - 100.4, 111/62, 85, 18, 94% RA
Gen: WDWN middle aged male in NAD. Oriented x 2, does not know
date. Mood, affect appropriate. Memory poor.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with flat neck veins.
CV: Irregular, mechanical S1, normal S2. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta enlarged by
palpation, about 5 cm. Guaiac postive with trace bright red
blood from rectum.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2123-11-10**] 10:46PM GLUCOSE-107* UREA N-32* CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-26 ANION GAP-10
[**2123-11-10**] 10:46PM estGFR-Using this
[**2123-11-10**] 10:46PM CALCIUM-7.9* PHOSPHATE-3.1 MAGNESIUM-2.2
[**2123-11-10**] 10:46PM WBC-8.3 RBC-2.41* HGB-7.5* HCT-21.4* MCV-89
MCH-31.3 MCHC-35.2* RDW-15.8*
[**2123-11-10**] 10:46PM NEUTS-80.3* LYMPHS-13.3* MONOS-2.9 EOS-3.5
BASOS-0.1
[**2123-11-10**] 10:46PM PLT COUNT-178
[**2123-11-10**] 10:46PM PT-18.3* PTT-37.1* INR(PT)-1.7*
[**2123-11-22**] 09:35AM BLOOD WBC-5.8 RBC-4.26* Hgb-12.5* Hct-38.5*
MCV-90 MCH-29.3 MCHC-32.4 RDW-15.1 Plt Ct-371
[**2123-11-21**] 05:45AM BLOOD WBC-5.6 RBC-4.24* Hgb-12.6* Hct-38.1*
MCV-90 MCH-29.7 MCHC-33.1 RDW-14.9 Plt Ct-417
[**2123-11-20**] 05:00AM BLOOD WBC-4.9 RBC-4.15* Hgb-12.5* Hct-37.6*
MCV-91 MCH-30.1 MCHC-33.3 RDW-15.1 Plt Ct-451*
[**2123-11-19**] 05:15AM BLOOD WBC-7.1 RBC-4.15* Hgb-12.3* Hct-36.9*
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.2 Plt Ct-407
[**2123-11-23**] 02:35AM BLOOD PTT-54.7*
[**2123-11-22**] 06:49PM BLOOD PTT-40.0*
[**2123-11-22**] 10:40AM BLOOD PT-12.7 PTT-34.6 INR(PT)-1.1
[**2123-11-22**] 09:35AM BLOOD Plt Ct-371
[**2123-11-21**] 05:15PM BLOOD PTT-53.3*
[**2123-11-21**] 05:45AM BLOOD Plt Ct-417
[**2123-11-21**] 05:45AM BLOOD PT-12.5 PTT-65.7* INR(PT)-1.1
[**2123-11-22**] 09:35AM BLOOD Glucose-126* UreaN-15 Creat-0.8 Na-141
K-3.5 Cl-106 HCO3-27 AnGap-12
[**2123-11-21**] 05:45AM BLOOD Glucose-95 UreaN-17 Creat-0.8 Na-143
K-3.9 Cl-109* HCO3-26 AnGap-12
.
BRIEF HISTORY: 65 year old man with past history of MVR for
rheumatic
heart disease and required coumadin use was admitted with a
gastrointestinal bleed of unclear source. Endoscopy, colonoscopy
and red
blood cell scan as well as enteroscopy were unremarkable. He is
referred
for mesenteric angiography with heparin load provocation.
INDICATIONS FOR CATHETERIZATION:
gastrointestinal bleeding
PROCEDURE:
Peripheral Catheter placement was performed of a Sims catheter
in the
Celiac/gastroduodinal, SMA and [**Female First Name (un) 899**] arteries.
Catheter placement was performed.
Peripheral Imaging was performed.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour45 minutes.
Arterial time = 0 hour45 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 155
ml, Indications - Renal
Premedications:
Fentanyl 50 mcg IV
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin [**Numeric Identifier 961**] units IV
Other medication:
Protamine 50 mg IV
Cardiac Cath Supplies Used:
.035 TERUMO, ANGLED GLIDEWIRE 180CM
- ALLEGIANCE, CUSTOM STERILE PACK
COMMENTS:
1. Selective mesenteric angiography revealed no evidence of AVM
or
bleeding or other anomalies with and without heparin
provocation.
FINAL DIAGNOSIS:
1. No source of gastrointestinal bleeding identified.
Brief Hospital Course:
Patient is a 65 year old man with h/o stroke and rheumatic heart
disease s/p mechanical AVR admitted for GIB. The patient
presented after negative colonoscopy and EGD at the outside
hospital. He was transfused an additional 3 units of blood
cells immediately w/ presentation hct 21.4. Tagged red blood
cell scan on hospital day 2 was negative. Given his tenuous
blood pressure and ongoing hemorrhagic stools he was transferred
to the MICU for closer monitoring. He rec'd 1 unit of PRBCs in
the MICU and was transferred back to the medical floor w/ stable
BP. In the setting of 2 colonoscopies at the OSH (which showed
blood at the distal ileum) and negative tagged RBC scan, GI
recommended provacative angiography for presumd AVM. Endoscopy
revealed small duodenal ulcer (oozing), was initially thought to
be not the source, it was couterized. Provocative angio was
negative for AV-malformations or source of bleed. Sice
cauterization of ulcer pt's HCT remained stable, and stools
negative for blood. Therefore coumadin was started, which upon
discharg remains not therapeutic.
H.Pylori serology was positive and patient will finish 14 days
of antibiotic.
Has a pacemaker in place. His rhythm flipped between atrial
fibrillation, NSR, and pacing. He was anticoagulated w/ goal
PTT 50-60.
.
MVR: Mechanical valve s/p 2 replacements. Anticoagulation goal
was kept low at goal PTT 50-60 given risk of CVA w/ mitral valve
but with ongoing bleeding.
.
# Right wrist pain with cellulitis: Patient complained of right
thumb/distal wrist pain, which has been present x 1 month.
Doppler was negative for DVT. Hand x-ray showed DJD of the
first CMC and triscaphoid joint. Anti-inflammatories were
initiated for DJD, Trated with 7 days of vanco for presumed MRSA
as pt had past staph positiv wound infection on the same site.
Medications on Admission:
Coumadin
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
2. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 7 days: continue for 7 more [**Last Name (un) **] to finish
a 14 day course (for H.Pylori).
3. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 7 days: continue for 7 more days for a
total course of 14 days for P.Pylori.
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Heparin (Porcine) in D5W Intravenous
Discharge Disposition:
Extended Care
Facility:
lakes regional
Discharge Diagnosis:
Primary
- GI bleed
Secondary
- History of Stroke
- Mitral valve replacement, mechanical valve
Discharge Condition:
Good, without GI bleed for more than 6 days (since intervention
on duodenal ulcer). Hematocrit unchanged over past 7 days
Discharge Instructions:
You were admitted to the hospital with a gastrointestinal bleed.
You were given several units of blood.
.
Your workup revealed a small bleeding duodenal ulcer, which was
taken care of during the procedure
.
If you experience the following return for evaluation:
Fever greater than 100.5, lightheadedness, shortness of breath,
dizzyness, chest pain, ongoing bleeding from your GI tract, low
blood pressure.
Followup Instructions:
Please see your primary care doctor in [**12-22**] weeks.
|
[
"2851",
"V5861",
"42731"
] |
Admission Date: [**2107-10-6**] Discharge Date: [**2107-10-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
Traumatic Left frontal SAH, s/p mechanical fall on warfarin
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 year old right-handed male with past medical history
significant for dementia, prior SDH operated about 1.5 years
prior, HTN who present s/p fall at home with a sub-arachnoid
bleed. The patient was walking up the stairs to
his home. Per his wife he was on the first stair up when she
heard him fall. He fell back on the concrete ground. The wife
believes he seemed out of it for about 30 seconds, but soon
recovered and was able to answer questions appropriately. He
was complaining of a severe headache and he was sent to his
local hospital in NW where a CT scan was performed. He was
noted to have an SAH and was sent to [**Hospital1 18**]. He has remained
conscious since the fall and has been answers questions
appropriately since arrival.
Past Medical History:
Of note the patient has had multiple falls and walks with
a cane. He had a fall two years prior resulting in an SDH that
was treated surgically at [**Hospital1 2025**]. He also has had difficult moving
his left shoulder and it was discovered recently he has a torn
rotator cuff on the left side.
-Gout
-HTN
-b/l cataracts
- blindness in left eye ?ischemic event 3 years prior
- CAD, h/o stent [**10**] years prior
Social History:
Patient lives at home with wife. She largely takes care of all
his needs. He is able to feed himself. He uses a cane to
ambulate. He has been declining cognitively over the last 5
years per the family. He has a long past smoking history (quit
30-40 years ago). He doesn't drink currently (did socially
some time ago) No drug use
Family History:
Non-contributory
Physical Exam:
On Admission:
T:96.1 BP:130/58 HR:50-60 R:18 98%O2Sats
Gen: Elderly thin man, in cervical collar, seems upset
Neck: In cervical collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, knows place in [**Location (un) 86**], and did
not know the date (apparently at baseline)
Recall: [**2-12**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils small 2mm and reactive, L pupil surgical. Visual
fields are full to confrontation on R, on L has no visual
acuity.
