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Admission Date: [**2121-3-26**] Discharge Date: [**2121-4-1**]
Date of Birth: [**2042-11-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2121-3-26**] 1. Aortic valve replacement with a 23-mm [**Doctor Last Name **] Magna
aortic valve bioprosthesis. 2. Coronary artery bypass grafting
x3 with left internal mammary artery to left anterior descending
coronary artery; reverse saphenous vein single graft from the
aorta to the first obtuse marginal coronary artery; reverse
saphenous vein single graft from the aorta to the distal right
coronary artery.
History of Present Illness:
78 year old russian speaking female with history of coronary
artery disease s/p stent placement to LAD in [**2120-9-12**].
She was feeling well until 2 months ago when she started
experiencing chest tightness. This is associated with dyspnea,
as well as several episodes of nocturnal and rest angina. She
underwent a cardiac cath at [**Hospital3 **] on [**2121-3-4**] which
revealed severe left main and three vessel disease. Based on
these findings, she was admitted and bypass surgery was
recommended. However, she did not want to pursue surgery and
wanted a second opinion (specifically to pursue minimally
invasive and off-pump). Since discharge from [**Hospital3 **],
she has had several episodes of chest pain at rest.
Past Medical History:
Coronary artery disease s/p LAD DES [**9-20**]
Hypertension
Hyperlipidemia
Spinal stenosis
Social History:
Lives: alone
Occupation: -
Tobacco: denies
ETOH: denies
Family History:
non-contributory
Physical Exam:
Pulse: 61 Resp: 20 O2 sat: 99%
B/P Right: 160/69 Left: 163/68
Height: 5'2" Weight: 165 lbs
General: well-developed elderly female in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: - Varicosities:
small right calf
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Pertinent Results:
Intra-op Labs
[**2121-3-26**] 09:36AM HGB-8.7* calcHCT-26
[**2121-3-26**] 09:36AM GLUCOSE-90 LACTATE-0.9 NA+-138 K+-3.8 CL--104
[**2121-3-26**] 02:42PM FIBRINOGE-284
[**2121-3-26**] 02:42PM PT-15.3* PTT-28.8 INR(PT)-1.3*
[**2121-3-26**] 02:42PM PLT COUNT-149*
[**2121-3-26**] 02:42PM WBC-14.6*# RBC-2.83*# HGB-7.0*# HCT-21.8*#
MCV-77* MCH-24.9* MCHC-32.3 RDW-16.2*
[**2121-3-26**] 02:42PM HGB-7.3* calcHCT-22
Discharge labs:
[**2121-3-31**] 06:30AM BLOOD WBC-7.7 RBC-3.98* Hgb-10.5* Hct-32.2*
MCV-81* MCH-26.4* MCHC-32.7 RDW-18.8* Plt Ct-81*
[**2121-3-31**] 06:30AM BLOOD Plt Ct-81*
[**2121-3-29**] 04:54AM BLOOD PT-11.9 PTT-26.8 INR(PT)-1.0
[**2121-3-30**] 06:30AM BLOOD Glucose-86 UreaN-26* Creat-0.9 Na-139
K-3.5 Cl-104 HCO3-25 AnGap-14
[**2121-3-26**] Echo: PRE BYPASS The left atrium is mildly dilated. The
left atrium is elongated. Mild spontaneous echo contrast is seen
in the body of the left atrium. No mass/thrombus is seen in the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate ([**12-14**]+), bordering on moderate aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). Moderate [2+] tricuspid regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results in the
operating room at the time of the study. POST BYPASS The patient
is being AV paced. There is normal biventricular systolic
function. There is a bioprosthesis in the aortic position. It
appears well seated. Leaflet function appears normal. There is
very trace aortic insufficiency the origin of which can not be
determined. The maximum gradient across the aortic valve is 17
mmHg with a mean of 9 mmHg at a cardiac output of 6
liters/minute. The effective orifice area of the valve is 1.8
cm2. The tricuspid regurgitation is improved and is now mild to
moderate. The thoracic aorta appears intact.
Radiology Report CHEST (PA & LAT)[**2121-3-31**] 11:37 AM
[**Hospital 93**] MEDICAL CONDITION: 78 year old woman s/p cabg
REASON FOR THIS EXAMINATION: eval for effusion
Final Report
Mild-to-moderate postoperative enlargement of the
cardiomediastinal silhouette has been stable since [**3-27**].
Small bilateral pleural effusions are unchanged since [**3-28**].
There is no pneumothorax or pulmonary edema.
Moderately severe bibasilar atelectasis is stable on the left,
worsened on the right.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Brief Hospital Course:
Ms. [**Known lastname 74551**] was a same day admit after undergoing pre-operative
work-up as an outpatient. On [**3-26**] she was brought directly to
the operating room where she underwent a coronary artery bypass
graft x 3 and aortic valve replacement. Please see operative
report for surgical details. In summary she had: Aortic valve
replacement with a 23-mm [**Doctor Last Name **] Magna aortic valve
bioprosthesis.
Coronary artery bypass grafting x3 with left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein single graft from the
aorta to the first obtuse marginal coronary artery; reverse
saphenous vein single graft from the aorta to the distal right
coronary artery. Her bypass time was 130 minutes with a
crossclamp of 108 minutes. She tolerated the operation well and
following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. She was somewhat labile
hemodynamically on the day of surgery requiring volume overnight
herand hemodynamics had improved on post operative day 1 she
woke and was extubated. A heparin induced antibody test was
done on post operative day 1 due to falling platelets, which was
negative. Her home dose of Plavix was restarted for a history
of LAD stent in [**9-20**]. Chest tubes and pacing wires were
removed per cardiac surgery protocol. She remained
hemodynamically stable and was transferred to the step down unit
on post operative day 3. Once on the floor, beta blockers were
titrated up and an ACE-I was started for better blood pressure
control. She was tolerating a full oral diet, continued to be
gently diuresed and her incisions were healing well. She had
generalized weakness preoperatively and required assistance for
transfers. She was transfered to rehabilitation at [**Hospital 7137**] in [**Location (un) **] on post operative day 6.
Medications on Admission:
Metoprolol 100mg qd
Plavix 75mg qd
Simvastatin 40mg qd
Aspirin 81mg qd
Hydrochlorothiazide 25mg qd
Nitro 2.5mg prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day): total 75mg three times a day .
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Aortic insufficiency s/p Aortic valve replacement
Past medical history
s/p LAD DES [**9-20**]
Hypertension
Hyperlipidemia
Spinal stenosis
Discharge Condition:
Alert and oriented x3 nonfocal - Russian speaking
Ambulates with walker, minimal distance
Sternal pain managed with Ultram prn
Sternal wound healing well, no eryhtema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
***If there are any questions or concerns please call the
cardiac surgery office [**Telephone/Fax (1) 170**]. The answering service will
contact the [**Name2 (NI) 24140**] person during off hours.***
Followup Instructions:
Appointments already scheduled
Surgeon Dr [**Last Name (STitle) **] - Thrusday [**5-1**] at 1:30 pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**12-14**] weeks [**Telephone/Fax (1) 589**]
Cardiologist Dr.[**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] in [**12-14**] weeks
Completed by:[**2121-4-1**]
|
[
"4241",
"2851",
"41401",
"2875",
"4019",
"2724",
"V4582"
] |
Admission Date: [**2119-2-8**] Discharge Date: [**2119-2-11**]
Date of Birth: [**2060-7-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a deaf 58 year old gentleman with a history of
likely hypertensive dialated cardiomyopathy (EF 50%,) poorly
controlled blood pressure, DM2 (last HbgA1c 9.5% in [**11-4**]), OSA
who presented to the ED with complains of sudden onset SOB. The
patient has had prior hospitalizations for acute pulmonary edema
in the setting of hypertensive urgency. He is followed by Dr.
[**First Name (STitle) 437**], with a recent improvement in cardiac function, with now
improved systolic function (20% in [**2098**] to 50%), but dialated
and hypertrophied ventricles. He was seen by his PCP one day
prior to presentation with complaints of 3 days of
conjunctivitis and rhinorhea with a slight, non-productive
cough, which was felt to be a viral syndrome, but he was
prescribed erythromycin ointment.
.
On the day of presenation, the patinet was waking and became
markedly short of breath. EMS was activated, and the patient was
placed on a NRB. On arrival to the ED, he was markedly
hypertensive 242/11/ HR 106, and afebrile. The patinent was
placed on BIPAP, was started on a nitro gtt, given ASA 325mg,
and was 100mg IV lasix, to which he put out 400cc of urine.
Cardiology was consulted in the ED, but felt that given recent
URI symptoms, a MICU admission would be more appropriate. The
patient was admitted to the MICU for further manegment.
.
The patient denies any fevers/chills, abdominal pain, diahrea,
or dysuria. He has not had any worsening LE swelling, orthopnea,
or PND. He reports to be compliant with home medication regimen.
He complaints of b/l chest pain currently, similar to prior
chest pain. Worse with palpation and deep inspiration.
Past Medical History:
1. Hypertension
2. Type 2 Diabetes Mellitus, on insulin
3. Hyperlipidemia
4. OSA
5. Cardiomyopathy
6. Deaf
Social History:
The patient currently lives alone; his brother, with a
significant drinking problem, had moved out of his home. He does
not drink or smoke or use illicit drugs. His family is not
involved with his care. He currently participates in a day
program. Patient has a low education level (unclear how much
school he has completed), and difficulty with [**Location (un) 1131**].
Family History:
NC
Physical Exam:
VITALS: Afebrile BP 147/74 (137-204/58-100) HR 87 RR 11 O2 100%
GEN: NAD, sitting up in bed comfortably, deaf, mute
HEENT: PERRL, no scleral icterus, MMM, EOMI, oropharynx clear
NECK: No JVD appreciated, No thyromegally, No LAD
LUNGS: + bibasilar wheezes, bibasilar crackle L>R, no rhonchi or
rales, good air movement
CV: RRR, 2/6 systolic murmur best heard at RUSB, no gallops or
rubs, no s3 or s4
ABD: soft, NT, ND, +BS, no HSM on exam
EXT: No edema, cyanosis or edema. bilateral radial and DP
pulses palpable bilaterally.
NEURO: alert, unable to assess orientation, strength 5/5 in all
4 extremities, sensation intact throughout although minimally
decreased in distal portions of feet. reflexes 2+ in bilateral
patellar location.
SKIN: no rashes or petechiae noted
Pertinent Results:
[**2119-2-8**] 06:35PM BLOOD WBC-5.4 RBC-4.98 Hgb-14.7 Hct-46.2 MCV-93
MCH-29.6 MCHC-31.9 RDW-12.8 Plt Ct-187
[**2119-2-10**] 06:35AM BLOOD WBC-7.8 RBC-4.15* Hgb-12.5* Hct-38.3*
MCV-92 MCH-30.2 MCHC-32.7 RDW-12.6 Plt Ct-147*
[**2119-2-8**] 06:35PM BLOOD Neuts-54.2 Lymphs-36.6 Monos-6.4 Eos-1.9
Baso-0.9
[**2119-2-8**] 06:35PM BLOOD Glucose-341* UreaN-15 Creat-1.1 Na-142
K-4.4 Cl-101 HCO3-31 AnGap-14
[**2119-2-10**] 06:35AM BLOOD Glucose-183* UreaN-17 Creat-1.1 Na-142
K-3.9 Cl-100 HCO3-36* AnGap-10
[**2119-2-8**] 06:35PM BLOOD CK(CPK)-386*
[**2119-2-9**] 03:59AM BLOOD CK(CPK)-202
[**2119-2-9**] 12:59PM BLOOD CK(CPK)-184
[**2119-2-10**] 06:35AM BLOOD CK(CPK)-128
[**2119-2-8**] 06:35PM BLOOD cTropnT-0.03*
[**2119-2-9**] 03:59AM BLOOD CK-MB-6 cTropnT-0.11*
[**2119-2-9**] 12:59PM BLOOD CK-MB-5 cTropnT-0.14*
[**2119-2-10**] 06:35AM BLOOD CK-MB-4 cTropnT-0.07*
[**2119-2-9**] 03:59AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9
[**2119-2-11**] 06:10AM BLOOD WBC-5.6 RBC-4.10* Hgb-12.3* Hct-37.2*
MCV-91 MCH-29.9 MCHC-33.0 RDW-12.5 Plt Ct-154
[**2119-2-11**] 06:10AM BLOOD Plt Ct-154
CHEST X-RAY [**2119-2-8**] - FINDINGS: There is mild cephalization of
the pulmonary vasculature and
prominence of the central pulmonary vasculature. There are no
definite focal consolidations. Study is slightly limited by
motion blurring. There is moderate cardiomegaly, stable. No
pneumothorax or pleural effusion is present.
Brief Hospital Course:
# HTN: He has had multiple recent hospitalizations for similar
systolic blood pressures. Initially he required a nitro drip to
control his blood pressure, however with improvement in his
blood pressure the drip was discontinued and, adjustments were
made to his home medications for optimum blood pressure control.
His lisinopril and carvedilol were at supratherapeutic doses
without additional benefit in blood pressure control thus his
carvedilol was decreased to 25 mg twice a day and lisinopril was
decreased to 40mg daily. His lasix was increased to 40mg twice a
day and his clonidine was increased to 0.3mg/q24 he once a week.
Amlodipine 10mg daily was added to his regimen. Outpatient
evaluation for obstructive sleep apnea is recommended, as well
as addition of spironolactone by his primary care doctor if
there are no contraindications.
# Hypoxia: Patient had pulmonary edema on CXR on admission. He
was initially placed on non-rebreather with good oxygen
saturation. In the ED, he also recieved IV furosemide for
diuresis. On arrival to the ICU, he was further diuresed and
weaned to oxygen by nasal canula without difficulty. He had no
oxygen requirement by the second hospital day. He was
discharged on an increased diuretic dose.
# Dilated Cardiomyopthy with CHF: Mr. [**Known lastname 805**] has a
long-standing daignosis of dilated cardiomyopathy (EF 51%) in
10/[**2118**]. This was felt to be contributing to his hypoxia in
setting of hypertensive urgency. He was diuresed as above.
Continue carvedilol and lisinopril. He is to follow-up with
his outpatient cardiologist after discharge.
# Chest Pain: Mr. [**Known lastname 805**]' presented with chest pain in
setting of hypertensive urgency. EKG unchanged, noted to have
recent exercise MIBI without ischemia. Cardiac enzymes were
cycled and were negative. He was continued on his aspirin,
statin, beta blocker.
# DM2: He was hypoglycemic in the early mornings and in the mid
afternoons. This was likely due to his NPH dosing. His NPH am
dose was decreased to 26 units and his pm dose was decreased to
18 units. Further titration should be continued as an
outpatient.
Medications on Admission:
Lipitor 40mg hs
carvedilol 50mg [**Hospital1 **]
Clonidone 0.2mg qweek
Erythromycin oilment qid
Lasix 40mg daily
Glipizide 10mg daily
Lisinopril 8mg daily
ASA 81mg daily
NPH 28u qam 22un qhs
Discharge Medications:
1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Twenty
Six (26) units Subcutaneous in the mornings.
9. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Eighteen
(18) units Subcutaneous in the evenings.
10. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal once a week: remove previous patch. Place new patch
on Mondays.
Disp:*4 patches* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypertensive Urgency
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital after developing shortness of
breath and some chest pain. You did not have a heart attack.
Your blood pressure was determined to be high and you were given
medication to reduce it. You also recieved some medication to
help your body get rid of excess fluid. You are being
discharged home on 1 more blood pressure medication and changes
have been made in the doses of your previous blood pressure
medications.
.
CHANGES IN MEDICATION:
START Amlodipine 10 mg by mouth daily
Increase lasix to 40mg twice a day
Increase Clonidine to 0.3mcg/24hr patch once a week (MONDAYS).
Decrease carvedilol to 25 mg twice a day
Decrease lisinopril to 40mg daily
Please continue all other medications as previously prescribed
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up with your primary care physician, [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 34732**], at your previously scheduled appointment. Details
are listed below:
Provider: [**First Name11 (Name Pattern1) 1141**] [**Last Name (NamePattern4) 93720**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2119-2-20**] 3:25
|
[
"4280",
"25000",
"V5867",
"2724",
"32723"
] |
Admission Date: [**2148-12-10**] Discharge Date: [**2148-12-16**]
Date of Birth: [**2077-12-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
1. Nasogastric tube placement
2. Colonoscopy
3. Esophagealgastroduodenoscopy
4. Angiogram with coiling
History of Present Illness:
This is a 70 year-old male with a history of gout and depression
who presents with GI bleed and transferred to [**Hospital1 18**] for further
management. The patient presented to [**Hospital3 3765**] on [**2148-12-2**]
with complaints of [**2-1**] days of multiple large liquid maroon
stool. He denied any recent NSAID use, but did report taking
ibuprofen 3 weeks prior during a UTI. His Hct on admission was
noted to be 18. He underwent EGD on [**12-2**] and was noted to have
mild gastritis & esophagitis, but no source of GI bleed. He
undewent colonscopy the following day that showed old and new
blood in the colon with non-bleeding diverticula, but no clear
source of bleeding.
.
The evening of [**2148-12-3**] the patient had an NSTEMI with the
development of burning chest pain and ECG showing ST depression
in v3-v4. CE were positive with a trop 2.90 (ULN: 0.78), but
flat CK (89). ECHO showed EF 40-45% with wall motion abnormality
consistent with apical infarct. The patient was started on low
dose beta-blocker and ASA, plavix and heparin gtt were not
started given his GI bleed. He undewent a tagged RBC scan on
[**2148-12-9**] that did not show evidence of active bleeding. He also
undewent a push enteroscopy on [**2148-12-9**] that also did not
identify the source of the bleed. The patient has received a
total of 17U pRBC since his admission requiring an average of 2U
per day. He states that he felt orthostatic at times, but
remained hemodynamically stable. He continues to have maroon
stools with his last one being yesterday. He has been NPO for
the last 2 days. The patients Hct this morning was 24.2. CE were
wnl at 0.206. He was transfused en route.
.
On arrive the patient states he feels well without N/V or
abdominal pain.
.
Of note, the patient also had 2 episodes of transient visual
distubances and was evaluated by neuro. He had carotid U/S that
did not showed no hemodynamically significant carotid stenosis.
It was thought to be related to his migraines.
Past Medical History:
Gout
Depression
h/o of Gastric Ulcers in his 20's
Social History:
Married and lives with his wife. [**Name (NI) **] is a retired Language
teacher. He smoked 1ppd x 10years but quit 40yrs prior to
admission. He has been sober for the last 20 years. His
daughter is a pediatrician.
Family History:
Patient was adopted.
Physical Exam:
On admission:
VS: 94.3 127/44 73 100% BiPAP 50%
GEN: somnelent, wearing BiPAP mask, able to nod yes/no to
questions and opens eyes to voice, knows daughter by the
bedside.
HEENT: MM dry, no conjunctival icterus, pallor, or injection.
Neck is supple without LAD or JVD
RESP: Mild wheezes anterior throughout.
CV: RRR. no m/r/g
ABD: Soft, NT/ND, no HSM, no rebound tenderness or guarding
EXT: cool distally, with symmetric palpable pulses bilaterally.
No edema.
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. Generalized 4/5 weakness in
upper and lower extremities, without focal deficits.
Pertinent Results:
Labs on admission:
[**2148-12-10**] 05:23PM BLOOD WBC-6.7 RBC-3.17* Hgb-9.9* Hct-27.6*
MCV-87 MCH-31.2 MCHC-35.8* RDW-16.4* Plt Ct-178
[**2148-12-10**] 05:23PM BLOOD Neuts-80* Bands-0 Lymphs-16* Monos-3
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2148-12-10**] 05:23PM BLOOD PT-13.5* PTT-27.1 INR(PT)-1.2*
[**2148-12-10**] 05:23PM BLOOD Glucose-93 UreaN-20 Creat-0.9 Na-140
K-3.7 Cl-109* HCO3-28 AnGap-7*
[**2148-12-10**] 05:23PM BLOOD ALT-7 AST-11 LD(LDH)-79* CK(CPK)-44*
AlkPhos-36* TotBili-0.5
[**2148-12-10**] 05:23PM BLOOD Albumin-2.2* Calcium-8.1* Phos-2.6*
Mg-1.8
Cardiac enzymes:
[**2148-12-10**] 05:23PM BLOOD CK-MB-3 cTropnT-0.24*
[**2148-12-11**] 02:35AM BLOOD CK-MB-2 cTropnT-0.18*
[**2148-12-11**] 06:07AM BLOOD CK-MB-4 cTropnT-0.18*
[**2148-12-11**] 04:07PM BLOOD CK-MB-9 cTropnT-0.20*
[**2148-12-11**] 10:54PM BLOOD CK-MB-9 cTropnT-0.23*
Imaging:
[**12-10**] Echo: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and ejection fraction are normal
(LVEF 70%). The apex is focally dyskinetic. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. The mitral valve
leaflets are myxomatous. There is borderline/mild posterior
leaflet mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion. Impression: focal
apical dyskinesis; consider Takotsubo cardiomyopathy vs apical
infarct
[**12-10**] CXR: roughly 3-cm wide opacity projecting over the
intersection of the left fourth anterior and tenth posterior
ribs could be superimposition of normal structures or early
region of consolidation, particularly if patient has had
aspiration episodes. Followup advised. Lungs are otherwise
clear. Heart size normal. No pleural or mediastinal
abnormalities. No free
subdiaphragmatic gas and no pneumothorax.
.
Tagged RBC scan
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for 120 minutes were obtained.
Blood flow images show normal abdominal blood flow.
Dynamic blood pool images show intermittent brisk bleeding from
the hepatic flexure of the colon.
Bleeding was first noticed at about 40 minutes.
IMPRESSION: Active bleeding from the hepatic flexure.
EGD:
Findings: Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Other
findings: No blood or bleeding seen.
Impression: No blood or bleeding seen.
Otherwise normal EGD to third part of the duodenum
COLONOSCOPY:
Findings:
Contents: Extensive red blood and large clots were seen
throughout the colon. The clots could not be suctioned
adequately despite multiple attempts. In addition, the magnitude
of blood was too great to allow for evaluation of the mucosa.
The procedure was aborted.
Excavated Lesions A single non-bleeding diverticulum was
identified in the sigmoid colon. Per report, there were
additional diverticula throughout the sigmoid on the last
procedure, so we presume that these were obscured by the massive
amount of blood.
Impression: Red blood and clots throughout the visualized
portions of the colon.
Diverticulum in the sigmoid colon
Otherwise normal colonoscopy to splenic flexure
DISCHARGE LABS:
[**2148-12-16**] 04:09AM BLOOD WBC-4.6 RBC-3.47* Hgb-10.8* Hct-31.2*
MCV-90 MCH-31.2 MCHC-34.7 RDW-16.0* Plt Ct-219
[**2148-12-15**] 04:56AM BLOOD Glucose-130* UreaN-11 Creat-0.9 Na-141
K-3.9 Cl-109* HCO3-29 AnGap-7*
[**2148-12-14**] 04:20AM BLOOD CK-MB-3 cTropnT-0.31*
[**2148-12-13**] 04:32AM BLOOD Triglyc-102
Brief Hospital Course:
Mr [**Known lastname 7842**] is a 70 year-old male with a history of gout and
depression who was transferred from [**Hospital3 3765**] for further
evaluation of GI bleed.
.
#. Large volume GI Bleed: Thorough OSH work-up without clear
source identified. Had received 17units of pRBCs at OSH.
Transferred here for question capsule study. Continued to have
BRBPR. HCT trended Q8hrs. Required additional 12units of pRBC in
house (total of 28units). Fibrinogen, coags wnl in setting of
massive transfusion requirement. GI bleed work-up in house:
tagged RBC scan on [**12-12**] with dynamic blood pool images
demonstrated intermittent brisk bleeding from the hepatic
flexure of the colon. Subsequent angio on [**12-12**] revealed blushing
in area of hepatic flexure, no intervention performed. Imaging
reviewed and on [**12-13**] decision made to repeat IR guided angio. 3
coils successfully deployed in the vasculature supplying hepatic
flexure. HCT stable post-procedure. Per GI will likely plan on
outpatient colonoscopy. On day of transfer out of [**Hospital Unit Name 153**]
transitioned from IV Q12hrs PPI -> PO PPI, maintained on clear
diet wirh plan to advance as tolerated. Of note, due to large
volume dye load patient received renal protective N-Ac and
bicarbonate.
TO DO:
- will need follow up CBC
- will need repeat colonoscopy at [**Hospital1 18**] in next 2-4 weeks to
re-assess area
- recommend surgical consultation at [**Hospital1 18**] to discuss
semi-elective resection of area of bowel that was bleeding.
.
#. NSTEMI: Pt with NSTEMI in the setting of GI bleed and severe
anemia at OSH. Likely secondary to demand in setting of blood
loss. Patient with 2 episodes with chest pain in the ICU. EKG
with dynamic changes in V2-4, flat CKs and trops peak at 0.3.
Cards consulted initially for question of pre-operative risk if
GI bleed necessitated. Bleed successfully controlled with coil.
Per cards, NTEMI not an indication for catherization however
will likely require stress as an outpatient. At time of transfer
pt chest pain free with biomarkers downtrending. Low dose
metoprolol 6.25mg [**Hospital1 **] discontinued on day of transfer due to
asymptomatic hypotension in the 90s. Continued on simvastatin
40mg daily. Of note has not been given ASA, plavix or heparin
given his continued GI bleed. Transfusion goal > 30.
TO DO:
- Needs to follow up with cardiology ASAP to consider stress
testing, cath, and further medical management
- ASA on HOLD given bleeding. Can re-consider after further
GI/cardiology evaluation
- Beta blocker held given HYPOTENSION with this medication in
[**Hospital Unit Name 153**] with chest pain. Can consider on follow up
- ON high dose statin
.
#. Gout. Continued home allopurinol
.
#. Depression. Continued home Venlafaxine XR 75mg daily,
Klonopin qhs prn.
Medications on Admission:
Allopurinol
Venlafaxine
ASA 81mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
3. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Outpatient Lab Work
Please check a CBC and EKG on next follow up
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
Blood loss anemia
NSTEMI (non-ST elevation myocardial infarction)
Depression
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a large lower GI bleed, as well as a heart
attach. The bleeding was caused by an area in your "hepatic
flexure." After many blood transfusions, the bleeding was
stopped via angiogram and coiling. Your heart attack was caused
by a lack of blood supply to the heart.
You will need to follow up with your PCP closely for repeat
blood work and for coordination of care. You will need to see
your cardiologist as soon as possible to further assess your
recent heart attack and need for further testing and treatment.
You will also need to schedule a colonoscopy in the next few
weeks, and consider a surgery evaluation. This is because we
are not definitively sure where or why you had your bleeding
Please call your doctor and/or return to the nearest emergency
department immediately if your bleeding resumes, OR you
experience chest pain or shortness of breath.
Your aspirin has been STOPPED for now given your severe
bleeding, though you may have to go back on it after discussion
with your PCP and cardiologist.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 26929**] in Wednesday [**12-18**]
at 1:30PM in [**Location (un) **] office
Please call [**Telephone/Fax (1) 463**] to schedule a colonoscopy at [**Hospital1 18**]
within the next 2-4 weeks.
Please follow up with your cardiologist as soon as possible, Dr.
[**Known firstname **] [**Last Name (NamePattern1) 89679**]. Please call [**Telephone/Fax (1) 85388**] to schedule an
appointment, or speak with your PCP about [**Name Initial (PRE) **] referral.
We recommend that you follow up with a surgeon here to discuss
possible surgical options. Please call [**Telephone/Fax (1) 600**] to schedule
an appointment
|
[
"41071",
"2851",
"41401",
"311",
"V1582"
] |
Admission Date: [**2179-11-26**] Discharge Date: [**2179-12-1**]
Date of Birth: [**2109-2-28**] Sex: M
Service: NEUROSURGERY
Allergies:
Ampicillin / Gentamicin
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Transfer from TICU s/p craniotomy for SDH, also with suspected
aortic abcess
Major Surgical or Invasive Procedure:
Status-post right craniotomy for evacuation of subdural hematoma
History of Present Illness:
70M with PMH of Hep C, HTN, HL, aortic and tricuspid valve
endocarditis s/p AVR and TVR on [**2178-12-17**] with a week of
progressive weakness, fatigue and headache. Recently admitted
[**9-24**] with persistent endocarditis, he has not felt well since
that admission. TTE on [**11-26**] showed recurrent aortic root
abscess. He had an MRI performed on the morning of [**11-27**] that
showed a R sided acute on subacute SDH. He had a head CT/CTA
which showed no vascular malformation and he was brought to the
OR for emergent craniotomy and evacuation. He had 2 packs of
platelets intra-operatively as he was on daily ASA. Initial plan
was for TEE, however AMS and weakness likely [**1-18**] SDH and Dx of
aortic root abscess confirmed by TTE.
====
70M with PMH of Hep C, HTN, HL, aortic and tricuspid valve
endocarditis s/p AVR and TVR on [**2178-12-17**] with a week of
progressive weakness, fatigue and headache. Recently admitted
[**9-24**] with persistent endocarditis. Saw Dr[**Doctor Last Name **] today who
wrote: "Today in clinic, [**Known firstname 5279**] feels "terrible" - no energy,
dizzy, headache, felt very cold yesterday (despite temp in his
apartment being 79). He has not felt well since admission in
[**Month (only) 359**]. Given these symptoms and his history of recurrent
endocarditis, will check blood cultures, CBC, chem 7 and get him
into hospital. Probable TEE in am."
.
The patient denies fevers, chills or nightsweats and no CP. He
also denies paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations, syncope or presyncope. he does endorse
worsening headache x 4 days. Of note, he underwent
EGD/Colonoscopy done for reflux and screening, respectively on
[**11-22**]. Findings were only significant for diverticulosis of the
sigmoid colon. He felt worse after this and the next day the
headache began.
.
Of note, his Abiotrophia endocarditis occurred about a year ago
and then again in [**Month (only) 359**], and he does have a porcine valve at
this time. He was about to complete a six-week course of
ampicillin and gentamicin in [**Month (only) **] when he noted diffuse
pruritus. He saw ID, who advised him to stop the Amp/Gent and
wrote: "So, therefore, we will try to do vancomycin for three
days. We will start at a gram every 24 hours given his renal
insufficiency, and this is a dose that he had used in the past.
After stopping the vancomycin, we will switch him to
moxifloxacin 400 mg daily for suppression, and we will need to
determine the duration of this at a later date." Echo done
(prelim) showed: Aortic root abscess with moderate aortic
regurgitation, bioprosthetic aortic valve replacement with
likely vegetation although not well seen and higher than
expected transvalvular gradient. Tricuspid valve replacement
well seated with normal gradients. Low-normal left ventricular
ejection fraction (EF 50-55%). WBC 7.6, afebrile in clinic
today.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. 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:
Aortic and tricuspid valve endocarditis s/p AVR and TVR in
[**12-25**] and recent admission [**9-24**] with abiotrophia/granulicatella
endocarditis and aortic abcess
- Psoriatic arthritis
- Hyperlipidemia
- Hypertension
- Hepatitis C
- diverticular disease
- degenerative joint disease
- MRSA
PAST SURGICAL HISTORY
- Aortic valve replacement with a 23mm St. [**Hospital 1525**] Medical Epic
tissue valve and a tricuspid valve replacement with a 33-mm
tissue valve in [**12-25**] by Dr. [**Last Name (STitle) **]
- s/p wisdom tooth extraction, root canal [**9-24**]
- osteomyelitis rifht foot after surgery
- s/p Right hip arthroplasty
- s/p hemorrhoidectomy
CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, Age
CARDIAC HISTORY:
-Endocarditis per above
Social History:
He is not married.
He has no children and lives alone.
No history of tobacco or alcohol.
Denies IVDA.
Family History:
No family history of CAD, MI, cancer. Per patient no family
medical problems.
Physical Exam:
VS: T 98 BP 132/89 HR 86 RR 17 O2 99/RA
GENERAL: Well appearing gentelman, conversant, laying in bed and
in no acute distress.
HEENT: Surgical scar with staples along the right occiput.
Sclera anicteric. No conjuntival hemmorhage. PERRL, EOMI. OP
clear, no exudates/pus
NECK: Supple, JVP ~9 cm.
CARDIAC: Regular rate, normal S1 S2. A 2/6 Systolic murmur is
appreciated along the right/left substernal boarder. No rubs or
gallops.
LUNGS: Clear to auscultation bilaterallery, no wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: Trace edema bilaterally. No osler nodes, [**Last Name (un) **]
lesions, or splinter hemorrhages. Palpable DP/PT pulses
bilaterally
SKIN: Pedal scaliness and hyperpigmentation with some evidence
of joint swelling.
NEURO: Alert and oriented x 3, CN 2-12 intact, 5/5 strength
throughout, sensation to light touch intact throughout, no
pronator drift, down going toes, normal finger to nose, normal
rapid alternating movements.
Pertinent Results:
EKG: sinus at 63, mildly irregular but no apparant PACs or PVCs,
no ST elevations. ST depression III, QtC 413. Unchanged from
[**10-15**]
2D-ECHOCARDIOGRAM: [**11-26**]
- Left atrium mildly dilated, mild LVH with normal cavity size
and global systolic function (LVEF>55%). Ascending aorta is
moderately dilated. Aortic arch is mildly dilated.
- A bioprosthetic aortic valve with mild (1+) paravalvular
aortic valve leak is present, through a relatively echolucent
area at the aortic annulus, adjacent to the right sinus of
Valsalva. The bioprosthesis itself is seated normally, without
evidence of dehiscence.
- A bioprosthetic tricuspid valve well seated, with normal
leaflet motion and transvalvular gradients. The severity of
tricuspid regurgitation seen is normal for this prosthesis.
- Estimated pulm artery systolic pressure is normal; borderline
pulmonary artery systolic hypertension.
MRI Head: [**11-27**]
Right sided subacute subdural hematoma which extends from
frontal
to occipital region is new since previous CT of [**2179-10-16**]. The
SDH is 15-mm in width with a midline shift.
CTA Head: [**11-27**]
- Right-sided subdural hematoma with mass effect and midline
shift.
- Except for vascular displacement due to mass effect from the
hematoma, no abnormalities are seen on CT angiography of the
head. No abnormal vascular structures or aneurysm identified.
CT Head: [**11-27**]
- Interval right craniotomy with expected post-surgical change
with
decreased mass effect. No evidence of new acute intracranial
hemorrhage or major vascular territory infarction.
LABORATORY DATA ON ADMISSION:
136 | 100 | 20
----------------< 112
4.2 | 24 | 1.4
Ca: 8.7 Mg: 2.2 P: 2.8
Phenytoin: 6.3
\ 90 /
8.0 --- 10.7
/30.9\
INR: 1.2
SELECT LABS ON DISCHARGE:
[**2179-11-30**] 07:15AM BLOOD WBC-6.1 RBC-3.72* Hgb-11.5* Hct-32.9*
MCV-89 MCH-31.1 MCHC-35.1* RDW-13.5 Plt Ct-206
[**2179-11-30**] 07:15AM BLOOD Plt Ct-206
[**2179-11-30**] 07:15AM BLOOD Glucose-90 UreaN-19 Creat-1.5* Na-136
K-4.2 Cl-98 HCO3-28 AnGap-14
[**2179-11-30**] 07:15AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.3 Mg-2.0
[**2179-11-30**] 07:15AM BLOOD Phenyto-8.6*
Brief Hospital Course:
70 year old gentleman with AVR/TVR [**2178-12-17**] [**1-18**] to
endocarditis, as well as HCV, HTN, and HL, admitted with concern
for persistant aortic abcess and subsequently found to have a
sub-dural hematoma of unclear etiology.
# Subdural Hematoma s/p Craniotomy and Evacuation: Discovered on
admission. Craniotomy and evacuation completed without
significant complications. Post-operative head CT showed
improvement in midline shift. Prophylactically treated with
dilantin and blood pressures kept < 140. Aspirin held. Patient
discharged with plans for removal of stiches in 2 weeks,
follow/up appointment in 4 weeks, and repeat non-contrast head
CT.
# Endocarditis: recurrent, with concern for persistent aortic
abcess on TTE. Follow up TEE unable to be completed during this
admission. Blood cultures all with no growth during this
admission. Afebrile. No new murmurs on exam. Patient continued
on moxifloxacin for suppression therapy.
# Arrythmia: History of Wenckebach and atrial fibrillation on
most recent hospitalization however in normal sinus rhythm
across this admission. Aspirin being held as above.
# HTN: Normotensive across hospitalization. Given SDH goal is
SBP < 140.
# Acute on Chronic Renal Insufficiency: Admitted with creatinine
at 1.8 vs baseline of 1.5, most likely pre-renal in setting of
lasix use. Home lasix held. Creatinine resolved and was 1.5 at
the time of discharge.
# Anemia: Stable, at baseline, HCT 32.9.
# Anxiety: Continued on home lorazepam and ativan.
# Psoriasis: Continued on home Calcipotriene and Clobetasol
creams.
# OSA: Continued on CPAP.
Medications on Admission:
Tylenol PRN pain
Fluticasone 50 mcg/Actuation Spray, daily
Clobetasol 0.05 % Cream [**Hospital1 **] for psoriasis
Calcipotriene 0.005 % Cream TID for psoriasis.
Docusate Sodium 100 mg [**Hospital1 **] PRN
Chlorhexidine Gluconate 0.12 % Mouthwash 15 ML [**Hospital1 **]
Lorazepam 0.5 mg QHS
Alprazolam 0.25mg [**Hospital1 **] PRN
Aspirin 325 mg daily
Moxifloxacin 400mg daily
Lasix 40mg [**Hospital1 **]
MVI
Discharge Medications:
1. Outpatient Lab Work
please check phenytoin level on Monday [**12-6**]. Please send
results to Dr.[**Name (NI) 12757**] office, phone: ([**Telephone/Fax (1) 26566**] fax: ([**Telephone/Fax (1) 109665**].
2. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO Daily () as
needed for Endocarditis: do not stop unless told to by your
infectious disease physician.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day): please have your phenytoin level checked
as directed.
[**Name Initial (NameIs) **]:*120 Capsule(s)* Refills:*2*
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. Calcipotriene 0.005 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) Mucous
membrane twice a day: resume your home regimen prior to
hospitalization.
9. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain for 10 days: Please
use only as needed for pain. Please do not drive or operate
machinery while taking this medication.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis:
- Subdural hematoma
Secondary diagnosis:
- Endocarditis
- Psoriatic arthritis
- Hypertension
- Hyperlipidemia
- Hepatitis C
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted from Dr.[**Doctor Last Name 35583**] office for evaluation
after reporting feeling unwell. Plans were made to undergo a
trans-esophageal echocardiogram (TEE), however a MRI obtained to
evaluate your headache demonstrated a type of bleeding around
the brain, called a subdural hematoma. You underwent surgical
evacuation of the bleeding and did well post-operatively.
The following medication changes were made:
- STOPPED aspirin due to the subdural bleed. Please discuss with
your neurosurgeon and cardiologist before re-starting this
- STARTED phenytoin 200 mg twice a day to prevent seizures. You
will need to have a level checked (through blood work) on
Monday, [**12-6**].
- STARTED oxycodone/acetaminophen 1-2 tablets every four hours
as needed for pain related to your surgery. Please note that
this contains acetaminophen (Tylenol).
- STOPPED lasix (taken for excess fluid)
Weigh yourself every morning, call Dr.[**Name (NI) 35583**] office to
discuss re-starting lasix (furosemide) if weight goes up more
than 3 lbs.
You were followed by the infectious disease team and should
continue the Moxifloxacin daily for your history of
endocarditis.
Please also follow up with your dentist for further management.
Followup Instructions:
Please follow up with Dr.[**Name (NI) 12757**] office around [**12-6**]
for staple removal. Please call his office to arranage for a
follow up appointment in the next few weeks--his office knows
you will be calling to arrange an appointment as his schedule is
being worked out. The number is ([**Telephone/Fax (1) 26566**]. You will need a
repeat head CAT scan at that time as well.
You will need to have blood work done to check the level of
phenytoin [**2179-12-6**], with the results faxed to Dr.[**Name (NI) 12757**]
office at fax ([**Telephone/Fax (1) 109666**].
Please follow up with your cardiologist, Dr.[**Doctor Last Name 3733**], at an
appointment made for you on [**12-21**] at 4:00 PM. If you need
to re-schedule, please call his office at ([**Telephone/Fax (1) 2037**].
Please follow up with Dr. [**Last Name (STitle) 13895**] (your infectious disease
provider) at an appointment made for you on Tuesday [**12-28**]
at 9:00 AM. If you need to re-schedule, please call ([**Telephone/Fax (1) 10**].
You also have an appointment with your renal (kidney) physician,
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**], on Feburary 2nd, [**2179**]. The number for the
clinic is [**Telephone/Fax (1) 721**].
|
[
"2724",
"32723",
"40390",
"5859",
"4280",
"42731"
] |
Admission Date: [**2201-6-26**] Discharge Date: [**2201-7-2**]
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
no neurosurgical procedures were done
History of Present Illness:
HPI: The pt is an 85 year-old gentleman with a history of
Parkinson's disease who presented to the ED after a fall.
The pt was not able to give a history at the time of my
encounter. Therefore, the following is per the ED staff.
Apparently, the pt was last seen well around 11pm. His wife
found
him at approximately 3am in the bathroom lying on the floor with
a laceration above the left eye. EMS was called and he was
brought to the [**Hospital1 18**] ED for evaluation. No EMS trip sheet was
left in the ED.
Past Medical History:
PMHx:
Parkinson's disease
colon cancer
prostate ca
malignant melenoma
lung cancer
Social History:
Social Hx: Lives with wife. Otherwise unknown.
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM:
O: T: 98.5F BP: 185/66 HR: 86 R 12 O2Sat 98% 2L
Gen: WD/WN, comfortable.
HEENT: Laceration over left eye. MM slightly dry.
Neck: In hard collar.
Lungs: Transmitted upper airway sounds bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert. Regards examiner inconsistently.
Does not speak nor attempt to answer questions. Does not follow
commands. Says "ouch" to pain.
Cranial Nerves:
I: Not tested
II: Left pupil 3mm to 2mm and reactive. Right pupil 2.5mm to 2mm
and reactive. Blinks to treat bilaterally.
III, IV, VI: Extraocular movements appear intact bilaterally.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Unable to test.
XII: Tongue midline.
Motor: Normal bulk throughout. Relatively high amplitude, low
frequency tremor of upper extremities at rest with cogwheeling
bilaterally. Unable to formally test strength due to mental
status, but moves all extremities spontaneously, though does not
briskly withdraw to pain.
Sensation: Grimaces to pain in all four extremities.
Reflexes: B T Br Pa Ac
Right 1 1 1 1 0
Left 1 1 1 1 0
Plantar response flexor on the left, extensor on the right.
Coordination: Unable to test.
Pertinent Results:
Labs notable for WBC of 15.3 and Hct of 59.4. Chemistry pending.
CT: Bifrontal SAH R >> L. SDH layering on top of the tentorium.
?
of facial fractures (but not ideally imaged)
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2201-6-28**] 2:47 AM
CHEST (PORTABLE AP)
Reason: worsening sputum production
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with SAH
REASON FOR THIS EXAMINATION:
worsening sputum production
ADDENDUM:
Findings were communicated to Dr. [**Last Name (STitle) **] over the phone by Dr.
[**Last Name (STitle) **] at the time of dictation.
REASON FOR EXAMINATION: Increased sputum production in a patient
with subarachnoid hemorrhage.
PORTABLE AP CHEST RADIOGRAPH WAS COMPARED TO [**2201-6-26**], AND
CHEST CT FROM [**2201-6-26**].
The heart size is normal. There is no change in mediastinal
contour. There is also unchanged appearance/mild improvement of
lingular consolidation, but new opacity in the right lower lobe
is demonstrated, which might be consistent with developing
infection/aspiration. The known right upper lobe spiculated
lesion is again demonstrated suspicious for pneumonia as well as
the right apical lesion, which was described on the recent CT
torso but not optimally visualized on the current radiograph.
The retrocardiac atelectasis is again noted.
The ET tube tip is 8 cm above the carina. The NG tube tip is in
the proximal stomach.
IMPRESSION:
New right lower lobe opacity, which might be consistent with
developing pneumonia/aspiration.
Unchanged lingular consolidation.
Known right upper lobe lesions concerning for neoplasm.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: MON [**2201-6-29**] 9:29 PM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2201-6-27**] 11:08 AM
CT HEAD W/O CONTRAST
Reason: assess for interval change.
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with SAH, SDH.
REASON FOR THIS EXAMINATION:
assess for interval change.
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 85-year-old male with subarachnoid hemorrhage, subdural
hemorrhage. Assess for interval change.
COMPARISON: [**2201-6-26**].
TECHNIQUE: Contiguous axial images of the head were obtained
without IV contrast.
FINDINGS: There has been no significant interval change in the
diffuse subarachnoid hemorrhage seen within the cortical sulci
as well as a layering hemorrhage within the lateral ventricles
bilaterally. No new foci of hemorrhage are identified. The
ventricular system is unchanged in size from the prior study.
There is no edema, shift of normally midline structures, or
acute major vascular territorial infarction. Again demonstrated
is a small amount of prominent right extra-axial space, which
could represent a small subdural hygroma on the right, similar
in appearance to [**2201-6-26**]. Visualized paranasal sinuses
demonstrate fluid within the sphenoid sinuses bilaterally, as
well as mucosal thickening of the left maxillary sinus. Osseous
structures are unremarkable. There is soft tissue hematoma
overlying the left frontal region.
IMPRESSION:
1. No significant change in the subarachnoid and
intraventricular hemorrhage compared to [**2201-6-26**] at 2:15
p.m.
2. Stable small right frontal extra-axial fluid collection,
likely reflecting a hygroma.
3. Left soft tissue hematoma overlying the left frontal region.
4. Mild sinus disease as noted above.
Cardiology Report ECG Study Date of [**2201-6-26**] 3:44:54 AM
Sinus rhythm. Right bundle-branch block with left anterior
fascicular
block. Baseline artifact makes interpretation difficult. No
previous tracing
available for comparison.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 158 134 366/418 80 -80 69
([**-8/3121**])
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2201-6-26**] 3:46 AM
CT HEAD W/O CONTRAST
Reason: FOUND DOWN, LAC ON FOREHEAD. ? BLEED.
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with found down in bathroom with lac on
forehead, increasingly unresponsive.
REASON FOR THIS EXAMINATION:
bleed?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 85-year-old male found down with laceration on
forehead.
COMPARISONS: None.
TECHNIQUE: MDCT axial images were obtained through the brain
without intravenous contrast. Multiplanar reconstructions were
performed.
FINDINGS: Rounded hyperdense material is seen along the right
frontal falx, and right tentorium consistent with subdural
hematoma. There is linear high- attenuation material tracking
within sulci in the bilateral frontal lobes and right sylvian
fissure consistent with subarachnoid hemorrhage. There is
prominence of the ventricles and sulci consistent with
age-related involutional change. There is no shift of the
normally midline structures, or major vascular territorial
infarct. Periventricular and subcortical white matter
hypodensities consistent with sequela from chronic microvascular
ischemia. There is a moderate soft tissue hematoma along the
superior margin of the left orbit. No radiopaque foreign bodies
are seen. Multiple hyperdense fluid levels are seen within the
sphenoid, ethmoid and left maxillary sinus likely representing
blood products. Small amount of fluid is also noted within the
frontal sinus. Findings are concerning for underlying fractures
and a facial bone CT is recommended for further
characterization.
IMPRESSION:
1. Subdural and subarachnoid hemorrhage as above. No evidence
for shift of midline structures or hydrocephalus.
2. Moderate left frontal soft tissue hematoma and multiple fluid
levels in the paranasal sinuses, concerning for underlying
fractures. A facial bone CT is recommended for further
characterization.
3. Atrophy.
Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13248**] at 4:00 am on
the date of dictation.
RADIOLOGY Final Report
CT C-SPINE W/O CONTRAST [**2201-6-26**] 3:47 AM
CT C-SPINE W/O CONTRAST
Reason: FOUND DOWN
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with found down in bathroom with lac on
forehead, increasingly unresponsive.
REASON FOR THIS EXAMINATION:
fx?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 85-year-old male found down with laceration on
forehead.
COMPARISON: Noncontrast head CT performed concurrently.
TECHNIQUE: MDCT axial images were obtained through the cervical
spine without intravenous contrast. Multiplanar reconstructions
were performed.
FINDINGS: There is no evidence of fracture or subluxation. No
prevertebral soft tissue abnormality is seen. There are
moderately severe multilevel degenerative changes characterized
by loss of intervertebral disc space height, cystic change and
marginal osteophyte formation most prominent at C5-6, C6-7 and
C7-T1. A 7 mm spiculated nodule is seen in the right lung apex.
Please refer to the accompanying torso CT (clip #[**Clip Number (Radiology) 78462**]) for
additional details.
IMPRESSION: No evidence of fracture or subluxation. Multilevel
degenerative change.
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2201-6-26**] 3:48 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: FOUND DOWN, HX CA. ASSESS FOR INJURY.
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with found down in bathroom with lac on
forehead, increasingly unresponsive. Has CA and may have PE as
cause of syncope.
REASON FOR THIS EXAMINATION:
PE? injury?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 85-year-old male found down with forehead
laceration. The patient has history of cancer and there is
concern for possible pulmonary embolism as cause of syncope.
TECHNIQUE: MDCT axial images were obtained through the chest
prior to and following administration of intravenous Optiray
contrast. Additional delayed images were obtained through the
abdomen and pelvis. Multiplanar reconstructions were performed.
CT CHEST WITHOUT AND WITH IV CONTRAST: No filling defects are
seen within the pulmonary arterial vasculature to indicate an
underlying pulmonary embolus. The thoracic aorta is normal in
caliber without evidence for dissection or aneurysmal
dilatation. There are coronary artery calcifications and
moderate calcified atheroma throughout the aortic arch. A right
paratracheal lymph node measures 1.1 cm in short axis. A
subcarinal node measures up to 2 cm in short axis. There is no
mediastinal or hilar lymphadenopathy. The proximal esophagus
appears dilated and air-filled, measuring up to 3 cm tapering
distally. The lungs demonstrate moderate changes of
centrilobular emphysema with upper lobe predominance. A large
spiculated mass is present in the right lung apex measuring
approximately 6.0 x 2.2 cm concerning for underlying carcinoma.
A 1.0 cm pulmonary nodule is present in the right apex. Nodular
soft tissue is also seen adjacent to surgical chain sutures in
the left upper lobe which could reflect tumor recurrence at a
site of prior wedge resection (series 2A image 43). There is
moderate nodular ground-glass opacity in the lingula and at the
left base representing an inflammatory or infectious etiology
such as aspiration. There is no pericardial or pleural effusion.
CT ABDOMEN WITH IV CONTRAST: There are multiple subcentimeter
hypodensities throughout the liver parenchyma, which are too
small to characterize. Layering sludge is seen within the
gallbladder. There is no evidence for gallbladder wall edema or
pericholecystic fluid to indicate acute cholecystitis. The
pancreas is atrophic. The spleen, adrenal glands, and
unopacified loops of bowel are grossly unremarkable. The kidneys
enhance symmetrically and excrete contrast normally. A low
attenuation 3 cm lesion in the upper pole of the right kidney is
compatible with a cyst. A 1-cm and 1.5 cm cystic lesion in the
mid right and lower left kidney respectively do not meet CT
criteria for a simple cyst and are incompletely characterized.
The ureters are not dilated. There is no free intraperitoneal
fluid or air. Small mesenteric and retroperitoneal lymph nodes
not not meet criteria for pathologic enlargement.
Atherosclerotic plaque is seen throughout the aorta. The celiac
axis, SMA, [**Female First Name (un) 899**], and renal arteries are opacified normally. There
is a right- sided aorto- fem bypass graft.
CT PELVIS WITH IV CONTRAST: Multiple surgical clips are seen in
the pelvis from previous prostatectomy. The bladder is
moderately distended. A large amount of stool is present
throughout the rectum and sigmoid colon. No inguinal or pelvic
lymphadenopathy is evident. No free fluid is seen in the cul-
de- sac.
BONE WINDOWS: No fractures are seen. There is a destructive
lytic lesion involving the left iliac [**Doctor First Name 362**] with cortical
disruption concerning for a metastatic focus. A lucent area is
also seen in the greater trochanter of the right femur. There
are moderate degenerative changes throughout the thoracic and
lower lumbar spine.
IMPRESSION:
1. No evidence of pulmonary embolus, aortic dissection or
traumatic injury within the chest, abdomen and pelvis.
2. 1.0 cm right upper lobe nodule, spiculated mass in the right
upper lobe and nodular thickening along chain sutures in the
posterior superior left lung concerning for carcinoma.
Correlation with outside studies and medical history is
recommended.
3. Nodular ground-glass opacity in the lingula and left lower
lobe, which could reflect an evolving infectious inflammatory
process or aspiration.
4. 1.5 cm cystic lesions in the kidneys which do not meet CT
criteria for a simple cyst. If clinically indicated, further
evaluation with renal ultrasound could be performed when the
patient's condition allows.
5. Cholelithiasis without evidence for acute cholecystitis.
6. Destructive lytic lesion in the right femoral greater
trochanter and left iliac [**Doctor First Name 362**] concerning for osseous
metastases. Bone scan could be performed if indicated to assess
for additional foci of osseous metastasis.
RADIOLOGY Final Report
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2201-6-26**] 5:31 AM
CT SINUS/MANDIBLE/MAXILLOFACIA
Reason: ?fracture
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with fall.
REASON FOR THIS EXAMINATION:
?fracture
CONTRAINDICATIONS for IV CONTRAST: None.
CT SINUS WITHOUT CONTRAST, [**2201-6-26**]
HISTORY: Fall. Question fracture.
Contiguous axial images were obtained through the paranasal
sinuses. No contrast was administered. No prior sinus imaging
studies are available for comparison. Comparison to a head CT
scan of [**2201-6-26**] at 4 a.m.
FINDINGS: Again identified is an air-fluid level in the left
maxillary sinus with air-fluid levels in the sphenoid sinuses
bilaterally. The ethmoid air cells are partially opacified, and
there is minimal mucosal thickening or fluid in the frontal
sinus. No fractures are identified. No other osseous
abnormalities are identified. The middle turbinates are
partially aerated bilaterally. There are [**Last Name (un) 36826**] type II fovea
ethmoidalis bilaterally.
CONCLUSION: Partial opacification of the paranasal sinuses as
described above with an air-fluid level in the left maxillary
sinus and in the sphenoid sinuses.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2201-6-26**] 6:07 AM
CHEST (PORTABLE AP)
Reason: s/p intubation. please check tube placement.
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with recent intubation
REASON FOR THIS EXAMINATION:
s/p intubation. please check tube placement.
INDICATION: 85-year-old man with recent intubation, evaluate for
tube placement.
COMPARISON: CT from [**2201-6-26**].
BEDSIDE RADIOGRAPH OF CHEST, SUPINE: ET tube is terminating 5.8
cm above the carina. NG tube is extending into the stomach,
looped on itself with tip within the gastric fundus.
Tiny nodular right upper lobe opacity was better seen on the
recent study. Additionally, 1.7 x 2 cm spiculated right upper
lobe subpleural opacity only partially reflects the larger
subpleural lesion well visualized on the recent CT. There is
mild oligemia consistent with emphysema. There is no pleural
effusion or pneumothorax. Faint left mid lung opacity likely
reflects aspiration/infection. Heart size is normal. There is no
pulmonary edema. There is no pneumothorax.
IMPRESSION:
1. Right upper lobe spiculated nodular foci as described above
only partially visualized on the current study and were better
evaluated on the recent CT torso.
2. ET tube is terminating 5.8 cm above the carina.
3. Faint left mid lung opacity, likely infectious.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2201-6-26**] 6:07 AM
CHEST (PORTABLE AP)
Reason: s/p intubation. please check tube placement.
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with recent intubation
REASON FOR THIS EXAMINATION:
s/p intubation. please check tube placement.
INDICATION: 85-year-old man with recent intubation, evaluate for
tube placement.
COMPARISON: CT from [**2201-6-26**].
BEDSIDE RADIOGRAPH OF CHEST, SUPINE: ET tube is terminating 5.8
cm above the carina. NG tube is extending into the stomach,
looped on itself with tip within the gastric fundus.
Tiny nodular right upper lobe opacity was better seen on the
recent study. Additionally, 1.7 x 2 cm spiculated right upper
lobe subpleural opacity only partially reflects the larger
subpleural lesion well visualized on the recent CT. There is
mild oligemia consistent with emphysema. There is no pleural
effusion or pneumothorax. Faint left mid lung opacity likely
reflects aspiration/infection. Heart size is normal. There is no
pulmonary edema. There is no pneumothorax.
IMPRESSION:
1. Right upper lobe spiculated nodular foci as described above
only partially visualized on the current study and were better
evaluated on the recent CT torso.
2. ET tube is terminating 5.8 cm above the carina.
3. Faint left mid lung opacity, likely infectious.
Brief Hospital Course:
Pt was seen in the emergency room s/p fall for SAH and SDH over
tentorium. Pt admitted to the ICU. He was intubated for airway
protection in the ED for decreased sats to 85% and treated for
pneumonia. He was started on dilantin for sz prophylaxis. He
was supported in the ICU and his serial CT scans of the brain
had improved. CT of chest and pelvis showed: 1.0 cm right upper
lobe nodule, spiculated mass in the right upper lobe and nodular
thickening along chain sutures in the posterior superior left
lung concerning for carcinoma. A Destructive lytic lesion in the
right femoral greater trochanter and left iliac [**Doctor First Name 362**] concerning
for osseous metastases and a renal mass was also noted.
His mental status improved slightly over the course of his
stay. However his overall medical condition is very
deconditioned metastic cancer his family decided to make the pt
[**Name (NI) 3225**] after discussion with the pts PCP and Oncologist. On [**7-1**] a
morphine drip was started and sinamet via NG was continued. The
patient died on [**7-2**] at 1550 surrounded by his family.
Medications on Admission:
Medications prior to admission: Unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Subarachnoid hemorrhage
subdural hematoma
Respiratory Failure
Pneumonia
Lung cancer
Malignant melenoma
prostate cancer
colon cancer
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2201-7-2**]
|
[
"486",
"51881"
] |
Admission Date: [**2142-6-23**] Discharge Date: [**2142-6-27**]
Date of Birth: [**2084-3-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Dyspnea, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
58M w/ PMH of hx of lung CA (BAC) with liver mets on gemcitabine
who presents with 2 days of worsening cough productive of white
sputum, subjective low grade fevers, shortness of breath. The
history is provided via translation by the son. [**Name (NI) **] reports that
he told his father he needed to go the [**Name (NI) **] on [**2142-6-23**] and drove
him in to [**Hospital1 18**] after speaking with his oncologist. Pt has had
chest pain with coughing, non-exertional, non-pleuritic. No leg
swelling, chills. No recent hospitalizations. On further
questioning, patient does endorse history of wheezing with cold
air. Denies orthopnea or PND. Of note, according to OMR patient
was seen [**2142-6-5**] for chemo and was c/o cough and congestion. He
was noted to be wheezy, with good oxygen sat on RA, and was
ordered for bronchodilators.
.
In the ED, initial VS: 99.4 125 138/84 96% RA. He was triggered
for being tachy to 130s and tachypneic to 30s, hypoxic to low
90s on RA. Tight breath sounds with wheezes on exam. More cough
and rhonchi after nebs. Considered PE in differential but given
infiltrate decided no CTA. Labs notable for lactate 2.2, WBC 8.5
with 86%N, Hct 35 (baseline), phos 1.8, AP 389 (had been
increasing recently). PCXR showed RLL infiltrate c/f PNA. EKG
showed sinus tachycardia. Blood cultures drawn. He was given
cefepime, ipratropium neb x2, albuterol nebs x3, vancomycin 1
gram, 1.5L NS.
.
Pt was transferred directly to the MICU from the ED because of
worsening tachypnea and tachycardia. On arrival to the MICU, he
stated he was breathing a little bit better.
Past Medical History:
- metastatic lung cancer (pt not a smoker)
** See onc note form [**2141-11-7**] for entire oncology hx
- benign sigmoid polyps
- Hernia repair on [**2141-5-19**].
metastatic lung cancer (pt not a smoker)-history below
--[**6-1**] CXR that revealed a 4 x 4 cm right middle lobe nodule.
---[**7-1**] CT scan revealed a 4.5 x 4.8 cm right perihilar mass as
well as numerous confluent right upper lobe nodules and
subcarinal lymphadenopathy. There were tiny contralateral
nodules noted in the left lower lobe, none larger than 3 mm.
--[**7-1**] needle core biopsy of the right lung mass, which revealed
adenocarcinoma, moderately differentiated, consistent with
non-mucinous bronchoalveolar carcinoma. EGFR mutation status
unknown. He was started on Tarceva.
--[**2137**]-[**2139**] He did well on Tarceva. Subsequent scans in
[**Month (only) **] as well as [**2138-11-24**] revealed a marked
improvement in his disease. He was scanned serially
approximately every three months while on Tarceva with no
evidence of worsening disease until [**10/2140**]
--[**11-3**] CT scan right perihilar mass was again noted to be as
large as 4 x 4 cm. Also in [**10/2140**], he developed visual changes
in the right eye. He was subsequently noted to have a large
detachment of the macula with an oval choroidal lesion
underneath the superior temporal arcade in the right eye,
presumably due to metastatic disease.
--[**12-3**] He subsequently underwent radiation up to 20 Gy at [**Hospital 88830**] Infirmary and has done well with good control of the
lesion per outside hospital reports.
--[**2-/2141**] CT scan revealed persistent right perihilar lung mass
measuring 4.1 cm, multiple nodules in a right perihilar
distribution GGO RML, 8 mm nodule in the right hepatic lobe, a
1.5 cm nodule immediately adjacent in the right hepatic lobe in
a subcapsular location, as well as a stable hepatic cyst,
suspicious lymph node in the region of the gastrohepatic
ligament measuring 9 mm in short axis. He continued on Tarceva.
--[**2141-5-5**] worsening periumbilical pain. CT scan revealed
abnormal increased density in the inferior right hilum with a
small right pleural effusion, a round area of decreased
attenuation in the right lobe of the liver, which had the
appearance of a cyst, and three rounded areas of decreased
attenuation in the right lobe of the liver, which appeared to
have increased in size when compared to the CAT scan done on
[**2141-3-8**]. There were also small lesions in the left lobe of
the liver.
--[**2141-5-19**] by Dr. [**First Name4 (NamePattern1) 5877**] [**Last Name (NamePattern1) 19122**] for repair of an umbilical
hernia. Pathology revealed a metastatic well-to-moderately
differentiated adenocarcinoma in the hernia sac and contents
with strong positivity for CK-7 and TTF-1 and negative for
CK-20. The sample was sent for EGFR testing, which was
negative.
---[**2141-5-29**] ultrasounded-guided core biopsy of the liver
revealed a metastatic adenocarcinoma consistent with a lung
primary of a bronchoalveolar type. No EGFR mutation was
detected. insufficient tissue for ALK testing.
--[**2141-6-14**] PET CT: FDG avid right perihilar coalescent
pulmonary mass with satellite lesions and moderate pleural
effusion. Avid supraclavicular, mediastinal and retroperitoneal
adenopathy as detailed. Left adrenal and multiple (at least 5)
hepatic metastases. Extensive omental caking. Osseous
metastases involving C3 vertebral body, posterior left 10th rib,
proximal femurs, left iliac [**Doctor First Name 362**], and sacrum.
--[**2141-6-14**] MRI brain: Proliferation of intraconal fat in the
right orbit, with mild mass effect on the optic nerve, likely
representing a sequela of known radiotherapy to this site. No
suspicious parenchymal, meningeal or bone lesion to suggest
metastatic disease.
--[**2141-8-8**]: started 5 cycles of carboplatin/alimta
--[**2141-9-21**]: CT torso: Interval improvement in the size of the
right lung nodules; perihilar mass 2.1 x 1.8 cm previously 4.2 x
3.4. Stable appearance of liver, adrenal and omental metastatic
disease. Significant interval worsening of multiple sclerotic
bony lesions, mild interval worsening of moderate-to-large
hyperenhancing right pleural effusion.
--[**2141-11-7**] started alimta maintenance
--[**2142-1-19**] CT torso:
Interval worsening hepatic metastatic lesions with increase in
size and number of the metastatic deposits. Stable to slightly
decreased pulmonary disease. Decrease in omental masses. Stable
right pleural effusion. Stable osseous metastatic tumor.
--[**2142-5-16**] CT torso, no appreciable change in the diffuse
multiple bilateral small pulmonary nodules or right-sided
pleural effusion or mediastinal adenopathy. There has been an
increase in the size and number of hepatic metastasis, the
largest now to 44 mm from 31 and now there is a new lesion from
segment III.
There is diffuse omental thickening and stranding consistent
with metastatic disease, which is present on prior study, but
subjectively appears to have increased. Bone windows again
demonstrate metastatic disease with potentially a new 3 mm
sclerotic focus at T8 and possibly L4.
--[**2142-5-8**] started gemcitabine 1000 mg/m2. week 3 held for
thrombocytopenia.
- benign sigmoid polyps
- Hernia repair on [**2141-5-19**]
- h/o duodenitis
- h/o thrombocytopenia
Social History:
The patient is married with three children, ages18 to 36, all in
the US. The youngest child still lives with himand his wife.
Family is very supportive. The patient isSpanish-speaking only.
He comes to clinic with his nephew. [**Name (NI) 88831**] until recently
worked in a factory, which made radiators.The patient has never
smoked. The patient takes no alcohol. [**Name (NI) 88831**] denies
illicits.
Family History:
No family history of lung cancer or other malignancies.
Physical Exam:
INITIAL
VS: T 98.7 HR 111 BP 115/80 O2sat 94% on 1L RR 22
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, OP clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Fast but regular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Diffuse inspiratory and expiratory wheezes, no stridor,
poor air entry throughout, no rales or rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
VS: T 98.7 HR 111 BP 115/80 O2sat 94% on 1L RR 22
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, OP clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Fast but regular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Diffuse inspiratory and expiratory wheezes, no stridor,
poor air entry throughout, no rales or rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
Pertinent Results:
[**2142-6-27**] 07:50AM BLOOD WBC-10.9 RBC-3.46* Hgb-10.6* Hct-32.4*
MCV-94 MCH-30.8 MCHC-32.9 RDW-17.2* Plt Ct-130*
[**2142-6-24**] 03:33AM BLOOD Neuts-80.9* Lymphs-15.8* Monos-2.9
Eos-0.1 Baso-0.3
[**2142-6-23**] 12:15PM BLOOD Neuts-86.2* Lymphs-9.6* Monos-1.4*
Eos-2.2 Baso-0.5
[**2142-6-27**] 07:50AM BLOOD PT-13.7* PTT-28.3 INR(PT)-1.3*
[**2142-6-26**] 07:00AM BLOOD PT-12.9* PTT-27.1 INR(PT)-1.2*
[**2142-6-25**] 07:06PM BLOOD PT-13.2* PTT-28.0 INR(PT)-1.2*
[**2142-6-26**] 07:00AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
[**2142-6-25**] 07:05AM BLOOD Glucose-113* UreaN-11 Creat-0.8 Na-142
K-4.1 Cl-107 HCO3-28 AnGap-11
[**2142-6-25**] 07:05AM BLOOD ALT-26 AST-20 LD(LDH)-313* AlkPhos-298*
TotBili-0.5
[**2142-6-25**] 07:05AM BLOOD cTropnT-<0.01 proBNP-521*
[**2142-6-23**] 12:15PM BLOOD proBNP-787*
[**2142-6-25**] 07:05AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.2
[**2142-6-24**] 03:33AM BLOOD Albumin-3.5 Calcium-7.7* Phos-1.8* Mg-2.3
.
Chest CT:
1. Extensive bilateral pulmonary emboli as described.
2. Right upper opacity is mostly likely infectious with lower
lobe
atelectasis.
3. Right juxtahilar lesion and innumerable pulmonary metastases
are increased with accompanying increased moderate pleural
effusion.
4. Increased compression and possible invasion of left main
stem bronchus by increased subcarinal soft tissue.
Head CT [**6-24**]:
1. Limited evaluation for hemorrhage given recent IV contrast
bolus through prior study. No definite acute hemorrhage.
2. No definite mass lesion to suggest intracranial metastatic
disease. If there is ongoing clinical concern, MRI of the brain
is recommended for
increased sensitivity for detection.
NOTE ADDED AT ATTENDING REVIEW: There are two tiny cortical
foci, one left frontal, one right parietal (series 2 image 22
and series 2 image 23), that are hyperdense and appear cortical.
There is no associated edema. It is possible these are normal
vessels on end, but in the setting of metastatic disease, the
possibility of metastases should be considered. Since contrast
was given for a Chest CTA, the high density may reflect contrast
enhancement, rather than hemorrhage or calcifictation. These
findings would be best pursued with an MR examination including
contrast.
Radiology Report BILAT LOWER EXT VEINS [**2142-6-26**]
IMPRESSION: Bilateral femoral vein deep venous thrombosis,
partially
occlusive.
MR HEAD [**2142-6-26**]
IMPRESSION: 1. Punctate focus of abnormal enhancement noted on
the right cerebellar hemisphere and two small ring-enhancing
lesions in the left cerebellar hemisphere, with no significant
mass effect or edema.
2. Supratentorially, there are two small foci of abnormal
enhancement in the left and right frontal lobes, with no
evidence of mass effect or edema, these lesions are highly
suspicious for metastatic disease.
IMPRESSION: AP chest compared to [**6-23**] and [**6-24**]:
[**2142-6-24**] CXR
Previous mild pulmonary edema has improved, most evident in the
left lung.
Small right pleural effusion is larger. Opacification at the
base of the
right lung could be the residual of edema and atelectasis, but
there is a
heterogeneous quality to it that raises concern for pneumonia.
Heart size is normal. This is confirmed in the right upper lobe
on the chest CTA performed
nearly concurrently. The small lung nodules seen on that study
are barely visible on this conventional bedside radiograph.
.
Discharge labs:
[**2142-6-27**] 07:50AM BLOOD WBC-10.9 RBC-3.46* Hgb-10.6* Hct-32.4*
MCV-94 MCH-30.8 MCHC-32.9 RDW-17.2* Plt Ct-130*
[**2142-6-26**] 07:00AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
Brief Hospital Course:
In summary this is a 58 male with metastatic NSCLC who presented
with cough, fevers, and dyspnea and found to have evidence of
multiple central PEs confirmed by CTA on [**2142-6-24**], as well as DVT
and endobronchial lesion, requiring stenting by IP.
.
# Pulmonary emboli: Was Confirmed on CTA. Pt was started on
Heparin and then bridged to Lovenox. LE Ultrasound revealed
bilateral DVTs. Troponin was negative and BNP were negative.
EKG did not show strain. Pt continued to be very wheezy on
exam, not moving air well which implied element of bronchospasm
also contributing to his respiratory symptoms. He was discharged
on long term lovenox given his malignancy. He will have an IVC
filter placed as below - given his need for endobronchial stent
next week.
.
#Possible Pneumonia: pt received broad spectrum antibiotics for
HCAP and was later switched to Levofloxacin when his pneumonia
was no longer concerning for HCAP. He did meet SIRS criteria
with tachypnea and tachycardia but had no evidence of septic
shock.
.
# Lung cancer with obstructive endobronchial lesion: pt has
broncheoalveolar carcinoma, known metastatic disease, and
currently is receiving gemcitabine. Head CT and Brain MRI
revealed metastatic diesease. Pt had elevated alk phos which was
likely from bony metastases. Mr [**Known lastname 34030**] will also follow up with
interventional pulmonary next week, and as he has an
endobronchial lesion that will require treatment to avoid lung
collapse.
.
# Anemia: Patient's hematocrit was stable and did not trend
downward. Hct had been steadily decreasing over the past month
(i.e. Hct on [**2142-5-29**] was 40 and today [**2142-6-27**] is 32). Likely
related to malignancy and/or Fe deficiency.
.
# Code: Confirmed Full code
Follow up plans:
Mr. [**Known lastname 34030**] will follow up next week for IVC filter placement
and endobronchial lesion stenting with interventional pulmonary.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Ondansetron 8 mg PO TID:PRN nausea
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
4. Benzonatate 100 mg PO TID:PRN cough
5. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
6. Ferrous Gluconate 325 mg PO DAILY
7. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
Hold for sedation, RR<10
8. albuterol sulfate *NF* 90 mcg/actuation Inhalation Q6H:PRN
SOB
2 puffs
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 80mg twice a day Disp #*60 Syringe
Refills:*0
2. Benzonatate 100 mg PO TID:PRN cough
3. Ferrous Gluconate 325 mg PO DAILY
4. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
5. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
Hold for sedation, RR<10
6. Levofloxacin 750 mg PO DAILY Duration: 4 Doses
7. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
8. PredniSONE 40 mg PO DAILY Duration: 1 Days
9. albuterol sulfate *NF* 90 mcg/actuation Inhalation Q6H:PRN
SOB
2 puffs
10. Ondansetron 8 mg PO TID:PRN nausea
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Emboli
Deep venous thrombosis
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 34030**],
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted because of fevers and increased shortness of breath.
During your hospital stay it was discovered that you had blood
clots in your lungs. Therefore you were started on medicine
(Lovenox) to help so the clots would not grow any larger. You
will need to follow the instructions you received from the nurse
and inject this medicine after going home. You will need to
follow up with the Interventional Pulmonary Service for possible
stenting of a possible blockage in the lung airways. They will
give you a call at home for a followup visit. If you do not hear
from the, please call Phone: [**Telephone/Fax (1) 3020**] to book an appointment
with the Lung (Pulmonary) doctors.
Please also follow up with your oncologist Dr. [**Last Name (STitle) **].
Details are mentioned below on your followup appointments.
Followup Instructions:
You will need to follow up with the [**Hospital1 18**] Interventional
Pulmonary Service for possible stenting of one of the closing
airways in your lungs. They will give you a call at home for a
followup visit.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2142-7-10**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], RN [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2142-7-17**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2142-7-17**] at 9:00 AM
With: DR. [**First Name8 (NamePattern2) 610**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"486",
"2875"
] |
Admission Date: [**2110-5-30**] Discharge Date: [**2110-6-18**]
Date of Birth: [**2047-3-20**] Sex: M
Service: LIVER TRANSPLANT SURGERY
CHIEF COMPLAINT: Sepsis, hepatic failure.
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old
male with a history of alcoholic cirrhosis, status post
orthotopic liver transplantation 15 years ago, who presents
with a 3-day history of epigastric pain. Positive fevers,
positive nausea, positive nonbilious vomiting. No diarrhea.
No upper respiratory infection type symptoms.
In the emergency department he had hypotension with a
systolic in the 50s and treated with IV fluids, a total of 9
liters of crystalloid. The patient went into respiratory
distress and was intubated. An ultrasound of his liver showed
dilated ducts and anastomotic stricture. An abdominal CT scan
at that time was obtained and showed a left lower lobe
consolidation with air bronchograms, mild right basilar
consolidation which could possibly represent aspiration
versus pneumonia versus atelectasis, a biliary ductal
dilatation, and small amounts of biliary air and central high
attenuation foci which could represent stones or sludge. As
seen on the prior ultrasound rounded right lateral hepatic
focus with low attenuation with air which could possibly
represent abscess, although evaluation was slightly limited
due to lack of IV contrast. There was stranding around both
kidneys.
PAST MEDICAL HISTORY: Significant for alcoholic cirrhosis,
status post orthotopic liver transplantation 15 years ago,
septic right knee, BCC of right cheek, hypertension.
ALLERGIES: NKDA.
MEDICATIONS ON ADMISSION: Lasix 40 daily, Neoral, ursodiol,
nifedipine XL 30 daily. At the [**Hospital1 **] he was
placed on Levophed, propofol, fentanyl drip, Protonix,
Versed, and vancomycin.
PHYSICAL EXAMINATION ON ADMISSION: Showed a fever of 101.8,
with a heart rate of 126, blood pressure of 102/58,
respiratory rate of 25, saturating 97% on assist control 700
x 25 with a PEEP of 10, and a gas of 7.23/50/95/22 and -6. He
was intubated and sedated, obese. PERRLA. No JVD. A regular
rate and rhythm without murmurs, rubs, or gallops. Positive
tachycardia. Lungs with occasional coarse breath sounds
bilaterally. The abdomen was obese, distended, positive bowel
sounds, soft. No peripheral clubbing, cyanosis, or edema.
LABORATORY VALUES ON ADMISSION: Showed a white count of 8.4,
hematocrit of 30.6, and platelets of 113 (with 71
neutrophils). Sodium of 145, potassium of 3.3, chloride of
117, bicarbonate of 13, BUN of 55, creatinine of 0.5, and
glucose of 101. ALT was 210, AST was 86, alkaline phosphatase
was 212, amylase was 16, lipase was 21, LD was 142, and
albumin was 2.4, ________lactate was 3.2.
HOSPITAL COURSE: In summary, the patient is a 63-year-old
male with alcoholic cirrhosis, status post orthotopic liver
transplantation 15 years ago, who is now in hepatic failure
with sepsis. Neurologically, he was sedated with fentanyl and
Versed. Cardiovascular: septic shock, on Levophed, and would
get his goal MAP greater than 65. Respiratory wise, he was on
assist control follow up. GI: n.p.o., NG tube, follow-up
abdominal CT. FEN: Normal saline at 100 cc an hour________
tight blood glucose control. Renal: Acute renal failure. ID:
Vancomycin and Zosyn. Hematology: Coagulopathy with p.r.n.
prophylaxis with Protonix.
The patient, on hospital day 2, continued to be maintained in
the SICU and was positive 3 liters the first day with falling
LFTs. On [**5-20**], blood cultures showed gram-negative rods,
and chest x-ray showed retrocardiac opacity with lower
opacity in the left lung. He was afebrile, and his vitals
were stable, and he was discussed with the________ team for
biliary drainage procedure.
On hospital day 2, the patient's ________ procedure was
moved due to instability of patient's transition and
tentatively scheduled for [**2110-6-2**]. The patient was
maintained on vancomycin and Zosyn. The patient ________
stopped by hospital day 4, multiple ventilator adjustments
were made with vast improvement. In addition, an insulin Gtt
was started. Antibiotics were continued. The patient was
tried to wean/extubate on [**2110-6-3**]. The gas 7.41/29/92/19
and -4.
On hospital day 6, the patient was continued on antibiotics
and lines were changed. White count was up to 21.3, and lines
were changed on hospital day 6. The percutaneous
cholangiogram that was done 2 days prior showed severe
________extrahepatic ductal dilatation, multiple filling
defects, and a communication between the right and left
hepatic ducts, and occlusion of the biliary jejunal
anastomosis, recanalization of balloon with dilatation of
biliary-enteric anastomosis with a 10-mm diameter balloon,
placement of right internal and external 8 French ________
catheter with external drainage bag was placed. The patient
was awake, white count came down by 5:25, and on [**6-7**] the
patient was transferred to the floor.
The patient was transferred to the floor on [**6-7**] and was to
undergo biopsy that Tuesday. The PTC tubes were draining well
at 17:13. Found to have probably/most likely cholangitis
only. Antibiotics were continued on the 30th. On the 31st, a
repeat cholangiogram was done, and many stones were seen in
the left duct with 1 large 3-mm stone. Cholangiogram on [**Month (only) **]
________. IV fluids were hep-locked on [**6-14**], and PTCs were
unclamped. Patient numbers continued to decline, and biliary
washout scheduled for the 5th was bumped to the next day, and
by hospital day 18, the patient was afebrile. Cholangiograms
had shown ________ left duct without retrieval of the 3-mm
stone, and the patient was to be discharged from the hospital
and return for outpatient stone removal with lithotripsy by
Dr. [**First Name (STitle) **]. On discharge, the patient was doing well.
DISCHARGE INSTRUCTIONS: He was instructed to call for any
fevers greater than 101.4 or if he had any concerns; and also
to follow up not only with Dr. [**Last Name (STitle) **] in clinic but also with
Dr. [**First Name (STitle) **] for procedure to be done. The patient was instructed
to follow up with the transplant service and to call ([**Telephone/Fax (1) 93597**], follow-up lithotripsy for removal of gallstone;
provider [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. The patient was instructed to follow up as
appropriately mentioned.
MEDICATIONS ON DISCHARGE: The patient was discharged on
Tylenol 650 suppository 1 to 2 suppositories per rectum
q.6h.; Protonix 40-mg tablets 1 tablet delayed release;
Percocet; ursodiol; Neoral 100 mg p.o. b.i.d.; and
levofloxacin.
DISCHARGE STATUS: The patient was discharged in good
condition without event with biliary drainage catheter in
place.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Doctor Last Name 9174**]
MEDQUIST36
D: [**2110-6-19**] 14:09:07
T: [**2110-6-20**] 13:50:34
Job#: [**Job Number 93598**]
cc:[**First Name (STitle) 93599**]
|
[
"78552",
"51881",
"5849",
"99592",
"4019"
] |
Admission Date: [**2148-4-8**] Discharge Date: [**2148-4-8**]
Date of Birth: [**2070-10-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hypoxia, s/p PEA arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 male nursing home resident, 2 admissions in past month, sent
to the ED from his NH with hypoxia and worsening L sided PNA.