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: Patient with decreased bulk throughout, normal tone. No
noted pronator drift bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Muscle in UE [**6-14**] with some decreased strength in left UE [**3-14**] to
pain and weakness from rotator cuff repair. Per family this is
at baseline
In LE all muscle groups tested [**6-14**]
-Sensory: No deficits to light touch, pinprick, cold sensation.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Pertinent Results:
Labs on Admission:
[**2107-10-6**] 07:15PM BLOOD WBC-25.2* RBC-3.45* Hgb-10.0* Hct-32.2*
MCV-93 MCH-28.9 MCHC-30.9* RDW-17.4* Plt Ct-66*
[**2107-10-6**] 07:15PM BLOOD Neuts-84.1* Lymphs-10.9* Monos-4.4 Eos-0
Baso-0.6
[**2107-10-6**] 07:15PM BLOOD PT-12.3 PTT-21.8* INR(PT)-1.0
[**2107-10-6**] 07:15PM BLOOD Glucose-114* UreaN-39* Creat-1.1 Na-145
K-4.3 Cl-109* HCO3-27 AnGap-13
[**2107-10-7**] 03:08AM BLOOD ALT-30 AST-16 AlkPhos-61 TotBili-0.6
[**2107-10-7**] 03:08AM BLOOD Albumin-3.4 Calcium-8.1* Phos-4.0 Mg-2.2
[**2107-10-7**] 05:57PM BLOOD Phenyto-14.8
Labs on Discharge:
7.9
5.9 >-----< 249
24.0
138 105 9
------------------< 87
3.9 24 0.7
MICRO:
[**2107-10-18**] 3:05 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2107-10-18**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.
[**2107-10-16**] 11:34 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2107-10-17**]**
MRSA SCREEN (Final [**2107-10-17**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2107-10-8**] 8:39 am STOOL CONSISTENCY: FORMED
**FINAL REPORT [**2107-10-9**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2107-10-9**]):
REPORTED BY PHONE TO D. HICKCOX, R.N. ON [**2107-10-9**] AT 0415.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
IMAGING:
Head CT [**10-6**]:NON-CONTRAST HEAD CT: There is right
parietooccipital scalp hematoma, without underlying acute
fracture seen. Two prior burr holes are noted in the right
parietal skull. Diffuse subarachnoid hemorrhage in the right
cerebral hemisphere and also foci in the left frontal lobe
appear similar to that seen on outside hospital CT performed six
hours prior. Several foci of subarachnoid hemorrhage along the
left superior convexity are newly apparent. There are also
bilateral small predominantly frontal subdural hematomas, which
measures up to 4 mm on the left, which appear unchanged. Small
focus of hemorrhagic contusion along the inferior right frontal
lobe is unchanged. There is new intraventricular extension of
hemorrhage layering bilaterally in the occipital horns.
High-density is also noted within the interpeduncular fossa.
Size of the ventricles is unchanged, without evidence of
hydrocephalus. No shift of normally midline structures or
effacement of the basal cisterns is seen. No evidence for large
vascular territorial infarction is seen. The ventricles and
sulci appear normal in size and configuration for the patient's
age. Vascular calcifications are noted along the carotid siphons
and vertebral
arteries. The patient has had prior bilateral lens replacement.
Mild mucosal thickening is noted within anterior ethmoid air
cells and the left maxillary sinus, with small mucus retention
cysts along the floor of the left maxillary sinus. The mastoid
air cells are normally aerated.
IMPRESSION: Acute subarachnoid, subdural, and intraparenchymal
hemorrhages as described above. Compared to six hours prior,
couple of new foci of
subarachnoid hemorrhage along the left superior complexity are
newly apparent, as well as intraventricular extension of
hemorrhage. No shift of normally midline structures, effacement
of the basal cisterns, or hydrocephalus.
Head CT [**10-8**]:
FINDINGS: No significant interval change. There is a
subarachnoid hemorrhage located in the right cerebral hemisphere
and left frontal lobe. Overall, the appearance is similar to
prior study. There is a tiny amount of blood layering along the
falx and tentorium as well as dependently within the bilateral
lateral ventricles, also subtle. There is a right frontal
subdural hematoma, which appears similar compared to prior
study. Previously noted left frontal subdural hematoma is
slightly less prominent. There is an area of contusion in the
right inferior frontal lobe with similar appearance compared to
prior study, with unchanged surrounding edema. There is no
evidence of new hemorrhage. There is no significant shift of
midline structures. The ventricles and sulci are prominent,
which could be due to age-related atrophy and appears similar
compared to prior study. There are bilateral carotids siphons
and vertebral artery calcifications. The patient is status post
two burr holes on the right calvarium. Visualized portion of
paranasal sinuses and mastoid air cells are within normal
limits.
IMPRESSION: Overall unchanged appearance of subarachnoid,
intraparenchymal, and intraventricular hemorrhage allowing for
some redistribution. No shift of midline structures.
CT CHEST W/O CONTRAST Study Date of [**2107-10-14**]
IMPRESSION:
1. Bilateral consolidative changes of the lung bases most likely
suggestive of aspiration, pneumonia is another likely
possibility. Atelectasis is less likely as there is no
associated volume loss.
2. Small bilateral pleural effusions. Loculated effusion is
noted adjacent
to the aorta on the left side.
3. Calcified cyst of the upper pole of the left kidney which
does not meet
the criteria for a simple cyst. For further evaluation, MR of
the abdomen can be obtained.
4. Wedge compression deformity of T4 and T7.
Brief Hospital Course:
The patient was admitted to the neurosurgery service after
falling backwards from a standing position and had a small SAH
found on head CT. The patient had several stable CT scans and
did not require surgery. He was transferred to the neurosurgical
floor on [**2107-10-8**]. He had fevers, elevated WBC, and his stool was
positive for c. difficile. He was started on flagyl. The patient
also had presumed aspiration pneumonia after several episodes of
vomiting. His first CXR did not show signs of pneumonia so
antibiotics were not started for that. However there was
evidence of a mediastinal mass and LUQ masses. He will need CT
of the chest and abdomen to evaluate those further.
.
The patient also had delirium and geriatrics was consulted. They
recommended stopping namenda, aricept, and dilantin. His mental
status improved. However he had a temperature of 101 again on
[**10-13**]. Since the patient had multiple medical issues and did not
require neurosurgery, he was transferred to the geriatrics
service on [**10-13**].
.
On the geriatrics service, the following issues were address:
.
# SAH: As above. Patient will need to follow up with
Neurosurgery as an outpatient. During this appointment,
Neurosurgery will address restarting aspirin 81 mg.
.
# C. diff colitis: Pt should continue for po Flagyl until [**11-1**].
.
# Aspiration pneumonia: Pt denies any dyspnea and he sats
mid-90s on RA. He was treated with 10 day course of ceftriaxone
and vancomycin, to be completed [**10-25**]. Speech and swallow made
the following recommendations:
1.) Diet: nectar thick liquids and pureed solids.
2.) Meds: crushed in puree
3.) TID oral care
4.) 1:1 supervision with meals to maintain aspiration
precautions
.
# Delirium on dementia: His namenda and aricept were held, and
he was started on Ritalin titrated up to 5 mg daily and Celexa 5
mg.
.
# CAD, s/p stent [**10**] years ago: He was continued on his
metoprolol. His aspirin was held. Reinitiation should be
discussed with Neurosurgery but is generally after 1 month
pending stable CT scan.
.
# HTN: This was controlled on his metoprolol.
.
# MDS with refractory anemia: His HCT remained at baseline of
~23. He was started on iron supplements.
.
# Gout: He was continued on allopurinol.
.
# Code: Currently FULL, in discussion with son [**Name (NI) 382**]
Medications on Admission:
ASA 81mg',MVI,FeSO4 325mg',Aricept 10mg',Prilosec
20mg',Allopurinol 100mg',Namenda 10mg",Calcium 125mg",Colchicine
6mg",Metoprolol 12.5"',Cerefolin-NAS QOD
Discharge Medications:
1. Multivitamin Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule [**Name (NI) **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Senna 8.6 mg Tablet [**Name (NI) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Allopurinol 100 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet [**Name (NI) **]: Two (2) Tablet PO every six
(6) hours.
6. Calcium Carbonate 500 mg Tablet, Chewable [**Name (NI) **]: Two (2)
Tablet, Chewable PO BID (2 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Name (NI) **]: Two (2)
Tablet PO DAILY (Daily).
8. Citalopram 20 mg Tablet [**Name (NI) **]: 0.25 Tablet PO DAILY (Daily).
9. Methylphenidate 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO QAM (once
a day (in the morning)).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Name (NI) **]: One (1)
Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet [**Name (NI) **]: [**2-11**] Tablet PO three
times a day.
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): [**Month (only) 116**] be dissolved in
nectar thick liquids.
13. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback [**Month (only) **]:
One (1) gram Intravenous Q24H (every 24 hours) for 5 days.
14. Vancomycin 1,000 mg Recon Soln [**Month (only) **]: 1,000 mg Intravenous
once a day for 5 days: PLs start at 8PM.
15. Metronidazole 500 mg Tablet [**Month (only) **]: One (1) Tablet PO Q6H
(every 6 hours) for 12 days.
16. Ciprofloxacin 0.3 % Drops [**Month (only) **]: 1-2 Drops Ophthalmic Q4H
(every 4 hours) for 7 days.
17. Heparin (Porcine) 5,000 unit/mL Solution [**Month (only) **]: 5,000 units
Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary:
Left frontal subarachnoid hemorrhage
.
Secondary:
C. difficle colitis
Aspiration pneumonia
Delirium
Coronary artery disease
Hypertension
Myelodysplastic Syndrome
Gout
Discharge Condition:
Neurologically Stable, afebrile
Discharge Instructions:
You were admitted to the hospital for a bleed in your brain.
This is now stable on CT scans of the head.