He was found to have an O2 sat in the 70's while receiving 100%
oxygen by non-rebreather face mask. He had some ectopy for
which he received 75 mg of amiodraone. He was intubated and his
oxygen saturations remained low in the 60's, with PAO2 in the
40's on vent settings of AC 500 x 15, 10 peep. His CXR showed
worsened PNA with white out of the L lung and his labs returned
with + UTI and elevated lactate. He was started on Vanc and
Zosyn. He had a PEA arrest in the ED requiring CPR and an amp
of epinephrine. A spontaneous pulse returned. His blood
pressure was opiginally in the 90's, which is his [**Last Name (NamePattern1) 5348**], and
then improved to the low 100's after the epinephrine. His heart
rate was in the 120's. He was transferred to the MICU for
further care.
.
On arrival to the floor patient was persistantly hypoxic and was
noted to go in and out of V tach. His legal guardian was called
and was not available. His PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**] was called
and it was established that the patient has recently had a legal
guardian appointed but that the legal guardian had not yet met
the patient. Per the PCP, [**Name10 (NameIs) **] was a plan in motion to go to
court to obtain a DNR/DNI order later this month. The patient
remained hypoxic and bradycardiac despite vent changes and
positioning manuvers. He received 4 mg and then 2 mg of
morphine to treat his respiratory distress. It was determined
that CPR was not indicated and the patient again had a PEA
arrest. He became asystolic and was pronounced dead at 12:55
PM. The medical examiner was called and they declined the case.
Past Medical History:
Recent hospitalization for hypoxia, hypotension of unknown
etiology
TIA in [**3-5**]
Schizophrenia, per PCP, [**Name Initial (NameIs) 5348**] AAOx1, verbally abusive
Depression
HTN
Dementia
R eye cataract
CAD, s/p CABG
Social History:
Nursing Home patient. Legal Guardian is [**Name (NI) 3608**] [**Name (NI) 4334**]. Patient
has a new guardian
Family History:
Non-contributory
Brief Hospital Course:
See HPI
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Urinary Tract Infection
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"5070",
"51881",
"42789",
"4019",
"V4581",
"311"
] |
Admission Date: [**2103-8-27**] Discharge Date: [**2103-9-10**]
Date of Birth: [**2042-11-25**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Niacin
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Transfer from outside hospital for hepatic abscess
Major Surgical or Invasive Procedure:
[**2103-8-26**] drain placement in hepatic abscess
[**2103-9-5**] CT guided drainage with upsizing of hepatic drain
[**2103-9-10**] picc line insertion
History of Present Illness:
Patient is a 60 year old male with rather insignificant PMH who
has developed some vague discomfort, feeling of overall
weakness, some abdominal discomfort and changes in bowel
patterns during approximately last week of [**Month (only) **]. He
presented to the [**Hospital 1727**] [**Hospital3 **] on [**2103-8-24**] where
abdominal CT scan was
obtained and found a multi loculated collection in the liver.
Patient was transferred to the [**Hospital6 43614**] Center on
[**2103-8-25**] for further management. His LFTs were elevated as was
his WBC. Initially, the thought was to drain the collection by
IR, however, radiology felt that it was no feasible. Overnight,
patient developed a septic picture with fevers to 103F,
hypotension and tachycardia. He was resuscitated with 5 liters
of fluids overnight and was taken to the operating room the
morning of [**8-26**] with the intention to drain the abscess. The
abscess was not clearly identified during the operation. Patient
lost 1200 cc of blood. His HCT dropped from 40 pre-op to 31
post-op. He became
hemodynamically unstable and was started on pressors. He was
reintubated shortly after the surgery for an uncertain reason.
Past Medical History:
PMH: hyperlipidemia, hepatitis A in [**2072**]. Hepatic abscess:
E.coli/Strep Anginosis
PSH: right Achilles tendon rupture repair, [**2103-8-26**] ex lap for
hepatic abscess
Social History:
He is married and works for CMP. He lives in [**State 1727**] and has
three children. He does not smoke and drinks rarely.
Family History:
His mother died of liver ca at age 78. His father has prostate
cancer, No history of colon cancer. He has a sister with CAD
in her 50s and a brother who is healthy.
Pertinent Results:
[**2103-8-29**] 12:00AM BLOOD WBC-25.4*# RBC-3.35* Hgb-10.6* Hct-31.1*
MCV-93 MCH-31.7 MCHC-34.1 RDW-14.6 Plt Ct-112*#
[**2103-9-9**] 05:50AM BLOOD WBC-5.9 RBC-3.05* Hgb-9.5* Hct-29.1*
MCV-95 MCH-31.2 MCHC-32.8 RDW-15.8* Plt Ct-553*
[**2103-9-6**] 04:20AM BLOOD PT-16.1* PTT-31.2 INR(PT)-1.4*
[**2103-9-7**] 04:35AM BLOOD Glucose-118* UreaN-18 Creat-0.8 Na-137
K-4.4 Cl-104 HCO3-27 AnGap-10
[**2103-8-27**] 12:50AM BLOOD ALT-451* AST-1849* LD(LDH)-1734*
AlkPhos-90 Amylase-106* TotBili-4.3* DirBili-3.8* IndBili-0.5
[**2103-9-9**] 05:50AM BLOOD ALT-28 AST-30 AlkPhos-95 TotBili-1.0
[**2103-9-4**] 06:40AM BLOOD Albumin-2.3* Calcium-7.4* Phos-2.6*
Mg-2.1
[**2103-8-27**] 04:43AM BLOOD CEA-1.5 AFP-<1.0
[**2103-9-8**] 07:15AM BLOOD CRP-43.9*
[**2103-8-27**] 02:40AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2103-8-27**] 04:43AM BLOOD CA [**11**]-9: 8
[**2103-8-27**] 02:40AM BLOOD HEPATITIS E ANTIBODY (IGM)-Test not
detected
Brief Hospital Course:
He was transferred to [**Hospital1 18**] SICU under the Acute Care Surgery
service on [**8-26**], intubated and on pressor support. He underwent
IR guided drainage of 25cc purulent/hemorrhagic fluid from the
abscess on [**2103-8-27**] and a drain was left in place. Subsequent CT
demonstrated a right posterior fluid collection that was
increased in size from previous CT. Gram stain on the JP fluid
culture initially showed 4+ GPC in pairs, chains and clusters.
He was started on vanco/cipro/flagyl.
The hepatobiliary service was consulted for assistance in
management and he was transferred to the West 1 service under
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He remained in the SICU as he was initially
hemodynamically labile. He became hypertensive after the IR
drainage. IV Lopressor was given as well as Versed gtt. Later on
[**2103-8-27**] he became hypotensive, was restarted on pressors and
bolused 3L IVF before a stress dose of hydrocortisone for
secondary to hypotension from sepsis.
An ID consult was obtained after the patient's liver mass was
proven to be an abscess. He was initially treated with
vancomycin, ciprofloxacin and Flagyl. The Cipro was d/c'ed and
replaced with cefepime on [**2103-8-27**]. The abscess culture on [**8-27**]
isolated Strep anginosus and E. coli which were pan sensitive.
On [**8-31**], a right basilic PICC line was placed. Vanco was stopped
on [**8-31**]. Cefepime was switched to Ceftriaxone on [**9-1**]. WBC
decreased daily from admission wbc of 25 to 5.9 on [**9-9**]. LFTS
decreased significantly from admission. He had low grade temps
up to 100.3 on [**9-5**] and [**9-6**].
On [**9-5**], CT of the abdomen/pelvis was done to re-assess the
hepatic abscess and this demonstrated little change in size or
appearance of right hepatic
abscess containing multiple septations, dense material and foci
of gas, but with apparent increase in fluid component. Pigtail
drainage catheter was retracted but with pigtail loop still
within the abscess cavity. The JP drain remained in place along
the right hepatic margin averaging 50-80cc output per day. There
was slight decrease in moderate right and small left pleural
effusions, with associated adjacent relaxation atelectasis.
There were two arterially enhancing foci in segment VI of liver.
Colonic diverticulosis was noted.
Repeat blood cultures remained negative until [**9-6**] when blood
cultures isolated streptococcus anginosus (Milleri) group. The
PICC was removed. On [**9-6**], he also had CT-guided exchange of
the drainage catheter with up sizing to a 10 French catheter in
a larger deeper pocket of the collection. 10 cc were sent to
microbiology. This fluid subsequently showed 4+ PMN and 1+ GPCs.
The JP was removed on [**9-9**].
A left basilic Vaxcel picc line was placed on [**9-10**] with tip in
lower SVC. Of note, he had h/o bilateral cephalic DVTs and a R
Basilic DVT. He was set up with VNA for home IV Ceftriaxone and
po flagyl to continue for a total of 6 weeks. He was to f/u with
ID and Dr. [**Last Name (STitle) **] in 2 weeks with a f/u ABD CT.
Vital signs were stable. He had required brief treatment with
tube feeds due to poor po kcal intake. A post pyloric feeding
tube was inserted on [**8-31**], but this was removed a few days prior
to discharge home as po intake improved and caloric intake was
appropriate.
He was initially very weak, but PT worked with him and declared
him safe for discharge without PT services. He was ambulating
independently at time of discharge.
Abdomen was non-distended and only slightly tender in RUQ. He
received iv Dilaudid initially, but this was not necessary
around the time of discharge. He was also taught how to flush
the pigtail with normal saline 5ml [**Hospital1 **]. Pigtail output averaged
18ml/day by day of discharge.
Medications on Admission:
Crestor 10 mg once daily
Discharge Medications:
1. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 weeks.
Disp:*84 Tablet(s)* Refills:*0*
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day) for 5 weeks.
Disp:*102 Tablet(s)* Refills:*1*
3. amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
5. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) Intravenous Q24H (every 24 hours) for 5 weeks: until
[**10-13**].
Disp:*33 doses* Refills:*0*
6. Saline Flush 0.9 % Syringe Sig: Five (5) ml Injection twice a
day: flush hepatic drain .
Disp:*50 * Refills:*1*
7. Outpatient Lab Work
Weekly labs cbc, chem 10, ast, alt, alk phos, t.bili
fax to [**Telephone/Fax (1) 22248**] attn: [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] RN coordinator and
[**Telephone/Fax (1) 1419**] attn: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**]
Discharge Disposition:
Home With Service
Facility:
Androscoggin VNA
Discharge Diagnosis:
Hepatic abscesses: strep anginosus, Ecoli
bacteremic: strep anginosis
Bilateral cephalic dvts, dvt right basilic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 48857**] if you have any of
the warning signs listed:
fever (101 or greater),chills, nausea, vomiting, jaundice,
increased abdominal pain/distention, increased drain output or
no drain output, picc line malfunction, redness or drainage at
drain site
Empty drain and record all outputs. Bring record of drain
outputs to next appointment
You will continue on antibiotics
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2103-9-24**]
10:10
Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2103-10-15**] 11:00
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2103-9-27**] 2:50
Completed by:[**2103-9-11**]
|
[
"5119",
"2724",
"4019"
] |
Admission Date: [**2167-3-13**] Discharge Date: [**2167-3-18**]
Date of Birth: [**2167-3-13**] Sex: M
Service: NEONATOLOGY/[**Location (un) **] NEWBORN SERVICE
36 weeks gestation by cesarean birth for worsening pregnancy
induced hypertension and a breech/breech presentation of both
infants. The mother is a 37-year-old para 1, now 3 woman
whose prenatal screens included blood type A+, antibody negative,
rubella immune, RPR nonreactive, hepatitis surface antigen
Apgars were 8 at 1 minute and 8 at 5 minutes.
The birth weight was 2,450 gm, 40th percentile for
gestational age. Birth length was 46.5 cm, 50th percentile
for gestational age and the head circumference was 33.5 cm in
the 70th percentile for gestational age.
HOSPITAL COURSE BY SYSTEMS:
continuous positive airway pressure for approximately five
hours, but he weaned to nasal cannula oxygen. He weaned to
room air on day of life #2 and he has remained there. His
clinical course was consistent with retained fetal lung
fluid. On exam, his respirations are comfortable. Lung
sounds are clear and equal.
2. CARDIOVASCULAR STATUS: He has remained normotensive
throughout his Neonatal Intensive Care Unit stay. He has a
normal S1, S2 heart sounds, no murmur. He is pink and well
perfused.
3. FLUIDS, ELECTROLYTES AND NUTRITION STATUS: Enteral feeds
were started on day of life #1 and he advanced without
difficulty to full volume feedings with a 24 hour period of
taking Enfamil 20 on an ad lib schedule. Mother has made
some attempts at breast feeding and pumping in addition to
formula feeding; she has been seen daily by the Lactation
Service. The baby remained euglycemic throughout his Neonatal
Intensive Care Unit stay. He has begun regaining weight prior to
discharge.
4. GASTROINTESTINAL STATUS: His bilirubin on day of life #3
was total bilirubin 9.8, direct 0.3. By discharge on day of life
#5 he appeared visibly less jaundiced.
5. HEMATOLOGICAL STATUS: His hematocrit at the time of
admission was 48.5. His platelets were 316,000. He has
never received any blood products.
6. INFECTIOUS DISEASE STATUS: A blood culture was sent at
the time of admission. He never required antibiotics and the
blood culture remained negative. At the time of admission,
his white count was 16.1 with differential of 37% polys and 0
bands.
7. SENSORY STATUS: A hearing screen was performed for
automated auditory brain stem responses and the infant passed
in both ears.
8. PSYCHOSOCIAL: Both mothers are very involved in the
infant's care.
The infant was transferred to the Newborn Nursery for continuing
care on [**2167-3-16**] and discharged home on [**2167-3-18**].
DISCHARGE CONDITION: Good.
Primary pediatric care will be provided by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 40637**] of
[**Hospital 1411**] Medical Associates. Address: [**Location (un) 40641**], [**Location (un) 1411**],
[**Numeric Identifier 9311**]. Telephone number: [**Telephone/Fax (1) 8506**]. She has been updated
during the hospital stay and prior to discharge.
CARE AND RECOMMENDATIONS: Continue feedings on an ad lib
schedule, Enfamil 20 and breast feeding. Follow up with Dr [**First Name4 (NamePattern1) 40637**]
[**Last Name (NamePattern1) 2974**] [**2167-3-20**]. Follow up with lactation service at [**Hospital1 18**] or
with LC at [**Hospital 1411**] Medical.
The infant is being discharged on no medications.
A state newborn screen was sent on [**2167-3-16**]. He has received his
hepatitis B vaccination and has passed hearing screening in both
ears. He has also passed car seat testing.
DISCHARGE DIAGNOSES:
1. Prematurity 36 weeks gestation
2. Twin #2
3. Status post transitional respiratory distress
4. Sepsis ruled out
5. Physiological jaundice
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 36532**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2167-3-17**] 06:48
T: [**2167-3-17**] 07:26
JOB#: [**Job Number 40642**]
|
[
"V053",
"V290"
] |
Admission Date: [**2161-4-25**] Discharge Date: [**2161-5-18**]
Date of Birth: [**2087-2-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Hypoxemic respiratory distress
Major Surgical or Invasive Procedure:
Endotracheal intubation
CVL placement
Flexible bronchoscopy
History of Present Illness:
Mr. [**Known lastname **] is a 74 year old gentleman with a past medical history
significant for COPD, colon CA s/p resection, AF with RVR, and a
recent admission for hypoxemic respiratory distress who presents
with fever, dyspnea, and non-productive cough now transferred to
the MICU for hypoxemic respiratory distress. The pateint reports
a 1 day history of fever to 102, non-productive cough, and
progressively worsening dyspnea for which he presented via EMS
to an OSH ED. At that time, per report, he had an SaO2 of 33%RA
improved to 75% NRB. At the OSH ED, he was placed on NIPPV with
improvement in symptoms. He had a CXR that demonstrated diffuse
bilateral infiltrates, and he received vancomycin and pip/tazo.
He was then transferred to the [**Hospital1 18**] ED at the request of his
family.
.
Of note, the patient was admitted to [**Hospital1 18**] from [**Date range (1) 30835**] for
hypoxemic respiratory distress. At that time, symptoms were felt
to be due to CHF and pneumonia, and the patient was diuresed
aggressively and treated with vancomycin and cefepime with
hospital course complicated by hemoptysis with MTB ruled out
with 3 negative induced sputums and AF with RVR.
.
On arrival to the [**Hospital1 18**] ED, initial VS 100.3 76 90/56 20 95%NRB.
Labs were notable for a leukocytosis to 17.1 with a neutrophil
predominance and INR >4, and the patient was then admitted to
the MICU for further management.
.
Currently, the patient states that his dyspnea is improved from
earlier today. Denies any CP, n/v/d, abd pain, palpitations.
Past Medical History:
1. Colon cancer stage II (T3N0M0), status post right
hemicolectomy in [**2152**].
2. History of TB treated in [**Location (un) 6847**] - apparently 2 years on
antibiotics and a few more months for prophylaxis.
3. Cryptogenic organizing pneumonia in [**2154**] discovered by VATS
biopsy.
4. Hypertension.
5. Cataracts status post bilateral surgery.
6. Eczema.
7. Atrial fibrillation: s/p DCCV [**2161-2-3**]
8. CHF: LVEF [**12-10**] 50%
9. DM 2
Social History:
Mr. [**Known lastname **] lives in [**Hospital1 392**] and he came from [**Location (un) 6847**] about 10
years ago. He lives with his wife. [**Name (NI) **] used to be a truck
drive. He continues to use alcohol occasionally. He is a former
tobacco user, smoked 1 pack per day for approximately 40 years
and he quit in [**2141**]. He denies exposure to asbestos and denies
any exposure to any animals or birds.
Family History:
His family history is notable for mother who had hypertension,
father who died of unknown cause, brother who died of head
trauma, and an older brother who is a smoker who has lung
cancer. He does have a daughter with breast cancer.
Physical Exam:
ADMISSION
VS: 97 69 101/57 24 95%NRB
Gen: NRB in place, no accessory muscle use.
HEENT: MMM, OP clear.
CV: Regular S1+S2, JVP flat.
Pulm: Diffuse fine crackles loudest at the bases bilaterally
extending 2/3 up lung fields.
Abd: S/NT/ND +bs
Ext: No c/c/e. Signs of chronic stasis dermatitis.
Neuro: AOx3, CN II-XII grossly intact.
.
DISCHARGE:
General Appearance: Well nourished, No acute distress, Trach in
place, Sitting in chair
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Poor dentition, NG tube
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : throughout with exception of wheeze, Wheezes :
occasional)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Warm
Pertinent Results:
Labs on Discharge:
Trop-T: <0.01 x 2
137 / 109 / 32 / 131 AGap=12
-------------
4.0 / 20 /1.5
Ca: 7.7 Mg: 2.1 P: 3.2
ALT: 14 AP: 83 Tbili: 1.3 Alb:
AST: 30 LDH: 478 Dbili:
proBNP: 1612
\ 95 /
17.1 ∆ 12.3 171
/ 35.4 \
N:82.5 L:12.4 M:4.0 E:0.8 Bas:0.3
PT: 44.7 PTT: 40.0 INR: 4.7
Triglyc: 137
Comments: Triglyc: Ldl(Calc) Invalid If Trig>400 Or Non-Fasting
Sample
HDL: 36
CHOL/HD: 4.1
LDLcalc: 83
Imaging:
CT chest [**5-6**]
Marked interval improvement of generalized infiltrative
pulmonary abnormality, seen also in fluctuation over the course
of this admission on chest radiography, suggesting that the
changes are in large part due to the status of pulmonary edema.
Persistent bilateral lower lobe interstitial thickening on a
background of moderately severe emphysema is not typical of
cryptogenic organizing pneumonia, etiologies such as viral
pneumonia and drug toxicity are considered more likely.
.
US [**5-9**]
1. Abnormal gallbladder, with distention, wall thickening, and
copious sludge concerning for acalculous cholecystitis.
2. Numerous echogenic foci with ring-down artifact in the
gallbladder wall, compatible with adenomyomatosis.
3. Mid aortic aneurysm measuring up to 3.9 cm, minimally
enlarged from prior CT.
BAL path: Alveolar macrophages, abundant acute infalmmation.
Negative for malignant cells.
.
Sputum
[**2161-5-1**] 12:08 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2161-5-7**]**
GRAM STAIN (Final [**2161-5-1**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2161-5-6**]):
SPARSE GROWTH Commensal Respiratory Flora.
DR. [**First Name (STitle) 13258**], S ([**Numeric Identifier 13259**]) REQUESTED FOR WORK UP ON [**2161-5-4**].
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
[**2161-5-10**] 11:18 am BILE
**FINAL REPORT [**2161-5-16**]**
GRAM STAIN (Final [**2161-5-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2161-5-13**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2161-5-16**]): NO GROWTH.
[**2161-5-14**] 2:51 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2161-5-17**]**
GRAM STAIN (Final [**2161-5-14**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2161-5-17**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
CXR: Diffuse patchy bilateral infiltrates
.
ECG: Sinus with 1:1 conduction. Borderline LAD.
.
PFTs ([**2-10**]): FEV1/FVC 74. FEV1 92%.
.
TTE ([**2160-12-29**]): LVEF 50%. TRG 26-28. Global systolic function.
Mild-moderate mitral regurgitation. Dilated ascending aorta.
.
CT Chest ([**2161-3-30**]):
1. Mediastinal lymphadenopathy has decreased in size since the
most recent study and is likely hyperplastic/reactive.
2. Resolution of bilateral effusions. Improvement in multifocal
lung opacities.
3. Extensive atherosclerotic disease of the thoracic aorta.
Focal aneurysmal dilatation of the abdominal aorta at the level
of the renal arteries, but incompletely imaged. Coronary artery
disease.
4. Nodular opacities in the right upper and lower lobes, which
could be reassessed at follow up CT in 6 months if warranted
clinically.
5. Decreased hilar and mediastinal adenopathy.
.
CTA Chest ([**2160-12-27**]):
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Moderate bilateral pleural effusions with atelectasis.
3. Diffuse multifocal bilateral ground-glass opacity, and focal
consolidation in the right lower lobe might represent COP,
however superimposed pneumonia cannot be excluded.
4. New moderate mediastinal lymphadenopathy.
Many of the opacities have a close resemblance to an earlier
episode of pulmonary disease shown to represent cryptogenic
organizing pneumonia. However, lymphadenopathy, airway
thickening and pleural effusions are new. In particular, a
relatively hypodense opacity in the right lower lobe appears
somewhat different than the more widespread interstitial
abnormality. These features may indicate that there is
bronchopneumonia in addition to a suspected recurrence of
organizing pneumonia. Given the history of malignancy, it may be
prudent to perform a CT follow-up primarily for the
lymphadenopathy, although probably reactive.
.
LUNG BIOPSY ([**2154**]): organizing pneumonitis with features of
bronchiolitis obliterans organizing pneumonia in the right upper
lobe and in the right lower lobe.
Brief Hospital Course:
Mr. [**Known lastname **] is a 74 year old gentleman with a past medical history
significant for cryptogenic organizing pneumonia, colon CA s/p
resection, atrial fibrillation with RVR, and a recent admission
for hypoxemic respiratory distress who presented with fever,
dyspnea, and productive cough intubated for hypoxemic
respiratory failure. He failed extubation initially due to poor
cough, mucus plug and hypoxemia. He was reintubated and due to
to lack of significant imporvement, he underwent tracheostomy.
1. Hypoxemic respiratory failure: Initially felt to be due to
pneumonia, AF with RVR and CHF leading to volume overload with a
possible contribution of his COP. He was intubated and
ventilated with a lung-protective (ARDS-net) protocol given his
A-a gradient and bilateral opacities. He was also treated with
vanomycin and cefepime for health-care associated pneumonia. On
[**5-2**], he had increased secretions and was febrile and antibiotics
were broadened to vancomycin/cefepime and meropenem. He was
extubated on [**5-5**] in the morning and then was noted to be in
respiratory distress later that morning and did not improve on
non-invasives. His poor performance was felt to be secondary to
poor cough. He was reintubated later that day ([**5-5**]). He
continued to require FiO2 greater than 40% intermittently but
regularly enough that we opted for tracheostomy which was
performed on [**5-12**]. He was started on steroids on [**5-7**] as he had
not had imporvement and there was question of BOOP/COP. He did
improve on steroids both clinically and readiographically. On
[**5-14**], he was transitioned to trach mask which he tolerated well.
He is on Bactrim ppx.
##steroid course: Patient started on high dose steroids [**2161-5-7**].
He should continue on 60 mg prednisone until [**2161-5-21**] for total 2
weeks of therapy - then decrease to 40 mg prednisone for 2 weeks
then 20 mg for 1 week then 10 mg for 1 week (for total 6 weeks
of steroid therapy).
##oupatient follow-up: [**Hospital1 18**] Pulmonary follow-up. Important
patient attend appointment.
Department: MEDICAL SPECIALTIES
When: MONDAY [**2161-6-8**] at 1:30 PM
With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
2. MRSA VAP: His sputum grew MRSA. He was treated with
vancomycin for a greater than 14 day course and his gram
negative coverage was 14 days as well. (vanc [**Date range (1) 33700**]; [**Last Name (un) 2830**]
[**Date range (1) 33701**]; cefepime [**Date range (1) 33702**]).
3. Atrial fibrillation: Amiodarone held over initial concern for
amio pulmonary toxicity; however pathology felt that amiodarone
toxicity was unlikely given lack of foamy macrophages. However
as patient has underlying lung disease amio less than ideal
consequently attempted control with nodal agents. He had several
episodes of afib with RVR and he converted to sinus in all
cases. He intermittently required IV dilt for control but became
bradycardic when on both po metoprolol and po diltiazim so
diltiazim was discontinued.
- On discharge patient in sinus and well controlled on
Metoprolol Tartrate 37.5 mg PO/NG QID
- Patient started on coumadin prior to discharge but not
therapeutic - please monitor INR and adjust coumadin as needed
4. Acalculous cholecystitis: pt developed abdominal pain and
elevated alkaline phosphatase. Evidence of acalculous
cholecystitison U/S and now s/p bedside percutaneous
cholecystectomy [**2161-5-10**] by IR. Culture negative.
- He should continue unasyn for 10-14 days, course to complete
[**5-24**].
- Surgery follow-up: Patient needs to have surgery follow-up 4
weeks following placement of perc chol ([**2161-5-10**]) consequently
around [**2161-6-9**] for clamp trial. Please call general surgery
clinic ([**Telephone/Fax (1) 30009**] to schedule an appointment. Unable to do
on discharge due to holiday schedule.
5. Pancreatitis ?????? elevated lipase and leukocytosis with
abdominal pain that imporved with holding tube feeds. Felt to be
secondary to propofol. Lipase down-trending and able to tolerate
feeds at goal.
6. Chest pain - he had one episode of chest pain. He was ruled
out for MI. He did have T wave inversions and he should have
outpatient followup based on his risk factors.
##Please call Cardiology ([**Telephone/Fax (1) 2037**] to schedule appointment
in 1 month to assess for outpatient stress.
7. HTN: SBPs elevated in 150-160??????s, moderately controlled on po
metoprolol and lisinopril.
- Would uptitrate lisinopril as needed.
8. DM 2: HISS with accuchecks.
- Decrease sliding scale with prednisone taper to prevent
hypoglycemia
9. Ringworm. Right lower extremity - appearted on day of
discharge. Started lotrimin on [**5-18**]. Should continue through 1
week following resolution of rash.
10. Leukocytosis: Peaked at 25. Following 14 day treatment for
MRSA VAP and when on Unasyn for cholecystitis. Repeat blood
cultures, urine cultures and c. diff negative. Trending down on
discharge.
- Continue unasyn for total 4 weeks of therapy (see above).
11. BPH: Re-started BPH meds and d/c'ed foley on day of
discharge.
12. Nutrition: Currently on tube feeds.
- Patient needs to be assessed by Speech and Swallow for
appropriate diet and Passy-Muir valve. Unable to do prior to
discharge due to holiday weekend.
.
If any questions don't hesistate to call [**Telephone/Fax (1) 33703**] and ask to
talk to ICU resident.
Medications on Admission:
Amiodarone 200 mg daily
Finasteride 5 mg daily
Glipizide 5 mg daily
Terazosin 2 mg qhs
Coumadin 2 mg daily, 4 mg on thursday
Colace 100 mg po bid
Loratidine 10 mg daily
Discharge Medications:
1. senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 100 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO BID (2
times a day).
3. therapeutic multivitamin Liquid [**Telephone/Fax (1) **]: Five (5) ML PO DAILY
(Daily).
4. acetaminophen 650 mg/20.3 mL Solution [**Telephone/Fax (1) **]: One (1) PO Q6H
(every 6 hours) as needed for pain or fever.
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for Constipation.
6. heparin (porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1)
Injection TID (3 times a day): Discontinue once coumadin
therapeutic. .
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Telephone/Fax (1) **]:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
8. chlorhexidine gluconate 0.12 % Mouthwash [**Telephone/Fax (1) **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
9. acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: 3-5 MLs
Miscellaneous Q6H (every 6 hours) as needed for thick
secretions.
10. olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for agitation.
11. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily): Stop when steroids completed. .
12. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO QID (4
times a day).
13. nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
14. lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
15. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4
PM: INR needs to be followed. .
17. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Last Name (STitle) **]: Two
(2) Tablet, Chewable PO BID (2 times a day).
18. finasteride 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
19. terazosin 1 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO HS (at
bedtime).
20. clotrimazole 1 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day): Apply to right lower leg lesions. Continue for 1
week after resolve. .
21. prednisone 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily): 60 mg until [**2161-5-21**] then decrease to 40 mg prednisone
for 2 weeks then 20 mg for 1 week then 10 mg for 1 week for
total 6 weeks of therapy. .
22. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
23. Ampicillin-Sulbactam 1.5 g IV Q6H
Day 1 [**2161-5-9**]
24. Outpatient Lab Work
Check INR [**2161-5-19**] and adjust coumadin as needed.
25. Insulin sliding scale
Follow insulin print out.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
Hypoxic respiratory failure requiring trach placement
MRSA VAP
COP
Atrial fibrillation
Acalculous cholecystitis
Pancreatitis
Chest pain
Ringworm
Diabetes
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 admitted for respiratory distress. You were treated
with antibiotics and steroids. You failed extubation
consequently had a trach placed.
.
Your hospital course was complicated by Atrial fibrillation,
Acalculous cholecystitis and Pancreatitis.
.
Please follow the discharge medication list supplied in your
paperwork.
.
The following appointments will need to be made (unable to make
all appointments due to holiday):
- [**Hospital1 18**] Pulmonary follow-up. Important patient attend
appointment:
Department: MEDICAL SPECIALTIES
When: MONDAY [**2161-6-8**] at 1:30 PM
With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
- Patient needs to have surgery follow-up 4 weeks following
placement of perc chol ([**2161-5-10**]) consequently around [**2161-6-9**] for
clamp trial. Please call general surgery clinic ([**Telephone/Fax (1) 30009**]
to schedule an appointment.
- Please call Cardiology ([**Telephone/Fax (1) 2037**] to schedule appointment
in 1 month to assess for outpatient stress due to chest pain and
new t-wave inversions (ruled out for MI).
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2161-6-8**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: MONDAY [**2161-6-8**] at 1:30 PM
Department: MEDICAL SPECIALTIES
When: MONDAY [**2161-6-8**] at 1:30 PM
With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
- Patient needs to have surgery follow-up 4 weeks following
placement of perc chol ([**2161-5-10**]) consequently around [**2161-6-9**] for
clamp trial. Please call general surgery clinic ([**Telephone/Fax (1) 30009**]
to schedule an appointment.
- Please call Cardiology ([**Telephone/Fax (1) 2037**] to schedule appointment
in 1 month to assess for outpatient stress.
Completed by:[**2161-5-18**]
|
[
"51881",
"486",
"2760",
"5849",
"42731",
"25000",
"5859",
"4280",
"V1582",
"V5861"
] |
Admission Date: [**2196-11-30**] Discharge Date: [**2196-12-7**]
Date of Birth: [**2123-5-24**] Sex: F
Service: MEDICINE
Allergies:
Hydrocodone / poppyseeds
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73F with complex medical history including COPD, CKD Stage 3,
PAF s/p ablation on coumadin, diastolic CHF, aortic stenosis s/p
percutaneous valvuloplasty, hypertension, hyperthyroidism on
Methimazole, presenting with abdominal pain at site of abdominal
hernia.
.
Patient presented to [**Hospital6 3105**] the day prior to
admission with complaints of progressively worsening abdominal
pain over the site of a periumbilical hernia (developed in
[**2191**]). Patient reports that the pain is always present, but
over the last several days, it has become intolerable, [**9-21**] and
constant. Pain is not relieved with tylenol. Pain is not
associated with nausea or vomiting, diarrhea, constipation, or
blood in stool. She has two solid bowel movements daily, and
last bowel movement was day prior to admission. She denies
fever or chills. She denies dysuria, urgency or frequency of
urination.
.
In addition, patient reports worsening exercise tolerance over
the same period of time. She is usually able to walk to the
kitchen without shortness of breath, but now reports dyspnea
when walking "to the table."
.
At [**Hospital6 3105**], patient received Ancef 1000mg IV
to treat abdominal cellulitis. She also received duonebs for
shortness of breath and morphine IV for pain control. A CT
abdomen showed no incarceration of the hernia with incidental
finding of lung consolidation concerning for pneumonia. She was
transferred to [**Hospital1 18**] for surgical evaluation of hernia.
.
In the ED, initial vital signs were: 97.3 85 133/39 18 100% 3L.
Physical exam was notable for aortic stenosis murmur [**4-17**],
bibasilar crackles with soft expiratory wheeze. Her abdominal
exam was significant for tender peri-umbilical and suprapubic
area with an umbilical hernia, a large pannus with peau d'orange
swelling and erythema in the suprapubic area. Her lower
extremity exam was significant for increased warmth and
erythema. Labs were significant for Cr 1.3, Hct 34.1, INR 1.7
(on coumadin), BNP > 1000 and troponin 0.03. General surgery was
consulted who noted no incarceration of hernia and suggested
admission to medicine for pain control. A portable CXR
demonstrated bilateral effusions and could not exlude pneumonia.
An EKG demonstrated SR at 78bpm without evidence of STEMI. She
was given 4mg IV morphine x 1 for pain control, and duonebs x2
for relief of shortness of breath. Vitals on transfer were: 98.1
83 134/50 16 94% 3L.
.
On the floor, initial vital signs were T97.7, BP 159/54, HR 79,
95% on 3L, RR 32. Patient was complaining of ongoing abdominal
pain and shortness of breath.
.
Of note, patient also reports that approximately two weeks ago
she fell off of her couch, landing on the floor. She called 911
and EMS services evaluated her at home, but did not take her to
the ER. She has been able to walk without weakness in her
extremities. She walks with the assistance of a walker at
baseline.
Past Medical History:
Abdominal hernia at site of old feeding tube
COPD- on 3L home oxygen
diastolic CHF (EF 65% documented on [**2196-9-14**] pre-valvuloplasty)
Aortic stenosis- s/p percutaneous aortic valvuloplasty [**9-/2196**] @
[**Hospital1 112**]
Atrial fibrillation- on coumadin
Sick sinus syndrome- permanent pacer
HTN
Hyperlipidemia
CRI (baseline Cr 1.3)
h/o VRE UTI on bactrim prophylaxis.
Anemia
Hyperthyroidism- on methimazole
Pancreatic mass in tail
Social History:
Lives alone in [**Name (NI) 3844**], [**First Name3 (LF) **]-in-law and granddaughter live
next door. VNA assists with medication daily. Husband died 1
year ago. Three children, one daughter died one year ago in
motorcycle accident, one daughter lives in [**Name (NI) 7661**] and one son.
[**Name (NI) 1139**]- quit 20 years ago
Alcohol- rare
Illicits- denies
Family History:
Mother- died in car accident
[**Name (NI) 12238**] emphysema
Sister- coronary artery disease
Physical Exam:
Admission Physical Exam:
Vitals: T:97.7 BP:159/54 P:79 R:32 O2:95% on 3L NC, Weight: 90.6
kgs
General: Elderly female sitting up in bed with pursed lip, rapid
breathing, but in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP difficult to evaluate but does not appear
elevated, no LAD
Lungs: Clear to auscultation bilaterally, course crackles in
bilateral bases extending 1/3 up.
CV: Regular rate and rhythm, normal S1 + S2, grade [**5-18**] harsh
holosystolic murmur throughout precordium but best heard at
RUSB, radiating to carotids
Abdomen: Large pannus with diffuse ecchymosis, large
supraumbilical hernia, tender to palpation but reducible. Peau
d'orange skin changes without erythema or warmth in pannus below
umbilicus, with significant pitting edema and swelling. No
redness or discharge in bilateral inguinal regions below pannus.
Ext: Diffuse ecchymosis on left>right thigh without palpable
hematoma. 2+ lower extremity edema bilaterally extending to
knee. DP/PT pulses not palpable.
Neuro: CN II-XII intact. Strength 5/5 throughout. Full ROM in
b/l hips
.
Discharge Physical Exam:
Vitals - Tm: 98.0, HR: 60-62, BP:(110-139/37-64) RR: 20-24 02
sat: 96-97% 3L NC
Weight: 92.6kgs down from 94.9kgs yesterday
GENERAL: Obese caucasian female in NAD. Oriented x3. Mood,
affect appropriate.
NECK: Supple, no JVD appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**4-17**] cresendo/decresendo murmur best
heard at LUSB, which radiates to right carotid.
LUNGS: Diminished but clear throughout
ABDOMEN: There is a large, reducible, umbilical hernia, which is
non-tender, and less swollen and erythematous. The area beneath
the pannus has cleared up, no open sores, mild erythema, no
drainage. The remainder of her abdomen is soft, non-distended.
EXTREMITIES: woody edema halfway up shins bilaterally,trace
edema otherwise, extremities warm, 1+ DP/PT bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Small
skin tear on left hand (no longer open, healing nicely).
PULSES:
Right: Carotid 2+ Radial 2+ DP 1+
Left: Carotid 2+ Radial 2+ DP 1+
Pertinent Results:
Admission Labs:
.
[**2196-11-30**] 02:00AM BLOOD WBC-7.4 RBC-3.52* Hgb-10.6* Hct-34.1*
MCV-97 MCH-30.0 MCHC-31.0 RDW-15.4 Plt Ct-276
[**2196-11-30**] 02:00AM BLOOD Neuts-75.7* Lymphs-16.0* Monos-7.0
Eos-1.1 Baso-0.3
[**2196-11-30**] 02:00AM BLOOD PT-19.3* PTT-24.6 INR(PT)-1.7*
[**2196-11-30**] 02:00AM BLOOD Plt Ct-276
[**2196-11-30**] 02:00AM BLOOD Glucose-88 UreaN-47* Creat-1.3* Na-143
K-4.3 Cl-103 HCO3-31 AnGap-13
[**2196-11-30**] 09:15PM BLOOD Glucose-99 UreaN-45* Creat-1.2* Na-143
K-4.0 Cl-104 HCO3-33* AnGap-10
[**2196-11-30**] 09:15PM BLOOD CK(CPK)-23*
[**2196-11-30**] 02:00AM BLOOD proBNP-3652*
[**2196-11-30**] 02:00AM BLOOD cTropnT-0.03*
[**2196-11-30**] 02:00AM BLOOD Calcium-9.2
[**2196-11-30**] 09:15PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3
[**2196-11-30**] 09:59PM BLOOD Type-[**Last Name (un) **] pO2-82* pCO2-62* pH-7.36
calTCO2-36* Base XS-6 Comment-GREEN TOP
[**2196-11-30**] 09:59PM BLOOD Lactate-1.5
.
Pertinent Labs:
.
[**2196-11-30**] 02:00AM BLOOD proBNP-3652*
[**2196-11-30**] 02:00AM BLOOD cTropnT-0.03*
[**2196-11-30**] 09:15PM BLOOD CK-MB-3 cTropnT-0.04*
[**2196-12-1**] 07:05PM BLOOD TSH-1.4
[**2196-12-2**] 05:26AM BLOOD Triglyc-126 HDL-55 CHOL/HD-3.4
LDLcalc-106
[**2196-11-30**] 09:59PM BLOOD Type-[**Last Name (un) **] pO2-82* pCO2-62* pH-7.36
calTCO2-36* Base XS-6 Comment-GREEN TOP
[**2196-11-30**] 09:59PM BLOOD Lactate-1.5
[**2196-12-6**] 04:50AM URINE RBC-8* WBC-52* Bacteri-MOD Yeast-NONE
Epi-1 TransE-<1
.
Discharge Labs:
.
[**2196-12-7**] 06:35AM BLOOD WBC-4.8 RBC-2.95* Hgb-8.7* Hct-27.2*
MCV-92 MCH-29.6 MCHC-32.0 RDW-15.8* Plt Ct-207
[**2196-12-7**] 06:35AM BLOOD Plt Ct-207
[**2196-12-7**] 06:35AM BLOOD PT-22.8* INR(PT)-2.1*
[**2196-12-7**] 06:35AM BLOOD Glucose-68* UreaN-52* Creat-1.3* Na-141
K-4.4 Cl-104 HCO3-30 AnGap-11
[**2196-12-7**] 06:35AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.6
.
Micro/Path:
.
MRSA Screen: Negative
.
Imaging/Studies:
.
ECG [**2196-11-30**]:
Normal sinus rhythm. Left ventricular hypertrophy by voltage.
Non-specific
ST-T wave changes that could reflect the ventricular
hypertrophy. No previous tracing available for comparison.
.
TTE [**2196-11-30**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is moderately
dilated with normal free wall contractility. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets are moderately thickened. There is moderate
aortic valve stenosis (valve area 1.0-1.2cm2). Mild to moderate
([**2-14**]+) aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. Moderate to severe (3+) 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. IMPRESSION: Mild symmetric
left ventricular hypertrophy with hyperdynamic LV systolic
function. Moderate to severe mitral regurgitation. Mild to
moderate aortic regurgitation. Hypertrophied and dilated right
ventricle with normal systolic function, severe tricuspid
regurgitation and severe pulmonary hypertension.
.
CXR Portable [**2196-11-30**]:
FINDINGS: There is moderate pulmonary edema and likely small
pleural
effusions. No pneumothorax is seen. There is moderate
cardiomegaly. The
presence of pericardial effusion is not well evaluated. A
left-sided
dual-lead pacemaker is in standard position.
.
CXR Portable [**2196-12-2**]:
IMPRESSION:
1. Moderate bilateral pulmonary edema, improved.
2. Moderate left pleural effusion and small right pleural
effusion, improved.
3. Bilateral ill-defined nodular opacities may represent vessels
en face, but PA and lateral views should be obtained once the
patient is stabilized.
.
CXR Portable [**2196-12-3**]:
IMPRESSION: AP chest compared to [**11-30**] and 21:
Mild pulmonary edema improved between [**11-30**] and 21 and has
not changed
subsequently. Severe cardiomegaly, moderate left pleural
effusion, and
generalized pulmonary vascular engorgement are stable.
Transvenous right
atrial and right ventricular pacer leads are continuous from the
left axillary pacemaker. No pneumothorax.
.
CXR PA/LAT [**2196-12-6**]:
MPRESSION: Persistent evidence of cardiac enlargement and
pulmonary vascular congestion. Significant improvement cannot be
identified. Variations in vascular pulmonary appearance may in
this case relate to different phases of inspiration.
.
Spirometry [**2196-12-5**]:
SPIROMETRY 2:44 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 0.86 2.30 37
FEV1 0.66 1.58 42
MMF 0.55 1.96 28
FEV1/FVC 76 69 111
LUNG VOLUMES 2:44 PM Pre drug Post drug
.
Actual Pred %Pred Actual %Pred
TLC 2.03 3.93 52
FRC 1.30 2.30 56
RV 1.12 1.63 68
VC 0.91 2.30 40
IC 0.73 1.64 45
ERV 0.18 0.66 27
RV/TLC 55 42 133
He Mix Time 0.00
.
OSH IMAGING:
CT abdomen/pelvis (OSH): Wide fascial defect with no evidence of
small
bowel dilation within hernia or within abdomen. Possible
pneumonia in lower base of lung. No evidence of incarceration.
Brief Hospital Course:
73 yo F with a history of COPD (3L home O2), diastolic CHF,
aortic stenosis s/p recent ballon valvuloplasty, and h/o
periumbilical hernia presenting with progressively worsening
dyspnea and abdominal pain.
.
ACTIVE DIAGNOSES:
.
# Diastolic CHF Exacerbation: On admission, patient reported
progressively worsening shortness of breath limiting her
exercise tolerance significantly. She was previously able to
walk to her kitchen and prior to admission could only walk "to
the table." She denied worsening cough or increased oxygen
requirement, but did note that her abdomen had become more
swollen and her lower extremity edema was significantly worse.
Given patient's history of aortic stenosis s/p valvuloplasty, we
were initially concerned about worsening aortic stenosis causing
progression of symptoms. TTE performed on the day of admission
showed that the valve area was 1.2, consistent with [**Hospital1 24300**] report of the post-valvuloplasty valve area. Patient
had evidence of significant pulmonary hypertension and right
ventricular overload. She was initially diuresed on the floor,
but became increasingly dyspneic and hypoxic, and was
transferred to the CCU for augmented diuresis on lasix drip. A
CXR was consistent with pulmonary edema [**3-16**] volume overload. She
was diuresed on a lasix drip for 24 hours, then transitioned to
home regimen of lasix 80mg PO BID. She had pulmonary function
testing in-house which demonstrated severely decreased lung
volumes, FVC, FEV1 but preserved FEV1/FVC consistent with a
severe restrictive defect and similar to prior PFT's at [**Hospital1 112**] a
year prior. She continued to be diuresed and was ultimately
switched to a maintenance dose of lasix of 40mg PO daily when
she reached her functional baseline of poor exercise tolerance
on 3LNC (her home O2 dose). She was also switched from captopril
to low-dose lisinopril. Follow-up was established with her PCP
and [**Name9 (PRE) 3782**] cardiologist in [**Location (un) 3844**].
.
# Non-incarcerated periumbilical hernia/Abdominal Pain: Patient
was initially seen at [**Hospital6 3105**] with chief
complaint of abdominal pain. She has a known large
periumbilical hernia related to old feeding tube. She had a CT
scan which was negative for incarceration of hernia, and on exam
at [**Hospital1 18**], hernia was large and easily reducible. The surgery
team saw the pt and did not think surgical intervention was
warranted. Exam was significant for pannus edema with peau
d'orange skin changes. Underneath the pannus there was some
erythema, but without obvious signs of infection. She was
evaluated by the wound care nurse, who recommended trial with an
abdominal binder, which refused by the patient. As her diuresis
progressed her pannus edema was significantly reduced and her
abdominal pain improved markedly. She was started on tylenol and
tramadol PRN for pain control.
.
CHRONIC DIAGNOSES:
.
# COPD: Patient was initially continued on her home medications
including albuterol nebulizer treatments prn, singulair and
prednisone 30mg daily. On further review of discharge summary
from [**2196-9-12**] admission at [**Hospital1 112**], it was clear that patient
should have been tapered off of prednisone several months
earlier. Therefore she was decreased to 20mg daily with plan to
continue with a slow taper at a suggested rate of 10mg after 1
week, 5mg after the next, and then cessation of therapy. She was
discharged on her 3LNC home O2 dose as above.
.
# Paroxysmal atrial fibrillation: Stable. Not in afib during
this admission per EKG's and tele. On coumadin 2mg daily with
subtherapeutic INR on admission of 1.7. She was continued on her
coumadin and her INR was 2.2 at the time discharge.
.
# Chronic kidney disease: Likely multifactorial. Baseline Cr
1.3. Patient was at baseline on admission but bumped to 1.7 in
the setting of aggressive diuresis. She was then transitioned to
PO lasix at a maintenance dose of 40mg PO daily and her Cr
returned to baseline.
.
#Hyperthyroidism: Stable. Continued on her home methimazole.
.
#Chronic Normocytic Anemia: Pt with significant anemia with
crits from high 20's to low 30's. Unclear etiology but likely
multifactorial and could be playing a role in her poor exercise
tolerance. Previously on procrit which she stopped taking due to
cost. Workup and management of this issue was deferred to the
outpatient setting.
.
TRANSITIONAL ISSUES:
#Dispo: Patient recommended for placement in rehab but she has
already used up all of her rehab time provided by her insurance
and is at the functional baseline. She was discharged home with
home VNA and home PT.
.
#Steroid Taper: Pt has inadvertently been on prednisone for a
period of months following discharge from [**Hospital1 112**] and was initiated
on a slow taper in-house from 30mg to 20mg. We suggested to
continue this taper to 10mg over the next week, then 5mg the
following week, then cessation of prednisone with monitoring of
her electrolytes and blood pressures to watch for adrenal
insufficiency.
.
#Bactrim PPX: Pt is currently on bactrim PPX in conjunction to
her prednisone. This medications can likely be discontinued
following cessation of her prednisone.
.
#Lasix: Her lasix dose was changed to 40mg PO once daily at the
time of discharge as a maintenance dose. However, it is likely
that her compliance with a low Na diet will decrease at home and
her dosage will likely need to be increased back towards her
80mg PO BID dose level on admission. She will need a Chem 7
during her next PCP [**Name Initial (PRE) 648**].
.
#Pain Control: Pt was started on tramadol PRN for control of
pain related to her pannus edema and reducible abdominal hernia.
She had previously tried oxycodone which had made her very
sleepy but tolerated tramadol quite well.
.
#Anemia: Pt with significant anemia during this hospitalization
who will need continued outpatient workup and management.
.
#Cardiology Follow-up: Pt set up with cardiology follow-up with
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in NH.
Medications on Admission:
- Prednisone 30mg daily
- Ativan 0.5 tid prn
- Iron 325mg [**Hospital1 **]
- Singulair 10mg daily
- MVI
- Celexa 40mg daily
- Albuterol nebulizer q4h prn
- Coumadin 2mg daily
- Miralax 17g daily
- Lasix 80mg [**Hospital1 **]
- Methimazole 5mg po daily
- Bactrim SS 400-80mg daily
- Sotalol 80mg daily
- Captopril 12.5mg daily
Discharge Medications:
1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
5. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. methimazole 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
8. sotalol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for one week, then decrease to 10mg daily for one week, then
decrease to 5mg daily for one week, then discontinue.
10. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO Q 8 hours PRN as
needed for anxiety.
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
13. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) nebulizer Inhalation four times a day.
14. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
17. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for abdominal pain.
18. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
19. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary:
-Diastolic congestive heart failure exacerbation
Secondary:
-COPD on 3L home oxygen
-pulmonary hypertension
-depression
-hypertension
-anemia
-GERD
-Hypothyroidism
-Reducible umbilical hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
PHYSICAL EXAM:
Vitals - Tm: 98.0, HR: 60-62, BP:(110-139/37-64) RR: 20-24 02
sat: 96-97% 3L NC
Weight: 92.6kgs down from 94.9kgs yesterday
In/Out (Last 24H): in 1230cc out 1650cc (negative 420cc)
.
Tele: No significant events
.
GENERAL: Obese caucasian female in NAD. Oriented x3. Mood,
affect appropriate.
NECK: Supple, no JVD appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**4-17**] cresendo/decresendo murmur best
heard at LUSB, which radiates to right carotid.
LUNGS: Diminished but clear throughout
ABDOMEN: There is a large, reducible, umbilical hernia, which is
non-tender, and less swollen and erythematous. The area beneath
the pannus has cleared up, no open sores, mild erythema, no
drainage. The remainder of her abdomen is soft, non-distended.
EXTREMITIES: woody edema halfway up shins bilaterally,trace
edema otherwise, extremities warm, 1+ DP/PT bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Small
skin tear on left hand (no longer open, healing nicely).
PULSES:
Right: Carotid 2+ Radial 2+ DP 1+
Left: Carotid 2+ Radial 2+ DP 1+
Labs: [**2196-12-7**]: WBC 4.8, Hct 27.2, plt 207, INR 2.1, Na 141, K
4.4, BUN 52, Cr 1.3, gluc 68
*Of note, pt has chronic anemia, had been on Procrit 4000 units
weekly but has not been taking this medication due to cost*
Discharge Instructions:
Dear Ms [**Known lastname **],
.
You were admitted to [**Hospital1 18**] with shortness of breath and
abdominal pain. Your shortness of breath was mostly due to a
congestive heart failure exacerbation, though your pulmonary
hypertension and COPD also played a role. To prevent further CHF
exacerbations, weigh yourself every morning, [**Name8 (MD) 138**] MD if weight
goes up more than 3 lbs. Be sure to limit your salt intake in
your diet and restrict your fluids to 1500cc/ day.
Your abdominal pain is due to your abominal hernia. This was
evaluated with a CT scan and by our surgeons, who did not feel
that surgery was required. Your pain did improve significantly
with removal of excess fluid. If you continue to have pain at
home you can take Tramadol 50mg every 8 hours as needed (you
should avoid using the Oxycodone).
You should resume your Coumadin at 2mg daily. You should have
your INR checked on Monday. The goal for your INR is [**3-17**].
Your kidneys are not working 100% but they appear to be at
baseline right now. You should have your electrolytes and kidney
function test repeated on Monday.
The following changes were made to your medications:
** STOP captopril (because you are switching to Lisinopril)
** START lisinopril at 2.5mg dose to treat yor heart failure
** CHANGE prednisone to a tapered dose: 20mg daily for one week,
then decrease to 10mg daily for one week, then decrease to 5mg
daily for one week, then discontinue medication.
** DECREASE your Lasix to 40mg daily, you will need to have your
electrolytes and kidney function tests repeated on Monday
** START Simvstatin 40mg daily (for cholesterol)
** START Tramadol 50mg every 8 hours as needed for abdominal
pain
.
Please follow-up with the appointments listed below:
Followup Instructions:
Name: [**Last Name (LF) **], [**Name8 (MD) **] NP
Location: [**Hospital1 **] PHYSICIAN SERVICES OF [**Name9 (PRE) **]
Address: [**Location (un) 53354**], [**Hospital1 **],[**Numeric Identifier 40170**]
Phone: [**Telephone/Fax (1) 53355**]
Appointment: TUESDAY [**12-14**] AT 4:00PM
Name: [**Last Name (LF) 925**], [**First Name3 (LF) **]
Specialty: CARDIOLOGY
Location: NE HEART INSTITUTE AT [**Hospital3 **] CENTER
Address: 1 [**Hospital1 **] DR, [**Location (un) **] [**Numeric Identifier 66328**]
Phone: [**Telephone/Fax (1) 91305**]
**We are working on a follow up appointment with Dr. [**First Name (STitle) **]
within 1 month. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.**
Completed by:[**2196-12-7**]
|
[
"5849",
"4280",
"496",
"311",
"53081",
"40390",
"V5861",
"42731"
] |
Admission Date: [**2169-5-7**] Discharge Date: [**2169-6-10**]
Date of Birth: [**2169-5-7**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 20561**] was born with a
birth weigh of 1.61 kilogram and gestational age of 31 and [**12-13**]
week gestation pregnancy born to a 36-year-old gravida 1, para
0, woman.
Prenatal screens revealed blood type A positive, antibody
negative, Rubella immune, rapid plasma reagin nonreactive,
hepatitis B surface antigen negative, and group B strep
status unknown.
The pregnancy was notable for being a twin gestation.
The pregnancy was complicated by the onset of preterm labor at
26 weeks. The mother experienced premature rupture of
membranes on the day of delivery and was taken to cesarean
section for breech presentation of this twin. She received
one dose of betamethasone. This infant emerged with good tone
and spontaneous respirations. Apgar scores were 8 at one
minute and 8 at five minutes. The infant required blow-by
oxygen in the delivery room. He was admitted to the Neonatal
Intensive Care Unit for treatment of prematurity.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
upon admission to the Neonatal Intensive Care Unit revealed
weight was 1.61 kilograms (75th percentile), length was 43 cm
(75th percentile), head circumference was 28.25 (25th to 50th
percentile). In general, an active, alert, and pink preterm
male with slightly decreased tone. Skin was intact. No
rashes or lesions. Head, eyes, ears, nose, and throat
examination revealed anterior fontanel was open and flat,
sutures open, positive red reflex in both eyes. Palate was
intact. The neck was supple and without masses. Chest
examination revealed bilateral breath sounds were clear and
equal with slightly diminished aeration. Symmetrical chest
movement. Cardiovascular examination revealed a regular rate
and rhythm without murmurs. Pulses were 2+. The abdomen
revealed no hepatosplenomegaly. A 3-vessel cord. Genitalia
revealed testes descended bilaterally. Normal phallus. Anus
was patent. Trunk and spine were intact. Extremities were
stable. Reflexes were appropriate for gestational age.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: [**Known lastname **] was admitted on room air and
remained on room air throughout his Neonatal Intensive Care
Unit admission. He had rare episodes of spontaneous apnea
and bradycardia, but none for the last two weeks of
admission.
2. CARDIOVASCULAR SYSTEM: [**Known lastname **] has maintained normal
heart rates and blood pressures. A soft murmur has been
audible during admission, but was not audible at the time of
discharge.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: Enteral feeds were
begun on day of life one and gradually advanced to full
volume. His maximum caloric intake was 28 calories per ounce
with additional protein ProMod supplement. At the time of
discharge, he was all p.o. feeding Enfamil 24 calories per
ounce and taking a minimum of 130 cc/kg per day. His
discharge weight was 2.89 kilograms, with a length of 47 cm,
and a head circumference of 31.5 cm.
Serum electrolytes were checked once during this admission
and were within normal limits.
4. INFECTIOUS DISEASE ISSUES: Due to his prematurity and
unknown group B strep, [**Known lastname **] was evaluated for sepsis.
White blood cell count was 5800 with a differential of 31%
polys and 1% bands. A blood culture was drawn, and
intravenous ampicillin and gentamicin were started. The
blood culture was no growth at 48 hours, and the antibiotics
were discontinued.
5. GASTROINTESTINAL ISSUES: [**Known lastname **] required treatment for
unconjugated hyperbilirubinemia with phototherapy. His peak
serum bilirubin occurred on day of life eight with a total of
9.3/0.3 direct mg/dL. He received 48 hours of phototherapy
and a rebound bilirubin on day of life 10 was 4.8/0.2 direct.
6. HEMATOLOGIC ISSUES: Hematocrit at birth was 54.2%.
[**Known lastname 805**] was treated with supplemental iron and was to be
discharged home on supplemental iron.
7. NEUROLOGIC ISSUES: [**Known lastname **] had a head ultrasound
performed on day of life 10 that was within normal limits.
He had maintained a normal neurologic examination, and there
were no neurologic concerns at the time of discharge.
8. SENSORY ISSUES: Audiology hearing screen was performed
with automated auditory brain stem responses, and [**Known lastname **]
passed in both ears.
9. OPHTHALMOLOGIC ISSUES: [**Known lastname **] had a screening eye
examination for retinopathy of prematurity on [**2169-5-31**].
His retinae showed mature vessels. A follow-up examination
is recommended in eight months.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge disposition was to home with
parents.
PRIMARY PEDIATRICIAN: Primary pediatrician is Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 47684**], [**Hospital 47685**] Pediatrics, [**Street Address(2) 47686**],
[**Location (un) 701**], [**Numeric Identifier 47687**] (telephone number
[**Telephone/Fax (1) 47682**]).
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feedings: Ad lib oral Enfamil 24-calories per ounce.
2. Medications: Ferrous sulfate 25 mg/mL dilution 0.2 cc
p.o. every day.
3. Car seat position screening was performed on [**2169-6-8**]; the infant was observed for 90 minutes without heart
rate drop or oxygen saturation drop.
4. State newborn screens were sent on [**5-11**] and [**2169-5-22**]; all results were within normal limits.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine was administered
on [**2169-5-30**].
IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation.
(2) Born between 32 and 35 weeks gestation with plans for day
care during respiratory syncytial virus season, with a smoker
in the household, or with preschool siblings; and/or (3) With
chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. Follow-up appointment recommended with Dr. [**Last Name (STitle) 47684**] on
[**2169-6-12**].
2. Follow-up appointment with Pediatric Ophthalmology at
eight months of age.
3. Consider hip ultrasound with the known history of breech
presentation.
DISCHARGE DIAGNOSES:
1. Prematurity at 31 and 1/7 weeks gestation.
2. Twin I of twin gestation.
3. Suspicion for sepsis ruled out.
4. Apnea of prematurity.
5. Unconjugated hyperbilirubinemia.
6. Breech presentation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2169-6-10**] 07:07
T: [**2169-6-10**] 08:41
JOB#: [**Job Number **]
|
[
"7742",
"V053"
] |
Admission Date: [**2129-1-15**] Discharge Date: [**2129-1-25**]
Date of Birth: [**2072-9-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
Intubation with mechanical ventilation
Femoral CVL placement
A-line placement
History of Present Illness:
56F w ESRD on PD last HD 3 days PTA ([**2129-1-12**]), history of
recurrent C. difficile infection currently on Flagyl and
Vancomycin taper discharged on [**2129-1-6**], whose friends
called EMS today after friends called them because the patient
hadn't contact[**Name (NI) **] them in a few days and she was found to be
slightly altered. She was brought to the ED where she was found
to have continued abdominal pain. She reports that her pain is
described as an [**7-4**] crampy nonradiating pain located across the
epigastrium that has not associations with food and is relieved
with psin medications. She reports that her BMs have increased
from ~4/day to ~7 loose, watery copius, nonbloody BMs. When she
was initially admitted on [**2129-1-6**] she reports having 24BMs per
day. This abdominal pain was associated with lightheadedness,
dizziness but no syncope. She denies any chest pain or
palpiations. She denies fevers. She does, however, report that
she's SOB with DOE with increasing leg swelling, but no increase
in orthopnea or PND. As above her last HD was 3 days PTA.
.
In the ED her vitals: 99.2 72/45 56. The hypotension (72/45)
was refractory to NS boluses thus requiring Levophed and R
femoral line placement. She had a leuckocytosis with left shift
and CT abdomen with evidence of colitis. Patient also had a
negative Head CT. She was given Dextrose for hypoglycemia,
cultures taken, and she was given Vanc/Zosyn empirically.
Past Medical History:
Past Medical History:
- ESRD on peritoneal dialysis daily (transitioned off HD just
before [**Holiday 1451**]), ? [**12-27**] HTN vs proliferative GN vs ? history
of lupus. Dry weight 78kg.
- [**Month/Day (2) 17911**] syndrome secondary to clots, on coumadin
- h/o Peritonitis (cloudy PD fluid)
- h/o E cloacae line bacteremia
- C diff colitis; first dx in [**6-/2128**], recurrence in [**10/2128**] and
[**12/2128**], requiring PO vancomycin w taper
- CAD--per OMR
- HTN
- Dyslipidemia
- Anemia: baseline Hct 25-31
- Asthma
- OSA on CPAP
- h/o right gluteal bleed while on heparin gtt
- h/o rheumatic fever
- OA in left shoulder
- h/o rotator cuff tear on left
- h/o TAH for fibroids
- s/p b/l total knee replacements [**2124**]
- h/o herpes zoster with post-herpetic neuralgia
-[**2128-12-14**] SBO
Social History:
Used to be a social worker. Currently smoking occasionally,
history of tobacco use of [**11-26**] PPD x 30 years. Occasional
alcohol. Former cocaine user in remote past.
Family History:
Father, uncle, and brother had CAD in their 40s.
Brother had renal disease and a stroke.
Physical Exam:
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS ON ADMISSION:
.
[**2129-1-15**] 01:50PM BLOOD WBC-18.2*# RBC-3.49* Hgb-10.2* Hct-33.0*
MCV-95 MCH-29.3 MCHC-31.0 RDW-18.5* Plt Ct-375
[**2129-1-15**] 01:50PM BLOOD Neuts-90.4* Lymphs-5.2* Monos-3.7 Eos-0.5
Baso-0.3
[**2129-1-15**] 01:50PM BLOOD PT-57.1* PTT-53.6* INR(PT)-6.7*
[**2129-1-15**] 01:50PM BLOOD Glucose-58* UreaN-54* Creat-11.6* Na-136
K-4.4 Cl-99 HCO3-17* AnGap-24*
[**2129-1-15**] 09:44PM BLOOD ALT-5 AST-22 LD(LDH)-372* CK(CPK)-746*
AlkPhos-168* TotBili-0.1
[**2129-1-15**] 09:44PM BLOOD CK-MB-18* MB Indx-2.4 cTropnT-0.12*
[**2129-1-15**] 09:44PM BLOOD Calcium-7.2* Phos-7.0*# Mg-2.0
.
HOSPITAL COURSE:
[**2129-1-18**] 04:55AM BLOOD TSH-3.4
[**2129-1-18**] 04:55AM BLOOD Free T4-0.98
[**2129-1-18**] 04:55AM BLOOD Cortsol-22.1*
[**2129-1-18**] 02:42AM BLOOD Cortsol-12.3
[**2129-1-17**] 03:11AM BLOOD Cortsol-20.2*
[**2129-1-17**] 10:10AM BLOOD IgG-1171 IgA-523* IgM-81
.
CT HEAD:
CONCLUSION:
1. No acute intracranial process.
2. Small focus of heterotopic [**Doctor Last Name 352**] matter as described above,
present on
multiple prior examinations.
3. Prominence of the retropharyngeal soft tissues, although was
seen on the prior CT, warrants direct visual inspection.
.
CT Abd/Pelvis:
IMPRESSION:
1. No evidence for megacolon.
2. Extremely limited study due to suboptimal contrast phase and
paucity of
mesenteric fat and lack of oral contrast.
3. Mild colonic wall thickening could be seen in the setting of
colitis or
bowel wall edema in the setting of peritoneal dialysis.
4. Chest wall collaterals and suboptimal contrast phase raised
the
possibility of [**Doctor Last Name 17911**] stenosis/occlusion versus sequlae of surgical
A/V dialysis fistula.
.
CT Chest:
IMPRESSION:
1. Small bilateral bibasilar consolidation, right greater than
left.
2. Small bilateral pleural effusions.
3. Cardiomegaly.
.
CXR ([**1-21**]):
REASON FOR EXAM: Respiratory failure, pneumonia.
Comparison is made with prior studies including 2/24,25,26/[**2128**].
There are low lung volumes. Bibasilar opacities have improved
markedly on the right. Small right pleural effusion is
unchanged. Cardiomegaly is stable. There is no pneumothorax.
Brief Hospital Course:
In short, Ms [**Known lastname 1391**] is a 56F w multiple medical problems,
notably HTN, ESRD (on PD), [**Name (NI) 17911**] clot (on home Coumadin), and
recent admission w recurrent C. difficile colitis (on [**Doctor Last Name **]/vanc
PO), who was originally admitted to the MICU w altered mental
status, hypotension in the setting of worsened diarrhea. She was
found to be in respiratory failure from a pneumonia requiring
mechanical ventilation, was treated with Vanc/Zosyn x 7 days
(completed), Levofloxacin x 14 days (through [**1-30**]) and fluids.
She was also on norepinephrine drip temporarily for pressure
support. She was then transferred to medicine for further
treatment.
# Pneumonia: Patient presented with septic physiology,
initially with unclear source. In the ICU, patient was started
on Levophed gtt for BP support. She was treated empirically
with broad-spectrum coverage with Vancomycin and Zosyn at time
of admission. On [**1-17**], patient was intubated due to acute
respiratory decompensation. A CT chest revealed bilateral
infiltrates. Levofloxacin was added for double-coverage of a
hospital-acquired pneumonia, both due to worsening respiratory
status and radiographic worsening of right-sided pulmonary
infiltrate. Subsequently, her leukocytosis began to resolved,
and respiratory status gradually improved. Sputum sample was
unrevealing, and legionella testing was negative. On [**1-19**], she
successfully underwent at trial of PS at 5/5, but was found to
have no cuff leak. Given concerns for laryngeal edema due to
her facial edema (underlying [**Month/Year (2) 17911**] syndrome), she was treated per
protocol with Decadron 5 mg q 6 hours x 24 hours. She was
successfully extubated with Anesthesia at bedside on [**1-20**].
Vancomycin and zosyn were continued for 7-day day course. Plan
is to complete a 14 day course of levofloxacin given suspicion
for atypical infection.
# Hypotension: Patient was maintained on Levophed gtt with goal
MAP > 60. Cardiac enzymes were mildly elevated, secondary to
demand from ESRD. An urgent TTE on night of admission showed no
evidence of tamponade. Levophed was weaned on [**1-20**], and
subsequent BP's were in the high 70's systolic with MAPs > 60.
Cortisol stim (12 -> 22) ruled out adrenal insufficiency.
Septic physiology was treated as above. All culture data were
unrevealing. She received a dose of IV albumin 25 grams without
improvement of BP.
# Recurrent C. diff infection: Patient has documented history
of recurrent c. diff infection. Given that source of infection
was initially undetermined, she was empirically started on IV
flagyl and PO vancomycin at time of admission to cover for c.
diff infection. Her c. diff toxin was negative this admission,
and IV flagyl was discontinued. She was continued on PO
vancomycin given her high risk of recurrent c. diff infection
while on antibiotics. Plan is to complete previously prescribed
taper of PO vancomycin following completion of levofloxacin
course:
Vancomycin 125 mg qid [**2129-1-7**], through [**2129-1-28**].
Vancomycin 125 mg [**Hospital1 **] [**2129-1-29**] through [**2129-2-4**].
Vancomycin 125 mg daily [**2129-2-5**] through [**2129-2-11**].
Vancomycin 125 mg Capsule Sig: One (1) Capsule PO AS
DIRECTED for 8 doses: On [**4-16**], [**2-16**], [**2-19**], [**2-22**], [**2-25**], [**2-28**],
[**3-3**].
# ESRD on PD: PD was continued while inpatient. Her oral
medications including Lanthanum, Sevelamer, and Cinacalcet were
briefly held while she was NPO and intubated. She was started
on Calcitriol during this admission.
# [**Month/Day (4) 17911**] Syndrome: INR was supratherapeutic during length of ICU
stay in the setting of antibiotics, and Coumadin was held. Goal
INR [**12-28**]. Substantial facial edema was noted, and intubation was
difficult.
Medications on Admission:
Citalopram 20 mg daily
Lorazepam 0.5 mg 1-2 Tablets PO Q12H prn
Cinacalcet 60 mg daily
Lanthanum 500 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Sevelamer Carbonate 2400 mg PO TID W/MEALS
Gabapentin 300 mg DAILY
Acetaminophen 500 mg tid prn
Warfarin 5 mg Daily
Vancomycin 125 mg qid [**2129-1-7**], through [**2129-1-28**].
Vancomycin 125 mg [**Hospital1 **] [**2129-1-29**] through [**2129-2-4**].
Vancomycin 125 mg daily [**2129-2-5**] through [**2129-2-11**].
Vancomycin 125 mg Capsule Sig: One (1) Capsule PO AS
DIRECTED for 8 doses: On [**4-16**], [**2-16**], [**2-19**], [**2-22**], [**2-25**], [**2-28**],
[**3-3**].
Metronidazole 500 mg [**Hospital1 **] Day 1: [**2129-1-7**], through [**2129-1-28**].
Morphine 15 mg Tablet Sig: 1-2 Tablets PO q6h:prn
Saccharomyces boulardii 250 mg po daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for anxiety.
3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Outpatient Lab Work
Twice weekly Labs at dialysis for INR to manage coumadin. Please
fax results to Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 445**]).
9. Vancocin 125 mg Capsule Sig: AS DIRECTED Capsule PO AS
DIRECTED: Through [**1-28**]: 1 tab four times daily; [**Date range (1) 17912**]: 1 tab
twice daily; [**Date range (1) 17913**]: 1 tab daily;
1 tab on [**4-16**], [**2-16**], [**2-19**], [**2-22**], [**2-25**], [**2-28**], [**3-3**].
10. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain for 10 days.
11. Saccharomyces boulardii 250 mg Capsule Sig: One (1) Capsule
PO once a day.
12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
13. Miconazole Nitrate 2 % Ointment Sig: One (1) Topical once a
day for 2 weeks.
Disp:*1 bottle* Refills:*0*
14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 6 days: end date [**2129-1-30**].
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
sepsis
hypotension
acute respiratory failure
hospital-acquired pneumonia
.
C. difficile colitis
end-stage renal disease
superior vena cava syndrome
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital with confusion, worsened
diarrhea and low blood pressure. You were found to have a lung
infection and bowel infection. You were temporarily in the
intensive care unit for critical care. Your condition has
improved.
Your medications were changed as follows:
1. Added levofloxacin for pneumonia; to take until [**2129-1-30**]
2. Added calcitriol
3. Please continue your other medications as prescribed.
Should you have any worsening in your symptoms, please call your
physicians immediately.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Friday 6th at 11 am.
[**Telephone/Fax (1) 133**].
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2129-2-1**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2129-2-24**] 10:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2129-8-18**]
1:55
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2129-3-25**] 8:45
Completed by:[**2129-2-3**]
|
[
"0389",
"78552",
"40391",
"486",
"51881",
"2762",
"99592",
"41401",
"2724",
"V5861",
"49390",
"32723"
] |
Admission Date: [**2170-10-4**] Discharge Date: [**2170-11-20**]
Date of Birth: [**2107-10-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
abdominal pain, SOB
Major Surgical or Invasive Procedure:
Bronchoscopy c biopsy
History of Present Illness:
This is a 62 year old female with PMH significant for multiple
sclerosis presents with abdominal pain x 5 days, along with SOB.
Describes having constant epigastric pain that is burning in
nature and worsened with eating; however somewhat better with
milk. The pain is non-positional in nature and is not
exacerbated by recumbency. States that spicy food exacerbates
her pain. Reports some associated nausea but no vomiting and
also reports constipation. In addition, the patient has had
increasing dysphagia for both solids and liquids the last few
months, a video swallow study in [**6-7**] was largely unremarkable.
Denies recent weight loss and reports a good appetite.
Pt also reports feeling increasingly shortness of breath over
the past 3-4 months. As she is wheelchair bound, she can't say
for sure that this is exertional. Denies PND, orthopnea, h/o LE
edema. Feels that her SOB is worse when she experiences
swallowing difficulty. Denies chest pain, dizziness, fevers,
chills, night sweats. Does report a non-productive cough that is
chronic in nature but has increased in frequency in the past few
weeks.
In the ED, T 98.1 HR 101 BP 138/104 RR 18 O2 sat 98% on RA.
Given GI cocktail with improvement in abdominal pain. CXR
significant for RUL mass, sent for chest CT that revealed a 3.7
x 2.4 cm non-cavitating, enhancing mass in the RUL of the lung
abutting the R side of the mediastinum. Pt admitted to medicine
for further work-up of lung mass.
.
ROS otherwise negative. Reports negative PPD 2 months ago.
Past Medical History:
Multiple Sclerosis dx in [**2161**]-99 followed by [**Hospital1 **] [**Hospital1 **],
recently failed Avonex, cognitive decline over past year.
Chronic LBP s/p L5-S1 diskectomy [**2148**]
Breast Fibroadenoma
Distant h/o rheumatic fever in her 20s, no sequealae
Social History:
Second marriage. Divorced from first husband.
Originally from [**Male First Name (un) 1056**]. Now needs assistance in all ADL's
from husband. [**Name (NI) 1139**]: remote h/o of smoking 1 cigarette a day
for 20 yrs, 20 yrs ago
EtOH: 1 glass red wine qd
Drugs: no illicit substance use
Family History:
+DM, HBP, hyperlipidemia; negative for MS, negative for
carcinoma.
Several relatives with [**Name (NI) 5895**]
Fatal MI in mother (80's)
Physical Exam:
T 97.4 BP 130/90 HR 100 RR 20 O2 sat 98% on RA
Gen - NAD, thin appearing Hispanic female, alert, friendly,
speaks in full sentences but occ grunting.
HEENT - Sclerae anicteric, PER, MM slightly dry, no lesions.
Neck supple. no JVD appreciated.
CV - RRR, S1S2, no m/r/g appreciated
Lungs - B/L coarse breath sounds, fair air movement
Abd - Soft, Tender to palp in epigastric/RUQ area, no guarding
Ext - No ext edema, mild wasting
Skin - No lesion
Neuro - AAO x 3, Myoclonus L>R, hyperrefexic in brachiorad and
patellar reflexes
Pertinent Results:
[**2170-10-3**] 05:55PM WBC-7.5# RBC-4.86 HGB-15.8 HCT-45.0 MCV-93
MCH-32.4* MCHC-35.0 RDW-13.9
[**2170-10-3**] 05:55PM PLT COUNT-237
[**2170-10-3**] 05:55PM GLUCOSE-88 UREA N-21* CREAT-0.7 SODIUM-143
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-32 ANION GAP-14
[**2170-10-3**] 05:55PM ALT(SGPT)-26 AST(SGOT)-25 ALK PHOS-64
AMYLASE-89 TOT BILI-0.4
[**2170-10-3**] 05:55PM LIPASE-63*
[**2170-10-3**] 05:55PM ALBUMIN-4.9*
[**2170-10-4**] 12:01AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2170-10-4**] 12:01AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2170-10-4**] 12:01AM URINE RBC-0 WBC-[**5-12**]* BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2170-10-4**] 12:01AM URINE GRANULAR-[**2-4**]* HYALINE-1*
.
CXR - 1. No free intraperitoneal air.
2. 4-cm mass within the right upper lung zone. Further
evaluation of this with a CT scan should be obtained.
.
Chest CT - 1. Approximately 3.7 x 2.4 cm noncalcified,
noncavitating enhancing mass in right upper lobe abutting the
right side of the mediastinum, with possible area of assocaited
post- obstructive subsegmental atelectasis. There is no
pathologically enlarged mediastinal or hilar lymphadenopathy.
These findings are concerning for a primary bronchogenic
carcinoma that may be accessible to
tiisue diagnosis by transbronchial biopsy. 2. 4-mm nonspecific
noncalcified subpleural nodule within the right lower lobe.
Second possible smaller nodule in the right lower lobe. 3. Tiny
hypodensity in the right lobe of the liver is too small to
characterize.
Brief Hospital Course:
62 yo F c multiple sclerosis, chronic LBP, initially presents
with hypercarbic respiratory distress, then intubated, trached
and found to have NSCLC.
.
# Lung cancer - Biopsy of the right upper lobe mass result came
back as nonsmall cell lung cancer and it is Stage III by mass
size. Oncology saw patient while in house. No treatment will be
offered given her prognosis and co-morbidity. Her husband had
refused to talk to oncology as inpatient. No staging had been
done due to husband's refusal to talk about her cancer. She will
be followed by oncology as outpatient as necessary for possible
palliative treamtment in the future.
.
# Respiratory failure-Patient initiailly presents with
hypercarbic respiratory failure and aspiration due to multiple
sclerosis. SHe was eventually intubated. Weaning had been
unsuccessful due mostly to muscles weakness from multiple
sclerosis. She had tracheostomy while in ICU. SHe will require
long term ventilatory support since her multiple sclerosis is
progressive. She is on pressure support on discharge. Her trach
had been downsized to size 7 prior to discharge to faciliate
ventilator assisted speech. She does have a lot of anxiety,
needs ativan prn and needs reassurance and training with speech
and swallow.
.
# Dysphagia/aspiration - Patient has significant aspiration per
studies by speech and swallow. However, patient is very eager to
eat. GIven her bad prognosis from her lung cancer and multiple
sclerosis, she needs to be evaluated by speech and swallow
again. If she insists on eating, she needs to understand the
aspiration riskk and the potential mortality from that.
.
# Multiple Sclerosis - Per most recent [**Month/Day (1) **] note, pt with
progressive cognitive decline requiring assitance with most
ADLs. [**Month/Day (1) 878**] recommended to discontinue Avonex treatment
given no clear benefit. Continue supportive management.
.
# urinary tract infection
She was found to have enterobacter UTI and was started on
bactrim to complete 7 days course(d1= [**11-17**])
.
# Chronic LBP - Currently stable. Continue lidoderm patch.
.
# Code - Full, confirmed with pt and husband.
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) ml
Injection TID (3 times a day).
3. Albuterol 90 mcg/Actuation Aerosol [**Month/Year (2) **]: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Six (6)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Senna 8.8 mg/5 mL Syrup [**Month/Year (2) **]: Five (5) ml PO BID (2 times a
day) as needed.
6. Docusate Sodium 150 mg/15 mL Liquid [**Month/Year (2) **]: One Hundred (100) mg
PO BID (2 times a day).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Year (2) **]:
One (1) Adhesive Patch, Medicated Topical Q O 12 H (): apply to
lumbar spine .
8. Simethicone 80 mg Tablet, Chewable [**Month/Year (2) **]: 0.5 Tablet, Chewable
PO QID (4 times a day).
9. Quetiapine 25 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO QHS (once a
day (at bedtime)).
10. Lorazepam 0.5 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day): hold for SBP<100, HR<60 .
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO BID (2 times a day) for 4 days: d1= [**11-17**].
14. Phenazopyridine 100 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3
times a day) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
1. respiratory failure from muscle weakness
2. non small cell lung carcinoma
3. multiple sclerosis
4. ventilator associated pneumonia
5. urinary tract infection
Discharge Condition:
stable
Discharge Instructions:
Please return to the ED or call your doctor if you have high
fever, shortness of breath, chest pain, failing on ventilator or
if there are any other concerns
Followup Instructions:
1. Please follow up with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4775**] 2 weeks
after discharge
2. Please call ([**Telephone/Fax (1) 14703**] to schedule an appointment with
oncology should you change your mind about talking to oncology
3. Please call ([**Telephone/Fax (1) 2528**] to schedule an appointment with
[**Last Name (NamePattern4) 109736**] [**Last Name (NamePattern1) **], MD [**First Name (Titles) 767**] [**Last Name (Titles) **] as needed.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"5070",
"5990",
"5845",
"53081"
] |
Admission Date: [**2124-2-4**] Discharge Date: [**2124-2-7**]
Date of Birth: [**2042-7-4**] Sex: M
Service: SURGERY
Allergies:
Keflex
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Post operative bleeding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 81M 10 days s/p resection of small bowel tumor who
presents with BRBPR X 2 (one last night, one this morning). He
denies any CP, SOB, nausea/vomiting, diziness, loss of
consciousness. He was taken to an OSH, where his Hct was 17,
coagulation parameters were normal. He had a tagged red cell
scan that localized bleeding to proximal small bowel by the
splenic flexure. He was given 2 units of PRBCs and transferred
to [**Hospital1 18**].
Past Medical History:
2 vessel CAD
- s/p PCI with DES in LCx and OM in [**6-/2123**] at [**Hospital1 18**]
Bladder Cancer s/p resection [**5-/2123**]
HTN
HLD
BPH s/p TURP
Depression
s/p appendectomy
Social History:
Wife just died of metastatic breast cancer during this admission
- Tobacco: never
- Alcohol: 6-8 beers a week
- Illicits: None
Family History:
Cardiac disease. Brother died of melanoma
Physical Exam:
Vitals: Afebrile, BP: 115/88 mmHg supine, HR 83bpm, RR 16 bpm,
O2: 99 % on 2L NC.
Gen: NAD, AAOX3
HEENT: No icterus. MMM. .
NECK: Supple, No LAD.
CV:RRR. normal S1,S2. gallops
LUNGS: CTAB anteriorly.
ABD: Soft, NT, slightly distended. Laparotomy wound stapled
and healing well.
EXT: NO CCE.
Pertinent Results:
MB: 3 Trop-T: <0.01
[**2124-2-7**] 05:00AM 29.6*
[**2124-2-6**] 05:40PM 30.8*
[**2124-2-6**] 08:11AM 29.6*
[**2124-2-6**] 01:49AM 29.1*
[**2124-2-5**] 10:06PM 26.7*#
[**2124-2-5**] 02:15PM 20.3*
Brief Hospital Course:
Patient is an 81 yo male s/p exploratory laporotomy and small
bowel resection for
a small bowel tumor on [**2124-1-25**]. Upon discharge he was stable
surgery and was holding his plavix. We have asked him to restart
plavix on wednesday [**2124-2-2**].
He developed the bleed on Thursday ([**2124-2-3**]), in the context of
re-initiating plavix. He was readmitted to [**Hospital6 **]
on [**2-4**] with BRBPR accompanied by chest pain, which he had his
last admission with severe anemia. His Hct was 17. Tagged RBC
scan showed bleeding in the proximal small bowel and he was
transferred to [**Hospital1 18**]. Here he has been transfused 7 units of
PRBC, 4u of FFP, and 2 bags of platelets. He continues to bleed
as evidenced by a falling Hct and maroon stools.
Patient's HCT was stable at 29 on [**2124-2-6**]. Patient had recieved
10 units of PRBC total and remains at a HCT of 19-30 for 24 hrs.
Patient was sent to a regular nursing floor. Patient with non
bloody stools, and no complaints of abdominal pain.
Patient was seen by cardiology for his left sided chest
pressure. His biomarkers were negative x3. Cardiology
recommended that there was no need to restart plavix, however,
patient should restart aspirin 81mg as soon as clinically able.
His target Hct >29 as primary treatment of coronary ischemia.
On [**2124-2-7**], patient was discharged to home with HCT >29,
hemodynamically stable with no complaints. Patient to follow up
with cardiology and surgery on an outpatient basis. He will
start his Aspirin 81mg in 48 hors after discharge.
Medications on Admission:
aspirin 325mg daily
plavix 75mg daily
ramipiril 5mg QD
Paxil 20mg QD
Lipitor 10mg Daily
Vitamin B 12 1000mcg monthly INJ
atenolol 100mg QD
Chlorthalidone 25mg PO daily
Discharge Medications:
1. paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Aspirin Low-Strength 81 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day:
Please start aspirin on Wednesday [**2124-2-9**].
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
LOWER GASTROINTESTINAL BLEEDING
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
* You were admitted to the hospital with weakness and dark
colored stools due to bleeding at previous surgery site.
* You required transfusion of blood products
* Your symptoms have resolved with transfusion of blood products
and holding of plavix. Please start aspirin in 48 hrs.
* You should continue to eat a regular diet and stay well
hydrated.
* If you develop fevers, abdominal pain or have any new symptoms
that concern you, please call the doctor or return to the
Emergency Room.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 2 weeks.
|
[
"2851",
"V4582",
"41401",
"4019",
"2724",
"311",
"412"
] |
Admission Date: [**2124-11-6**] Discharge Date: [**2124-11-11**]
Date of Birth: [**2095-3-3**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: I was asked to see this patient
in consult by Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] of cardiology. This
29-year-old male with history of hypertension,
hypercholesterolemia, is status post chemotherapy and x-ray
therapy for Hodgkin's disease. He has had [**3-18**] month history
of exertional chest discomfort which was relieved with rest.
He underwent a stress echocardiogram on [**10-27**] which was
stopped secondary to anginal symptoms. His EF at that time
was 40-45% with wall motion abnormalities. He then underwent
cardiac catheterization on [**10-31**] which showed an ejection
fraction of 40-45%, no MR, a 50% left main lesion, a 99%
proximal LAD lesion. His circumflex and right coronaries
were okay. He was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] for off pump
coronary artery bypass grafting.
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia,
fatty liver with elevated LFTs, Hodgkin's disease, status
post chemotherapy and radiation therapy at age 15. He had a
remote history of tobacco. He also had a positive family
history in that his mother had a myocardial infarction at age
37.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission include Aspirin 81 mg po q d.
PHYSICAL EXAMINATION: Heart rate 83, blood pressure 121/76,
he was satting 100% on room air. His HEENT exam was benign.
He had 2+ bilateral carotid pulses with no bruits or JVD.
His lungs were clear bilaterally. Heart was regular rate and
rhythm with no murmur, rub or gallop. He had a
noncontributory abdominal exam. His extremities had no
clubbing, cyanosis or edema. His radial artery had 2+
bilateral pulses as well as 2+ DP and PT pulses.
Neurologically is grossly intact, alert and oriented times
three.
Preoperative labs were sent off in preparation for his future
surgery with Dr. [**Last Name (STitle) 1537**] when he was seen on the 18th and the
patient returned on [**11-6**] for surgery and had an off pump
coronary artery bypass grafting times one with a LIMA to the
LAD by Dr. [**Last Name (STitle) 1537**]. He was transferred to cardiothoracic ICU in
stable condition on a Propofol drip.
HOSPITAL COURSE: On postoperative day #1 the patient had
been extubated the day prior. His postoperative labs were
white count 8.1, hematocrit 21.3, platelet count 153,000,
potassium 3.9, sodium 135, chloride 101, CO2 27, BUN 7,
creatinine 0.6 and blood sugar 96. He was tachycardic
slightly at 111, in sinus rhythm with a blood pressure of
98/52 and T max of 101.7. He was satting 95% on two liters
nasal cannula. He started on his beta blocker and Lasix
diuresis. His diet was advanced. His hematocrit was
followed closely. He continued to finish his perioperative
antibiotics and was on no hemodynamic drips at that time. He
was alert and oriented postoperatively and neurologically
intact. On postoperative day #2 he had no events overnight,
he remained tachycardic, in sinus rhythm at 114 on his
Lopressor which was increased to 25 mg [**Hospital1 **]. He also started
his Plavix and continued with Lasix. His hematocrit remained
stable at 21.3 with a potassium of 4.3 and creatinine of 0.5.
Chest tubes put out 275 cc so plan was to watch him during
the day and discontinue his chest tubes later in the day. He
was seen by case management. Given his young age, it was
anticipated he would be able to be transferred out to Far-2
on postoperative day #2.
He continued with tachycardia and was given additional doses
of Lopressor as needed. He was also encouraged to use
incentive spirometer, had poor effort at his own pulmonary
toilet, but he continued to do well on the floor. He was
alert and oriented with good peripheral pulses. He continued
to be slightly tachycardic. He had decreased breath sounds
of the left lobe of his lung, remained persistently
tachycardic. His hematocrit dropped to 20.3 on postoperative
day #3, down from 21.3 and the need for transfusion was
discussed. They continued to follow the patient closely.
The central venous line was removed and repeat EKG and chest
x-ray were done.
He was evaluated again by physical therapy. Catheter tip was
sent for culture given his tachycardia. All his narcotics
were discontinued and he was given Tylenol for pain. As his
systolic pressure was in the 80's to 90's range, he also
received a normal saline bolus but his systolic blood
pressure did not change.
Throughout the course of the day he was monitored for his
blood pressure and tachycardia. Given his persistent,
slightly elevated temperature, the cultures were sent off.
On postoperative day #4 he had some generalized weakness, a
little bit of confusion the evening prior after his Percocet
which was discontinued. On postoperative day #4 he had blood
pressure 114/72 with a pulse of 116 and sinus tachycardia.
He was satting 92% on room air. His hematocrit was 22 with
potassium of 4.2, BUN 14 and creatinine 0.6. He was alert
and oriented. His lungs were clear bilaterally in his upper
lobes but diminished breath sounds in bilateral bases. Heart
was regular rate and rhythm with normal S1 and S2 sounds.
His extremities were warm and well perfused. His sternal
incision was clean and dry and intact. He was encouraged to
ambulate and he was unable to increase his activity level,
then transfusion would be considered after his oxygen had
been weaned off. His Lopressor was increased to 50 mg [**Hospital1 **] at
that time with plan to discharge him home in the next couple
of days as he increased his stamina. He was strongly
encouraged to ambulate and continue aggressive pulmonary
toilet. Given his young age, all of this was thought to be
within reason.
On the night of the 28th he had a T max of 100.1, he was
ambulating in the [**Doctor Last Name **], he continued in sinus rhythm in the
100's to 120's, he was receiving Tylenol, Motrin po for his
incisional discomfort. He was given regular insulin on a
sliding scale and his incisional discomfort was treated as
needed. He was encouraged to use incentive spirometry every
hour. Patient was instructed to use his Percocet sparingly
once he did arrive at home and on the day of discharge the
patient had no acute events overnight on postoperative day
#5, but he did complain of a slight headache. His blood
pressure was 106/63 with a T max of 100.1, hematocrit 22,
potassium 4.2 and a creatinine of 0.6. He remained on
Metoprolol 50 mg [**Hospital1 **] with heart rate of 118. He had
decreased breath sounds in both bases. His hematocrit was
rechecked, his beta blocker was increased to 75 [**Hospital1 **] and
discharge planning was completed. The patient was discharged
to home in stable condition on [**2124-11-11**].
DISCHARGE MEDICATIONS: Lasix 20 mg po bid for 10 days, KCL
20 mEq po bid for 10 days, Colace 100 mg po bid, Zantac 150
mg po bid, Aspirin 325 mg po q d, Plavix 75 mg po q d, iron
complex 150 mg po q d, Metoprolol 50 mg po bid and Percocet
5/325 1-2 tabs po prn q 4-6 hours prn. Please note the
patient was instructed to use his narcotics sparingly.
DISCHARGE DIAGNOSIS:
1. Status post off pump coronary artery bypass grafting
times one.
2. Hypertension.
3. Hypercholesterolemia.
4. Fatty liver with elevated LFTs.
5. Hodgkin's disease status post chemotherapy and radiation
therapy at age 15.
Again, the patient was discharged to home in stable condition
on [**2124-11-11**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2124-11-28**] 12:02
T: [**2124-12-1**] 12:32
JOB#: [**Job Number 35143**]
|
[
"41401",
"4019",
"2720"
] |
Admission Date: [**2118-6-9**] Discharge Date: [**2118-6-13**]
Date of Birth: [**2066-8-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2118-6-9**] Coronary artery bypass graft times three (LIMA to LAD,
SVG to Ramus, SVG to PDA)
History of Present Illness:
Mr. [**Known lastname **] is a 51 year old male who presented to outside
hospital with exertional chest discomfort for the last six
months. EKG was notable for previous anterior wall myocardial
infarction(patient denies any history of previous MI), and
echocardiogram was consistent with mild ischemic cardiomyopathy.
Subsequent cardiac catheterization revealed severe multivessel
coronary artery disease including a left main lesion. Based upon
the above results, he was referred for surgical
revascularization.
Past Medical History:
Past Medical History:
Coronary Artery Disease
Prior Myocardial Infarction
Type II Diabetes Mellitus - newly diagnosed
Dyslipidemia
Past Surgical History:
Left Leg Vein Stripping
Multiple Knee Surgeries
Neck Surgery - Anterior Fusion
Social History:
Occupation: Senior [**Hospital 82143**] Medical Device Company
Lives with: Wife
[**Name (NI) **]: Caucasian
Tobacco: Quit yesterday, 35 pack year history
ETOH: social
Family History:
Mr. [**Known lastname 82144**] father had a myocardial infarction at age 55.
Physical Exam:
Pulse: 88 Resp:14 O2 sat: 99% RA
B/P Right: Left: 127/87
Height: 74 in Weight: 97.7 K
General: WDWN male in no acute distress
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], left leg stripping
Neuro: Grossly intact
Pertinent Results:
[**2118-6-11**] 06:50AM BLOOD WBC-11.5* RBC-3.43* Hgb-11.4* Hct-33.1*
MCV-97 MCH-33.3* MCHC-34.5 RDW-12.5 Plt Ct-123*
[**2118-6-9**] 11:35AM BLOOD WBC-22.2*# RBC-3.59* Hgb-12.0*#
Hct-35.3*# MCV-98 MCH-33.4* MCHC-34.0 RDW-12.5 Plt Ct-147*
[**2118-6-9**] 12:51PM BLOOD PT-14.3* PTT-30.9 INR(PT)-1.2*
[**2118-6-9**] 11:35AM BLOOD PT-14.6* PTT-27.2 INR(PT)-1.3*
[**2118-6-13**] 06:25AM BLOOD WBC-9.3 RBC-3.49* Hgb-11.7* Hct-34.5*
MCV-99* MCH-33.6* MCHC-34.0 RDW-12.2 Plt Ct-177
[**2118-6-13**] 06:25AM BLOOD Plt Ct-177
[**2118-6-9**] 12:51PM BLOOD PT-14.3* PTT-30.9 INR(PT)-1.2*
[**2118-6-13**] 06:25AM BLOOD Glucose-135* UreaN-12 Creat-0.7 Na-142
K-4.7 Cl-106 HCO3-24 AnGap-17
=======================================================
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82145**] (Complete)
Done [**2118-6-9**] at 8:42:50 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: [**2066-8-11**]
Age (years): 51 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Chest pain. Coronary artery disease.
Hypertension. Left ventricular function. Mitral valve disease.
ICD-9 Codes: 402.90, 786.51, 440.0, 424.0
Test Information
Date/Time: [**2118-6-9**] at 08:42 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 50% >= 55%
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA
ejection velocity. Cannot exclude LAA thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No thrombus in
the RAA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Normal RV wall thickness. Normal RV chamber size.
AORTA: Mildly dilated aortic sinus. Mildly dilated ascending
aorta. Normal aortic arch diameter. Focal calcifications in
aortic arch. Normal descending aorta diameter. Complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (?#). No AS. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No
mass or vegetation on mitral valve. Mild mitral annular
calcification. Calcified tips of papillary muscles. No MS.
Moderate (2+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may
be underestimated (Coanda effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
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 patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is moderately dilated. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. A left atrial appendage thrombus cannot be
excluded.
2. No thrombus is seen in the right atrial appendage No atrial
septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly depressed (LVEF= 40-45
%).
4. Right ventricular chamber size and free wall motion are
normal. Right ventricular chamber size is normal.
5. The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened . There is no aortic valve
stenosis. No aortic regurgitation is seen.
7. The mitral valve leaflets are moderately thickened. No mass
or vegetation is seen on the mitral valve. There is posterior
leaflet restriction and dilation of the annulus. Moderate (2+)
mitral regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect).
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. Sinus rhythm. Improved
biventricular systolic function after CABG. LVEF is now 50%.
There is improvement of the anterior and anteroseptal walls. The
MR is now mild. The aortic contour is normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2118-6-9**] 12:16
=============================================
Radiology Report CHEST (PA & LAT) Study Date of [**2118-6-12**] 7:00 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2118-6-12**] 7:00 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 82146**]
Reason: eval for pneumothorax s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
51 year old man s/p AVR
Preliminary Report !! WET READ !!
No change since recent comparison.
DR. [**First Name (STitle) **] [**Doctor Last Name 4391**]
Wet read entered: SUN [**2118-6-12**] 7:18 PM
Brief Hospital Course:
Mr [**Known lastname **] was a same day admission for coronary bypass grafting.
On [**2118-6-9**] Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a coronary artery bypass graft
times three (Left internal mammary to Left anterior descending
artery, Saphenous Vein Graft to Ramus, Saphenous Vein Graft to
Posterior Descending Artery). Cross Clamp time was 67 minutes,
bypass time was 90minutes. Please refer to Dr[**Last Name (STitle) 5305**]
operative note for further details. He tolerated the operation
well and was transferred in critical but stable condition to the
surgical intensive care unit. He did well in the immediate
post-operative period and was quickly extubated and weaned from
his pressors. By the following day he was ready for transfer to
the surgical step down floor for further monitoring. All lines
and drains were discontinued according to cardiac surgery
protocols. He was gently diuresed toward his pre-operative
weight. He was given beta blockers and an ACE-I as tolerated.
Physical therapy saw him in consultation. The remainder of his
postoperative course was uneventful. He continued to progress
and was ready for discharge to home on POD#4 with VNA. All
follow up appointments were advised.
Medications on Admission:
Medications at home:
Aspirin 325 qd
Metformin 750 qam
Lisinopril 10 qd
Metoprolol 12.5 qd
Simvastatin 40 qd
Nitro prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metformin 750 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*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 7 days.
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
coronary artery disease, s/p Coronary bypass grafting x3
PMH: Diabetes Mellitus, Dyslipidemia
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**] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**]) please
call for appointment
Dr [**Last Name (STitle) 82147**] (PCP) in [**1-14**] weeks ([**Telephone/Fax (1) 82148**]) please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2118-6-13**]
|
[
"41401",
"25000",
"2724"
] |
Admission Date: [**2190-4-3**] Discharge Date: [**2190-4-8**]
Date of Birth: [**2145-7-16**] Sex: F
Service: NEUROLOGY
Allergies:
Flagyl / Codeine
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
code stroke for L-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
44yo RH F h/o ITP s/p splenectomy, HTN, migraines with aura
who was mopping on Saturday and was last seen well at 5:30pm.
She
suddenly saw flashing lights as she does prior to a migraine and
walked into her brother's room to mop there and complained of
feeling very hot and dizzy, by which she means that she felt
like
she was going to have a seizure, by which she means that her
left
fingers "wanted to clench" and she was fighting it. She denies
light-headedness or feeling like the room was spinning. She then
slumped to the left and felt her arm/leg were weak and had some
very slight shaking of that side. She did not lose consciousness
or continence at any time. Her boyfriend observed her face to be
twisted (it is unclear if this means that there was a droop) and
saw her foaming slightly at the mouth. She seemed confused to
her
sister, looking around to both sides, "as if she did not know
what was going on". She complained of feeling hot and short of
breath. She did not have any slurred speech or difficulty
speaking. Upon EMS arrival, they tried to get her to stand but
her left leg was dragging.
She presented here as a code stroke and received tPA for an
NIHSS
of 5 (for left NLF flattening, a mild left
hemiparesis with left drift, a dense left hemianopia, possibly
some additional inattention to the left and extinction to double
simulataneous stimulation) at 7:40pm.
She was admitted to the neuro-ICU and suffered no complications
of tPA. She is now transferred to the neurology floor for
further
treatment and evaluation.
Past Medical History:
PMH:
HTN
ITP s/p splenectomy in [**2186**] (rec'd pneumovax)
Migraines with visual aura - daily for the past two years.
Consist of throbbing headaches preceeded by a visual [**Month (only) **] of
flashing lights. A/w nausea, P/P, worsened with cough/sneeze,
made better with motrin/sleep. Occasionally a/w L-sided numbness
h/o anxiety/panic attacks (no hospitalizations)
Social History:
SH: lives with boyfriend. Smoked for 20yrs, [**4-22**] cigs/day, quit
1yr ago. No etoh/drugs
Family History:
FH: +migraines in MGM, mother. Father and brother with [**Name (NI) 20976**]. No
h/o stroke or autoimmune disease
Physical Exam:
Normal neurologic exam
Brief Hospital Course:
The patient was seen in the ED and presented as a code stroke.
She was given IV tPA and admitted to the neurologic ICU for
24-hour observation and treatment of her acute stroke. She had
no complications of IV tPA treatment. CTA/CTP showed "No
hemorrhage, mass, hydrocephalus, shift of normally midline
structures is detected. Low density region is seen within the
left caudate nucleus, anterior limb of left internal capsule,
and medial aspect of the left lentiform nucleus consistent with
an area of chronic infarction, as there is also ex-vacuo
dilatation of the left frontal [**Doctor Last Name 534**] of the lateral ventricle.
The [**Doctor Last Name 352**]- white matter differentiation is preserved. The
contrast enhanced CT scan demonstrates areas of prolonged mean
transit time and reduced blood flow in the right frontal region,
linear in distribution, and a larger, wedge- shaped area in the
right posterior temporal region." CTA showed no stenoses that
would account for the above. Her exam and imaging were
consistent with acute right middle cerebral artery infarction.
MRI/A showed "Multiple foci of acute infarcts in the right
hemisphere, possibly embolic etiology. No hemodynamically
significant stenosis or filling defect noted in the intracranial
vasculature."
Her exam improved completely, to normal, by the time she was
transferred to the neurology floor and upon discharge. She had
already recanalized her vasculature by the time she received tPA
and most likely her improvement is due to endogenous thrombolyis
rather than tPA. The mechanism of her infarction is thought to
be a clot that broke up. TTE and TEE failed to reveal a
cardioembolic source. Possible risk factors include her migraine
headaches. Given her age, a hypercoagulable workup is pending.
Lipids were elevated and she was started on a statin. She was
also started on verapamil for migraine prophylaxis.
She was also found to be hypertensive and had a renal U/S, which
showed no renal artery stenosis; she was therefore started on an
ACEI for blood pressure control. Renal ultrasound incidentally
showed fatty liver; hepatitis panel was pending at discharge.
She will follow-up with neurology in stroke clinic.
Her hospital course was significant for a leukocytosis. She
remained afebrile with a normal differential, however, and the
leukocytosis is overall decreasing. CXR and UA were negative and
the clinical suspicion for infection is low. Most likely, it
represents a leukamoid reaction after the acute stroke. It
should be followed as an outpatient by her PCP.
She also had an episode of vaginal spotting and green discharge,
from a 2cm, round lesion on her labia that burst. She reported a
foul odor. Her exam is normal. We spoke with OB/Gyn, who
recommended follow-up as an outpatient and scheduled you her for
an appointment.
She will be seen as an outpatient in stroke clinic.
Medications on Admission:
motrin daily
no ASA
Atenolol 50
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right middle cerebral artery infarction
Migraine
Discharge Condition:
Normal neurologic exam
Discharge Instructions:
You were admitted to the neurology service after having a
stroke. Your deficits have resolved, but you will need to be
treated to prevent future strokes. This includes treatment for
high cholesterol and high blood pressure, diet and exercise.
Please continue to take all medications as prescribed and keep
all appointments.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 2530**] [**Name11 (NameIs) **] , [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2190-5-14**] 8:30
Provider: [**First Name8 (NamePattern2) 8031**] [**Last Name (NamePattern1) 10314**], MD Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2190-5-10**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2190-6-1**]
10:30
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2190-4-8**]
|
[
"4019",
"2720"
] |
Admission Date: [**2172-6-16**] Discharge Date: [**2172-6-19**]
Date of Birth: [**2116-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Chief Complaint: chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
56 yo M with pmh of HTN, hyperlipidemia, transferred from an OSH
where he presented with severe chest pain, diaphoresis,
shortness of breath of sudden onset this AM. He initially
attributed the chest pain to heart burn, however, the pain
worsened and moved to the left chest and he began to have pain
radiating to the neck and down the left arm. By EMS, he was
given 4 baby ASA, 4mg morphine and 1 SL NTG which provided some
relief of pain. Initial EKG showed 3-[**Street Address(2) 5366**] elevations in II,
III, AVF and ST depressions in I and AVL. On arrival at the OSH
he was started on a NTG gtt, heparin gtt, aggrastat gtt and
loaded with plavix 600mg. He was then transferred to [**Hospital1 18**] for
cardiac
catheterization. In the Cath lab he was found to have a 100% mid
cx acute occlusion with thrombus at the bifurcation of the Om
and CX. 2 bare metal stents were deployed to the LCX. Following
the procedure the pt. was hypoxic requiring 02 and had AIVR with
reperfusion of his coronaries. Therefore, he was transferred to
the CCU for further monitoring.
.
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 sudden onset of chest
pain, SOB, diaphoresis and the absence of dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
EKG following catheterization demonstrated resolution of the ST
elevation and depressions and Q waves developing inferiorly.
Past Medical History:
hypertension
hyper lipidemia
Social History:
married, lives with wife. Owns a home heating business. no
tobacco/etoh/IVDA
Family History:
Father- [**Name (NI) 1291**], vascular surgery of lower ext., macular
degeneration
Mother- breast CA (expired)
Physical Exam:
Blood pressure was 136/93 mm Hg while seated. Pulse was 81
beats/min and regular, respiratory rate was 19 breaths/min on a
NRB. Generally the patient was well developed, well nourished
and
well groomed. The patient was oriented to person, place and
time.
The patient's mood and affect were not inappropriate.
There was no xanthalesma and conjunctiva were pink with no
pallor
or cyanosis of the oral mucosa. The neck was supple without
detectable JVP. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
The abdomen was soft nontender and nondistended. The extremities
had no pallor, cyanosis, clubbing or edema. There were no
abdominal, femoral or carotid bruits. Inspection and/or
palpation
of skin and subcutaneous tissue showed no stasis dermatitis,
ulcers, scars, or xanthomas.
The catheterization site is dressed, non-erythematous, no bruit
auscultated and no hematoma was palpated.
Pulses:
Right: dopplerable DP and PT
[**Name (NI) 2325**]: dopplerable DP and PT
Pertinent Results:
Cath report [**2172-6-16**]:
1. Selective coronary angiuoplasty of this left dominant system
demonstrated single vessel coronary artery disease. The LMCA was
free
from angiographically-apparent disease. The LAD had mild luminal
irregularities. The LCX was a large vessel with 100% total
occlusion and
thrombus at mid segment extending into the proximal portion of a
large
OM1. The RCA was a small vessel without obstructive disease.
2. Limited resting hemodynamic assessment revealed elevated
right heart
filling pressures with mean PCWP of 24 mmHg. There was mild
pulmonary
hypertension with systolic pulmonary arterial pressure was of 37
mmHg.
Systemic blood pressure was normal (123/78 mmHg).
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease with abrupt occlusion of a
large
.
2D-ECHOCARDIOGRAM: [**2172-6-16**]
Conclusions: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with
akinesis of the basal and mid inferior/inferolateral
walls, and mid-lateral wall (LVEF 40-45%), consistent with
coronary disease in the left circumflex territory. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There
is no pericardial effusion. Limited study.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Dilated thoracic aorta.
.
CARDIAC CATH performed on [**2172-6-16**] demonstrated: LMCA- normal,
LAD-mild disease, RCA-SMALL, LCX- 100% LCX and OM occlusion. 2
bare metal stents were deployed. Stented main LCX and rescued OM
with resulting 0% occlusion in the LCX and 30-40% in the OM with
normal flow.
.
LABORATORY DATA:
.
141 110 11 14.4
---|-------|------< 106 13.1>------< 266
4 22 0.9 40.5
.
[**2172-6-16**] 01:39PM CK-MB-339* MB INDX-8.4* cTropnT-8.43*
[**2172-6-16**] 01:39PM CK(CPK)-4046*
[**2172-6-16**] 09:42PM CK-MB-217* MB INDX-7.5* cTropnT-12.07*
[**2172-6-16**] 09:42PM CK(CPK)-2880*
Brief Hospital Course:
This is a 56 yo male with a pmh of HTN, hyperlipidemia who was
transferred to [**Hospital1 18**] for cardiac catheterization for an inferior
STEMI now s/p cardiac catheterization and stenting to the circ.
and OM, he was admitted to the CCU for STEMI, hypoxia and AIVR
following cardiac catheterization.
1. CAD/STEMI: The patient presented with signs and symptoms
consistent with an anterior STEMI. He was transferred from an
OSH for cardiac catheterization. In the cath lab ePt. presented
with a STEMI now s/p PTCA with stenting (bare metal) of
the LCX and rescue of the OM. Following the catheterization he
had an episode of AIVR and was hypoxic [**3-13**] to volume
overload/CHF. He was initially requiring a NRB which was weaned
off along with diuresis. For his CAD he was started on plavix 75
qday which will need to be continued for a minimum of 1 year. He
will also need to continue ASA 32 qday, atorvstatin 80, toprol
xl (d/c'd on 100 qday).
.
2. Congestive heart failure: The patient required significant
supplemental 02 likely [**3-13**] to CHF in setting of acute MI. His EF
by echo was 40-45%. He was diuresed aggressively and his 02 was
weaned. He was discharged on po lasix.
.
3. Glucose intolerance: The patient had an elevated BG
throughout his stay. He will follow up with his primary care
physician regarding possible [**Name9 (PRE) 2320**].
.
4. PPX: bowel reg., pneumoboots
.
5. FEN: heart healthy diet. PT consult
.
6. Code: full
Medications on Admission:
Diovan 80 qday
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. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Acute ST-elevation myocardial infarction
2. Glucose intolerance
3. Congestive heart failure
Discharge Condition:
good, pain free
Discharge Instructions:
You had a heart attack and had a stent placed in an artery in
your heart.
Followup Instructions:
Please follow-up with your cardiologist Dr. [**Last Name (STitle) 11493**] on Monday
Your fasting blood sugar was elevated, putting you at risk for
diabetes. You should mention this to your PCP.
Completed by:[**2172-6-19**]
|
[
"41071",
"4280",
"41401",
"4019",
"2724"
] |
Admission Date: [**2149-4-1**] Discharge Date: [**2149-4-7**]
Date of Birth: [**2078-7-25**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Ciprofloxacin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
nausea, chills, fevers x1 day
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 y/o man with PMH significant for Crohn's disease and chronic
TPN complicated by multiple line infections admitted to the [**Hospital Unit Name 153**]
on [**4-1**] with probable sepsis thought to be due to line
infection. In pertinent recent history, pt has had multiple
recent line infections with [**Female First Name (un) 564**] parapsilosis, VRE, and
Klebsiella pneumoniae. His last hospitalization was from
[**Date range (1) 40090**] with Klebsiella, Pseudomonas and Citrobacter in his
urine and Klebsiella in blood. At that time, he was treated with
linezolid/ambisome/ertapenem and discharged on ceftaz. Pt
stopped the ceftaz on [**3-26**].
.
Pt returned to the ED on [**4-1**] with, fever, cough, and chills.
In the ED, the pt was initially hypertensive in the 200s with a
temperature of 102. He was tachypnic in the 40s. Pt then
developed rigors and his SBP dropped into the 60s. His lactate
returned elevated at 5.6. Pt received 3 liters of IV fluid and
his lactate decreased to 2.8. Pt was started on levophed for BP
support. ID was consulted and the pt received meropenem,
ambisome, and linezolid. Pt mentated well throughout this entire
time. He was transferred to the [**Hospital Unit Name 153**] for further care.
.
In the [**Hospital Unit Name 153**], the pt was successfuly weaned off of the levophed
overnight. He received D5W with 3 amps of bicarb. Blood cultures
from his L groin line and peripherally from the left forearm
grew gram negative rods. [**Last Name (un) **] stim test had appropriate bump of
approximately 9 points. Pt was continued on meropenem but
ambisome and linezolid were discontinued per the ID consult. At
this time, ID and IR working together to determine what will
need to be done regarding access. Plan was made to get imaging
of possible subclavian and IJ sites tomorrow and then will
determine where to place new line. Plan to treat through
existing line until new access site obtained. He will be
transfer to the floor for further care at this time.
Past Medical History:
1. Crohn's disease - diagnosed in mid 70s, s/p multiple small
bowel and R colon resections resulting in short bowel syndrome,
TPN dependent x20 yrs, with multiple bacteremias/candidemias;
c/b obstructions, fistula, abscesses. Has an end-ileostomy; s/p
recent mucous fistula closure and [**Doctor Last Name 3379**] pouch. Short gut
syndrome
2. R renal cell Ca s/p R nephrectomy
3. chronic kidney disease, thought to be [**2-26**] interstitial
nephritis, baseline Cr 2.7
4. h/o ARDS with residual interstitial fibrosis
5. h/o CVA [**59**] years ago on Plavix
6. occlusion of central venous access
7. h/o LUE DVT
8. h/o pancytopenia with nl bone marrow
9. last echo 11/140/4: EF 60%, mild AR, mild TR, mild MR
10. Recent ID related admissions:
- [**1-4**] to [**1-17**]: Femoral line in place since [**12-13**] grew C
parapsilosis. Pt was treated with IV vanc/ceftaz/caspofungin for
12 days then changed to ambisome.
- [**1-29**] to [**2-19**]: Pt in ICU due to hypotension, acidemia, and
hypoxia. Required dopamine. Developed acute on chronic renal
failure. Cultures grew klebsiella and VRE. CT showed dilated CBD
at 1 cm, bilateral pleural effusions, question of diffuse
varices. ERCP was done which showed a dilated CBG but no stone,
mass or stricture. Pt was treated with ambisome, zyvox, and
artapenem. He had a new line placed on [**2-14**].
- [**2-27**] to [**3-8**]: Admitted with tenderness and erythema at the
Hickman site. Urine and blood cultures grew klebsiella and
pseudomonas. Pt was treated with zyvox, ertapenem, and ambisome.
Hickman line was removed. Line was then replaced on [**3-6**]. Pt
was discharged on ceftaz as above.
PSH:
1. multiple bowel resections as above, has R end ileostomy,
mucous fistula, now closed
2. cholecystectomy [**2-26**] gallstones
3. hernia repair (adjacent to mucous fistula)
4. R nephrectomy [**2-26**] renal cell Ca
Social History:
Lives with daughter and wife, remote tobacco history, no
significant alcohol, no IVDU.
Family History:
noncontributory; no Crohn's
Physical Exam:
Gen: elderly male, NAD, oriented and conversational
HEENT: PERRL, EOMI, MM dry
Neck: no JVD
CV: RRR, nl S1/S2, no murmurs appreciated
Pulm: CTAB, good air movement
Abd: ostomy in place, draining yellowish stool; midline
incisional scar, intact and well-healed; L tunneled cath on L
part of abdomen, without erythema, drainable pus, tenderness to
palpation, or other evidence of infection
Ext: 2+ distal pulses, fingers cool to touch but with good cap
refill, amputated 3rd-5th fingers on L hand
Pertinent Results:
CXR ([**4-1**])- Normal mediastinal contours. Ill defined opacity
overlying the right hilum not seen in lateral film and most
probably due to technique. Lungs are hyperinflated with
flattening of the diaphragsm consistent with emmphysematous
changes. Blunting of the left costophrenic angle posteriorly
which may be related to pleural thickening or small pleural
effusion.
.
Liver US ([**4-2**])- Liver of normal echogenicity with no
intrahepatic ductal dilation. Common bile duct measure 4 mm in
diameter proximally and up to 6-8 mm in its mid portion. No
ascites. Main portal vein is patent and its flow is hepatopetal.
.
CT abdomen and pelvis ([**4-2**])- Lungs demonstrate emphysematous
changes with bibasilar atelectasis and small bilateral pleural
effusions. In the left lobe of the liver, there is a 1 cm focus
of low attenuation consistent with a simple cyst. Small amount
of fluid surrounding the liver and in the right paracolic
gutter. Pt is s/p cholecystectomy and right nephrectomy. There
is compensatory hypertrophy of the left kidney. There is a 3.6
cm simple cyst in the lower pole of the left kidney. Fluid
surrounding the loops extending into the pelvis. There is fluid
in the pelvis surrounding loops of bowel. No free air in the
pelvis.
MRI Chest ([**2149-4-3**])- Gadolinium enhanced MR [**First Name (Titles) 36062**] [**Last Name (Titles) 4579**]s patency of the right internal jugular vein
proximally, but within the distal neck, this vessel becomes
diminutive and is not traceable. Similarly, the distal aspect of
the SVC (the portion emptying into the right atrium) is well
visualized, but more proximally, this is not seen. There is a
prominent azygos vein and collateral network. The azygos vein
measures 12-13 mm in diameter. No axillary or subclavian vein is
evident on either side. The left internal jugular vein is
similarly very small. A diffuse network of superficial
collateral vessels is noted bilaterally.
Brief Hospital Course:
1. Sepsis - Pt was initially placed on MUST protocol for sepsis
when he spiked fever, had high lactate, and hypotension. He was
put on Levophed transiently, which was able to be weaned over
the course of the first night. Pt was bolused further with D5W
with 3amps bicarb as had an underlying metabolic acidosis. Pt
was pan-cultured, and within 24 hours, blood cultures from L
tunneled [**Doctor Last Name **] x2 grew GNR, as did a L forearm blood culture.
Pt was initially started on meropenem, ambisome, and linezolid,
given past candidemias and infections with Klebsiella, as well
as VRE colonization. His tunneled cath was left in place, as IV
access was a [**Last Name 16423**] problem ([**Name (NI) **] placed, but pt could not get
another central line due to massive central venous thrombosis
and occlusion), and peripheral IVs could not be placed by IV RNs
in the setting of active infection. Per ID recommendation,
antibiotics were narrowed to meropenem only. He remained
hemodynamically stable since he was transferred to the floor.
MRA/MRV of the chest was done to assess any patent veins that
could potentially be accessed. Unfortunately, all of the
central veins were occluded and the venous drainage seem to be
supplied by extensive collaterals. After reviewing this
imaging, Dr. [**First Name (STitle) **] from IR and ID decided to treat through the
existing tunneled femoral line for 4 weeks, and place a new
tunneled line by possible recanalization while pt is on
meropenem. He will then be on meropenem for additional week to
completely eradicate the infection. He will be getting
meropenem 1 gm [**Hospital1 **] at home. He will have a VNA come once/day to
hang the antibiotic. It is preferable that either his wife or
daughter could hang the second antibiotic in the evening to
minimize the risk of re-infection.
2. Line issues - Pt requires permanent line for TPN. Dr. [**First Name (STitle) **]
from IR was consulted, and possibilities include placing a
tunneled cath from abdomen to neck versus recanalization of SVC.
Concern was raised for pt's technique for hooking himself up to
TPN and ostomy care. As stated above, decision was made to
treat through the existing line for 4 weeks, and then to have a
new permanent line placed while he is on antibiotic. He was
instructed to minimize the contact with the TPN and the
antibiotic that will be administered. His wife and daughter
seem to be able to help out with these tasks at home.
3. Pancytopenia - etiology unclear, reportedly had normal bone
marrow biopsy. As had thrombocytopenia, a HIT antibody was sent
from the ED which came back negative.
4. Crohn's disease - Pt did not have signs of an acute flare, as
abdominal exam is benign. Pt with chronic diarrhea from short
gut syndrome; C diff was sent which came back negative.
5. Elevated alk phos - pt s/p recent cholecystectomy and ERCP
with dilated CBD. A biliary source was considered as the
etiology of GNR sepsis, and a RUQ ultrasound and CT abdomen were
performed but showed no evidence of focal infection.
6. Chronic kidney disease - Pt's Cr at baseline (2.1-2.6 at
NEBH). Meds were renally dosed.
7. COPD - pt with emphysematous changes on CXR. He was
continued on spiriva, albuterol, and atrovent, with prn nebs.
Pt was moving good air without evidence of acute COPD flare.
8. FEN - TPN was held initially due to infection and concern of
adding bacterial medium. He was given a po diet, as he
tolerates po. His TPN was later re-started at his home regimen.
He will resume with his home TPN regimen daily.
Medications on Admission:
ambisome twice weekly for fungemia prevention
lomotil
flovent
spiriva
norvasc 5mg po daily
trazodone 50mg po daily
celexa 10mg po daily
remeron
catapres 0.1mg patch qSaturday
plavix 75mg po daily
protonix 40mg po daily
immodium
recent ceftaz course 1g q24h, completed [**3-26**]
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
2. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
3. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSAT (every Saturday).
4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Trazodone HCl 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at
bedtime) as needed.
9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-26**]
Puffs Inhalation Q6H (every 6 hours) as needed.
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q12H (every 12 hours) for 5 weeks.
Disp:*70 Recon Soln(s)* Refills:*0*
13. TPN
Pleaes resume TPN at the regimen he was on previously.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
Primary diagnosis:
1) Citrobacter freundii bacteremia with line sepsis
Secondary diagnosis:
2) Crohn's disease
3) Short-Gut syndrome, TPN Dependent x 20 years
4) Chronic Pancytopenia
5) Chronic renal insuffeciency
Discharge Condition:
Stable
Discharge Instructions:
Patient needs to take all of the medications as instructed. He
needs to take Meropenem twice/day for 4 weeks. Preferably,
meropnem should be administered by someone else to reduce
contamination. He needs to have CBC with diff and Chem 12
checked twice/week and have the result faxed to Dr. [**Last Name (STitle) **].
Pt needs to follow up with Dr. [**First Name (STitle) **] in [**3-28**] weeks. He needs to
seek medical attention for fevers, chills, chest pain, shortness
of breath, abdominal pain, bleeding from line site, or any other
concerning sympoms.
Followup Instructions:
1. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 1356**]
within one week of discharge. Call [**Telephone/Fax (1) 40091**] to schedule an
appointment.
2. Please call Dr.[**Name (NI) 40092**] office [**Telephone/Fax (1) 25094**] to follow up with
her in [**3-28**] weeks.
3. Please have the lab result faxed to Dr. [**Last Name (STitle) **] (FAX:
[**Telephone/Fax (1) 1419**])
4. Call your Hematologist, Dr. [**Last Name (STitle) **] for a follow-up appointment
to further discuss your pancytopenia (low white cell count, low
red cell count, and low platelet count)
5. Please follow up with Dr. [**Last Name (STitle) **] on [**4-21**] at 1:30pm
Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2149-4-21**] 1:30
Completed by:[**2149-4-7**]
|
[
"99592",
"78552",
"2762",
"40391"
] |
Admission Date: [**2150-5-19**] Discharge Date: [**2150-5-24**]
Date of Birth: [**2103-11-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5510**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46 y/o female with a history of DMI, numerous admissions for
DKA/gastroparesis who was admitted to MICU on [**2150-5-19**] with DKA
(AG 28) in the setting of nausea/vomiting. On transfer to
medical wards, her AG has closed, but her nausea and vomiting
persist.
.
Patient notes that she developed nausea at 5am on date of
admission. Nausea for greater part of the day. Then developed
vomiting and diaphoresis in early evening (after 5pm) and some
mild right sided abdominal pain. Then developed intractable
vomiting so presented to the ED around 6pm.
.
Initial ED VS 99, 180/111, 144 and 100/RA. Upon initial
evalatuion, was noted to be diabetic so was given SC insulin,
then had noted to have anion gap. Given IV fluid with Zofran 4mg
IV x 2, Ativan 0.5 mg x 2. Was noted to be hypertensive with SBP
200s, denied any blurred vision, headache and transferred
physician was not concerned about signs of hypertensive urgeny.
Also noted to have self-gagging in ED while nauseous. Given 10U
SC insulin, repeat glucose 499, transferred to MICU for insulin
gtt due to AG and concern for DKA. Tachycardia to 130s upon
transfer.
.
Upon arrival to MICU, confirmed history as above. States no
identifiable infectious symptoms. Admits to some urinary
retention in ED which is new for her. Rest of ROS was negative.
.
In the MICU, patient was followed by [**Last Name (un) **]. She was placed on
insulin gtt. Her AG closed, but per nausea/vomiting persisted.
There was also concern for self-gagging and intentional vigorous
coughing resulting in post-tussive emesis. GI was notified of
patient, and they will consider EGD with botox injection for her
gastroparesis.
Past Medical History:
Type I Diabetes: neuropathy, h/o gastroparesis, h/o gastric
pacer
Hypertension
GERD/Esophagitis
Port placement in [**2146**] secondary to poor IV access
Social History:
Lives at home with her husband and has no children. She denies
tobacco, alcohol and drug use. WOrks in a development office
Family History:
mother - lung cancer, diabetes
father - died of heart disease
Maternal GM/uncle have Type 1 diabetes mellitus per previous
records
Physical Exam:
Admission Physical Exam:
VITAL SIGNS: 98.7, 130, 152/102, 19, 96/RA
GEN: vomiting, AOx3; intermittently putting finger in throat to
aid in vomiting
HEENT: JVP 9cm, OP clear, MMM, face diaphoretic
CHEST: CTAB
CV: Tachycardic, regular with 2/6 systolic murmur at RUSB
ABD: soft, minimally tender, ND, no masses or organomegaly, BS+
EXT: WWP, no c/c/e
NEURO: grossly normal
DERM: no rashes
Pertinent Results:
LABS ON ADMISSION:
[**2150-5-19**] 08:20PM BLOOD WBC-13.2*# RBC-4.83 Hgb-12.8 Hct-39.0
MCV-81* MCH-26.5* MCHC-32.8 RDW-14.8 Plt Ct-342#
[**2150-5-19**] 08:20PM BLOOD Neuts-84.0* Lymphs-11.7* Monos-3.6
Eos-0.2 Baso-0.5
[**2150-5-19**] 08:20PM BLOOD Plt Ct-342#
[**2150-5-19**] 08:20PM BLOOD Glucose-529* UreaN-15 Creat-1.0 Na-129*
K-4.5 Cl-88* HCO3-18* AnGap-28*
[**2150-5-19**] 08:20PM BLOOD ALT-17 AST-19 AlkPhos-85 TotBili-0.7
[**2150-5-19**] 08:20PM BLOOD Lipase-46
[**2150-5-19**] 08:20PM BLOOD Albumin-4.5
[**2150-5-19**] 08:20PM BLOOD Acetone-MODERATE
[**2150-5-20**] 01:31AM BLOOD Type-[**Last Name (un) **] Temp-36.4 pO2-44* pCO2-37
pH-7.41 calTCO2-24 Base XS-0
[**2150-5-19**] 10:01PM BLOOD Glucose-499* Lactate-3.7*
.
LABS ON DISCHARGE:
[**2150-5-23**] 06:17AM BLOOD WBC-9.5 RBC-4.03* Hgb-10.8* Hct-32.3*
MCV-80* MCH-26.8* MCHC-33.4 RDW-14.6 Plt Ct-209
[**2150-5-23**] 06:17AM BLOOD Plt Ct-209
[**2150-5-23**] 06:17AM BLOOD Glucose-57* UreaN-5* Creat-0.8 Na-134
K-3.7 Cl-99 HCO3-28 AnGap-11
[**2150-5-23**] 06:17AM BLOOD Calcium-8.5 Phos-4.7* Mg-2.1
[**2150-5-20**] 05:17AM BLOOD Lactate-1.0
.
MICRO:
[**5-19**] blood cx - NGTD
[**5-20**] urine cx - negative
Brief Hospital Course:
46 y/o female with DM1, numerous admissions for gastroparesis,
nausea, vomiting who was admitted with diabetic ketoacidosis.
.
# Diabetic Ketoacidosis due to gastroparesis: in setting of
anion gap acidosis (AG 28) with moderate acetone and FS > 400;
all consistent with DKA in setting of gastroparesis and
longstanding IDDM. Unclear etiology for current flair. Was
placed on an insulin drip until her anion gap closed on [**2150-5-20**].
She was then continued on an insulin gtt for an additional 24
hours given poor oral intake. With continued controlled blood
sugar with SC insulin, she was transitioned off the infusion and
continued on a subcutaneous sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recommendations. No etiology beyond a known history of
gastroparesis was found for her current presentation. Infectious
work-up was negative. On discharge, patient's blood sugars were
well controlled with lantus 28 units at supper-time, and RISS.
Gastroenterology followed the patient throughout her stay. There
was consideration for EGD with Botox injections, but this will
be pursued as an outpatient with her GI physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10689**].
.
# Anion gap acidosis: likely related to DKA, lactate elevated to
3.7 on admission. She took her full dose lantus night prior to
admission, no insulin the day of admission given nausea. As
above, gap closed with insulin infusion. Potassium was monitored
closely and repleated as needed and lactic acidosis resolved to
1.0 on discharge.
.
# Nausea/vomiting: consistent with DKA in setting of
gastroparesis and longstanding DM. Unclear etiology for current
flair. LFTs and lipase wnl. Denies non-compliance. Has not
tolerated erythromycin in the past for her gastroparesis. Was
continued on home anti-emetics. Also, during this admission,
there was witnessed induction of vomiting and concern for
intentional coughing triggering post-tussive emesis for which
patient met with SW (see below).
.
# Hypertension: Poorly controlled upon arrival. Patient states
she takes lisinopril but not metoprolol (though on prior d/c
summary). Given initial NPO status, was continued on enalapril
and metoprolol IV. Once she was tolerating PO foods, these were
converted to her home blood pressure regimen with good control.
.
# Urinary retention: Patient stated she had no urge to urinate
the day of admission but foley was placed with 900cc urine
output. Denies any fever, chills or preceeding dysuria. No
changes in lower extremity strength, numbness or saddle
sensation. Urinalysis was not indicative of infection. Foley
was removed the within 48 hours and she had no evidence of
retention.
.
# Diabetes Mellitus: As above, was controlled initially with
insulin infusion, and then transitioned to subcutaneous dosing.
On discharge, she was placed on her same regimen prior to
admission with good blood sugar control. This discharge regimen
was 28 units lantus with supper and RISS.
.
# Social: numerous admissions for gastroparesis/DKA. Has seen
psych in the past as well. Also, during this admission, there
was witnessed induction of vomiting and concern for intentional
coughing triggering post-tussive emesis. Met with SW;
consideration for domestic violence screen given repeated
hospitalizations with concern for secondary gain. However, per
SW impression, there was no concern for domestic violence or
secondary gain.
.
# Dispo: discharge to home, PCP and GI [**Name9 (PRE) 702**], consideration
for outpatient EGD with botox injection
Medications on Admission:
Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for nausea.
Domperidone (Bulk) Powder Sig: Ten (10) mg Miscellaneous three
times a day.
Lantus 100 unit/mL Solution Sig: Twenty Eight (28) units
Subcutaneous at bedtime: Take as previously prescribed prior to
admission.
Humalog 100 unit/mL Solution Sig: 1-16 units Subcutaneous three
times a day: Take as previously prescribed per sliding scale.
Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig:
One (1) Capsule, Delayed Release(E.C.) PO once a day.
Compazine 10 mg Tablet Sig: 0.5-1 Tablet PO every six (6) hours
as needed for nausea.
ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a
day.
Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours: As previously prescribed.
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for nausea.
3. Domperidone (Bulk) Powder Sig: Ten (10) mg Miscellaneous
three times a day.
4. Lantus 100 unit/mL Solution Sig: 28 units at supper-time
units Subcutaneous once a day.
5. Humalog 100 unit/mL Solution Sig: 1-16 units units
Subcutaneous three times a day: Take as previously prescribed
per sliding scale.
6. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
7. Prochlorperazine Maleate 5 mg Tablet Sig: 1-2 Tablets PO Q6H
(every 6 hours) as needed for nausea.
8. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) transdermal
Transdermal every seventy-two (72) hours.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. diabetic ketoacidosis
2. nausea/vomiting
3. gastroparesis
.
SECONDARY:
1. type I diabetes with associated neuropathy
2. status post gastric pacer
3. hypertension
4. GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for very high blood sugars,
nausea, vomiting, and a flare of your gastroparesis. Your
elevated blood sugars required ICU admission and intravenous
insulin. You were followed closely by the [**Last Name (un) **] doctors. [**First Name (Titles) 2172**] [**Last Name (Titles) 17094**] sugars subsequently improved, and on discharge you are to
continue 28 units of lantus at supper-time.
.
You also had nausea/vomiting and a flare of your gastroparesis.
Your diet was slowly advanced, and you were tolerating a regular
diet on discharge. We discussed the possibility of EGD with
botox injection, but this can be pursued and arranged as an
outpatient with your GI doctor, Dr. [**Last Name (STitle) 10689**].
.
NEW MEDICATIONS/MEDICATION CHANGES:
- none
.
Please seek medical attention for worsening nausea, vomiting,
abdominal pain, inability to tolerate food, fevers, chills,
persistently high blood sugars, chest pain, shortness of breath,
or any other concerns.
Followup Instructions:
Please call [**Telephone/Fax (1) 7477**] to schedule an [**Telephone/Fax (1) 648**] with your
primary care doctor, Dr. [**First Name (STitle) **].
.
Please call Dr.[**Name (NI) 17074**] office to schedule an [**Name (NI) 648**] to
discuss options for treating your gastroparesis, including
outpatient EGD with botox injection.
Completed by:[**2150-5-24**]
|
[
"4019",
"53081"
] |
Admission Date: [**2138-8-3**] Discharge Date: [**2138-8-5**]
Date of Birth: [**2138-8-1**] Sex: F
Service: NEONATOLOGY
HISTORY OF THE PRESENT ILLNESS: Baby girl [**Known lastname **] was the
4000 gram product of 41 week gestation born to a 29-year-old
G1, P1 mother. Prenatal screens: O positive, antibody
negative, RPR nonreactive, rubella immune, hepatitis surface
antigen negative, GBS negative mother with an estimated date
maximum temperature of 100.6 in labor. Prenatal ultrasound
demonstrated dilated kidneys, "likely" hydronephrosis.
Infant delivery by normal spontaneous vaginal delivery and
received routine care in the delivery room. Assigned Apgar
scores of 9 and 9 at 1 and 5 minutes respectively. Infant
noted at approximately 12 hours of life to have a dusky
episode. Evaluated by neonatology. Infant brought to the
benign. Clinical examination reassuring. Infant transferred
back to the Newborn Nursery for continued observation and
teaching. Subsequent dusky episode noted at 5 am on [**2138-8-3**]. At this time, the infant was transferred to the
Newborn Intensive Care Unit for further monitoring.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: Weight 37.90. Infant was pink, well perfused,
regular rate and rhythm, no murmur, clear breath sounds.
ABDOMEN: Soft, positive bowel sounds, no hepatosplenomegaly/
PULSES: 2+ pulses. SKIN: Clear without petechia, purpura,
or rashes. Nonfocal neurological examination.
HOSPITAL COURSE: (by system)
RESPIRATORY: The infant was placed oximeter and
cardiorespiratory monitor for monitoring for further dusky
episodes. Infant has had no further dusky episodes in the
Newborn Intensive Care Unit. RA saturations have been in the
high 90s to 100 range.
CARDIOVASCULAR: Within normal limits. No audible murmurs.
FLUIDS, ELECTROLYTES, AND NUTRITION: Infant is ad lib breast
feeding two to three hours. Current weight: 3790.
GASTROINTESTINAL/GENITOURINARY: Prenatal diagnosis of
question of hydronephrosis, plan to follow up with the
pediatrician to schedule outpatient renal ultrasound. Infant
has been voiding sufficient quantitities.
HEMATOLOGY: Hematocrit on admission was 59.8. No further
hematocrit were obtained or blood products were given.
INFECTIOUS DISEASE: CBC and blood culture obtained in light
of material temperature maximum of 100.6 and dusky episode in
Newborn Nursery. CBC was benign. Blood culture remained
negative at 48 hours. Infant has not received any
antibiotics during this hospital course.
NEUROLOGICAL: Appropriate for gestational age.
SENSORY: Hearing scan was performed by automated auditory
brain-stem responses and infant passed both ears.
PSYCHOSOCIAL: Social worker has been involved with the
family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**]. Pediatrician:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from [**Hospital 1887**] Pediatrics. Telephone #:
[**Telephone/Fax (1) 37518**].
FEEDS AT DISCHARGE: Continue ad lib feedings, breast milk.
MEDICATIONS: Not applicable.
CAR-SEAT POSITION SCREENING: Passed.
STATE NEWBORN SCREEN STATUS: Status has been sent on [**2138-8-4**]. Results: Pending.
IMMUNIZATIONS RECEIVED: The patient received hepatitis B
vaccine on [**2138-8-1**].
FINAL DIAGNOSIS:
1. Post-date infant status post cyanotic episode secondary
to discoordination.
2. Status post rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 44313**]
MEDQUIST36
D: [**2138-8-5**] 11:44
T: [**2138-8-5**] 11:56
JOB#: [**Job Number 44314**]
|
[
"V290",
"V053"
] |
Admission Date: [**2190-10-5**] Discharge Date: [**2190-10-6**]
Date of Birth: [**2123-4-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
mesenteric ischemia
Major Surgical or Invasive Procedure:
ex lap
History of Present Illness:
67M acute abdominal pain x 8 hours, transferred from OSH with
diagnosis of mesenteric ischemia.
Past Medical History:
h/o etoh abuse
PVD
Social History:
etoh abuse
+IVDA
h/o cigs
Family History:
estranged from family
Physical Exam:
intubated
tense distended abdomen
Pertinent Results:
refer to carevue
Brief Hospital Course:
Taken emergently to OR, discovered to have diffusely ischemic
small bowels.
Transferred to SICU, where he quickly passed away without pain
Medications on Admission:
coumadin
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
ischemic bowel
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2190-10-6**]
|
[
"2762",
"V5861"
] |
Admission Date: [**2111-8-4**] Discharge Date: [**2111-8-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Hemodialysis - one treatment only.
History of Present Illness:
HPI: This is an 86 yo F with a past medical history of dementia,
CHF, depression, anxiety, multiple lumbar compression fractures,
who has been recently treated for a UTI with cipro and then
started on flagyl for c diff, referred to [**Hospital1 18**] ED from nursing
home after she was found to have a BUN/Cr 140/11.7 with no prior
history of renal failure.
.
In the ED, she was found to be alert and confused, seemingly at
baseline with intermittent agitation, and with stable vitals.
She was found to have low urine output, and hyperkalemia. She
was given calcium gluconate, insulin and kayexalate and renal
was consulted, who felt that her renal failure was likely
secondary to dehydration from cdiff and recommended IVF
hydration. She had a renal ultrasound that was negative for
nephrolithiasis, hydronephrosis or free fluid. She was also
incidentally found to have a left sided pleural effusion.
.
She was transferred to the [**Hospital Unit Name 153**] for further management of her
acute renal failure for increased level of nursing care
secondary to agitation.
Past Medical History:
CHF
Dementia
depression
anxiety
osteoporosis
multiple lumbar compression fractures
Social History:
SOCHx: Italian speaking, lives at [**Hospital3 **] home. Has 2
sons.
Family History:
Non contributory to current illness
Physical Exam:
97.6 76 98/45 21 96%ra
general: asleep, comfortable, nad
heent: perrl, OP clear, edentulous. MM dry.
neck: no JVD, supple
chest: RRR no m/r/g
lungs: ctab, no w/r/r
abd: obese, ND, NT +BS. ? dullness to percussion in llq
ext: trace pitting edema at the ankles, 1+ DP pulses, cool
hands/toes but no cyanosis/clubbing
neuro: moving ext x 4, no evidence of focal deficits. Babinski
downgoing bilaterally
skin: cool and dry
Pertinent Results:
[**2111-8-4**] 03:30PM PLT SMR-NORMAL PLT COUNT-258#
[**2111-8-4**] 03:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2111-8-4**] 03:30PM NEUTS-94.8* BANDS-0 LYMPHS-3.2* MONOS-1.6*
EOS-0.3 BASOS-0
[**2111-8-4**] 03:30PM WBC-32.5*# RBC-4.59 HGB-13.8 HCT-39.6 MCV-86
MCH-30.1 MCHC-34.9 RDW-14.5
[**2111-8-4**] 03:30PM ALBUMIN-2.8* CALCIUM-9.7 PHOSPHATE-5.7*
MAGNESIUM-3.1*
[**2111-8-4**] 03:30PM CK-MB-NotDone cTropnT-0.05*
[**2111-8-4**] 03:30PM LIPASE-70*
[**2111-8-4**] 03:30PM ALT(SGPT)-16 AST(SGOT)-22 CK(CPK)-11* ALK
PHOS-148* AMYLASE-778* TOT BILI-0.5
[**2111-8-4**] 03:30PM estGFR-Using this
[**2111-8-4**] 03:30PM GLUCOSE-114* UREA N-133* CREAT-12.0*#
SODIUM-134 POTASSIUM-6.1* CHLORIDE-99 TOTAL CO2-17* ANION
GAP-24*
[**2111-8-4**] 03:44PM LACTATE-1.6
[**2111-8-4**] 03:44PM COMMENTS-GREEN TOP
[**2111-8-4**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2111-8-4**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2111-8-4**] 08:45PM GLUCOSE-79 UREA N-125* CREAT-11.0* SODIUM-138
POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-17* ANION GAP-20
[**2111-8-4**] 08:49PM K+-5.1
[**2111-8-4**] 08:49PM COMMENTS-GREEN TOP
Brief Hospital Course:
ARF:
tunnelled line placed in Rt. Subclavian Vein by IR.
HD completed only once, for uremia
Renal function has slowly improved, steadily, thoroughout the
hospitalization
HD cath removed [**8-12**]
O/P renal follow up arranged at [**Hospital1 18**]
Recommend matching I's And O's with D51/2NS as needed if still
having post atn diuresis that is not matched by intake
Avoid nephrotoxins, renally dose all meds.
continue to hold lasix for now
C.diff enterocolitis:
- cx positive, and OB pos stools continue (not unexpected in
colitis); Hct and VS stable. Monitor Hct, and monitor for overt
blood per rectum at rehab. Has only had occult GIB during
hospitalization.
Vancomycin and flagyl orally for total 14 days (last day will be
[**8-15**]).
Osteoporosis with compression fractures:
- lidocaine patch
- tylenol scheduled
Nutrition;
Pt. not eating enough calories during hospitaliztion. Likely
due to a combination of uremia (anorexic) and colitis. As these
resolve, PO intake should improve. Nutrition consult obtained
and TF started. Slowly taking more PO at time of discharge.
Medications on Admission:
Aricept
citalopram
alendronate
lasix
lorazepam
tramadol
MVI
Ca and vit D
KCl
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days: last day [**8-15**].
Disp:*16 Capsule(s)* Refills:*0*
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: last day [**8-15**]. Tablet(s)
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAILY ().
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO QDAILYPRN ().
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q6H (every 6
hours) as needed: for breakthrough pain.
Tramodol d/c's due to possible serotonin syndrome if taken
regularly with SSRI
Furosemide d/c'd due to pre renal etiology of disease
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] TCU - [**Location (un) 86**]
Discharge Diagnosis:
Acute Renal Failure
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2111-8-27**]
1:00;
Renal division (KIDNEY DOCTOR)
|
[
"5845",
"4280"
] |
Admission Date: [**2149-8-7**] Discharge Date: [**2149-8-11**]
Date of Birth: [**2112-8-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Subdural hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
36yo M transferred from OSH after trauma to head, CT with
SDH. Pt was intoxicated, and does not recall exact details of
event, but likely hit on head by someone, woke up in pool of
blood. +HA, no N/V, no blurred vision.
Past Medical History:
None
Social History:
2-3 beers/day, 1PPD tobacco
Family History:
Non contributory
Physical Exam:
T: BP: 107/77 HR: 70 R: 18 100% RA
Gen: NAD, lying in bed with C-collar
Lungs: CTA bilaterally.
Cardiac: RRR
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, not very cooperative with exam
(agitated)
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: PERRL, 3 to 2.5 mm bilaterally.
III, IV, VI: EOMI bilaterally without nystagmus.
Pt refused to cooperate with rest of CN exam.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-22**] throughout. Pt refused pronator
drift exam.
Sensation: Intact to light touch
Toes downgoing bilaterally
Pertinent Results:
CT HEAD W/O CONTRAST [**2149-8-7**] 11:42 AM
IMPRESSION:
1. Unchanged appearance of the bifrontal contusions. Stable
appearance of bifrontal, left temporal, and [**Hospital1 **]-tentorial
subdural hematomas.
2. Stable left occipital bone vertical fracture.
3. Complete opacification of the left maxillary sinus.
CT HEAD W/O CONTRAST [**2149-8-7**] 1:30 AM
FINDINGS: Right frontal subdural hematoma seen measuring upwards
of 3 mm. A subdural hematoma tracking along the left hemisphere
also seen, measuring upwards of 5 mm. High-density material is
seen tracking along the sulci and the frontal lobes, consistent
with subarachnoid hemorrhage. There are bilateral hemorrhagic
frontal lobe contusions. High-density material also seen
tracking along the left tentorium greater than right, also
consistent with subdural hematoma. No significant shift of
normally midline structures identified. No evidence of
hydrocephalus. Vertically oriented fracture line seen in the
right occipital and parietal, seen extending all the way down to
the foramen magnum. Bilateral nasal bone fractures seen.
Opacification of the left maxillary sinus noted. Evaluation of
the fracture is limited by patient motion; however, possible
medial orbital wall versus lamina papyracea fracture seen.
Mucosal thickening is seen in the ethmoid sinuses.
IMPRESSION:
1. Bilateral subdural and subarachnoid hemorrhage. Frontal
contusions also seen. No significant shift of midline
structures.
2. Non-displaced vertically oriented occipital and parietal bone
fracture seen extending down to the foramen magnum.
3. Concern for left orbital fracture. Dedicated orbital imaging
could be helpful for further evaluation.
4. Bilateral nasal bone fractures.
CT HEAD W/O CONTRAST [**2149-8-8**] 10:37 AM
Again seen are multiple small hemorrhagic contusions of the
inferior frontal lobes bilaterally, worse on the left. Also
again seen is a small left frontal temporal subdural hematoma
and a tiny right frontal subdural hematoma. Subdural hematoma
layering along the tentorium cerebelli is again seen.
The ventricles and extraaxial CSF spaces are unchanged. The
[**Doctor Last Name 352**]/white matter differentiation is maintained.
The visualized orbits are normal. Near complete opacification of
the visualized left maxillary sinus is seen. There is mucosal
thickening of the ethmoid air cells. Non-displaced fracture of
the right occipital bone is again noted with scalp
swelling/hematoma with skin staples.
IMPRESSION: No significant change since [**2149-8-7**] with
bifrontal hemorrhagic contusions, left frontal temporal subdural
hematoma, tiny right frontal subdural hematoma, and subdural
hematoma along the tentorium.
Brief Hospital Course:
Patient is 36yo Male admitted to neurosurgery ICU on [**2149-8-7**] for
traumatic SDH/SAH/frontal contussion. Patient was alert and
oriented at admission and his initial neuro exam was non-focal.
His repeat head CT showed stable ICH and he remain
neurologically stable. He was transferred out of ICU to regular
floor on [**2149-8-9**].
Upon discharge, he is neurologically stable, ambulating in
hallways and tolerating regular diet. His pain is controlled by
po pain medication. He was started on dilantin for seizure
prophylaxis which he we stay on for 7 days.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on narcotics.
Disp:*60 Capsule(s)* Refills:*0*
2. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a
day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
q6hr prn as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural/subarachnoid hemorrhage
Intraparenchymal contusion
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) 739**] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
Please Call Plastic surgery to follow up on your orbital
fracture.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2149-8-11**]
|
[
"3051"
] |
Admission Date: [**2146-7-6**] Discharge Date: [**2146-7-13**]
Date of Birth: [**2099-4-8**] Sex: M
Service: Cardiothoracic Surgery
ADMITTING DIAGNOSES:
1. Coronary artery disease - status post percutaneous
transluminal coronary angioplasty and status post myocardial
infarction.
2. Unstable angina.
3. Hypertension.
4. Hypercholesterolemia.
DISCHARGE DIAGNOSES:
1. Coronary artery disease - status post coronary artery
bypass grafting, status post percutaneous transluminal
coronary angioplasty, status post myocardial infarction.
2. Diabetes mellitus type 2.
3. Hypertension.
4. Hypercholesterolemia.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 10794**] is a 47-year-old man
with a history of coronary artery disease status post
myocardial infarction and status post percutaneous
transluminal coronary angioplasty in [**2137**] and [**2138**] who
presented with about a [**1-24**] week history of chest discomfort
and pain which occurred sometimes with activity and sometimes
at rest. He underwent ETT on [**2146-6-29**] that was positive and
he subsequently underwent cardiac catheterization that showed
100% occlusion of the right coronary artery and 90% of the
left main. It was determined that coronary artery bypass
grafting would be the best treatment for Mr. [**Known lastname 10794**] and the
patient was scheduled to undergo coronary artery bypass
grafting on [**2146-6-8**].
PHYSICAL EXAMINATION: Preoperative evaluation of this
gentleman revealed him to be 5'[**53**]" tall and 250 pounds, pulse
was 60 and sinus rhythm, blood pressure 148/80, respiratory
rate 16, saturating 98% on room air. He was in no acute
distress. HEENT: Unremarkable. Neck: No jugular venous
distension. Carotid pulses were [**1-25**] and there was no bruit.
Lungs: Clear to auscultation bilaterally. Heart: Regular
in rate and rhythm without any murmur appreciated. Abdomen:
Soft and nontender with no hepatosplenomegaly or pulsatile
masses noted. Extremities: Warm and well perfused with
pulses [**1-25**] in the upper and lower extremities. Neurologic:
He was grossly intact.
LABORATORY DATA: Preoperative hematocrit was 39.0. His
preoperative coagulation times were PT 13.5, PTT 57.0 and INR
1.2. His preoperative potassium was 4.3 with a BUN and
creatinine of 12 and 0.7 respectively. His preoperative
chest x-ray showed no evidence of acute cardiopulmonary
abnormality. His EKG had shown evidence of his prior
myocardial infarction and ischemic symptoms were present.
HOSPITAL COURSE: As mentioned previously he was admitted on
[**2146-7-6**] and underwent his preoperative evaluation, through
which echocardiogram revealed an ejection fraction of 55%.
He also underwent placement of an intra-aortic balloon pump
preoperatively on [**2146-7-8**]. Later that day he underwent a
coronary artery bypass grafting x 2 with left internal
mammary artery to left anterior descending coronary artery
and saphenous vein graft to obtuse marginal, during which
cardiopulmonary bypass time was 75 minutes and cross-clamp
time was 45 minutes. There was no note of intraoperative
complications. The patient left the operating room on a
nitroglycerin and a propofol drip. He was subsequently
extubated without difficulty. He had his intra-aortic
balloon pump removed on postoperative day one while in the
cardiac surgery recovery unit. He was also started on beta
blockade and aggressive diuresis. Postoperatively it was
noted that he had fasting blood sugars of 200 to 300,
therefore [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] diabetes consultation was obtained. His
hemoglobin A1c was notably 11.3. As per their
recommendations, the patient was started on b.i.d. dosing of
insulin and oral glucose control medications. Nutrition was
also consulted to see the patient and he will follow up with
these services as an outpatient. The patient was discharged
to the floor. He was transferred to the floor from the
cardiac surgery recovery unit on postoperative day three,
where he continued his beta blockade and diuresis with Lasix.
His blood sugars were subsequently better controlled on the
floor, ranging in the 120s to 140s, and given that the
patient was able to ambulate without difficulty and complete
level 5 in terms of physical therapy, he was discharged to
home in good condition.
[**Last Name (STitle) 25726**] follow up with Dr. [**Last Name (Prefixes) **] in four weeks. He
has multiple appointments for diabetes education and vision
care as an outpatient.
At the time of discharge his laboratory studies were as
follows: His hematocrit was 26.8. His BUN and creatinine
were 23 and 0.8 respectively with a potassium of 4.2.
DISCHARGE MEDICATIONS:
1. Lopressor 50 p.o. b.i.d.
2. Colace 100 p.o. b.i.d. p.r.n.
3. Aspirin 325 mg p.o. q.d.
4. Imdur 60 mg p.o. q.d.
5. Percocet 5-325, 1-2 tablets p.o. q. 4 hours p.r.n.
6. Simvastatin 40 mg p.o. q.d.
7. Captopril 25 mg p.o. t.i.d.
8. Pioglitazone 15 mg p.o. q.d.
9. Insulin NPH 18 units in the morning, 8 units before
bedtime.
10. Lasix was discontinued as the patient had returned to his
preoperative weight at the time of discharge.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 39415**]
MEDQUIST36
D: [**2146-7-13**] 10:50
T: [**2146-7-13**] 11:07
JOB#: [**Job Number 39416**]
|
[
"41401",
"412",
"25000",
"2720",
"4019"
] |
Admission Date: [**2149-5-21**] Discharge Date: [**2149-5-27**]
Date of Birth: [**2075-3-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2149-5-21**] Coronary artery bypass graft x 4, Aortic valve
replacement (25mm tissue)
History of Present Illness:
74 year old male with moderate aortic stenosis and recent
echocardiogram demonstrating [**Location (un) 109**] 1.4 cm2 and reports shortness
of breath associated with chest tightness after climbing one
flight of stairs and when walking up an incline. He was referred
for right and left heart catheterization. He was found to have
coronary artery disease and is now being referred to cardiac
surgery for revascularization.
Past Medical History:
Aortic stenosis, moderate, calculated [**Location (un) 109**] 1.4 cm2
Atrial fibrillation on Pradaxa since [**2149-4-29**]
Hypertension
Hyperlipidemia
Gout (pt not aware, noted in records)
Arthritis
Cataract, bilateral
S/P left knee replacement
S/P appendectomy
S/p carpal tunnel surgery
Social History:
Race:Caucasian
Last Dental Exam:3 months ago, will call dentist to have dental
clearance faxed to office
Lives with:Wife
Contact: [**Name (NI) **] [**Name (NI) 15582**] (wife) Phone# [**Telephone/Fax (1) 110537**]
Occupation: Retired elevator mechanic
Cigarettes: Smoked no [] yes [x] Hx:quit 40 years ago
Other Tobacco use:denies
ETOH: Quit one month ago, Former daily ETOH 2-3 beers
Illicit drug use:denies
Family History:
Premature coronary artery disease - non contributory
Physical Exam:
Pulse:68 Resp:18 O2 sat:98/RA
B/P Right:87/52 Left:83/54
Height:5'[**47**]" Weight:190 lbs
General:
Skin: Dry [x] intact [x]
HEENT: EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur [x] grade 2 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: p Left: p
Radial Right: p Left: p
Carotid Bruit Right: - Left: -
Pertinent Results:
[**5-21**] TEE:
LEFT ATRIUM: No spontaneous echo contrast in the body of the LA.
Moderate to severe spontaneous echo contrast in the LAA.
Depressed LAA emptying velocity (<0.2m/s) Cannot exclude LAA
thrombus. All four pulmonary veins identified and enter the left
atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast
in the body of the 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: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH with normal cavity
size and global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Focal calcifications in aortic root. Mildly dilated
ascending aorta. Simple atheroma in ascending aorta. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (area 1.2-1.9cm2). Moderate AS
(area 1.0-1.2cm2) Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Mild to moderate ([**1-6**]+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. 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
the patient.
Conclusions
PRE BYPASS No spontaneous echo contrast is seen in the body of
the left atrium. Moderate to severe spontaneous echo contrast is
present in the left atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). A left atrial
appendage thrombus cannot be excluded. Mild spontaneous echo
contrast is seen in the body of the right atrium. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). The right ventricle
displays normal free wall contractility. The ascending aorta is
mildly dilated. There are simple atheroma in the ascending
aorta. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. The left coronary cusp is essentially
immobilized. There is mild to moderate aortic valve stenosis
(valve area 1.4 cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-6**]+) 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 thetime of the study.
POST BYPASS The patient is atrially paced. There is normal
biventricular systolic function. There is a bioprosthesis
located in the aortic position. It is well seated and the
leaflets appear to be moving normally. There may be very trace
aortic insufficiency though it was seen only after initial
separation from bypass and its source could not be determined.
The maximum gradient through the valve was 11 mmHg with a mean
gradient of 5 mmHg at at cardiac output of 4.6 liters/minute.
The mitral regurgitation appears to be slightly improved -now
mild. The left atrial appendage has been resected. The thoracic
aorta appears intact after decannulation. No other significant
change from the pre-bypass period.
[**2149-5-26**] 05:31AM BLOOD WBC-7.5 RBC-3.16* Hgb-9.5* Hct-29.4*
MCV-93 MCH-30.0 MCHC-32.3 RDW-14.5 Plt Ct-142*
[**2149-5-21**] 02:49PM BLOOD WBC-11.8* RBC-2.83* Hgb-8.7* Hct-26.3*
MCV-93 MCH-30.8 MCHC-33.1 RDW-13.1 Plt Ct-128*
[**2149-5-27**] 04:40AM BLOOD PT-25.7* INR(PT)-2.5*
[**2149-5-21**] 08:40AM BLOOD PT-13.7* PTT-23.5* INR(PT)-1.3*
[**2149-5-26**] 05:31AM BLOOD Glucose-95 UreaN-22* Creat-0.8 Na-141
K-4.0 Cl-103 HCO3-29 AnGap-13
[**2149-5-21**] 04:04PM BLOOD UreaN-12 Creat-0.7 Na-140 K-4.2 Cl-111*
HCO3-23 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 15582**] was a same day admit and brought to the operating
room on [**5-21**] where he underwent a coronary artery bypass graft x
4 (LIMA-LAD, SVG-Diag, SVG-PLVa-PDA jump) aortic valve
replacement tissue 25mm and LAA ligation. Please see operative
note for surgical details. Following surgery he was transferred
to the CVICU for invasive monitoring. He was a-paced over Sinus
Bradycardia and required Neo and volume for hypotension and low
Cardiac Index. He awoke neurologically intact and was extubated
without incident. He required neo until POD#3. Mr.[**Known lastname 15582**] has
a history of afib/flutter and went back into it on post-op day
two. He was mostly in atrial flutter which was rapid at times
and his meds were adjusted. He was rapid atrial paced to SR for
several hours but returned to a-flutter. He was started briefly
on amio but due to hypotension this was discontinued and he was
then started on Digoxin with good effect. His pacing wires and
Chest Tubes were removed per protocol, without difficulty. He
had a slight drop in his platlet count but this has since
resolved. On POD #4 he transferred to the floor in rate control
atrial flutter and stable condition. He was evaluated by the
Physical Therapy department for strength and mobility.The
remainder of his hospital course was essentially uneventful. On
Post-op #6 he was discharged to home with VNA services.
Dr.[**First Name (STitle) 5656**], his PCP will follow Coumadin dosing. All follow up
appointments were advised. [**Month (only) 116**] want to consider future ablation
for atrial flutter.
Medications on Admission:
ATENOLOL 25 mg Daily
DABIGATRAN ETEXILATE [PRADAXA] 150 mg [**Hospital1 **]
INDOMETHACIN 50 mg TID PRN
SIMVASTATIN 20 mg Daily
TRIAMTERENE-HYDROCHLOROTHIAZID 37.5 mg-25 mg Capsule - one
Capsule Daily
ASPIRIN 81 mg daily
Discharge Medications:
1. acetaminophen 325 mg [**Hospital1 8426**] Sig: Two (2) [**Hospital1 8426**] PO Q4H (every
4 hours) as needed for temperature >38.0.
2. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 [**Hospital1 8426**], Delayed Release (E.C.)(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. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. simvastatin 10 mg [**Hospital1 8426**] Sig: Two (2) [**Hospital1 8426**] PO DAILY
(Daily).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
6. metoprolol tartrate 25 mg [**Hospital1 8426**] Sig: Three (3) [**Hospital1 8426**] PO TID
(3 times a day).
Disp:*270 [**Hospital1 8426**](s)* Refills:*2*
7. ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
8. digoxin 250 mcg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
9. hydromorphone 2 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO Q6H (every 6
hours) as needed for pain.
Disp:*50 [**Hospital1 8426**](s)* Refills:*0*
10. potassium chloride 10 mEq [**Hospital1 8426**] Extended Release Sig: Two
(2) [**Hospital1 8426**] Extended Release PO BID (2 times a day) for 10 days.
Disp:*40 [**Hospital1 8426**] Extended Release(s)* Refills:*0*
11. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] ONCE (Once).
Disp:*90 [**Last Name (Titles) 8426**](s)* Refills:*2*
12. warfarin 2.5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO ONCE (Once)
for 1 doses.
Disp:*1 [**Last Name (Titles) 8426**](s)* Refills:*0*
13. Lasix 20 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO twice a day for 10
days.
Disp:*20 [**Last Name (Titles) 8426**](s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft
Aortic stenosis s/p Aortic valve replacement
Past medical history:
Atrial fibrillation on Pradaxa since [**2149-4-29**]
Hypertension
Hyperlipidemia
Gout (pt not aware, noted in records)
Arthritis
Cataract, bilateral
S/P left knee replacement
S/P appendectomy
S/p carpal tunnel surgery
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 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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
WOUND CARE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2149-5-29**] 11:00
Surgeon: Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 170**] Date/Time:[**2149-6-26**] 1:00
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] [**2149-6-13**] at 2:15p
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5656**] in [**4-10**] 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:[**2149-5-27**]
|
[
"4241",
"41401",
"42731",
"4019",
"2724",
"2859"
] |
Admission Date: [**2127-6-6**] Discharge Date: [**2127-6-23**]
Date of Birth: [**2071-7-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
CC:[**Hospital1 72740**]
Major Surgical or Invasive Procedure:
LEFT CRANIOTOMY
Stereotactic radiosurgery to left frontal brain mass
History of Present Illness:
HPI: 55 F c PMH of Osteoporosis, Bell's Palsy,
hypercholesterolemia presents to [**Hospital1 **] p tx from [**Hospital 1474**] hospital
with 2 cm L parietal lesion with significant edema on MR there.