During your hospital course, you develop an infection of the
colon called C. difficle colitis. You need to finish your
course of antibiotics. In addition, you also develop a
pneumonia and have two intravenous antibiotics.
You are being discharged to a extended care facility.
The following are recommendations from Neurosurgery:
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc. You must discuss with your Neurosurgeon before
starting aspirin.
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:
Neurosurgery Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within
2 weeks of discharge from the extended care facility. Her
clinic number is [**Telephone/Fax (1) 70684**].
|
[
"5070",
"V5861",
"4019",
"V4582",
"41401"
] |
Admission Date: [**2122-1-13**] Discharge Date: [**2122-1-16**]
Date of Birth: [**2078-7-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with stenting of LAD
History of Present Illness:
43 year old male with history of HTN, family hx of premature
CAD, presented with pain that started Sunday, resolved after 2
hours. The pain returned on Monday afternoon after he smoked
cocaine. The pain was constant since the cocaine use. He took
TUMS, Pepcid, and ASA with no relief. The pain was sharp
"pressure" in his chest, no SOB, no N/V, diaphoresis. Presented
to [**Hospital3 **] ED. EKG there showed anterior ST
elevations V1-V5. He was started on a nitro drip, heparin drip,
given ativan, and morphine, however he continued to have chest
pain. He was transfered to [**Hospital1 18**] for cardiac catheterization.
His catheterization showed LAD 100% mid, RCA 30% at the origin.
The LAD lesion was stented with a drug eluting stent.
Past Medical History:
HTN
Social History:
Denies cigarette smoking, denies EtOH, uses cocaine
intermittently, last used 2 weeks prior to this episode,
construction worker.
Family History:
Father and Brother with history of sudden death in 40s
Physical Exam:
Vitals: Pulse 82, RR 22, BP 117/84
General: alert, oriented, but slightly sedated male in NAD
HEENT: PERRLA, MMM, OP clear
Neck: no jugular venous distention, supple
CV: RRR, no rubs, murmers or gallops
Lungs: Clear to auscultation bilaterally
Abd: soft, non-tender, non-distended
Ext: no clubbing, cyanosis, or edema, 2+ DP/PT pulses, groin
cath site C/D/I with no bruising, erythema, or bruit.
Neuro: intact
Pertinent Results:
CK at OSH 3059, Troponin I 27.44
EKG: NSR 93 ST elevations V1-V6, small q waves III,aVF
Toxicology:
[**2122-1-13**] 08:52PM ASA-6 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2122-1-13**] 08:52PM URINE HOURS-RANDOM
[**2122-1-13**] 08:52PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
Complete blood counts:
[**2122-1-13**] 08:52PM PLT COUNT-191
[**2122-1-16**] 11:10AM BLOOD WBC-6.4 RBC-4.15* Hgb-14.3 Hct-40.7
MCV-98 MCH-34.5* MCHC-35.1* RDW-12.4 Plt Ct-201
[**2122-1-13**] 10:48PM BLOOD WBC-11.2* RBC-4.19* Hgb-14.2 Hct-40.1
MCV-96 MCH-33.8* MCHC-35.3* RDW-12.5 Plt Ct-204
[**2122-1-16**] 11:10AM BLOOD Plt Ct-201
Coags:
[**2122-1-16**] 11:10AM BLOOD PT-13.5 PTT-49.1* INR(PT)-1.1
Chemistries:
[**2122-1-16**] 11:10AM BLOOD Glucose-118* UreaN-14 Creat-0.8 Na-137
K-4.5 Cl-101 HCO3-28 AnGap-13
[**2122-1-13**] 10:48PM BLOOD Glucose-134* UreaN-8 Creat-0.7 Na-137
K-3.6 Cl-102 HCO3-26 AnGap-13
[**2122-1-16**] 11:10AM BLOOD Mg-2.0
[**2122-1-13**] 10:48PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.5*
Cardiac enzymes:
[**2122-1-15**] 04:52AM BLOOD CK(CPK)-435*
[**2122-1-13**] 10:48PM BLOOD CK(CPK)-2672*
[**2122-1-15**] 04:52AM BLOOD CK-MB-17* MB Indx-3.9
[**2122-1-13**] 10:48PM BLOOD CK-MB-289* MB Indx-10.8*
Lipids:
[**2122-1-14**] 06:50AM BLOOD Triglyc-80 HDL-77 CHOL/HD-2.1 LDLcalc-71
Echocardiogram from [**2122-1-14**]:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with near
akinesis of the distal half of the septum and anterior walls,
distal inferior wall and apex. The apex is not aneurysmal and no
intraventricular thrombus is seen. The remaining segments
contract well. Right ventricular chamber size is normal. There
is focal hypokinesis of the apical free wall of the right
ventricle. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a small to moderate sized
pericardial effusion anterior to the right ventricular outflow
tract (suggests loculated) without evidence for hemodynamic
compromise.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD (mid-LAD lesion). RV apical hypokinesis. Mild mitral
regurgitation.Small-moderate loculated anterior pericardial
effusion without evidence for hemodynamic compromise.
Based on [**2114**] AHA endocarditis prophylaxis recommendations,
the echo findings indicate a low risk (prophylaxis not
recommended). Clinical decisions regarding the need for
prophylaxis should be based on clinical and echocardiographic
data.
Brief Hospital Course:
1. ST elevation MI- This 43 year old male with no PMHx
presented to OSH with chest pain and was found to have STEMI on
EKG. He was transferred to [**Hospital1 18**] for emergent cardiac
catheterization where: "Selective coronary arteriography
revealed a right dominant system with total occlusion of the mid
LAD, likely due to dissection rather than plaque rupture. The
LMCA did not show any angiographic evidence of coronary artery
disease. The LAD had a total occlusion in its mid-segment that
was stented, as was a D1 branch (see below). The LCx did not
show any angiographic evidence of coronary artery disease. The
RCA had an ostial 30% stenosis." Post catheterization he was
transferred to the CCU for further monitoring. He was continued
on integrillin for 18 hours post catheterization. He was
started on Plavix which should be continued for 9 months.
Initially a beta-blocker was not started given the history of
cocaine usage, however the patient stated on multiple occasions
that he would never use cocaine again. The benefits of
beta-blocker therapy were thoroughly explained to him and the
dangers of taking a beta-blocker while using cocaine were
explained. After this was explained he was started on
Metoprolol as well as Aspirin and an ACE inhibitor. He was
advised to continue taking these medications. The day following
catheterization he was doing very well and was transferred out
of the CCU to the hospital floor. He had a echocardiogram to
assess his LV function which showed anterior and apical
akinesia. Based upon these results it was determined that he
should be anticoagulated. He was placed on IV Heparin and
discharged on Coumadin with Lovenox injections to bridge to a
therapeutic INR. For the duration of his hospital stay he had
no events on telemetry. He was evaluated by physical therapy
who determined that he was safe to go home. He was discharged
home with appropriate follow up.
2. Substance abuse - While he was in the hospital he met with
Addiction Abuse consulting team who discussed cessation of
cocaine use. The patient was also made aware of resources
available to him if he needs any additional recovery support.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: [**1-31**] Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day for 4 days.
Disp:*8 syringes* Refills:*0*
8. Outpatient Lab Work
INR measured on Monday 20 at [**Hospital6 8283**] and
faxed to Dr. [**Last Name (STitle) 59573**] office
Discharge Disposition:
Home
Discharge Diagnosis:
Myocardial infarction
Discharge Condition:
Good, same level of functioning as prior to admisison.
Discharge Instructions:
Continue to take all medications as prescribed. Have your INR
checked on Monday at [**Hospital6 **] lab and sent to
Dr. [**Last Name (STitle) 19751**] office. Follow up with your primary care doctor
and cardiologist as directed. Continue to perform Lovenox
injections until your INR has been measured on Monday and is at
a sufficient level.
Followup Instructions:
[**1-29**] at 2pm. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
On Monday go to [**Hospital6 **] lab to have your INR
drawn and have your INR value sent to Dr. [**Last Name (STitle) 19751**].
Follow up with Dr. [**Last Name (STitle) **] [**2-2**] at 4pm at [**Hospital1 1562**]
Cardiology ([**Telephone/Fax (1) 41298**]
|
[
"41401",
"4019"
] |
Admission Date: [**2142-5-13**] Discharge Date: [**2142-5-24**]
Date of Birth: [**2063-3-18**] Sex: M
Service: MEDICINE
Allergies:
Vioxx / Lipitor / Colchicine
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
Intubation [**5-14**] and extubation [**5-15**]
History of Present Illness:
79 y/o M NH resident w/ IDDM, CAD s/p CABG, chronic systolic CHF
(LVEF 25%), CHB s/p pacer/BiV ICD, gout, AFib on coumadin a/w 3
days of progressive SOB, dry cough, decreased urine output and
symmetrical LE edema. Notably, his dose of lasix was decreased
prior to [**2142-5-2**] from 100 mg PO daily (on d/c [**2142-4-13**]) to 40 mg
qAM/20 mg qPM, possibly out of concern for hyperuricemia.
Lisinopril (5->2.5 mg) and carvedilol (6.25 [**Hospital1 **] -> 3.125 [**Hospital1 **])
were also recently reduced. He denies fever, chills, URI
symptoms, chest pain, palpitations, sputum production, wheezing,
abdominal pain, N/V/D, joint or calf pain.
In the ED, initial V/S 97.6 116/62 92 18 100% 2L NC. He then
became increasingly somnolent - ABG 7.29/70/69/32 - resolved
with naloxone 0.5 mg. Cr 1.4 CK 31 trop 0.10 proBNP [**Numeric Identifier 36570**] INR
3.4. Given ASA 81 mg x 3, lasix 100 mg IV, and vanc/zosyn for
presumed HAP.
.
Pt was given IV lasix 120 x 2 and metolazone on arrival to the
floor and put out abt 600 cc to that. The next morning he was
noted to be more somnolent, responding only to sternal rub. His
ABG showed 7.28/76/95. He was xferred to CCU.
.
On arrival to CCU, pt was noted to be somnolent, responding only
to sternal rub. Denies SOB, CP.
Past Medical History:
-CAD, s/p CABG in [**2121**] ([**Hospital1 756**] and Women??????s)
-CHF, NYHA class IV, EF ~ 15%
-HTN
-s/p DDP pacemaker placement, IVCD implantation: [**Company 1543**]
Concerto biventricular ICD (last interrogation [**11-7**], 92% BiV
paced)
-Atrial fibrillation (on coumadin)
-Complete heart block after AV ablation
-Mitral regurgitation
-Ventricular tachycardia s/p ablation of VT
-IDDM (Type 2)
-Chronic renal insufficiency
-Chronic left knee pain, s/p steroid injections
-Gout with known colichicine myopathy
-Pseudogout
Social History:
Married. Former smoker, quit 20 years ago formally, but still
smokes once or twice a year. Drinks 1 EtOH beverage per day.
Retired mechanical engineer. Was a fighter pilot for [**Country **] and
then NATO, and survived a crash in [**2090**]. Also, was a wrestler
with the Turkish Olympic team in [**2077**]. Since retiring, he enjoys
photography and volunteers at his local senior center.
Family History:
Long history of cardiac disease, osteoarthritis in siblings. No
history of gout in family.
Physical Exam:
CCU admission exam
GEN: sleepy
HEENT: sclera anicteric MMM
NECK: supple with JVP @ angle of jaw
CV: reg rate nl S1S2 II/VI holosystolic murmur at apex no S3S4
PULM: diminished bilaterally bibasilar rales scattered end-insp
wheezes no rhonchi
ABD: soft obese NTND NABS
EXT: warm, dry diminished distal pulses 3+ pitting edema to
knees bilat no calf tenderness
NEURO: A&Ox3, moving all 4 extremities
Pertinent Results:
CCU labs:
[**2142-5-16**] 04:36AM BLOOD WBC-12.0* RBC-3.33* Hgb-10.6* Hct-35.0*
MCV-105* MCH-31.9 MCHC-30.4* RDW-18.0* Plt Ct-171
[**2142-5-15**] 04:17AM BLOOD WBC-9.1 RBC-3.14* Hgb-10.4* Hct-31.8*
MCV-101* MCH-33.2* MCHC-32.8 RDW-18.1* Plt Ct-151
[**2142-5-14**] 06:05AM BLOOD WBC-12.0* RBC-3.51* Hgb-11.5* Hct-37.1*
MCV-106* MCH-32.7* MCHC-31.0 RDW-17.4* Plt Ct-204
[**2142-5-13**] 11:10AM BLOOD WBC-9.7 RBC-3.43* Hgb-11.1* Hct-36.5*
MCV-107* MCH-32.4* MCHC-30.4* RDW-17.4* Plt Ct-145*
[**2142-5-13**] 11:10AM BLOOD Neuts-88.7* Lymphs-8.2* Monos-2.5 Eos-0.5
Baso-0.1
[**2142-5-16**] 04:36AM BLOOD PT-33.1* PTT-39.0* INR(PT)-3.5*
[**2142-5-15**] 01:27PM BLOOD PT-37.1* PTT-38.7* INR(PT)-4.0*
[**2142-5-15**] 04:17AM BLOOD PT-40.9* INR(PT)-4.5*
[**2142-5-14**] 06:05AM BLOOD PT-36.4* PTT-41.2* INR(PT)-3.9*
[**2142-5-13**] 11:10AM BLOOD PT-32.5* PTT-38.7* INR(PT)-3.4*
[**2142-5-16**] 04:36AM BLOOD Glucose-164* UreaN-38* Creat-1.5* Na-141
K-4.4 Cl-97 HCO3-33* AnGap-15
[**2142-5-15**] 01:27PM BLOOD UreaN-33* Creat-1.4* Na-140 K-3.9 Cl-99
HCO3-34* AnGap-11
[**2142-5-15**] 04:17AM BLOOD Glucose-71 UreaN-34* Creat-1.4* Na-137
K-4.2 Cl-98 HCO3-31 AnGap-12
[**2142-5-14**] 05:09PM BLOOD Glucose-113* UreaN-35* Creat-1.4* Na-137
K-3.5 Cl-98 HCO3-32 AnGap-11
[**2142-5-14**] 06:05AM BLOOD Glucose-19* UreaN-34* Creat-1.5* Na-140
K-3.9 Cl-97 HCO3-34* AnGap-13
[**2142-5-13**] 11:10AM BLOOD Glucose-235* UreaN-28* Creat-1.4* Na-141
K-4.7 Cl-100 HCO3-32 AnGap-14
[**2142-5-15**] 04:17AM BLOOD ALT-15 AST-19 LD(LDH)-333* AlkPhos-92
TotBili-0.9
[**2142-5-14**] 06:05AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2142-5-13**] 07:15PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2142-5-13**] 11:10AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 36570**]*
[**2142-5-13**] 11:10AM BLOOD cTropnT-0.10*
[**2142-5-16**] 04:36AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.2
[**2142-5-15**] 01:27PM BLOOD Calcium-8.5 Phos-3.2 Mg-2.3
[**2142-5-15**] 04:17AM BLOOD Albumin-2.8* Calcium-8.3* Phos-2.9 Mg-1.8
[**2142-5-14**] 06:05AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0
[**2142-5-13**] 11:10AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.0
[**2142-5-13**] 11:10AM BLOOD TSH-3.0
[**2142-5-14**] 06:05AM BLOOD Digoxin-1.5
[**2142-5-16**] 04:42AM BLOOD Type-ART Temp-36.9 pO2-71* pCO2-73*
pH-7.29* calTCO2-37* Base XS-5
[**2142-5-16**] 04:42AM BLOOD Type-ART Temp-36.9 pO2-71* pCO2-73*
pH-7.29* calTCO2-37* Base XS-5
[**2142-5-15**] 02:51PM BLOOD Type-ART pO2-61* pCO2-55* pH-7.39
calTCO2-35* Base XS-6
[**2142-5-15**] 02:27PM BLOOD Type-ART pO2-63* pCO2-62* pH-7.38
calTCO2-38* Base XS-8
[**2142-5-15**] 01:32PM BLOOD Type-ART pO2-106* pCO2-48* pH-7.38
calTCO2-29 Base XS-1
[**2142-5-15**] 01:15PM BLOOD Type-ART pO2-106* pCO2-39 pH-7.40
calTCO2-25 Base XS-0
[**2142-5-15**] 09:00AM BLOOD Type-ART pO2-119* pCO2-55* pH-7.40
calTCO2-35* Base XS-7
[**2142-5-14**] 05:22PM BLOOD Type-ART pO2-76* pCO2-52* pH-7.46*
calTCO2-38* Base XS-10
[**2142-5-14**] 01:13PM BLOOD Type-ART pO2-113* pCO2-49* pH-7.43
calTCO2-34* Base XS-7
[**2142-5-14**] 10:37AM BLOOD Type-ART pO2-120* pCO2-86* pH-7.24*
calTCO2-39* Base XS-6
[**2142-5-14**] 08:24AM BLOOD Type-ART pO2-95 pCO2-76* pH-7.28*
calTCO2-37* Base XS-5
[**2142-5-13**] 02:11PM BLOOD Type-ART pO2-69* pCO2-70* pH-7.29*
calTCO2-35* Base XS-4
.
Discharge labs [**2142-5-24**]:
Na 138
Cl 93
BUN 34
K 4.9
Bicarb 35
Cr 1.3
Ca: 8.8
Mg: 2.0
P: 2.5
PT: 23.6
INR: 2.3
.
[**2142-5-14**] TTE: There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is severely dilated.
There is an apical left ventricular aneurysm. No masses or
thrombi are seen in the left ventricle. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The estimated cardiac index
is depressed (<2.0L/min/m2). The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**2-2**]+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Severely dilated and hypokinetic left ventricle. The
inferior and inferolateral walls have relatively preserved
function. There is a dyskinetic apical aneurysm. No thrombus is
seen, even after the addition of contrast. At least mild to
moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2142-3-21**],
overall left ventricular ejection fraction is worse.
.
[**2142-5-19**] CXR: Moderate cardiomegaly is unchanged. There is no
pulmonary edema. Continues improving in the aeration of the
right lower lobe. There is a small left pleural effusion. The
appearance of the sternal wires is unchanged. Left transvenous
pacemaker leads are in standard position.
Brief Hospital Course:
79 y/o M h/o IDDM, CAD s/p CABG, chronic systolic CHF (LVEF 25%
in [**3-12**]), complete heart block s/p pacer/BiV ICD, AFib on
coumadin a/w acute on chronic systolic CHF due to inadequate
diuresis, and HCAP.
.
#PUMP: history/exam/bnp/cxr consistent w/ decompensated CHF,
likely [**3-5**] inadequate diuresis/afterload reduction. Of note, it
seems that at previous rehab, left ventricular lead was turned
off [**3-5**] high impedence. This led to a reduction in EF and BP the
facilities reaction to which was to decrease the pt's lasix, BB
and ACEI. This likely led to this decompensation. The pt
originally suffered from hypercarbic respiratory failure [**3-5**]
fluid overload and was intubated on [**5-14**] and extubated [**5-15**]
after aggressive diuresis. He did recieve a course of
Levofloxacin for presumed HAP as his chest Xrays could not rule
out infiltrate with his severe fluid overload. He was first
diuresed with a lasix drip several liters then transitioned to
Torsemide which was titrated to 20mg [**Hospital1 **]. Here, his digoxin was
continued and captopril and carvedilol were restarted.