Pt previously had MR brain in [**2126-9-20**] p being diagnosed
with bell's palsy with neg w/u but some L facial paresthesias,
pain, tingling. Pt continued to experience intermittent
persistent symptoms until [**Month (only) 404**], presented to PCP (Dr
[**Last Name (STitle) **]
with cough, back pain) but no workup done per patient. Finally
developed RUE weakness, numbness, tingling xlast 4 wks and went
to [**Hospital3 **] on [**2127-5-28**] where CXR was done,sent home, and
told concern for either lung cancer/lymphoma. Pt had CT neck on
[**5-30**] for LAD per PCP and CT Torso on [**6-2**] concerning for
multiple
masses. Pt had MR [**6-5**] @ [**Hospital 1474**] hospital and was transferred
to [**Hospital1 **] p brain involvement seen. Pt was scheduled to have tissue
diagnosis on [**6-6**] but sent here first. Bone scan and skeletal
survey were to happen on [**6-7**] @ [**Hospital3 417**] hospital then PET
[**6-13**] @ [**Hospital **] hosp.
Past Medical History:
PMHx: Osteoporosis, Bell's Palsy, hypercholesterolemia
Social History:
Social Hx: neg alcohol/drugs, +35 yr pack smoking hx.
Family History:
not obtained
Physical Exam:
PHYSICAL EXAM:
O: T: 99.6 BP: 134/59 HR: 104 R 18 O2Sats 94RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: Nonreactive L pupil (dir/indir - Adie's pupil
c
irreg borders) and [**3-21**] on R. EOMs intact
Neck: Supple. + massive L supraclavicular firm fixed LAD
Lungs: coarse bilaterally
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+, no peritoneal signs.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-22**] 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: Nonreactive L pupil (dir/indir - Adie's pupil c irreg
borders) and [**3-21**] on R. 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 with decreased strength on
Right.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally LE. Poor strength
throughout RUE. + pronator drift on RUE.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally except on RUE. Not intact to light touch
diffusely below mid arm, not intact to proprioception/pinprick
or
vibration.
Reflexes: B T Br Pa Ac
Right 0 0 0 2 2
Left 2 2 2 2 2
Toes downgoing equiv Bilaterally
Coordination: Finger-nose-finger, rapid alternating
movements, heel to shin all worse on R than L.
Pertinent Results:
MRI/MRA Brain (OSH): Limited study. +2 cm parietal mass at grey
white junction with significant edema and 4mm L->R mass effect/
midline shift with some subfalcine herniation but no uncal
herniation. No transtentorial herniation. Lesion most
concerning for metastasis given clinical history.
[**2127-6-6**] 12:30AM WBC-7.8 RBC-4.58 HGB-13.8 HCT-40.3 MCV-88
MCH-30.2 MCHC-34.3 RDW-12.9
[**2127-6-6**] 12:30AM NEUTS-89.4* BANDS-0 LYMPHS-8.0* MONOS-1.6*
EOS-0.5 BASOS-0.6
[**2127-6-6**] 12:30AM PLT COUNT-547*
[**2127-6-6**] 12:30AM PT-12.3 PTT-26.6 INR(PT)-1.1
[**2127-6-6**] 12:30AM GLUCOSE-137* UREA N-9 CREAT-0.5 SODIUM-136
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16
[**2127-6-6**] 12:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2127-6-6**] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG
RADIOLOGY Preliminary Report
MR HEAD W & W/O CONTRAST [**2127-6-13**] 5:56 PM
MR HEAD W & W/O CONTRAST
Reason: Please do per cyberknife protocol
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
55 year old woman with left frontal mass
REASON FOR THIS EXAMINATION:
Please do per cyberknife protocol
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with CyberKnife protocol, for
further evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were acquired. Following
gadolinium, T1 sagittal, axial and coronal images were obtained.
In addition, MP-RAGE axial images were obtained following
gadolinium for CyberKnife planning. The MP-RAGE images are
limited by motion.
FINDINGS: The diffusion images demonstrate no evidence of acute
infarct. Since the previous study of [**2127-6-12**], the patient has
undergone left-sided craniotomy. Postoperative changes are
visualized. Edema is seen in the left parietooccipital region
with a well-defined T2 low signal abnormality in the posterior
frontal region, which demonstrate enhancement following
gadolinium. The mass measures approximately 2 cm in size. There
is also some surrounding parenchymal or meningeal enhancement,
which appear postoperative. There is no mass effect, midline
shift, or hydrocephalus. Small amount of blood products are seen
at the surgical site.
IMPRESSION: A 2 cm enhancing lesion in the posterior frontal
lobe with surrounding edema. Postoperative changes since the
previous MRI of [**2127-6-12**]. Post-gadolinium MP-RAGE images for
CyberKnife planning are limited by motion.
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
CT HEAD W/O CONTRAST [**2127-6-13**] 8:04 AM
CT HEAD W/O CONTRAST
Reason: evaluate for bleed
[**Hospital 93**] MEDICAL CONDITION:
55 year old woman s/p craniotomy - please perform exam on [**6-13**]
AM
REASON FOR THIS EXAMINATION:
evaluate for bleed
CONTRAINDICATIONS for IV CONTRAST: None.
CT HEAD WITHOUT CONTRAST [**2127-6-13**]
HISTORY: Status post craniotomy.
Contiguous axial images were obtained through the brain. No
contrast was administered. Comparison to a head CT of [**2127-6-6**] and MR examinations of [**6-10**] and 24.
FINDINGS: Again identified is a left frontal mass that is
slightly hyperdense to cortex. This is surrounded by extensive
vasogenic edema. The patient is now status post left frontal
craniotomy with postoperative changes including a small amount
of intracranial air. There is no evidence of hemorrhage. Local
mass effect and slight left to right midline shift appear
unchanged.
CONCLUSION: Status post left frontal craniotomy with a small
amount of intracranial air. No evidence of hemorrhage. The mass
is surrounded by vasogenic edema appears unchanged.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: FRI [**2127-6-13**] 4:04 PM
Sinus rhythm. Compared to the previous tracing of [**2127-6-6**] no
significant
change.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
81 124 100 372/409.14 76 77 68
BONE SCAN [**2127-6-11**]
BONE SCAN
Reason: BONE PAIN NECK BACK R. UPPER EXTREMITY R/O METS
RADIOPHARMECEUTICAL DATA:
25.2 mCi Tc-[**Age over 90 **]m MDP ([**2127-6-11**]);
HISTORY: Metastatic cancer.
INTERPRETATION:
Whole body images of the skeleton were obtained in anterior and
posterior
projections.
There is linear increased uptake in the left 6th rib
posteriorly. In the CT
([**2127-6-6**]) this corresponds to a healing fracture with a
prominent soft tissue
component. This appearance is suggestive of a pathologic
fracture secondary to
osseous metastasis. There are no other skeletal metastases.
There is also a simple fracture of the right 11th rib
posteriorly.
The kidneys and urinary bladder are visualized, the normal route
of tracer
excretion.
IMPRESSION:
1. Linear increase uptake in the left 6th rib posteriorly
corresponding to a
fracture in the CT. However, the linear appearance on the bone
scan and the
soft tissue component seen on CT are suggestive of a pathologic
fracture
secondary to osseous metastasis. There are no other skeletal
metastases.
2. Simple right 11th rib fracture.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 37819**], M.D.
Approved: WED [**2127-6-11**] 2:14 PM
HUMERUS (AP & LAT) RIGHT [**2127-6-10**] 1:46 PM
HUMERUS (AP & LAT) RIGHT
Reason: right arm pain - r/o pathological frature
[**Hospital 93**] MEDICAL CONDITION:
55 year old woman with bone pain
REASON FOR THIS EXAMINATION:
right arm pain - r/o pathological frature
INDICATIONS: 55-year-old woman with right arm pain. Question
pathological fracture.
RIGHT HUMERUS, TWO VIEWS: No prior studies are available. There
is no evidence of fracture, dislocation, or bony destruction.
Mild arthrosis is noted at the acromioclavicular joint.
IMPRESSION: No evidence of fracture.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: FRI [**2127-6-13**] 5:54 PM
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 72741**],[**Known firstname **] [**2071-7-16**] 55 Female [**-7/1994**]
[**Numeric Identifier 72742**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd
SPECIMEN SUBMITTED:
cervical lymph node biopsy
Procedure date Tissue received Report Date Diagnosed
by
[**2127-6-7**] [**2127-6-7**] [**2127-6-10**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/nbh
DIAGNOSIS:
Cervical lymph node, biopsy:
Metastatic non-small cell carcinoma, see note:
Note: Tumor cells are positive for cytokeratin and TTF-1,
(focal), but negative for mammoglobin, GCDFP, and LCA. A lung
primary is favored, but other sites should be considered.
Clinical: 59 year old woman with multiple intraabdominal and
thoracic nodes with adrenal mass and brain, 35 pack year
history, ? SCL CA/SCLCA/lymphoma/other.
Gross: The specimen is received fresh in a specimen jar labeled
"[**Known firstname **] [**Known lastname 1557**]" and the medical record number. The specimen is
otherwise not labeled. The specimen consists of multiple cores
of pink-tan tissue measuring in aggregate 1.0 x 0.3 x 0.2 cm.
Tissue sent for flow cytometry. Touch preps are taken and the
remainder is submitted for formalin fixation in A.
CHEST (PA & LAT) [**2127-6-6**] 5:01 AM
CHEST (PA & LAT)
Reason: eval for lung mass
[**Hospital 93**] MEDICAL CONDITION:
55 year old woman with newly dx brain mass and ?mediastinal LAD
at OSH, c/o chest and back pain.
REASON FOR THIS EXAMINATION:
eval for lung mass
INDICATION: 55-year-old female with newly diagnosed brain mass.
COMPARISON: None.
PA AND LATERAL CHEST X-RAY: The cardiac silhouette is normal in
size. Lobular soft tissue within the anterior mediastinum and
bilateral hila suggests underlying prominent lymphadenopathy.
There are no focal consolidations or effusions. The surrounding
soft tissue and osseous structures are unremarkable.
IMPRESSION:
Non-specific anterior mediastinum mass. Diagnsotic
considerations include marked lymph node enlargement and sub
sternal thyroid mass. A CT examination of the chest is
recommended for further evaluation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: FRI [**2127-6-6**] 6:03 PM
CT CHEST W/CONTRAST [**2127-6-6**] 11:32 AM
CT CHEST W/CONTRAST; CT ABD W&W/O C
Reason: eval for mass/lesions or lymphadenopathy
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
55 year old woman with recent dx brain mass (L frontal posterior
lobe), transferred for eval
REASON FOR THIS EXAMINATION:
eval for mass/lesions or lymphadenopathy
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 55-year-old woman with recent diagnosis of brain mass.
To evaluate for source of primary.
TECHNIQUE: Multidetector contiguous axial images of the chest,
abdomen, and pelvis were obtained following the administration
of oral and intravenous contrast with multiplanar reformatted
images.
CT CHEST WITH IV CONTRAST: The thyroid gland is normal in
appearance. Enlarged heterogenously enhancing left cervical
lymph nodal mass (3,1) measuring 4.5 x 2.6 cm is present.
Prevascular lymphadenopathy, (3,14) measuring 6.1 x 5.8 cm
attenuates the caliber of left subclavian vein which remains
patent. Enlarged right paratracheal lymph node (3,17) measures
3.7 x 3.4 cm. Subcarinal lymph node (3,24) measures 22 x 12 mm.
Left hilar lymphadenopathy measures 3.0 x 3.9 cm. (3,27). Lung
windows demonstrate no nodules or pleural effusions.
CT ABDOMEN: Left adrenal lesion measuring 1.4 x 1.9 cm,
measuring 42 Hounsfield units on the non-contrast images,
increasing to 85 Hounsfield units in the post-contrast images is
concerning for an adrenal mass lesion. No enhancing liver
lesions are present. Small low-density lesion in the medial left
lobe adjacent to the falciform ligament could represent focal
fatty infiltration. The portal vein is patent.
The right adrenal gland, kidneys, pancreas, and spleen, and
loops of small and large bowel are normal in appearance.
Enlarged mesenteric lymph nodes measure 7 to 10 mm in diameter
(3,67). Multiple retroperitoneal, left paraaortic lymph nodes
(3,64) measure 6 and 7 mm, and up to 9 mm (3,70). Aortocaval
node measures 6 mm in diameter (3,66). Retrocrural lymph node
(3,50) measures 7 mm in short axis diameter.
CT PELVIS: The uterus, bladder, and loops of bowel in the pelvis
are normal in appearance. There is no free fluid.
BONE WINDOWS: No suspicious lytic or blastic lesions.
Multiplanar reformatted images confirm the above findings.
Findings were discussed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7356**] on [**2127-6-6**].
IMPRESSION:
1. Left cervical, mediastinal (prevascular, pretracheal and
paratracheal) and hilar lymphadenopathy with smaller
retroperitoneal, retrocrural and mesenteric lymphadenopathy.
2. Left adrenal mass.
Overall findings most suggestive for lymphoma. Metastatic
disease from an undetermined site of primary carcinoma unlikely.
The left cervical adenopathy should be easily accessible for
biopsy.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Approved: FRI [**2127-6-6**] 11:41 PM
Brief Hospital Course:
Pt was admitted through the emergency room for brain mass
detected on CT at OSH.
She was placed on decadron (which improved RUE weakness) and
keppra for sz control. Metastatic workup was undertaken.
Neuroonc/radonc/medonc services were consulted.
.
General surgery was consulted for biopsy of supraclavicular node
on left side. The biopsy yielded: Metastatic non-small cell
carcinoma. Craniotomy was unsuccessful for tumor resection on
[**2127-6-12**]. She should have sutures/staples removed after 14 days
(ie on [**2127-6-26**]).
.
The patient had stereotactic radiosurgery on [**6-18**] and her mental
status improved further afterwards. Neurologically she has had
some improvement following stereotactic radiosurgery. At the
time of discharge there is mild weakness in range 4- to 5- of
the R upper and lower limbs. She has longstanding constricted
non-reactive R pupil and slightly irregular pupil on left of
normal calibre and reactivity.
.
Dr. [**Last Name (STitle) **] from Med-Onc discussed possible chemotherapy options
with the pt. and family on [**6-18**]. She will be seen in follow up
clinic on [**2127-6-26**] for further discussion of chemotherapy.
Palliative care was involved on [**6-19**].
.
On admission pain management was initiated for pain to the
sternum/back/right arm and neck which was ongoing. She had a RUE
xray for r/o pathological fracture which was negative. Bone scan
showed .The pain service continued to follow the patient and her
meds were adjusted accordingly. Post-operatively, the patient
had some hallucinations as well as problems with pain control.
Her mental status improved and her pain became better
controlled. She is currently treated with x2 lidocaine patches
and both oxycontin and oxycodone. The patient's oxycontin dose
was increased from 10mg [**Hospital1 **] to 30mg [**Hospital1 **] per palliative care
recommendations on [**6-19**]. Please monitor for somnolence and
decrease dose if necessary. She has regular acetaminophen.
Please monitor LFTs. Tizanidine is helping with sleep.
.
Salt tablets were added on [**6-18**] for sodium of 130. Please
monitor sodium levels and adjust salt tablet dose accordingly.
Her serum sodium for [**6-21**] and [**6-22**] was 131.
.
The patient continues on dexamethasone and the dose could be
tapered in 5 days from [**2127-6-21**]. Please monitor symptoms and
examination to ensure she is tolerating weaning doses.
.
PT/OT assessment and therapy were provided.
.
Mrs [**Known lastname 1557**] had a mapping session for radiation to her lung
lesion on Thursday, [**2127-6-19**].
.
Medications on Admission:
All: NKDA
Medications prior to admission: fosamax, oxycodone
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection every eight (8) hours.
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical Q24 (): Wear patch for
12h then off for 12h in 24h period.
7. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3-4H (Every 3 to 4
Hours) as needed.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO BID (2
times a day): Please monitor sodium and decrease sodium
replacement if needed.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for heartburn.
11. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
12. Pantoprazole 40 mg IV Q24H
13. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
15. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
16. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours: Continue until [**6-24**], then decrease to 4mg tid for 2
days, then 3mg tid for 2 days, then 2mg tid for 2 days, then 2mg
[**Hospital1 **] for 2 days, then 1mg [**Hospital1 **] for 2 days then cease. .
17. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Left frontal brain mass
Discharge Condition:
Neurologically she has had some improvement following
stereotactic radiosurgery. There is mild weakness in range 4-
to 5- of the R upper and lower limbs. She has longstanding
constricted non-reactive R pupil and slightly irregular pupil on
left of normal calibre and reactivity.
Discharge Instructions:
?????? Check your incision daily for signs of infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
CALL YOUR DOCTORS (AND NEUROSURGEON) IMMEDIATELY IF YOU
EXPERIENCE ANY OF THE FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
.
You are being treated with salt tablets because sodium was low.
Please have your sodium monitored. You may need to change the
dose of salt tablets or cease according to levels.
Please also be aware that you are being treated with steroids.
The dose will be decreased in 5 days from [**2127-6-20**] with a tapering
dose prescribed over the following days. Please talk with your
doctor if you have worsening symptoms of headache,
nausea/vomiting or worsening weakness while tapering steroids.
Your blood sugar levels should be monitored while on steroids
and insulin given if levels high.
Followup Instructions:
PLEASE ARRANGE TO SEE YOUR PCP WITHIN THE NEXT WEEK IF POSSIBLE
DR [**Last Name (STitle) **] [**Numeric Identifier 72743**].
Provider: [**Name10 (NameIs) **] Oncology [**Name6 (MD) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) **]:[**0-0-**] Date/Time:[**2127-6-26**] 3:00
YOU WILL NEED AN MRI OF THE BRAIN WITH GADOLIDIUM PRIOR TO YOUR
BRAIN [**Hospital **] CLINIC APPOINTMENT on [**7-21**] 1.15 pm [**Location (un) **] [**Location (un) **].
YOUR APPOINTMENT IN BRAIN [**Hospital **] CLINIC TO SEE DR. [**Last Name (STitle) **], DR
[**Last Name (STitle) **], AND DR [**Last Name (STitle) **] IS BOOKED FOR [**7-21**] AT 3PM, [**Location (un) **] [**Hospital Ward Name **] BUILDING.
Completed by:[**2127-6-23**]
|
[
"2720",
"3051"
] |
Admission Date: [**2143-3-4**] Discharge Date: [**2143-3-5**]
Date of Birth: [**2099-6-20**] Sex: F
Service: MEDICINE
Allergies:
Latex
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
Pertinent Results:
[**2143-3-4**] 11:19PM GLUCOSE-130* UREA N-25* CREAT-0.8 SODIUM-140
POTASSIUM-3.7 CHLORIDE-114* TOTAL CO2-16* ANION GAP-14
[**2143-3-4**] 11:19PM CALCIUM-7.3* PHOSPHATE-2.8 MAGNESIUM-1.8
[**2143-3-4**] 08:04PM GLUCOSE-153* UREA N-28* CREAT-0.9 SODIUM-138
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-15* ANION GAP-16
[**2143-3-4**] 08:04PM CK(CPK)-51
[**2143-3-4**] 08:04PM CK-MB-2 cTropnT-<0.01
[**2143-3-4**] 08:04PM CALCIUM-7.5* PHOSPHATE-2.9 MAGNESIUM-1.8
[**2143-3-4**] 04:41PM TYPE-[**Last Name (un) **] PO2-78* PCO2-35 PH-7.17* TOTAL
CO2-13* BASE XS--14 COMMENTS-ADDED TO G
[**2143-3-4**] 04:15PM GLUCOSE-245* UREA N-33* CREAT-1.1 SODIUM-138
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-13* ANION GAP-24*
[**2143-3-4**] 04:15PM WBC-17.2* RBC-4.51 HGB-14.2 HCT-39.7 MCV-88
MCH-31.4 MCHC-35.7* RDW-13.2
[**2143-3-4**] 04:15PM NEUTS-81.2* LYMPHS-16.6* MONOS-2.1 EOS-0
BASOS-0.1
[**2143-3-4**] 04:15PM PLT COUNT-302
[**2143-3-4**] 03:05PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2143-3-4**] 03:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2143-3-4**] 03:05PM URINE RBC-0 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-[**3-17**]
[**2143-3-4**] 02:15PM GLUCOSE-441* UREA N-40* CREAT-1.4* SODIUM-134
POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-8* ANION GAP-36*
[**2143-3-4**] 02:15PM ALT(SGPT)-21 AST(SGOT)-27 ALK PHOS-157*
AMYLASE-94 TOT BILI-1.3
[**2143-3-4**] 02:15PM LIPASE-26
[**2143-3-4**] 02:15PM WBC-19.1*# RBC-5.08# HGB-16.5*# HCT-46.2
MCV-91 MCH-32.4* MCHC-35.7* RDW-12.9
[**2143-3-4**] 02:15PM NEUTS-87.6* BANDS-0 LYMPHS-8.7* MONOS-1.8*
EOS-0 BASOS-1.7
[**2143-3-4**] 02:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2143-3-4**] 02:15PM GLUCOSE-441* UREA N-40* CREAT-1.4* SODIUM-134
POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-8* ANION GAP-36*
Brief Hospital Course:
Assessment: 43F with h/o T1DM presented in DKA.
Plan:
1) DKA: DKA was likely a viral syndrome as she had sick contact
with her daughter. It was unlikely the flu as she was immunized
and she had no other symptoms associated with the flu. She was
aggressively hydrated and started on IV insulin and D5 when
sugars when less than 250. Her AG gap closed promptly. She was
restarted on her insulin pump and overlapped with the insulin
drip by one hour. Her IV fluids were discontinued once she
tolerated oral intake. [**Last Name (un) **] was consulted and she was to
follow up with them as an outpatient. Her electrolytes were
aggressively repleted including her potassium and phosphate
which were within normal limits on discharge
2) T1DM: Her insulin pump was restarted when the AG closed.
Has optic complications including vitreous hemorrhage.
3)Anticardiolipin Ab: Her aspirin was held secondary to history
of vitreous hemorrhage.
4)Hypertension: She was continued on her ACEI
5)H/O malignant melanoma: [**Doctor Last Name 10834**] level IV, dx [**2135**], right upper
arm. She was to followup with outpatient dermatology
9) code: full
10) contact: husband
Discharge Medications:
1. Moexipril 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
5. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal [**Hospital1 **] (2 times a day).
6. Urine Ketones Strips Sig: One (1) once a day.
Disp:*30 strips* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis.
Discharge Condition:
Good
Discharge Instructions:
Please return to taking your normal doses of insulin and pump
adjustments.
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 1395**], for
appointment within one week.
Dr. [**First Name (STitle) 1395**] can be reached at ([**Telephone/Fax (1) 15205**].
Please also keep the following scheduled appointment:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2143-4-8**] 8:20
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"2875",
"4019"
] |
Admission Date: [**2160-5-11**] Discharge Date: [**2160-5-15**]
Date of Birth: [**2117-1-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
s/p trauma, EtOH intoxication
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
43M with no known medical history presents s/p assault. EMS was
called to the scene and discovered the patient intoxicated,
unable to provide history. Per EMS report, the patient and a
friend were drinking EtOH all day. They had an argument over a
woman and his friend hit him in the head three times with a
closed fist. The patient fell to the ground and lost
consciousness for an unknown period of time. When EMS and
police arrived, the patient was verbal, asking for water, but
was not able to respond to other questions. He was observed to
be intoxicated.
On arrival to the ED, initial VS were 97 120 131/89 22 95% RA.
He was unable to respond to questioning regarding pain or
further medical history. He is not known to the [**Hospital1 18**] system or
to Atrius, therefore no medical history is available. He was
sedated with droperidol for agitation and combativeness. He
became apneic and was intubated. CT head and CT C-spine were
negative. On exam he had a small occipital hematoma without
further traumatic injury evident. Surgery was consulted and did
not feel that his AMS or respiratory failure had a traumatic
component. Labs revealed EtOH level of 154 and was positive for
benzos. CBC was normal, Chem10 showed hypokalemia to 3.2 without
other abnormality. Following CTs, it was not possible to
extubate the patient, given hypoxic respiratory failure and
concern for withdrawl from both EtOH and benzos. VS prior to
transfer: Afebrile 150/101 80s 14 100% on 500/14/70%.
On arrival to the MICU, patient's VSS. On fentanyl 50 and midaz
1, patient not responding to sternal rub, not following
commands. PERRL.
Review of systems: Unable to obtain due to mental status
Past Medical History:
-schizophrenia, on risperdol and is seen at [**Hospital1 2177**]
-alcoholism
-homelessness
Social History:
Patient is homeless. Otherwise unknown. Claims to drink a
fifth of tequilla and 6 beers occasionally. CAGE 0/4
Family History:
unknown
Physical Exam:
On Admission:
-------------
Vitals: 97.3 131/87 89 18 100%on CMV peep 8
General: appears comfortable; does not open eyes to voice or
follow simple commands
HEENT: Sclera anicteric, pupils 2mm and reactiv; 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: Scattered crackles bilaterally
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, 1+ edema to mid calf
Neuro: Rass -2; pupils 2mm and reactive
.
On discharge:
VSS
General: AAOX3 in NAD
HEENT: sinus not TTP, head has some mild, minimally erythematous
echymosis on the back of head, no nystagmus
CV: RRR, no RMG
Lungs: CTAB, no WRR
Abdomen: obese, NT, active BS X4, no HSM
Neuro: CN 2-12 grossly intact-eomi, perrla, sensation grossly
intact, strength wnl, refused to ambulate with me, but witnessed
multiple times ambulating in the [**Doctor Last Name **] without signs of imbalance
.
Pertinent Results:
Labs on Admission:
-------------------
[**2160-5-11**] 09:15PM BLOOD WBC-7.6 RBC-4.61 Hgb-14.1 Hct-43.4 MCV-94
MCH-30.7 MCHC-32.6 RDW-13.4 Plt Ct-207
[**2160-5-11**] 09:15PM BLOOD Neuts-86.7* Lymphs-10.2* Monos-2.2
Eos-0.5 Baso-0.4
[**2160-5-11**] 09:15PM BLOOD Glucose-108* UreaN-8 Creat-0.6 Na-142
K-3.2* Cl-107 HCO3-19* AnGap-19
[**2160-5-11**] 09:15PM BLOOD ALT-37 AST-30 AlkPhos-67 TotBili-0.3
[**2160-5-12**] 04:28AM BLOOD Calcium-8.1* Phos-4.4 Mg-1.8
[**2160-5-11**] 09:40PM BLOOD Type-ART Temp-36.1 Rates-14/ Tidal V-500
PEEP-8 FiO2-60 pO2-70* pCO2-40 pH-7.32* calTCO2-22 Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2160-5-12**] 02:35AM BLOOD Lactate-2.5*
Labs prior to discharge:
-all wnl on day of discharge
.
H-CT [**2160-5-11**]
IMPRESSION: No acute intracranial process.
.
[**2160-5-11**] C-spine CT
IMPRESSION: No acute fracture or malalignment.
.
[**2160-5-12**] CXR
IMPRESSION: No acute cardiopulmonary process.
.
TTE [**2160-5-13**]
The left atrium is mildly dilated. There is mild 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. Overall left ventricular
systolic function is grossly normal (LVEF ? 55%). 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.
IMPRESSION: Suboptimal image quality. This examination is
inadequate to exclude focal wall motion abnormalities of the
left ventricle or any abnormality of the right ventricle
.
[**2160-5-13**] Rib films
IMPRESSION: Normal examination. No evidence of rib fracture or
pneumothorax.
.
[**2160-5-12**] EKG
Sinus rhythm. Findings are within normal limits. Non-diagnostic
Q waves in
the inferior leads. Compared to the previous tracing of [**2160-5-11**]
there is no
significant diagnostic change.
Brief Hospital Course:
43 year old homeless man with PMHx of schizophrenia and
alcoholism who presented to the ED s/p assault, who was
transferred to the MICU for hypoxic respiratory failure s/p
intubation and was observed on the floor for signs of withdrawal
# Hypoxic respiratory failure: The patient was admitted to the
hospital with shortness of breath after being found down, and
was intubated with large A-a gradient (288). His respiratory
failure was most likely caused by an aspiration pneumonitis
given that he promptly improved. Portable Chest X-ray at the
time of intubation showed possible aspiration in LLL.
Alternatively, patient could have had pulmonary
contusion/alveolitis, but had no further evidence of chest
trauma. Given substance abuse, he may also have had a component
of hypoventillation as patient noted to have apenic episodes and
somnolence prior to intubation, but would not account for A-a
gradient. Patient was able to be extubated after less than 12
hours. He was oxygenating well on room air. Follow up CXR
showed no signs of pneumonia and his antibiotics were stopped.
.
# Altered mental status: Patient presented with altered mental
status, likely due to acute intoxication with EtOH and
benzodiazepines. There was no evidence of acute intracranial
process on CT scan. There was no evidence of infection, CXR
negative and UC was negative.
.
# EtOH and benzo intoxication/abuse: Patient admitted with EtOH
level 164 and positive urine benzos. The patient was followed
for over 72 hours and monitored for signs of withdrawal with the
CIWA scale. The patient was approached twice by social work and
daily by the medical team encouraging alcohol abstinence. He
insisted that he did not have an alcohol problem and refused to
take literature of AA meetings and other resources available to
him.
.
# BLE edema
The patient reports that this has been an issue for about 1
month. He also reported cp and sob during this admission.
Given these other symptoms, and TTE was obtained which was a
difficult study, but showed a normal EF. The patient had a
bottle of lasix 20 mg QD from [**Hospital1 **] which I informed him he
could continue. We re-started the lasix the day prior to
discharge and check his electrolytes and they were wnl. I
informed the patient that he can continue this medication until
following up with his new PCP at [**Hospital1 2177**] on [**5-21**], at which time
he should have his labs checked and defer further diuretic use
to his pcp.
.
# CP and SOB
The patient CP was reproducible on PE and the suspicion for ACS
was low. Serial TnI's were done and negative. His EKG's were
normal. His CP improved with tramadol and toradol. His SOB was
pleuritic and he was not tachycardia, hypoxic or tachypneic.
The suspicion for PE was low. The patients got dedicated rib
films and those were negative. His pain was thought to be due
to pulmonary contusion and pleurisy from trauma. He was
prescribed NSAID's and tramadol for pain upon discharge and an
albuterol inhaler.
.
# headaches and dizziness
The patient had the above complaints without any other
neurologic signs or symptoms. H-CT was negative. He
intermittently refused his medications and orthostatics VS, but
when he finally agreed to doing them he was not orthostatic. He
was seen ambulating the hallway without issues and PT/OT
evaluated the patient and though he was stable for d/c. The
patients h/a resolve and dizziness is thought to be due to post
concussion syndrome. The medical team repeatedly discussed with
the patient that some of these symptoms may take weeks to months
to resolve. We emphasized follow up with a primary care
physician. [**Name10 (NameIs) **] patient said he understood.
.
# cough with allergic rhinitis and post nasal drip
The patient was advised to use nasal saline which he refused.
He was also offered claritin, but he left without the
prescription. He was treated symptomatically in house with
tesselon pearles.
.
#Homelessness
The patient was repeatedly offered help with his housing
situation. Every time the medical team brought up discharge
planning and assistance, the patient refused assistance. When
attempting to discharge the patient he reports "not being
ready". We again reinforced how important follow up was with a
PCP. [**Name10 (NameIs) **] patient was pacing the [**Doctor Last Name **] prior to discharge and
repeatedly asked for his lasix back. Once he received this
medication, he left without his discharge paper work. CM also
checked to see if he had medication coverage and he does.
.
# Transitional Issues:
-Follow up with PCP [**Last Name (NamePattern4) **] 1 -2 weeks and assess the need for lasix,
check basic metabolic panel
-Follow up with Psyc in [**1-14**] weeks and continued to reinforce
alcohol cessation
Medications on Admission:
unknown
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
[**1-14**] Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Disp:*QS for 2 weeks * Refills:*0*
2. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
3. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-14**] Sprays Nasal
Q6H (every 6 hours).
Disp:*QS for 1 month * Refills:*2*
4. risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*14 Tablet(s)* Refills:*0*
10. ibuprofen 200 mg Tablet Sig: Three (3) Tablet PO every six
(6) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p assault with post concussive syndrome
intoxication
alcoholism
schizophrenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ICU at [**Hospital1 18**] after being found
intoxicated and being assualted. You had CT scans of your brain
and cervical spine showed no acute changes but did show some
mild shrinking of your brain possibly related to alcohol
consumption. You were sent to the floor and treated for alcohol
withdrawl. You also had a echocardiogram as a work up for your
swelling. You heart appeared normal. You will sent to a
shelter. We recommend that you stop drinking alcohol and follow
up with your PCP and psychiatrist at [**Hospital1 2177**] in 1 week.
.
Medication changes:
1) start albuterol inhaler for shortness of breath
2) start benzomatate for your cough
3) start sodium chloride nasally for your cough
4) start thiamine, folic acid and multivitamins to maximize your
nutrition
5) start tramadol for moderate to severe pain
6) start ibuprofen for mild to moderate pain
7) continue lasix as prescribed to you at [**Hospital1 3278**] for 1-2 weeks
until follow up with your primary care physician and get your
electrolytes checked when seeing your PCP
8) start claritin for your allergies
Followup Instructions:
You are seen at the [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] Health Group there contact
number is [**Telephone/Fax (1) 89925**]. The office was unavailable and a message
was left trying to confirm your appointment on [**2160-5-21**]. Please
call the office at the above number to do so.
|
[
"51881",
"2762",
"32723"
] |
Admission Date: [**2192-10-1**] Discharge Date: [**2192-12-24**]
Date of Birth: [**2123-3-25**] Sex: M
Service: [**Year (4 digits) **]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Speech disturbance, Right sided weakness, Transferred from OSH
for higher level of care
Major Surgical or Invasive Procedure:
Intubation
Tracheostomy and PEG
PICC line
History of Present Illness:
69yoM w/hx of HTN and hyperlipidemia who presents from OSH with
ischemic stroke (L-PCA infarction involving L-occipital and
posterior temporal lobes with conversion to hemorrhagic stroke).
Pt is from [**Country 11150**] and was brought to [**Hospital6 28728**] Center
by
his son. [**Name (NI) **] reports that patient vomitted in his sleep and was
unable to speak. On admission to [**Location (un) 1121**] patient was
arousable, but 'non verbal,' unable to follow commands and
'flaccid' in R-upper and lower exremities as per ED note.
.
Hosp Course at [**Hospital1 3597**].
[**9-19**] presented at OSH with aphasia, R-sided weakness
8/25 MRI showed acute ischemic change of L occipital, parietal
and temporal lobes - left thalamus diffusely involved.
Hemorrhage was noted in area of thalamus.
[**9-24**] TEE showed no obvious source of embolus, with normal EF, no
PFO. Continued to have confusion/vomitting. CT showed L-PCA
territory infarction with areas of hemorrhage. Mass effect and
midline shift present. Pt started on Aspirin 325mg, vomitting
resolved.
[**9-25**] Pt started to improve (per family) prior to increasing
somnolence on [**9-29**] (see below). Pt had fluent speech, required 2
people to help stand, 1 to help sit, weaker on R side, mild
R-facial droop, was not oriented to date, but knew he was in
hospital.
[**9-29**] . Pt became drowsy. CT of head showed increasing acute
intracranial hemorrhage within large L PCA territory, increasing
mass effect and midline shift compared with [**9-24**]. Neurosrug
consulted, recommended transfer to [**Hospital1 2025**]. Family decided to keep
pt at [**Hospital3 7362**] and decline neurosurgical intervention. Pt
transferred to ICU.
[**9-30**] pt became more delirious and agitated. Able to speak but as
per son and wife, his wording was not making any sense
[**10-1**] neuro exam remained the same, Head CT showed increased
hemorrhage and surrounding edema in L hemisphere with slight
increase in shift of midline. Possibly interventricular
hemorrhages as well. Pt reaffirmed decision to decline
neurosurgical intervention, but agreed to transfer pt to [**Hospital1 18**].
.
Of note per OSH report BP remained 'in good control' throughout
hosp course.
.
Past Medical History:
1. L-ischemic stroke conversion into hemorrhagic stroke with
increasing ICP midline shifts
2. Hyponatremia most likely secondary to SIADH
3. Newly Dx'd DM on OSH admission
5. Hyperlipidemia
6. Hypertension
7. Left Thyroid Nodule - found incidentally on Head CT.
Social History:
Lives with in [**Country 11150**] came to visit son at beginning of [**Month (only) **].
Planning to go home [**10-30**]. Prior to stroke, walking at
home, speaking fluently, had a retail business. Native language
is Tamil. Denies tobacco, alcohol, illicits.
Married w/ 3 children.
Family History:
Fam Hx: Mother died of cervical cancer ?age, father died of 'old
age'.
Physical Exam:
Physical Exam on Admission:
VS: 97.2, HR 99, BP 150/68, RR 21, 97%RA
GEN: elderly male lying in bed intermittently agitated
HEENT: OP clear, neck supple
CV: RRR, no m/r/g
PULM: CTA-B laterally
ABD: soft, NT, ND
EXT: no peripheral edema
.
Neurological Exam:
Mental Status: Awakens to voice, answers in "nonsens words" (per
his family who were translating) when asked the date, where he
was. Per family speech not slurred. Pt able to repeat short
phrases, but not long phrases (longer than 3 words). Pt uses
"made up words" on confrontation naming, and got more agitated
with each question. He was unable to read, unable to write.
However, at the very end of the exam he said "don't disturb me I
want to sleep" fluently. He can follow midline, appendicular
and
x-body commands. No evidence of neglect
.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils post-surgical bilaerally, reactive 2->1.5mm, VFF to
confrontation. Pt unable to cooperate with fundoscopic exam
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: R sided facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, but unable to get past bottom
lip.
.
-Motor: Normal bulk throughout, increased tone in RLE. Pt unable
to cooperate with pronator testing. No adventitious movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 1 2 2 1 3 1 2 2 2 2 2 2 3 3
.
-Sensory: No deficits to light touch, but pt unable to cooperate
with rest of sensory exam.
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 2 2 2 1
R 3 2 2 3 1
Plantar response was upgoing on the R, down on the L.
.
-Coordination: Pt unable to cooperate with FNF
.
-Gait: Deferred
__________________________________________________________
DISCHARGE EXAM
HEENT: AT/NC, trach in place - capped
CV: RRR, no m/r/g
PULM: CTA-B laterally
ABD: soft, NT, ND
EXT: no peripheral edema
Neurological: Awake, alert, oriented to self only. Language is
fluent (speaks Tamil). Follows simple axial and appendicular
commands.
PERRL, EOMI, right facial droop.
LUE and LLE has 3-4/5 strength throughout. RUE has 2/5 strength
throughout; RLE toes wiggle.
He is able to sit with zero to moderate assistance. He is able
to stand with 1-2 person assist.
Pertinent Results:
Labs on Admission:
[**2192-10-1**] 09:05PM BLOOD WBC-6.0 RBC-5.04 Hgb-15.0 Hct-43.2 MCV-86
MCH-29.8 MCHC-34.7 RDW-12.1 Plt Ct-368
[**2192-10-1**] 09:05PM BLOOD PT-14.5* PTT-27.7 INR(PT)-1.3*
[**2192-10-1**] 09:39PM BLOOD ESR-52*
[**2192-10-1**] 09:05PM BLOOD Glucose-164* UreaN-16 Creat-0.8 Na-136
K-4.1 Cl-104 HCO3-19* AnGap-17
[**2192-10-1**] 09:05PM BLOOD ALT-27 AST-68* LD(LDH)-534* CK(CPK)-301
AlkPhos-46 TotBili-0.4
[**2192-10-1**] 09:05PM BLOOD CK-MB-22* MB Indx-7.3* cTropnT-0.49*
[**2192-10-1**] 09:39PM BLOOD CK-MB-21* MB Indx-7.0* cTropnT-0.49*
[**2192-10-2**] 05:20AM BLOOD CK-MB-14* MB Indx-6.4* cTropnT-0.55*
[**2192-10-1**] 09:05PM BLOOD Albumin-4.0 Calcium-9.4 Phos-2.7 Mg-2.2
[**2192-10-1**] 09:39PM BLOOD %HbA1c-8.3* eAG-192*
[**2192-10-2**] 05:20AM BLOOD Triglyc-59 HDL-36 CHOL/HD-3.1 LDLcalc-64
[**2192-10-1**] 09:05PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.5 Leuks-TR
[**2192-10-1**] 09:05PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
[**2192-10-7**] 08:45PM URINE CastHy-3*
[**2192-10-1**] 09:05PM URINE Mucous-RARE
[**2192-10-2**] 01:57PM URINE Hours-RANDOM Creat-73 Na-178 K-50 Cl-201
No labs were done prior to discharge as pt was clinically
stable.
EEG:
[**2192-10-5**] This is an abnormal EEG due to the presence of bursts
of
generalized slowing superimposed upon an asymmetry of background
activity. The first finding is suggestive of a mild to moderate
encephalopathy of toxic, metabolic, or anoxic etiologies. The
second
abnormality suggests a widespread area of subcortical
dysfunction
involving the left hemisphere. No evidence of ongoing or
potential
seizure activity was seen at the time of this recording.
[**2192-10-8**] Markedly abnormal portable EEG due to the background
voltage suppression on the left side, particularly posteriorly,
and due
to the additional slowing and occasional suppression on the left
side.
These findings suggest a focal structural abnormality on the
left, but
the tracing cannot specify its etiology. In addition, the
background
was slow in all areas, suggesting a concomitant widespread
encephalopathy. Medications, metabolic disturbances, and
infections are
among the most common causes of these encephalopathies. There
were no
epileptiform features or electrographic seizures in the
recording.
[**2192-10-13**] This telemetry captured no pushbutton activations.
There
were no electrographic seizures. The record showed an
encephalopathic
pattern throughout. For about an hour on the morning of [**10-13**],
the blunted sharp waves were particularly rhythmic at about 1.3
Hz in
the right frontal region. Their resolution later that morning
was
likely to have followed administration of phenytoin as described
by the
clinical teams. The encephalopathy persisted.
[**2192-10-14**] This telemetry captured no pushbutton activations.
It
showed a slow or suppressed background throughout, particularly
in the
left posterior quadrant. The focal voltage suppression indicates
some
cortical dysfunction there. Some of the record appeared to
suggest
ongoing sleep, but most indicated an encephalopathy, with the
faster
regular alpha frequencies suggesting medication effect. There
were no
clearly epileptiform features or electrographic seizures.
[**2192-10-16**] This extended routine EEG over the morning of [**10-16**]
showed a very suppressed background over the left side,
particularly
posteriorly. The faster alpha frequencies on the right were
widespread
and suggested medication effect rather than normal wakefulness.
There
were no epileptiform features or electrographic seizures.
Neuroimaging:
[**2192-10-2**] Suboptimal MRI study secondary to patient motion.
Hemorrhagic
infarction seen in the left posterior cerebral artery territory
with
involvement of the splenium of corpus callosum. There is
surrounding edema
causing partial effacement of left lateral and third ventricles
along with a midline shift of 1 cm towards the right side.
[**2192-10-2**]
Large left hemispheric acute infarction, also involving the left
thalamus
and cerebral peduncle, with extensive hemorrhagic
transformation. Partial effacement of the left lateral and third
ventricles. Dilated temporal [**Doctor Last Name 534**] of the right lateral ventricle
suggests trapping.
[**2192-10-7**]
Evolving left PCA territory infarct with hemorrhagic conversion.
Stable mass effect and rightward shift of midline structures. No
significant interval increase in the hemorrhage.
[**2192-10-13**]
No significant change from the prior exam- see details above in
the left temporal and callosal lesion and edema . However, there
is a small hypodense focus in the right lentiform nucleus that
is more conspicuous since the prior study and not seen on more
earlier studies and may represent a focus of evolving acute
infarct.
[**2192-10-15**]
No appreciable change from prior examination. No new areas of
hemorrhage.
[**2192-10-20**]: Expected evolution of blood products within the left
PCA infart, with slightly decreased mass effect. No evidence of
new intracranial abnormalities.
ECG [**2192-10-22**]:
Sinus tachycardia. Probable prior anteroseptal myocardial
infarction. Diffuse non-specific ST-T wave flattening. Compared
to the previous tracing of [**2192-10-17**] no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
102 134 82 318/391 58 0 95
TTE - ECHO [**2192-10-26**]:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with distal septal and apical hypokinesis
(distal LAD). The remaining segments contract normally (LVEF =
45-50%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. No PFO, ASD or cardiac source of embolism seen.
Other Radiology:
[**2192-10-21**] ABDOMEN SUPINE PORTABLE:
Gastrostomy tube appears to be in a satisfactory position. The
stomach is not dilated. There is gas throughout the bowel as far
as the rectum. No dilated loops of small bowel are present.
Bowel gas [**Doctor Last Name 5926**] is therefore unremarkable. There is no evidence
either
obstruction or ileus.
[**2192-10-26**] CTA Chest with and without contrast:
IMPRESSION:
1. No evidence of pulmonary embolism to the subsegmental levels
bilaterally.
2. Minimal bilateral dependent atelectasis.
3. Left hepatic lobe hypodensities too small to characterize but
not
significantly changed compared to prior CT.
[**2192-11-13**] Renal Ultrasound:
IMPRESSION:
1. Bilateral caliceal diverticula. Small renal stone in the left
lower pole. Simple cyst in the mid portion of the right kidney.
No hydronephrosis.
[**2192-12-6**] Video Oropharyngeal Swallow:
IMPRESSION:
1. Weakness at the base of the tongue.
2. No evidence of aspiration or penetration.
Brief Hospital Course:
Mr. [**Known lastname 90726**] was admitted to the [**Hospital1 18**] NeuroICU as a transfer from
[**Hospital 3597**] [**Hospital 12018**] Hospital. His outside hospital course was
described above. Briefly, his problems began when following
dinner one night, he vomitted while in bed and was poorly
responsive. At the OSH, he was found to have a dense right
hemiparesis with global aphasia and left gaze preference and was
started on a large aspirin therapy. While his CT scan showed an
evolving left PCA stroke, he did have some punctate hemorrhagic
regions in the thalamaus on the left. He initially did well,
participated in rehabilitation and speech therapy, and was
showing improvement. His A1c returned elevated (newly diagnosed
diabetic) and both a TEE/TTE were unrevealing for a thrombus. On
[**2192-9-29**], he developed an acute worsening in his mental status
with delirium and drowsiness. A NCHCT at that time showed
worsening of his edema and hemorrhagic conversion. His ASA was
held and he was transferred to the ICU where over the next two
days, his examination remained stable. He remained
hemodynamically stable during his course, but for some mild
hyponatremia, he was started on hypertonic saline (3%).
The family eventually agreed to be transferred to the [**Hospital1 18**] for
a higher level of care. On arrival to us, his examination was
such that he had a profound right homonymous hemianopia with
right sided neglect, right hemiparesis and facial droop, a
largely expressive aphasia (language had to be tested in Telugu
(Tamil) through his son/family). Throughout the course of his
stay, this was his best examination. Over the course of the next
several days, his examination deteriorated to the point where he
was poorly responsive to sternal rub, he started to display
weakness of the left lower and upper extremities. Through his
deterioration, he was initiated on a variety of therapies to
reduce his intracranial pressure, including high dose IV
mannitol, hypertonic saline (3% or 23%) and IV steroids. He
developed fevers during this period (thought to be of a
pulmonary source) and was initiated on cooling blankets and
broad spectrum IV antibiotics. At the peak of his diminished
consciousness, he had an episode where he frankly aspirated his
tube feeds. Following this he was sedated and intubated. Under
the guidance of Dr. [**Last Name (STitle) 87490**] of the Neuro-ICU, we undertook an
intravascular cooling protocol to reduce ICP. He attained a core
body temperature of 34C for at least 24 hours and during this
period, his shivering was controlled with high doses of
fentanyl/propofol. He was slowly warmed, and following regaining
normothermia, he remained intubated for a few days. Off
sedation, his examination was quite poor: intact brainstem
reflexes, but with no response to calling his name, no
spontaneous eye opening, no movements of his lower extremities.
His steroids were slowly tapered.
We had at least two formal family meetings where we discussed
his grave prognosis. On the final family meeting on [**10-16**], the family wished to pursue a full code and trach/PEG. Their
ultimate goals were to have the patient transported back to
[**Country 11150**] for continued care. He was shown to be having
electrographic seizure activity on EEG, and was started on
pheytoin, which stopped the seizure activity. He received his
tracheostomy/gastrostomy tube on Setmeber 23, [**2192**] and was
tolerating trach collar well the next day. He started to spike
fevers to 103 shortly therafter and was found to have MRSA
colonization of his trach. He was started on linezolid on [**10-20**],
but continued to spike through this antibioic so he was
broadened to zosyn also on [**10-21**]. He had some transient episodes
of hypotension, felt to be from likely sepsis, and he was put on
pressors for <24 hours. These were weaned without issue, and he
was started on IVF to help with volume status. His UCx then
grew out klebseilla, which was sensitive to zosyn, so his ABx
were not changed. His phenytoin levels were difficult to
control and so he was switched to keppra on [**10-25**].
Ultimately he was transferred out of the ICU on [**10-25**] when he was
afebrile x 24hrs, was more alert, was intermittently responding
to commands and was able to be sat up in the chair without
issue. His neurologic exam had improved such that he was able to
open his eyes to voice and tracked relatively well, primarily to
the left. He was able to move his LUE spontaneously and
purposefully. He continued to have dense weakness of the RUE and
RLE but did show very small movements of the right hand. He was
able to speak phrases with the Passy-Muir valve in place. He
remained mildly tachycardic to the 90s-120s and was maintained
on Lopressor 25 mg PO q6h and continuous normal saline IV fluids
which attenuated this. An echocardiogram was performed which
showed mild regional left ventricular systolic dysfunction
consistent with CAD with an EF of 45-50%. A CTA was also
performed due to concern for PE which was negative. He completed
a 10 day course of linezolid and piperacillin-tazobactam for his
MRSA tracheobronchitis and UTI. He had another fever on [**11-8**]
which was likely secondary to continued infection from
Klebsiella which grew in a urine culture from that day; we
replaced his Foley catheter (which was required for urine output
monitoring, avoid exacerbating pressure ulcers, and
transitioning of care to another facility/travel).
Mr. [**Known lastname 90726**] remained medically stable over the next 4 weeks. He
was re-evaluated by the swallow therapists and found to be safe
for all consistencies po after a video swallow exam on [**2192-12-6**].
He continues to receive nighttime tube feeds until he is able to
take in a full diet. His trach has been capped intermittently
and he is able to tolerate it capped for 48 hours without
difficulty. He continues to make strides with physical therapy
and is now able to stand with 1-2 person assitance.
On day of dispo, at the request of the transporting doctor, we
changed his DVT prophylaxis from heprain SQ to lovenox. Pt was
sent with 6 doses of [**Hospital1 **] dosed lovenox as well as a week supply
of heparin in case his transport took longer than expected. He
was also sent with 2 doses of dextrose in case his blood sugar
dipped too low.
PENDING LABS:
Viral Cx final read [**2192-12-3**]
TRANSITIONAL CARE ISSUES:
Patient's transportation to [**Country 11150**] has been arranged and plan is
to have patient go to a rehab facility once in [**Country 11150**].
Medications on Admission:
atorvastatin 10mg PO
incorandil 5mg [**Hospital1 **]
metoprolol 25mg [**Hospital1 **]
flavedon mr [**First Name (Titles) 31366**] [**Last Name (Titles) **]
Aspirin EC 150mg
ramipril 2.5mg [**Hospital1 **]
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*7 Tablet(s)* Refills:*0*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*14 Tablet(s)* Refills:*0*
6. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID
(2 times a day).
Disp:*14 doses* Refills:*0*
7. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for dry skin.
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Disp:*28 Tablet(s)* Refills:*0*
10. benzoyl peroxide 10 % Gel Sig: One (1) Appl Topical DAILY
(Daily): for neck folliculitis.
11. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous Q breakfast.
Disp:*7 doses* Refills:*0*
12. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
Two (22) units Subcutaneous Q dinner.
Disp:*7 doses* Refills:*0*
13. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous QAHS: Titrate to sliding scale with QAHS finger
sticks.
14. Insulin Syringe 1 mL 30 x [**6-11**] Syringe Sig: One (1)
syringes Miscellaneous twice a day.
Disp:*20 syringes* Refills:*0*
15. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 6 doses.
Disp:*6 syringes* Refills:*0*
16. dextrose 50% in water (D50W) Syringe Sig: Two (2)
syringes Intravenous once a day for 2 doses.
Disp:*2 doses* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 90727**] Nursing Facility
Discharge Diagnosis:
Primary: Acute Ischemic Stroke, Intracerebral hemorrhage
Secondary: Urinary Tract Infection (bacterial, Klebsiella),
Seizure (electrographic), MRSA Tracheobronchitis
Discharge Condition:
Mental Status: Awake and alert, able to speak in native
language.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro: awake, alert, and able to communicate with his family
with spontaneous speech in his native language and follow basic
commands. He has a tracheostomy as well as a PEG tube, but
recently passed a swallow evaluation and is tolerating food by
mouth. His pupils are reactive, extraocular movements are
intact, and has a right facial droop. He is able to lift his
left arm and leg antigravity (approximately 4/5 strength, but
formal assessment is difficult due to cooperation). His right
arm and leg are 1-2/5. He is able to stand with two-person
assist.
Discharge Instructions:
Dear Mr. [**Known lastname 90726**],
You were seen in the hospital for a large ACUTE ISCHEMIC STROKE
which was complicated by HEMORRHAGIC CONVERSION (bleeding).
While here you needed to be on a ventilator (breathing machine)
for a very long time. Because of this, we had to place a
tracheostomy and a PEG tube to help you breath and get
nutrition. Your hospital course was complicated by a URINARY
TRACT INFECTION and TRACHEOBRONCHITIS, both of which were
treated and have resolved.
We made the following changes to your medications:
INCREASED metoprolol from 25mg po bid to 25mg po EVERY 6 HOURS
STOPPED atorvastatin 10mg PO
STOPPED incorandil 5mg [**Hospital1 **]
STOPPED flavedon mr [**First Name (Titles) 31366**] [**Last Name (Titles) **]
INCREASED Aspirin EC 150mg to Aspirin 325MG DAILY
STOPPED ramipril 2.5mg [**Hospital1 **]
STARTED famotidine 20mg po BID
STARTED Keppra (levetiracetam) 1000MG po BID
STARTED INSULIN NPH 5 UNITS subcut qAM and 22 UNITS subcut qPM
STARTED LOVENOX 30mg subcutaneously every 12 hours
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
It is hoped that Mr. [**Known lastname 90726**] will soon be traveling back to [**Country 11150**]
to follow up with the accepting physician:
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **]
MD, DM (AIIMS)
Assistant Professor [**First Name (Titles) **] [**Last Name (Titles) 878**]
National Institute of Mental Health and Neurosciences (NIMHANS)
[**Location (un) 90727**]- [**Numeric Identifier 90728**]
Office- [**Numeric Identifier 90729**]
Home- [**Numeric Identifier 90730**]
Fax- +91-[**Numeric Identifier 90731**]
Email-[**Company 90732**]
[**Last Name (un) 90733**].in
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"51881",
"5990",
"4019",
"2724",
"41401",
"42789",
"25000"
] |
Admission Date: [**2127-4-30**] Discharge Date: [**2127-5-30**]
Date of Birth: [**2065-12-24**] Sex: M
Service: MEDICINE
Allergies:
Ativan / Prochlorperazine
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
DLBCL, inability to keep up with transfusion requirements
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 61-year-old man with a history of diffuse large
B-cell lymphoma status post six cycles of R-CHOP between [**6-/2126**]
and [**10/2126**], status post five cycles of high-dose methotrexate
and one dose of intrathecal methotrexate, and s/p 3 cycles of
ESHAP chemotherapy and two doses of intra-thecal ARA-C. His
last cycle of ESHAP was [**Date range (1) 79455**]. Mr. [**Known lastname **] is well known
to the [**Known lastname 3242**] service, his last admission being from [**2127-2-23**] to
[**2127-4-25**] and complicated by fever and neutropenia secondary to
clostridium difficile infection (stool C. diff negative prior to
discharge), typhlitis, VRE urosepsis, upper and lower extremity
DVTs, and atrial fibrillation with rapid ventricular rate. He
was discharged to [**Hospital3 105**] and returns because of a
falling platelet count and inability to keep up with his
transfusion needs while maintaining anticoagulation with
lovenox.
Since discharge the patient reports that he has had difficulties
with episodes of dry heaves and was started on marinol the day
prior to transfer. He has also had some mild abdominal
discomfort intermittantly that improves somewhat with eating.
He has had a few episodes of diarrhea as well. He has not had
any frank fevers, however, his wife notes that his temperature
has been rising somewhat. He has had variable PO intake, at
times eating well and at times eating little to nothing at
mealtimes. The swelling in his upper and lower extremities has
decreased remarkably and he has lost nearly 30 pounds of weight.
He states he was placed on oxygen 2 days ago, but has not had
any shortness of breath. He has been working with physical
therapy at [**Hospital1 **], but is not up walking yet.
ROS: as above. In addition, he notes no upper respiratory
symptoms (runny nose, sore throat), cough, reflux, shortness of
breath, chest pain, blood per rectum, dysuria, rashes,
arthralgias.
Past Medical History:
Oncologic History:
Mr. [**Known lastname **] initially presented to an outside hospital in [**6-25**]
with a 30-pound weight loss over the prior 6 months. He was
worked up and found to have a soft tissue mass in the cardiac
ventricles involving the myocardium and extending into the
interatrial septum. He was also noted to have multiple pulmonary
nodules, bilateral pleural effusions, a pericardial effusion,
large bilateral adrenal masses, and diffuse soft tissue masses
involving both kidneys. The [**Hospital 228**] hospital course was
complicated by the development of tamponade physiology, and the
patient ultimately underwent a pericardial window. A renal
biopsy on [**2127-7-23**] confirmed diffuse large B-cell lymphoma (Stage
4B), and a pericardial biopsy on [**2127-7-25**] also was consistent with
large B-cell lymphoma. He was diffusely immunoreactive for CD20
and co-expressed Bcl-2 and Bcl-6. CD43, CD5, TdT, Bcl-1, S100
were negative. LMP for EBV was negative. CD10 and CD30 were
weekly expressed. In addition, a bone marrow biopsy demonstrated
bone marrow involvement by lymphoma. The patient was initiated
on R-CHOP on [**2126-7-26**] and received six cycles between [**7-/2126**] and
[**10/2126**] and is also status post five cycles of high-dose
methotrexate and one dose of intrathecal methotrexate.
CT abdomen on [**2-11**] showed evidence of new liver lesion
concerning for disease recurrence. CT guided liver biopsy on
[**2127-2-26**] was positive and on further evaluation was found to have
involvement in his heart, chest wall and retropharyngeal space.
He also was assumed to have it in his CSF, even though the first
LP had only one aytpical cell. He received a total of 3 cycles
of ESHAP chemotherapy and two doses of intra-thecal ARA-C. His
last cycle of ESHAP was [**Date range (1) 79455**]. No discrete hepatic
lesions were noted on CT abdomen on [**3-21**]. Flow cytometry showed
indefinite evidence of lymphomatous involvement of the CSF. He
was followed by neuro-oncology in-house who recommended no
further IT ARA-C and to follow his neurologic symptoms
clinically, and to re-refer him back to his outpatient
neuro-oncologist (Dr. [**Last Name (STitle) 79456**] if he had any worsening
confusion or neurologic symptoms. Given that he had received 3
x IT chemo and 3 cycles of high-dose Ara-C, it was felt to be
sufficient for CNS prophylaxis.
Other Medical History:
# Large B Cell lymphoma as above
# Recent C Diff Colitis
# Hx of DVTs, upper & lower extremities, on Lovenox
# Strep viridans bacteremia (1 bottle; PICC-associated? treated
w/ ceftriaxone/PCN/ceftriaxone x4 weeks total)
# Erythema nodosum, right forearm ([**8-/2126**])
# Intermittant atrial fibrillation with RVR
# Cardiogenic Syncope
# History of febrile neutropenia
# Typhlitis
# VRE Urosepsis
# Nephrolithiasis
# Anemia
# Gerd
Past Surgical History:
# Amputation of right 2nd digit after electrical accident
Social History:
Social History: (Per OMR)
The patient is married and has one son. [**Name (NI) **] is a retired
engineer. + 60 pk year history of tobacco, but quit in [**Month (only) 205**] of
[**2125**], just prior to his diagnosis of lymphoma due to symptoms of
profound weakness. Drinks socially, ~ 2 drinks per month. No
illicit drug use. One son is alive and healthy, and is also a
physician. [**Name10 (NameIs) **] has been able to accomplish basic ADLs with
minimal assistance, but is dependent on advanced ADLs.
Family History:
FHx:
Family History: (per OMR)
Father - died of [**Name (NI) **]
Mother - SLE, DM, CAD; died age 75
Brother - cardiac arrythmias
Brother - prostate CA
Son - healthy
Physical Exam:
V/S: T 99.0, BP 112/78, HR 78, RR 18, 97% on 2L NC
GEN: Thin, pale, male in NAD
HEENT: Sclera anicteric, left pupil 4 mm, right pupil 3 mm, both
pupils reactive to light. MMM, OP clear.
NECK: No lymphadenopathy, left IJ central line with dried blood
under the dressing
CHEST: Decreased BS bilaterally without wheezes, rhonchi, or
crackles.
CV: RRR, normal s1 and s2, no murmurs or extra heart sounds
appreciated
ABD: +BS, soft, non-tender, no hepatosmplenolmegaly
EXT: Warm, well perfused. 2+ edema in the left LE and 1+ edema
in the right upper extremity. 2+ DP pulse on right, not
appreciable on left secondary to edema.
SKIN: sacral ulcer, no rashes noted
NEURO: A&O x 3, decreased strength throughout. Unable to
dorsiflex ankles bilaterally. Reflexes 0-1+ bilaterally
throughout.
Pertinent Results:
Admission Labs:
[**2127-4-30**] 03:34PM BLOOD WBC-0.5*# RBC-3.04* Hgb-9.8*# Hct-27.1*
MCV-89 MCH-32.3* MCHC-36.2* RDW-16.3* Plt Ct-38*
[**2127-4-30**] 03:34PM BLOOD Neuts-24* Bands-2 Lymphs-62* Monos-8
Eos-0 Baso-2 Atyps-0 Metas-2* Myelos-0
[**2127-4-30**] 03:34PM BLOOD PT-13.4 PTT-26.7 INR(PT)-1.1
[**2127-4-30**] 03:34PM BLOOD Gran Ct-129*
[**2127-4-30**] 03:34PM BLOOD Glucose-111* UreaN-12 Creat-0.5 Na-140
K-4.8 Cl-103 HCO3-31
[**2127-4-30**] 03:34PM BLOOD ALT-9 AST-15 LD(LDH)-265* AlkPhos-82
TotBili-0.6
[**2127-4-30**] 03:34PM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.3* Mg-1.7
Microbiology:
[**2127-5-2**] 4:45 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2127-5-3**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2127-5-3**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Imaging:
[**2127-4-30**] CXR - The left internal jugular line tip is at the
cavoatrial junction. Cardiomediastinal silhouette is stable.
There is interval development of bilateral pleural effusions and
bibasal atelectasis. There is also increased opacity in the
right upper lung that is seen in addition to the known cavity
demonstrated on [**2127-3-21**] chest CT. No pneumothorax is
demonstrated. Small bilateral pleural effusions are present
that appears to be increased since the prior study.
[**2127-5-2**] RUE ultrasound - IMPRESSION:
1. Overall unchanged appearance of right upper extremity DVT
extending
through the subclavian, axillary, and brachial veins. Peripheral
flow in the subclavian and brachial veins indicates nonocclusive
thrombus in these
vessels. However, thrombus remains occlusive in the axillary
vein.
2. Occlusive thrombus in the basilic vein, not well visualized
previously,
but likely unchanged.
3. Persistent respiratory variability of the left subclavian
vein indicates the SVC remains patent, without occlusive central
propagation of right subclavian thrombus.
[**2127-5-3**] ECG - Normal sinus rhythm. Axis is minus 40 degrees.
Possible biatrial enlargement. Poor R wave progression in leads
V1-V4. Non-specific ST-T wave changes diffusely. Compared to the
previous tracing of [**2127-4-25**] there is no diagnostic interval
change. Consider left ventricular hypertrophy.
[**2127-5-4**] CXR - The left central venous line tip is at the
cavoatrial junction. Cardiomediastinal silhouette is unchanged
including left ventriculomegaly. The lung volumes are
unchanged, slightly decreased compared to more remote prior
studies. The known severe emphysema with bibasilar opacities,
pleural effusion and known right upper lung consolidation
appears to be unchanged as well. There is no evidence of
interval development of pulmonary edema.
[**2127-5-6**] CXR - FINDINGS: In comparison with the study of [**5-4**],
there is again evidence of chronic pulmonary disease with
bilateral pleural effusions and atelectatic changes at the
bases. The retrocardiac opacification is somewhat more prominent
than on the previous study. Central catheter remains in place.
[**2127-5-7**] CT Torso with contrast - IMPRESSION:
1. New moderate bilateral pleural effusions with associated
atelectasis.
There is no new consolidation within the lung parenchyma to
suggest presence of pneumonia.
2. Unchanged appearance of right upper lobe consolidation with
central
cavitation.
3. Previously identified left chest wall mass and cardiac masses
are not
visualized on the current study, consistent with continued
interval
improvement in lymphoma.
4. Resolution of wall thickening involving the cecum and
ascending colon.
5. Cholelithiasis within the gallbladder neck, but no CT
evidence of acute
cholecystitis.
6. Bilateral renal cortical thinning, most consistent with
scarring.
7. Unchanged adrenal fullness.
8. Extensive atherosclerotic disease of the distal aorta, with
unchanged
bilateral common iliac artery aneurysms and significant
intramural clot on the right.
[**2127-5-14**] ECHO - The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2127-4-9**], no
change.
[**2127-5-15**] CXR - IMPRESSION: Regression of previously identified
bilateral pleural effusion. Unfortunately, no lateral view has
been obtained which could identify the presence or absence of
remaining pleural effusion accumulating in the posterior sinuses
in this patient in standing position.
[**2127-5-16**] Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study
SPIROMETRY 11:03 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 4.74 4.52 105 4.36 96 -8
FEV1 3.10 3.18 98 2.76 87 -11
MMF 2.24 3.03 74 1.90 63 -15
FEV1/FVC 65 70 93 63 90 -3
LUNG VOLUMES 11:03 AM Pre drug Post drug
Actual Pred %Pred
TLC 7.24 6.88 105
FRC 4.65 3.88 120
RV 2.59 2.36 110
VC 4.83 4.52 107
IC 2.59 3.00 86
ERV 2.06 1.52 136
RV/TLC 36 34 104
He Mix Time 2.50
DLCO 11:03 AM
Actual Pred %Pred
DSB 9.31 26.50 35
VA(sb) 6.22 6.88 90
HB 9.50
DSB(HB 11.36 26.50 43
DL/VA 1.83 3.85 47
[**2127-5-18**] CT Torso with contrast - IMPRESSION:
1. Significant interval decrease of bilateral pleural effusions.
Multiple
small focal nodularities, consistent with tree-in-[**Male First Name (un) 239**]
appearance,
predominantly in the right lung but also seen in the left lung,
concerning for infectious process. Unchanged surgical sutures
and apical scar in the right lung.
2. No acute changes in the abdomen compared to the CT torso
performed 10 days ago. Unchanged left-sided common femoral/iliac
DVT. IVC filter in expected. position. Unchanged gallstones
without evidence of acute cholecystitis. Slightly prominent
pancreatic duct.
Brief Hospital Course:
Mr. [**Known lastname **] is a 61 year old male with diffuse large B cell
lymphoma, s/p multiple cycles of treatment, most recently his
third cycle of ESHAP chemotherapy with a history of upper and
lower extremity DVTs, atrial fibrillation with RVR, and recent
C. difficile colitis who was admitted with neutropenia and
thrombocytopenia and inability to keep up with his transfusion
requirements.
#. Diffuse large B cell lymphoma - The patient is s/p multiple
cycles of chemotherapy, including several cycles of intrathecal
chemotherapy that were felt sufficient for CNS prophylaxis. The
patient had a CT scan on [**2127-5-7**] that demonstrated a dramatic
remission of his formerly bulky disease. Repeat CT scan on [**5-18**]
failed to identify recurrent lymphoma. However, when the
patient developed hypercalcemia and delerium it was felt that
his Diffuse large B cell lymphoma had likely recurred. His
hypercalcemia eventually responded to pamidronate, fluids and
calcitonin. However, his delerium did not fully resolve. Given
the patient's likely disease recurrence despite multiple rounds
of chemotherapy, it was felt that the patient was unlikely to
benefit from additional chemotherapy. In discussion, with the
patient and his family, it was decided not to pursue additional
diagnostic studies such as a lumbar puncture or a bone marrow
biopsy. The patient's care was shifted towards comfort measures
and he passed aways peacefully on [**2127-5-30**] with his family at his
side.
# The patient had multiple other medical issues that required
treatment during this admission. He was neutropenic secondary
to his most recent ESHAP therapy. His is ANC nadired at 37. He
was placed on neutropenic precautions while he remained
neutropenic. The patient required multiple transfusions of
platelets during this admission. His platelet levels eventually
recovered as his neutropenia resolved. The patient had a
history of RUE DVT and was noted to have a thrombus in his right
iliac artery aneurysm. His dose of lovenox had to be lowered in
order to continue anticoagulation while the patient's platelets
were so low. During this hospitalization, he completed
treatment for his previously documented Afib and his symptoms
resolved.
#. Atrial fibrillation with RVR - The patient has a history of
intermittant afib with RVR, particularly in response to lasix.
The patient was initially kept on the metoprolol regimen that he
came from [**Hospital1 **] on. After a couple of days in the hospital
the patient had a rising oxygen requirement and was given
several small doses of lasix to remove extra fluid from his
multiple transfusions. He over went into afib with rvr in the
middle of the night and usually responded to 25-50 mg PO of
metoprolol tartrate. On [**5-10**] the patient was in afib with rvr,
assymptomatic and hemodynamically stable, for multiple hours and
did not respond to 50 mg PO metoprolol. Cardiology was
informally consulted and they recommended returning to the
patient's prior regimen of metoprolol succinate 200 mg daily and
metoprolol tartrate 50 mg Q midnight and stopping diuresis. The
patient responded very well to this regimen initially. However,
after the patient had difficulties with hypercaclemia, he became
more delerious and stopped eating and drinking. The patient
became more hypotensive despite fluid and electrolyte repletion.
Pt had sustained afib with RVR and required transfer to ICU on
[**5-26**]. He required Neo gtt to maintain his MAP >60. Digoxin
loading was attempted; however, his hr did not respond. He was
then tried on amiodarone. During this time, a family discussion
was held and it was decided to transition goals of care to
comfort. He actually converted into NSR upon transfer back to
[**Month/Day (4) 3242**] service, off neo, on [**5-28**].
.
#. Hypoxia - The patient did not require oxygen during his
previous admission, however, he was on 2L NC when trasfered from
the OSH. The patient was noted to become hypoxic, particularly
at night, requiring increased amounts of oxygen (up to 4L NC) to
keep his O2 sats greater than 90%. Chest x-rays and CT-chest
showed no evidence of infection, but did show new bilateral
pleural effusions compared to imaging from his prior admission
in addition to his previously known lung disease.
Interventional pulmonology was [**Name (NI) 653**], however, they did not
feel that the effusions were large enough to drain. Lasix was
used to try to remove some of the extra fluid and the patient's
oxygen requirement did decrease such that his O2 sats were 95%
or greater sitting up during the day, however, he continued to
require oxygen while lying in bed and sleeping. A repeat ECHO
was performed, however, it showed no change from his prior study
appoximately a month earlier. Pulmonology was consulted Repeat
x-ray showed improvement in the patient's effusions, and his
oxygen requirement resolved on its own, likely a delayed effect
of diuresis, requiring several days for fluid shifts to
transpire. The patient also underwent pulmonary function
testing due to concern for emphysema based on CT scan and prior
smoking history and need for such testing if stem cell
transplant were to be considereed. The patient was noted to
have a very low DLCO. It was felt that this was most likely
multifactorial, arising from emphysema, underlying lung disease
and scar from his prior pneumonia, and possibly chronic
thromboembolic disease given his known DVTs.
Medications on Admission:
Neutraphos 2 grams TID
Metoprolol tartrate 100 mg [**Hospital1 **]
Reglan 10 mg PO QIDACHS
Reglan 10 mg IV BID prn nausea
Protonix 40 mg daily
Acyclovir 400 mg PO Q8H
Fluconazole 200 mg PO daily
Multivitamin, 1 tab daily
Flagyl 500 mg IV Q8H
Zofran 8 mg Q6H prn nausea
Simethicone
Mylanta 80 mg, 1 tab QID prn
Marinol 5 mg Q4H prn nausea
Magnesium sulfate 1g IV Q6H
Methadone 2.5 mg TID
KCl 40 mEq TID
Lidoderm patch 5% to back 12 hours on and 12 hours off
Filgrastin 300 mcg sc daily for ANC <[**2117**]
Lovenox 60 mg Q12H (held on morning of admission)
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses:
1. Diffuse large B cell lymphoma s/p 3rd cycle of ESHAP
chemotherapy
2. Thrombocytopenia secondary to chemotherapy
3. Neutropenia secondary to chemotherapy
4. Hypoxia secondary to pleural effusions
5. Atrial fibrillation with rapid ventricular rate
6. Deep venous thromboses
7. C. difficile colitis
Discharge Condition:
expired
Discharge Instructions:
NONE
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2127-6-21**]
|
[
"5119",
"2762",
"2760",
"2875",
"42731",
"53081"
] |
Admission Date: [**2191-6-26**] Discharge Date: [**2191-7-7**]
Date of Birth: [**2123-6-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Compression fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: This is a 68yo woman w/ pmh of HTN, LE edema, DM2 presented
to OSH w/ intractable low back pain and altered mental status.
She had a fall [**5-14**] and was found to have compression fx
T11, sent home on vicodin. Her daughter brought here to her PCP
[**12-25**] decreased mobility and persistent back pain and she had an
MRI on [**6-6**] (no report). Admitted on [**6-25**] to OSH and had CT TL
spine, which showed burst fx at T11 with piece of bone sticking
into central canal with what was thought to be an unstable
spine. NSU consulted & recommended transfer here.
She was also found to be in ARF (BUN 100/ creat 3.5)
hyponatremia (120), hypokalemia 3.0. Received IVF and HCTZ held.
Hemodynamically stable on regular floor.
.
Dr. [**First Name (STitle) **] discussed case with Ortho Spine Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] here,
who recommended transfer here to Medicine due to metabolic
derangements, with Ortho Spine following closely until she is
medically stable for surgery.
.
On arrival to [**Hospital1 18**], she was initially a bit confused but
cleared and was able to give some history. She denies any
fevers/chills/cough/chest pain, diarrhea. She endorses [**4-2**]
lower back pain w/o radiation. Her daughter and son-in-law were
at her bedside and they state that she has been confused w/
slurred speech and increased urinary incontinence w/ [**Month (only) **] po
intake X 1 week (although she continued to take her pills). She
has been completely bed-ridden over the past week. Not anuric.
Her daughter states that she is the type of person who resists
going to the doctor or having tests performed.
.
ROS:
(+) as above; daughter endorses 20 lb wt loss in the past 2
months.
(-) Denies fever, chills. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denied cough, shortness of breath.
Denied chest pain or tightness, palpitations. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain.
Ms. [**Known lastname **] is a 68yo female with PMH significant for HTN, LE
edema, and DM2 who is being transferred to the MICU for
hypotension. The patient recently fell on [**5-14**] and was
found to have a T11 compression fracture. She was sent home on
Vicodin and since then has had persistent back pain and limited
mobility. She was then admitted on [**6-25**] to an OSH and underwent a
CT of the thoracic-lumbar spine which confirmed the T11 burst
fracture but also showed a piece of bone protruding into the
central canal. This was thought to be an unstable spine and she
was transferred to the [**Hospital1 18**] for further work-up.
.
Upon transfer to the medical floor, the patient was slightly
confused and admitted to decreased PO intake and urinary output
over the past week. This morning the patient was noted to be
hypotensive with SBPs in 80's. She was immediately given a fluid
bolus with little improvement in her blood pressure. She was
then transferred to MICU 7 for further management.
Past Medical History:
T11 burst fracture
Hypertension
Osteoporosis
Gout
Obesity
Chronic lower edema
s/p colostomy in [**2171**] for diverticular perforation
s/p appendectomy
s/p partial hysterectomy
Social History:
lives with her 18 year old granddaughter in [**Name (NI) 1474**]
Family History:
non contributory
Physical Exam:
Vitals: T: 95.8 P: 122 BP: 102/60 R: 16 SaO2: 97% on RA
General: Awake, alert, NAD mildly confused.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, dry MM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally
Cardiac: tachy, reg, nl. S1S2, no M/R/G noted
Abdomen: obese, soft, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses b/l, +
signs of arterial insufficiency
Lymphatics: No cervical, supraclavicular lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor
-DTRs: 1+ biceps, trace patellar and no ankle jerks bilaterally.
Plantar response was flexor bilaterally.
Pertinent Results:
==================
RADIOLOGY
==================
CTA CHEST: IMPRESSION:
1. Negative examination for PE or aortic dissection.
2. Narrowing of the right subclavian vein in the region
underneath the right
clavicle, resulting in extensive collateralization of veins in
that area.
3. Bilateral bibasilar small to moderate pleural effusion. No
evidence of
pneumothorax.
4. T11 burst fracture with narrowing of the spinal canal at that
level
(please refer to the thoracic spine CT for better evaluation of
the T11
vertebral body fracture).
5.A 3.5mm RUL nodule;for which either a 3 month follow up exam
is recommended
if the patient has risk factors for malignency or a one year
followup if no
risk factors are noted.
RUQ U/S 1. No evidence for cholecystitis or biliary obstruction
in this technically limited abdominal ultrasound. 2.
Splenomegaly. Clinical correlation recommended.
TTE The left atrium is normal in size. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. Overall left ventricular systolic function is
normal (LVEF>55%). Cannot exclude basal anteroseptal hypokinesis
but views are technically suboptimal for assessment of regional
wall motion. Right ventricular chamber size and free wall motion
are normal. There are three aortic valve leaflets. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
Brief Hospital Course:
1)Hypotension: Patient was hypotensive with SBP~80's on the
medical floor, and given difficulties with access she was
transferred to the MICU. Differential included urosepsis vs.
neurogenic shock (in the setting of burst fracture and bony
fragment protruding into canal). She had good rectal tone on
exam and no impairment of pain /temperature or motor ability,
suggesting that this is less likely neurogenic shock.
<br>
Patient was fluid resusitated after an ultrasound guided right
axillary/subclavian central line was placed. Although CVP
improved with fluids, her systolic blood pressure remained low,
averaging 90's to 100's. Echocardiogram was obtained and
revealed preserved ejection fraction without focal wall motion
abnormalities without pericardial effusion. Cortisol levels were
checked and [**Last Name (un) 104**]-stim performed with adequate response. Although
patient experienced episodes of atrial fibrillation (see below
for details), these were independent of hypotension. UA obtained
was concerning for urinary track infection and patient was
treated with 3 days of Ciprofloxacin. Although etiology of
relative hypotension is unclear, suspect that although on
admission this was due to severe hypovolemia, this is now most
likely secondary to poor vascular tone from prolonged bedrest
(patient had not been out of bed for weeks prior to admission).
She is mentating well and without complaints with SBP as low as
mid 80's.
<br>
Given low voltages on ECG, unexplained conduction disorders,
hypotension and fracture, we considered amyloidosis as a
possible unifying diagnosis. Serum and urine electrophoresis was
negative, with no monoclonal spike on immunofixation. A fat pad
biopsy was obtained and the results from that test are still
pending. TB was also a concern because it can increase the risk
of amyloidosis and could also present a unifying diagnosis. A
PPD was placed in the MICU and read as negative 48 hours later
on the medicine floor. Back on the floor the patient maintained
blood pressures that were appropriate and she did not have any
symptomatic hypotension.
<br>
2)T11 burst fracture: Some evidence of compression, however no
deficits on exam. Differential included pathologic fracture
(with high suspicion for multiple myeloma). Ortho spine team
evaluated the patient but due to very difficult procedure for
fixation, they would like to pursue conservative therapy at this
time. Patient will need to wear TLSO brace when out of bed at
all times. Has ortho surgery follow-up on [**2194-7-20**]:00 AM
with Dr. [**Last Name (STitle) 363**] in [**Hospital Ward Name 23**] outpatient clinics.