Spironolactone was also started. He was kept on a low sodium
diet with 1L fluid restriction. At time of transfer, his weight
is stable. Should he experience weight gain, his cardiologist
should be contact[**Name (NI) **] and possible medication adjustments
including adding a thiazide diuretic to his regimen.
.
#RHYTHM: Pt's Left ventricular lead was turned back on this
admission. Of note, no changes should be made to his pacer
without informing his cardiologist, Dr. [**Last Name (STitle) **]. He was
continued on digoxin, carvedilol. At time of discharge, his INR
is therapeutic and he is on coumadin 5mg daily.
.
#CAD: no acute issues this hospitalization. He was ruled out for
MI, monitored on tele and continued on aspirin, ACEI, BB.
.
#[**Name (NI) 15493**] Pt's blood sugars remained well controlled here on basal
and sliding scale insulin.
.
#[**Name (NI) 27724**] The pt had a slight inflammation on his right middle
finger proximal IP joint. He had minimal pain from this at
discharge. His rheumatologist was contact[**Name (NI) **] and he was continued
on methylprednisone 12mg daily and allopurinol 40mg daily. He
will followup with rheumatology on [**6-9**] for possible steroid
taper.
.
# Myopathy- the pt has cochicine and steroid-induced myopathy.
Neurology saw him in house and think his weakness has not
progressed. He will follow up with them as scheduled for EMG. Of
note, neurology recommends aggressive physical and occupational
therapy for this pt to regain functionality.
.
#CRI - Cr stable at baseline of 1.3 at time of discharge.
Medications on Admission:
MEDS (from NH records):
Coumadin 3 mg daily
Lasix 40 mg qam, 20 mg qpm
Lisinopril 2.5 mg daily
ASA 81 mg
Carvedilol 3.125 mg daily
Digoxin 0.125 mcg QOD
Eplerenone 12.5 mg daily
Methylprednisolone 12 mg daily (taper)
Prilosec 20 mg daily
Vitamin D [**Numeric Identifier 1871**] U 2X/week
Meclizine 12.5 mg [**Hospital1 **]
zoloft 50 mg daily
Senna 1 tab [**Hospital1 **]
colace 100 mg TID
Atrovent inh 2 puffs qid
Flovent 110 mcg 2 puffs [**Hospital1 **]
Lactulose 20 g qhs prn
allopurinol 400 mg daily
glypizide 2.5 mg daily
Lantus 24 units qhs
RISS
Oxycontin 10 mg [**Hospital1 **]
Trazodone 50 mg qhs prn
tylenol prn
MOM prn
dulcolax prn
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Methylprednisolone 8 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
7. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4 () as needed.
14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
15. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
17. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
18. Allopurinol 100 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
19. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
21. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
22. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
23. Humalog 100 unit/mL Solution Sig: One (1) sliding scale
Subcutaneous four times a day: Please give 2 units for
fingerstick 150-200; 4 units for 200-250; 6 units for 250-300; 8
units for 300-350.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic systolic heart failure
Secondary diagnosis:
Acute on Chronic renal failure
Hypercarbic respiratory failure
Gout
Steroid and colchicine myopathy
DM type II
Discharge Condition:
Stable-
Discharge Instructions:
You were admitted with an exacerbation of your congestive heart
failure. We think this was due to inactivity of your pacemaker
and to being taken off some of your heart failure medications.
While you were here, we turned both wires of your pacemaker on
and gave you medications to help you diurese fluids. At the
time of discharge, you have had good diuresis, are stable on
your medications and ready for acute rehabilitation.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1L daily
.
Please take all your medications as directed.
.
You must participated fully in all your physical and
occupational therapy if you are going to regain your strength.
.
Please follow up as below.
.
Please call your doctor or return to the ED if you have any
chest pain, shortness of breath, fevers, vomitting, headaches or
any other concerning symptoms.
Followup Instructions:
Please follow up with:
Neurology for EMG on [**6-26**] at 1p at [**Hospital Ward Name 23**] [**Location (un) **]. They
do not think you need to follow up with them before that time.
.
Rheumatology on Friday [**6-8**] at 3:30p at [**Last Name (NamePattern1) 439**],
[**Location (un) **].
.
Please follow up with device clinic for your pacemaker Friday
[**6-8**] at 9am in [**Hospital Ward Name 23**] building [**Location (un) 436**]. If you need to
reschedule, please call [**Telephone/Fax (1) 9832**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
Completed by:[**2142-5-25**]
|
[
"5849",
"51881",
"486",
"2762",
"4280",
"25000",
"V4581",
"42731",
"V5861",
"4240",
"40390",
"5859"
] |
Admission Date: [**2131-1-11**] Discharge Date: [**2131-1-21**]
Date of Birth: [**2085-12-16**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Zoloft / Effexor / Atenolol
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
L knee pain
Major Surgical or Invasive Procedure:
[**2131-1-11**] Left total knee arthroplasty
History of Present Illness:
I met with [**First Name8 (NamePattern2) **] [**Known lastname **] today. He earlier in the day had met with
Dr. [**First Name (STitle) **] [**Name (STitle) 7376**] to consider whether or not any additional
procedures can and should be done to his left knee, which has
been persistently problem[**Name (NI) 115**] and painful despite many
operations
over many years. He has been told that nonsurgical management
is
best. As for his ipsilateral left knee, which Dr. [**Last Name (STitle) **] has
referred to me for treatment, it will be best served with a
total
knee arthroplasty. I refer to the note from [**2130-11-9**],
which extensively outlines their conversation six weeks ago and
his referral in my direction. Basically, this patient has had
eight different arthroscopic procedures performed on the left
knee. He originally had discoid meniscus, subsequently
developed
osteoarthritis, and at this point has had no improvement with
the
most recent couple of meniscectomies/chondroplasties. This is
not, however, his only problem. [**Name (NI) **] is disabled for the past
several years with a combination of ankle pain and knee pain.
He
is status post lumbar surgeries with radicular symptoms and
polyneuropathy. He has also had cervical spine operations in
the
past.
Past Medical History:
Diabetes, HTN, high cholesterol, chronic pain, disability, neck
pain
Social History:
He lives in [**State 1727**]
Family History:
N/C
Physical Exam:
At the time of discharge:
AVSS
NAD
wound c/d/i without erythema
[**Last Name (un) 938**]/FHL/TA/GS intact
SILT distally
Pertinent Results:
[**2131-1-12**] 06:40AM BLOOD WBC-9.5 RBC-3.98* Hgb-11.9* Hct-35.0*
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.4 Plt Ct-191
[**2131-1-13**] 07:36AM BLOOD WBC-10.6 RBC-3.54* Hgb-10.6* Hct-31.5*
MCV-89 MCH-29.9 MCHC-33.7 RDW-13.4 Plt Ct-163
[**2131-1-14**] 06:35AM BLOOD WBC-9.8 RBC-3.51* Hgb-10.3* Hct-31.2*
MCV-89 MCH-29.2 MCHC-32.9 RDW-13.4 Plt Ct-184
[**2131-1-15**] 03:30PM BLOOD WBC-7.6 RBC-3.10* Hgb-9.2* Hct-27.8*
MCV-90 MCH-29.8 MCHC-33.3 RDW-13.4 Plt Ct-207
[**2131-1-16**] 06:38AM BLOOD WBC-6.8 RBC-2.86* Hgb-8.4* Hct-25.6*
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.6 Plt Ct-246
[**2131-1-17**] 04:17AM BLOOD WBC-7.5 RBC-3.02* Hgb-8.7* Hct-26.8*
MCV-89 MCH-29.0 MCHC-32.6 RDW-13.5 Plt Ct-239
[**2131-1-18**] 04:28AM BLOOD WBC-8.6 RBC-2.96* Hgb-8.8* Hct-25.7*
MCV-87 MCH-29.7 MCHC-34.3 RDW-13.7 Plt Ct-241
[**2131-1-19**] 08:10AM BLOOD WBC-12.6* RBC-3.15* Hgb-9.3* Hct-27.0*
MCV-86 MCH-29.6 MCHC-34.5 RDW-13.6 Plt Ct-272
[**2131-1-20**] 07:35AM BLOOD WBC-11.5* RBC-3.08* Hgb-9.4* Hct-26.5*
MCV-86 MCH-30.5 MCHC-35.5* RDW-13.5 Plt Ct-270
[**2131-1-21**] 07:05AM BLOOD WBC-12.7* RBC-3.37* Hgb-10.0* Hct-28.9*
MCV-86 MCH-29.6 MCHC-34.4 RDW-13.2 Plt Ct-306
[**2131-1-12**] 06:40AM BLOOD Glucose-182* UreaN-18 Creat-1.1 Na-136
K-4.4 Cl-102 HCO3-28 AnGap-10
[**2131-1-15**] 06:25AM BLOOD Glucose-136* UreaN-56* Creat-3.0*# Na-138
K-5.4* Cl-100 HCO3-31 AnGap-12
[**2131-1-15**] 03:30PM BLOOD Glucose-192* UreaN-55* Creat-2.0* Na-138
K-5.1 Cl-100 HCO3-32 AnGap-11
[**2131-1-16**] 06:38AM BLOOD Glucose-168* UreaN-45* Creat-1.5* Na-141
K-5.3* Cl-107 HCO3-28 AnGap-11
[**2131-1-16**] 03:59PM BLOOD Glucose-169* UreaN-40* Creat-1.2 Na-143
K-4.2 Cl-106 HCO3-31 AnGap-10
[**2131-1-17**] 04:17AM BLOOD Glucose-154* UreaN-27* Creat-1.0 Na-144
K-4.5 Cl-105 HCO3-31 AnGap-13
[**2131-1-18**] 04:28AM BLOOD Glucose-160* UreaN-17 Creat-1.0 Na-142
K-4.4 Cl-104 HCO3-33* AnGap-9
[**2131-1-19**] 08:10AM BLOOD Glucose-209* UreaN-14 Creat-0.9 Na-136
K-4.1 Cl-100 HCO3-29 AnGap-11
[**2131-1-20**] 07:35AM BLOOD Glucose-175* UreaN-13 Creat-0.8 Na-138
K-3.9 Cl-99 HCO3-29 AnGap-14
[**2131-1-21**] 07:05AM BLOOD Glucose-172* UreaN-15 Creat-0.9 Na-138
K-3.8 Cl-99 HCO3-29 AnGap-14
[**2131-1-21**] 07:05AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.1
[**2131-1-13**] - xrays of L knee show good hardware alignment without
complication
[**2131-1-13**] - CXR - no acute cardiopulmonary changes
[**2131-1-13**] - CT PE IMPRESSION:
No evidence of large central filling defects within the
pulmonary
arteries. However, given suboptimal contrast administration,
more distal
pulmonary emboli within the segmental and subsegmental arterial
branches
cannot be excluded. Repeat study could be performed if
clinically indicated.