<br>
3)Atrial fibrillation: Noted during MICU admission. Patient
however was asymptomatic during these episodes. Rate control was
attempted with diltiazem, with good response but limited by
hypotension as above. Amiodarone was started with IV load, and
transition to oral dose at 200mg daily. Patient had baseline
LFT's and TFT's. Will need PFT's in the near future. LFTs were
up at one point and then trended down, but not to a normal level
prior to discharge. The patient will be instructed to have her
PCP drawn liver enzymes to follow-up from her hospitalization.
Given lack of surgical intervention, anticoagulation was started
with low dose coumadin, with care given relative
thrombocytopenia, mild liver enzyme elevation and concurrent
amiodarone use. INR trended up to 3.3 prior to discharge, likely
in part due to concomitant use of Cipro the day prior to
admission.
<br>
4)Acute on chronic renal failure: Per PCP's office, baseline Cr
appears to be 1.5, likely elevated [**12-25**] hypertension and DM2.
Elevated to 3.2 at OSH and trended down to 1.0 during her stay
in the MICU. Most likely represented pre-renal azotemia in the
setting of hypotension and underlying infection. On the medicine
floor, IVF were continued and Cr remained normal.
<br>
5)Thrombocytopenia: Per PCP, [**Name10 (NameIs) **] has not had low platelets
in the past. Decreased to 112 on admission to OSH and decreased
to 76 during hospital stay. Unsure if she received heparin
products at the last hospital. HIT panel negative. Hematology /
Oncology was consulted and felt that given her cholestatic
picture, she may have an underlying chronic hepatitis. On
discharge platelets were trending up and ended up being 161.
<br>
6)Hyperbilirubinemia / Liver enzyme elevations: Bilirubin
elevated to 2.9 and elevated alk phos. Question underlying
process given hypotension. Right upper quadrant ultrasound
without infiltration or fibrosis. Hepatitis panel was obtained
and revealed:
Hepatitis B Surface Antibody NEGATIVE
Hepatitis B Virus Core Antibody NEGATIVE
Hepatitis A Virus Antibody POSITIVE
Hepatitis C Virus Antibody NEGATIVE
<br>
7)Type 2 Diabetes: Unclear if patient is on oral regimen at
home. In the MICU, her blood sugars were very well controlled.
She was placed on an insulin sliding scale. This controlled the
patient's blood sugars during this hospitilization. On discharge
she had not required insulin by sliding scale for 5 days. She
was not sent to the rehab facility with SSI discharge orders.
<br>
8)Hypertension: Patient on Triameterene/HCTZ as an outpatient
which was held given her hypotension. She can revisit this
medication with her PCP as an outpatient. We will not discharge
her on this medication.
<br>
9)Hyperlipidemia: Patient on Gemfibrozil as outpatient; this was
held given LFT abnormalities. She should consult with her PCP
about restarting this medication once her LFTs are followed-up
as an outpatient.
<br>
10) Urinary tract infection: The day prior to being discharged
from the hospital, patient had significant pain attributed to
foley catheter. UA revealed likely UTI. Started on Cipro 500 mg
Q12H for a total of 7 days with first day being [**2191-7-6**].
Medications on Admission:
triamterene/HCTZ 37.5/25
allopurinol 300 mg daily
gemfibrozil 600 mg po bid
fosamax 70 mg weekly
motrin 600 mg [**Hospital1 **] prn
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain .
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 39225**] & Rehab Center - [**Hospital1 1474**]
Discharge Diagnosis:
PRIMARY DIAGNOSES
1) T11 Burst facture
2) Atrial Fibillation
SECONDARY DIAGNOSES
1) Hypotension
2) Transaminitis
3) Hyperbilirubinemia
Discharge Condition:
stable, afebrile
Discharge Instructions:
You presented to the hospital with worsening back pain and were
found to have a t11 burst fracture. Orthopedic Surgery was
consulted and did not recommend surgery, but suggested
conservative management with a back brace. Once you regain some
of your strength in rehabilitation, you will need to follow-up
with Dr. [**Last Name (STitle) 363**] ([**Telephone/Fax (1) 3573**]) on [**2194-7-20**]:00 AM at [**Hospital Ward Name 23**]
building ([**Hospital1 18**] [**Hospital Ward Name 516**]) for further management of your
spine fracture. You should wear your brace until that time.
In the hospital you developed low blood pressure and needed to
be transferred to the MICU. No reason was found for why you
developed this low blood pressure, but it improved with IV
fluids. In the MICU, you were found to have Atrial Fibrillation.
You were started on medications to control your heart rate, as
well as a medication to thin your blood called coumadin. Please
continue amiodarone, metoprolol and coumadin after you leave the
hospital and be sure to have your INR levels checked biweekly to
determine the appropriate coumadin dosage.
The day prior to being discharged from the hospital, you had
significant pain attributed to your bladder catheter. You were
found to have a urinary tract infection which is being treated
with a 7 day course of a drug called Cipro. Your PCP should be
aware that Cipro affects your blooding thinning and we have
reduced the dosage of your coumadin while your are taking Cipro.
We have held your home doses of triamterene/HCTZ and gemfibrozil
due to low blood pressure and liver abnormalities while in the
hospital. You should talk to Dr. [**Last Name (STitle) 10740**], your PCP about
restarting these medications.
Please have a repeat chest CT in 3 months to evaluate A 3.5 mm
right upper lung nodule.
Please seek immediate medical attention if you have any chest
pain, palpitations, shortness of breath, loss of
consciousnesses, weakness, dysarthria, loss of sensation or any
other change in your condition.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10740**] within 1 week following
your hospitalization. Dr. [**Last Name (STitle) 10740**] can decide about restarting your
home antihypertensive medications.
Please follow up with orthopedics Dr. [**Last Name (STitle) 363**] ([**Telephone/Fax (1) 3573**]) on
[**2194-7-20**]:00 AM at [**Hospital Ward Name 23**] building ([**Hospital1 18**] [**Hospital Ward Name 516**]) for
further management of your spine fracture.
Completed by:[**2191-7-7**]
|
[
"5849",
"2761",
"5990",
"2762",
"40390",
"42731",
"2724",
"5859"
] |
Admission Date: [**2164-11-19**] Discharge Date: [**2164-11-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
outside hospital transfer with hypotension adn hypothermia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 89 year-old female with a history of [**Last Name (un) 309**] Body
dementia, CAD, HTN who presents with 3 days of progressive
altered mental status. At baseline, the patient is alert and
oriented x 3 and was in her usual state of health until 2 days
prior to admission. At that time her daughters noted that she
was not eating. The following day, she was not talking and was
less interactive than usual, answering questions with only "yes"
or "no". On the morning of admission, she was found unresponsive
and moaning and so EMS was called. On arrival EMS found her to
be hypothermic in the 80s (apartment was normal temperature) and
not responsive.
.
In the ED, initial vitals were T 85, BP 136/80, HR 52, RR 16, O2
sat 93% on 2L. On exam, she was moaning but not interactive.
Moving all extremities and was noted to have a cough. CXR was
concerning for LLL pna. UA positive. She was noted to be in ARF
with Cr 1.2 from baseline 0.6. At 11:50pm became hypotensive to
70s (HR 70s), however her BP quickly improved to 100s-90s with
IVF. Received vanco, ceftriaxone, and azithromycin. Hypothermia
was treated with a warming blanket and warmed IVF. Head CT neg.
EKG showed old LBBB however trop mildly elevated at 0.04 and so
she was given PR ASA. Abdominal CT with IV contrast revealed
diverticulosis (without diverticulitis), chronic LLL
atelectasis, no mesenteric ischemia, no abscess. She was
admitted to the [**Hospital Unit Name 153**] for further management.
Past Medical History:
-HTN
-GI Bleed--[**2158**], in setting of NSAID use as well as H.Pylori
infection, which was treated. That hospitalization included ICU
admission with multiple PRBC transfusions, several EGDs with
clipping and electrocaudery of bleeding lesion, intubation and
tx for PNA, and IMI that was likely in the setting of anemia.
-CAD--had an elevation in trop in setting of GIB as above (Echo
in [**10-31**] showed preserved EF (55%) with basal inferolateral
hypokinesis and septal apex hypokinesis, and [**11-30**]+ MR)
-CVA--[**10-31**] with L hemiparesis (distal right middle cerebral
artery
lenticulostriate artery infarction)
-Dementia--probable [**Last Name (un) 309**] Body
Social History:
One of her daughters is a nurse. She does not smoke and rarely
drinks alcohol. Prior history of [**1-1**] glasses of ETOH/day. She
likes drinking coffee, at least three cups a day.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 93.2 BP: 128/105 HR: 86 RR: 22 O2Sat: 96% on 2L
GEN: somnolent elderly female, unarousable, withdraws to painful
stimuli
HEENT: pupils pinpoint and minimally reactive, sclera anicteric,
no epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: HS muffled by heavy breathing, RRR, no M/G/R, normal S1 S2,
weak distal pulses
PULM: Lungs CTAB anteriorly however exam limited by patient's
mental status
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: L arm contracted. No LE edema.
RECTAL: guaiac negative per ED
NEURO: unresponsive, withdraws to painful stimuli, moves RUE and
bilateral [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 35718**]. Plantar reflex downgoing. ?
bilateral ankle clonus
SKIN: Scattered ecchymoses on extremities.
Pertinent Results:
[**2164-11-20**] 03:30AM BLOOD WBC-9.7 RBC-3.76* Hgb-11.2*# Hct-33.3*
MCV-89 MCH-29.9 MCHC-33.8 RDW-16.4* Plt Ct-106*
[**2164-11-19**] 08:00PM BLOOD WBC-9.1 RBC-4.67# Hgb-14.4# Hct-42.1#
MCV-90 MCH-31.0 MCHC-34.3 RDW-16.5* Plt Ct-133*
[**2164-11-19**] 08:00PM BLOOD Neuts-91.7* Lymphs-5.5* Monos-1.7*
Eos-0.9 Baso-0.1
[**2164-11-19**] 08:00PM BLOOD PT-14.5* PTT-37.1* INR(PT)-1.3*
[**2164-11-19**] 08:00PM BLOOD Glucose-84 UreaN-30* Creat-1.2* Na-146*
K-4.8 Cl-108 HCO3-29 AnGap-14
[**2164-11-20**] 03:30AM BLOOD Glucose-64* UreaN-28* Creat-1.1 Na-144
K-4.6 Cl-115* HCO3-19* AnGap-15
[**2164-11-19**] 08:00PM BLOOD ALT-24 AST-27 CK(CPK)-61 AlkPhos-137*
Amylase-149* TotBili-0.5
[**2164-11-20**] 03:46AM BLOOD CK-MB-12* MB Indx-23.5* cTropnT-0.03*
[**2164-11-20**] 03:30AM BLOOD Calcium-7.4* Phos-3.1 Mg-1.9
[**2164-11-20**] 03:46AM BLOOD TSH-3.4
[**2164-11-20**] 03:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-11-20**] 06:26AM BLOOD Type-ART pO2-44* pCO2-44 pH-7.28*
calTCO2-22 Base XS--5
[**2164-11-19**] 08:05PM BLOOD Lactate-1.2
[**2164-11-19**] 10:30PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-SM
[**2164-11-19**] 10:30PM URINE RBC-0-2 WBC-[**10-18**]* Bacteri-MANY
Yeast-NONE Epi-0-2
[**2164-11-19**] 10:30PM URINE CastHy-[**5-8**]*
CT Abdomen/Pelvis:
IMPRESSION:
1. No evidence of mesenteric ischemia or acute abdominal
process.
2. Atherosclerotic disease of the aorta and its branches, with
bilateral
renal artery stenoses, and lesser stenoses of the celiac and
SMA.
3. Replaced right hepatic artery.
4 . Severe diverticulosis, without evidence of diverticulitis.
5. Right adnexal cyst, for which an outpatient ultrasound is
recommended.
The study and the report were reviewed by the staff radiologist.
INDICATION: 89-year-old with altered mental status.
COMPARISON: [**2162-9-11**].
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage,
edema, or
major vascular territorial infarct. Extensive encephalomalacia
related to a
prior right MCA territory infarct is unchanged. There is
associated ex vacuo
dilatation of the right lateral ventricle. The ventricles and
sulci are
prominent, consistent with age-related involutional changes. The
basal
cisterns are preserved. There is no calvarial or soft tissue
abnormality. The
visualized paranasal sinuses and mastoid air cells are normally
pneumatized
and aerated. The lenses have been replaced.
IMPRESSION: No acute intracranial process including no evidence
of
hemorrhage.
Brief Hospital Course:
On arrival to the [**Hospital Unit Name 153**], the patient was hemodynamically stable.
However, within 2 hours, her BP dropped to the 60s systolic with
MAPs in the 40-50s. She was bolused 2L IVF and started on
peripheral dopamine. The patient was known to be DNR/DNI and the
family did not want a central line, however, they wanted the
rest of the family to be able to come in so we used the dopamine
for several hours with the goal of stopping it when the family
arrived. In the morning, we had a family meeting and it was
decided to make the patient CMO. Her dopamine was d/c'd and she
was given morphine for pain control. She remained stable
throughout the day and was transferred to the floor. On the
floor she was continued on morphine with no vital signs or labs
checked. She remained on the Morphine drip for several days. Her
daughters refused hospice at home or transfer to hospice house
because of the costs. A SNIF has refused to take her for end of
life care because she was on morphine drip. She finally expired
on [**2165-11-25**] at 3:00 PM.
Medications on Admission:
Aricept 5mg PO BID
ASA 325mg PO daily
Calcium 500 + D one tab PO daily
Detrol LA 2mg PO qHS
Seroquel 37.5mg PO daily prn agitation
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Sepsis
Discharge Condition:
expired
|
[
"0389",
"78552",
"5849",
"486",
"5990",
"99592",
"4019"
] |
Admission Date: [**2177-3-26**] Discharge Date: [**2177-4-11**]
Date of Birth: [**2116-5-14**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10416**]
Chief Complaint:
chronic R frontal scalp wound
Major Surgical or Invasive Procedure:
[**3-26**]:
1. Debridement and removal of calvarial bone flap.
2. Placement of titanium mesh cranioplasty.
3. Debridement of scalp open wound.
4. Soft tissue reconstruction with right radial forearm
free flap with subsequently split thickness skin graft.
History of Present Illness:
The patient is a 60y.o. man who suffered a myocardial infarction
in [**2170**] that
required him to undergo angioplasty and stent placement and
ongoing Coumadin therapy. He subsequently developed an acute
subdural hematoma on the right side that required emergent
evacuation and craniectomy that was performed at the [**Hospital1 3372**]. Following adequate clinic stabilization, his
cranial bone flap was replaced; however, he subsequently
developed a chronic draining wound in his right frontal scalp
that has persisted for the subsequent seven years. He has been
followed intermittently by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the Plastic
Surgery Clinic and was last seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in his
clinic on
[**2177-1-20**]. During the course of that evaluation, the
patient was recommended for a CT scan that showed necrosis of
the central portion of the patient's right frontal/temporal bone
flap that appears to be associated with full thickness bone loss
at the central portion of the flap. He presented on [**3-26**] for
cranioplasty and free flap scalp reconstruction.
Past Medical History:
- CAD s/p MI with PCI ([**12/2170**])
- R frontal ICH ([**1-/2171**]) in setting of anticoagulation for MI
- AML s/p chemo in [**2156**], in remission
- h/o seizures
- Anal fissure [**2170**]
- OSA
- HTN
- Hyperlipidemia
- H/o 'MRSA infection' in [**12/2170**]
- Depression
Social History:
no EtOH or Smoking. The patient is married, lives at home with
his wife and works as an office manager.
Family History:
Mother - died at 83 of cirrhosis [**1-18**] surgical complications of
[**Name (NI) 10259**]
Father - died at 57 secondary to CAD
Physical Exam:
Pre-op:
AVSS
Gen: well appearing, NAD
HEENT: obvious depression in the superior frontal region of his
scalp with an associated, approximately 1 cm diameter draining
sinus tract that is productive of fibrinous material. There is
no surrounding erythema, but there is significant chronic
inflammatory tissue surrounding this tract site.
Lungs: CTA
Heart: RRR
Abd: soft, N-T, N-D
Pertinent Results:
CT HEAD W/O CONTRAST [**2177-3-27**] 4:48 PM
FINDINGS: Comparison is made to head CT from [**2177-1-22**] and head MR
from [**2177-2-12**].
The previously seen craniotomy bone flap has been removed and
there is a new mesh in the craniotomy defect. There is overlying
soft tissue air as well as a new scalp flap. Surgical clips are
seen within the flap.
There is a tiny amount of air deep to the mesh. There is
heterogeneous high- density material immediately under the mesh,
which may represent post-surgical fluid, but if there is concern
for infection, this could be further evaluated with MR.
Again seen is encephalomalacia of the adjacent right frontal
lobe. There are no intracranial hemorrhages.
Again seen is a dilated CSF space in the left middle cranial
fossa, consistent with an arachnoid cyst.
The ventricles and extra-axial CSF spaces are unchanged in size.
The visualized orbits appear normal. The visualized paranasal
sinuses are clear.
IMPRESSION: No intracranial hemorrhages.
TTE (Complete) Done [**2177-3-31**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate to severe focal left ventricular hypokinesis with
akinesis of the anteroseptum and anterior walls and hypokinesis
of the inferoseptum and anterolateral walls (LVEF ?30 %). 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. The mitral valve
leaflets are not well seen. Trivial mitral regurgitation is
seen.
[**2177-3-26**] 11:29AM HGB-13.0* calcHCT-39
[**2177-3-26**] 08:50PM WBC-9.7# RBC-3.49* HGB-11.6* HCT-33.3* MCV-95
MCH-33.1* MCHC-34.7 RDW-13.0
[**2177-3-26**] 08:50PM CK-MB-17* MB INDX-1.0 cTropnT-<0.01
Brief Hospital Course:
The patient was admitted on [**3-26**] for cranioplasty and free radial
scalp flap for chronic, non-healing scalp wound. The infected
cranial graft was removed and a titanium mesh placed. Next a
free flap was taken from the R radial forearm and transposed to
the scalp. A split thickness skin graft from the thigh was used
for the radial wound. A lumbar drain was placed intra-op by
neurosurgery to minimize pressure on the repair. The patient was
transferred to the ICU ventilated following surgery for post op
management. He was extubated on POD#1. Flap doppler checks were
performed frequently post-operatively and showed good pulses.
He was transferred to the floor on [**3-31**].
NEURO:
On POD#1 the patient had 2 witnessed generalized tonic-clinic
seizures. He was treated acutely with ativan and neurology was
called. The patient reported missing an unspecified number of
tegretol doses prior to admission. The patient was loaded with
dilantin and put on a course of dilantin and tegretol. Tegretol
levels were drawn to follow the level which remained
subtherapeutic for most of the hospital course and required 2
additional loading doses. Ativan was used to bridge between the
dilantin and tegretol, and the dilantin was tapered off, being
discontinued on [**4-9**]. Tegretol level was increased [**4-11**] for
discharge with follow up with patient's primary neurologist on
[**4-18**].
Lumbar drain: post op 20cc/hour were drained with clamping of
the drain in the interim. This was tapered to 10cc/h after 48h
and the drain was d/c'd on [**3-31**] without complication.
Cardiology: the patient was tachycardic post-op and required
beta blockade and diltiazem to reduce his rate. He did remain
normotensive post-op.
ID:The patient was initially covered with vancomycin and zosyn.
OR tissue cultures grew MRSA. Blood cultures and CSF cultures
had no growth.Zosyn was d/c'd on [**3-28**] following reports from the
OR cultures. Rifampin was started on [**4-2**] for additional
coverage per ID consult's recommendation.
Wound: The radial donor site was initially treated with a VAC
dressing. This was taken down on [**4-1**] and the wound was dressed
with xerform and kerlix and changed daily. The graft took well
an continued to heal without complication. The STSG donor site
was dressed with xeroform and allowed to dry.
Nutrition: the patient started a clear liquid diet on POD#1 and
a regular heart healthy diet on POD#2.
Medications on Admission:
Atenolol 12.5mg QD
Carbamazepine 400mg [**Hospital1 **]
Lipitor 40mg qHS
ASA 81mg QD
MVI, fish oil
Discharge Medications:
1. Outpatient Lab Work
Weekly CBC with Diff, electrolytes, LFTs, ESR and CRP.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 4 weeks.
Disp:*56 Recon Soln(s)* Refills:*0*
4. Rifampin 150 mg Capsule Sig: Three (3) Capsule PO twice a day
for 4 weeks.
Disp:*168 Capsule(s)* Refills:*0*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Lipitor 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous twice a day as needed: flush IV BID and PRN.
Disp:*60 ML(s)* Refills:*2*
10. Normal Saline Flush 0.9 % Syringe Sig: Five (5) cc Injection
twice a day for 4 weeks: [**Hospital1 **] with IV meds and PRN .
Disp:*75 flushes* Refills:*2*
11. Carbamazepine 200 mg Tablet Sig: Five (5) Tablet PO twice a
day.
Disp:*300 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Chronic scalp wound.
Discharge Condition:
Good. Tolerating a regular diet. Pain well controlled on oral
medication.
Discharge Instructions:
Take medications as directed.
Resume a regular diet.
Change the dressing on your arm daily with xerform, kerlix and
ACE bandage.
The dressing on your thigh will fall off on its own.
Call your physician for fever >101.5, discoloration of the scalp
flap, pain, redness, swelling or drainage at the wound sites, or
any other symptoms that may concern you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in the office in 1 week. Call for
appointment:([**Telephone/Fax (1) 10419**]
You have an appointment with Dr. [**Last Name (STitle) 32878**], your neurologist on
[**2177-4-18**] at 12:30PM to follow up your anti-epileptic medication
regimen. You should have a tegretol level drawn at this time.
You will need weekly lab draws while you are on rifampin (until
[**5-8**]) which include CBC with differential, BUN/Creatinine, LFTs,
ESR, CRP. Please fax the results of these test to the Infectious
disease nurse [**First Name (Titles) **] [**Last Name (Titles) 18**] at [**Telephone/Fax (1) 432**]. Call [**Telephone/Fax (1) 14774**] with
questions regarding the antibiotics or labs.
|
[
"4280",
"4019",
"2724",
"412",
"V4582"
] |
Admission Date: [**2180-11-23**] Discharge Date: [**2180-12-7**]
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 81 -year-old
gentleman with known aortic stenosis who was admitted to [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2180-11-23**], with
chest pain and ultimately ruled in for acute myocardial
infarction. He presented initially to [**Hospital3 **] and
was transferred to the [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]
for definitive therapy for his evolving myocardial
infarction. On arrival, he was brought to the Cardiac
Catheterization Laboratory and was diagnosed with three
vessel coronary artery disease.
In the Cardiac Catheter Laboratory, a successful percutaneous
transluminal coronary angioplasty stenting of the proximal
and then right coronary artery was performed using a 3.0 X 18
mm Bx Velocity heparin-coated stent. Please see previously
dictated percutaneous transluminal coronary angioplasty note
for more details. Also it was noted that his aortic valve
gradient was 49 mmHg with a valve area of 0.71 cm2.
He presented to the Medicine Service with the potential for
going for a cardiac surgery later in the admission.
PAST MEDICAL HISTORY:
1. Status post colostomy for rectal cancer approximately ten
years ago.
2. Aortic stenosis with a valve area of 0.71 cm2 with
gradient 49 mmHg.
ADMITTING MEDICATIONS: Vitamin C, aspirin prn.
ALLERGIES: Adverse drug reactions to Lipitor and Zocor,
causing increase in liver function tests. Lipitor causes
muscle pain.
SOCIAL HISTORY: Denies abuse of tobacco and alcohol. He
lives in [**Location 38**] with his wife.
PHYSICAL EXAMINATION: On admission, temperature 97.8 F,
pulse 55, blood pressure 116/60, respirations 16. General
appearance: In no apparent distress, well appearing 81
-year-old gentleman. Head, eyes, ears, nose, and throat:
moist mucous membranes, oropharynx clear, partial plates in
upper and lower mouth. Pupils are equal, round, and reactive
to light and accommodation, bilateral cataracts, extraocular
muscles are intact. Neck is supple, carotids of 1+
transmitted murmur, presumably from aortic stenosis. No
jugular venous distention was appreciated by the examiner.
Respiratory: clear to auscultation bilaterally without
wheezes, rales, or rhonchi. Cardiovascular: regular rate and
rhythm, normal S1, S2, grade III/VI systolic murmur radiating
to the carotid arteries. Abdomen: soft, nontender,
nondistended, with an ostomy in the left lower quadrant.
Extremities: no clubbing, cyanosis, or edema. Dorsalis pedis
and posterior tibial pulses are 2+ bilaterally. There is no
femoral bruit appreciated. A small hematoma on the right
groin which is nontender. Hematoma is from the
catheterization.
ADMISSION LABORATORY DATA: Cardiac catheterization performed
on [**2180-11-23**]:
1. The patient has a right dominant system with severe three
vessel disease. The left main coronary artery is without
significant stenosis. There is probably 80% proximal left
anterior descending stenosis located just distal to the first
diagonal takeoff. There is also 80% mid left anterior
descending stenosis just after the second diagonal takeoff.
Left proximal circumflex artery had a focal 80% stenosis
before the origin of the first obtuse marginal artery. There
is a focal 80% stenosis just after the first obtuse marginal
artery as well. There is focal 70% stenosis at the origin of
the second obtuse marginal artery. The right coronary artery
had a diffusely diseased proximal portion with up to 90%
stenosis. After the marginal artery, there is more diffuse
disease in the mid right coronary artery with subtotal 99%
occlusion. The distal right coronary artery had a tubular
40% stenosis.
2. The patient had elevated right and left sided filling
pressures. The right atrial mean pressure was measured to be
10 mmHg. The right ventricular filling pressures were 33/12
mmHg and the pulmonary artery pressures were 33/20 mmHg,
consistent with mild pulmonary hypertension. The pulmonary
capillary wedge pressure mean was 18 mmHg, while the left
ventricular end diastolic pressure was 23 mmHg. This site is
consistent with moderately elevated left sided filling
pressures. The cardiac output was 4.71 using the Fick
equation in the cardiac index with 2.8 liters/min2. The mean
aortic gradient was found to be 49 mmHg, calculated in aortic
valve area, using the Gorlin equation with 0.7 cm2,
consistent with severe aortic stenosis.
3. Estimated left ventricular ejection fraction of 50%.
HOSPITAL COURSE: The patient was admitted to the Medical
Service where he ruled in for a ST elevation inferior
myocardial infarction. The patient was started on aspirin,
Plavix, metoprolol, Aggrastat, and nitroglycerin while on the
Medicine Service. Surgery was initially planned, coronary
artery bypass graft of three vessels, and aortic valve
replacement. Surgery was initially planned for [**2180-11-28**], but as the patient had been on Plavix prior to this,
the surgery had to be delayed until [**2180-12-1**].
The patient went to the Operating Room on [**2180-12-1**],
where he had an aortic valve replacement, a CE #23 valve. He
had a left internal mammary artery anastomosis to his left
anterior descending artery. He had saphenous vein graft to
obtuse marginal artery and saphenous vein graft to the right
coronary artery. Please see previously dictated operative
note for more details. The patient tolerated the procedure
well and was transferred from the Operating Room to the
Cardiac Surgery Recovery Unit. The patient remained
intubated at this time.
On the evening of his operation, [**2180-12-1**], he
initially started to have high outputs and demonstrate
evidence of postoperative bleeding. The patient was brought
back to the Operating Room emergently. His mediastinum was
opened and explored. Blood was evacuated from the
mediastinum and there was no evidence of surgical bleeding.
The patient was again closed and brought back to the Cardiac
Surgery Recovery Unit.
On postoperative day one, [**12-2**], the patient was
extubated and was on a nitroglycerin and Nipride drip. By
postoperative day two, the patient was only on the
nitroglycerin drip and was tolerating po after being
extubated. On postoperative day three, the patient was off
all of his active drips. The patient's Foley catheter was
removed and he was transferred to the Patient Care Floor. On
postoperative day four, the patient's chest tube and pacing
wires were removed. He was able to ambulate to a level 3 and
had no complaints.
On the evening of postoperative day four, the patient went
into atrial fibrillation with a normal ventricular rate. For
this, he was treated by increasing his Lopressor to 50 mg po
bid and he was loaded with amiodarone. The patient reverted
back to sinus rhythm by 06:00 PM and has remained in sinus
rhythm for the duration of the hospital course. Otherwise,
the patient's course has been uncomplicated and he was
discharged to rehabilitation on postoperative day six.
DISPOSITION: Discharged to rehabilitation.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. ST elevation myocardial infarction.
2. Status post aortic valve replacement with a CE valve.
3. Coronary artery bypass graft times three.
4. Atrial fibrillation (resolved, now on amiodarone).
5. Postoperative bleeding, status post re-exploration and
closure.
DISCHARGE MEDICATIONS: Lopressor 50 mg po bid, Lasix 20 mg
po q twelve hours times one week, potassium chloride 20 mEq
po q day times one week, Colace 100 mg po bid while on
Percocet, aspirin 325 mg po q day, regular insulin sliding
scale q AC and HS: for blood sugar 150 to 200 - 3 units
subcutaneous insulin, blood sugar 201 to 250 - 6 units
subcutaneous insulin, blood sugar 251 to 300 - 9 units
subcutaneous insulin, Norvasc 5.0 mg po q day, Captopril 6.25
mg po tid, amiodarone 400 mg po tid until [**12-13**], then 400 mg
po bid until [**12-20**], then 400 mg po q day, Percocet 5/325 mg
one to two tablets po q four to six hours prn pain, ibuprofen
400 mg po q six hours prn pain.
FOLLOW UP: The patient will see Dr. [**Last Name (STitle) 70**] in his office
in three to four weeks and will follow up with his primary
care physician in three weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 6355**]
MEDQUIST36
D: [**2180-12-7**] 12:40
T: [**2180-12-7**] 12:46
JOB#: [**Job Number 39460**]
|
[
"41071",
"4241",
"41401",
"9971",
"42731",
"4019"
] |
Admission Date: [**2178-2-16**] Discharge Date: [**2178-3-6**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
woman status post coronary artery bypass graft times three on
[**2178-1-18**]. The patient was discharged to
rehabilitation on [**2178-1-27**] and readmitted on [**2178-2-1**] with pneumonia. On readmission the patient was
noticed to have erythema and drainage from sternal incision
and this is opened and packed with normal saline wet to dry
dressing changes. The patient was discharged to
rehabilitation on [**2178-2-4**] on Levofloxacin. The
patient was seen today in the clinic for increased drainage
from the sternal incision. The patient also reported being
treated by rehabilitation for infection in the left lower
extremity saphenous vein harvest site.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease
2. Peptic ulcer disease
3. Peripheral vascular disease
4. Status post bifemoral bypass graft
5. Status post coronary artery bypass graft times three
6. Status post myocardial infarction in [**2171**]
7. History of recent pneumonia
8. History of ventricular tachycardia on Amiodarone
9. History of Raynaud's
10. Hypertension
11. Increased cholesterol
12. History of atrial fibrillation
MEDICATIONS: Lopressor 25 mg p.o. b.i.d.; Percocet prn;
Ativan prn; Niferex 150 mg p.o. b.i.d.; Duricef 500 mg p.o.
b.i.d.; Pulmicort 200 mcg metered dose inhaler; Captopril 25
mg p.o. t.i.d.; Lasix 20 mg p.o. q.d.; Plavix 75 mg p.o.
q.d.; Protonix 40 mg p.o. q.d.; Lipitor 10 mg p.o. q.d.;
Amiodarone 400 mg p.o. q.d.; Colace 100 mg p.o. t.i.d.;
Meprobamate 400 mg p.o. t.i.d.; Combivent; [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mg
p.o. q.d.
PHYSICAL EXAMINATION: Vital signs temperature 99.8, pulse
74, blood pressure 177/58, respirations 18, saturations 98%
on 2 liters of nasal cannula. On examination the patient is
anxious, tearful. Neurological, alert and oriented to
person, place, +/- time, +/- situation. Regular rate and
rhythm. Respiratory rate increased with breathsounds
decreased at the bases. No wheezes and no consolidation.
Gastrointestinal: Bowel sounds, soft, nontender and
nondistended. The patient reports multiple loose bowel
movements over the last day. Trace lower extremity edema.
Extremities warm. Sternal incision is open at the base,
approximately 1 cm by 1 cm with yellow fibrinous base
visible, Vicryl suture, moderate serous cloudy drainage. The
sternum with positive click and pain to palpation. Left
lower extremity and ankle with erythema, yellow fibrinous,
warm, tender to touch. Upper left lower extremity with dark
eschar over incision.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2178-3-5**] 17:38
T: [**2178-3-5**] 18:34
JOB#: [**Job Number 109609**]
|
[
"496",
"42731",
"V4581",
"412",
"4019",
"2720"
] |
Admission Date: [**2150-12-30**] Discharge Date: [**2151-1-20**]
Service: MEDICINE
Allergies:
Morphine / Bactrim / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Syncope, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 F with history of breast cancer s/p lumpectomy in [**2145**],
dementia, atrial fibrillation, PSVT, orthostatic hypotension and
history of syncopal episodes and multiple falls with recent C2/3
spinous process
fractures in [**10-5**], who presents after a syncopal episode with
C2 spinous process fracture on CT. Patient was in USOH at rehab
(where she has had several falls), when to the bathroom to
urinate, became dizzy, syncopized and "hit the floor" quickly.
She landed on her left side, and is not sure whether she
actually lost consciousness. (event not witnessed). She cannot
recall any prodromal symptoms other than dizziness. She was
brought to [**Hospital1 **] [**Location (un) 620**], where she was found to be hypoxic to 87%
on RA, Head CT neg, CXR showed fluffy bilateral infiltrates read
as pulmonary edema, shoulder and pelvic XRay without fracture,
and CT neck showed "subacute C2 fracture." She received
Ceftriaxone and was sent to [**Hospital1 18**] [**Location (un) 86**] for further management.
.
The patient has had prior admissions for syncope, which is
thought to be secondary to orthostatic hypotension. She has had
a 24 hour holter monitor during a symptomatic episode, which
showed sinus bradycardia in the 50s. She is followed by Dr.
[**Last Name (STitle) **] of gerontology for her othostatic hypotension, who
recently increased her florinef to 0.1 mg daily in [**Month (only) 1096**]
[**2149**].
Past Medical History:
Atrial fibrillation
Hypothyroidism
Breast cancer s/p lumpectomy [**2145**]
Anemia
s/p CCY
s/p shoulder surgery
Social History:
widow of [**Hospital1 **] pediatrician Dr [**Known lastname 6174**], No ETOH, smoked for ~10
years, quit ~60 years ago, no illicit drugs. lives alone,
functionally independent, no cane or walker
Family History:
Noncontributory - Mother died of MI in 80s. Father died of
unknown type of cancer.
Physical Exam:
On admission:
VS - Temp 96.5 F, BP 184/76, HR 76, R 20, O2-sat 97% 3L
orthostatics neg per nursing
GENERAL - well-appearing elderly female in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - fine crackles midway up b/l, with anterior rales b/l
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, decreased
strength throughout, gait not assessed
Rectal: stool guaiac +
Pertinent Results:
LABS ON ADMISSION:
[**2150-12-30**] 09:35AM BLOOD WBC-10.8 RBC-3.73* Hgb-10.0* Hct-31.2*
MCV-84 MCH-26.8* MCHC-32.1 RDW-15.2 Plt Ct-329
[**2150-12-31**] 06:30AM BLOOD WBC-9.6 RBC-3.34* Hgb-9.2* Hct-28.0*
MCV-84 MCH-27.7 MCHC-33.0 RDW-15.1 Plt Ct-292
[**2150-12-31**] 03:20PM BLOOD Hct-31.1*
[**2151-1-1**] 06:00AM BLOOD WBC-12.3* RBC-3.54* Hgb-9.8* Hct-30.2*
MCV-85 MCH-27.7 MCHC-32.4 RDW-15.2 Plt Ct-355
[**2150-12-30**] 09:35AM BLOOD Neuts-84.3* Lymphs-9.5* Monos-5.4 Eos-0.6
Baso-0.3
[**2150-12-30**] 09:35AM BLOOD PT-11.9 PTT-23.6 INR(PT)-1.0
[**2151-1-1**] 06:00AM BLOOD Glucose-132* UreaN-17 Creat-0.9 Na-134
K-4.0 Cl-97 HCO3-25 AnGap-16
[**2151-1-1**] 06:00AM BLOOD ALT-39 AST-31 LD(LDH)-354* AlkPhos-87
TotBili-0.5
[**2150-12-30**] 09:35AM BLOOD CK-MB-3 proBNP-4668*
[**2150-12-30**] 09:35AM BLOOD cTropnT-<0.01
[**2150-12-30**] 07:20PM BLOOD CK-MB-2 cTropnT-<0.01
[**2151-1-1**] 06:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1
[**2150-12-30**] 09:35AM BLOOD D-Dimer-2920*
[**2150-12-30**] 09:35AM BLOOD TSH-6.1*
[**2151-1-1**] 06:00AM BLOOD T3-42*
MICRO:
[**2150-12-31**] URINE CULTURE - NO GROWTH
IMAGING:
-EKG [**2150-12-30**]: Sinus rhythm. Findings are within normal limits.
Compared to the previous tracing of [**2150-10-4**] there is no
significant diagnostic change.
-CXR [**2150-12-30**]: Diffuse bilateral opacities may represent
pulmonary edema or ARDS, although infectious process not
excluded.
-C-SPINE (AP, FLEX & EXT): No significant interval change.
Unchanged, grade 1 anterolisthesis of C4 on C5 which normalizes
with extension. Unchanged severe degenerative changes.
-CTA CHEST W&W/O C&RECONS, NON-CORONARY: 1. No evidence of
pulmonary embolus. 2. Diffuse bilateral ground glass and
interstitial pulmonary opacities. Differential includes ARDS or
pulmonary edema. Superimposed infectious process not excluded.
Recommend chest radiograph after diuresis for further
evaluation.
3. Bilateral small pleural effusions.
4. Mild mediastinal lymphadenopathy may be reactive.
-ECHO: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60-70%). The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. with
normal free wall contractility. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild to
moderate ([**11-28**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion. Compared with the findings of the
prior study (images reviewed) of [**2149-9-5**], the apparent
pulmonary artery systolic pressure is markedly increased.
CXR [**2150-12-31**]: AP chest compared to [**12-30**] and baseline
examination [**5-15**]: Symmetrically distributed coarse
peribronchial opacification is probably pulmonary edema
worsening in some areas of the lungs, relatively sparing others
because of emphysema and relatively mild pulmonary fibrosis.
Moderate cardiomegaly with particularly severe left atrial
enlargement is longstanding. Pleural effusion is small if any.
An alternative to atypical pulmonary edema would be multifocal
interstitial pneumonia and particularly viral.
Brief Hospital Course:
Upon admission to the medicine team, she was afebrile, but had a
chest xray concerning for multilobular pneumonia, and possibly
also for changes consistent with pulmomnary fibrosis from
Amiodarone, which she had been taking since [**2144**] for A Fib. She
was started on antibiotics (Cefepime, Cipro and Vancomycin for
HAP), and methylprednisolone 80mg q8h for treatment of
amiodarone toxicity, as well as albuterol and ipratropium
nebulizers for symptomatic treatment. Over a period of four days
her oxygen requirement improved from 6 liters to 3 liters and
she seemed to be markedly improving.
.
On [**1-4**], the patient became tachypneic, began grasping at her
throat, and was unresponsive to commands. A code blue was
called. Upon the ICU team's arrival to the patient she was being
intubated. She continued to have a pulse, but was bradycardic to
low 30s, with BP 60/palp. Pulse became weak. She was given
Atropine 0.5mg x2, and started on a Dopamine gtt. About 1 minute
into the drip, HR was >100 and SBP rose to 210. Doapmine was
stopped and she was transfered to the MICU, placed on the
ventilator and sedated on Versed and Fentanyl. Her post-arrest
lactate was 7.2, but by midnight it was 1.7.
On [**1-5**] she was bronchoscoped, and her steroids were continued
for presumed Amiodarone pulmonary toxicity. She could not be
immediately weaned from the vent, and in fact on [**1-6**] required
an increase in FiO2 from 50% to 60% and PEEP of 8. Of note, she
had a BNP of 9540. On [**1-7**], tube feeds were started, and a CT of
her chest was interpreted as an acute CHF exacerbation
superimposed on chronic Amiodarone lung toxicity processes.
Weaning from the vent remained [**Name (NI) 2480**], and discussions were
held with the patient's son and family meetings arranged. On
[**1-9**], she was still intubated, and her Cefepime and Vancomycin
completed a 7-day course for HAP and were discontinued. She did
spike a temp of 100.9 and had cultures and C Diff studies sent,
all of which were ultimately negative. On [**1-10**] for elevated
potassiums (with normal EKGs) she received kayexalate, and on
[**1-11**] she was diursed with Lasix. She became hypernatremic at
150, received D5W and free water tube feed flushes, and her
hypernatremia resolved back into normal ranges by [**1-12**]. On [**1-13**]
she was extubated successfully, and her steroid dosing was
changed to 1 mg/kg/day. Upon extubation she was withdrawn and at
times difficult, for example refusing all nursing attention on
[**1-14**]. Tube feeds were begun.
On [**1-15**], after a family meeting, she was made a DNR/DNI. The
patient was subsequently transferred out of the ICU to the
regular medicine floor. Over the next several days, the
patient's oxygen requirement and her work of breathing
increased. On [**1-18**], after several family meetings with the
primary medical team and the palliative care team, the patient
was made CMO and a dilaudid drip initiated for comfort. The
patient died on the evening of [**2151-1-20**].
Medications on Admission:
-ALENDRONATE 70 mg PO weekly
-AMIODARONE HCL - 200MG PO daily
-Tylenol 1000 mg q6h prn
-FLUDROCORTISONE [FLORINEF] - 0.1 mg daily (increased [**11-4**])
-Levothyroxane - 100MCG daily
-phenylephrine 10 mg daily (started in [**Month (only) **])
-ASPIRIN - 325 mg daily
-Niferex 150 mg daily
-Vit D 1000 U PO daily
-Prilosec 20 mg daily
-Oscal 600/vit D [**Hospital1 **]
-Prozac 10 mg daily
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
|
[
"486",
"51881",
"2760",
"4280",
"42731",
"2449",
"2859"
] |
Admission Date: [**2181-10-19**] Discharge Date: [**2181-10-23**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
Bleeding from the left ear
Major Surgical or Invasive Procedure:
1. Upper endoscopy [**2181-10-19**]
2. Colonoscopy [**2181-10-22**]
History of Present Illness:
[**Age over 90 **] year old female with PMH significant for HTN, atrial fib on
coumadin, and CHF (EF 20%) admitted to the [**Hospital Unit Name 153**] on [**10-19**] with a
Hct of 20. Pt was in her normal state of health until four days
prior to admission when her ear began bleeding after she cleaned
it with a Qtip. Pt denies pain or decrease in hearing from this
ear. She presented to the ED on [**10-19**] for evaluation of the
continued bleeding.
In the [**Name (NI) **], pt was found to have a Hct of 20--- it was 33.5 on
[**2181-8-25**]. Rectal exam showed melena. NG lavage was negative
showeing clear fluid and no bile. Pt denied any abdominal pain.
Pt's INR was 3.3 and she was given vit K 1 mg, 2U FFP, and 1U
PRBC. Her post-transfusion Hct was 22. Pt then had an EGD which
showed normal mucosa in the stomach, possible gastric inlet
patch 17 cm from incisors, 20 mm in diameter, erythematous and
not friable (unlikely to have caused her bleeding), normal
mucosa in the duodenum and spots in the stomach. After EGD, pt
desatted and became tachycardic to the 170s. She responded well
to a NRB and lasix.
In further discussion, pt had noted two "purple colored" stools
prior to admission and several maroon colored stools. She also
noted feeling week and fatigued. She has felt lightheaded for
approximately six months. Pt has had a significant weight loss
over the past few months from 130 to 90 pounds. She notes a
decrease in her appetite and intrest in activities since her
husband's death last year.
Past Medical History:
1. Hypertension
2. CHF- LVEF 20%
3. Mitral Regurgitation documented on prior echo
4. Recent ([**8-17**]) hospitalization for CP. This was felt to be
musculoskeletal.
5. Atrial fib- Diagnosed in [**1-17**] and thought to be secondary to
mitral regurgitation. Pt has been anticoagulated on coumadin.
6. Hemicolectomy 10 y ago for diverticular bleed. No malignancy
found, per pt.
7. Colonoscopy [**2176**]- Previous side to end ileo-colonic
anastomosis of the ascending colon
Polyp in the rectum (polypectomy)
Diverticulosis of the sigmoid colon and descending colon
Grade 2 internal hemorrhoids
Otherwise normal Colonoscopy to ascending colon.
8. S/P left hip replacement
Social History:
Lived with her husband until he passed away in [**Month (only) 359**]. Pt now
lives alone. Her sons and daughter-in-law are involved in her
care. Non-smoker. Occassional EtOH.
Family History:
Non-contributory.
Physical Exam:
Gen- Pleasant lady resting in bed. Alert and oriented. NAD.
Heent- PERRL, EOMI, mmm, OP clear
Cardiac- Irreguraly irregular. II/VI SEM.
Pulm- CTAB. No wheezes, rales, or rhonchi.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- No c/c/e.
Neuro- AOX3, nonfocal exam.
Pertinent Results:
[**2181-10-19**] 08:45AM BLOOD WBC-4.1 RBC-2.74*# Hgb-6.1*# Hct-20.0*#
MCV-73* MCH-22.2* MCHC-30.4* RDW-15.5 Plt Ct-151
[**2181-10-19**] 08:45AM BLOOD Neuts-78.6* Lymphs-15.6* Monos-5.1
Eos-0.7 Baso-0.1
[**2181-10-19**] 08:45AM BLOOD Hypochr-3+ Poiklo-1+ Microcy-2+
[**2181-10-19**] 08:45AM BLOOD PT-21.6* PTT-33.4 INR(PT)-3.3
[**2181-10-19**] 09:21PM BLOOD Glucose-96 UreaN-17 Creat-0.9 Na-144
K-4.0 Cl-107 HCO3-24 AnGap-17
[**2181-10-19**] 09:21PM BLOOD ALT-19 AST-26 LD(LDH)-206 AlkPhos-76
Amylase-88 TotBili-1.2
[**2181-10-19**] 06:50PM BLOOD CK(CPK)-112
[**2181-10-19**] 09:21PM BLOOD Lipase-41
[**2181-10-19**] 06:50PM BLOOD CK-MB-3 cTropnT-<0.01
[**2181-10-19**] 09:21PM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7
[**2181-10-19**] 09:56AM BLOOD Hgb-6.0* calcHCT-18
.
CHEST (PORTABLE AP) [**2181-10-19**] 8:47 PM
Reason: Evaluate for pulm edema.
IMPRESSION: Mild pulmonary edema and bilateral pleural
effusions.
.
EKG [**2181-10-19**]
Atrial fibrillation with a rapid ventricular response.
Ventricular premature beats. Left anterior fascicular block.
Left ventricular hypertrophy. Poor R wave progression, cannot
exclude old anteroseptal myocardial infarction but could be due
to left ventricular hypertrophy. Compared to the previous
tracing of [**2181-8-24**] the rate is faster.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
109 0 96 332/396.28 0 -37 128
.
CHEST (PORTABLE AP) [**2181-10-21**] 5:58 AM
Reason: pulm edema, with GI bleed
Improving CHF.
Brief Hospital Course:
This is a [**Age over 90 **] year old female with past medical history
significant for hypertension, atrial fibrillation on coumadin,
and congestive heart failure (ejection fraction of 20%) admitted
to the [**Hospital Unit Name 153**] on [**10-19**] with a Hct 20 down from 34 and INR 3.3. NG
lavage was clear without bile. An upper endoscopy was performed
which was negative for source of bleed and patient suffered post
procedure flash pulm edema which resolved with IV lasix. Patient
received another 2 units of PRBC with an appropriate increase in
her Hct. Pt received 40 mg IV lasix between these units of blood
and her respiratory status remained stable. Patient's hematocrit
remained stable with no further bleeding. Pt was transferred to
the floor on [**10-21**] for further care.
.
1. GI bleed- Patient presented with melanotic stools. Patient
was at high risk for bleed given anticoagulation with coumadin.
Negative NG lavage and no evidence of active bleeding on EGD
[**10-19**]. Differential diagnosis of lower source of bleeding
included diverticular bleed, AVM or internal hemorrhoids. A
colonoscopy was performed on [**10-22**] with diverticulosis of the
sigmoid and descending colon and grade 2 internal hemorrhoids
without active bleed. Per GI, colonscopy findings Were
nonbleeding but could have caused bleed per GI. Patient was
continued on IV protonix twice daily and her Hct was followed
every 6 hours with a transfusion threshold of Hct 30. Patient's
hematocrit remained stable after colonoscopy until day of
discharge.
.
2. [**Name (NI) 4964**] Pt with LVEF of 20%. Her respiratory status is stable at
this time but need to monitor closely for any fluid overload.
Will give IV lasix with any needed blood transfusions.
.
3. Atrial fib- Pt was well rate controlled. Since she was
hemodynamically stable and no evidence of further bleeding, she
was continued on her beta blocker. Coumadin was held. Patient
was not resumed on her coumadin at discharge given her risk of
GI bleed in the setting of recent bleed. She will follow-up with
her PCP and discuss long term plans for anti-coagulation.
.
4. HTN- Continued on beta blocker at this time as vitals stable
and no further active bleeding. Held lisinopril, CCB.
.
5. CAD- Continued on beta blocker given stable vitals but
holding ASA.
.
6. Ear bleeding- Traumatic in nature. Was irrigated in the ED
with removal of several clots. Scant bleeding since that time.
.
7. FEN- Full liquids. Electrolyte replacement as needed.
.
8. Proph- Pneumoboots; PPI
.
9. Code status- DNR/DNI.
Medications on Admission:
1. Metoprolol Tartrate 25 mg [**Hospital1 **]
2. Sertraline 50 mg daily
3. Verapamil 40 mg Q12H
4. Warfarin Sodium 2 mg Sun, Thurs, and Fri
5. Warfarin Sodium 1 mg Mon, Wed, and Sat
6. Lasix 20 mg daily
7. Lisinopril
8. Aspirin 81 mg qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed: Not to exceed 4g/day.
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Verapamil 40 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. Melena
2. Diverticulosis of sigmoid and descending colon
3. Grade 2 internal hemorrhoids
Secondary diagnosis:
1. Afib
2. CHF with EF 20%
3. History of diverticular bleed status post partial colectomy
4. Hypertension
Discharge Condition:
Stable
Discharge Instructions:
1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
2. Please take medications as prescribed.
3. Please call your PCP or return to the ED if you have bright
red blood in your stool, black tarry stools, chest pain,
shortness of breath or any other worrying symptoms.
4. You have been taken off of your coumadin as it can contribute
to bleeding. Please do not take any more of this medication.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] in
[**Telephone/Fax (1) 10492**] in one week. Call his office at [**Telephone/Fax (1) 10492**] to
make the appointment. I have spoke with Dr. [**Last Name (STitle) 1007**] and they will
be expecting your call.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
Completed by:[**2181-10-24**]
|
[
"42731",
"4280",
"2851",
"4019",
"V5861"
] |
Admission Date: [**2134-4-26**] Discharge Date: [**2134-5-3**]
Date of Birth: [**2062-5-6**] Sex: F
Service: Coronary Care Unit
CHIEF COMPLAINT: Retroperitoneal hematoma.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
female with right carotid stenosis of 70% to 80% and 3-vessel
coronary artery disease initially admitted to CMI Service and
transferred to the Coronary Care Unit Service with a
retroperitoneal hematoma status post catheterization.
On a routine workup, Ms. [**Known lastname 122**] was found to have right
carotid stenosis of 70% to 80% and was then referred to
Vascular Surgery for a carotid endarterectomy. During a
preoperative workup for the carotid endarterectomy she was
found to have a positive cardiac stress test.
She underwent cardiac catheterization at [**Hospital3 1280**] Hospital
on [**2134-4-23**] which revealed 3-vessel coronary artery
disease with a 99% ostial right coronary artery lesion, an
80% lesion at the bifurcation of the mid left anterior
descending artery, as well as a 70% to 80% occlusion of the
left circumflex to first obtuse marginal.
The patient was admitted to [**Hospital1 188**] on [**2134-4-26**] for an angioplasty and stenting of the
right coronary artery which was unsuccessful. Of note, on
cardiac catheterization moderate-to-severe diffuse left iliac
disease was seen.
Status post procedure, the patient experienced multiple
episodes of hypotension with systolic blood pressures down to
the 70s, requiring a total of 2.5 liters of normal saline
boluses to maintain her blood pressure. An emergent
computerized axial tomography of the abdomen and pelvis
revealed extraperitoneal blood within the pelvis with a right
groin hematoma, and she was transferred to the Coronary Care
Unit Service for observation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Chronic obstructive pulmonary disease.
3. Hypothyroidism.
4. Hypercholesterolemia.
5. Non-insulin-dependent diabetes mellitus.
6. Right carotid stenosis of 80% to 90% with left carotid
stenosis of about 40%.
7. Motor vehicle accident in [**2116**] with fractured pelvis,
ribs, and a liver laceration at that time.
8. Question of liver dysfunction.
9. Status post hysterectomy.
10. Status post cataract surgery.
11. Arthritis of the bilateral hips.
12. Claudication of the bilateral calves.
13. Dyspepsia.
ALLERGIES: She has no known drug allergies.
MEDICATIONS ON ADMISSION: (Medications at home were)
1. Aspirin 325 mg p.o. once per day.
2. Synthroid 100 mcg p.o. q.d.
3. Lescol-XL 80 mg p.o. q.h.s.
4. Combivent 2 puffs inhaled twice per day.
5. Pulmicort 2 puffs inhaled twice per day.
6. Zestril 10 mg p.o. once per day.
7. Lopressor 50 mg p.o. three times per day.
8. Plavix (started on [**2134-4-24**]).
9. Levofloxacin was given on [**4-23**], [**4-24**], and [**4-25**] for
positive urinalysis but asymptomatic; treated for an
uncomplicated urinary tract infection.
MEDICATIONS ON TRANSFER: (On transfer from the CMI Service
medications were)
1. Home medications.
2. Tylenol as needed.
3. Oxazepam.
4. Zofran.
5. Phenergan.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, her vital signs revealed temperature was 98.5,
blood pressure was 123/47, heart rate was 80, respiratory
rate was 16, and oxygen saturation was 98% on room air.
Mucous membranes were moist. No jugular venous pressure.
The neck was obese. Bilateral basilar crackles anteriorly.
Heart was regular in rate and rhythm. Normal first heart
sounds and second heart sounds. A 3/6 systolic murmur at the
base. Bilateral carotid bruits. The abdomen was soft and
obese with mild tenderness in the lower quadrant. No edema
in her extremities with palpable femoral pulses and palpable
dorsalis pedis pulses.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data
revealed her hematocrit was 36 at [**Hospital3 1280**] Hospital and
dropped to 31.9 status post catheterization and subsequently
dropped to 24.2. Other laboratory data revealed white blood
cell count was 13.7 and platelets were 238. Differential
with 79% neutrophils, 6% bands, and 11% lymphocytes. INR was
1.1. Sodium was 133, potassium was 4.2, chloride was 101,
bicarbonate was 23, blood urea nitrogen was 13, creatinine
was 0.8, and blood glucose was 110. Calcium was 7.5,
phosphate was 3.6, and magnesium was 1.8. ALT was 41, AST
was 40, LDH was 236, alkaline phosphatase was 54, total
bilirubin was 0.3. Fibrinogen was 240. Urinalysis revealed
trace protein; otherwise negative. Albumin was 3.3.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray was negative.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit for monitoring of the retroperitoneal hematoma and
for blood transfusions.
A right internal jugular cordis was placed for access and for
large volume transfusions in case the patient's hematocrit
continued to drop. She received 5 units of packed red blood
cells for a hematocrit of 24.2 with her hematocrit
subsequently rising to 33.3. However, her hematocrit
continued to drift down to 27.5 and subsequently required
more transfusions. Throughout the hospital course, the
patient received 8 units of packed red blood cells with a
stable hematocrit for the last three days of her hospital
course. Her discharge hematocrit was ranging from 36 to
37.6.
During her hospital course, on [**2134-4-27**], the patient
developed an ischemic left leg with complaints of pain in her
left leg. Popliteal, dorsalis pedis pulses, and posterior
tibialis pulses were not dopplerable. There was a biphasic
femoral pulse. The patient also developed hypotension with a
drop in her hematocrit, and a bump in her troponin to 2.5,
and a bump in her creatine kinase to 226.
The patient was seen by Vascular Surgery and Dr. [**First Name (STitle) **] in
Interventional Cardiology who took her to the Catheterization
Laboratory and to the operating room.
In the Catheterization Laboratory, angiography showed
mild-to-moderate disease at the aortic bifurcation and ostium
of the common iliac artery. External iliac artery and
internal iliac artery showed mild atherosclerosis. There was
a long tubular 80% ulcerated lesion in the common iliac
artery with 30% occlusion at the bifurcation. In the common
femoral artery there was a filling defect consistent with
thrombus. The ostial left common iliac artery was stented
with good results.
She was taken to the operating room for exploration of the
left groin. A left femoral endarterectomy was performed, and
a Dacron patch was placed with angioplasty of the left
femoral artery by Dr. [**Last Name (STitle) **].
Postoperatively, the patient had good peripheral pulses and
remained stable. However, she developed a cellulitis of the
left groin at the surgical site on Keflex. Her antibiotic
regimen was switched from Keflex to vancomycin with a good
response. Due to the need for a 7-day course of vancomycin
status post discharge, the patient required a peripherally
inserted central catheter line. A bedside peripherally
inserted central catheter line was unable to be placed. The
patient received a peripherally inserted central catheter
line by Interventional Radiology for vancomycin.
She also developed left lower extremity edema and received a
lower extremity Doppler that was negative for deep venous
thrombosis. It was felt that her edema was likely due to
inflammation and poor lymphatic drainage from due to the
cellulitis and inflammation.
While in house, she was also seen by Cardiothoracic Surgery
for a coronary artery bypass graft surgery. Due to her
retroperitoneal bleed it was thought to be wise to defer her
coronary artery bypass graft and her carotid endarterectomy
for one month until her bleeding stabilized.
She also underwent a transthoracic echocardiogram to evaluate
her cardiac function. It showed a left ventricular ejection
fraction of greater or equal to 70% with normal wall motion.
The left ventricular wall thickness and cavity size were both
normal. She had 1+ aortic regurgitation.
DISCHARGE DISPOSITION: The patient was discharged in stable
condition. The patient was to finish her course of
vancomycin at home and was to follow up with Vascular and
Cardiothoracic Surgery.
DISCHARGE DIAGNOSES:
1. Retroperitoneal hematoma.
2. Anterior myocardial infarction; subendocardial.
3. Coronary artery disease.
4. Extreme atherosclerosis with ischemic leg.
5. Cerebral atherosclerosis.
6. Post procedural hemorrhage.
7. Cellulitis of the surgical groin site.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS/FOLLOWUP:
1. She was to follow up with Dr. [**Last Name (STitle) **] in Vascular
Surgery in one week.
2. She was to follow up with Dr. [**Last Name (Prefixes) **] in
Cardiothoracic Surgery as well.
INTERVENTIONS:
1. Cardiac catheterization.
2. Central line placement.
3. Angiography and stenting to the left iliac artery and
left femoral artery endarterectomy.
CONDITION AT DISCHARGE: She was discharged in good
condition.
MEDICATIONS ON DISCHARGE:
1. Combivent 2 puffs inhaled twice per day.
2. Plavix 75 mg p.o. once per day
3. Aspirin 325 mg p.o. once per day.
4. Levothyroxine 100 mcg p.o. once per day.
5. Protonix 40 mg p.o. once per day.
6. Lescol-XL 80 mg p.o. q.h.s.
7. Lisinopril 20 mg p.o. once per day.
8. Metoprolol-XL 150 mg p.o. once per day.
9. Vancomycin 1.25 g intravenously q.12h.
10. Pulmicort 2 puffs inhaled twice per day.
Of note, the patient's systolic blood pressure was 130s to
180s. She was at baseline high. It was recommended that she
maintain her blood pressure higher than the normal range for
adequate perfusion of her brain given her carotid stenosis
and her chronic baseline high blood pressure.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 6371**]
MEDQUIST36
D: [**2134-5-4**] 14:35
T: [**2134-5-7**] 11:15
JOB#: [**Job Number **]
|
[
"41401",
"41071",
"496"
] |
Admission Date: [**2160-3-12**] Discharge Date: [**2160-3-28**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
white female who was transferred from an outside hospital
where she presented initially with epigastric pain,
subsequently became septic at the outside hospital, had an
eventual diagnosis of gallstone pancreatitis and ascending
cholangitis based on their work-up. She became acutely ill
during her hospitalization there, required to be intubated
and was transferred to the [**Hospital1 188**] for further care. This was at the end of [**Month (only) 956**] of
this year. The patient underwent on arrival here, assessment
showed that the patient was septic with features of ARDS,
gallstone pancreatitis and ascending cholangitis were
confirmed based on her laboratory work-up and she underwent
an ERCP with sphincterotomy on the [**12-11**] of this
year. Subsequently her amylase, lipase and LFTs
progressively declined, however, the patient was intubated
for a prolonged period and was a slow and difficult wean.
During the course of her hospitalization here at the [**Hospital1 1444**] she went into atrial
fibrillation and atrial flutter a few times. She was
cardioverted successfully on two occasions on [**3-18**] and [**3-20**].
Cardiology and EP service saw her and their initial plan was
to perform flutter ablation when the patient was
hemodynamically more stable. The patient recovered from her
sepsis and the issue then became of ventilator dependence.
She also demonstrated mental status changes with poor return
of mental function after her hemodynamic instability had been
overcome. She therefore underwent a CT scan of her head on
[**3-22**] and that was negative for any acute process. The patient
eventually got a tracheostomy. This was done on [**3-25**]. She
grew Enterobacter cloacae and proteus mirabilis from her
sputum sample which was taken following some deterioration in
her increased requirement of vent support and for that she
was placed on Levofloxacin around [**3-25**].
The patient has been tolerating enteral feeds via a feeding
tube. She is planned to have a percutaneous endoscopic
gastrostomy tube placement today.
CONDITION ON DISCHARGE:
Neurologically the patient has shown some slight improvement
in neuro function. She does respond to voice by opening her
eyes and seems to track movement. She responds more to her
family members, however, does not really follow commands.
Cardiorespiratory system, the patient has been on Amiodarone
since [**3-18**] following her cardioversion. Since then she has
been in normal sinus rhythm. The EP services saw her and at
this stage did not feel that she stands dependent from
flutter ablation. She is to continue on her Amiodarone at
400 mg q d for another two months and barring any further
episodes of flutter or fibrillation, that should be weaned
down to 200 mg q d.
Respiratory, the patient has a tracheostomy tube and is
undergoing a slow vent wean.
GI, the patient is going to get a PEG tube placement today
and resume her enteral feedings which she has been tolerating
at goal.
GU, the patient has been making good urine. She was being
diuresed during her initial part of her hospital course,
diuresis has been held for the last few days since she has
been making good urine with normal renal function on
chemistry.
ID, the patient is currently on day #4 of Levofloxacin which
was started for a positive sputum culture, however, the
patient was not febrile and did not have a white count but
did seem to have increased respiratory secretions and because
of difficulty we weighed the benefits and risks and decided
to give her the Levofloxacin trial. This is to continue for
a 10 day period.
Heme, the patient is on Epogen. She has myelodysplastic
syndrome, chronic standing.
DISCHARGE STATUS: The patient is stable for discharge to
rehab. She has tracheostomy. She needs vent wean and she
needs to be fed via a PEG tube.
DISCHARGE DIAGNOSIS:
1. Gallstone pancreatitis.
2. Ascending cholangitis.
3. Status post ERCP and sphincterotomy on [**3-13**].
4. Atrial fibrillation status post cardioversion on [**3-18**] and
[**2160-3-20**].
5. Prolonged intubation, status post tracheostomy.
6. History of dysmyelopoietic syndrome characterized by
pancytopenia, anemia and thrombocytopenia.
7. History of coronary artery disease, reflux disease,
osteoarthritis, hypercholesterolemia, hypertension and
paroxysmal atrial fibrillation.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Name8 (MD) 27609**]
MEDQUIST36
D: [**2160-3-28**] 09:08
T: [**2160-3-28**] 09:30
JOB#: [**Job Number 38564**]
|
[
"0389",
"51881",
"42731"
] |
Admission Date: [**2121-1-17**] Discharge Date: [**2121-1-24**]
Date of Birth: [**2054-3-23**] Sex: M
Service: MEDICINE
Allergies:
Azulfidine / Remicade / Sulfa (Sulfonamide Antibiotics) /
Methotrexate / Azathioprine
Attending:[**First Name3 (LF) 1945**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 year old male with history of Crohn's disease c/b fistulas
s/p multiple surgeries, ESRD on HD qMWF, who originally
presented to OSH with sudden onset of neck pain and blurry
vision. Patient reports that he woke up this morning, and when
he stood up, suddenly felt acute onset of neck pain in the back
of his neck. The pain was both at the midline and sides,
described to be pressure like. No trauma to neck. Also felt
lightheaded, vision blurry, and felt like he might pass out.
Sitting down relieved his symptom somewhat. Patient went to
[**Hospital1 2436**] ED where he was noted to be hypotensive in the 70s.
He received a 1 L bolus with some improvement of his symptoms.
Noncontrast head CT and CXR at OSH reported to be normal. He
was transferred to [**Hospital1 18**] for neurological evaluation for
concerns for vertebral artery dissection. By the time patient
arrived at [**Hospital1 18**] ED, his neck pain had resolved, and his blurry
vision had improved. His Tmax at home was 100.0. Denies any
chills or headaches.
.
In the ED, initial vs were: 98.6, 116, 115/55, 18, 100% RA.
Neurology evaluated the patient, recommended CTA head and neck
which is preliminarily read as no evidence of dissection. His
labs were notable for a K of 6.6 on admission, for which he
received kayexalate, as well as insulin/D50, which improved his
K to 5.2. Patient then began to become hypotensive again, down
to the 70s. He was started on levophed, given a total of <1 L
of fluids, with recovery of his pressure to the 100s. Tmax in
the ED was 103, for which he got 1 gram of tylenol. Also
noticed to have thick yellow urine. Per patient, says he
produces about half a cup of urine a day. Patient received
vancomycin, zosyn, cipro, and 4 g of Mg. Vitals on transfer
were: 102/52, 108, 20, 99%2L.
.
In the MICU, patient is feeling comfortable, neck pain resolved,
blurry vision resolved, no longer feeling dizzy. No complaints.
.
Past Medical History:
Crohns disease s/p multiple surgeries
ESRD on HD
nephrolithiasis
h/o UTIs
Social History:
lives alone, never married, denies tobacco, alcohol, illicit
drug use
Family History:
Father - DM, HTN
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: AAOx3, NAD, pleasant
HEENT: PERRLA, EOMI, neck supple, no LAD, no JVD
CV: S1S2, tachycardic, II/VI SEM
Chest: CTA b/l, no w/r/r, left HD catheter clean and dressed
Abd: several healed surgical scars, ostomy x2 clean and dressed,
soft, ND, NT, +BS
Ext: RUE AV fistula, LUE PICC line clean and dressed, no e/c/c,
2+ peripheral pulses
Pertinent Results:
CXR ([**2120-1-18**])
IMPRESSION: Right base atelectasis due to low lung volumes. No
definite focal consolidation or superimposed edema.
.
CTA head/neck ([**2120-1-18**]) - PRELIM
Prominent left vertebral artery likely related to tortuosity. No
definite dissection. no aneurysm or thrombosis. Final read
pending neuroradiology fellow input.
.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 19776**] (Complete)
Done [**2121-1-22**] at 3:25:23 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Hospital1 **] C
[**Location (un) 830**], [**Hospital1 **] 311
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2054-3-23**]
Age (years): 66 M Hgt (in): 66
BP (mm Hg): 144/65 Wgt (lb): 145
HR (bpm): 85 BSA (m2): 1.75 m2
Indication: ?Endocarditis.
ICD-9 Codes: 424.90, 424.1, 424.0
Test Information
Date/Time: [**2121-1-22**] at 15:25 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: Cardiology Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2011W000-0:00 Machine: Vivid i-3
Sedation: Versed: 1.5 mg
Fentanyl: 75 mcg
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
TR Gradient (+ RA = PASP): *26 mm Hg <= 25 mm Hg
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or vegetations on aortic valve. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or
vegetation on mitral valve. Moderate (2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or
vegetation on tricuspid valve. Mild [1+] TR. Borderline PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No vegetation/mass on pulmonic valve. 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 monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The patient was sedated
for the TEE. Medications and dosages are listed above (see Test
Information section). The posterior pharynx was anesthetized
with 2% viscous lidocaine. 0.1 mg of IV glycopyrrolate was given
as an antisialogogue prior to TEE probe insertion. No TEE
related complications. Echocardiographic results were reviewed
by telephone with the houseofficer caring for the patient.
Conclusions
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). with
normal free wall contractility. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 40 cm from the incisors. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Moderate (2+) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Moderate mitral regurgitation. Mild aortic regurgitation.
Globally normal biventricular systolic function.
Dr. [**Last Name (STitle) 9434**] was notified by telephone on [**2121-1-22**] at 1 pm.
.
.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier **]TTE (Complete)
Done [**2121-1-21**] at 9:00:00 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Hospital1 **] C
[**Location (un) 830**], [**Hospital1 **] 311
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2054-3-23**]
Age (years): 66 M Hgt (in): 66
BP (mm Hg): 126/73 Wgt (lb): 135
HR (bpm): 90 BSA (m2): 1.69 m2
Indication: Endocarditis.
ICD-9 Codes: 424.1, 424.0, 424.2, 424.90,
Test Information
Date/Time: [**2121-1-21**] at 09:00 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: TTE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2011W000-: Machine: Vivid [**7-17**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.5 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.8 m/s
Left Atrium - Peak Pulm Vein D: 0.5 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 56% >= 55%
Left Ventricle - Stroke Volume: 88 ml/beat
Left Ventricle - Cardiac Output: 7.92 L/min
Left Ventricle - Cardiac Index: 4.68 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 11 < 15
Aorta - Sinus Level: *4.3 cm <= 3.6 cm
Aorta - Ascending: *3.9 cm <= 3.4 cm
Aorta - Arch: *3.5 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 28
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: 169 ms 140-250 ms
TR Gradient (+ RA = PASP): *42 mm Hg <= 25 mm Hg
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildy dilated aortic root. Mildly dilated ascending
aorta. Mildly dilated aortic arch.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: No mass or vegetation on mitral valve. Moderate
(2+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
mass or vegetation on tricuspid valve. Moderate [2+] TR.
Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function. Quantitative (3D) LVEF = 56%.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. No mass or
vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: No vegetations seen (adequate-quality study). Mild
aortic regurgitation. Moderate mitral and tricuspid
regurgitation. Normal global and regional biventricular systolic
function. In presence of high clinical suspicion, absence of
vegetations on transthoracic echocardiogram does not exclude
endocarditis.
Brief Hospital Course:
66 M with h/o Crohn's disease, ESRD on HD presents with
hypotension, possibly due to urosepsis
.
# Hypotension - possibly due to urosepsis. He has a history of
UTIs. He is also on chronic steroids for Crohn's disease.
Patient admitted with fever, tachycardia, white count of 16.1,
and a dirty UA. There were no other sources of infection to
explain white count and septic physiology. CXR shows
atelectasis, no evidence of pneumonia. Initially started on
levophed in ED, able to wean and d/c by [**2121-1-18**]. Covered with
vanc and zosyn. Blood culture showed staph species from PICC
line which was discontinued. His HD line was discontinued and he
had a line holiday. He was continued on vancomycin dosed ad HD.
TTE and TEE both showed no evidence of vegetations. He was
afebrile and HD stable with negative surveilence cultures for
three days and a new HD line was placed. He was discharged home
hemodynamically stable.
.
# Dizziness/blurry vision - likely [**2-12**] hypotension. Symptoms
improved at OSH with IV fluid bolus and with initiation of
pressors here. Symptoms resolved with stablization of blood
pressure. CT showed no evidence of dissection. He was
asymptomatic for the remainder of his stay.
.
# ESRD on HD - admitted with K of 6.6, improved to 5.2 with IV
fluids, kayexalate, and D50/insulin. Continued HD as an
inpatient. Nephrocaps were started. He was discharged with
instructions to continue HD on his outpatient shcedule.
.
# Neck pain - unclear what etiology of his neck pain is, but it
had resolved by the time he got to the MICU. CTA head and neck
without evidence of dissection on prelim read. He had no more
neck pain during his admission.
.
# Crohn's disease - complicated by fistulas s/p multiple
surgeries. Prednisone continued. Otherwise stable. He will
follow up with his Gastroenterologist as an outpatient.
Medications on Admission:
omeprazole 20 mg [**Hospital1 **]
metoprolol 50 mg [**Hospital1 **]
allopurinol 100 mg daily
ropinirole 4 mg qhs
prednisone 10 mg daily
alprazolam 0.5 mg daily prn anxiety
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ropinirole 1 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
4. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*28 Cap(s)* Refills:*2*
6. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
7. vancomycin in D5W 1 gram/200 mL Piggyback Sig: as directed
Intravenous HD PROTOCOL (HD Protochol) for 24 days.
Discharge Disposition:
Home
Discharge Diagnosis:
MRSA bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were amditted to [**Hospital1 18**] because you had a blood stream
infection caused by MRSA that caused you to go into shock. You
were managed in the ICU overnight with medications to help
maintain your blood pressures. The next morning you were able to
maintain your blood pressure on your own and were transferred
from the ICU to the floor. You have been treated with IV
antibiotics and will continue with them until [**2121-2-16**]. You will
receive these at dialysis. We changed your HD line.
.
While you were here we made the following changes to your
medication:
#) We STOPPED your metoprolol. You should discuss the need to
restart this medication with your PCP at your next visit
.
#) We STARTED you on nephrocaps. You should take this once a day
.
#) We STARTED you on Vancomycin. This antibiotic should be given
to you at each dialysis appointment until [**2121-2-16**]
.
You shoudl continue to take your other medications as prescribed
Followup Instructions:
Thursday [**2121-1-30**] at 530pm with Dr. [**Last Name (STitle) **] for a follow up
appointment. Please call them at [**Telephone/Fax (1) 19777**] if you need to
reschedule for any reason.
.
You should also call your vascular surgeons to follow up with
them regarding your dialysis graft.
.
|
[
"5990",
"2767",
"53081"
] |
Admission Date: [**2198-9-3**] Discharge Date: [**2198-9-17**]
Date of Birth: [**2198-9-3**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname **] twin 2 was the
1125 gram product of a 28 and [**1-9**] week gestation, twin
gestation born go a 40-year-old G1 P0 now 2 mom. Pregnancy
complicated by preterm labor and cervical shortening, which
required admission to the [**Hospital3 **]. Treatment with
tocolysis and betamethasone. Rupture of membranes on other
twin occurred on [**8-27**], delivery [**9-3**], due to
onset of labor with breech breech presentation.
Prenatal screens, A positive, antibody negative, hepatitis
surface antigen negative, RPR nonreactive, Rubella immune.
GBS unknown.
Infant emerged with good heart rate and respiratory effort.
Apgars were 5 and 8. Required blow by O2 and CPAP in delivery
room, brought to the newborn intensive care unit for further
management of prematurity.
PHYSICAL EXAMINATION: On admission birth weight was 1.125
kilograms. Head circumference was 26.5 cm, L=38.5 cm.
Pink, active, nondysmorphic. Skin without lesions. Head
within normal limits. Cardiovascular, normal S1, S2. No
audible murmurs. Lungs with coarse crackles bilaterally.
Abd: soft, no masses, no hepatosplenomegaly. Anus patent.
Normal female premature genitalia. Spine intact. Hips held in
breech presentation. Normal neuro exam, nonfocal and age
appropriate.
HOSPITAL COURSE: Respiratory. [**Doctor First Name **] admitted to the
newborn intensive care unit with increasing respiratory
distress, intubate to manage respiratory distress syndrome.
Received surfactant x 2 doses; CPAP 10/5 through [**9-8**]; RA [**9-8**]
to [**9-9**]; NC [**9-9**] to [**9-11**]; RA [**9-12**] to [**9-15**]; NC 200 cc/min O2
from [**9-16**] to [**9-17**], weaned to RA. NC O2 primarily for Rx of
bradycardi.
Currently Rx caffeine citrate(8 mg/kg/day)po since [**01**]/ 3, [**2197**].
Cardiovascular. Has had no cardiovascular issues throughout
her hospital course.
Growth, Fluid and electrolyte.
Birth weight was 1.125 kilograms. Head
circumference was 26.5 cm. Length was 38.5 cm. She was
initially started on 80 cc per kilo per day of D10W. Enteral
feedings were initiated on day of life #2. She achieved full
enteral feedings by [**9-12**] (day 9); currently
tolerating 150 cc/kg/day Special Care 26 calories.
GI. Peak bilirubin was on day of life #2 of 4.1/0.2. Last bili
[**9-11**] = 3.7 This issue has resolved.
Hematology. Adm Hct= 42.8. Last Hct =41% day 2. No blood
transfusion during this hospital course.
Infectious disease. A CBC and blood culture obtained on
admission. CBC had a white count of 7.7K, 8 polys and 1 band.
Repeat CBC improved WBC= 8.2k, 40 neutrophils, 0 bands, 47
lymphs, platelet count of 229. She received ampicillin,
gentamycin for a total of 48 hours at which time blood cultures
remained negative and antibiotics were discontinued.
Neurologic. She has been appropriate for gestational age.
Head ultrasound on day of life #8 was within normal limits.
Ophthalmology ROP screen, hearing screen not performed at [**Hospital1 18**],
should performed prior to [**Hospital1 2436**] discharge.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 **].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] [**Name (STitle) **]. Telephone
number is [**Telephone/Fax (1) 37906**].
CARE AND RECOMMENDATIONS: Feeds at discharge continue 150 cc
per kilo per day of breast milk 26 calorie, advancing caloric
density as required. Medications, caffeine citrate 8 mg po
every day, ferrous sulfate of 0.15 milliliters po every day
(25 mg per milliliter), vitamin E 5 units po every day.
Car seat screening to be conducted at [**Hospital3 **]. .
State newborn screens initially sent [**9-6**]: increased amino
acids likely due to parenteral nutrition.
repeat screen sent on [**2198-9-16**].
Immunizations: none at [**Hospital1 18**]. Will receive prior to [**Hospital1 2436**]
discharge.
DISCHARGE DIAGNOSES: Premature infant twin #2.
Respiratory distress syndrome
Negative sepsis evaluation Rx antibiotics x 48 hr.
Apnea and bradycardia of prematurity. Rx with caffeine.
Hyperbilirubinemia.resolved.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2198-9-17**] 00:29:51
T: [**2198-9-17**] 07:05:32
Job#: [**Job Number 68974**]
|
[
"7742",
"V290"
] |
Admission Date: [**2199-12-19**] Discharge Date: [**2199-12-20**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Non-responsive
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
The pt is a 86 year-old right-handed female with a past
medical history of dementia, DM2, PAD who presents with was
reported normal this morning at her inpatient dementia unit.
By report she is able to walk and interacts at baseline,
although
we were not able to get a full sense of her baseline, she is in
an inpatient dementia unit and requires full assistance in
eating, dressing and bathing and requires 24/7 care. This
morning she was noted to be walking around normally but at 9am
(by report she has been seen normal minutes before) she was
found
on the ground. It was assumed that she had fallen. On the
floor
she was noted not to be moving her right arm or right leg, and
she had a right facial droop. She was not responding to
commands
and was getting increasingly non-responsive. She was sent to
[**Hospital1 18**] ED where she was called as a code stroke with an NIH
stroke
scale of 25.
On arrival she was not responsive to voice, and extensor
postured
to pain with both her arms to sternal rub. She had an enlarged
left pupil. As she had vomited she was intubated and a stat CT
was done which revealed a large left IPH.
Past Medical History:
per OMR, patient unable to verify
Dementia
Gerd
Osteoporosis
CAD
DM2
PAD- multiple stents in LE arteries
Social History:
Lives at [**Hospital3 **].
Family History:
Non-contributory
Physical Exam:
Vitals: T:98 P:55 R: 16 BP:122/77 SaO2:100
General: eyes closed not responsive
HEENT: NC/AT,
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds
Neurologic:
-Mental Status: Eyes closes, no response to name, eyes do not
open with pain. Extensor postures to pain with arms
-Cranial Nerves:
I: Olfaction not tested.
II: L eye 4mm non reactive, right 2mm minimally reactive
III, IV, VI: Minimal dolls eyes present
VI: corneal present b/l
VII: R droop of lower half of face in comparison to left
IX, X: Gag intact
-Motor: Extensor postures bilaterally to sternal rub, nox
stimuli
, triple flexes at right leg, non-reflexive withdrawal at left
leg
-Sensory: extensor withdraws to pain bilaterally, and at left
foot, not at right
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally
DISCHARGE EXAM
Patient expired
no spontaneous breathing
no pulse
absent cardiac sounds
Pupils 5mm b/l and non-reactive
Pertinent Results:
[**2199-12-19**] 10:53AM TYPE-ART RATES-/14 TIDAL VOL-400 O2-100
PO2-428* PCO2-42 PH-7.39 TOTAL CO2-26 BASE XS-0 AADO2-255 REQ
O2-49 INTUBATED-INTUBATED
[**2199-12-19**] 10:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2199-12-19**] 10:50AM URINE BLOOD-SM NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-12-19**] 10:50AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2199-12-19**] 10:50AM URINE AMORPH-MOD
[**2199-12-19**] 10:00AM GLUCOSE-153* UREA N-25* CREAT-1.1 SODIUM-142
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17
[**2199-12-19**] 10:00AM estGFR-Using this
[**2199-12-19**] 10:00AM WBC-8.1 RBC-3.93* HGB-11.6* HCT-35.1* MCV-89
MCH-29.5 MCHC-33.1 RDW-15.8*
[**2199-12-19**] 10:00AM PT-12.1 PTT-23.3 INR(PT)-1.0
[**2199-12-19**] 10:00AM PLT COUNT-237
Brief Hospital Course:
Patient was admitted to the neuro-ICU
On arrival patient was intubated. Exam was notable for
unresponsiveness to sternal rub, L pupil was 7mm and
nonreactive, Doll's eyes were present, and corneals were
present. Patient was withdrawing arms and legs to painful
stimuli bilaterally w/ no spontaneous movements. Family was
present on arrival and discussion was had in regards to
withdrawal of care. ICH score was 5 and family was informed of
terminal prognosis. Her daughter and grandaughter were present
and wanted to wait until additional family members arrived from
[**Location **]. Patient was made comfort measures only and extubated.
Patient expired at 7:45 am on Friday [**2199-12-20**].
Family was present.
Medications on Admission:
Aricept 10 mg qd
ASA 325 mg qd
FeSO4 325 mg qd
Glipizide 10mg qd
Lisinopril 20mg qd
Metformin 500 mg [**Hospital1 **]
Metoprolol 50 mg qd
MVI
Nystatin to buttocks [**Hospital1 **]
Plavix 75mg qd
Ranitidine 150 mg qd
Simvastatin 40 mg qd
Torsemide 20 mg qd
Acetominophen 325 mg PRN
Nitrotab PRN
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2199-12-20**]
|
[
"25000",
"53081"
] |
Admission Date: [**2158-12-3**] Discharge Date: [**2158-12-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Levofloxacin since. Patient has stable [**1-17**] pillow orthopnea, no
palpitations, no headache but has constant pain in her low back
and legs. (+) Ankle edema, remote history of TIA, no bleeding
disorders.
Denies bleeding at the time of surgery, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. 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.
.
In the ED, initial vitals were 97.1, HR 50, BP 124/60, RR 18, O2
100% on NRB. ECG obtained revealed ~1mm ST elevation on V1-V2
and aVR, code STEMI was called and cardiology fellow contact[**Name (NI) **].
After reviewing the above history and ECG from [**5-/2155**] changes, emergent cath was deferred and patient
admitted to CCU for ongoing high oxygen requirement, bradycardia
and monitoring.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY: NONE
3. OTHER PAST MEDICAL HISTORY:
# Metastatic breast CA
-- on femera, s/p bilateral mastectomies;
-- metastatic to sternum since [**2150**]
-- c/b RUE lymphedema
# emphysema
# Severe pulmonary hypertension (likely secondary)
# AFib on coumadin
# HTN
# Hyperlipidemia
# Hypothyroidism
# Pseudogout
# History of UTIs
# Hiatal hernia - no operations
# Cellulitis in arm and legs - hospitalized 2-4 times
# TIAs - 8-10 years ago hospitalized at least once
# Macular degeneration in L eye
# Broken leg - no surgery
# Short term memory loss for several years
Social History:
- no significant smoking history
- no alcohol use
- no drug use
- no known exposure to asbestos
- worked as a teacher, now lives in [**Hospital3 **] home with 3
workers 24/7. Daughter is with her almost every day and is very
involved with her care.
Family History:
- Son with DM type II, HTN, high cholesterol
- Daughter with pre-DM, allergies, asthma, LCIS age 48
- Son died age 1.5 yo of presumed liver problems
- [**Name (NI) **] was an only child, no known family hx of lung dz or
other liver dz
- Ashkenazi [**Hospital1 **] decent
Physical Exam:
General Appearance: Thin
Eyes / Conjunctiva: Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
II/VI Crescendo
Peripheral Vascular: DP/PT 2+
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : Bases), (Breath Sounds: Crackles : Bases,
Rhonchorous: Bases)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: 3+, Left lower
extremity edema: 3+, pitting up to mid thigh
Pertinent Results:
On admission:
[**2158-12-3**] 02:01PM BLOOD WBC-7.2 RBC-3.81* Hgb-11.1* Hct-34.6*
MCV-91 MCH-29.1 MCHC-32.0 RDW-16.8* Plt Ct-338
[**2158-12-3**] 02:01PM BLOOD Neuts-81.4* Lymphs-10.0* Monos-4.8
Eos-3.1 Baso-0.7
[**2158-12-3**] 02:01PM BLOOD PT-34.5* PTT-39.9* INR(PT)-3.5*
[**2158-12-3**] 02:01PM BLOOD Glucose-196* UreaN-37* Creat-1.8* Na-137
K-5.5* Cl-103 HCO3-22 AnGap-18
[**2158-12-3**] 02:01PM BLOOD Calcium-9.0 Phos-4.7* Mg-2.5
[**2158-12-3**] 02:01PM BLOOD CK 77 CK-MB-NotDone proBNP-6453*
cTropnT-0.05*
[**2158-12-3**] 07:41PM BLOOD CK 71 CK-MB-NotDone cTropnT-0.04*
[**2158-12-4**] 01:48AM BLOOD CK 63 CK-MB-NotDone cTropnT-0.04*
Brief Hospital Course:
[**Age over 90 **] year old woman with multiple medical problems including long
standing metastatic breast cancer, severe pulmonary
hypertension, emphysema, atrial fibrillation, presenting with
worsened hypoxia and chest pain, with minimal ST changes, and
negative cardiac enzymes.
.
# ANGINA: Given patients severely limited functional status, it
was difficult to assess whether her symptoms were caued by
unstable angina vs stable angina. ST elevations were not
significantly different from baseline. However there were new
ST segment depressions compared to prior. Cardiac enzymes were
negative X 3. Heparin was not initiated given INR
supratherapeutic on presentation. Given low prob of ACS,
atorvastatin was continued at home dose. Per cardiology, pt was
considered to be a high risk candidate for catheterization and
unlikely to benefit from intervention, presently and in the
future. Pt had no further episodes of chest pain or acute
dyspnea. Double product control will be important going forward.
Metoprolol decreased due to bradycardia. Her nifedipine was
held initially due to concern about renal toxicity and low blood
pressures. It was not restarted prior to discharge, but may
need to be restarted as an outpatient.
.
#. BRADYCARDIA: Bradycardia was thought to be due to medication
effect. HR improved to low 70s off of nodal agents. Metoprolol
intially held and restarted at a lower dose and converted to
sustained release. On discharge, her heart rate was
consistently in the 55-60 range.
#. ACUTE SYSTOLIC HEART FAILURE: Patient was grossly volume
overloaded on admission. Per report, pt's medications are
provided by her care givers. She did not respond to bolus of IV
80mg and started on a Lasix drip with diuresis of 1.5-2L daily.
Her volume status improved as did her oxygen requirement. On
discharge, her home lasix dose was increased. Her daughter
notes that the patient does not seem to repond well to lasix
anymore. She may benefit from metolazone or another diuretic
therapy in the future.
#. ACUTE RENAL FAILURE: Given volume overload suspect poor
forward flow from CHF is most likely etiology. Pt was diuresed
and her renal function improved to near baseline and should be
rechecked as an outpatient. Her valsartan was held in the acute
setting, but restarted prior to discharge.
# HYPOXIA: Multifactorial in setting of pulm hypertension,
volume overload with pulmonary edema, and emphysema. There was
some question of RLL on Xray with no clinical correlation. She
was intially started on ceftriaxone and azithromycin which was
discontinued given improvement in CXR and O2 requirement with
diuresis. She was continued on levoquin for treatment of her
lacrimal duct abscess. Patient finished her course of levoquin
prior to discharge.
# ATRIAL FIBRILLATION: Well rate controlled. Pt was admitted
with supratherapuetic INR. Coumadin held until INR reached
goal. Restarted at lower dose prior to discharge. Will need
INR checked in follow up.
# BREAST CANCER: Pt was continued on Femara. She should discuss
need to continue this medicatin with her primary oncologist.
.
# CODE: FULL, confirmed with patient and daughter. However,
both the daughter and the patient wished to discuss this issue
further with the patient's PCP who was not available during this
hospitalization.
Medications on Admission:
Nitro patch 3mcg
Metoprolol 25mg [**Hospital1 **]
Nifedipine 90mg daily
Furosemide 80mg (Hold on Sunday)
Valsartan 80mg
Atorvastatin 10mg daily
Coumadin
Ranitidine 150mg [**Hospital1 **]
Femara 2.5mg
Colchicine 0.6mg
Gabapentin 300mg TID
Levothyroxine 125mcg
Discharge Medications:
1. Nitroglycerin 0.3 mg/hr Patch 24 hr Sig: One (1) patch
Transdermal Q24H (every 24 hours).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
Disp:*45 Tablet(s)* Refills:*2*
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
7. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO Daily ().
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Succinate 25 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:
Primary: Acute on Chronic Systolic Heart Failure
Chest pain related to metastatic cancer
Secondary:
Pulmonary Hypertension
Bradycardia
Acute renal failure
Atrial Fibrillation
Breast Cancer
Lacrimal duct infection
Discharge Condition:
Mental Status:Confused - always, very hard of hearing
Level of Consciousness:Alert and interactive
Activity Status:Please see PT eval for full details.
Discharge Instructions:
Dear Mrs. [**Known lastname 108981**],
You were admitted for evaluation of your chest pain and
difficulty breathing. You were found to have worsening heart
failure. Your chest pain resolved and may have been due to your
heart failure or the breast cancer in your breast bone. You did
not have any evidence of a heart attack. Your oxygen
requirement returned to baseline with the removal of fluid.
We made the following changes to your medications:
We INCREASED the dose of your lasix. Please take lasix twice
daily as instructed.
We DECREASED the dose of your metoprolol and changed it to the
long-acting form so you only need to take it once daily.
We DISCONTINUED your nifedipine due to low normal blood
pressures.
We DISCONTINUED aspirin.
We DISCONTINUED Levofloxacin as you finished your treatment
course for the eye infection.
We DECREASED your dose of coumadin
You will need to continue to have your INR monitored through the
coumadin clinic. Please have your INR checked on Monday during
your appointment with Dr. [**First Name (STitle) 216**].
Please keep all follow up appointments.
Please adhere to a low salt diet.
Please weigh yourself daily.
Followup Instructions:
We have arranged the following appointments for you:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD
Phone: [**Telephone/Fax (1) 250**]
Date/Time: [**2158-12-11**] 11:50am
Location: [**Hospital Ward Name **] CENTER, [**Location (un) **]
Please check INR, electrolytes and kidney function on Monday.
Please check blood pressure.
Completed by:[**2158-12-7**]
|
[
"5849",
"4280",
"4019",
"2724",
"2449",
"42731",
"V5861",
"4168",
"42789"
] |
Admission Date: [**2146-5-1**] Discharge Date: [**2146-5-4**]
Date of Birth: [**2146-5-1**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Last Name (un) **] [**Known lastname 61187**] is the former 3000-
gram product of a 38-week gestation pregnancy born to a 36-
year-old G2, P1 now 2 woman. Prenatal screens: Blood type B-
positive, antibody negative, rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group B strep status
unknown. The pregnancy was uncomplicated. The mother had
spontaneous onset of labor with rupture of membranes less
than 24 hours prior to delivery. She developed a fever to 100
degrees Fahrenheit in labor.
Infant was born by vaginal delivery. Vaccum assistance was used.
The baby was noted to have a body
cord at the time of delivery. He emerged limp and apneic. He
required vigorous stimulation, drying, and eventual
intubation and ventilation to achieve onset of respirations.
Apgars were 5 at 1 minute, 6 at 5 minutes, and 8 at 10 minutes.
He was admitted to the neonatal intensive care unit for further
evaluation and treatment.
PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: Weight 3.020
kilograms, length 52.5 cm, head circumference 35.5 cm. Length
and head circumference are greater than 90th percentile.
Weight is 50th percentile. General: Well-appearing term
infant in open crib. Pink and well perfused in room air.
Mildly jaundiced over face and trunk. Quiet, alert, and
responsive. Head, eyes, ears, nose, throat: Anterior fontanel
open and flat. Sutures approximated. Eyes with mild
periorbital edema. Nares patent. Mucous membranes moist and
pink. Chest: Symmetric, clear, equal breath sounds,
comfortable respirations, occasional expiratory stridor.
Cardiovascular: Regular rate and rhythm, no murmur, pulses
+2. Abdomen: Soft, no masses, active bowel sounds, cord
drying. GU: Testes descended in canals bilaterally. Normal
phallus. Extremities: Well-developed, moving all. Neuro:
Active with good tone, symmetric primitive reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: [**Last Name (un) **] was extubated to room air shortly
after admission to the neonatal intensive care unit. His
apnea present at birth resolved. Chest x-ray was within
normal limits. At the time of discharge, he is breathing
comfortably in room air with a respiratory rate of 30-50s
breaths per minute, oxygen saturations greater than 97%.
2. Cardiovascular: [**Last Name (un) **] required 1 normal saline bolus upon
admission to the neonatal intensive care unit for poor
perfusion. Since that time, he has maintained normal
heart rates and blood pressures. At the time of
discharge, baseline heart rate is 130-160 beats per
minute with a blood pressure of 60/38 mmHg with a mean of
46 mmHg.
3. Fluid, electrolytes, and nutrition: Enteral feeds were
started on the day of the birth and have been advanced to
full volume and are well tolerated. At the time of
discharge, he is taking Similac formula ad-lib p.o.
4. Infectious disease: Due to the unknown etiology of his
presentation at birth, the low-grade maternal fever, and
unknown maternal group B strep status, [**Last Name (un) **] was
evaluated for sepsis upon admission to the neonatal
intensive care unit. A complete blood count was within
normal limits. A blood culture was obtained prior to
starting intravenous ampicillin and gentamicin. The blood
cultures were no growth at 48 hours, and the antibiotics
were discontinued.
5. Hematological: Hematocrit at birth was 54.5%. [**Last Name (un) **] did
not receive any transfusions of blood products.
6. Gastrointestinal: Serum bilirubin was checked on day of
life 2 and had a total of 7.4 mg per deciliter. Bili on
[**5-4**] wa 8.4. Follow up bili should be checked on [**5-5**] or [**5-6**].
7. Sensory: Hearing screening was performed with automated
auditory brainstem responses and passed in both ears on
[**2146-5-4**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Street Address(2) 52503**],
[**Location (un) 1439**], [**Numeric Identifier 55889**], phone number ([**Telephone/Fax (1) 72275**]; fax number
([**Telephone/Fax (1) 72276**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding ad-lib Similac formula.
2. No medications.
3. Iron and vitamin D supplementation. Iron supplementation
is recommended for preterm and low birth weight infants
until 12 months of corrected age. All infants fed
predominantly breast milk should receive vitamin D
supplementation at 200 international units which may be
provided as a multivitamin preparation daily until 12
months corrected age.
4. Car seat position screening is not indicated.
5. State newborn screen was sent on [**2146-5-3**].
6. No immunizations administered. Parents desire their
infant receive the hepatitis vaccine in the
pediatrician's office.
7. Immunizations recommended: Influenza vacce is recommended for
babies after 6 months of age.
Before this age and for the 1st 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 rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the
hospital if they are clinically stable and at least 6
weeks, but fewer than 12 weeks of age.
8. Follow-up appointments scheduled or recommended:
Appointment with Dr. [**Last Name (STitle) **] within 2 days of discharge.
VNA referral was also made.
9. Follow up bilirubin should be checked in the next 2 days.
DISCHARGE DIAGNOSES:
1. Thirty-eight-week-gestation infant.
2. Birth apnea.
3. Suspicion for sepsis ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2146-5-4**] 03:13:59
T: [**2146-5-4**] 07:09:02
Job#: [**Job Number 72277**]
|
[
"V290"
] |
Admission Date: [**2190-7-2**] Discharge Date: [**2190-7-8**]
Date of Birth: [**2106-10-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
endoscopy, colonoscopy
History of Present Illness:
83 y/o Russian-only speaking M with hx of dCHF, COPD, HTN, and
BPH who presented to the ED with a headache and lightheadedness.
He reports no nausea, vomiting, diarrhea. His last BM was
yesterday and had bright red blood in it. He says his stools
are always dark given that he takes iron. He also states that
over the weekend last week, he was admitted to an OSH for anemia
and was given a blood transfusion and sent home. He did not
have an endoscopy or colonoscopy. Of note, he also is carrying
a prescription for levoquin for an unknown reason. He doesn't
know why he is supposed to be taking it. He denies fainting,
falling, abdominal pain. He has never had a colonoscopy or
endoscopy before. He does not take NSAIDs, drink etoh or have a
hx of ulcers of GERD like symptoms.
.
In the ED, initial vitals were afebrile, P 70, BP 130/90, R 24
and 98% on 2L. He was guiac positive with bright red blood on
the rectal exam. He had a NGL that returned bile without blood.
His vital signs were stable throughout his ED course. He had
one 18g and one 16g PIV placed. GI evaluated him in the
emergency room and requested a nuclear red blood tagged scan
this evening. He did receive 2 units of blood in the ED for a
hct of 22.1.
.
On arrival to the floor, he is feeling well. He complains of a
headache, but otherwise has no complaints.
Past Medical History:
1. Diastolic CHF
2. Hypertension
3. BPH
4. COPD/Restrictive PFTs
5. Osteoarthritis
6. Left cataract surgery
7. Renal mass removed in [**2186**]
8. History of cellulitis in left lower extremity in [**2181**]
9. Right greater than left venostasis
10. PUD
11. Chronic renal insufficiency
Social History:
Russian-speaking. Smoked 1ppd x 20 yrs, quit 40 years ago.
Denies current tobacco, alcohol, or illicit drug use. Lives
alone in senior living facility. Has home health aid 4d per
week. Pt has VNA but has had issues with noncompliance in the
past.
Family History:
There is no family history of premature coronary artery disease,
unexplained heart failure, or sudden death.
Physical Exam:
Tc-97.3
BP- 158/70
RR- 22
O2 sat-97% on 3L
Gen: NAD, alert, lying in bed
CV: RRR
Lungs: mild crackles at right lung base
Abd: soft, NT, ND, +BS
Ext: no pedal edema
Neuro: alert and oriented x 3, CN II-XII grossly intact
Psych: mood, affect appropriate
Pertinent Results:
[**2190-7-2**] 07:21PM HCT-25.2*
[**2190-7-2**] 01:46PM GLUCOSE-140* UREA N-53* CREAT-2.2* SODIUM-141
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-31 ANION GAP-13
[**2190-7-2**] 01:46PM estGFR-Using this
[**2190-7-2**] 01:46PM ALT(SGPT)-6 AST(SGOT)-10 ALK PHOS-81 TOT
BILI-0.4
[**2190-7-2**] 01:46PM cTropnT-0.02*
[**2190-7-2**] 01:46PM ALBUMIN-3.4*
[**2190-7-2**] 01:46PM WBC-5.4 RBC-2.33* HGB-7.0* HCT-22.1* MCV-95
MCH-30.1 MCHC-31.8 RDW-16.1*
[**2190-7-2**] 01:46PM NEUTS-83.5* LYMPHS-12.9* MONOS-2.8 EOS-0.6
BASOS-0.2
[**2190-7-2**] 01:46PM PLT COUNT-120*
[**2190-7-2**] 01:46PM PT-16.0* PTT-29.7 INR(PT)-1.4*
.
CXR [**2190-7-2**]
IMPRESSION: New dense opacification at right lung base
concerning for
infection, particularly given short term development since
[**2190-6-9**]. Recommend follow-up to resolution.
.
EKG [**7-2**] NSR, RBBB, ST depression in II, TW flattening in
precordial leads
[**2190-7-5**] 07:20PM BLOOD Hct-30.5*
[**2190-7-4**] 05:50AM BLOOD WBC-4.7 RBC-3.36* Hgb-9.9* Hct-31.0*
MCV-92 MCH-29.3 MCHC-31.8 RDW-16.5* Plt Ct-110*
[**2190-7-3**] 12:34AM BLOOD WBC-5.2 RBC-3.17*# Hgb-9.3*# Hct-28.5*
MCV-90 MCH-29.2 MCHC-32.5 RDW-16.8* Plt Ct-108*
[**2190-7-5**] 05:01AM BLOOD Glucose-105* UreaN-41* Creat-1.8* Na-145
K-4.2 Cl-109* HCO3-30 AnGap-10
[**2190-7-4**] 05:50AM BLOOD Glucose-95 UreaN-41* Creat-1.8* Na-144
K-4.2 Cl-106 HCO3-31 AnGap-11
Brief Hospital Course:
# Bright red blood per rectum: The patient presented with a
hematocrit of 21, down from a baseline hematocrit of 30, with
maroon stools with clots. The patient was actively bleeding and
symptomatic despite stable vital signs. The patient received 2
units of packed red blood cells in the emergency room and an
additional unit upon arriving in the MICU. The
gastro-intestinal team was consulted and planned to scope the
patient (colonoscopy and upper endoscopy)on Tuesday [**7-6**]. The
patient was treated with IV pantoprazole and an oral bowel
regiment (no stool since admission). The patient's hematocrit
was stable overnight without active bleeding and stable vital
signs. In total, patient received 5 units of blood with Hct
increaed to around 30. The patient was transferred to the
floor on the afternoon of [**7-3**] for further management. On the
floor, his hematocrits were stable. He was prepped for
endoscopy and underwent the procedure on [**7-7**]. [**Last Name (un) **] and EGD did
not reveal any source of bleeding. GI suggests out-pt capsule
study and repeat screening [**Last Name (un) **] at discretion of PMD as prep was
not adequate to screen for colon CA.
.
# Right Lower Lung Opacity: The patient's CXR had a right lower
lobe opacity on chest xray. It was decided to not pursue
treatment as the patient was asymptomatic, afebrile, and had a
normal white count. Of note - the patient was given a
prescription for levaquin one week prior at an OSH for reasons
the patient does not recall.
.
# Diastolic Congestive Heart Failure: The patient has known
diastolic congestive heart failure with multiple admissions in
the past few months for shortness of breath. The patient was
considered to be at risk for developing flash pulmonary edema
while receiving transfusions. The patients pressures and
respiratory status were stable overnight. On the floor, his
home medications (labetalol, lasix, amlodipine) were restarted.
.
# Hypertension: The patient was normotensive on admission to the
MICU. The patient has a history uncontrolled hypertension. The
patient's anti-hypertensive medications were held to maintain
normo-tensive pressures as the patiet was at risk for flash
edema given blood products and diastolic heart failure. His
home medications were restarted on the floor. To control his
blood pressure, his labetalol was increased to 400 mg tid and
captopril was added and up-titrated to 50 mg tid. On discharge,
his blood pressures are controlled with SBP in 150s. Will
discharge patient on increased dose of HTN medications.
Recommend follow-up with PCP for adjustment of meds.
.
# Chronic Obstructive Pulmonary Disease: The patient is on 2
liters of nasal cannula oxygen supplementation at home. The
patient was administered albuterol nebulizer treatment as needed
and was continued on his home dose of tiotropium and fluticasone
inhalers during his stay. The patient did not have any episodes
of respiratory distress in the MICU. On the floor, he was kept
on [**3-5**] L of oxygen and had stable O2 sats.
.
# CKD: The patient's creatinine was 2.2 on admission to the
MICU which is up from baseline of 1. The patient was likely
pre-renal on admission secondary to blood loss. The patient's
creatinine was 1.7 at the time of discharge form the MICU. On
the floor, Cr remained at 1.8.
.
# BPH: The patient was continued on doxazosin and finasteride
daily.
.
# Glaucoma/Cataracts: The patient was continued on his home eye
drop regiment.
.
# Nutrition: As the patients's hematocrit was stable and there
was no active bleeding evident, he was advanced to a soft diet
on [**7-3**]. He was kept NPO for the procedure. He advanced to
regular diet prior to discharge.
Medications on Admission:
Nexium 40 mg daily
Finasteride 5 mg daily
Spiriva 18 mcg daily
Albuterol neb
Lorazepam 1 mg qHS
Tobramycin-Dexamethaxone 0.3-0.1% gtts [**Hospital1 **]
MVI daily
Ferrous sulfate 300 mg daily
Brimonidine 0.15% gtts q8hrs
Dorzolamide-Timolol 2-0.5% gtts [**Hospital1 **]
Latanoprost 0.005% gtts qHS
Polyvinyl Alcohol-Povidone 1.4-0.6% Dropperette PRN
Doxazosin 4 mg daily
ASA 325 mg daily
Labetolol 400 mg [**Hospital1 **]
Amlodipine 5 mg daily
Fluticasone 110 mcg 2 puffs [**Hospital1 **]
Lisinopril 5 mg daily
Lasix 60 mg daily
Home O2 for COPD
Discharge Medications:
1. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig: One
(1) Drop Ophthalmic [**Hospital1 **] (2 times a day).
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Disp:*180 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed.
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed.
13. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
15. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2)
Inhalation twice a day.
16. Captopril 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Primary Diagnosis: GI Bleed
Secondary Diagnosis:
1. Diastolic CHF
2. Hypertension
3. BPH
4. COPD/Restrictive PFTs
5. chronic renal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for blood in your stools. You were transfused
blood for anemia. You underwent a procedure called endoscopy
and colonoscopy, and no source of bleeding was identified.
Please continue your medications. Please CHANGE your labetalol
dose to 400 mg three times a day. Please START captopril 50 mg
three times a day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please keep the following appointments. If you cannot make an
appointment, please call to reschedule.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) 4606**]
Appointment: [**Telephone/Fax (1) 766**] [**2190-7-19**] 11:15am
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2190-8-4**] at 10:30 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"5119",
"40390",
"496",
"4280",
"2859",
"5859",
"4168"
] |
Admission Date: [**2157-2-27**] Discharge Date: [**2157-3-4**]
Date of Birth: [**2087-8-27**] Sex: M
Service: Medicine
ADDENDUM: The patient was discharged on [**2157-3-4**]. He
was kept overnight since he continued to ooze some bright red
blood per rectum, and his hematocrit drifted down to 38.7. He
was transfused one more unit, and his repeat hematocrit was 31.6.
The patient was stable. His right internal jugular line was
sacral decubitus ulcer changes is to continue dressing changes
b.i.d. with Duoderm as well as placing a rectal bag that does not
involve the area of ulcer to prevent skin breakdown. In
addition, to his medication regimen we have added Canasa
suppositories q.d.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAD
Dictated By:[**Name8 (MD) 1020**]
MEDQUIST36
D: [**2157-3-4**] 15:28
T: [**2157-3-5**] 04:00
JOB#: [**Job Number 93643**]
|
[
"4019"
] |
Admission Date: [**2144-1-23**] Discharge Date: [**2144-1-26**]
Date of Birth: [**2074-10-9**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old
female with a history of two previous right carotid
endarterectomies, who presented on [**2144-1-24**] for carotid
stenting. She had left hand and leg weakness associated with
slurred speech on [**1-16**]. When at work, a supervisor noted she
had little insight into these problems but noted speech to
worsen later in the day and left arm to become heavier.
Initial evaluation at [**Hospital **] Hospital was remarkable for
rapid resolution of the symptoms and a head CT showed right
frontal small vessel ischemic changes. CT angiogram showed a
high grade right ICA stenosis, distal to previous
endarterectomy. The patient was transferred to [**Hospital1 346**] for carotid revascularization. She
had two previous right carotid endarterectomies. Her
steroetype symptoms started again in [**5-16**].
Past medical history includes hypertension, high cholesterol,
coronary artery disease, transient ischemic attacks,
rheumatoid arthritis. Meds at home include atenolol,
hydrochlorothiazide, lisinopril, Protonix, Aggrenox, Ambien,
Wellbutrin, Lipitor.
SOCIAL HISTORY: The patient recently quit smoking. She has a
50-pack year history. She is a nightly wine drinker.
HOSPITAL COURSE: On exam the patient had a pulse of 70, a
blood pressure of 150-80. She did have positive carotid
bruits. Lungs were clear. Heart was regular. She was awake,
oriented, had normal language, attention, calculation, memory,
full vision fields. Pupils equally round and reactive to
light. Extraocular muscles are intact. Face was symmetric.
She had no dysarthria. She had full strength in all limbs.
She had no drift. Normal sensation in all extremities.
Coordination was normal. Gait was normal.
She had a white count of 10.2, hematocrit of 32.5, platelet
count of 342. Electrolytes were all normal.
The patient was admitted to the hospital at that time and was
taken to the angio suite for right carotid stenting. From
there, her hospital c At the close of the pstenting.
From there, her hospital course developed when she
experienced hypertension towards the end of the procedure
followed by acute hypotension after being treated with
nitroglycerin. Upon trying to awaken the patient, the patient
had left extremity weakness and slurred speech. She was taken
to the CAT scanner and en route her symptoms became worse.
The patient became unable to protect her airway and the
patient was emergently intubated. On imaging, the patient had
an extensive intracerebral hemorrhage within her right and
left ventricles into the parenchyma of her right cerebrum and
into her brainstem. The patient was transferred to the
Intensive Care Unit for further care. A central line was
placed. An A-line was placed. Neurosurgery was consulted and
placed an intraventricular drain, however, indicated that this
was probably a hopeless situation as the patient had brainstem
involvement. Over the course of the next 36 hours, the
patient progressed to brain death despite intraventricular
drain placement and mannitol administration. It is now
[**2144-1-26**] and the patient is being taken to the Operating
Room for organ donation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 59105**]
Dictated By:[**Last Name (NamePattern1) 3956**]
MEDQUIST36
D: [**2144-1-26**] 20:29:06
T: [**2144-1-26**] 21:58:32
Job#: [**Job Number **] & 1114
|
[
"2760",
"4019",
"41401"
] |
Admission Date: [**2197-12-31**] Discharge Date: [**2198-1-6**]
Date of Birth: [**2150-10-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Malaise, cough, fever
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Mr. [**Known lastname 931**] is a 47 M with DM1 s/p kidney/pancreas transplant
on chronic prednisone, HTN, CRI, who presented with a
non-productive cough, SOB, malaise, increase in LE edema, and
fever 100.1 starting [**12-28**]. The patient thought he may have
pneumonia and went to [**Hospital3 6592**] for assessment. At [**Hospital1 **],
his Cr 3.6 from baseline Cr 2.0. WBC 16.4 with Bands 5. CK
389, MB 24, MBI 6.6, TropT 7.84, BNP [**Numeric Identifier 26568**]. An EKG showed
evidence of an anterolateral STEMI, and patient was transferred
to [**Hospital1 18**] for further management.
.
The patient was transferred to [**Hospital1 18**] transplant surgery service
because of his previous kidney/pancreas transplant. O2 sat was
99% RA. He was given IVF 75/hr, which was stopped a few hours
later. The Cards fellow requested transfer to [**Hospital Ward Name 121**] 3, and a
trigger was called on [**Hospital Ward Name 121**] 3 for O2 sat 93% on nonrebreather.
He was given lasix 40 IV before transfer to CCU on monitoring.
.
In the CCU, EKG showed 1-2 mm STE V2-V6; Q waves V2-V5, I, AVL;
STE in AVR, AVL, suggesting an anterolateral STEMI and proximal
LAD infarct that occurred several days prior. CK 267, MB 17,
Trop 6.19. In the early am, the case was discussed with Dr.
[**Last Name (STitle) **] (interventional attending) who did not wish to take
patient to the cath lab immediately. The patient was found to
have a systolic murmur. No valvular pathology was noted on
previous TEE (normal EF with normal wall motion). A bedside TTE
was performed to assess mechanical complication of STEMI. TTE
showed EF 30%, 1+MR, mid anterior wall and apex akinetic, no
thrombus.
Past Medical History:
DM1 x 12 yo
R toe amputation
Osteopenia
Urethral stricture
Penile implant
Sleep apnea history
Kidney/pancreas transplant [**2183**]:
His kidney transplant is present in his RLQ, pancreas transplant
is in his LLQ (enteric conversion was performed where pancreas
was moved from bladder to GI). He had one rejection episode in
[**2183**], but transplant has generally taken well on prednisone and
prograf. Since the pancreas transplant, the patient has not
required any insulin since [**2183**], and he does not need to check
his blood glucose at home. He has been completely compliant
with his medications, and has not been taking ASA.
Social History:
No ETOH, 20 pky smoker, quit [**2183**] before transplant, smokes
marijuana rarely, no heroin, no cocaine. Married with 2
children, works for [**Company 11293**].
Family History:
Brother - MI at age 52, died from this MI
Father - MI at age 53, died from this MI
No CVA
Physical Exam:
VS: 97.7 / 135/85 / 70 / 20 / 94% on NRB
GEN: Abdominal breathing but not overtly SOB, alert, appears
comfortable
HEENT: JVD to 8 cm, no LAD, PERRL, no carotid bruits
LUNGS: Rales 1/2way up both lungs
HEART: 3/6 systolic murmur increasing on inspiration, [**4-17**]
systolic murmur radiating to axilla, no r/g, no S3, no S4
ABDOMEN: Kidney transplant in RLQ, Pancreas transplant in LLQ,
+BS, soft, nonobese, ND NT
NEURO: [**6-16**] motor, CN 2-12 intact
SKIN: No rashes, telangiectasias, bruises, petechiae
EXTR: Trace bilateral LE edema, no c/c, 1+ R DP pulse,
nonpalpable L DP pulse
Pertinent Results:
[**2197-12-31**] 11:15PM PT-13.5* PTT-29.6 INR(PT)-1.2*
[**2197-12-31**] 11:15PM PLT COUNT-230
[**2197-12-31**] 11:15PM ALBUMIN-3.4 CALCIUM-8.4 PHOSPHATE-4.3
MAGNESIUM-2.3
[**2197-12-31**] 11:15PM LIPASE-21
[**2197-12-31**] 11:15PM GLUCOSE-129* UREA N-62* CREAT-3.7*#
SODIUM-139 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-18* ANION GAP-17
.
[**2198-1-1**] 06:00PM CK 203*
[**2198-1-1**] 10:41AM CK 263*1
.
[**2198-1-1**] 06:00PM CKMB 13* MBI 6.4* TropT 6.62*1
[**2198-1-1**] 10:41AM CKMB 17* MBI 6.5* TropT 6.19*1
[**2198-1-1**] 04:50AM CKMB 20* MBI 6.9* TropT 6.09*
.
CXR: IMPRESSION: PA and lateral chest compared to the most
recent prior chest radiograph, [**2195-6-1**]:
There is a severe interstitial pulmonary abnormality
predominantly in the lower lungs with some coalescence in the
right middle and lower lobes accompanied by small bilateral
pleural effusions. This could be due to pulmonary edema except
that the heart is normal size and there is no mediastinal,
pulmonary or hilar vascular engorgement. Alternative
explanations are acute interstitial pneumonia or acute
myocardial infarction.
.
TTE: Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated with severe hypokinesis/akinesis of the distal half of
the septum and anterior walls and distal inferior and lateral
walls. The apex is akinetic and mildly aneurysmal. No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are moderately thickened. There is moderate aortic
stenosis (AoVA = 0.8cm2). Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction c/w
CAD (mid-LAD territory). Moderate pulmonary artery systolic
hypertension.
.
Adenosine MIBI: IMPRESSION: 1. Moderate, predominantly fixed
perfusion defect involving the mid-distal anterior wall, the
apex, and the distal septum. 2. Marked left ventricular
enlargement. 3. Severe global hypokinesis, with superimposed
apical dyskinesis. LVEF=18%.
.
Adenosine MIBI:
SUMMARY OF DATA FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
mg/kg/min.
METHOD:
Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi.
Tracer was
injected approximately one hour prior to obtaining the resting
images.
Two minutes after the cessation of infusion of dipyridamole,
approximately three times the resting dose of Tc99m sestamibi
was administered IV. Stress images were obtained approximately
one hour following tracer injection.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
The image quality is adequate.
Left ventricular cavity size is markedly enlarged.
Resting and stress perfusion images reveal uniform moderate,
predominantly fixed perfusion defect involving the mid-distal
anterior wall, the apex, and the distal septum.
Gated images reveal severe global hypokinesis, with superimposed
apical
dyskinesis.
The calculated left ventricular ejection fraction is 18%.
IMPRESSION: 1. Moderate, predominantly fixed perfusion defect
involving the
mid-distal anterior wall, the apex, and the distal septum. 2.
Marked left
ventricular enlargement. 3. Severe global hypokinesis, with
superimposed
apical dyskinesis. LVEF=18%.
.
[**1-5**] CXR: CHEST: Comparison is made with the prior chest x-ray
of [**1-4**]. The perihilar interstitial opacities, most
marked in the anterior segment of the right upper lobe are again
seen. This pattern of interstitial infiltrate would be unusual
and prolonged for simple failure and I suspect the presence of
pneumonia in addition. The size of the effusions has decreased
consistent with improved failure, but I doubt the infiltrates
are caused by this.
IMPRESSION: Persistent perihilar infiltrates, pneumonia is
suspected.
Brief Hospital Course:
This is a 47 M with DM1, kidney/pancreas transplant [**2183**], HTN,
CRI, who is here s/p anterolateral STEMI, presenting with
shortness of breath which is likely attributed to a CHF
exacerbation.
.
1. CARDIAC:
A. CAD: This patient was admitted with evidence of an
anterolateral STEMI on EKG with STE V2-V6; Q waves V2-V5, I,
AVL; STE in AVR, AVL. The EKG suggested a proximal LAD infarct.
This infarct likely occurred several days PTA given the
precordial Q waves and the falling CKs. The peak recorded CK was
362. However, given the suspected time course, the true peak was
likely much higher. Cardiac catheterization was deferred due to
the patient's renal failure and because he was already many days
out from his MI. The patient therefore, underwent an adenosine
MIBI. This showed a fixed perfusion defect involving the
mid-distal anterior wall, the apex, and the
distal septum. It also showed depressed systolic function with
an EF of 18% and
severe global hypokinesis, with superimposed apical dyskinesis.
The patient was started on ASA 325, lipitor 80, and metoprolol
50 TID. Hydralazine 10 mg Q6 was also started for BP control.
Once the patient's renal failure improved, a low dose ACEI was
started. The patient was asked to have a chem 7 drawn on Monday
[**1-8**] and to follow up with his PCP for further titration of his
BP and other cardiac medications.
.
B. Pump: The patient was admitted to the floors with a CHF
exacerbation s/p an anterolateral STEMI. He was transferred to
the CCU for increasing respiratory distress secondary to volume
overload and CHF. The patient was diuresed with lasix with good
effect and his hypoxia resolved. An echo was done which showed
and EF 30%, AS with valve area 0.8, and akinesis of the apex,
distal half of the septum anterior and lateral walls. An
adenosine MIBI showed an EF of 18% with a fixed perfusion defect
as described above. The patient was initially kept on heparin
for the apical akinesis and low EF, with the intention of
bridging to coumadin. However, given the patient has a h/o
hemorrhagic CVA, the heparin was stopped and the coumadin was
not started. It was decided that the risk of future cerebral
hemorrhage was greater than the risk of thrombus formation and
emobilization [**3-16**] the apical akinesis. The patient was
discharged on lasix 40mg QD given his elevated BNP and low EF.
He was also discharged on ACEI and metoprolol for their
cardioprotective effects. The patient will likely need a repeat
echo in approximately 3 mo after maximum medical therapy and
possible consideration of an ICD placement given his low EF.
.
C. Rhythm:
The patient was maintained in NSR throughout the duration of his
hospitalization. he was started on metoprolol and monitored on
telemetry w/o event.
.
2. Respiratory distress: The patient was admitted to the CCU in
respiratory distress from florid pulmonary edema. Initially he
was sating 94% on a NRB. The pt also has a 20 pky smoking
history and a h/o obstructive sleep apnea. He was not on home
oxygen, and was never on CPAP or Bipap. Given his obvious volume
overload, the patient was diuresed with lasix and put on a nitro
drip. His O2 requirement diminished quickly and the nitro drip
was weaned off. The patient's dyspnea resolved completely. He
was also afterload reduced with hydralazine and lisinopril once
his Cr stabilized. Although serial CXR showed possible b/l PNA,
the patient never had a productive cough. ID was consulted and
did not recommend treating for CAP. Transplant nephrology was
also following the patient and did not recommend empiric
treatment for CAP.
.
3. Acute on CRI: The patient was admitted with Cr 3.7 which
increased to 4.1 upon diuresis from a baseline Cr 2.0. Urine
lytes were sent and FEurea was 29% indicating pre-renal cause
for the acute component of his renal failure. Although the
patient was clearly total body volume overloaded, he likely
likely had poor forward flow due to his diminished systolic
function from his recent STEMI. Although his creatinine
increased slightly upon diuresis, his Cr slowly decreased to
2.9. Upon restarting low dose lisinopril, his Cr bumped modestly
to 3.1. Therefore, we will have him get a chem 7 checked two
days after discharge to follow up on his Cr and potassium
levels. Transplant nephrology was involved during throughout his
hospitalization.
.
4. Leukocytosis/fever: The patient's WBC 16.4 upon admission
the patient also spiked fevers to 102 but did not exhibit any
localizing symptoms of infection. Urine and blood cultures were
negative. Urine legionella Ag was sent but pending upon
discharge. His stool was negative for C.diff x 1. CXR showed
possible b/l PNA. However, the patient denied any productive
cough and did not show any clinical signs of infection. As the
patient was diuresed, the b/l perihilar opacities seen on CXR
improved. Therefore, the perihilar opacities on CXR were thought
to be due to CHF> and the fever and leukocytosis were attributed
to his STEMI and atelectasis.
Given the patient is a transplant patient and is
immunosuppressed on chronic prednisone treatment, ID was
consulted concerning the fevers. They supported the idea of
holding off on antibiotic treatment given the lack of clinical
symptoms of PNA. By the time of discharge, the patient had been
afebrile for >24hrs. He was advised to call his PCP if he
continued to experience fevers.
.
5. Hypertension: Initially the patient was put on a nitro drip
to maintain his SBP between 130-150. This was done to prevent
flash pulmonary edema while also maintaining sufficient
perfusion to his renal transplant. For BP control the patient
was started on Toprol 150 QD and hydralazine. Once his RF began
to resolve, he was started on a low dose ACEI and his
hydralazine was discontinued.
.
6. Renal/Pancreas transplant: The patient was followed by
transplant nephrology during his hospitalization. Has not needed
insulin since pancreas transplant [**2183**]. His tacrolimus levels
were checked QD and were maintained between [**6-17**]. He continued to
receive Prograf 2 QAM, 1 QPM and prednisone 12.5 QPM. He was
advised to follow up with transplant physicians upon discharge.
.
7. Anemia: The patient has a baseline Hct 32, likely due to ACD
and iron deficiency. which was stable during his
hosptialization.
.
Medications on Admission:
Tacrolimus 2 QAM, 1 QPM
Prednisone 12.5 QPM
Labetalol 600 [**Hospital1 **]
Diltiazem 120 [**Hospital1 **]
Discharge Medications:
1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
2. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please check Chem 7 (Na, K, Cl, HCO3, BUN, Cr)
Please get these labs drawn on Monday [**1-8**]
Please fax the results to Dr. [**Last Name (STitle) 15473**] fax: ([**Telephone/Fax (1) 21178**] phone:
([**Telephone/Fax (1) 26569**].
12. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO once a day.
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Outpatient Physical Therapy
Please refer patient to outpatient cardiac rehabilitation
program
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Anterolateral ST elevation MI
Fevers; unknown etiology now resolved
Systolic Heart failure, EF 18%
.
Secondary:
Diabetes
s/p pancreatic/kidney transplant
Osteopenia
History of urethral stricture
Sleep apnea
Discharge Condition:
Good. Patient is hemodynamically stable with O2 saturation > 95%
on room air.
Discharge Instructions:
1. Please take all medications as prescribed
.
2. Please keep all outpatient appointments
.
3. Please return to the hospital or seek immediate medical
attention for symptoms of shortness of breath, chest pain,
dizziness, loss of consciouness or continuing fevers.
.
4. Please take your temperature daily. If you continue to have
elevated temperatures you should call your primary care
physician or Dr. [**Last Name (STitle) **] to discuss additional necessary
workup.
Followup Instructions:
1. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15473**]
next week. Please call Dr.[**Name (NI) 26570**] office at [**Telephone/Fax (1) 673**] to
make an appointment.
.
2. Please get your blood drawn on monday and have the results
sent to Dr.[**Name (NI) 26570**] office [**Telephone/Fax (1) 673**]. It is very important
you have blood work performed to ensure your renal function is
normal. You will be given a lab appointment slip to have this
performed at your PCPs office or lab facility. Please have the
results sent to your PCP.
.
3. It is very important that you have close follow up with Dr.
[**Last Name (STitle) **] as well given some kidney dysfunction on admission.
Please call the office of Dr. [**Last Name (STitle) 26571**] at ([**Telephone/Fax (1) 3618**] to make
an appointment to be seen within two week's time. As above, it
is important you have lab values checked early next week so that
your current medical regimen may be monitored.
.
4. You will need follow up with Cardiology given your recent
myocardial infarction and need for ongoing monitoring and
titration of your new cardiac medications. You should call the
cardiology office at ([**Telephone/Fax (1) 5909**] to set up an appointment
with Dr. [**Last Name (STitle) **] within one month.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2198-3-6**]
|
[
"4280",
"5859",
"5849",
"4241",
"40390",
"2859",
"41401"
] |
Admission Date: [**2160-9-3**] Discharge Date: [**2160-9-7**]
Date of Birth: [**2094-12-11**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Unresponsive with generalized tonic-clonic shaking.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The pt is a 65 year-old woman (uncertain handedness) with a
past medical history of a left MCA stroke in [**2142**] (residual R
HP), HTN, aortic insufficiency, Atrial fibrillation on coumadin,
who was rehabilitating at a facility
from a recent right ankle fracture when she was noticed to be
unresponsive the morning of [**9-3**]. She was estimated to have
been found unresponsive at 8:15am. She was subsequently noted to
have
tonic clonic shaking of the right upper and lower extremities.
She was then sent to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4117**] where a head CT, which per
report, demonstrated the old infarct unchanged since an imaging
study in [**2160-5-6**]. The UA was negative and CBC (WBC 10.1)
was
not suggestive of an infection. INR was 2.9. The patient was
given
6mg of ativan and 1 gram of phosphenytoin but she continue to
convulse.
She was sent to [**Hospital1 18**] for further management.
In the [**Hospital1 18**] ED, the patient continued to seize intermittently
w/o
regaining alertness; her heart rate was in the 140s-150s but was
also noted to have a fever of 102.4. Because of INR 2.9, ER
staff
deferred LP and started her on
Vanco/CTX/Acyclovir. Phenytoin level was 15.5. The patient was
given
an additional two doses of ativan 2mg each. She was given 200mg
IV dilantin.
Finally she was given 1000mg of IV keppra. She appeared to stop
seizing after this latter dose.
ROS
The patient can not furnish a ROS.
There is no mention of recent illness in the transfer records
other than a recent right ankle fracture.
Past Medical History:
PMH:
Stroke left hemisphere with residual right hemiparesis ([**2142**])
HTN
Aortic insufficiency
Atrial Fibrillation on coumadin
Right ankle fx
Facial skin cancer s/p excision [**2141**].
Social History:
Social Hx:
Married.
Family History:
Unknown
Physical Exam:
Vitals: T:102.4 P:90-150afib R:22-26 BP:158/84 SaO2:99-100% on
4L
NC
General: Unresponsive to name or noxious.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Tachy, irreg. irreg.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: Pulses thready. No C/C/E.
Skin: Upper extremities were hyperemic.
Neurologic:
-Mental Status: No response to name. Nonverbal. Doesn't follow
commands. No audible sounds made.
-Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and
brisk.
No clear blink to threat. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages. Positive corneal reflex
L>R).
Positive dolls reflex. Positive gag reflex. Right lip appears
post-surgical.
-Motor: Tone is increased (spastic) in the Right upper and lower
extremities. Nonetheless, she spontaneously moved R UE [**3-11**]
(postures to nox stim) and R LE [**4-9**] (triple flexion to nox
stim).
L UE w/d [**4-9**] to nox stim only. L LE w/d [**3-11**] to nox stim only.
No seizure activity noted.
-Sensory: To noxious as above.
-Coordination: Not tested.
- Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Toes
C5 C7 C6 L4 S1 CST
L2 2 2 2 2 down
R3 3 3 3 2 up
-Gait: Unable to test.
Pertinent Results:
[**2160-9-3**] 03:25PM COMMENTS-GREEN TOP
[**2160-9-3**] 03:25PM GLUCOSE-156* LACTATE-2.9*
[**2160-9-3**] 03:15PM GLUCOSE-168* UREA N-15 CREAT-0.8 SODIUM-138
POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-19* ANION GAP-19
[**2160-9-3**] 03:15PM estGFR-Using this
[**2160-9-3**] 03:15PM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-1.8
[**2160-9-3**] 03:15PM DIGOXIN-0.5*
[**2160-9-3**] 03:15PM PHENYTOIN-15.5
[**2160-9-3**] 03:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2160-9-3**] 03:15PM URINE HOURS-RANDOM
[**2160-9-3**] 03:15PM URINE HOURS-RANDOM
[**2160-9-3**] 03:15PM URINE UHOLD-HOLD
[**2160-9-3**] 03:15PM URINE GR HOLD-HOLD
[**2160-9-3**] 03:15PM WBC-13.5* RBC-4.72 HGB-14.7 HCT-42.1 MCV-89
MCH-31.2 MCHC-34.9 RDW-12.6
[**2160-9-3**] 03:15PM NEUTS-85.1* LYMPHS-10.6* MONOS-3.6 EOS-0.2
BASOS-0.4
[**2160-9-3**] 03:15PM PLT COUNT-282
[**2160-9-3**] 03:15PM PT-29.0* PTT-31.1 INR(PT)-2.9*
[**2160-9-3**] 03:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2160-9-3**] 03:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2160-9-3**] 03:15PM URINE RBC-21-50* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0
EKG: 07 / 30/ 08: Atrial fibrillation, mean ventricular rate
121. Possible septal myocardial infarction. Diffuse T wave
inversion. Probable left ventricular hypertrophy.
Cxr 07/ 31/ 08: The lungs are clear. The heart is mildly
enlarged. The pulmonary vascularity is within normal limits.
There is no pneumothorax or pleural effusion. The aorta is
tortuous. No pneumonia.
CT CNS w/o Contrast: 07/ 30/ 08: There is left frontal
encephalomalacia with ex vacuo dilatation of the frontal [**Doctor Last Name 534**] of
the left lateral ventricle consistent with prior infarct. There
is no evidence of new hemorrhage, mass effect or hydrocephalus.
There is basal ganglia calcification on the right. There is some
mild cortical atrophy. There are no fractures.
IMPRESSION: No evidence of acute intracranial hemorrhage or
major vascular
territorial infarct.
Left frontal encephalomalacia and ex vacuo dilatation of the
frontal [**Doctor Last Name 534**] of the left lateral ventricle consistent with prior
infarct.
NOTE ADDED AT ATTENDING REVIEW: There is a large region of
hypodensity and
swelling in the distribution of the superior division of the
right middle
cerebral artery. This is characteristic of infarction. This is
well developed at this time, likely greater than 6-12 hours old,
but rapidity of swelling can be variable in embolic infarction.
There is no evidence of hemorrhage.
There is a possible right posterior cerebral artery acute
infarction, but this area is obscured by artifact.
EEG: 07/ 31/ 08: This 24-hour video EEG telemetry captures no
clinical or
electrographic seizures. Low voltage slowing is demonstrated
throughout
the recording. In addition, superimposed bursts of mixed
frequency
theta and delta slowing are seen over the right frontal,
parietal, and
temporal regions, as well as the left temporal region.
Interictal
discharges were also observed in these areas; however, no
sustained
epileptiform activity was observed.
Echocardiogram: 07/ 31/ 08: The left atrium is elongated. There
is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. No masses or thrombi are seen in the
left ventricle. 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 mild aortic valve stenosis (area 1.2-1.9cm2). Moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: No ASD, or cardiac source of embolism seen. Normal
global biventricular systolic function. Mild aortic stenosis.
Moderate aortic regurgitation.
07/ 31/ 08: Carotid Dupplex: 1) Occlusion of the left internal
carotid artery. 2) Less than 40% stenosis of the right internal
carotid artery.
MRI CNS w and w/o contrast: 08/ 01/ 08: Comparison is made with
CT head [**2160-9-3**].
There has been marked interval worsening since the prior study.
Note is now made of bilateral ACA and MCA territory infarctions.
The
bilateral PCA territories appear to be relatively preserved
although there is involvement of the left superior PCA
territory. Acute infarction of the right basal ganglia are also
noted. There is approximately 7.5 mm midline shift to the left
with the ipsilateral ventricular effacement. There is early
right uncal herniation.
There are old infarcts in the bilateral cerebellum.
There is an old infarction in the left frontal lobe and basal
ganglia.
MRA demonstrates lack of flow related enhancement in the left
ICA. There is minimal reconstitution via a left patent PCOM.
There is occlusion of the right supraclinoid ICA at its
bifurcation. There is lack of flow related enhancement in the
left distal vertebral artery which could reflect occlusion. The
right vertebral artery appears to be irregular and
atherosclerotic. The basilar artery appears to be diminutive.
IMPRESSION: Massive bilateral ECA and MCA territory infarctions
with right to left midline shift of approximately 7.5 mm. There
is occlusion of the right supraclinoid ICA. There is lack of
flow related enhancement in the left ICA both intracranially and
in the cervical portion. There is lack of visualization of the
left vertebral artery which may be occluded.
Brief Hospital Course:
Mrs. [**Known lastname **] signed a DNR/ DNI form on [**2160-8-28**] witnessed
by her primary care
physician. [**Name10 (NameIs) 2772**], her daughter and her husband state she would
not be agreeable to DNR by the time. They believe she signed the
form because she did not fully understand the implications of
the document. In addition, she signed it when she had an ankle
fracture. Hence her family thinks the situation was at the time
different and she would not approve of it while admitted at
[**Hospital1 18**] in the critical care unit. I consulted the hospital's
legal services (Ms [**Last Name (Titles) 79458**], who contact[**Name (NI) **] Ms [**Name (NI) 79459**]). I was
informed that the preferred course of action given the situation
and according to the [**State 350**] law would be to intubate Ms
[**Known lastname **], were it required. Hence the DNR form was reversed
according to the family's wishes.
When Mrs. [**Known lastname **] was in the [**Hospital1 18**] ED on [**9-3**], she was in
status epilepticus. The status epilepticus was stopped after
administration of phosphenytoin and Keppra. CT brain showed her
chronic left MCA infarct and an acute infarct in the right MCA
territory. Per the Radiology attending report, this acute
infarct was at least 6-12 hours old. The patient likely had this
right MCA stroke first. Then the infarct probably triggered her
seizure during the morning of [**9-3**] at about 8:15am. When she
was in the [**Hospital1 18**] ED, she was not a candidate for IV TPA, IA TPA,
or mechanical intervention to treat the stroke for two reasons:
the time of onset of her infarct was not known and she was
anti-coagulated on coumadin with an INR of 2.9.
Carotid ultrasound on [**2160-9-4**] showed complete occlusion of
the
left ICA. MRI brain on [**9-5**] showed massive infarcts of both
anterior hemispheres and also part of the left PCA territory.
There was 7.5mm of midline shift to the left. Early uncal
herniation was apparent. MRA brain showed occlusion of the right
supraclinoid. The left vertebral appeared to be occluded.
The neurology team in the critical care unit met with the [**Known lastname **]
family and discussed the ongoing events and condition of the
patient throughout the course of this admission. Eventually, the
family decided to make the patient CMO. When Mrs. [**Known lastname **] passed
away, the family requested an autopsy. The documentation was
filled out to fulfill the families wishes.
Medications on Admission:
Calcium Carbonate -- Unknown Strength Three times daily
Nifedical XL 30 mg Daily
Coumadin Unknown Strength Daily
Propranolol 10 mg TID
Digoxin 250 mcg Daily
Vitamin D 400 unit Daily
[**Doctor Last Name **] Milk of Magnesia 30 cc Daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
The patient had a massive bilateral ischemic infarct of the
anterior hemispheres and the left superior PCA territory. This
massive infarct resulted in uncal herniation which led to her
passing.
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"4241",
"42731",
"4019",
"V5861"
] |
Admission Date: [**2179-4-30**] Discharge Date: [**2179-5-20**]
Date of Birth: [**2119-8-30**] Sex: F
Service: [**Doctor Last Name **]
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
African-American female with a history of multiple myeloma,
status post autologous bone marrow transplant in [**2175-7-3**], congestive heart failure (with an ejection fraction of
25% to 30%), status post total hip replacement in [**2179-7-3**] secondary to multiple myeloma infiltration who was home
from rehabilitation approximately two weeks ago.
According to her daughter, the patient has been tired; which
had been attributed to her oxycodone which was taken for
pain. Her opiate dose was recently decreased, but for the
past two to three days she has been complaining of increased
fatigue, confusion, lethargy, decreased appetite, and
decreased oral intake. She has had decreased fluid intake.
According to her family, she has not had any fevers, chills,
cough, shortness of breath, nausea, vomiting, diarrhea, or
constipation. She has not had any rashes or neck stiffness.
No photophobia. No abdominal pain. She had been seen by the
Hematology/Oncology fellow on [**2179-4-29**] who found her
tired but responsive and alert.
The following morning, her daughter found her shaking with
her eyes rolled back. The patient was found to have a
critically high glucose by the Emergency Medical Service. In
the ambulance, the patient had a generalized tonic-clonic
seizure for two minutes. In the Emergency Room she had her
third seizure initiating in her left arm and then progressing
to a generalized tonic-clonic seizure. She was given Ativan
and Dilantin 1 g. Her glucose was found to be in the 600s.
She had a head computed tomography which was negative. Her
blood urea nitrogen was 43 and creatinine was 1.7. She was
started on an insulin drip and was receiving intravenous
fluids. She was somnolent after the seizure.
PAST MEDICAL HISTORY:
1. Multiple myeloma diagnosed in [**2174**]; status post
vincristine, dexamethasone, doxorubicin treatment and
chemotherapy in [**2175**]. She had an autologous bone marrow
transplant in [**2175-8-2**]. She has been started on
thalidomide in [**2178-1-2**]. She has been tried on
Methylin, and prednisone, and Decadron.
2. Congestive heart failure with an ejection fraction of 25%
to 30%. Echocardiogram done in [**2178-12-3**].
3. 3+ mitral regurgitation.
4. Mass at the head of pancreas with magnetic resonance
imaging in [**2179-3-5**] concerning for lymphoma versus
adenocarcinoma of the pancreas.
5. History of hyperglycemia.
6. Hypertension.
7. Cholecystectomy.
8. Right total hip replacement in [**2179-3-5**].
9. Chronic renal insufficiency.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lasix.
2. Metoprolol.
3. OxyContin.
4. Oxycodone
5. Lisinopril.
6. Dexamethasone 40 mg p.o. q.d. (for four days from [**4-23**] to [**4-27**]).
SOCIAL HISTORY: She lives with her daughter.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 96.1,
heart rate was 120, blood pressure was 154/70, respiratory
rate was 33, oxygen saturation was 98% on 4 liters of oxygen
by nasal cannula. In general, the patient was tired but
arousable. Oriented to place and month. Head, eyes, ears,
nose, and throat examination revealed pupils were 2 mm
bilaterally. No icterus. The mucous membranes were dry.
The oropharynx was clear. The neck was supple. Pulmonary
examination revealed crackles at the left base; left greater
than right. Expiratory wheezes. Cardiovascular examination
revealed normal first heart sound and second heart sound with
a systolic murmur. The abdomen revealed normal bowel sounds.
Soft, nontender, and nondistended. Extremities revealed no
edema. Dorsalis pedis pulses were 2+ bilaterally.
Neurologically, arousable. Cranial nerves II through XII
were intact. Questionable rightward gaze preference.
Strength was [**5-7**] in the upper and lower extremities.
Sensation was intact.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
revealed arterial blood gas was 7.41/33/112. White blood
cell count was white blood cell count was 5.5., hematocrit
was 38.7, and platelets were 46. Differential with 80%
neutrophils and 18% lymphocytes. Absolute neutrophil count
was 4980. Cortisol level was 34. Sodium was 139, potassium
was 3.2, chloride was 100, bicarbonate was 21, blood urea
nitrogen was 43, creatinine was 1.7 (most recent creatinine
was 1.1), and blood glucose was 663. Her urine showed a
glucose of greater than 1000 with 15 ketones, pH was 5, 3 to
5 white blood cells, 3 to 5 red blood cells, a few bacteria,
trace acetone in the serum. ALT was 21, AST was 13, alkaline
phosphatase was 112, amylase was 104, total bilirubin was
0.7., creatine kinase was 80, LDH was 450. Troponin was less
than 0.3. Calcium was 8.1, magnesium was 2.4, phosphate was
4. Albumin was 3. IgG on [**2179-4-9**] was 2335 and on
[**4-22**] was 1868. Serum toxicology screen was negative as
was urine toxicology screen.
RADIOLOGY/IMAGING: An echocardiogram done in [**2178-4-2**] showed an ejection fraction of 25% to 30% with global
hypokinesis, 3+ mitral regurgitation, and left ventricular
moderately dilated.
A chest x-ray done on admission showed left lower lobe
atelectasis versus infiltrate, a small left effusion,
moderate congestive heart failure.
A computed tomography of the head showed punched out lesions.
Magnetic resonance imaging of the abdomen on [**2179-4-20**]
showed 7-cm X 3-cm at the pancreatic head; atypical for
adenoma, question of plasmacytoma versus lymphoma.
HOSPITAL COURSE BY SYSTEM:
1. ENDOCRINE SYSTEM: The patient was found to be
hyperglycemic, hyperosmolar >....................< acidosis.
She did not carry of diabetes prior to this. It was thought
that it was secondary to her course of dexamethasone followed
by decreased oral intake and dehydration exacerbating it.
She was given hydration and an insulin drip. Her glucose
corrected fairly rapidly.
On the second day of admission, the patient's glucose had
decreased to 204. Her arterial blood gas had a pH of 7.38,
PCO2 of 36, PO2 of 123. She was converted from an insulin
drip to regular insulin sliding-scale. She was continued
with fluid hydration. She no longer had any free water
boluses.
She was transferred out of the Medical Intensive Care Unit on
the fourth day of admission. It was felt that her glucose
may have been elevated secondary to dexamethasone and
possible infection. She did not have any further episodes of
hyperglycemia. She was started on glipizide 5 mg p.o. q.d.
She had better control with the glipizide. Her insulin was
adjusted for better coverage, and it was increased according
to needs. Her fingersticks were stopped once palliative
care had been decided.
2. NEUROLOGIC SYSTEM: The patient had seizures thought to
be secondary to metabolic derangement. She was seen by the
Neurology Service and started on Dilantin. It was felt that
she likely had seizure due to hyperglycemia or hyponatremia.
She did not have any further episodes of seizures during the
course of this admission. Her mental status did wax and
wane, but essentially improved from admission. She did not
have any intracranial lesions. However, she could not
tolerate a magnetic resonance imaging, and was unable to be
fully excluded. She did have an electroencephalogram to
assess for any seizure focus, and that also did not show any
conclusive evidence for seizure. The electroencephalogram
had suggested possible left focal cortical abnormalities.
She was continued on oral Dilantin. The electroencephalogram
had suggested a left temporal focus, but since the CT scan
did not show any evidence, it was further pursued as she
could not tolerate a magnetic resonance imaging. She had a
repeat electroencephalogram which did not show any focal
slowing. Unlikely to be having ongoing seizures with the
report, and a repeat magnetic resonance imaging was not able
to be performed.
3. INFECTIOUS DISEASE: The patient had a fever on her first
day of admission. Subsequently, she had a lumbar puncture
done. A chest x-ray was suggestive of possible left lower
lobe pneumonia. She was started on levofloxacin. She had a
lumbar puncture done. She was started on ceftriaxone at a
meningitis dose initially. The cerebrospinal fluid did not
show any polymorphonuclear cells. It did not show any
organisms. It showed 11 white blood cells with 77%
polymorphonuclear leukocytes. The glucose was 220 and
protein was 483.
It was felt that the low volume may have been from aspiration
or vomiting during seizure. Consequently, a Flagyl dose was
started. Ceftriaxone was continued for a course of 10 days
as was the metronidazole. She completed a course of
antibiotics of ceftriaxone and metronidazole.
4. HEMATOLOGY/ONCOLOGY: The patient had multiple myeloma.
She was on periodic dexamethasone which was thought to be the
culprit for her hyperglycemia. It was found that she had
some nodular masses on her abdomen. Dermatology was
consulted and a biopsy was taken. It was found to be
consistent with a plasmacytoma or extension of her multiple
myeloma. It was felt that her diffuse tumor burden was
increasing despite the chemotherapy that she had been
receiving. She also had a peripancreatic mass which was
most likely part of this similar condition. There was some
discussion of whether to biopsy this mass; however, she never
was stable enough for biopsy.
5. CARDIOVASCULAR SYSTEM: The patient had multiple episodes
of dyspnea during the course of this admission. It was felt
that given her history of congestive heart failure that she
likely had congestive heart failure. She was given Lasix
periodically. She had some improvement with the Lasix. She
had persistent tachycardia during the course of this
admission, and it was felt to be due to possible dehydration.
She received fluids and also with her history of congestive
heart failure, she was continued on Lasix 40 mg once per day
with metoprolol. She was also started on captopril, and it
was increased as tolerated.
6. RENAL SYSTEM: The patient had an increasing creatinine
on her initial admission. However, her creatinine improved
with some fluid hydration. It was felt to be prerenal.
However, her urine output throughout the course of this
admission was felt to be poor. She would receive fluid
intermittently with an occasional response to fluids.
Because of her history of congestive heart failure, the fluid
intake was gently given.
7. PULMONARY SYSTEM: The patient had episodes of dyspnea
during the course of this admission. The possible etiologies
were pneumonia, tumor burden, along with congestive heart
failure.
She was treated antibiotics and occasional Lasix. However,
it was felt that she had other causes that were more likely
than pulmonary embolism. She did not receive a CT angiogram
during the course of this admission.
8. GASTROINTESTINAL SYSTEM: The patient had an episode of
melena during the course of this admission. She was
evaluated by Gastroenterology. Because of her poor
prognosis, she was not a candidate for interventional
studies. She had a guaiac-positive stool and a decrease in
hematocrit. She was given units of packed red blood cells as
needed. Because of the deterioration in her condition and
move toward hospice care, it was decided to hold off on the
interventional studies.
The patient's prognosis was very poor. She had expanding
tumor involvement including skin and likely pancreas. She
had likely tumor burden in her lungs. It was decided with
the attending and the family that the patient would best be
served by do not resuscitate/do not intubate with comfort
measures. Hospice was asked to see the patient and further
lengthy discussions were started.
On [**2179-5-20**], the patient was found to no longer have
any spontaneous breaths. Her pupils were dilated and
nonreactive. She did not respond to any pain. She had no
audible heart sounds. She was pronounced at 9:30 a.m.
Family members were present. The patient's family declined
autopsy.
DISCHARGE STATUS: The patient expired.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 4523**]
MEDQUIST36
D: [**2180-1-6**] 10:45
T: [**2180-1-8**] 08:55
JOB#: [**Job Number 16948**]
|
[
"2760",
"486",
"4280",
"2875"
] |
Admission Date: [**2117-9-18**] Discharge Date: [**2117-9-29**]
Date of Birth: [**2056-12-12**] 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:
[**2117-9-20**] Cardiac Catheterization with Successful placement of
Cypher Stent to Left Circumflex
[**2117-9-21**] Cardiac Catheterization with Failed PCI of Right
Coronary Artery. Placement of IABP
[**2117-9-21**] Emergent Coronary Artery Bypass Grafting on IABP(Left
internal mammary to left anterior descending, vein grafts to
distal right coronary artery and obtuse marginal). Closure of
Atrial Septal Defect.
History of Present Illness:
Mr. [**Known lastname 29571**] is a 60 year old male with a history of PVD, HTN,
and hyperlipidemia. He presented with substernal chest pressure
beginning morning of admission. 5 days prior to admission,
patient was loading his pick-up truck and developed substernal
chest pressure. The pain was not associated with any other
symptoms and was relieved with rest. Exertional chest pressure
relieved by rest continued throughout that day but patient did
not seek medical attention. Patient had an appointment with his
PCP the following day and had an EKG performed which showed some
concerning features per the patient and he was scheduled for an
exercise stress test. However, patient notes that his doctor
noted similar changes in his EKG as far back as [**2108**]. Patient
exercised for 9 minutes and developed the same substernal chest
pressure which again relieved with rest and the nuclear imaging
showed a perfusion defect per the patient. He was started on
Atenolol on the day prior to admission and was scheduled for an
elective catheterization at [**Hospital1 336**] this coming Thursday.
The morning of admission, he awoke at 5:45 am to go to the
bathroom and again developed substernal chest pressure. The
pain was [**8-5**], did not radiate and was not associated with SOB,
lightheadedness, nausea, vomiting, or diaphoresis. He was
brought to an outside hospital where he continued to have chest
pain which completely resolved post- SL NTG x 2. He also
received asa 325 mg, NTG paste, lopressor 25 mg po, and 80 mg of
lovenox sc. He had an EKG performed which showed NSR @ 92,
inferior QWs, TW inversions in III, TW flattening in aVF, and
upsloping ST depressions in V4-6. A right sided EKG was
performed which showed no ST-TW changes in V4R. His TropI was
0.28, CK was 77, and CK-MB was 2.4 and he was transferred to
[**Hospital1 18**]. In the [**Hospital1 18**] ED, patient continued to be chest pain free.
His TnT here was 0.16, CK was 70, and MB was not done. He was
given a 300 mg plavix bolus and started on Heparin gtt. An EKG
here showed NSR @ 81, and the same ST-TW changes as the EKG from
the outside hospital. He was admitted for further evaluation and
treatment.
Past Medical History:
Hypertension, Peripheral Vascular Disease s/p Left FemPop
Bypass, History of Staph Wound Infection, Hypercholesterolemia,
Anemia, History of Urinary Retention
Social History:
Married. Lives with wife in [**Name (NI) 1475**]. He has a 28 year old
son. [**Name (NI) **] and his wife were planning to vacation in [**Name (NI) 108**] for
the winter in 2 weeks. No current tobacco. Quit 32 years ago.
>15 pk/yr history. Drinks ~5-6 beers/day. Had stopped drinking
for 2 months post-bypass w/o any signs of withdrawal. Started
drinking again ~1 month ago. Retired physical education
instructor.
Family History:
Unknown. Adopted.
Physical Exam:
Admission:
T: 98.8 BP: 138/76 HR: 81 RR: 18 O2 98% 2LNC
Gen: Pleasant, well appearing male in NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: RRR. nl S1, S2. [**2-1**] holosystolic murmur
LUNGS: CTAB, good BS BL, No W/R/C
ABD: NABS. Soft, NT. Moderately distended. No HSM
EXT: WWP, NO CCE. 2+ L femoral pulse. 1+ R femoral pulse. 1+ L
DP pulse. Nonpalpable R DP pulse.
SKIN: No rashes/lesions, ecchymoses. Large healed L inner thigh
scar.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Decreased
sensation in LLE below the knee. 5/5 strength throughout.
Discharge:
VS: T 99.6 HR 81SR BP 130/56 RR 18 O2Sat 100%RA
Gen: NAD
Neuro: A&Ox3, MAE, non-focal exam
Pulm: CTA-bilat
CV: RRR, no M/R/G. Sternum stable, incision CDI
Abdm: soft/NT/ND/NABS
Ext: warm, 1+ pedal edema bilat. Left EVH site w/minimal serous
drainage
Pertinent Results:
[**2117-9-18**] 07:00PM CK-MB-NotDone cTropnT-0.17*
[**2117-9-18**] 10:45AM GLUCOSE-106* UREA N-14 CREAT-0.9 SODIUM-137
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
[**2117-9-18**] 10:45AM WBC-8.5 RBC-4.29* HGB-12.7* HCT-36.1* MCV-84
MCH-29.7 MCHC-35.3* RDW-13.7
[**2117-9-18**] 10:45AM PLT COUNT-370
[**2117-9-18**] 10:45AM PT-12.3 PTT-32.7 INR(PT)-1.1
[**2117-9-29**] 10:20AM BLOOD WBC-13.5* RBC-3.08* Hgb-9.3* Hct-26.1*
MCV-85 MCH-30.2 MCHC-35.7* RDW-14.1 Plt Ct-757*
[**2117-9-29**] 10:20AM BLOOD Glucose-96 UreaN-13 Creat-1.1 Na-134
K-3.9 Cl-93* HCO3-33* AnGap-12
Cardiology Report ECHO Study Date of [**2117-9-21**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 45% (nl >=55%)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the
RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic
interatrial septum.
PFO is present.
LEFT VENTRICLE: Mildly depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
hypo; basal inferior - hypo; anterior apex - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Mildly dilated
ascending aorta.
Simple atheroma in ascending aorta. Normal aortic arch diameter.
Complex
(mobile) atheroma in the aortic arch. Normal descending aorta
diameter. There
are complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
See Conclusions for post-bypass
data
Conclusions:
PRE-BYPASS:
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.
A patent foramen ovale is present.
Overall left ventricular systolic function is mildly depressed.
Resting
regional wall motion abnormalities include mild to moderate
hypokinesis of the
mid and apical anterior wall and basal inferiior and
inferoseptal wall.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. There are simple atheroma
in the
ascending aorta. There are complex (mobile) atheroma in the
aortic arch and in
the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not
present. No aortic regurgitation is seen.
Trivial mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
The tip of the Intraaortic balloon pump is placed 2cm below the
left
subclavian artery in the descending thoracic aorta.
POST-BYPASS:
aortic contour is intact.
Normal right ventricular systolic function.
Overall left ventricular systolic function is 45-50% on no
inotropic support.
Valvular findings remain the same.
A mild improvement is seen in the overall systolic function of
the LV
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD on [**2117-9-22**]
16:35.
Brief Hospital Course:
Mr. [**Known lastname 29571**] remained pain free on intravenous Heparin and
medical therapy. The following day, he underwent cardiac
catheterization. Angiography revealed right dominant system with
a 60% lesion in the mid LAD, 90% proximal stenosis of the left
circumflex and a subtotal occlusion of the mid RCA. He
subsequently underwent successfull PTCA/Cypher stenting of the
proximal circumflex. Integrilin was initiated and Plavix was
continued. The next day, he returned to the cardiac cath lab for
RCA intervention. Unfortunately PCI resulted in distal
dissection with slow flow in the RCA. Attempts to cross and
dilate proximally failed to re-establish antegrade flow. The
procedure was aborted. He complained of mild chest pain and an
IABP was placed. Cardiac surgery was notified and he was
emergently brought to the operating room for surgical
revascularization. Dr. [**First Name (STitle) **] performed emergent three vessel
coronary artery bypass grafting. An atrial septal defect was
detected at time of operation and was subsequently closed. For
further surgical details, please see seperate dictated operative
note. Following the procedure, he was brought to the CSRU for
invasvive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated. He maintained good hemodynamics as the
IABP was weaned and removed. Beta blockade was resumed and he
transferred to the SDU on postoperative day one.
Medications on Admission:
lisinopril 20 mg po daily
crestor 40 mg po daily
tricor 145 mg po daily
flomax 0.4 mg po daily
asa 81 mg po daily
atenolol (started [**9-17**] but had not yet taken a dose)
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg QD x7 days then
200md QD.
Disp:*40 Tablet(s)* Refills:*0*
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease, Recent Myocardial Infarction, RCA
dissection at time of PCI s/p CABG s/p Cypher Stent to
circumflex, Atrial Septal Defect s/p closure, Hypertension,
Peripheral Vascular Disease s/p FemPop Bypass, History of Staph
Wound Infection, Hypercholesterolemia, Anemia, History of
Urinary Retention
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Cardiac surgeon, Dr. [**First Name (STitle) **] in [**3-31**] weeks.
Dr. [**Last Name (STitle) **] in [**1-29**] weeks.
Dr. [**Last Name (STitle) **] in [**1-29**] weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2117-9-29**]
|
[
"41071",
"9971",
"42731",
"41401",
"4019",
"2720"
] |
Admission Date: [**2123-3-26**] Discharge Date: [**2123-3-29**]
Date of Birth: [**2064-4-28**] Sex: M
Service: Coronary Care Unit
HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old man
with history of coronary artery disease status post inferior
myocardial infarction [**2113-4-28**] with stent to the right
coronary artery, angioplasty to the obtuse marginal in
[**Month (only) 359**] of '[**14**], stent to the right coronary artery in
[**2114-11-28**], angioplasty to the posterolateral branch of
the right coronary artery in [**2116-6-28**], who presented with
unstable angina x3 weeks to an outside hospital. Patient
states that he has been chest pain free for approximately
seven years prior to approximately three weeks ago when his
chest pain recurred.
Patient reports that the chest pain was his typical angina,
but mild compared to previous experiences and resolved with
1-2 nitroglycerin. these symptoms sometimes occurred at rest
over the past three weeks. His episodes have increased in
frequency over the past three weeks. Patient denies any
associated symptoms such as shortness of breath, nausea, or
vomiting.
On the evening of admission, the patient awoke from sleep
with 9/10 chest pain and diaphoresis, and took six sublingual
nitroglycerin as well as aspirin without resolution of chest
pain, so he called ambulance. Patient was brought to an
outside hospital, where ECG changes showed inferior ST
elevations and anterior ST depressions. Patient received
Heparin drip, Morphine, and nitroglycerin at the outside
hospital and became chest pain free. Patient also received
Retavase at the outside hospital.
Patient had been scheduled for elective cardiac
catheterization at [**Hospital1 **], therefore he was
transferred to [**Hospital1 **] [**First Name (Titles) **] [**2123-3-26**] the
same evening that he presented to the outside hospital. In
the ambulance upon transfer, patient had recurrent chest pain
and received a second dose of Retavase. The patient's
inferior ST changes had resolved by the time he arrived at
the Emergency Room at [**Hospital1 **] and he was
originally pain free. However, his pain recurred, and a
repeat electrocardiogram showed ST elevations approximately 1
mm in the inferior leads, st depression in V1 and V2 and 1 & avl
with t wave inversion in avl.The patient was therefore brought
from the Emergency Room to the Coronary Cath Laboratory.
At catheterization, the patient was found to have 80% mid
left circ stenosis as well as 90% lesion in the RCA between
two previous stents. The patient received two hepacoat stents to
his
right coronary artery with good flow afterwards. Patient was
then transferred to the Coronary Care Unit for further
management. Upon arrival at the Coronary Care Unit, the
patient denied any symptoms such as chest pain or shortness
of breath.
Review of systems was notable for skin lesions that the
patient states has been diagnosed as shingles.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
4. Cirrhosis secondary to alcohol use, which per the patient
has resolved.
5. Status post cholecystectomy.
SOCIAL HISTORY: Patient smokes [**9-7**] cigarettes per day.
Also drinks alcohol socially, but denies drug use.
FAMILY HISTORY: [**Name (NI) **] mother passed away from a
myocardial infarction in her 70s, and patient's father passed
away from a myocardial infarction in his 50s.
REVIEW OF SYSTEMS: Was otherwise noncontributory.
PHYSICAL EXAM ON ADMISSION: Middle-aged gentleman lying in
bed in no apparent distress with normal S1, S2, regular rate
and rhythm with no murmurs or extra heart sounds. Patient's
vital signs: Heart rate in the 70s, respiratory rate 18,
blood pressure 104/69, height 6'0", weight 218 pounds.
Remainder of the exam was within normal limits including good
pulses throughout, stable groin site, as well as clear lungs
and no jugular venous distention. Patient did have a ventral
hernia in his abdomen, which was reducible.
DIAGNOSTICS ON ADMISSION: Patient's ECG with normal sinus
rhythm with resolution of inferior-right precordial and lateral
ST changes upon
arrival to the CCU.
LABORATORY DATA: White blood cell count 11.6, hematocrit
stable at 42, platelets 256. The ck peaked in the 300's and the
troponin was positive. The BUN rose to 34 while the creatinine
remained normal, presumably after lasix and contrast induced
diuresis given earlier in his course.
CONCISE SUMMARY OF HOSPITAL COURSE: Patient is a 58-year-old
man with coronary artery disease status post multiple
catheterizations in the mid 90s, but without any symptoms and
medically stable for about seven years. Patient presented to
outside hospital with acute chest pain and found to have
inferior-right precordial and lateral ST changes. Patient is
status post
thrombolytics at the outside hospital, but with recurrence of
symptoms and underwent catheterization at [**Hospital1 18**].
1. Status post repeat cardiac catheterization with stent
placement and resolution of symptoms: Patient's ECG changes
normalized after coronary catheterization and the patient
remained asymptomatic throughout the remainder of his
hospital stay. Patient was continued on his daily aspirin of
325 mg. Patient was also started on Plavix 75 once a day.