[**2131-1-16**] - ECHO
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size is normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity sizes with preserved global systolic function.
[**2131-1-16**] - LE doppler
IMPRESSION: No evidence of DVT.
[**2131-1-17**] - CXR
FINDINGS: The monitoring and support devices are in unchanged
position. The right upper lobe is now better ventilated than on
the previous radiograph. The size of the cardiac silhouette is
unchanged. The remaining lung parenchyma has identical
appearance. Small retrocardiac areas of hypoventilations, but no
newly appeared focal parenchymal opacities suggestive of
pneumonia. The left costophrenic sinus is not completely
depicted, costophrenic sinus is without signs of pleural
effusion.
[**2131-1-17**] - CT PE
1. Limited study for the evaluation of pulmonary embolism due to
body
habitus, breathing motion artifact, and poor opacification of
the pulmonary
artery. No evidence of central or lobar pulmonary embolism.
Although the
study is sub-optimal, the previously described questionable
filling defect in
the left lower lobe branch of the pulmonary artery are not
confirmed in this
study.
2. Endotracheal tube terminates at 2.6 cm above the carina.
3. Bilateral small upper lobe atelectasis, right greater than
left.
4. Fatty liver.
[**2131-1-18**] - CXR
Moderate cardiomegaly is unchanged. There are low lung volumes.
Biapical
medial atelectases are unchanged. There are no pleural
effusions. Left IJ
catheter tip is in the left brachiocephalic vein.
Brief Hospital Course:
The patient was admitted on [**2131-1-11**] and, later that day, was
taken to the operating room by Dr. [**Last Name (STitle) **] for L TKA without
complication. Please see operative report for details.
Postoperatively the patient did well. The patient was initially
treated with a PCA followed by PO pain medications on POD#1.
The patient received IV antibiotics for 24 hours
postoperatively, as well as lovenox for DVT prophylaxis starting
on the morning of POD#1. ***The patient was placed in a CPM
machine with range of motion that started at 0-45 degrees of
flexion before being increased to 90 degrees as tolerated.***
The drain was removed without incident on POD#1. The Foley
catheter was removed without incident. The surgical dressing was
removed on POD#2 and the surgical incision was found to be
clean, dry, and intact without erythema or purulent drainage.
While in the hospital, the patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge the patient was
tolerating a regular diet and feeling well. The patient was
afebrile with stable vital signs. The patient's hematocrit was
stable, and the patient's pain was adequately controlled on a PO
regimen. The operative extremity was neurovascularly intact and
the wound was benign. The patient was discharged to
rehabilitation in a stable condition. The patient's
weight-bearing status was WBAT in [**Doctor Last Name 6587**] brace. ***The patient
is to continue using the CPM machine advancing as tolerated to
0-100 degrees.***
Patient developed asymptomatic hypoxia post-op day #1 ([**1-13**]).
Chest CTA was negative for PE. Patient was noted to be more
somnolent on [**1-14**]; ABGs showed respiratory acidosis and severe
hypercarbia. He was treated with CPAP and his mental status
improved. Routine labs on [**1-15**] showed a creatinine of 3.0, up
from 1.1 on admission. Medical consult was called to evaluate
him, and decision was made in light of the acute renal failure,
hypoxemia and hypercarbia, and altered mental status to transfer
him to medicine. He subsequently was admitted to the MICU and
intubated. He remained intubated for 3 days and was again ruled
out for a PE with a CT scan. He was extubated, renal failure
improved and he was transferred back to the orthopedic service.
He spiked to 103 and 102 on [**1-18**] and [**1-19**] respectively. Vanco
and Zosyn were restarted for a likely Hospital acquired
pneumonia. He is to finish a 10 day course of vanco and zosyn.
# Acute renal failure: Several possibilities exist. Patient may
have decreased renal perfusion from hypovolemia and the
combination of ACEI and NSAIDS (patient was kept on his home
lisinopril and post-operatively was given toradol and naproxen
for 3 days). AIN was less likely, given lack of culprit
medications. Contrast nephropathy is a possibility, as is
obstructive uropathy (patient had urinary retention of 1 liter).
Renal ultrasound, urine electrolytes are pending. ACEI, NSAIDs
should be D/C'd, and lovenox should be renally dosed.
# Hypoxemia/hypercarbia: Multifactorial from post-op atelectasis
with underlying restrictive lung disease from obesity and
obstructive sleep apnea predisposing to hypercarbia. No
evidence of pneumonia, CHF or PE. Patient has responded to
daytime CPAP, and this may need to be re-initiated. He was
started on Vanco/Zosyn while in the ICU but this was d/c'ed
after second CT-PE showed no PE or consolidation. However when
he was transferred back to the floor, he spiked again to 103 and
again to 102 so he was started back on the vanco and zosyn. He
will complete a 10 day course.
# Somnolence: Multifactorial from narcotic medications and
hypercarbia. Patient was given narcan x 4 with some
improvement.
# DM2 uncontrolled with complications: Elevated BS. He was
controlled on long acting and sliding scale insulin.
# s/p TKR: stable post-operatively.
Medications on Admission:
Celebrex 200'', diazepam 5''', Cymbalta 20', Lidoderm patches,
Perocet, Novolog 70/30, Levemir 85 units qa.m., Actos 45',
Protonix 40', oxycontin 80'', lipitor 80', ASA 81', androgel
50mg/5gm,
Discharge Disposition:
Extended Care
Facility:
Marshwood Skilled Nsg Center
Discharge Diagnosis:
L knee osteoarthritis
Discharge Condition:
Stable
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2131-2-9**] 9:00
CC:[**Numeric Identifier 80201**]
Completed by:[**2131-1-21**]
|
[
"5845",
"5180",
"5070",
"486",
"53081",
"32723"
] |
Admission Date: [**2162-2-10**] Discharge Date: [**2162-2-13**]
Date of Birth: [**2076-10-2**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
cardiac catheterization with Bare metal stents x7 (3 BMS to OM,
2 BMS to LAD and 2 BMS to LCX)
History of Present Illness:
Ms. [**Known lastname 12740**] is a 85yo female with history of HTN, hypothyroidism,
and GERD, who presents from OSH with history of worsening chest
pressure, with concern for ACS, sent to [**Hospital1 18**] for cardiac cath.
Pt states that for the past year, she has had shortness of
breath and chest pressure with ambulation. She describes the
chest pressure as central, substernal, non-radiating pressure,
relieved by rest. She was at her ophthalmologist's office this
Monday, and was noted to have a high blood pressure. She then
spoke with the her PCP regarding her high BP and SOB, and he
recommended she come to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] this morning, so he could
evaluate her. She said that for at least the last few weeks to
months, her chest pressure has remained the same: associated
with exertion, walking or doing household chores. In fact, she
walked on the treadmill for 3 mins yesterday, and had to stop
because of chest pressure [**2161-6-8**], that was relieved after 5
minutes of rest. She has had occasional nausea, but denied
vomiting, diaphoresis, presyncope, syncope, palpitations with
this. She has only had one episode of rest pain, which occurred
[**2-4**] nights ago, while she was sitting on her couch watching a
movie. The pressure lasted for 5mins and went away completely.
Today, at the OSH ED, her initial VS were 202/73, 57, 14, 100%
2LNC. Her BP went up to 232/86. At OSH, pt was found to have ST
depressions II, III, aVF, V4-V6, and ST elevations in aVR, V1,
V2. Trop I 0.23 with normal Cr. CXR at OSH read as no acute
process. She was started on ASA 325mg, nitro patch, plavix load
600mg, Atorvastatin 80mg x1, and Lovenox at OSH. Presented to
[**Hospital1 18**] for cardiac cath.
.