Patient was maintained on his beta blocker of Toprol XL 50 mg
q.d. Patient had not been on a statin for approximately 1.5
years due to leg cramping, however, he was started on
pravastatin 20 mg once a day with planned close followup with
his primary care physician. [**Name10 (NameIs) **] is to followup with Dr.
[**Last Name (STitle) **] within two weeks of discharge from the hospital.
The patient was also continued on his Heparin drip, which he
was on upon transfer from the outside hospital, and this was
continued for 48 hours post catheterization. Patient was
also encouraged to quit smoking.
2. Pump: Patient had not an echocardiogram or left
ventriculogram for many years, and he therefore underwent a
repeat echocardiogram on [**3-26**], which revealed an
ejection fraction of 55-60% with normal wall motion and no
visualized valvular defects. However, this was a suboptimal
study.
3. Rhythm: Patient remained in normal sinus rhythm
throughout his hospital stay and is seen on telemetry.
4. Fluids, electrolytes, and nutrition: Patient was
maintained on a cardiac diet and his electrolytes especially
potassium and magnesium were repleted as needed.
5. Prophylaxis: Patient was on a Heparin drip throughout his
hospital stay and was eating well without history of
gastroesophageal reflux disease or peptic ulcer disease.
Patient was also ambulating well by the time of discharge.
6. Code status: Full.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Acute inferoposterior and lateral non-
transmural myocardial infarction.
DISCHARGE MEDICATIONS:
1. Aspirin 325 once a day.
2. Plavix 75 once a day.
3. Toprol XL 50 mg once a day.
4. Pravastatin was discontinued at discharge because of the
severe episode of leg weakness on Lipitor.
5. Nitroglycerine tabs
FOLLOW-UP INSTRUCTIONS: Patient is to followup with Dr.
[**Last Name (STitle) **] within two weeks of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Name8 (MD) 6906**]
MEDQUIST36
D: [**2123-3-28**] 23:01
T: [**2123-3-29**] 04:57
JOB#: [**Job Number 6907**]
|
[
"41401",
"V4582",
"412",
"3051",
"4019",
"2720"
] |
Admission Date: [**2187-12-5**] Discharge Date: [**2187-12-15**]
Date of Birth: [**2117-9-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional Angina
Major Surgical or Invasive Procedure:
[**2187-12-10**] - CABGx2 (Left internal mammary->Left anterior
descending, Saphenous vein graft->
[**2187-12-5**] - Cardiac Catheterization
History of Present Illness:
70 yo F with CAD s/p mulitple PCIs between [**2174**]-[**2184**] with eight
coronary stents, DM type I, HTN, HL and medullary sponge kidney
s/p RA who presents for cardiac catheterization for CABG
evaluation. She presented to her cardiologist, with recurrent
exertional angina and he reccomended cath. She states that for
the past 6 mo her chest discomfort has become more frequent and
severe. She states that she gets CP when she walks on an incline
or walks fast, substernal, radiating to arms bilateral,
sometimes to the jaw as well, relieved by rest and accompanied
by SOB, diaphoresis. She presented today for a diagnostic cath.
On cath she was found to have The LAD had a 90% proximal
in-stent restenosis and an 80% mid-vessel stenosis. The LCX had
a patent Ramus stent and no significant stenoses. The RCA had a
70% proximal stenosis and a 70% distal stenosis.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: Multiple PCIs at
[**Hospital 12017**] Hospital and [**Hospital3 17921**] Center in [**Location (un) 3844**]
between [**2174**] and [**2184**] with a total of 8 prior stents. Most
recent stent procedure was on [**2184-2-18**] at which time long
Taxus stents were placed in the LAD and a long Taxus stent was
placed in the RCA and the left renal artery was also stented.
OTHER:
Renal artery stent
Medullary sponge kidney without known sequelae
Endometriosis
Type I IDDM diagnosed at age 52
Hypertension
Hyperlipidemia
Benign breast lumpectomy
Tonsillectomy
Social History:
-Tobacco history:
-ETOH:
-Illicit drugs:
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T 97.8, BP 124/48, HR 68, RR 18, Sat 97% RA
GENERAL: Well appearing in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without JVP elevation.
CARDIAC: PMI not felt. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Cath site c/d/i, no
bruits or hematoma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ 2+ DP 2+ PT 2+
Left: Carotid 2+ 2+ DP 2+ PT 2+
Pertinent Results:
[**2187-12-5**] Cardiac Catheterization
1. Selective coronary angiography of this right-dominant system
demonstrated two-vessel coronary artery disease. The LMCA had
no
significant stenoses. The LAD had a 90% proximal in-stent
restenosis
and an 80% mid-vessel stenosis. The LCX had a patent Ramus
stent and no
significant stenoses. The RCA had a 70% proximal stenosis and a
70%
distal stenosis.
2. Limited resting hemodynamics demonstrated mildly elevated
left
ventricular filling pressures with an LVEDP of 21 mmHg. There
was no
gradient seen on left-heart pullback. Systemic arterial
hypertension was
noted with a central aortic pressure of 165/61 mmHg.
3. Left ventriculography revealed normal global and regional
systolic
function and no significant mitral regurgitation.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Left ventricular diastolic dysfunction.
3. Systemic arterial hypertension.
[**2187-12-10**] ECHO
PRE BYPASS 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 thickness,
cavity size, and global systolic function are normal (LVEF>55%).
The right ventricular cavity is mildly dilated with normal free
wall contractility. There are simple atheroma in the ascending
aorta. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS Normal biventricular systolic function. Thoracic
aorta is intact. No significant change from pre-bypass study.
[**2187-12-6**] carotid USThere is less than 40% stenosis within the
internal carotid arteries bilaterally.
Preop
[**2187-12-5**] 09:40AM PT-12.6 PTT-31.6 INR(PT)-1.1
[**2187-12-5**] 09:40AM PLT COUNT-273
[**2187-12-5**] 09:40AM WBC-6.9 RBC-3.84* HGB-10.9* HCT-32.6* MCV-85
MCH-28.4 MCHC-33.4 RDW-14.3
[**2187-12-5**] 09:40AM %HbA1c-8.0*
[**2187-12-5**] 09:40AM ALBUMIN-3.9
[**2187-12-5**] 09:40AM ALT(SGPT)-12 AST(SGOT)-13 ALK PHOS-47 TOT
BILI-0.3
[**2187-12-5**] 09:40AM GLUCOSE-145* UREA N-17 CREAT-0.9 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-24 ANION GAP-13
post-op
[**2187-12-14**] 09:00AM BLOOD WBC-10.1 RBC-3.87* Hgb-11.2* Hct-32.7*
MCV-85 MCH-29.0 MCHC-34.3 RDW-14.7 Plt Ct-290
[**2187-12-14**] 09:00AM BLOOD Plt Ct-290
[**2187-12-10**] 03:22PM BLOOD PT-13.5* PTT-41.1* INR(PT)-1.2*
[**2187-12-14**] 09:00AM BLOOD Glucose-188* UreaN-12 Creat-1.0 Na-137
K-4.8 Cl-97 HCO3-33* AnGap-12
[**2187-12-13**] 05:35AM BLOOD ALT-31 AST-26 LD(LDH)-218 AlkPhos-51
Amylase-15 TotBili-0.5
Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-12-12**] 3:57
PM
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman with small ap. PTX post CT pull
Final Report
HISTORY: Chest tube removal, to evaluate for pneumothorax.
FINDINGS: In comparison with the study of [**12-11**], the chest tube
has been
removed and there is no evidence of pneumothorax. There has also
been removal of the right central catheter.
Bibasilar atelectatic change persists. Small pleural effusions
are again
noted.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: WED [**2187-12-12**] 9:44 PM
Imaging Lab
Brief Hospital Course:
Mrs. [**Known lastname 6160**] was admitted to the [**Hospital1 18**] on [**2187-12-5**] for a
cardiac catheterization given the progression of her chest pain.
This revealed severe two vessel disease with patent stents in
her left circumflex system. Given the severity of her disease,
the cardiac surgical service was consulted. She was worked-up in
the usual preoperative manner including a carotid duplex
ultrasound which revealed a less than 40% stenosis within the
internal carotid arteries bilaterally. As she had been on
plavix, her surgery was delayed several days to allow the
medication to clear. On [**2187-12-10**], Mrs. [**Known lastname 6160**] was taken to th
eoperating room where she underwent coronary artery bypass
grafting to two vessels. Please see operative note for details.
In summary she had coronary bypass graft with left internal
mamary to left anterior descending artery and reverse saphenous
vein graft to right coronary artery. Her bypass time was 48
minutes with a crossclamp time of 38 minutes. She tolerated the
operation well and was transferred from the operating room to
the cardiac surgery ICU in stable condition. In the immediate
post operative period she was hemodynamically stable, she woke
neurologically intact, was weaned from the ventilator and
extubated. On POD1 she was transferred to the stepdown floor for
continued care and recovery from surgery. Beta blockade, aspirin
and a statin were resumed. Plavix was reastarted given her
multiple circumflex system stents. [**Hospital **] clinic was consulted
for assistance with her diabetes control.
The remainder of her post operative course was uneventful and on
POD 5 she was discharged home with visiting nurses.
Medications on Admission:
Plavix 75mg po daily
Lantus 12 units q HS
Humalog Pen Sliding Scale 3x/day
NPH 4 units q am
Lisinopril 10mg po daily
Ranexa 500mg po daily (prescribed for [**Hospital1 **], but pt only takes
once
daily d/t hair loss side effect)
Crestor 20mg po daily
ASA 81 mg po daily
Centrum Silver 1 tab po daily
Omeprazole 20mg po BID
SL Nitro PRN
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): 20mg [**Hospital1 **] x10 days then
20mg QD x10 days.
Disp:*30 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO twice a day: 20 mEq [**Hospital1 **] x10 days
then
20 mEQ QD x10 days.
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: resume preop
schedule.
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous QHS.
11. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Four
(4) units Subcutaneous QAM.
12. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous three times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 15739**] District Visiting Nurse Assoc.
Discharge Diagnosis:
CAD s/p CABGx2 (LIMA-LAD, SVG-RCA)
Hypertension
Hyperlipidemia
CAD s/p multiple(8)PCIs from [**2174**]-[**2184**]
Renal artery stent
Type I DM diagnosed age 52
Medullary sponge kidney without known sequelae x40 yrs
Endometriosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Wound: healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) **] on [**First Name9 (NamePattern2) 5929**] [**1-10**] @1:15PM [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) 70843**] in [**1-5**] weeks call to schedule
appointments
Cardiologist Dr. [**Last Name (STitle) **] in [**1-5**] weeks call to schedule
appointments
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2187-12-15**]
|
[
"41401",
"4019",
"V1582",
"V5867",
"2724"
] |
Admission Date: [**2179-1-1**] Discharge Date: [**2179-1-12**]
Date of Birth: [**2114-5-15**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
unresponsive episode
Major Surgical or Invasive Procedure:
Bronchial Lavage
FNA of lung nodule
TEE
History of Present Illness:
[**Known firstname **] [**Known lastname 90431**] is a 64-year-old man with past medical
history notable for atrial fibrillation, prior occipital stroke,
and diabetes who presents after being found down outside of his
car. The patient himself has poor recollection of the events
surrounding his admission. He does remember driving He pulled
his car over and got out of his car, he was then found down
approximately 300 feet from his car down the road. He was noted
to be face down, confused and with a right frontal hematoma.
He does note problems with his memory over the last few weeks.
He sites
being unable to remember appointments and dates. His girlfriend
who was interviewed prior also noticed that the patient was
having difficulty with memory.
Past Medical History:
Atrial fibrillation
R occipital stroke
DM
Social History:
Patient smokes 2 cigars a week, 1 to 2 glasses of wine on
occasion. Retired computer programmer
Family History:
Maternal side: alzheimers disease
Physical Exam:
Admission Physical Examination:
Gen:patient sitting in bed, bandage above right eye, awake,
alert
HEENT: R sided hematoma over right eye,MMM,no nuchal rigidity
CV:NL S1/S2, RRR
Lungs:CTA B/L, no crackles,
Abd:soft , non tender, normal bowel sounds.
Ext:FROM, + 2 pulses through out
Skin:dark skin tag noted on upper left chest.
Neuro:
MS: oriented to name, [**1-1**] or 5th, [**2179**], [**Hospital 90432**]
Hospital, Unsure of which one, DOW backward completed in 25 s,
[**Doctor Last Name 1841**] Backwards([**Month (only) **],[**Month (only) 1096**]),
3 objects:(ball, [**Location (un) **], honesty), able to repeat the words,
remembers [**11-30**] with multiple choice at 3 minutes, 0/3 at five
minutes. Calculation intact. Repetition intact.
Names fingers, thumb, thumb nail, for feather says [**Location (un) **],
no paraphrasic errors, speech is fluent with normal prosody. He
has trouble with Luria motor sequencing bilaterally
CN:left upper temporal field cut on gross visual field
testing,EOMI,PERRLA(4mm to 2mm bilaterally), no facial
assymetry,
no ptosis, hearing intact, palate elevates symmetrically, tongue
is midline with FROM,
Motor:
No pronator Drift, no asterixis, No grasp.
Delt [**Hospital1 **] Tri FE WE WF IP Quad HS TA GC
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensory: decreased proprioception and vibration of toes
bilaterally,
Cb:No dysmetria or ataxia on finger to nose.
Gait: Unstaedy at times. Not ataxic or wide based.Negative
Romberg.
DTR: +2 at the biseps, triceps, brachioradialis, patella, +1 at
ankles, toes appear to be up going by TFL.
Pertinent Results:
[**2179-1-1**] 09:25PM WBC-5.7 RBC-4.53* HGB-14.3 HCT-40.2 MCV-89
MCH-31.6 MCHC-35.6* RDW-13.1
[**2179-1-1**] 09:25PM PLT COUNT-284
[**2179-1-1**] 09:25PM PT-24.6* PTT-23.6 INR(PT)-2.4*
[**2179-1-1**] 09:25PM FIBRINOGE-481*
[**2179-1-1**] 09:36PM GLUCOSE-336* LACTATE-2.8* NA+-137 K+-4.3
CL--96* TCO2-25
[**2179-1-1**] 09:25PM CALCIUM-9.9 PHOSPHATE-2.8 MAGNESIUM-2.0
[**2179-1-1**] 09:25PM UREA N-15 CREAT-1.2
[**2179-1-1**] 09:25PM cTropnT-<0.01
[**2179-1-1**] 09:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Studies:
CT head ([**2179-1-1**]): Hypodensity in the right basal ganglia and
right frontal lobe of unclear etiology and could represent
subacute/acute infarction or possible underlying mass
CT torso: No acute traumatic findings, Multiple pulmonary
nodules measuring up to 1.2 cm (superior segment RLL), Remote
splenic infarct
CT C-spine: No acute fracture or malalignment
CTA: Unchanged edema within the right frontal white matter with
MR suspicious for resolving underlying hematoma. There is no
evidence of aneurysm, AVM, or other vascular cause; Probable 7mm
pseudoaneurysm arising from the distal right superficial
temporal artery with adjacent subcutaneous soft tissue injury;
Chronic right occipital infarct.
MR head ([**2179-1-2**]): Right basal ganglia signal abnormality with
blood products and irregular enhancement could be due to a
subacute infarct with enhancement or less likely due to an
enhancing primary neoplasm. Given the appearances are more
suggestive of a subacute infarct, a followup study should be
obtained; Moderate ventriculomegaly out of proportion for sulci
indicates normal pressure hydrocephalus in proper clinical
setting; Right frontal scalp hematoma with a small 1-cm area of
gadolinium enhancement could be due to active extravasation at
the time of imaging.
EEG: normal EEG in the waking and sleeping states. Note is made
of a poorly organized background rhythm which is a normal
variant. There were no epileptiform discharges or electrographic
seizures.
MR head (with ASL and MR Spec): process in the right basal
ganglia most likely represents a slightly atypical appearance of
evolving non- and hemorrhagic contusion related to the patient's
trauma (with overlying subgaleal hematoma); Subacute infarct
with subsequent hemorrhagic conversion (serendipitously
subjacent to the site of scalp trauma) seems less likely; No
increased perfusion or spectroscopic abnormality to specifically
suggest underlying neoplasm.
Bronchial Lavage: Negative for malignant cells
FNA (lung nodule): atypical
TTE: The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Right ventricular chamber size and free wall
motion are normal. There are focal calcifications in the aortic
arch. The number of aortic valve leaflets cannot be determined.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
TEE: Small mobile echodensity on the aortic valve as described
above c/w Lambl's or vegetation. Mild aortic regurgitation.
Interatrial septal aneurysm with possible patent foramen ovale
Brief Hospital Course:
Mr. [**Known lastname 90431**] is a 64 year old with recurrent AFib (converted)
on coumadin and
diabetes found 300 feet from his car (driving alone), on
theground confused, with right frontal subgaleal hematoma
Basal Ganglia Lesion: Initial MR imaging showed right basal
ganglia signal abnormality with blood products. It was unclear
if this was due to atypical hematoma, underlying mass that bled,
underlying AVM that bled or stroke with hemorrhagic conversion.
A CTA was obtained to see if any vascular abnormalities could be
identified; no evidence of aneurysm, AVM, or other vascular
cause was identified. Given the possibility of an underlying
mass, CT torso was evaluated and a derm consult was obtained to
look for any possible primary tumors. No evidence of skin lesion
concerning for melanoma as per Derm, but there was pulmonary
nodules (largest of which is 1.2 cm) identified. At the request
of Neuro-oncology, MRI was repeated with ASL and Spectroscopy.
Based on these sequences, there was low suspicion of underlying
neoplasm and the final report noted that the process in the
right basal ganglia most likely represents a slightly atypical
appearance of evolving non- and hemorrhagic contusion. While
this is possible, it would not explain why he became
unresponsive, resulting in the trauma. Images reviewed with
stroke attending and there was concern that there might have
been an underlying AVM or cavernoma that resulted in the bleed,
which was subacute, and which resulted in a seizure. A subacute
bleed would also explain the findings noted by his girlfried
that he had been having increased confusion and falls in the 2
[**Last Name (un) 90433**] prior to admission. A routine EEG was obtained; this was
normal. However, given the concern for seizure activity
resulting in his unresponsive episode, he was started on Keppra;
his current dose is 1000 mg [**Hospital1 **]. The plan is for him to have a
repeat MRI 6 weeks from the initial MRI and than follow-up with
Dr. [**First Name (STitle) **]. If there is any evidence of unerlying mass on the
repeat MRI, he will follow-up with Dr. [**Last Name (STitle) 724**] in the
[**Hospital **] clinic.
Lambl's Excursions: Given his history of stroke and the
possibility that his right basal ganglia lesion was due to
hemorrhagic conversion of a stroke, an ECHO was performed to
evaluate for clot. The TTE showed an elongated left atrium but
was otherwise normal. A TEE was then performed, which showed
small mobile echodensity on the aortic valve as described above
c/w Lambl's or vegetation. No evidence of any infection and
blood cultures have been taken and have remained sterile, so
unlikely vegetation. A Lambl's excursion can produce clots,
resulting in strokes. Of note, he was also on Coumadin in the
past for a.fib, but this was held on admission due to his bleed.
Currently, it is beleived that the risk of restarting Coumadin
given the basal ganglia hemorrhagic contusion/hemorrhage
outweighs the benefit of starting it for stroke prevention.
However, given his history of a. fib, right basal gnaglia
stroke, and now the finding of the echodensity on aortic valve,
he will likely need to be restarted on Coumadin in future,
particularly after repeat MRI if blood products resolved and no
evidence of underlying mass. At this time, he was started on ASA
325 mg for stroke prevention and will be continued on this until
it is safe to restart him on Coumadin.
Pulm Nodule: On CT torso, pulmonary nodules were found, largest
one being 1.2 cm. He had a bronchial lavage and FNA of the
nodule. The bronchial lavage was negative for malignant cells.
The FNA was atypical but nondiagnostic. He will follow-up with
Dr. [**Last Name (STitle) **] and have a PET scan for evaluation of this nodule in 4
weeks.
Diabetes: He has history of diabetes and was on Humalog and
Lantus at home. During hospitalization, he remained on sliding
scale insulin. His FSGs on day of discharge were in upper 100s
and low 200s. He was NPO multiple days for studies/procedures so
Lantus and Humalog were not restarted, but when he returns to
his usual regimen in rehab/as outpatient, restarting his home
diabetic regimen should be considered.
UTI: He was found to have UTI and was started on a 10 day course
of Bactrim. He will complete this course at rehab.
Medications on Admission:
Humalog 20 Units
Lantus 40 Units
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
4. Insulin
Please follow sliding scale insulin as provided.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
R basal ganglia bleed -ruptured AVM vs. hematoma vs. hemorrhagic
conversion of stroke vs. underlying mass
Likely seizure
pulmonary nodule
Lambl's Excrecence
DM
old R occipital stroke
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 came to the hospital after being found unresponsive by
your car. You were initially admitted to the trauma ICU, but
there was no evidence of any traumatic injuries found on
imaging, so you were transferred to the neurology service. MRI
of your head showed blood in the part of your brain called the
basal ganglia; it is unclear if this blood is from a traumatic
injury, from an underlying stroke or mass or from a rupted
arterial malformation. You underwent further brain imaging to
help clarify, and while definitive results are limited by the
blood that is present, it does not appear that there is an
underlying mass.
During the work-up for the brain imaging abnormality, you had
a CT scan of your torso, which showed some pulmonary nodules.
You underwent a procedure called bronchial lavage and fine
needle aspiration of the nodule to see if the nodule was
malignant. The FNA results were inconclusive, so the pulmonary
service would like to see in 4 weeks with a PET scan to
follow-up on this.
Given the bleeding found in your head, it is likely that you
had a seizure and this resulted in your unresponsive episode;
you were started on an antiseizure medication called Keppra.
Given your history of stroke and the possibility that this was
a stroke with hemorrhagic conversion, you had imaging of your
heart to see if there were any clots. The TTE showed enlargement
of the left atrium, so a more invasive procedure called
transesophageal echo was performed. This showed likely Lambel's
Excrecence on your aortic valve; this has a low likelihood of
sending clots, resulting in strokes. Given your bleed, we
believe the risks of anticoagulation with Coumadin outweigh the
benefits at this time, so we have started you on Aspirin 325 mg.
After your repeat MRI, we may consider starting Coumadin again
for stroke prevention.
With your likely seizure, as per Massachussets law, you are
not allowed to drive for 6 months.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **] (pulmonary), MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2179-2-23**] 8:30
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2179-2-23**] 9:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**] (neurology), MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2179-3-1**] 2:30
You will be contact[**Name (NI) **] regarding PET scan, which pulmonary is
requesting prior to follow-up with them.
An MRI has been ordered for you for [**2179-2-15**] (please do not get
earlier than this date as it needs to be 6 weeks from initial
MRI to make sure blood products have cleared). It is important
to get this MRI completed prior to seeing Dr. [**First Name (STitle) **].
Completed by:[**2179-1-12**]
|
[
"5990",
"4241",
"42731",
"25000",
"3051",
"V5867",
"V5861"
] |
Admission Date: [**2129-5-9**] Discharge Date: [**2129-5-16**]
Date of Birth: [**2081-12-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer after V-fib arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
47 year old male with history of Stage II Melanoma (disease free
x 6 years) presented to PCP's office with fevers and sustained a
vfib arrest. He has been having fevers and rigors for the past
week. He saw PCP three days ago who could not find an
infectious source. He was given cipro emperically since he has
h/o cellulitis of his right axilla where his bx site was in the
past. He did not feel better and today went back to his PCP for
follow up. His PCP was going to admit him to [**Hospital1 **] for w/u of
fevers and then he had a vfib arrest. He was intubated and
resuscitated. EKG showed ST elevations inferiorly. Then
transferred to [**Hospital1 18**] for catheterization.
Catheterization showed RCA massive thrombus s/p angiojet and
BMS. Then he is admitted to CCU for further care.
ROS: Per wife, no weight loss, chronic fevers, chest pain,
shortness of breath, abd pain, n/v/d. No orthopnea, PND,
claudications, peripheral edema.
Past Medical History:
Stage IIIA melanoma, chest wall, s/p chemo, disease free x 6
years
Cellulitis
Cardiac History:
CABG: none
Percutaneous coronary intervention: none
Pacemaker/ICD placed: none
Social History:
He has smoked [**1-12**] pack of cigarettes per day for 10-15 years,
last approximately two months ago. He drinks approximately
three beers per week. He is married. He works for an
investment company as a portfolio manager.
Family History:
His mother died of lung cancer, his father died of head and neck
cancer. He has five siblings who are alive and well
Physical Exam:
VITALS: 97.7, 140/90, 115, 14, 100% on PS 670x17
GEN: intubated and sedated
HEENT: intubated
NECK: No JVD
CV: RRR, no M/G/R
PULM: CTAB, no W/R/R
ABD: Soft, NT, ND, +BS
EXT: No peripheral edema
PULSES: 2+ DP/PT pulses
Pertinent Results:
[**2129-5-9**] 02:15PM BLOOD WBC-8.7# RBC-4.24* Hgb-13.9* Hct-37.5*
MCV-88# MCH-32.7* MCHC-37.0* RDW-13.0 Plt Ct-144*
[**2129-5-10**] 06:01AM BLOOD WBC-6.4 RBC-3.52* Hgb-11.3* Hct-31.0*
MCV-88 MCH-32.2* MCHC-36.5* RDW-13.3 Plt Ct-172
[**2129-5-14**] 07:07AM BLOOD WBC-6.7 RBC-3.28* Hgb-10.3* Hct-30.1*
MCV-92 MCH-31.4 MCHC-34.2 RDW-13.1 Plt Ct-404
[**2129-5-15**] 06:15AM BLOOD WBC-7.7 RBC-3.31* Hgb-10.6* Hct-29.9*
MCV-90 MCH-31.9 MCHC-35.3* RDW-12.8 Plt Ct-517*
[**2129-5-15**] 06:15AM BLOOD PT-12.8 PTT-25.7 INR(PT)-1.1
[**2129-5-9**] 02:15PM BLOOD Glucose-263* UreaN-19 Creat-1.0 Na-133
K-3.4 Cl-94* HCO3-27 AnGap-15
[**2129-5-15**] 06:15AM BLOOD Glucose-108* UreaN-12 Creat-0.9 Na-142
K-4.1 Cl-104 HCO3-28 AnGap-14
[**2129-5-9**] 11:25PM BLOOD CK(CPK)-2040*
[**2129-5-10**] 06:01AM BLOOD CK(CPK)-2262*
[**2129-5-10**] 02:54PM BLOOD CK(CPK)-1511*
[**2129-5-11**] 05:15AM BLOOD CK(CPK)-700*
[**2129-5-9**] 11:25PM BLOOD CK-MB-206* MB Indx-10.1*
[**2129-5-10**] 06:01AM BLOOD CK-MB-197* MB Indx-8.7* cTropnT-2.13*
[**2129-5-10**] 02:54PM BLOOD CK-MB-101* MB Indx-6.7*
[**2129-5-11**] 05:15AM BLOOD CK-MB-29* MB Indx-4.1 cTropnT-2.07*
[**2129-5-15**] 06:15AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2 Cholest-74
[**2129-5-9**] 02:15PM BLOOD VitB12-357
[**2129-5-9**] 02:15PM BLOOD %HbA1c-5.4
[**2129-5-15**] 06:15AM BLOOD Triglyc-125 HDL-26 CHOL/HD-2.8 LDLcalc-23
[**2129-5-11**] 05:15AM BLOOD TSH-1.1
[**2129-5-9**] 02:23PM BLOOD Type-ART pO2-39* pCO2-72* pH-7.23*
calTCO2-32* Base XS-0 Intubat-INTUBATED
[**2129-5-9**] 03:07PM BLOOD Type-ART Rates-16/ Tidal V-550 pO2-57*
pCO2-62* pH-7.27* calTCO2-30 Base XS-0 -ASSIST/CON
Intubat-INTUBATED
EKG:
OSH EKG: Sinus tach at 120 BPM, NA, [**Last Name (LF) **], [**First Name3 (LF) **] elevations 2mm in II,
III, F with ST depression 2mm in AVL
2D-ECHOCARDIOGRAM: none
ETT: none
CARDIAC CATH:
RCA massive thrmobus s/p angiojet and BMS
No LAD/LM/Lcx dz.
[**2129-5-9**] 2:15 pm BLOOD CULTURE
**FINAL REPORT [**2129-5-12**]**
Blood Culture, Routine (Final [**2129-5-12**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.
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. VANCOMYCIN Sensitivity testing performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 2 S
[**2129-5-9**] 5:27 pm BLOOD CULTURE Source: Line-aline1.
**FINAL REPORT [**2129-5-15**]**
Blood Culture, Routine (Final [**2129-5-15**]):
PRESUMPTIVE VEILLONELLA SPECIES. ISOLATED FROM ONE SET
ONLY.
Anaerobic Bottle Gram Stain (Final [**2129-5-13**]):
GRAM NEGATIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1507**] AT 14:00PM ON [**2129-5-13**]
- FA3
Brief Hospital Course:
This is a 47 year old caucasian male with history of melanoma of
his chest wall presented to OSH with fevers and had ventricular
fibrillation cardiac arrest from Acute Myocardial Infarction.
Cardiac catheterization done here showed a filling defect in the
Right Coronary Artery, now status post Bare Metal Stent. Blood
cultures are now growing Methicillin Sensitive Staphylococcus
Aureus and Veilonella species. A Transesophageal Echocardiogram
was done for presumed endocarditis, which showed a possible
vegetation on the aortic valve. Hospital course by problem:
# Polymicrobial Bacteremia/Endocarditis - Mr. [**Known lastname 4698**] came into
the hospital status post cardiac arrest. He had a one week
history of fevers/malaise prior to his admission. Blood
cultures were drawn by his PCP at [**Hospital3 4107**] which began
speciating Gram + cocci the day after his admission. He has
been placed on Nafcillin and Gentamicin for Methicillin
sensitive Staphylococcus Aureus. Gram stain from [**5-9**] anaerobic
bottle is also growing Veilonella species which is an oral
pathogen. ID has been consulted and recommended Flagyl 500mg PO
x 10 days for treatment of Veilonella as this was thought to
represent a transient bacteremia which likely ocurred after
intubation. The Endocarditis is thought to be due to the MSSA
and will be treated with Nafcillin 2mg IV q4h for 6 weeks. He
has completed a 7 day course of Gentamicin IV while in the
hospital. He will follow up with Infectious Disease as an
outpatient. Surveillance labs will be drawn as an outpatient
and faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
# Tachycardia - Mr. [**Known lastname 4698**] was initially tachycardic on
admission. This was thought to be secondary to his bacteremia.
He was started on Metoprolol which was titrated to a normal
heart rate. He is to continue on Toprol XL 300mg daily.
# STEMI: Mr. [**Known lastname 4698**] suffered from a STEMI due to an RCA
thrombus and is now s/p BMS. A TEE was done which showed a
possible vegetation vs Lambl's excrescence on the Aortic Valve.
This most likely represents a vegetation as it was located on
the right coronary cusp which correlates with the RCA thrombus
seen on c.cath.
He was started on Aspirin 325mg daily, Plavix 75mg daily,
Atorvastatin 10mg daily, bblocker, and Lisinopril 2.5mg daily.
# Valves: No history of valvular disease. TEE done as above
which showed a possible Vegetation on the aortic valve;
consistent with endocarditis.
# Ventricular fibrillation cardiac arrest: Mr. [**Known lastname 4698**]
presented to [**Hospital1 18**] status post cardiac arrest. This was likely
in the setting of his acute STEMI. There is no need for ICD at
this time.
# Pump: LVEF 40-50%. No history of Congestive Heart Failure.
He was euvolemic on discharge
# Rhythm: Sinus rhythm while in the hospital
Medications on Admission:
Ciprofloxacin
Discharge Medications:
1. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H (every 4 hours) for 6 weeks: Last day [**2129-6-23**].
Disp:*360 gms* Refills:*1*
2. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
3. PICC Line
PICC line care per protocol
4. 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*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed.
Disp:*20 Tablet(s)* Refills:*0*
9. 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*
10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 7 days: Last day [**5-23**].
Disp:*21 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
Please obtain weekly lab work starting [**2129-5-23**] and ending
[**2129-6-23**]. Please have these labs drawn: CBC with differential,
Chem 7, AST, ALT, Total bili, Alk Phos. Results should be faxed
to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD at [**Telephone/Fax (1) 432**].
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home therapy
Discharge Diagnosis:
STEMI s/p BMS to RCA
MSSA and Veilonella Bacteremia
Endocarditis
Cardiac Arrest
Discharge Condition:
Stable
Discharge Instructions:
You were admitted into the hospital for evaluation of your
cardiac arrest. You had a cardiac catheterization which showed
an obstruction of your right coronary artery. A Bare Metal
Stent was placed successfully to correct this obstruction. The
obstruction is thought to be due to a septic emboli which was
due to the infection in your blood. This infection was also
found on your Aortic Valve which is one of your heart's valves.
You have been treated for your infection with Intravenous
Antibiotics. You are to continue on Nafcillin 2gm IV every 4
hours for 6 weeks. Flagyl 500mg every 8 hours for 7 days.
You suffered a heart attack from the obstruction in your
coronary artery. You have been placed on several new cardiac
medications. You are to continue on Aspirin 325mg daily, Plavix
75mg daily, Toprol XL 300mg daily and Atorvastatin 10mg daily.
If you experience worsening chest pain, shortness of breath,
fevers, chills, nausea, vomiting, palpitations or any other
concerning symptoms then please call your doctor or report to
the nearest emergency room.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18323**] MD, Phone: [**Telephone/Fax (1) 18325**]
Date/Time: [**2129-5-24**] at 10:15am.
Please follow up with your new cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
Phone: ([**Telephone/Fax (1) 5862**]. Date/Time: [**2129-6-17**], 2:40pm
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2129-5-30**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2129-6-20**]
10:00
|
[
"41401"
] |
Admission Date: [**2178-8-5**] Discharge Date: [**2178-8-12**]
Service: MICU-ORANG
HISTORY OF PRESENT ILLNESS: An 85-year-old female with a
history of
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 14605**]
MEDQUIST36
D: [**2178-8-12**] 16:06
T: [**2178-8-12**] 17:44
JOB#: [**Job Number 34998**]
|
[
"42731",
"2762",
"4240",
"4280",
"5119"
] |
Admission Date: [**2117-5-22**] Discharge Date: [**2117-5-26**]
Date of Birth: [**2096-9-27**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9855**]
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
[**2117-5-22**]: ORIF Right femur fracture
History of Present Illness:
Mr. [**Known lastname **] was involved in a motorvehicle crash. He was taken
to the [**Hospital1 18**] for further evaluation of his injuries.
Past Medical History:
denies
Social History:
n/a
Family History:
n/a
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Obease, soft non/distended
Extremities: RLE + pulses, sensation movement, + deformity +
pain
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2117-5-22**] after being
involved in a motorvehicle crash. He was evaluated by the
orthopaedic and trauma services. He was found to have a right
femur fracture. He was admitted to the trauma service, his
spine was cleared. Later that day he was prepped, consented,
and taken to the operating room. He tolerated the procedure
well, was extubated, and transferred to the recovery room. In
the recovery room he remained hemodynamically stable with his
pain controlled. He was then transferred to the floor for
further care. On the floor he was given two 500cc Normal Saline
boluses for fluid volume deficit after surgery due to
tachycardia. He also had oxygen saturation readings of 86-90%.
Medicine was consulted and on [**2117-5-23**] he was admitted to the
trauma intensive care unit under the care of trauma surgery. He
underwent a CTA which was negative for pulmonary embolism. His
oxygen saturations increased with aggressive pulmonary hygiene
and maintance fluid. On [**2117-5-24**] he was stable and able to be
transferred out of the intensive care unit. His care was then
transferred to the orthopaedic service. He was seen by physical
therapy to improve his strength and mobility.
The rest of his hospital stay was uneventful with his lab data
and vital signs within normal limits and his pain controlled.
He is being discharged today in stable condition.
Medications on Admission:
denies
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours) for 4 weeks.
Disp:*56 injection* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation.
Disp:*45 Capsule(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain: wean as you can tolerate.
Disp:*80 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
5. Outpatient Physical Therapy
WBAT RLE
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
Right femur fracture
Fluid volume deficit
Discharge Condition:
Stable
Discharge Instructions:
Continue to be weight bearing as tolerated on your right leg
Continue to take your lovenox injections as instructed
If you notice any increased redness, drainage, or swelling, or
if you have a temperature greater than 101.5 please call the
office or come to the emergency department.
If you become suddenly short of breath or if you develop any
calf pain call 911 or go directly to the emergency department.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Treatments Frequency:
Staples can come out 14 days after surgery or at your follow up
appointment
You may apply a dry sterile dressing daily or as needed for
drainage or comfort
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 2719**] in 2 weeks, please call
[**Telephone/Fax (1) 1228**] to schedule that appointment
|
[
"42789"
] |
Admission Date: [**2124-1-26**] Discharge Date: [**2124-1-30**]
Date of Birth: [**2064-7-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2124-1-26**] Coronary artery bypass grafting x 3 - left internal
mammary artery to the left anterior descending coronary
artery; reversed saphenous vein single graft from the
aorta to the first diagonal coronary artery; reversed
saphenous vein single graft from the aorta to the ramus
intermedius coronary artery.
Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
59 yo male with no prior cardiac history admitted [**11-28**] with
progressive shortness of breath. BNP was elevated and he was
treated for acute systolic heart failure. Echocardiogram showed
moderate mitral regurgitation and left ventricular ejection
fraction 15%. Cardiac catherization revealed coronary artery
disease and he was referred for surgical revasulcarization.
Past Medical History:
Ischemic Cardiomyopathy/Chronic Systolic Heart Failure
Coronary Artery Disease
Prior Myocardial Infarction
Dyslipidemia
Hypertension
Social History:
Works for building products company
Lives alone but has support systems
Denies tobacco
Rare ETOH
Family History:
Mother with myocardial infarction in her 70's
Physical Exam:
BP 94/60, P 64, RR 14
Wt 187 lbs
Ht 73 inches
General: Well developed male in no acute distress
Skin: Unremarkable
HEENT: Oropharynx benign, sclera anicteric
Neck: Supple, no JVD
Chest: Lungs clear bilaterally
Heart: Regular rate and rhythm, normal s1s2, +s3, faint
holosystolic murmur
Abdomen: benign
Ext: warm, no edema
Neuro: Non-focal
Pulses: 2+ distallly, no carotid or femoral bruits
Pertinent Results:
[**2124-1-29**] 07:35AM BLOOD WBC-8.3 RBC-3.05* Hgb-9.1* Hct-25.2*
MCV-83 MCH-29.7 MCHC-35.9* RDW-13.4 Plt Ct-144*
[**2124-1-26**] 01:30PM BLOOD WBC-19.6*# RBC-3.38*# Hgb-10.0*#
Hct-28.1*# MCV-82.9 MCH-29.7 MCHC-35.8* RDW-13.2 Plt Ct-179
[**2124-1-29**] 07:35AM BLOOD Plt Ct-144*
[**2124-1-26**] 02:39PM BLOOD PT-15.5* PTT-30.9 INR(PT)-1.4*
[**2124-1-26**] 01:30PM BLOOD PT-14.9* PTT-25.2 INR(PT)-1.3*
[**2124-1-26**] 01:30PM BLOOD Plt Ct-179
[**2124-1-29**] 07:35AM BLOOD Glucose-102 UreaN-12 Creat-0.9 Na-137
K-3.5 Cl-97 HCO3-33* AnGap-11
[**2124-1-26**] 02:39PM BLOOD UreaN-15 Creat-0.9 Cl-109* HCO3-26
[**2124-1-29**] 07:35AM BLOOD Mg-2.1
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81843**]
(Complete) Done [**2124-1-26**] at 6:06:29 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2064-7-3**]
Age (years): 59 M Hgt (in):
BP (mm Hg): 100/70 Wgt (lb):
HR (bpm): 112 BSA (m2):
Indication: coronary artery bypass grafting
ICD-9 Codes: 786.05, 440.0
Test Information
Date/Time: [**2124-1-26**] at 18:06 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 15% to 20% >= 55%
Aorta - Sinus Level: *4.0 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV
cavity. Severe regional LV systolic dysfunction. False LV tendon
(normal variant). Severely depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Normal aortic arch diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Resting tachycardia
for the patient. See Conclusions for post-bypass data
The mid papillary short axis view looked better in comparison to
the mid esophageal views in terms of LV systolic function. The
increased heart rate made the systolic function appear better as
well
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated.
There is severe regional left ventricular systolic dysfunction
with severe focalities in anteroseptal, anterior and inferior
septal walls.. Overall left ventricular systolic function is
severely depressed (LVEF= 20 %).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in
person of the results on Mr.[**Last Name (Titles) 81844**].
POST-BYPASS:
Normal RV systolic function. There is a mild improvement in the
systolic function of the anterior and anteroseptal walls. LVEF
25%. Trivial MR, AI and TR.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2124-1-28**] 11:11
Brief Hospital Course:
Mr. [**Known lastname 18036**] was admitted and underwent coronary artery bypass
grafting surgery by Dr. [**Last Name (STitle) 914**]. For surgical details, please
see operative note. Following the operation, he was brought to
the CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. He
was started on diuretics, ACE inhibitor, and betablockers. He
was transferred to the floor postoperative day one. Physical
therapy worked with him on strength and mobility. He continued
to progress, diuretics were adjusted, and beta blockers titrated
for heart rate control. He was ready for discharge home post
operative day four with plan for VNA to be arranged [**2124-1-31**] by
case manager. Has been prescribed lasix for two weeks with plan
to follow up with cardiologist prior to completion for
evaluation of continued dosing of diuretics.
Sternal incision no erythema no drainage sternum stable
Right leg EVH with no erythema no drainage
Edema trace - weight at discharge 88 kg and preop 85 kg
Medications on Admission:
Aspirin 81 qd, Coreg 6.25 [**Hospital1 **], Digoxin 0.25 qd, Lasix 80 qd,
Lisinopril 40 qd, Niacin CR 500 qd, Zocor 10 qhs, Aldactone 2.5
qd, Ambien 5 qhs
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Simvastatin 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks: continue lasix until follow up with Cardiologist -
please see within 2 weeks .
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day for 2 weeks.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
10. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
Coronary artery disease s/p cabg x3
Acute on chronic systolic heart failure
mitral regurgitation
hypertension
cardiomyopathy
prior myocardial infarction
hypercholesterolemia
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. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 39975**] in 2 weeks
Dr. [**Last Name (STitle) 81845**] in 6 weeks
Completed by:[**2124-1-30**]
|
[
"41401",
"4019",
"4280",
"4168",
"412"
] |
Admission Date: [**2114-3-19**] Discharge Date: [**2114-3-27**]
Date of Birth: [**2050-6-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
urgent coronary artery bypass graftsx 3(LIMA-LAD,SVG-OM,SVG-RCA)
[**2114-3-20**]
Left heart catheterization, coronary angiogram [**2114-3-20**]
History of Present Illness:
This 63 year old [**Known lastname **] male was seen at [**Hospital3 **] for
chest pain. He ruled out for infarction, however, a stress test
was positive for ischemia with preserved left ventricular
function. He continued to have episodic pain and was transferred
on IV Nitroglycerin and Heparin pain free for catheterization.
Past Medical History:
asthma
hypertension
gastroesophageal reflux
hyperlipidemia
Social History:
retired engineer, lives alone.
quit smoking 20 years ago,drinks [**1-13**] glasses of wine daily.
Family History:
non contributory
Physical Exam:
Admission:
Pulse:71 Resp: 18 O2 sat: 99 RA
B/P Right: 129/83 Left: 117/81
Height: 70in Weight:192 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: dressing in place Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
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.
There are focal calcifications in the aortic arch. The
descending thoracic aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known lastname 1007**], J before
surgical incisioin.
Post Bypass:
Preserved biventricular systolic function.
LVEF 55%.
All other findings similar to prebypass.
Intact thoracic aorta
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2114-3-20**] 16:08
?????? [**2107**] CareGroup IS. All rights reserved.
[**2114-3-22**] 05:55AM BLOOD WBC-10.2 RBC-3.73* Hgb-11.1* Hct-31.9*
MCV-85 MCH-29.8 MCHC-34.9 RDW-14.0 Plt Ct-106*
[**2114-3-21**] 03:29AM BLOOD WBC-10.8 RBC-3.67* Hgb-11.3* Hct-31.3*
MCV-85 MCH-30.7 MCHC-36.1* RDW-14.2 Plt Ct-87*
[**2114-3-22**] 05:55AM BLOOD Glucose-119* UreaN-13 Creat-0.9 Na-139
K-4.2 Cl-104 HCO3-29 AnGap-10
[**2114-3-23**] 09:05AM BLOOD UreaN-15 Creat-1.1 K-4.1
Brief Hospital Course:
Catheterization revealed a 95% left main lesion and 50% RCA
stenosis. Surgical intervention was requested and he was taken
to the Operating Room that day for bypass surgery. See operative
note for details.
He weaned from bypass on a Propofol infusion in stable condtion.
He remained stable, awoke intact, was weaned from the
ventilator and extubated. Beta blockade was resumed as well as
diuresis begun.
He transferred to the floor on POD #1 where Physical Therapy saw
him for mobility and strengthening. CTs and temporary pacemaker
wires wre removed according to protocol. Beta blocker was
initiated and the patient was diuresed toward his preoperative
weight. He was cleared for discharge to rehab on POD # 3.
Medications on Admission:
Ranitidine 150mg po bid
Fluticasone-salmeterol diskus IH [**Hospital1 **]
Imdur 30mg daily
Lopressor 12.5mg [**Hospital1 **]
simvastatin 20mg qd
ASA 325mg qd
IV heparin
IV NTG
Plavix - last dose: [**3-20**] 600mg
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x3
hypertension
hyperlipidemia
asthma
gastroesophageal reflux
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Vicodin prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 170**]) on [**4-25**] at 1pm
Primary Care: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] ([**Telephone/Fax (1) 81482**]in [**1-13**] weeks
Cardiologist: Dr.[**Last Name (STitle) 86567**] in [**1-13**] weeks
Completed by:[**2114-3-23**]
|
[
"41401",
"4019",
"53081",
"2724",
"49390"
] |
Admission Date: [**2187-11-18**] Discharge Date: [**2187-12-17**]
Date of Birth: [**2114-8-13**] Sex: M
Service: TRAUMA [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 73 year old male
pedestrian struck by a car with [**Location (un) 2611**] Coma Scale of 3 at
the scene. There at the scene, he was intubated and brought
to the Emergency Room. The patient was hemodynamically
stable upon arrival and was otherwise unresponsive.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Benign prostatic hyperplasia.
3. Degenerative disc disease.
MEDICATIONS: Multivitamin.
ALLERGIES: Penicillin which gives hives.
PHYSICAL EXAMINATION: Temperature 97.4 F.; blood pressure
160/palpable; heart rate 78; 100% on the ventilator. He was
intubated and moving all extremities, right side greater than
the right side with the lower extremities greater than the
upper extremities. Pupils were minimally reactive to light,
equal at 2 millimeters. His trachea was midline. Lungs were
clear to auscultation. Heart was regular rate and rhythm.
Abdomen was soft, nontender, nondistended. Rectal was guaiac
negative. Pelvis was stable. Back: He had no stepoffs and
no deformities.
LABORATORY: His hematocrit upon admission was 42. Arterial
blood gas was 7.41, 45/285/30/3.
A chest x-ray was performed which was negative as well as a
pelvis x-ray which was negative.
A head CT scan revealed a left posterior [**Doctor Last Name 534**] hemorrhage. A
max/facial CT scan revealed a left orbital and ethmoid
fracture. An abdominal CT scan was negative. The cervical
spine x-ray was negative.
HOSPITAL COURSE: The patient was admitted, transferred to
the Intensive Care Unit and given serial neurological
examinations. Neurosurgery evaluation was obtained. Serial
neurological examinations were done. The patient had a
repeat head CT scan which revealed no worsening of the left
posterior [**Doctor Last Name 534**] hemorrhage.
An Ophthalmology consultation was obtained for the orbital
fracture and it was decided that no intervention was required
at the time.
A Plastic Surgery consultation was obtained for an ethmoidal
fracture and again no intervention was done. The patient was
started on Clindamycin for anti-microbial coverage.
The patient was started on tube feeds which was tolerated
well. An MRI revealed a question of C6 ligamentous injury.
It was decided at that time to leave the cervical collar on
for an additional six weeks.
It was decided that the patient should wear the cervical
collar for an additional six weeks starting [**11-27**]. The
patient was started on Levofloxacin for an E. coli urinary
tract infection. The patient began to follow on commands.
It was decided that the patient should have a tracheostomy
performed. A repeat head CT scan done [**11-28**] showed
continuing resolution of the hemorrhage areas in the
posterior [**Doctor Last Name 534**] area. The patient had blood cultures which
grew Gram positive cocci. At that time, he was started on
Vancomycin.
Next, the patient developed a growth of Gram negative rods
from his sputum. Repeat blood cultures showed a coagulase
negative Staphylococcus. The patient was started on
appropriate antimicrobial coverage. The patient was
extubated on [**12-1**], which was tolerated well initially.
The patient was started on subcutaneous heparin and Venodyne
for prophylaxis.
He was on Vancomycin, Zosyn and Levofloxacin. The patient
had a Speech and Swallow evaluation done in which they
recommended a PEG or G-tube be placed. The patient was
started on total parenteral nutrition while tube feeds were
being held. A G-tube was placed on [**12-12**] in the
Operating Room; this was done in a percutaneous fashion. A
catheter tip grew out Methicillin resistant Staphylococcus
aureus. The patient was being worked with aggressive
Physical Therapy and Occupational Therapy throughout the
admission.
The patient was transferred to the floor post surgical care
on [**12-13**]. After placement of the G-tube, the tube feeds
were restarted and the total parenteral nutrition was
discontinued. The patient was screened for rehabilitation
and accepted for a bed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q. 24 hours.
2. Subcutaneous heparin 5000 units q. eight hours.
3. Lopressor 25 mg p.o. twice a day; to be held for systolic
blood pressure of less than 100 and a heart rate less than
60.
4. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n.
5. Dulcolax 10 mg p.r. q. h.s. p.r.n.
6. Regular insulin sliding scale.
DISCHARGE INSTRUCTIONS:
1. The cervical collar is to be left in place for six weeks
beginning [**2187-11-27**].
2. The patient should follow-up with [**Hospital 4695**] Clinic.
3. The patient to follow-up with the Trauma Clinic.
DISCHARGE STATUS: To a rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Status post pedestrian versus car injuries.
2. Left posterior [**Doctor Last Name 534**] hemorrhage.
3. Questionable C6 ligamentous injury.
4. Left orbital fracture.
5. Left clavicular fracture.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2187-12-15**] 15:15
T: [**2187-12-15**] 15:41
JOB#: [**Job Number 45559**]
|
[
"5990",
"5070",
"4019"
] |
Admission Date: [**2105-6-10**] Discharge Date: [**2105-6-17**]
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
lower abdominal pain, dysuria
Major Surgical or Invasive Procedure:
[**6-10**] (in IR): Successful placement of 8F percutaneous
nephrostomy tube into the left
kidney and placed to external bag drainage.
History of Present Illness:
This is an 86y/o F with h/o nephrolithiasis requiring
percutaneous nephrostomy placement in [**4-5**] who presented to ED
with 2-3 days of lower abdominal pain with associated dysuria
and decreased PO intake Patient states that she decided to
come to ED because her discomfort had not subsided. She had been
unable to sleep because of the pain. Denies any exacerbating or
alleviating factors to her pain. At its worst it was a [**9-6**]
sharp pain that began in her left flank region and radiated down
to her lower mid abdomen. Otherwise it was dull constant achy
pain in her lower abdomen with [**2105-1-29**] in severity. Denies
fevers, chills, upper abdominal pain, chest pain, SOB, myalgias,
dizziness, nausea, vomiting or diarrhea. The patient does
endorse a chronic dry cough that she states she has had for the
past few months.
In the ED, initial vs were: T 100.4 P 100 BP 148/58 R 20 O2 sat
95. A CTA was completed showing an 8mm L ureteral stone and
hydronephrosis. Patient had a WBC of 26.6 with prominent left
shift as well as a Cr of 1.6 (up from baseline of 0.8-1.1).
Urology was consulted and decision was made for emergent left
nephrostomy placement by IR to decompress hydronephrosis. She
received 2L NS in ED as well as 1g of Cefriaxone.
.
After procedure, the patient was transported to the ICU for
observation given WBC, comorbidities, and possible sepsis. On
admission to ICU, patient was stable and did not have any
complaints. No abdominal pain, flank pain, or dysuria. She was
feeling very hungry. She stated that she felt much better after
the procedure.
.
Past Medical History:
Nephrolithiasis: Cystoscopy, left ureteroscopy, laser
lithotripsy, left ureteral stent placement - [**2104-5-13**] - Dr.
[**First Name (STitle) **] [**Name (STitle) **] and removal [**2104-5-21**]
HTN
Obesity
Osteoarthritis
Anxiety/ depression
Osteopenia
SEVERE Hearing loss/Tinnitus
Hx of breast cancer s/p left mastectomy
Meningiomas
Cataracts
Rosacea
s/p CCY
Depression
Social History:
Lives in [**Location (un) **] in [**Location 1268**]. Husband lives in [**Location **]
x 17 years. No children. Previously used to work in Pathology.
No EtOH, tobacco, or illicits.
Family History:
NC
Physical Exam:
afebrile 200/80 p70 R24 98RA ** pt very agitated
Gen: HOH. Oriented x3. Severely dysarthic, and difficult to
communicate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, no
exudates or ulceration.
Neck: JVP not elevated.
CV: Irreg Irreg. Normal rate.
Chest: Resp were unlabored, no accessory muscle use. Occas
wheezes
Abd: Obese, Soft, NTND. +BS.
Ext: No c/c/edema.
Neuro: Severely dysarthric, (pt appears frustrated with
communication. Alert and oriented., 5/5 strength in upper and
lower extremities bilaterally. R sided facial droop.
Pertinent Results:
[**2105-6-10**] 04:45AM BLOOD WBC-26.6*# RBC-4.42 Hgb-13.1 Hct-37.2
MCV-84 MCH-29.6 MCHC-35.1* RDW-13.6 Plt Ct-213
[**2105-6-10**] 04:45AM BLOOD Glucose-132* UreaN-33* Creat-1.6* Na-138
K-3.4 Cl-99 HCO3-26 AnGap-16
[**2105-6-15**] 09:05AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-142
K-3.9 Cl-105 HCO3-32 AnGap-9]
[**2105-6-17**] 04:38AM BLOOD WBC-8.6 RBC-3.82* Hgb-11.2* Hct-33.0*
MCV-86 MCH-29.3 MCHC-33.9 RDW-13.8 Plt Ct-257
[**2105-6-17**] 04:38AM BLOOD Glucose-107* Creat-0.7 Na-141 K-3.7
Cl-104 HCO3-31 AnGap-10
[**2105-6-17**] 04:38AM BLOOD Cholest-118
[**2105-6-13**] 02:17PM BLOOD %HbA1c-5.7 eAG-117
[**2105-6-17**] 04:38AM BLOOD Triglyc-118 HDL-29 CHOL/HD-4.1 LDLcalc-65
LDLmeas-64
[**2105-6-16**] 11:43AM BLOOD TSH-2.8
[**2105-6-15**] 03:58AM BLOOD Vanco-17.4
MIcro:
[**2105-6-10**] 5:30 am BLOOD CULTURE
**FINAL REPORT [**2105-6-16**]**
Blood Culture, Routine (Final [**2105-6-16**]):
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
AEROCOCCUS SPECIES. AEROCOCCUS URINAE, PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2105-6-11**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 12707**] ON [**2105-6-11**] AT 0300.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2105-6-11**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO NICHAN TCHEKMEDYIAN AT 4:00PM ON
[**2105-6-11**].
Echo: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
normal (LVEF 70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The estimated pulmonary artery
systolic pressure is normal. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: no vegetations seen
.
CT head:
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage,
mass effect,
edema, shift of normally midline structures, or major vascular
territorial
infarct. Previously noted 1 cm parafalcine and right
infratentorial calcified
hemangiomas are unchanged since at least [**2103-9-1**].
Periventricular
white matter hypodensities are redemonstrated, consistent with
known small
vessel ischemic disease. Ventricles and sulci are unchanged in
configuration,
slightly prominent, reflective of mild degree of age-related
involution.
Hyperostosis frontalis is redemonstrated. Osseous structures are
intact.
Paranasal sinuses and mastoid air cells are well aerated.
Vascular
calcifications are noted in the cavernous carotid and vertebral
arteries.
Globes and soft tissues are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Stable calcified hemangiomas.
3. Chronic small vessel ischemic disease.
.
[**6-14**] CXR:
FRONTAL CHEST RADIOGRAPH: Examination is limited by technique.
Right-sided
PICC line is seen with tip residing in the proximal SVC. There
is no
pneumothorax. The cardiomediastinal silhouette is normal. No
focal
consolidation, pneumothorax, or pleural effusion.
IMPRESSION: Right-sided PICC line tip is difficult to visualize
but likely
resides in the proximal SVC.
.
Nephrostogram:
IMPRESSION: 1. Nephrostogram shows mild to moderate left
hydronephrosis and
dilatation of the proximal ureter.
2.Successful placement of 8F percutaneous nephrostomy tube into
the left
kidney and placed to external bag drainage.
[**6-10**] CT abd:
1. Left nephrolithiasis, with an 8-mm obstructing stone in the
proximal-to-mid left ureter associated with periureteral
inflammatory change
and upstream moderate hydroureteronephrosis.
2. Status post cholecystectomy.
3. Unchanged nonspecific thickening of the left adrenal.
4. Colonic diverticulosis.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
86 y/o F with h/o nephrolithiasis s/p L nephrostomy placement
and lithotripsy in [**3-/2104**], here with obstructing 8mm L ureteral
stone requiring emergent percutaneous nephrostomy placement, c/w
urosepsis. Now s/p procedure.
.
# Sepsis: Initially, the patient had an elevated WBC and was
tachycardic. She had a blood culture positive for Proteus
Mirabilis and unsepciated GPC. She was started on Vancomycin and
Cefepime while the blood culture was still speciating. Her fluid
balance and WBC were closely monitored. She was changed to
Vancomycin and Ceftriaxone (discontinued Cefepime) after
speciation finalized. She has been afebrile and WBC is
resolving. Plan for total of 2 weeks of vanco and CTX ending
[**2105-6-28**]. Should monitor vanco trough on [**6-19**] for goal of [**9-11**].
#. S/P Percutaneous Nephrostomy Placement: IR performed the
procedure on [**6-10**]. Her nephrostomy tube output was closely
monitored. Urology and IR recommendations were followed. She
will follow up as outpatient with subspecialty clinic and for
further workup of renal stone. Information regarding care of
this tube is included in the d/c papers. She will follow up with
Dr. [**Last Name (STitle) **] (scheduled [**2105-7-6**]).
#. Acute Renal failure: Thought to be multifactorial - including
post-renal origin from obstruction in ureter. Creatinine has
returned to baseline 0.7. The patient received IV fluids and her
Cr was monitored daily.
.
#. Lacunar infarct: The patient did become agitated while in
the ICU. The etiology of her mental status changes were
orignally unclear however, medications that might contribute to
her delirium, such as anticholinergics, were avoided. She
continued to be agitated on transfer to [**Hospital Ward Name **] to medicine
team. Neurology was consulted. CT head showed lacunar infarct.
Pt refused MRI. Originally with significant dysarthria and R
facial weakness. MS [**First Name (Titles) **] [**Last Name (Titles) 99052**] resolved prior to d/c. Alc
and lipids normal. Started on anticoagulation for stroke in
setting of new afib, see below.
.
#. Hypertension: The patient's home medication HCTZ was held due
to her acute kidney injury. Her pressures were monitored
closely. She was kept at permissive HTN <180 with PRN IV
hydralazine 10mg. After resolution of her symptoms she was
started on low dose ACE inhibitor. continue to titrate as
warrented.
.
# Afib: new onset in setting of urosepsis. Given acute CVA
started anticoagulation. Bridging with enoxaparin. Started on
coumadin. Goal INR [**12-31**]. Will need INR draw on [**6-19**]. By discharge
in PAF.
.
# depression, continued home meds.
.
# Confirmed code DNR/DNI with patient
Medications on Admission:
HYDROCHLOROTHIAZIDE 25 mg po q daily
VENLAFAXINE [EFFEXOR XR] - 150 mg Capsule, Sust. Release 24 hr
po q day
VITAMIN C 500 mg po q day
ASPIRIN 81 mg po q day
CALCIUM CARBONATE-VITAMIN D3 - One Tablet po BID
VITAMIN D3 1,000 unit po q day
COLACE 100 mg po every other night
LORATADINE 10 mg po q day in morning as needed for allergies
MULTIVITAMIN - One Tablet by mouth once a day
SENNOSIDES [SENOKOT] - 8.6 mg po BID prn constipation
Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet 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 Q4H (every 4 hours) as
needed for wheezing.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO QAM (once a day (in the morning)).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO ONCE (Once) as needed for agitation.
9. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
Disp:*45 Tablet(s)* Refills:*2*
10. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **]
(2 times a day): Continue Enoxaparin until therapeutic
anticoagulation on Coumadin.
Disp:*60 qs* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. HydrALAzine 10 mg IV Q6H:PRN SBP>180
hold for sbp <100
14. Vancomycin in 0.9% Sodium Cl 1.25 gram/150 mL Solution Sig:
One (1) Intravenous every twenty-four(24) hours for 11 days.
Disp:*qs qs* Refills:*0*
15. Ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous every
twenty-four(24) hours for 11 days.
Disp:*qs qs* Refills:*0*
16. Calcium Citrate 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*1*
17. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
18. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
19. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Lacunar infarct
New onset atrial fibrillation
Septicemia
Renal stone
Discharge Condition:
Mental Status: Confused - sometimes. - VERY hard of hearing
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a bloodstream infection
secondary to a kidney stone and kidney infection. You were
started on antibiotics and a nephrostomy tube was placed.
You tolerated the procedure well w/o apparent complications and
have been maintained on antibiotis. Hospital course was
complicated by development of a irregular heart ryrhem (atrial
fibrillation) and episode of difficulty speaking though to be
[**12-30**] new stroke (lacunar infarct).
Neurology was consulted and thought your difficulty speaking
from from a stroke. They recommended initiation of blood
thinners. You refused MRI to followup the size of the infarct.
You continued to improve in mental status and your dysarthria
resolved.
.
You conferenced with Pastoral Care services and decided to
establish your code status as DNR/DNI.
.
You must continue Warfarin and Enoxaparin to thin your blood.
You will need frequent checks of your coumadin level. Please
have blood drawn on Friday [**2105-6-19**] to monitor INR (currently
1.4; goal 2.0-3.0).
.
Please continue your antibiotics Vancomycin and Ceftriaxone
until [**2105-6-28**]. Please have your blood drawn Friday [**2105-6-19**] to
check your Vancomycin trough. The level should be between
10.0-15.0.
.
You had a nephrostomy tube placed and instructions for care of
this tube are included in your discharge papers.
.
The following changes were made to your medications:
STARTED Lisinopril 10mg Daily
STARTED Enoxaparin Sodium 90 mg SC BID, cont this medication
until your doctor tells you to stop.
STARTED Ceftriaxone 2g Q24 cont until [**2105-6-28**]
STARTED Vancomycin 1250mg Q24 cont until [**2105-6-28**], vancomycin
trough goal [**9-11**]
STOPPED HCTZ
STOPPED VIT D: please ask your kidney doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**]
this medication
.
Follow up with your doctors at the [**Name5 (PTitle) 32723**] below.
Followup Instructions:
Department: GERONTOLOGY
When: TUESDAY [**2105-11-10**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES (urology)
When: MONDAY [**2105-7-6**] at 1 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"0389",
"5849",
"5990",
"99592",
"42731",
"311"
] |
Admission Date: [**2189-10-26**] Discharge Date: [**2189-10-28**]
Date of Birth: [**2150-2-3**] Sex: M
Service: VSU
CHIEF COMPLAINT: Right toe pain.
HISTORY OF PRESENT ILLNESS: This is a 39-year-old man
admitted to the medical service on [**2189-10-26**], and
transferred to the vascular surgical service on [**2189-10-28**].
This is a 39-year-old insulin dependent diabetic male who
presents with right toe infection and DKA. He was in an
outside hospital until [**2189-8-10**], when he noted a
facial rash after applying coconut oil. He was diagnosed with
folliculitis and treated with erythromycin x10 days. His rash
resolved. Then he presented to the ER on [**2189-10-15**],
with return of the rash on his face and questionable open
sore on his toe which he did not mention to the doctor in the
ER and was begun again on erythromycin 500 QID x10 days.
On [**2189-10-22**], his wife noted a large ulceration on his
right great toe. His wife who is a [**Name (NI) **] had intermittently
rubbed cream on his feet for the past few months. On
[**2189-7-27**], his toe became malodorous and swollen. He
had to walk with a cane due to the pain and swelling
progressed. Then on [**10-26**] he noted the toe began to
turn black. While he was still able to walk on his toe, he
was concerned it has gotten 'out of hand' and he presented to
the emergency room. He in the emergency room he was found to
be in DKA. He was placed on insulin drip. He was seen by the
podiatrist in consult with concern for osteomyelitis and
underlying peripheral vascular disease. He was given dose of
gentamycin, Unasyn and vancomycin and transferred to the MICU
for continued care.
ALLERGIES: No known drug allergies.
MEDICATIONS: No medications on admission.
PAST MEDICAL HISTORY:
1. His illnesses include diabetes diagnosed in [**2173**]. He
presented with a glucose of 100 after experiencing a
fall. He is seen at [**Hospital **] clinic intermittently. He was
started on insulin in [**2179**]. His hemoglobin A1C on [**3-18**]
was 15.2. In [**2181**] he discontinued insulin and started
metformin and then glyburide but has been largely
noncompliant with his medical regime.
2. Morbid obesity.
3. Hyperglycemia.
4. Asthma. He has unknown PFTs. He has never been intubated
or on steroids.
5. History of hypertension, poorly controlled.
6. Left 4th and 5th metatarsal fractures.
SOCIAL HISTORY: He is a Muslim. He denies alcohol, drugs, or
tobacco use. He reports marijuana in the past. The patient is
currently not working secondary to his disability related to
his obesity and diabetes. The patient was with his wife and 4
children.
FAMILY HISTORY: Positive on the maternal side for diabetes
and hypertension on the paternal side.
PHYSICAL EXAMINATION: VITAL SIGNS: 99.3, blood pressure
140/70, heart rate 90, respirations 22, oxygen saturation 98%
on room air. GENERAL APPEARANCE: An obese male in no acute
distress. Oriented x3. HEENT exam was unremarkable. Lungs
clear to auscultation bilaterally. Heart has regular rate and
rhythm with a 2/6 systolic ejection murmur at the left lower
sternal border. Abdomen is benign. Extremities: Right great
toe is black, and edematous with discoloration extending to
the tarsal joint with 2+ DP and PT pulses bilaterally. There
is some erythema and edema in the mid calf level. There is
mild TPP over the distal tibia. The patient 2-point
discrimination is diminished on the plantar surface of the
toes bilaterally. Light touch sensation is preserved. Right
toe was nontender with a sterile probe. There is a 1 x 1
darkened spot over the pulp of the third digit of the left
middle finger. Motor is [**3-19**] at plantar, dorsiflexors, GCs,
quads, bilaterally. Gait was not assessed. Toe is malodorous.
ADMISSION LABORATORY DATA: Lactate of 2.0. Electrolytes -
sodium 127, K 5.3, chloride 88, CO2 20, BUN 24, creatinine
1.2, glucose 635, white count 16.6, hematocrit 37.5,
platelets 309, INR 1.2. Foot x-ray, ankle x-rays were
obtained. Chest x-ray was also obtained.
Initial toe culture from the right great toe grew beta
streptococcus group B x2. Staph coag positive, rare, probable
Enterococcus rare. Anaerobic cultures were negative. Blood
cultures with no growth. Urine culture with no growth.
Right foot film showed first toe was subcutaneous emphysema
and possibly lucency in the medial aspect of the first distal
phalanx on AP view only, osteomyelitis could not be excluded.
There was soft tissue edema. There was no evidence of
fracture or malalignment. Degenerative changes were noted.
X-rays of the tib-fib on the right were obtained which were
negative for radiographic evidence of osteomyelitis. [**Last Name (un) **]
service was consulted on [**2189-10-27**] for management of
the patient's diabetes. He remained on insulin drip. When
glucoses were in the 200 ranges, he was begun on 70/30
insulin at that time with continued improvement in his
glycemic control. On [**2189-10-28**], the patient underwent
open toe amputation without complicated and was transferred
to the PACU in stable condition, returning later to the
nursing floor.
The patient was transferred out of the MICU. The remaining
hospital course was unremarkable. The patients glycemic
control improved and he underwent a primary closure of the
amputation sites on [**2189-11-3**]. He tolerated the
procedure well. The patient was converted from Lantus and
Humalog Insulin to 70/30 insulin and a Humalog sliding scale.
The patient will be discharged to home with services. He will
continue his antibiotics for a total of 2 more weeks. He
should follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] at that time.
We will arrange for nursing to make sure the patient is
instructed on insulin administration and glycemic monitoring.
The patient should follow up with Dr. [**Last Name (STitle) **] at [**Last Name (un) **] after
discharge to home. He will be touch-down weightbearing
essential distances only. He will also be seen in follow up.
DISCHARGE DIAGNOSES:
1. Osteomyelitis of the right toe with ischemic changes.
2. Type 2 diabetes, uncontrolled with history of diabetic
ketoacidosis, resolved.
3. History of morbid obesity.
4. History of hyperlipidemia.
5. History of asthma with no history of intubation or
administration of steroids.
6. History of hypertension.
7. History of left 4th, 5th metatarsal fractures.
SURGICAL PROCEDURES: Left toe amputation on [**2189-10-28**], and primary closure of toe amputation on [**11-3**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2189-11-5**] 12:52:00
T: [**2189-11-6**] 14:24:40
Job#: [**Job Number 109967**]
|
[
"49390",
"2724",
"4019"
] |
Admission Date: [**2132-3-22**] Discharge Date: [**2132-4-1**]
Date of Birth: [**2060-3-7**] Sex: M
Service: MEDICINE
Allergies:
Procardia / Aliskiren
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
72 yo m with hx GBM and ICH [**2131-12-31**] around mass, who presents
to ER via EMS due to lethargy at facilty today. Per the daughter
and son, the pt was agitated and was complaining of abdominal
pain yeserterday. He did not want to eat and was throwing
objects. He had 3 large BMs. Today pt was more unresponsive,
destated to 88% on 6liters NC. EMS found pt to have FS of 80 at
sceen.
.
In the ER, VS on arrival were HR 63, SBP 80-90, RR 14, 100%,
rectal temp 100. Pt had a FS of 34 and was given 1 Amp D50. He
was lethargic and minimally responsive and did not improve with
dextrose. Pt was intubated after about 20 min for airway
protection. Prior to this he had intermitent apnea and a wet
sounding cough. CXR showed a possible bilaterally PNA, and CT
head with no new head bleed. Hct was found to be 26 from 32 and
pt was ordered for 1 unit of blood. Trop was elevated to 0.26
with EKG changes concerning for new twave inversions in lateral
leads. EKGs were sent to cards. Pt was trace guaiac positive on
exam. NG lavage was negative. SBP dropped to 77 and pt was
started on levophed after at 2.5 liters IVF had been given. Pt
was given vanco, ctx, and levo. Pt given dexamethasone 10mg for
stress steriods. On transfer VS were- HR 61, BP 118/58 (levophed
0.12), RR 14, Fio2 100%, peep 10, TV 500, sat 100%.
Past Medical History:
-Right frontotemporal glioblastoma multiforme WHO Grade IV,
status post biopsy on [**2131-9-27**], on protocol using
hypofractionated involved-field radiotherapy with temozolomide
followed by Cyberknife boost
-Ischemic stroke
-Malignant HTN
-CAD s/p IMI
-Chronic diastolic CHF
-PAF (ED visit [**7-24**])
-Type II diabetes mellitus
-Anxiety/Depression
Social History:
He is a resident of [**First Name5 (NamePattern1) 4542**] [**Last Name (NamePattern1) 19207**] & Nursing Center in
[**Location (un) 38**], MA. He is a retired rocket scientist from [**Country 532**].
He worked for USSR space program and NASA. A former pipe
smoker, he quit in [**2097**]. He is a social drinker and he does not
abuse illicit drugs.
Family History:
Father: Type [**Name (NI) **] diabetes and hypertension. Mother: [**Name (NI) **] [**Name (NI) 3730**].
Brother: Type [**Name (NI) **] Diabetes.
Physical Exam:
Admission exam:
VS: hr 56, bp 130/64, Sat 97%, AC fio2 70%, TV 500 RR 14, PEEP
10
GEN: intubated, arousable, Russian Speaking
HEENT: PERRL, NTG tube in place, neck supple
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: abd is distended, NT, +BS
EXT: no c/c, edema in left LE/ankle
SKIN: tinea on right heel, no jaundice
NEURO: sedated
Pertinent Results:
ADMISSION LABS:
[**2132-3-22**] 06:45PM BLOOD WBC-7.8 RBC-2.74* Hgb-8.8* Hct-26.1*
MCV-95# MCH-31.9 MCHC-33.6 RDW-16.5* Plt Ct-189
[**2132-3-22**] 06:45PM BLOOD Neuts-93.1* Lymphs-5.7* Monos-1.0*
Eos-0.1 Baso-0.1
[**2132-3-22**] 06:45PM BLOOD PT-12.7 PTT-25.0 INR(PT)-1.1
[**2132-3-22**] 06:45PM BLOOD Ret Aut-2.1
[**2132-3-22**] 06:45PM BLOOD Glucose-83 UreaN-52* Creat-1.6* Na-148*
K-3.9 Cl-108 HCO3-27 AnGap-17
[**2132-3-22**] 06:45PM BLOOD ALT-50* AST-67* AlkPhos-91 TotBili-0.4
[**2132-3-22**] 06:45PM BLOOD CK-MB-4
[**2132-3-22**] 06:45PM BLOOD cTropnT-0.26*
[**2132-3-22**] 10:27PM BLOOD cTropnT-0.20*
[**2132-3-23**] 03:09AM BLOOD CK-MB-5 cTropnT-0.16* proBNP-387*
[**2132-3-22**] 06:45PM BLOOD Calcium-8.2* Phos-4.9*# Mg-2.5
[**2132-3-22**] 06:45PM BLOOD VitB12-512
[**2132-3-26**] 05:12AM BLOOD Triglyc-133
[**2132-3-22**] 06:45PM BLOOD TSH-0.41
[**2132-3-22**] 08:47PM BLOOD Type-[**Last Name (un) **] Temp-37.8 pO2-85 pCO2-43 pH-7.42
calTCO2-29 Base XS-2 Intubat-INTUBATED Comment-GREEN TOP
[**2132-3-22**] 07:00PM BLOOD Lactate-1.7
.
CT head w/o contrast [**2132-3-22**]:
IMPRESSION:
No acute change from prior study. Right cerebral hypodensity is
consistent
with known GBM. Dystrophic calcification in the right temporal
lobe and right basal ganglia reflects either post-treatment
change or prior hemorrhage. There is no acute hemorrhage
identified. Encephalomalacia from prior right parietal and
right occipital infarcts is noted. Global prominence of the
sulci and ventricles is compatible with
encephalomalacia. No hydrocephalus.
.
CT C/A/P [**2132-3-23**]: IMPRESSION:
1. Abdominal pneumoperitoneum, which may be due to jejunal
ischemia and infarct given abnormal-appearing jejunal loops with
wall thickening, possible pneumatosis and mesenteric fat
stranding and fluid. Evaluation, however, is limited by lack of
IV contrast.
2. Bibasilar consolidations which may be atelectasis, although
pneumonia is not excluded. Small effusions.
3. Small pericardial effusion.
4. Atherosclerotic disease of the aorta and coronary vessels.
.
Echo [**2132-3-24**]: The right atrium is moderately dilated. LVEF>55%.
The left ventricular inflow pattern suggests impaired
relaxation. Borderline pulmonary artery systolic hypertension.
There is a small pericardial effusion. There is evidence of
diastolic dysfunction.
.
KUB [**2132-3-26**]: IMPRESSION: Small amount of free air visualized in
the left lateral decubitus abdominal radiograph and consistent
with persistant pneumoperitoneum.
.
DISCHARGE LABS:
[**2132-4-1**] 09:20AM BLOOD WBC-10.9 RBC-3.00* Hgb-9.5* Hct-29.5*
MCV-98 MCH-31.8 MCHC-32.4 RDW-15.5 Plt Ct-266
[**2132-4-1**] 09:20AM BLOOD Glucose-177* UreaN-25* Creat-0.8 Na-143
K-3.6 Cl-105 HCO3-28 AnGap-14
[**2132-3-28**] 04:56AM BLOOD ALT-20 AST-18 AlkPhos-71 TotBili-0.2
[**2132-3-26**] 05:12AM BLOOD ALT-22 AST-14 LD(LDH)-468* AlkPhos-74
TotBili-0.1
[**2132-3-31**] 06:36AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.7
Brief Hospital Course:
72 yo m with hx of Ischemic stroke, HTN , CAD s/p IMI, diastolic
CHF, PAF, Type II diabetes mellitus, rec UTI??????s and GBM with
recent intracranial hemorrhage [**12-25**], who presented with altered
mental status with concern for pneumonia, intubated in ER due to
altered mental status and airway protection. He was admitted to
ICU where an abdominal CT was obtained for abdominal distention
and pneumoperitoneum was found. Hypotension due to sepsis was
treated with pressors and IVF. He was not a surgical candidate,
so the bowel perforation was treated with vanco, 7 days
ceftiaxone, and metronidazole (started [**2132-3-23**]). Abx changed
[**2132-3-29**] to cipro with metronidazole for a planned 14 day course,
finishing [**2132-4-6**]. Ceftriaxone also covered a Proteus and
Klebsiella UTI.
.
# Pneumoperitoneum with sepsis: Managed medically due to poor
surgical candidacy. The repeated normal lactate spoke against
bowel ischemia as the underlying process. Bowel perforation may
have been promoted by chronic steroid therapy. Hypotension
required IV fluids and pressors. Patient was intially kept NPO
than gradually advanced to full diet and tolerated this well.
Plan is to continue cipro and metronidazole to complete a 14 day
course finishing [**2132-4-6**].
.
# Altered mental status: Continued delirium. He needed one arm
restraint to maintain IV access while getting IV antibiotics.
Once changed to PO, he no longer required IV access or
restraints. His family is opposed to any use of
anti-psychotics.
.
# HTN: Intially off his home [**Last Name (un) **], BB, and diuretic as he was
strictly NPO and hypotensive. After initial hypotension, he
developed HTN with SBP's to the 180's. He was treated with IV
Labetolol gtt + clonidine patch. Most outpatient meds were
re-established: eplerenone, torsemide, labetalol, clonidine, and
amlodipine. Valsartan 160mg [**Hospital1 **] will be added back as an
outpatient.
.
# UTI: Proteus and Klebsiella UTI treated with ceftriaxone.
.
# DMII: Volatile blood sugars. Insulin glargine and sliding
scale increased per. Endocrinology consultation. Plan to taper
dexamethasone to 2mg [**Hospital1 **] and further after discharge as
discussed with Neuro-Oncology.
.
# Acute Renal Failure: Resolved. Originally Cr 1.6 from
baseline 1.0, BUN was elevated. FeNa = 0.25% indicating
pre-renal azotemia. In the setting of almost normal BNP, this
was likely [**3-19**] to hypovolemia/distributive shock rather than CHF
exacerbation with poor forward flow. Subsequently after IV
fluid and improving renal functions, he started to diurese. He
was restarted on his home dose of torsamide 30mg daily as well
as eplerenone 50mg daily.
.
# GBM/Intracranial hemorrhage: Continued outpatient
levetiracetam. Tapering dexamethasone.
.
# Asymmetrical leg edema: Considering inability to anticoagulate
given recent ICH and family's wish for no filter, further
work-up was not be pursued.
.
# Anemia: Stable without transfusions, though was trace guaiac
positive in ED.
.
# Cough: Controlled with PRN benzonatate and ipratropium nebs.
.
# Tinea pedis: Continued miconazole cream [**Hospital1 **].
.
# EKG changes/Troponin elevation: Due to demand ischemia. Chest
pain free. Continued statin and beta blocker therapy.
.
# Pain/headache: Palliative care consulted. Acetaminophen TID
scheduled.
.
# FEN: Regular diabetic diet with thiamine supplement.
Hypophosphatemia repleted. Repleted hypokalemia.
.
# PPx: Pneumoboots. No heparin due to ICH history. PPI, bowel
meds.
.
# Lines: Port.
.
# Precautions: Fall.
.
# Code: DNR, but okay to intubate. Patient and family are
anticipating additional Palliative consultation at skilled
nursing facility.