During her cardiac catheterization, she was found to have XXX
stenosis of LCx, and had initially XXX stents to XXXX. However,
she continued to have chest pain, and repeat ECG's showed ST
depressions in II, III, aVF, with II>III, and depressions in
V4-V6, with STE in aVR, and V1-V3. Pt then had XXX stents to LAD
and LCx. Subsequently, she was chest pain free and repeat ECG
showed resolution of ST depressions in II, III, aVF, and
lessened depressions in V4-V6, with mild continued elevation in
aVR. She required nitro gtt for BP control, but was otherwise
hemodynamically stable and chest pain free on transfer to the
CCU for monitoring.
.
On presentation to the CCU, her VS were temp 96.9, BP 120/91, HR
80, RR 19, 96% on 2LNC. She was completely chest pain free and
without complaints.
.
On review of systems, she reports occasional GERD and anxiety.
But otherwise, she denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: as below
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypothyroidism
HTN
TAH for fibroids
GERD
Social History:
She lives at home by herself and performs all of her ADL's. She
has a friend near by ([**Name (NI) **]), and is close with her daughter
[**Name (NI) **], who accompanies her here today.
-Tobacco history: quit 56yrs ago
-ETOH: very rarely, a few drinks per year
-Illicit drugs: denies
Family History:
Brother with CABG at 68yo, Mother with history of angina.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL:
VS: 96.9 80 120/91 19 96% 2LNC
GENERAL: WDWN pleasant, elderly female in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP non-elevated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs, no S3 or S4
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly,
without appreciated crackles or wheezes though limited given pt
lying down
ABDOMEN: +BS, Soft, NTND. No HSM or tenderness. No abdominal
bruits.
EXTREMITIES: no edema, dressing in place on left groin without
bleeding or evidence of hematoma. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Neuro: alert and oriented, CN II-XII intact, intact to light
sensation throughout
.
DISCHARGE PHYSICAL:
Temp Max: 98.4 Temp current: 97.7 HR: 55-60 RR: 16-18 BP:
106-202/52-74 O2 Sat: 99% RA
Gen: alert, anxious, walking around room
HEENT: supple, no JVD
CV: RRR, +S1 S2, no M/R/G
RESP: CTAB without wheezes or crackles
ABD: +BS, soft, NT/ND
EXTR: no peripheral edema, 2+ DP pulses bilaterally; right groin
with ecchymoses, but without bruit
NEURO: Alert, oriented, no halluciations
Skin: ecchymoses on right groin and abdomen
Access: PIV
Tubes: none
Pertinent Results:
ADMISSION LABS:
Hct 37 WBC 7.1 Plt 269
Na 134 K 4.3 Cl 103 HCO3 25 BUN 14 Cr 0.8
.
DISCHARGE LABS:
Hct 37.5 WBC 8.4 Plt 269
Na 143 K 3.9 Cl 108 HCO3 23 BUN 17 Cr 0.8
.
PERTINENT LABS:
CE'S:
[**2-10**] 9pm: CK-MB 5 Trop 0.11
[**2-11**] 4am: CK-MB 10 MBI 12.8 Trop 0.12
[**2-11**] 2pm: CK-MB 15 MBI 10.8 Trop 0.33
[**2-11**] 10pm:CK-MB 11 MBI 7.7 Trop 0.40
A1C: 5.9
LIPID PANEL: Total 222 LDL 145 HDL 58 TG 93
.
STUDIES:
CARDIAC CATH [**2162-2-10**]: PRELIM
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated two vessel disease. The LMCA had a 30% ostial
stenosis. The
LAD had a 70% proximal stenosis. The Cx had a 90% long mid
vessel
stenosis as well as a distal 80% stenosis. The RCA had a very
posterior
origin and was difficult to engage but had only minimal plaquing
throughout.
2. Limited resting hemodynamics revealed a central aortic
pressure of
157/62 mmHg. There was elevated left sided filling pressures
with an
LVEDP of 30 mmHg.
3. Careful pullback of the catheter from the LV to the aorta
revealed no
transvalvular gradient.
4. Successful stenting of the mid LCx with a MiniVision OTW
2.0x23
mm bare-metal stent (BMS) overlapped with a Minivision OTW
2.0x12 mm
BMS (distally). Successful stenting of the LCx distal to new
stents with
two overlapping MiniVision OTW 2.0x12 mm bare-metal stents.
Successful
stenting of the distal LCx/OM1 with a MiniVision 2.0x8 mm BMS.
Final
angiography revealed normal TIMI 3 flow, no angiographically
apparent
dissection and 0% residual stenosis in the new stents deployed.
(see
PTCA comments)
5. Successful stenting of the proximal-mid LAD with two
separated
MiniVision OTW 2.0x12 mm bare-metal stent (BMS). Final
angiography
revealed normal TIMI 3 flow, no angiographically apparent
dissection and
0% residual stenosis in the new stents. (see PTC comments)
6. R 6Fr femoral artery angioseal closure deviced deployed
without
complications. (see PTCA comments)
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate left ventricular diastolic dysfunction.
3. Successful stenting of the prox-mid LAD and mid-distal
LCx/OM1 with
multiple bare-metal stents. (see PTCA comments)
4. Dynamic changes in the diameter of the ostium of the left
main and
catheter dampening consfor 18 hours post procedure
4. ASA indefinitely; plavix (clopidogrel) 75 mg daily for at
least one
month for bare-metal stents (see PTCA comments)
5. R 6Fr femoral artery angioseal closure device deployed
without
complications (see PTCA comments)
.
TTE [**2162-2-11**]: PRELIM
Conclusions
The left and right atria are normal in size. Lefft ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. No mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension.
IMPRESSION: nomal biventricular systolic function.
.
CXR [**2162-2-11**]:
FINDINGS: The lung volumes are normal. Borderline size of the
cardiac
silhouette without pulmonary edema. No pleural effusions.
Minimal bilateral symmetrical apical thickening. Normal
appearance of the hilar and mediastinal structures.
.
MICRO:
UCx [**2162-2-11**]: URINE CULTURE (Final [**2162-2-12**]): NO GROWTH.
Brief Hospital Course:
HOSPITAL COURSE:
Ms. [**Known lastname 12740**] is a 85yo female with history of HTN, hypothyroidism,
and GERD, who presents from OSH with history of worsening chest
pain, concern for [**Hospital 61476**] transferred to [**Hospital1 18**] for cardiac cath,
now s/p 7 BMS to LCx and LAD. Pt is hemodynamically stable, and
transferred to CCU for close monitoring.
.
ACTIVE ISSUES:
.
# CORONARIES: Differential included ACS vs. demand ischemia [**2-3**]
uncontrolled HTN. Pt's anginal symptoms seemed to be stable in
nature rather than increasing or crescendo in nature to suggest
unstable plaque. Pt had been severely hypertensive with LVH
findings suggested on ECG. Pt went to cardiac cath with 2 stents
initially to LCx; however, pain continued post-procedure, with
concern for spasm of left main given elevations in aVR. Pt
subsequently had 3 more stents placed to LCx and 2 to LAD.
Cardiac enzymes were cycled and peaked post-procedure and
down-trended. She was started on ASA 325, Plavix 75mg daily,
Atorvastatin 80mg daily, and Integrilin for 18hrs. She was
started on metoprolol for beta blockade. ACEI was initially held
given large dye load and concern for contrast-induced
nephropathy. This was restarted as below. TTE demonstrated
preserved biventricular systolic function. A1c was sent for risk
factor stratification and was 5.9. Lipid panel was sent and
showed LDL of 145. She was continued on Atorvstatin 80mg daily.
PT consult was placed. She remained completely chest pain free.
She was discharged to continue ASA, Plavix, Atorvastatin,
Lisinopril and Metoprolol succinate.
.
# PUMP: No history of heart failure. Pt appeared euvolemic with
elevation of JVP and clear lungs. CXR demonstrated no evidence
of pulmonary edema. As above, TTE demonstrated preserved
systolic function.
.
# RHYTHM: Initial ECG at OSH and prior to cardiac cath
demonstrated shortened PR interval, with question of possible
junction rhythm. Repeat ECG's demonstrated sinus rhythm. She was
monitored on telemetry without events.
.
# HTN: Pt presented with hypertensive urgency with SBP to 230 at
OSH. On transfer, blood pressure improved from cath, on nitro
gtt. She required titration of nitro gtt for control. We were
able to wean off the nitro. As above, ACEI was initially held
given large dye load and concern for development of
contrast-induced nephropathy. She was started on metoprolol
succinate 25mg daily. Lisinopril dose was increased to 40mg
daily. She was instructed to follow-up with her PCP for further
BP management.
.
# Large dye load: Received 440cc of contrast. Pt was started on
IVF due to concern for contrast-induced nephropathy. Cr and
lytes were monitored and remained stable without Cr bump. Pt had
dark urine on hospital day 2, with RBC's in urine attributed to
foley placement, and negative UCx. Urine output remained normal
and discoloration resolved. Cr remained normal. As above, ACEI
was initially held and restarted prior to discharge.
.
# Nausea/HA: likely [**2-3**] nitro and relatively low BP, and nausea
likely also [**2-3**] GERD. Resolved after BP better control. Started
on H2 blocker for GERD with improved. symptoms.
.
INACTIVE ISSUES:
.
# Hypothyroidism: continue home regimen of levothyroxine 25mcg
qod.
.
# GERD: Pt had symptoms prior to admission. She was started
Ranitidine 150mg po bid, with improvement of her symptoms.
.
TRANSITIONAL CARE:
1. CODE: FULL
2. FOLLOW-UP: PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
3. MEDICAL MANAGEMENT:
- Started ASA 325mg, Plavix 75mg daily, Atorvastatin 80mg daily,
Metoprolol XL 25mg daily; Increased dose of Lisinopril from 20mg
daily to 40mg daily
- Pt instructed to have f/u labs to monitor Cr/lytes on
increased dose of ACEI with PCP; also to discuss further
uptitration of BP meds as needed
Medications on Admission:
Lisinopril 20mg daily
Levothyroxine 0.25mg every other day
Coenzyme Q10
Receives Avastin shots every few weeks for macular degeneration
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. coenzyme Q10 Oral
8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 min for total of 2 doses: call 911 or Dr.
[**Last Name (STitle) **] for any chest pain.
Disp:*25 tablets* Refills:*0*
9. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Non St Elevation Myocardial Infarction
Hypertension
Delerium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 12740**],
It was a pleasure taking care of you during this admission.
You had a small heart attack and needed a cardiac
catheterization. We found many blockages in your heart arteries
and you received a total of 7 stents during the course of 2
catheterizations. An echocardiogram showed that your heart is
functioning well. Your blood pressure was high so we gave you
some intravenous medicine to help lower it. You were confused
overnight, perhaps from a sleeping pill called trazadone. Do not
take this medicine again. You received a large dose of dye
during the catheterizations so we are concerned that your kidney
function will worsen. So far, that has not happenend but we will
need to follow your kidney function closely after you leave. You
will follow up with Dr. [**Last Name (STitle) **] on Monday.
We made the following changes to your medicines:
1. Start taking aspirin and Plavix (clopidogrel) daily to keep
all the stents open. This is extremely important to prevent
another heart attack or even death if the stents suddenly
closed. Do not stop taking aspirin and Plavix unless Dr. [**Last Name (STitle) **]
tells you it is OK.
2.Start using nitroglycerin if you have any chest pain or
trouble breathing similar to the symptoms that preceded your
hospitalization. You can take 2 nitroglycerin tablets under your
tongue 5 minutes apart. Please call 911 for any pain or severe
trouble breathing.
3. Start taking Atorvastatin to lower your cholesterol
4. Start taking Metoprolol to lower your heart rate and blood
pressure
5. Start taking Ranitidine to prevent stomach upset from the
Plavix and aspirin
6. We increased the dose of your lisinopril from 20mg daily to
40mg daily to help control your blood pressure.
**Again, it is very important to have your blood checked on
Monday with Dr. [**Last Name (STitle) 89629**] to check for your kidney function and
electrolytes now that we increased the Lisinopril. You may also
need additional blood pressure medication or increased doses.
Please discuss this with Dr. [**Last Name (STitle) **].
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 251**] T.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appointment: Monday [**2-15**] at 2PM
Completed by:[**2162-2-13**]
|
[
"41071",
"2449",
"4019",
"41401",
"53081"
] |
Admission Date: [**2122-9-15**] Discharge Date: [**2122-9-25**]
Date of Birth: [**2041-10-30**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
Right lower quadrant pain, severe R-sided chest pain, altered
mental status and anorexia of 2 days duration.
Major Surgical or Invasive Procedure:
Appendectomy ([**2122-9-15**])
History of Present Illness:
The patient is an 80-year-old female who presented to our ED
with the above complaints. She denied nausea, vomiting,
diarrhea, hematochezia and melena.
Past Medical History:
Mesenteric ischemia
Diabetes mellitus type II
Peripheral vascular disease
Hypertension
Thyroid hormone dependent
Past Surgical History:
Placement of inferior mesenteric artery stent for mesenteric
ischemia
Total thyroidectomy
Social History:
Lives in [**State 15946**], MA, denies tobacco or alcohol use and history.
Has a son who is a nurse.
Family History:
Non-contributory
Physical Exam:
VS: T99.5 P65 BP112/39 R20 sat 96%RA
Gen - ill-appearing, slightly confused
HEENT - anicteric, dry MM
Cor - RRR without m/g/r
Lungs - CTA bilat.
[**Last Name (un) **] - bowel sounds present, tense at RLQ, distended, quite
tender, +guarding
Ext - no edema, cool toes
Pertinent Results:
[**2122-9-14**] 11:45PM WBC-19.7* RBC-3.33* HGB-10.6* HCT-30.9*
MCV-93 MCH-31.6 MCHC-34.2 RDW-14.1
[**2122-9-14**] 11:45PM NEUTS-86.4* LYMPHS-9.0* MONOS-3.9 EOS-0.7
BASOS-0.1
[**2122-9-14**] 11:45PM PLT COUNT-174 LPLT-1+
[**2122-9-15**] 02:20AM URINE RBC-0 WBC-[**6-13**]* BACTERIA-FEW YEAST-NONE
EPI-[**6-13**]
[**2122-9-15**] 02:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2122-9-15**] 02:20AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
Brief Hospital Course:
The patient was admitted to the Platinum Surgery service under
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**]. Both her physical exam and her CT scan
confirmed the presence of appendicitis. Specifically, she had a
13mm appendix with an appendicolith, and marked inflammatory
stranding in the right lower quadrant centered about the
appendix. The appendix was dilated but filled proximally with
air and stool. The appearance was consistent with uncomplicated
distal acute appendicitis. She was also noted to have a ventral
hernia containing fat. She was administered levofloxacin,
metronidazole, hydrated and was taken to the operating room for
a laparoscopic appendectomy and ventral herniorrhaphy, and her
appendix was noted to be gangrenous. Please refer to the
operative note for further details of the operation. A drain was
left in the surgical bed.
In the immediate post-operative period, she was given 1 unit of
packed red blood cells (PRBCs). Ampicillin was added to her
antibiotic regimen to broaden gram-negative coverage given the
state of her appendix. Her pain was controlled adequately and
her urine output was adequate.
On POD#2, she worked with physical therapy. Leter in the day,
she was noted to have slightly decreased breath sounds and mild
shortness of breath (SOB). She was administered a diuretic and
nebulizer therapy with vast improvement in her pulmonary status.
Later the same evening, she developed asymptomatic atrial
fibrillation that ceased with 5mg intravenous metoprolol.
Work-up for acute coronary syndrome was negative.
On POD#3 ([**2122-9-18**]), the patient again manifested atrial
fibrillation and SOB, and began to have oliguria, with a urine
output of 40ml over 4 hours. She was transferred to the
intensive care unit for close monitoring. A central venous line
was placed, and she was given a unit of PRBCs for a hematocrit
of 29.3. A nasogastric tube was placed for decompression of the
stomach, and this yielded 300ml of contents straightaway. After
stabilization and conversion to normal sinus rhythm, the patient
was transferred back to the floor on POD#5. She had two bowel
movements and was allowed a clear liquid diet, which she
tolerated well.
On POD#6 overnight, the patient again had atrial fibrillation
but was asymptomatic. On the morning of POD#7, she again
suffered dyspnea, and a chest x-ray showed cephalization. She
responded well to intravenous furosemide. Later in the day, she
complained of nausea. Evaluation for acute coronary syndrome
proved negative. She was seen by the cardiology service for
evaluation of her atrial fibrillation and dyspnea. Her
metoprolol dosage was optimized over the next day.
The cardiology service recommended a trial of beta blocker in
the absence of albuterol and a trans-thoracic echocardiogram.
The former was quite successful in preventing her paroxysmal
atrial fibrillation, and the latter showed mild L atrial
dilatation, LVEF of 70%, and 1+MR.
On POD#8, her [**Location (un) 1661**]-[**Location (un) 1662**] drain was removed, and she was
advanced to a regular diet. Her antibiotics were discontinued.
She felt quite well, and expressed a desire to be discharged.
She did have a few bouts of diarrhea, but laboratory tests were
negative for clostridium difficile colitis.
On POD#9, the patient was discharged to the [**Hospital1 10151**] Center in good condition. She was afebrile,
tolerating a regular diet, able to walk about and manage most of
her activities of daily living, and was pain-free. She is to
follow up in clinic with Dr. [**Last Name (STitle) 6633**] in 2 weeks for evaluation
and outpatient treatment.
Medications on Admission:
bisporolol-HCTZ 2.5/6.25mg QD
ASA 81mg QD
clopidogrel 75mg QD
glipizide 5mg [**Hospital1 **]
ezetimibe-simvastatin 10/20mg QD
lisinopril 10'
levothyroxine 125mcg q TWTSaSu, 62.5mcg q MF
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet PO MONDAY AND
FRIDAY ().
9. Hydrochlorothiazide 25 mg Tablet Sig: 0.26 Tablet PO DAILY
(Daily).
10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO TUES
THROUGH THURSDAY, SAT & SUNDAY ().
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Acute appendicitis/gangrenous appendix
Congestive heart failure
Discharge Condition:
Vital signs stable, afebrile, alert/oriented, tolerating po,
ambulant with assistance. Overall, very good.
Discharge Instructions:
Please call for fever greater than 101, nausea/vomiting,
inability to eat, wound redness, warmth, swelling, foul smelling
drainage, abdominal pain that is not controlled by medication or
any other concerns.
You may resume your regular diabetic diet.
You may resume your normal activities.
Please resume taking all medications you were taking prior to
this surgery and pain medications.
Please follow up as directed.
No heavy lifting for 4-6weeks or until directed otherwise. [**Month (only) 116**]
leave wound open to air, please leave the steristrips intact
until they fall off.
Followup Instructions:
Please follow up with your primary care physician in [**State 15946**],
MA. Call for an appointment to be seen the week you get
discharged from [**Hospital3 **].
Call Dr. [**Last Name (STitle) 17477**] office for an appointment in 2 weeks. Her
phone number is: (81) [**Telephone/Fax (1) **].
Completed by:[**2122-9-25**]
|
[
"4280",
"9971",
"42731",
"25000",
"4019"
] |
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