Medications on Admission:
Amlodipine 10mg PO daily
Clonidine 0.3mg/24hr patch qwk
Labetaolol 400mg PO BID
Epleranone 50mg PO daily
Torsemide 30mg PO daily
Valsartan 160mg PO BID
Simvastatin 40mg PO daily
Levetiractam 500mg PO q8hr
Dexamethasone 3mg PO BID
Omeprazole 20mg PO daily
Docusate 100mg PO BID
Senna 8.6mg PO BID
Buspirone 5mg PO daily
Citalopram 20mg PO daily
Clonazepam 0.5mg PO qHS
Trazadone 25mg q2PM and 12.5mg TID prn agitation
Insulin
Glyburide
Timolol 0.5% 1 gtt OU [**Hospital1 **]
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
3. labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. eplerenone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. torsemide 10 mg Tablet Sig: Three (3) Tablet PO once a day.
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
8. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): Continue x3 days, then taper to 1mg PO BID x3 days,
then taper to 0.5mg PO BID.
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 5 days: Finishes [**2132-4-6**].
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: Finishes [**2132-4-6**].
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
13. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain not relieved by tylenol.
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
16. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
17. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash on heal.
18. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
19. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. insulin glargine 100 unit/mL Cartridge Sig: Sixty Five (65)
Units Subcutaneous once a day.
21. insulin aspart 100 unit/mL Cartridge Sig: As directed Units
Subcutaneous QACHS: Insulin sliding scale, see sheet.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
1. Bowel perforation.
2. Altered mental status.
3. Hypotension (low blood pressure).
4. Urinary tract infection.
5. Hypertension.
6. Acute kidney failure.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for altered mental status (delirium,
confusion) and required intubation (breathing machine) in order
to protect your airway and keep breathing. While in the ICU, CT
scan showed a bowel perforation. You were not well enough for
surgery, so this was treated with antibiotics. In addition, for
very low blood pressure, you needed IV fluids and pressors
(medications that increase blood pressure. Once your blood
pressure returned, you needed blood pressure medication for
hypertension. Acute kidney failure resolved with IV fluids.
You were also treated for a Proteus and Klebsiella urinary tract
infection. Your diabetes was difficult to control and the
insuline doses were adjusted by the Endocrinologist (diabetes
doctor). To help manage the very high blood sugar levels, the
dexamethasone for the glioblastoma multiforme (brain cancer) was
decreased.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
MEDICATION CHANGES:
1. Valsartan 160mg 2x a day was held for hypotension, but this
can be restarted as the blood pressure increases.
2. Dexamethasone dose was decreased from 3mg to 2mg two times a
day. After three days, this dose can be tapered further to 1mg
two times a day x3 days, then to 0.5mg two times a day.
3. Insulin glargine (Lantus) dose was changed to 65 Units daily.
4. Insulin sliding scale was adjusted (see sheet).
5. Buspirone 5mg daily was not given during this
hospitalization, but can be restarted.
6. Citalopram 20mg daily was not given during this
hospitalization, but can be restarted.
7. Trazadone 25mg q2PM and 12.5mg TID PRN agitation was not
given during this hospitalization, but can be restarted.
8. Acetaminophen 650mg PO 3x a day (scheduled) was added for
chronic pain.
9. Ciprofloxacin finishes [**2132-4-6**].
10. Metronidazole finishes [**2132-4-6**].
Followup Instructions:
PLEASE CALL YOUR ONCOLOGIST DR. [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **] THIS WEEK FOR A
FOLLOW-UP APPOINTMENT.
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2132-5-21**] at 10:30 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"0389",
"78552",
"5990",
"5849",
"2760",
"4280",
"41401",
"412",
"42731",
"25000",
"99592",
"4019"
] |
Admission Date: [**2175-1-11**] Discharge Date: [**2175-2-6**]
Date of Birth: [**2107-6-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Corgard / Procainamide / Cardura /
Aldomet / Flexeril / Minoxidil / Timolol / Reglan / Isordil /
Atenolol / Vioxx / Hytrin / Indapamide / Primidone / Normodyne /
Hydralazine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
67 year-old man, patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3314**], with known CAD
referred for cardiac catheterization due to worsening symptoms.
Major Surgical or Invasive Procedure:
1. Coronary artery bypass grafting x3 with the left internal
mammary artery to the left anterior descending artery,
and reverse saphenous vein graft to the distal right
coronary artery and the circumflex artery.
2. Modified Maze procedure using the cryoablation with
Resection of Left Atrial Appendage.
3. Endoscopic greater saphenous vein harvest of the left
leg.
4. EpiAortic Duplex Scan
History of Present Illness:
This 67 year old man has a history of difficult to control
hypertension, CAD and COPD here with chest discomfort. Over the
past two to three months the patient has noticed a lot of chest
discomfort, described as indigestion. It can occur up to
four times a day and then not occur for an entire day. It has
not
seemed to correlate with food or activity and has responded to
both rest and SL nitroglycerin. He denied any associated
symptoms, no n/v, no diaphoresis, no ligtheadedness, never
syncopized, no palpitation.s He has not undergone any recent
stress testing and is now referred for cardiac catheterization
to evaluate for a progression of his CAD.
In [**2171-6-18**] the patient underwent cardiac and renal
angiography at [**Hospital1 18**]. No significant renal artery stenosis was
noted, although he did have coronary artery disease. The LMCA
had a 60% distal eccentric lesion. The LAD had only mild diffuse
disease. The RCA had a 70% mid stenosis and a focal 80% ostial
PDA. There was moderately elevated right and left heart filling
pressures with moderate pulmonary
hypertension.
.
Most recent testing:
[**2173-4-14**] ETT: 3 minutes 30 seconds Modified [**Doctor First Name **] protocol, 98%
max PHR, stopping due SOB. No chest pain. Imaging: no ischemia
or
MI. LVEF 51%.
.
ROS: Denies orthopnea, PND
+ Intermittent LE edema (wears compression stockings)
+ Occasional palpitations, unrelated to activity
+ Frequent lightheadedness associated with bending down or
climbing stairs
+ Bilateral calf cramping with walking one mile
Past Medical History:
Hypertension, difficult to control
Diabetes
CHF
Pacemaker
Atrial fibrillation
CRI - baseline 1.8
Gout
CEA (patient reports a left CEA, CCC mentions right CEA)
Glaucoma
GERD
COPD
[**2172**] pneumonia
Hemorrhoids
Social History:
Patient lives with his significant other [**Name (NI) 1258**]
[**Name (NI) 52326**]; Patient previously smoked 3 packs a day. He quit in
[**2154**]
Family History:
Sister s/p CABG at age 57. Brother with CAD in
his 50's
Physical Exam:
AVSS
AAOX3 NAD
RRR
CTAB
S/NT/ND
Warm no edema
Pertinent Results:
[**2175-1-12**] CXR: PORTABLE AP CHEST (TWO VIEWS): There is a
left-sided pacemaker with leads terminating in the right atrium
and right ventricle. The heart size is normal. The mediastinal
contours are normal. There is no pulmonary vascular congestion.
The lungs are clear. There is no pleural effusion or
pneumothorax.
.
[**2175-1-12**] Cath: 60% LM disease, 70% RCA, 80%RPDA (all are old and
stable) and then a new 90% LAD lesion
.
[**2175-1-12**] Carotid u/s: IMPRESSION:
1. 80-99% left ICA stenosis.
2. Widely patent right common and internal carotid arteries in
this patient who is apparently status post right carotid
endarterectomy.
.
[**2175-1-12**] ECHO:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is [**4-27**]
mmHg. There is moderate symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is low normal (LVEF
50%) secondary to hypokinesis of the interventricular septum.
Mild (1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal.
There is a trivial/physiologic pericardial effusion.
.
[**2175-1-13**] Stent to carotid artery: FINAL DIAGNOSIS:
1. Critical left internal carotid artery stenosis.
2. Successful angioplasty and stenting of the left internal
carotid
artery using a 6.0/8.0x30mm Acculink self expanding stent.
.
Brief Hospital Course:
Mr. [**Known lastname **] 67 year-old man with worsening chest pain and known CAD
who was
referred for cardiac catheterization. He was found to have LM
(60%), RCA (70%) RPDA 80%, (these are old) and new LAD (90%)
lesion. No intervention was performed and he was evaluated for
CABG.
.
# cardiac:
ISCHEMIA: patient was found to have 3 vessel disease during cath
and no intervention was done. He was worked up for CABG. During
this work up, his right internal carotid artery was found to be
80-99% stenosed although he was asymptomatic. He was taken back
to the cath lab and had successful carotid artery stenting done
in preparation for CABG. He was evaluated by neurology prior to
stenting procedure.
.
While awaiting CABG, his blood pressure was controlled with his
home medications of metoprolol, valsartan, lisinopril, imdur and
labetolol gtt. His goal range of SBP was 140-160. (His high end
SBP was 200 without labetolol gtt.) He was continued on aspirin
and plavix and a statin.
.
RHYTHM - Patient is s/p pace maker placement. Patient has been
in atrial fibrillation with good rate control. He was
maintained on a heparin gtt and rate controlled with metoprolol
and digoxin (home meds).
.
PUMP - Patient was clinically euvolemic. ECHO showed LVH, with
EF 50%. His home furosemide was given only on a prn basis.
.
# CRI - Old studies report no history of RAS. His CRI is likely
secondary to his hypertension (at home he reports running around
SBP 180's). His baseline Cr is 1.8 and this remained stable.
.
# DM - he was maintained on his insulin SS and home standing
NPH for diabetes control. He was also maintained on his
neurontin for neuropathy.
.
# Gout - patient complains of feeling beginnings of gout
symptoms on left foot. No evidence of clinical gout. He takes
colchicine at home to help and was given a dose of colchicine
.
# ppx - bowel reg, heparin gtt, H2blocker
.
# Full code
.
# communication - [**First Name9 (NamePattern2) 52327**] [**Last Name (un) 52326**] [**Telephone/Fax (1) 52328**] wife
Cardiac Surgery Discharge summery
The patient was taken to the operating room on [**2175-1-16**] where he
under wwent:
1. Coronary artery bypass grafting x3 with the left internal
mammary artery to the left anterior descending artery,
and reverse saphenous vein graft to the distal right
coronary artery and the circumflex artery.
2. Modified Maze procedure using the cryoablation with
Resection of Left Atrial Appendage.
3. Endoscopic greater saphenous vein harvest of the left
leg.
4. EpiAortic Duplex Scan
Postopeerativly he was admitted to the ICU. His post operative
course was complicated by acute reanl failure and RV
dsyfunction. He underwent cardiac catheterization on POD1 where
the acute marginal artery was found to be occluded. He
underwent successful balloon angioplasty of this vessel and
placement of an intra-aortic balloon pump. Post-procedure the
patient remained intubated and was receiving BP support. While
in the ICU the patient was in acute renal failure and received
several days of CVVHD his maximum creatineane was 3.8 the pt was
also placed of enteral feeding while in the ICU. Eventualy the
pt was weaned of pressors and of the vent and successfully
extubated. The patient also had reatun of renal function and
was able to be weaned off dialysis. The patients post operative
course was complicated by a fib for which he received amioderone
and beta blocker therapy. At the time of discharge the patient
had good pain control on po pain medications. He was in normal
sinus rhythm and on an an amoiderone taper. His O2 sats were
greater then 92% on 2L NC of suplemental oxygen. He was
tolerating a regular diet and he had good blood sugar control on
a regular insulin sliding scale. He had return of renal
function. At the time of discharge his serum creatinine was 3.1
and he was makung urine without the aid of diuretics. At the
time of discharge his hematocrit was stable he was a febrile and
his white blood cell count was not elevated. The pt was
evaluated by physical therapy and is able to ambulate with
assistant however he would desaturate to 88% on RA with
mobility. The patient will benefit from acute rehab.
Medications on Admission:
Humalog 75/25 25-30 units every morning, 84-86 units every
evening at 7pm
Diovan 160mg twice a day
Digitek .125mg daily every morning
Furosemide 40mg, two tablets every morning, two tablets at 12pm
Gabapentin 600mg one every morning
Imdur 60mg daily every morning
Lipitor 10mg daily every evening
Lisinopril 10mg daily every evening
Lopressor 50mg, two tablets twice a day
Minoxidil 2.5mg daily every evening
Norvasc 5mg daily every evening at 7pm
KCL 10meq, two capsules three times a day
Ranitidine 150mg daily at 7pm
Coumadin 5mg, last dose on [**2175-1-5**] (had been taking 5/2.5/2.5
cycles)
Methazolamide 25mg, three times a day
Colchicine 0.6mg prn for gout
Advair inhaler prn
Albuterol inhaler prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Date Range **]:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Date Range **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
[**Date Range **]:*80 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*0*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Take one tablet daily or as directed by MD.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
[**Last Name (Titles) **]:*360 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO take one
tablet two times per day for seven days then take one tablet one
time per day.
[**Last Name (Titles) **]:*35 Tablet(s)* Refills:*0*
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
[**Last Name (Titles) **]:*1 * Refills:*2*
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*1 * Refills:*0*
10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
[**Hospital1 **]:*90 Capsule(s)* Refills:*0*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Hospital1 **]:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**]
Discharge Diagnosis:
CAD
Hypertension, difficult to control
Diabetes
CHF
Pacemaker
Atrial fibrillation
CRI - baseline 1.8
Gout
CEA (patient reports a left CEA, CCC mentions right CEA)
Glaucoma
GERD
COPD
[**2172**] pneumonia
Hemorrhoids
Discharge Condition:
Stable
Discharge Instructions:
may shower over incisions and pat dry
no lotions , creams or powders on any incision
no driving for one month
no lfting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 3314**] or PCP [**Last Name (NamePattern4) **] [**12-20**] weeks
see Dr. [**Last Name (STitle) 7047**] in [**2-19**] weeks
see Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2175-2-6**]
|
[
"41401",
"4280",
"496",
"42731",
"5845",
"486",
"2724",
"25000",
"40390"
] |
Admission Date: [**2118-9-1**] Discharge Date: [**2118-9-13**]
Date of Birth: [**2054-4-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2118-9-6**] - CABGx4 (left internal mammary->Left anterior
descending artery, Saphenous vein graft(SVG)->Diagonal artery,
SVG->Obtuse marginal artery, SVG->Right coronary artery).
[**2118-9-2**] - Cardiac Catheterization
History of Present Illness:
Patient is a 64 year old female with past medical history of
hypertension, hyperlipidemia, and GERD, who presented to [**Hospital1 18**]
[**Location (un) 620**] on [**2118-8-29**] with chest pain. She was ruled out for a
myocardial infarction and underwent an exercise tolerance test.
In addition, she was having DOE for past 6 weeks including when
she climbs stairs. When she walks less than a quarter of a
mile, she has to sit down and rest bc of dyspnea and chest
pressure. During these episodes she never has syncope,
palpatation, diaphoresis, N/V or blurry vision. Of note, the
patient has been less active that usual because of
deconditioning after bladder surgery and complications.
.
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, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. All of the other review
of systems were negative except patient has had nasal congestion
and mild cough with URI for past week and a half. She also had
reported an increase in stress and guilt in her life and
resulting anxiety.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
HTN
hyperlipidemia
recent rectocele that was repaired w complications including
urinary retention, and required self cath for the past few weeks
GERD
Social History:
Social history is significant for the absence of current tobacco
use. She occasionally drinks alcohol.
Family History:
Mother had CABG at age of 57 and then again at 69 yo, now alive
with Alzhemiers. Father alive with diabetes.
Physical Exam:
Admission:
VS - T 97.5 BP 111/77 HR 71 RR 18 O2sat 95% RA
Gen: WDWN middle aged 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 no JVP, no LAD, no carotid bruits
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, 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 not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, or xanthomas. .
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2118-9-1**] 07:14PM GLUCOSE-146* UREA N-14 CREAT-0.8 SODIUM-140
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
[**2118-9-1**] 07:14PM estGFR-Using this
[**2118-9-1**] 07:14PM ALT(SGPT)-39 AST(SGOT)-30 LD(LDH)-147
CK(CPK)-75 ALK PHOS-64 TOT BILI-0.3
[**2118-9-1**] 07:14PM CK-MB-NotDone cTropnT-<0.01
[**2118-9-1**] 07:14PM ALBUMIN-4.2 CALCIUM-9.6 PHOSPHATE-3.4
MAGNESIUM-2.2
[**2118-9-1**] 07:14PM TSH-1.5
[**2118-9-1**] 07:14PM PT-13.8* PTT-42.8* INR(PT)-1.2*
[**2118-9-1**] 07:14PM PLT COUNT-244
[**2118-9-1**] 07:14PM WBC-7.1 RBC-4.07* HGB-12.1 HCT-36.2 MCV-89
MCH-29.8 MCHC-33.5 RDW-12.7
[**2118-9-1**] 07:14PM TSH-1.5
[**2118-9-2**]:EKG demonstrated minor ST depressions in V4-V6.
Stress echo: 1. average exercise tolerance for age
2.Normal HR and BP response to exercise
3.ST depression of 1.5mm however, baseline EKG had nonspecific T
wave changes, thus decreasing the specificity of the EKG
4.Echo images reported separately.(we do not have the records of
this.)
.
LABORATORY DATA:
[**Age over 90 2239**]|104|14 glc146 AGap=13
-----------
4.0|27 |0.8
CK: 75 MB: Notdone Trop-T: <0.01
Ca: 9.6 Mg: 2.2 P: 3.4
ALT: 39 AP: 64 Tbili: 0.3 Alb: 4.2
AST: 30 LDH: 147
\12.1/
7.1------244
/36.2\
PT: 13.8 PTT: 42.8 INR: 1.2
[**2118-9-2**] Cardiac Catheterization
1. Selective coronary angiography of this right dominant system
revealed
three-vessel coronary artery disease. The LMCA was normal. The
LAD had
diffuse disease with an intra-myocardial portion. There is a
large D1
with a mid-segment tubular 90% lesion and a 90% proximal lesion.
The
non-dominant LCX had a long, tubular 90% OM1 stenosis. The
dominant RCA
had a focal 90% proximal lesion.
2. Resting hemodynamics demonstrated normal systemic arterial
pressures
of 138/76 mmHg. Left and right sided filling pressures were
normal, with
LVEDP of 12 mmHg, mean PCW of 9 mmHg, RVEDP 10 mmHg. Calculated
cardiac
index was 2.6 l/min/m2. There was no transaortic gradient on
pullback of
catheter from LV to aorta.
3. Left ventriculogram demonstrated no significant mitral or
aortic
regurgitation. Calculated LVEF was 56% without wall motion
abnormalities.
[**2118-9-5**] Carotid Duplex Ultrasound
No stenosis of the carotid arteries bilaterally.
[**2118-9-6**] ECHO
PRE-BYPASS:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. No
aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. There is
myomatous degeneration of the mitral valve. Moderate prolapse of
the posterior mitral valve leaflet. Mild prolapse of the
anterior mitral valve leaflet. Mild MR.
7. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced.
1. LV function is preserved.
2. Aorta is intact post decannulation.
3. Other findings are unchanged
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2118-9-1**] for further
management of her angina. A cardiac catheterization was
performed which showed severe multi-vessel disease. Given the
severity of her disease the cardiac surgical service was
consulted for surgical management. Mrs. [**Known lastname **] was worked-up in
the usual preoperative manner including a carotid duplex
ultrasound which was negative for stenosis of the carotid
arteries bilaterally. An echocardiogram was performed which
showed mild symmetric LVH with preserved regional and global
biventricular systolic function and mild prolapse of the
posterior leaflet of the mitral valve with trivial mitral
regurgitation. On [**2118-9-6**], Mrs. [**Known lastname **] was taken to the
operating room where she underwent coronary artery bypass
grafting to four vessels. Postoperatively she was transferred to
the intensive care unit for monitoring. Within 24 hours, she
awoke neurologically intact and was extubated. Beta blockade,
aspirin and a statin were resumed. On postoperative day two, she
was transferred to the step down unit for further monitoring.
She was gently diuresed towards her preoperative weight. The
physical therapy service was consulted for assistance with her
postoperative strength and mobility.
During her post-operative course she developed numerous bouts of
paroxysmal rapid atrial fibrillation. She was loaded on
amiodarone, metoprolol, and started on Coumadin. By post-op day
6 she remained AFIB free for greater than 24 hours. INR was 1.3
on discharge.
Mrs. [**Known lastname **] continued to make steady progress and was discharged
home on postoperative day 7. She will follow-up with Dr.
[**Last Name (STitle) **], Dr [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **], the coumadin clinic at [**Hospital1 18**]
[**Location (un) 620**] and her primary care physician as an outpatient.
Medications on Admission:
- Aspirin 325 mg
- Levoxyl 50 mcg
- Lisinopril 5 mg
- Lorazepam 0.5 mg as needed
- Simvastatin 10 mg
- Cepacol TID PRN
- Saline nasal spray
- Omeprazole 40 mg
- Multivitamin
- Calcium with vitamin D TID
.
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses: Please follow up with your physician to monitor your INR
and adjust your dose.
Disp:*10 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 7 days.
Disp:*7 Tablet Sustained Release(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): You will take two tablets twice daily for one week. Then
two tablets once daily for one week. And lastly one tablet once
daily for 2 weeks.
Disp:*120 Tablet(s)* Refills:*0*
11. Miconazole-3 200-2 mg-% (9 g) Combo Pack Sig: One (1)
Vaginal HS (at bedtime) for 3 days.
Disp:*3 * Refills:*0*
12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Area VNA
Discharge Diagnosis:
CAD s/p CABGx4
HTN
Hyperlipidemia
GERD
Rectocele
Hypothyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
You have an apppointment with Dr. [**First Name (STitle) **] in [**Hospital1 18**] [**Location (un) 620**] on
Tuesday [**2118-9-27**] at 10am. Go in the main entrance which is
on the side because of construction. You must register as a new
patient downstairs before going up to his office.
Please also call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8430**] [**Telephone/Fax (1) 8431**] to schedule a
follow up appointment to be seen in 2 weeks.
Completed by:[**2118-9-13**]
|
[
"41401",
"4019",
"2724",
"53081",
"42731",
"2449"
] |
Admission Date: [**2190-4-25**] Discharge Date: [**2190-5-5**]
Date of Birth: [**2113-3-23**] Sex: F
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:
Emergent repair of Asc. Aorta/hemiarch(#36Gelweave)AVR(#21 CE
Magna pericardial)CABGx1(SVG-PDA)[**4-25**]
History of Present Illness:
77 y/o woman with 1 week of vague chest discomfort, worsened on
day of admission, presented to OSH, found to have Type A aortic
dissection, transferred for definitive care
Past Medical History:
50 pk yr smoker
s/p hysterectomy
s/p cataract extractions
Social History:
Lives independently
50 pk year smoker
Family History:
non-contributory
Physical Exam:
Deferred - patient taken emergently to operating room.
Discharge:
VS T 97 HR 83 SR BP 129/82 RR 18 O2sat 95% 2LNP
Gen NAD, sitting in chair
Neuro Alert oriented to person/place(city)/time(month). Left
upper and lower extremity weakness, UE>LE. Strength improved
over last several days.
Pulm Scattered rhonchi
CV RRR, no murmur. Sternum stable, incision CDI. Lft clavicle
incision w/steris CDI
Abdm Soft, NT/+BS
Ext Warm 1+ pedal edema bilat
Pertinent Results:
[**2190-5-5**] 06:15AM BLOOD WBC-14.7* RBC-3.12* Hgb-9.2* Hct-28.3*
MCV-91 MCH-29.6 MCHC-32.7 RDW-13.9 Plt Ct-358
[**2190-5-4**] 05:10AM BLOOD WBC-15.4* RBC-2.99* Hgb-8.9* Hct-27.1*
MCV-91 MCH-29.9 MCHC-33.0 RDW-14.0 Plt Ct-371
[**2190-5-3**] 06:10AM BLOOD WBC-17.3* RBC-3.06* Hgb-9.3* Hct-27.8*
MCV-91 MCH-30.5 MCHC-33.5 RDW-14.1 Plt Ct-444*
[**2190-4-25**] 06:48AM BLOOD WBC-13.0* RBC-2.45* Hgb-7.2* Hct-22.1*
MCV-90 MCH-29.4 MCHC-32.6 RDW-13.0 Plt Ct-152
[**2190-5-5**] 06:15AM BLOOD PT-18.1* INR(PT)-1.7*
[**2190-5-4**] 05:10AM BLOOD PT-24.6* INR(PT)-2.4*
[**2190-5-3**] 06:10AM BLOOD PT-24.5* PTT-38.9* INR(PT)-2.4*
[**2190-5-2**] 04:30AM BLOOD PT-24.8* PTT-39.0* INR(PT)-2.4*
[**2190-4-25**] 06:48AM BLOOD PT-16.5* PTT-58.6* INR(PT)-1.5*
[**2190-5-5**] 06:15AM BLOOD UreaN-14 Creat-0.4 K-3.7
[**2190-5-3**] 06:10AM BLOOD Glucose-81 UreaN-19 Creat-0.5 Na-144
K-4.0 Cl-110* HCO3-22 AnGap-16
[**2190-4-25**] 08:21AM BLOOD UreaN-11 Creat-0.5 Cl-116* HCO3-20*
[**2190-5-2**] 10:55AM BLOOD ALT-26 AST-25 LD(LDH)-342* AlkPhos-71
Amylase-17 TotBili-0.3
[**2190-4-30**] 01:23AM BLOOD ALT-19 AST-24 LD(LDH)-410* AlkPhos-63
Amylase-15 TotBili-0.4
RADIOLOGY Final Report
CHEST (PA & LAT) [**2190-5-2**] 1:36 PM
CHEST (PA & LAT)
Reason: pna
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with inrease WBC
REASON FOR THIS EXAMINATION:
pna
CHEST RADIOGRAPH
INDICATION: Followup.
COMPARISON: [**2190-4-29**].
FINDINGS: As compared to the previous examination, the
introduction sheath right has been removed. Otherwise, the
radiograph is almost unchanged. There is slight cardiomegaly
with retrocardiac atelectasis and evidence of bilateral pleural
effusion that lead to blunting of the costophrenic sinuses. In
the interval, no parenchymal opacities suggestive of pneumonia
have occurred. Unchanged surgical clips in projection over the
lateral aspect of the second and third rib.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 78045**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78046**]
(Complete) Done [**2190-4-25**] at 3:39:16 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2113-3-23**]
Age (years): 77 F Hgt (in): 62
BP (mm Hg): 112/84 Wgt (lb): 150
HR (bpm): 92 BSA (m2): 1.69 m2
Indication: Intra-op TEE for Type A dissection repair
ICD-9 Codes: 440.0, 441.00, 424.1
Test Information
Date/Time: [**2190-4-25**] at 03:39 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Left Ventricle - Stroke Volume: 69 ml/beat
Left Ventricle - Cardiac Output: 6.36 L/min
Left Ventricle - Cardiac Index: 3.76 >= 2.0 L/min/M2
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: *4.8 cm <= 3.4 cm
Aorta - Arch: *3.3 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.0 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.6 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *26 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 14 mm Hg
Aortic Valve - LVOT pk vel: 0.90 m/sec
Aortic Valve - LVOT VTI: 22
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *1.2 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Moderately
dilated ascending aorta. Mildly dilated aortic arch. Simple
atheroma in aortic arch. Mildly dilated descending aorta. Simple
atheroma in descending aorta. Ascending aortic intimal
flap/dissection..
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. Moderate AS (AoVA 1.0-1.2cm2) Moderate
(2+) AR.
MITRAL VALVE: Physiologic MR (within normal limits).
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Small 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. See Conclusions for post-bypass data The
post-bypass study was performed while the patient was receiving
vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. No spontaneous echo contrast is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
2. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is moderately dilated. The aortic arch is
mildly dilated. There are simple atheroma in the aortic arch.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. A mobile
density is seen in the ascending aorta consistent with an
intimal flap/aortic dissection. 5. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate
(2+) aortic regurgitation is seen.
6. Physiologic mitral regurgitation is seen (within normal
limits).
7. There is a small pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced.
1. A bioprosthesis is well seated in the Aortic position.
Leaflets move well. No significant AI. Mean gradient of 10 mm of
Hg with CO of 4.2 l/min.
2. Biventricular function is preserved.
3. An ascending aortic graft is noted.
4. Other changes are unchanged.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2190-4-25**] 07:13
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2190-4-29**] 4:58 PM
CT HEAD W/O CONTRAST
Reason: assess for cva
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman s/p AVR/Asc Ao repair/cabg
REASON FOR THIS EXAMINATION:
assess for cva
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 77-year-old female status post aortic valve replacement
and CABG. Please assess for CVA.
TECHNIQUE: Non-contrast head CT.
COMPARISON: None.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or infarction. There is extensive periventricular and
subcortical white matter hypodensity, most consistent with
sequelae of chronic small vessel ischemic disease, and there is
probably a more focal area of chronic encephalomalacia in the
left occipital lobe. Mild ventricular prominence may be
consistent with age-related atrophy. Otherwise, ventricles and
sulci are unremarkable in size and configuration.
There is no fracture. Note is made of marked calcification of
the bilateral cavernous internal carotid arteries, basilar
artery, and bilateral vertebral arteries.
Minor mucosal thickening is seen in the ethmoid air cells.
IMPRESSION: No acute intracranial process. Marked chronic
microangiopathic changes. Please note that MRI, with
diffusion-weighted imaging is more sensitive for the detection
of acute brain ischemia.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5718**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Brief Hospital Course:
She was admitted directly to the OR for emergent repair of Type
A aortic dissection, please see OR report for details. In
summary she had an Ascending Aorta Hemiarch Replacement with
26mm Gelweave graft/Aortic valve replacement with 21mm CE Magna
pericardial valve/CABGx1 with SVG-PDA. Her bypass time was 152
minutes, her crossclamp time was 136 minutes, and circulatory
arrest time was 1 minute/total body with 25 minutes for lower
body circ arrest. She tolerated the operation and was
transferred to the ICU in stable condition.
She was kept sedated throughout the operative day, on POD1-2 she
was slowly diuresed and weaned form the venitlator and was
extuabted on POD #3. She was noted to have Left sided weakness,
a Head CT was negative despite continued left sided weakness,
she was seen by PT/OT. She remained in the ICU for pulmonary
toilet, hemodynamically she was stable and her respiratory
status improved and was transferred to the floor on POD #6. A
u/a revealed UTI and she was started on cipro. Over the next
several days the patients activity was advanced with the
assistance of nursing and PT. Her medical regime was refined and
on POD 10 she was transferred to rehabilitation.
Medications on Admission:
None.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain. Tablet(s)
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day): Until fully ambulatory.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Flovent Diskus 50 mcg/Actuation Disk with Device Sig: One
(1) Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 24402**], ME
Discharge Diagnosis:
s/p emergent Asc Ao replacement/AVR/CABG
Post-operative left sided weakness UE>LE
PMH:Type A Aortic Dissection/coronary sinus dissection
s/p hysterectomy
s/p cataract removal
tobacco abuse
Discharge Condition:
stable
Discharge Instructions:
No lifting > 10 # for 10 weeks
may shower, no creams or lotions to any incisions
no driving for 1 month
Followup Instructions:
With PCP [**Last Name (NamePattern4) **] [**3-14**] weeks
with Dr. [**First Name (STitle) **] in [**5-15**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2190-5-5**]
|
[
"5990",
"4241",
"41401",
"4019",
"3051"
] |
Admission Date: [**2197-10-21**] Discharge Date:
Date of Birth: [**2127-3-9**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
gentleman with chronic pancreatitis who presented early in
[**2195**] with a 23 pound weight loss and jaundice. At that time
patient was found to have dilated biliary ducts on CT scan.
Patient underwent multiple ERCP procedures and common bile
multiple removals and revisions of stents due to infection.
Patient's washings for cytology from his multiple ERCP
procedures were all negative for malignant cells. Patient
underwent choledochojejunostomy in [**2196-6-26**] to bypass
biliary obstruction from the common bile duct. Patient had
multiple pancreatic biopsies at that time that were negative
for malignancy. Patient did well until several months later
the spring of [**2196**] for nutritional support as well as
undergoing gastrojejunostomy to bypass the duodenum secondary
to gastroparesis. Patient has had increasing ascites for the
last several months which was tapped at an outside hospital
and found to be exudative. Patient presented to [**Hospital6 11896**] with several hours of vomiting blood on
[**2197-10-16**]. Patient was found to be hypotensive in the
emergency room with hematocrit of 19. Patient was
resuscitated with packed red blood cells and propranolol.
Patient was found to have grade 2 varices on EGD on [**10-17**]
that were not acutely bleeding. Over the next few days
patient was treated with fluids and medicated for anxiety
with large quantities of opiates and benzodiazepines.
Patient became increasing obtunded and was eventually
transferred to [**Hospital1 18**] for liver biopsy. Of note, patient had
two negative ultrasounds of his right upper quadrant which
ruled out [**Hospital1 32004**] vein thrombosis. On presentation patient
had developed coagulopathy with increased PT/PTT.
PAST MEDICAL HISTORY: As per HPI. Also a history of
coronary artery disease status post CABG. History of
hypertension. History of type 2 diabetes. History of
pulmonary nodules. History of post traumatic stress
disorder.
ALLERGIES: Morphine and codeine as well as plastic tape,
nylon tape.
MEDICATIONS ON TRANSFER: Elavil 25 mg p.o. once a day,
Ambien 10 mg p.o. once a day, Duragesic 75 mg q.72 hours,
Risperdal 0.5 mg b.i.d., Ativan p.r.n., tobramycin eyedrops,
Lacri-Lube eyedrops, lactulose 30 cc b.i.d., Inderal 20 mg
t.i.d., Protonix GGT at 8 mg per hour, regular insulin
sliding scale as well as 15 of NPH and 4 units of regular
insulin in the morning.
PHYSICAL EXAMINATION: On admission temperature was 98.3,
blood pressure 122/70, pulse 80, breathing 30 times a minute,
sating 93% on 2 liters. Patient was obtunded. He moved his
extremities spontaneously, but did not respond to sternal
rub. Pupils were equal, round and reactive to light
bilaterally. Chest was roughly clear to auscultation,
although patient had minimal inspiratory effort.
Cardiovascular exam revealed regular rate, normal S1, S2, no
murmurs. Abdomen was distended and firm with caput medusae.
Patient had a recently healed midline incision. Patient had
normoactive bowel sounds. Extremities showed trace edema
bilaterally in his lower extremities. On neurological exam
patient was unable to follow commands. He did have
withdrawal to painful stimuli on his extremities, but did not
respond to sternal rub and did spontaneously move all four
extremities.
LABORATORY DATA: Chest x-ray on admission showed patchy
infiltrates diffusely in the right lung versus question of
right sided effusion. Electrolytes on admission were sodium
139, K 4.0, chloride 108, bicarb 23, BUN 15, creatinine 0.6.
Free calcium was 1.13. INR was 1.5, PTT 31.9. Patient had
white count of 9.6, hematocrit 34, platelets 206. Patient's
t-bili was 1.8, alka phos was markedly elevated at 318, LDH
was elevated at 179, AST and ALT were mildly elevated at 52
and 48 respectively. Patient's albumin on admission was 2.4.
Patient's ABG on admission was 7.50, 30, 57 on 2 liters nasal
cannula which improved to 7.54, 26 and 198 on 100% face mask.
ASSESSMENT: In short, this is a 70 year old male with a long
complicated GI history who presented with new ascites in the
last several months and with a large GI bleed at [**Hospital6 11896**] on [**2197-10-16**]. Patient is hemodynamically
stable with stable hematocrit, but completely obtunded and
with new coagulopathy on admission.
HOSPITAL COURSE:
1. Encephalopathy. Patient was found to be profoundly
encephalopathic upon admission. It was not clear whether
this was entirely due to hepatic encephalopathy or due to
excessive sedation. All sedative medications were held for
the course of the patient's hospitalization. Patient was
started on lactulose. Patient's mental status improved with
lactulose throughout the next several days. Patient was
alert and oriented, able to follow conversation, although did
remain somewhat confused about larger issues. Patient
remained alert and oriented throughout the rest of his
hospital stay on lactulose.
2. GI bleed. Patient had a large GI bleed at the outside
hospital. Because of this patient was started on octreotide,
Protonix infusion and continued on propranolol. Serial
hematocrits were checked. Patient underwent banding of his
varices on [**2197-10-26**]. At that time patient's EGD report noted
grade 3 varices in the lower third of the esophagus that were
not bleeding.
3. Hepatic decompensation. Patient had elevated LFTs upon
admission and no clear cause for his liver failure.
Ultrasound of the right upper quadrant was repeated in-house
which did show nonocclusive [**Date Range 32004**] vein thrombosis. Patient
was transferred, as noted above, for transjugular liver
biopsy which patient underwent. Unfortunately, there was not
enough sample tissue obtained to make a definitive diagnosis.
However, the tissue that was present was suggestive of
cirrhosis. Patient's LFTs trended down and were within
normal limits upon the time of discharge with the exception
of his coagulation factors and his albumin which remained
markedly elevated and depressed respectively. Patient did
have difficulty with ascites during his hospitalization. He
was started on spironolactone to try to mobilize fluid with
some success. However, patient continued to develop
progressive ascites and lower extremity edema. Patient had a
diagnostic tap upon admission which was consistent with
transudative ascitic fluid secondary to [**Date Range 32004**] hypertension,
grew no organisms and gram stain was unremarkable. At the
time of this dictation therapeutic tap of patient's ascites
was being considered.
4. Infectious disease. Patient was thought to have
aspiration pneumonia upon admission and was started on levo
and Flagyl of which he was supposed to finish a 10 day
course. Unfortunately, patient lost the GJ-tube that had
been placed at the outside hospital and had a new tube
replaced which, unfortunately, became infected and began to
show purulent discharge. Because of this patient was
continued on levo and Flagyl and started on vanco. At the
time of this dictation patient has been afebrile with a
steady white blood cell count. He is currently on vanc, levo
and Flagyl. However, he will likely continue to be treated
with vancomycin alone since he has a history of MSSA.
Cultures are pending at the time of this dictation.
5. Hematology. Patient's hematocrit remained roughly stable
throughout the course of his admission, between 28 and 32.
Patient's hematocrit was monitored frequently. Patient had
no evidence of acute bleeding during the course of his
hospital stay. Patient's platelets were 206 on admission.
They trended down to a nadir of 96. Heparin antibodies were
checked and found to be negative. Patient's platelets were
continued to be followed. They remained stable in the low
100s at the time of this dictation. Patient's INR and PTT
remained elevated throughout the course of his
hospitalization. He had minimal response to p.o. vitamin K.
His INR was as high as 2.2. PTT was as elevated as 45.
Patient had been switched from p.o. to subcu vitamin K and
his coagulation factors were trending down at the time of
this dictation.
6. Endocrine. Patient had a history of type 2 diabetes
requiring insulin. While patient was NPO, he was maintained
on regular insulin sliding scale. When patient was fed p.o.
and/or taking tube feeds, he was maintained on NPH standing
dose as well as regular insulin sliding scale with good
glycemic control.
7. Fluids, electrolytes and nutrition. Nutrition was a
[**Last Name 16423**] problem during the patient's admission. His G-tube
fell out and needed to be replaced, which was done under
fluoroscopy in interventional radiology. Patient tolerated
tube feeds well, however, his tube began to show purulent
discharge several days after it was placed surrounding the
opening site. Patient had marked tenderness around the site.
Feeds were stopped and patient was started on antibiotics.
The discharge around the site resolved after treatment with
vancomycin as did the tenderness and erythema. At this
dictation it is still being decided whether patient should be
fed with tube feeds versus TPN. Another issue with his
GJ-tube is that as his ascites has expanded, patient has
begun to develop leakage of stool around the GJ-tube site.
Tube placement was checked again by IR. It was not found to
be leaking into the peritoneum. It was thought that the
stool is likely small bowel contents refluxing into patient's
gastric space. It should be noted again that patient has
gastrojejunostomy secondary to gastroparesis and the tube
itself is a GJ-tube. Patient required frequent repletion of
his calcium, potassium and magnesium while in-house.
8. Cardiovascular. Patient had a history of coronary artery
disease. This issue was not active during the course of his
hospitalization. Patient had no signs of heart failure or
ischemia.
9. Renal. Patient had good urine output while he had a
Foley in. However, once the Foley was discontinued, patient
had some difficulty urinating and needed to be straight
cathed several times for urine output. Patient's urine was
checked and sent for culture. Cultures were negative two
days prior to discharge. Patient's BUN and creatinine
remained stable throughout the course of his hospitalization.
10. Psych. Patient has a history of post traumatic stress
disorder secondary to having been imprisoned in a Japanese
war camp in the [**Country 31115**] as a child. Patient has a great
deal of anxiety and claustrophobia secondary to this.
Patient was evaluated by psychiatry in-house who felt patient
would benefit from Risperdal. Patient was treated with
Risperdal throughout the course of his hospitalization with
good control of his anxiety. Patient's family also brought
patient a VCR on which he watched movies which also helped
soothe patient's anxiety. Psychiatry felt patient likely had
some element of reversible dementia and should have formal
neurocognitive evaluation as an outpatient.
11. Disposition. At this time patient is awaiting rehab
placement or transfer back to [**Hospital6 **] to be cared
for by [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 3100**] who is his primary gastroenterologist.
At this time patient is in stable condition.
MEDICATIONS AT TIME OF DICTATION:
1. Regular insulin sliding scale.
2. Propranolol 20 mg p.o. or per NG t.i.d. with parameters
to hold for systolic blood pressure less than 100.
3. Protonix 40 mg p.o. b.i.d.
4. Risperdal 1.5 mg p.o. b.i.d. as well as 1 mg p.o. b.i.d.
p.r.n. agitation.
5. Levofloxacin 500 mg p.o. q.24 hours.
6. Flagyl 500 mg t.i.d.
7. Vancomycin 1 gm q.12 hours.
8. Vitamin K 10 mg subcutaneously q.day.
9. Lacri-Lube ointment ophthalmologic as well as tobramycin
ophthalmologic solutions.
10. Lactulose 30 mg p.o. q.eight hours p.r.n. titrated to
four bowel movements a day.
DISCHARGE DIAGNOSES:
1. Cirrhosis, etiology unclear.
2. [**Name2 (NI) **] vein thrombosis, nonocclusive.
3. Esophageal varices, status post banding.
4. Hepatic encephalopathy.
5. Coronary artery disease, status post CABG.
6. Type 2 diabetes mellitus.
7. Hypertension.
8. Post traumatic stress disorder.
9. Anxiety.
10. Status post open cholecystectomy.
11. Status post choledochojejunostomy.
12. Status post gastrojejunostomy.
13. Status post GJ-tube placement.
An addendum to this discharge summary will be added at such
as the patient is discharged.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 21723**]
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2197-11-3**] 19:52
T: [**2197-11-3**] 20:31
JOB#: [**Job Number 106625**]
|
[
"5070"
] |
Admission Date: [**2189-5-6**] Discharge Date: [**2189-5-21**]
Date of Birth: [**2138-6-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
MICU-->Acetaminophen overdose/respiratory distress
floor--> fulminant hepatic failure [**1-28**] acetominophen OD
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50F Hepatitis C, IVDU found down by sister and brought to OSH.
Apparently suicide note left at scene. Pt was last seen over 24
hours ago. Pt was intubated in the field. Narcan 4mg IM given en
route to OSH by EMS. Upon arrival to OSH ED, VS T 85 BP 66/28 P
88 Pox 97% on ventilator. Initial ABG 7.23/22/652 on 100% FiO2
with vent settings PS 10, PEEP 0. Other labs were significant
for tylenol level of 511, INR 2.1 and AST/ALT in the 300-400
range; K 2.6. Hct stable at 51.6. Of note, when NG tube placed,
500cc coffee ground material was retrieved. Patient treated with
charcoal per report, but not per records, given dose of NAC
140mg/kg (total 8.4 grams based on guesstimated weight of 60kg),
vitamin K 10 mg SC x 1, 2.5L NS with 40mEq K, Ativan 1 mg IV x
2, 1 amp HCO3and transferred to [**Hospital1 18**] for further management.
.
In the MICU, pt's HD and respiratory issues stablized. She was
extubated [**5-7**], has been hemodynamically stable since then but
her coagulopathy worsened, LFTs peaked at..., and she was noted
to be intermittently confused and disoriented, progressing to
frank encephalopathy. Her renal function deteriorated as well
[**1-28**] ATN from tylenol, hypotension/UGIB. She was followed by
toxicology,
hepatology, renal and psych services. Not considered transplant
candidate as pt has long hx of chronic, intractable depression
with multiple suicide attempts, and has clearly and consistently
stated plan to die with significantly downward course over last
three years. She received NAC until her INR was <2 and her LFTs
gradually improved. Her creat has been climbing and on day of
transfer is 6.3 (was 0.9 on admission), though her Uop had been
increasing. Given she had no further ICU needs, she was
transferred to the floor for management by the medicine team.
Past Medical History:
: (no records here, usually followed at [**Hospital1 2025**])
1. Hepatitis C (genotype, VL, past Rx); Patient had liver bx at
[**Hospital1 2025**] in [**2186**] which showed mildly active hep C hepatitis, no
cirrhosis.
2. IVDU
3. Psych history-Multiple personality disorder; chronic suicidal
ideation in the past
Last suicide attempt 6 months ago
4. "Very bad lungs" ?emphysema
.
Social History:
: Tobacco 2ppd x 35(+)years; No ETOH abuse; drug addict; ?extra
methadone two days ago; lives at home alone; worked at a drug
treatment program for pregnant women until she relapsed 2 months
ago
.
Family History:
"Alot of psych" per sister
Schizophrenia, bipolar
Father [**Name (NI) 3495**] disease; MI at age 50; had a pacemaker
Mother emphysema
Physical Exam:
On presentation to the MICU:
T 93.6 (oral) BP 92/59 HR 109 RR 30(+)
Vent settings AC 500 x 30 PEEP 4 FiO2 40%
General intubated, sedated, arousal; coffee ground material
suctioned from NGT
HEENT pupils dilated, minimally reactive. right slightly greater
than left.
Heart tachycardic s1 s2 no m/g/r
Lungs CTA B
Abd soft NT, ND, BS(+); transverse scar across abdomen
Ext warm, no edema; 2(+) DP pulses
Neuro arousable, but not oriented, moving all extremities and
responds to pain
.
On transfer:
Gen: Sleeping, NAD, NGT in place
HEENT: icteric sclerae, pupils
CVS: RRR, 2/VI SEM
Chest: CTA B
Abd: soft, NT/ND, NABS
Ext:
Neuro: A&Ox , +asterixis; MAE
Pertinent Results:
On admission:
[**2189-5-6**] 11:51PM GLUCOSE-216* UREA N-16 CREAT-1.1 SODIUM-143
POTASSIUM-3.0* CHLORIDE-107 TOTAL CO2-14* ANION GAP-25
[**2189-5-6**] 11:51PM ALT(SGPT)-435* AST(SGOT)-402* LD(LDH)-469*
ALK PHOS-58 AMYLASE-1171* TOT BILI-0.9
[**2189-5-6**] 11:51PM LIPASE-50
[**2189-5-6**] 11:51PM ALBUMIN-3.7 CALCIUM-7.8* PHOSPHATE-4.0
[**2189-5-6**] 11:51PM OSMOLAL-302
[**2189-5-6**] 11:51PM ASA-NEG ETHANOL-NEG ACETMNPHN-473.4*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-5-6**] 11:51PM WBC-12.5* RBC-5.13 HGB-13.9 HCT-41.2 MCV-80*
MCH-27.0 MCHC-33.7 RDW-16.2*
[**2189-5-6**] 11:51PM NEUTS-87.9* BANDS-0 LYMPHS-8.4* MONOS-3.5
EOS-0.1 BASOS-0.2
[**2189-5-6**] 11:51PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL TARGET-1+ BURR-2+
[**2189-5-6**] 11:51PM PLT SMR-LOW PLT COUNT-135*
[**2189-5-6**] 11:51PM PT-20.4* PTT-38.0* INR(PT)-2.7
.
On d/c:
[**2189-5-13**] 05:55AM BLOOD WBC-12.8* RBC-3.17* Hgb-8.1* Hct-24.0*
MCV-76* MCH-25.6* MCHC-33.9 RDW-16.1* Plt Ct-103*
[**2189-5-12**] 04:03AM BLOOD Neuts-82.7* Bands-0 Lymphs-12.4*
Monos-4.3 Eos-0.3 Baso-0.3
[**2189-5-8**] 02:36AM BLOOD PT-42.8* PTT-49.5* INR(PT)-12.1
[**2189-5-13**] 05:55AM BLOOD PT-14.2* PTT-29.2 INR(PT)-1.3
[**2189-5-13**] 05:55AM BLOOD Glucose-128* UreaN-70* Creat-6.3* Na-148*
K-3.5 Cl-102 HCO3-20* AnGap-30*
[**2189-5-13**] 05:55AM BLOOD ALT-1128* AST-95* AlkPhos-216*
TotBili-3.8*
[**2189-5-8**] 06:28AM BLOOD ALT-9220* AST-[**Numeric Identifier 104156**]* CK(CPK)-4041*
AlkPhos-70 TotBili-3.5*
[**2189-5-13**] 05:55AM BLOOD Calcium-9.9 Phos-4.8* Mg-2.3 Iron-13*
[**2189-5-13**] 05:55AM BLOOD calTIBC-192* Ferritn-225* TRF-148*
[**2189-5-12**] 04:03AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-PND
HAV Ab-POSITIVE
[**2189-5-12**] 04:03AM BLOOD Acetmnp-NEG
[**2189-5-6**] 11:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-473.4*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2189-5-19**] 05:05AM BLOOD WBC-8.2 RBC-3.73*# Hgb-10.6*# Hct-30.5*#
MCV-82 MCH-28.4 MCHC-34.7 RDW-16.4* Plt Ct-90*
[**2189-5-19**] 05:05AM BLOOD Plt Ct-90*
[**2189-5-19**] 05:05AM BLOOD Glucose-73 UreaN-49* Creat-3.7* Na-141
K-3.7 Cl-105 HCO3-23 AnGap-17
[**2189-5-18**] 04:56AM BLOOD ALT-221* AST-36 LD(LDH)-287* AlkPhos-151*
TotBili-1.2
[**2189-5-19**] 05:05AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.6
[**2189-5-12**] 04:03AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE HAV Ab-POSITIVE
CT head: No intracranial hemorrhage is seen.
Repeat: No intracranial hemorrhage is identified. The previously
noted focal hypodensity adjacent to the left frontal gyrus is no
longer apparent, and likely represented an artifact.
.
Abd U/S: ) Patent intrahepatic vasculature. Widely patent main
portal vein, with flow in the appropriate direction.
2) Cholelithiasis, without son[**Name (NI) 493**] evidence of acute
cholecystitis. The dilated common duct is of unknown
significance. Clinical correlation is recommended.
3) Trace perihepatic ascites
.
CXR ([**5-13**]): Increasing alveolar air space opacities most likely
representing aspiration. Small right apical pneumothorax.
Interval extubation.
Echo: The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no pericardial effusion.
.
Video swallow eval: IMPRESSION: Premature spillover leading to
significant aspiration. Moderate residual within the
vallecula/piriform sinuses, requiring multiple swallows to
clear. Please see speech pathologist's report for more detail
and recommendations.
.
CXR:Bilateral upper lobe air space consolidation. No significant
change radiographically compared to [**2189-5-14**].
.
Brief Hospital Course:
A/P: 50F Hepatitis C, IVDU presents from OSH with tylenol OD
level > 500, respiratory failure, ?sepsis.
.
# Respiratory failure-The patient was initially intubated for
airway protection in the field due to diphenhydramine OD
(Tylenol PM). CRX did not show PNA. She was weaned from the vent
and extubated witin 24 hours. She has had not resp issues since.
.
# Tylenol PM overdose/fulminant hepatic failure: Her initial
level was >500 which was very very concerning for potential
fulminant liver failure. She was given NAC infusion uneil her
INR was below 2. Her LFTs, HCT, and coagulation studies were
checked q 4 hours. LFTs and coags both peaked her 4th hospital
day. She was given FFP for an INR of 12. She was maintained on
D10 fluids while her LFTS were climbing and an no episodes of
hypoglycemia. As these trended [**Last Name (un) 8636**], her total bilirubin
begain to rise and she developed asterixs. During her stay,
toxicology and hepatology services were consulting. Since the
patient had recently used IVD, she was not a canditate for
transplant. Her NAC was continued until her Tylenol dose was
undectebale on [**5-12**]. Of note, the patient underwent a liver bx
at [**Hospital1 2025**] (records in chart) in [**2185**] which showed chronic hep C
without cirrhosis. Full Hep panel revealed that she has Ab to
HepBc and HepBs as well as HAV Ab. It is unclear whether the Hep
A Ab represents prior infection vs. immunization; however, her
HepBcAb positivity indicates that she was exposed to the virus
in the past. Hep B VL was pending at discharge and may be
followed-up on an outpatient basis. Pt's LFTs were decreasing
and should be followed for resolution.
.
# Renal failure: [**1-28**] ATN from APAP toxicity/HoTN. The patient's
renal failure was worsening at time of transfer to the floor.
However, it peaked at..and then started to trend down. Dialysis
was not necessary. Her creat was 3.7 on day of discharge. The
renal service followed the pt through her time on the floor.
.
# Acidosis- The patient was admitted with an ABG 7.23/22/300s
c/w and anion gap metabolic acidosis with respiratory
compensation. There was high suspicion for ketoacidosis given
she has been down for an unknown period of time, but urine
ketones negative. Her lactate, however, was 12.5, so likely all
[**1-28**] lactic acidosis from hypotension, low tissue perfusion, and
less likely sepsis. As her renal failure progressed, she
developed a gap metabolic acidosis from uremia and a comcominant
metabolic alkalosis of unknown cause. Her gap closed as her
renal function improved.
.
# GI bleed-At the OSH, the patient reportdely had 500cc of
coffee ground emesis from her NGT once it was placed. Her HCT
decreased here from 41 to 26, but this was likely from the
massive fluid recusatiaion she recieved. No evidence of bleeding
here. She was cotinuted on PPI [**Hospital1 **] and received 4U PRBCs for
HCT<25 with appropriate response. Stools were OB-. She should
have an outpatient EGD in [**4-1**] weeks for further evaluation.
.
# Anemia: The paitent likley has a baseline anemia, exacerbated
by her renal and liver failure and her recent bleed. She was Fe
deficient with a component of ACD. FeSO4 was started and epogen
was initiated. Pt's stools were OB negative and there was no
evidence of hemolysis on lab studies. She should continue to
receive epogen 3000units weekly until her renal function
normalizes. She should be work-up for Fe deficiency as an
outpatient. Her HCT on discharge was 35.
.
# Elevated CK-Likely from being found down. Resolved with IVF.
.
# Psych/IVDU-Multiple sucide attempts. The Psychiatry service
followed the pt while in-house and recommended starting seroquel
for her anxiety. Ativan was held, as pt was noted to be
disoriented on initial transfer to the floor. She may receive
haldol prn for agitation. Her Geodon and ativan may be restarted
once her LFTs return to baseline and psychiatry approves.
.
#AMS: As noted, pt had periods of agitation and confusion during
her hospitalization. Head CT showed no bleed. EEG revealed
diffuse encephalopathy. This was likely multifactorial, related
to her liver failure, renal failure, baseline medical issues,
and medications she was receiving. Her mental status continued
to improve and she was at her baseline level of functioning on
discharge.
.
#Aspiration PNA: Pt had a low-grade temp to 100.1 and CXR showed
upper airway consolidation. Levaquin was started for a 10 day
course, which will be completed on an outpatient basis. She
should have a follow-up CXR in [**4-1**] weeks to document clearance.
.
12. Code-FULL
.
13. [**Doctor First Name 104157**] [**Name (NI) 104158**], sister ([**Telephone/Fax (1) 104159**] cell ([**Telephone/Fax (1) 104160**]
[**Name (NI) **], sister ([**Telephone/Fax (1) 104161**]
.
14. [**Name (NI) 11053**] Pt was dischrged to Deaconness 4 for psychiatric
rehab once she was medically stable and above issues had been
fully addressed.
Medications on Admission:
1. Geodon (dose unknown)
2. Seroquel (dose unknown)
3. Methadone 90 mg daily
4. Ativan 1 mg PO BID-TID
on transfer:
RISS
Protonix 40"
lactulose 30""
e-mycin 250"'
methadone 15"'
Epo 1000QM/W/F
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
2. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
3. Methadone HCl 5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
4. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
5. Epoetin Alfa 2,000 unit/mL Solution Sig: 1000 (1000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): please give 4 hours after protonix.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 8 days: first dose given [**2189-5-18**].
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
10. Methadone HCl 10 mg Tablet Sig: Three (3) Tablet PO QHS
(once a day (at bedtime)).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Tylenol overdose
Acute Renal Failure
Fulminant hepatic failure
aspiration pneumonia
Anemia
Upper GI bleed
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor and return to the hospital for any
fever/chills, shortness of breath, confusion, abdominal
pain/swelling, or any other concerning symptoms you may have.
.
Please take all medications, as prescribed and keep your
follow-up appointments.
Followup Instructions:
Please follow-up with Dr.[**Last Name (STitle) **] in one week after discharge.
Please call for appointment.
.
Please follow-up with your Hepatologist in [**7-5**] days after
discharge. Please call for appointment.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"51881",
"5845",
"5070",
"2875",
"2760",
"3051"
] |
Admission Date: [**2164-12-12**] Discharge Date: [**2164-12-19**]
Date of Birth: [**2104-5-17**] Sex: F
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old
female who is admitted for elective total hip replacement.
She has a history of hypertrophic obstructive cardiomyopathy,
hypertension and multiple psychiatric disorders, and was
admitted to [**Hospital1 69**] in [**2164-7-23**], status post fracture of her left hip. At that point,
she underwent open reduction and internal fixation which has
since failed to completely heal and she returns now for an
elective total hip replacement. Of note, during her [**Month (only) 205**]
admission, she had a complicated hospital course spending
several months in the Intensive Care Unit following a bout of
congestive heart failure and hypoxemia believed to be related
to her hypertrophic obstructive cardiomyopathy. She has a
left ventricular ejection fraction of greater than 55% by her
echocardiogram of [**2164-7-23**], but is extremely sensitive to
fluid balance. Since her discharge from [**Hospital1 346**] in [**Month (only) 216**]/[**2164-9-23**], the
patient has apparently been nonweight-bearing on the left
lower extremity secondary to pain in the left hip with
movement or weight bearing. She also relates feeling
extremely anxious recently regarding both her upcoming
surgery and the fact that she has no place to live following
surgery as her brother is selling the apartment that she has
been living in. She says that she has felt several times
that "life is not worth living" but denies any active
suicidal ideation, homicidal ideation or suicidal plan. She
also denies any recent auditory or visual hallucinations.
PAST MEDICAL HISTORY:
1. Hypertrophic obstructive cardiomyopathy diagnosed in
[**2162**], sensitive to fluid overload and diuresis.
Echocardiogram of [**2164-8-14**], also demonstrated elongated left
atrium, mildly dilated right atrium, symmetric left
ventricular hypertrophy, however, there is severe resting
left ventricular outflow obstruction.
2. Hypertension.
3. Schizo-affective disorder.
4. Depression.
5. Anxiety.
6. Basal cell carcinoma on her breast.
7. Questionable neuroleptic malignant syndrome secondary to
Zyprexa but she is currently taking without difficulty.
PAST SURGICAL HISTORY:
1. Status post left hip open reduction and internal fixation
in [**2164-7-23**].
2. Status post total abdominal hysterectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Tylenol p.r.n. pain.
2. Zyprexa 5 mg p.o. q.a.m. and 20 mg p.o. q.h.s.
3. Trazodone 25 mg p.o. twice a day.
4. Combivent inhaler MDI two puffs four times a day p.r.n.
Shortness of breath.
5. Bumetanide 1 mg p.o. once daily.
6. Metoprolol 50 mg p.o. once daily.
7. Protonix 40 mg p.o. once daily.
8. Celexa 60 mg p.o. once daily.
9. Calcium Carbonate 1250 mg p.o. three times a day.
SOCIAL HISTORY: The patient is currently living at a nursing
home where she has been since her discharge from [**Hospital1 346**]. She denies any tobacco, alcohol or
drug use.
PHYSICAL EXAMINATION: Upon admission, the patient's vital
signs are temperature 97.1, blood pressure 90/60, heart rate
60 and regular, respiratory rate 18, oxygen saturation 96% in
room air. In general, she was an obese female, anxious but
not in any acute distress. Head, eyes, ears, nose and throat
- She is normocephalic and atraumatic. The pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. The oropharynx is clear and moist.
Neck is supple, no jugular venous distention, no
lymphadenopathy. Chest - The chest is clear to auscultation
bilaterally. Cardiovascular - The patient has regular rate
and rhythm, but she has a harsh IV/VI early systolic murmur
heard diffusely across her precordium radiating towards the
neck, heard loudest at the left sternal border. There were
no rubs, gallops or heaves. Abdomen is obese, soft,
nontender, nondistended, normal bowel sounds. Back - There
was no costovertebral angle tenderness. Extremities - There
is a well healed scar in her left hip with limited range of
active and passive motion of the left hip. The left leg was
held in midflexion and external rotation. There was 1+
bilateral lower extremity edema, no calf tenderness on either
side. Neurologically, she was alert and oriented times
three. Cranial nerves II through XII are grossly intact.
Motor was [**5-27**] upper extremities bilaterally and in the right
leg it was [**5-27**] as well as the left leg was 2 to [**3-27**] hip
flexion. Sensation was intact in both extremities upper and
lower. Reflexes were 2+ throughout. Psychiatry - she had
questionable suicidal ideation as mentioned above and no plan
and no homicidal ideation, no hallucinations and her mood was
appropriate at the time of physical examination.
LABORATORY DATA: Her complete blood count on admission was
as follows: White blood cell count 5.9, hematocrit 32.7,
platelet count 199,000. Chem7 was sodium 144, potassium 3.8,
chloride 104, bicarbonate 27, blood urea nitrogen 22,
creatinine 1.1. Her sugar was 89. Her calcium was 10.6,
magnesium 2.0 and her phosphate was 4.0.
Electrocardiogram showed normal sinus rhythm with left
ventricular hypertrophy, but no significant changes from
[**2164-8-23**].
The patient had a portable chest x-ray to rule out congestive
heart failure on [**2164-12-14**]. The pulmonary vascularity was
minimally indistinct suggesting mild congestive heart
failure. There were low lung volumes but no pleural
effusions or focal consolidations.
On the day prior to discharge, the patient had the following
laboratory values: White blood cell count was 4.7,
hematocrit 34.2 and her platelet count was 129,000, MCV 88.
Prothrombin time was 17.8, partial thromboplastin time 38.6
and her INR was 2.1. Sodium was 143, potassium 3.8, chloride
107, bicarbonate 29, blood urea nitrogen 15, creatinine 0.8,
and glucose 117. Calcium 9.0, magnesium 1.7, phosphorus 2.6.
She had blood cultures from [**2164-12-15**], that were negative at
the date of discharge.
HOSPITAL COURSE:
1. Orthopedic - The patient underwent left total hip
replacement without significant orthopedic complications. She
was discharged to the floor on postoperative day number four
and did well from the orthopedic standpoint. She was able to
get out of bed to chair without difficulty. She had
difficulty continuing to move her left lower extremity but
this was not surprising given the extent of the surgery. She
also developed a pressure ulcer on the lateral malleolus of
the left leg that was likely due to the persistent position
of external rotation. The ulcer was without active bleeding
or discharge and no surrounding erythema. There were no
other evidence of infection of this ulcer and wet to dry
dressings were applied twice a day and a heel pad was put in
place to minimize further pressure on the site. She received
physical therapy and deemed a good candidate for
rehabilitation at this time.
2. Cardiovascular - The patient has a history of
hypertrophic obstructive cardiomyopathy with a complicated
hospital course in the past. She was sent to the Surgical
Intensive Care Unit after her total hip replacement as
planned prior to the operation for hemodynamic monitoring.
She developed mild hypotension in the Post Anesthesia Care
Unit and required less than 24 hours of Neo-Synephrine for
blood pressure support. She was weaned from the
Neo-Synephrine within 24 hours of entering the Surgical
Intensive Care Unit and did well from a cardiovascular
standpoint thereafter. Her blood pressure was mildly
elevated to systolic of 160 but she was completely
asymptomatic with no chest pain, shortness of breath or
palpitations. She was well controlled below 90 during her
stay on the floor. She continued to receive her Lopressor
and Bumetanide in order to optimize her cardiovascular
performance. She was exquisitely sensitive to fluids on her
previous admission and she was attempted to keep euvolemic
during the hospitalization stay to prevent recurrence of her
congestive heart failure.
3. Psychiatric - The patient has an extensive psychiatric
history including schizo-affective disorder, depression,
anxiety. She related some chronic suicidal ideation but
without a plan but no homicidal ideation, auditory or visual
hallucinations during the hospital stay. She was continued
on her Celexa, Trazodone and Seroquil during her hospital
stay. There were no changes in her psychiatric status.
4. Hematologic - The patient was treated with Coumadin for
anticoagulation and with a goal INR of 1.5. She is to be
anticoagulated for a three to six week course or she can be
switched to 30 mg twice a day of subcutaneous Lovenox once in
the rehabilitation facility setting. She had a mild drop in
her hematocrit which corrected prior to discharge. She also
had a mild drop in her platelets which also corrected the day
prior to discharge. These were deemed most likely due to
mild blood loss in the Emergency Department and taking the
dilution from the intravenous fluid she received.
CONDITION ON DISCHARGE: The patient was in good condition at
discharge.
DISCHARGE STATUS: The patient will be discharged to the
[**Hospital **] Rehabilitation facility where she is applying for
long term residency.
DISCHARGE DIAGNOSES:
1. Status post elective total hip replacement on the left.
2. Hypertrophic obstructive cardiomyopathy and mitral
regurgitation.
3. Hypertension.
4. Schizo-affective disorder.
5. Depression.
6. Anxiety.
7. Left heel pressure ulcer.
8. History of basal cell carcinoma on the breast.
MEDICATIONS ON DISCHARGE:
1. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
2. Zyprexa 5 mg p.o. q.a.m. and 20 mg p.o. q.h.s.
3. Trazodone 25 mg p.o. twice a day.
4. Combivent MDI two puffs four times a day p.r.n. shortness
of breath.
5. Bumetanide 1 mg p.o. once daily.
6. Lopressor 50 mg p.o. once daily.
7. Protonix 40 mg p.o. once daily.
8. Celexa 60 mg p.o. once daily.
9. Calcium Carbonate 1250 mg p.o. three times a day.
10. Coumadin 2.5 mg p.o. once daily for a goal INR of 1.5 to
2.0, the last dose of her Coumadin should be [**2165-1-12**].
11. Iron Sulfate 325 mg p.o. once daily.
12. Colace 100 mg p.o. twice a day.
FOLLOW-UP PLANS: The patient is to follow-up with Orthopedic
surgeon, Dr. [**First Name (STitle) 1022**], two weeks following discharge. She is also
to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2204**], one to two weeks after discharge.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2164-12-18**] 18:41
T: [**2164-12-18**] 20:05
JOB#: [**Job Number **]
|
[
"2875",
"4019"
] |
Admission Date: [**2169-4-7**] Discharge Date: [**2169-4-21**]
Date of Birth: [**2125-7-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / ciprofloxacin / Percocet / clindamycin /
Levofloxacin / Sulfa(Sulfonamide Antibiotics) / meropenem /
Allopurinol
Attending:[**First Name3 (LF) 3967**]
Chief Complaint:
blasts on peripheral smear
Major Surgical or Invasive Procedure:
Bronchoscopy with BAL - no immediate complications
History of Present Illness:
43 yo F with SLE, ESRD on HD MWF, thyroid cancer, GERD and HTN
who is referred to the ED after blood work showed a white count
of 30k with 22% blasts and smear consistent with acute leukemia.
.
Patient reports two weeks ago labs showed low platelets. Repeat
labs on [**2169-4-3**] with worsening thrombocytopenia and elevated
wbc's with 70% blasts. Patient referred to Dr. [**First Name (STitle) 4223**] of
[**Location (un) **] who obtained labs today which showed WBC 32.5, Hb 8.7,
PLT 31, 22% blasts and smear consistent with acute leukemia.
Dr. [**First Name (STitle) 4223**] sent patient to [**Hospital1 18**].
.
Patient has no complaints and has been feeling well. She does
note easy bruisability. Patient denies any cough, shortness of
breath or chest pain. No abdominal pain or headache. No recent
fever however was febrile in the ED to 101.2. Denies any
nausea, vomiting or diarrhea. Patient was dialyzed today. Of
note patient received 1gm of vancomycin on [**2169-3-31**], [**2169-4-3**] and
[**2169-4-5**] due to a small abrasion on her left foot.
.
ED: 101.2 104 142/75 16 98%RA; oxycodone 5mg, ativan 1mg,
allopurinol 100mg; heme consulted and performed bone marrow bx
.
ROS: as per HPI, 10 pt ROS otherwise negative
Past Medical History:
SLE in remission
ESRD on HD (M/W/F) with AVF on chronic AC
THYROID CANCER s/p total thyroidectomy
GERD
HTN
anxiety
Chronic LBP
RLS
Social History:
Lives alone; sister, [**Name (NI) 21457**] and brother-in-law live next door.
On disability. Quit tobacco 12 years ago. Rare etoh. No
illicits.
Family History:
No fhx of leukemia. Mother with ovarian cancer. Father with
renal cancer.
Physical Exam:
Admission Physical Exam:
VS: 99 130/96 63 15 97%RA
Appearance: alert, NAD, tearful
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, nt, nd, +bs
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes, left forearm fistula with palpable thrill, left
heel with healing abrasion
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
Pertinent Results:
[**2169-4-7**] 08:15PM PLT SMR-VERY LOW PLT COUNT-37*
[**2169-4-7**] 08:15PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ BURR-1+
TEARDROP-OCCASIONAL
[**2169-4-7**] 08:15PM NEUTS-1* BANDS-0 LYMPHS-7* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-92*
[**2169-4-7**] 08:15PM WBC-42.3* RBC-2.82* HGB-9.3* HCT-28.9*
MCV-103* MCH-32.8* MCHC-32.0 RDW-22.5*
[**2169-4-7**] 08:15PM HAPTOGLOB-133
[**2169-4-7**] 08:15PM CALCIUM-8.5 PHOSPHATE-2.0* MAGNESIUM-1.8 URIC
ACID-2.9
[**2169-4-7**] 08:15PM ALT(SGPT)-15 AST(SGOT)-29 LD(LDH)-362* ALK
PHOS-77 TOT BILI-0.4
[**2169-4-7**] 08:15PM estGFR-Using this
[**2169-4-7**] 08:15PM GLUCOSE-109* UREA N-14 CREAT-5.2* SODIUM-136
POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-38* ANION GAP-10
[**2169-4-7**] 08:45PM LACTATE-1.3
[**2169-4-7**] 09:13PM FIBRINOGE-346
[**2169-4-7**] 09:13PM PT-20.3* PTT-32.0 INR(PT)-1.9*
.
[**2169-4-7**] OSH Labs:
.
32.5> 8.7/27.3 <31 22% blasts
.
[**2169-4-3**] OSH Labs:
.
26> 9.7/28.7 <44 70% blasts
.
[**2169-3-6**] OSH Labs:
.
5.37> 11/33 <73
.
[**2169-4-7**] Pa/Lat CXR: No acute cardiopulmonary process.
.
[**2169-4-9**] CT abdomen/pelvis:
1. Nodular opacities in the left lower lung with additional
small
ground-glass opacities bilaterally may represent infection.
Chest CT
recommended for further assessment given infectious symptoms.
2. Abdominal wall varices of indeterminate etiology.
3. Splenomegaly.
4. Coronary artery calcification
.
[**2169-4-9**] CT chest without contrast:
1. Left upper lung parenchymal consolidation likely pneumonia.
2. Multiple ground-glass and mixed solid and ground-glass
opacities in
bilateral lungs may be infectious in etiology although the
differential
includes neoplasm. A short-term (<3 month) repeat chest CT
should be
performed post-treatment to document resolution.
2. Extensive coronary artery calcifications
3. Mediastinal lymph nodes may be reactive.
4. Right subpectoral node. Recommend correlation with mammogram.
5. Small bilateral pleural effusions with adjacent compressive
atelectasis.
6. Chest wall collateral vessels. Coarse calcification in the
SVC could
relate to chronic thrombus.
Brief Hospital Course:
43 yo F with SLE, ESRD on HD MWF, thyroid cancer, GERD and HTN,
admitted with gram negative sepsis and acute leukemia, found to
have AML. Hospital Course complicated by Tumor Lysis Syndrome,
Febrile Neutropenia with Enterobacter Bacteremia, mucositis,
delirium, agitation. With the patient clearly declining despite
best efforts at recovery, the patient was made CMO by her
healthcare proxy. The patient expired on [**2169-4-21**].
#Acute myeloid leukemia: Patient with rapidly rising WBC count
on admission despite therapy with hydrea. She underwent CT
chest that showed hilar and pretracheal lymphadenopathy, likely
consistent with leukemia, although possibly related to
infection. Labs consistent with early tumor lysis syndrome.
The patient was started on daily dialysis for tumor lysis
syndrome. Given tumor lysis syndrome prior to initiation of
chemotherapy, she was transferred to the ICU for leukophoresis
to decrease WBC count burden prior to initiating chemotherapy.
WBC count decreased from 78 to 28 with leukophoresis, and the
patient became more awake with decreased peripheral cyanosis.
She was initiated on 7+3 and was transitioned back to the BMT
floor. On the floor, she completed 7+3, the patient's course
was complicated by gram negative bacteremia, mucositis and
delirium and agitation. S/p chemotherapeutic regimen, patient
still had a significant number of blasts in peripheral blood,
signifying a very poor prognosis.
# Mucositis: significant mucositis, requiring patient to be NPO,
placed on TPN, and oral medications to be switched to IV
medications. Also with e/o stridor, likely from mucosal
sloughing, crusting and bleeding. ENT consulted on pt and did
endoscopy of pharynx, confirming structural defect. Dilaudid
PCA was initiated for symptomatic relief.
# Agitation / delirium: On approximately hospital day #12,
patient had significant agitation and delirium, likely secondary
to difficulty in achieving equilibrium with new IV medications,
in the setting of severe mucositis. The patient was treated
with dilaudid, clonazepam and ativan.
#Neutropenic fever: Patient febrile on admission to 101.7. On
admission, she was found to have gram negative bacteremia with
enterobacter cloacae. She also had ground glass opacities on
CT. Patient with hypoxia and mild hypotension (to SBP 92 from
130s), concerning for developing sepsis. She was placed on
vancomycin and meropenem on admission. She was then broadened
to posaconazole to cover for possible pulmonary fungal
infection. She underwent bronchoscopy with BAL to further
evaluate her ground glass opacities. 4 days into admission, the
patient developed a firey-erythematous blanching rash on her
back, that spread to cover her trunk and proximal thighs.
Antibiotics were changed to daptomycin, aztreonam, and ambisome
out of concern for drug rash. The rash gradually improved.
#ESRD on HD MWF: Followed by renal throughout admission.
Patient with chronic left arm fistula, on coumadin at home for
fistula thrombosis prevention - this was discontinued on
admission for impending chemotheraphy-related coagulopathy. On
admission, the patient was dialyzed on her regular MWF schedule.
With increasing tumor burden, she experienced tumor lysis
syndrome with hyperkalemia to 6.7, and received 2 extra sessions
of dialysis for electrolyte correction. She was continued on
home renagel. She was started on allopurinol on admission.
However, it was discontinued, as it likely caused LFT elevations
and may have been responsible for the patient's rash.
# Transaminitis: The patient developed worsening transaminits
on admission, attributed to drug effect in the setting of
initiation chemotherapy and allopurinol. The patient had no
right upper quadrant pain, and right upper quadrant ultrasound
was negative for obstruction. Allopurinol was discontinued, and
transaminitis improved, making it the likely culprit of her
laboratory abnormalities.
# Rash: Early in admission, the patient developed a fiery-red
blanching rash on her back that spread to the remainder of her
torso and proximal thighs. Antibiotics were switched as above,
and allopurinol was discontinued. The patient was evaluated by
dermatology who felt the rash was likely a drug rash from
meropenem or allopurinol. Slowly, the rash improved.
Dermatology was consulted to assist in her care.
#HTN: Patient with a history of hypertension on labetalol. The
patient became borderline hypotensive on admission, and
labetalol was held.
#Chronic LBP: On oxycontin, oxycodone, and neurontin at home.
#Hypothyroidism: Chronic. The patient was continued on home
synthroid.
#GERD: chronic. The patient was continued on home omeprazole.
#RLS: Chronic. The patient was continued on home requip.
#Anxiety: Patient with chronic anxiety, worsened acutely in the
setting of new diagnosis. On home clonazepam. Transitioned to
ativan on admission, given potential for nausea with chemo. She
was followed by social work for coping.
Medications on Admission:
Coumadin 2.5 mg alternating with 5mg daily
Levothyroxine 0.125 mg 1 tab daily -> PLEASE CLARIFY DOSE IN AM
OxyContin CR 10 mg [**Hospital1 **]
oxycodone 5 mg PRN
Requip 1mg qhs
Neurontin 300 mg qhs
Ativan 2 mg 1 tab [**Hospital1 **] prn
Renagel 800 mg 3 tab tid
Klonopin 1 mg [**Hospital1 **]
pravastatin 40 mg daily - d/c'ed 2 weeks ago due to low
platelets
Omeprazole 20mg daily
Labetalol 2 tabs qhs - PLEASE CLARIFY DOSE IN AM
Lidoderm patch prn
Discharge Disposition:
Expired
Discharge Diagnosis:
primary cause of death: cardiorespiratory failure
secondary causes of death: AML, ESRD, delirium, lupus
Discharge Condition:
expired
[**Name6 (MD) **] [**Last Name (NamePattern4) 3974**] MD, [**MD Number(3) 3975**]
|
[
"40391",
"53081",
"2875",
"2767"
] |
Admission Date: [**2186-4-30**] Discharge Date: [**2186-5-1**]
Date of Birth: [**2110-8-7**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Chlorpromazine / Griseofulvin / Haldol /
Molindone
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Pneumonia, ?respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75F schizoaffective d/o, DM, here w/ likely PNA. USOH until ~1.5
weeks prior to admission, developed lethargy, hypoxia, and was
started on ceftriaxone, then levofloxacin, tamiflu and given IV
fluids - O2 Sat 88%RA, hypernatremic to 152.
Transferred to [**Hospital1 18**] last night increasing dyspnea for ~4hours
per EMS note. In ED, initial vitals 103.4 98 140/80 34 98% on
NRB. Given lasix 60IV, vanco, zosyn, with good effect (1400cc
UOP), bronchodilators. Initially attempted on NPPV without good
success given need for suctioning and bronchodilators.
On arrival to MICU, pt was breathing at a rate of 20-25,
comfortable appearing, low grade temp of 100.0. Appears to
understand and attempts to speak, but edentulous and seems to
respond with nonsensical responses
Past Medical History:
CHF
Schizoaffective disorder
HTN
DM
Social History:
[**Hospital1 5595**] resident. Has attorney/guardian [**Name (NI) 2048**] [**Name (NI) **] [**Telephone/Fax (1) 26357**].
Family History:
Non-contributory.
Physical Exam:
VS 100 82 127/47 19 98% Face tent
GENERAL: NAD, nonverbal
HEENT: PERRL, EOMI, OM dry, edentulous.
NECK: JVP flat, supple, no LAD.
CARDIOVASCULAR: S1, S2, reg, no MRG.
LUNGS: diffuse rhonchi, wheezes, cannot comply with exam.
ABDOMEN: Soft, NT, ND, no rebound or guarding.
EXTREMITIES: Warm, no CCE.
NEURO: unable to assess orientation, but alert and awake. Moving
all four purposefully
Pertinent Results:
[**2186-4-30**] 04:50AM WBC-6.8 RBC-3.85* HGB-12.3 HCT-35.9* MCV-93
MCH-31.9 MCHC-34.1 RDW-14.3
[**2186-4-30**] 04:50AM NEUTS-85.0* BANDS-0 LYMPHS-12.0* MONOS-1.6*
EOS-0.9 BASOS-0.5
[**2186-4-30**] 04:48AM PO2-122* PCO2-44 PH-7.42 TOTAL CO2-30 BASE
XS-4 COMMENTS-TRAUMA
[**2186-4-30**] 04:02PM GLUCOSE-153* UREA N-18 CREAT-0.7 SODIUM-147*
POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-31 ANION GAP-10
[**2186-4-30**] 04:50AM cTropnT-<0.01
EKG: NSR 92, 3mm R wave in V1, no ST changes.
Micro: Blood cultures from [**2186-4-30**] - pending as of discharge
Imaging: [**2186-4-30**] CXR - Study is limited secondary to patient
motion. No definite pleural effusions are seen. No pneumothorax
is identified. There is suggestion of central perihilar vascular
congestion, which may reflect a component of mild CHF. The
cardiac and mediastinal contours are stable. No pleural
effusions or pneumothorax are seen. A portion of the right
hemicolon appears interposed between the diaphragm and the
liver.
Brief Hospital Course:
In brief, the patient is a 75F PMH DM2, schizoaffective d/o,
hypertension, CHF admitted with respiratory distress likely
secondary to pneumonia.
.
Respiratory Distress: Patient presented with signs and symptoms
of pneumonia. As she is a nursing home resident, she will be
treated with 8 day of IV antibiotics for hospital acquired
pneumonia. She rapidly improved her oxygenation. Blood
cultures were negative at the time of discharge. She was
evaluted by the speech pathologist who recommended pureed solids
with nectar thickened liquids. She continued to received
bronchodilators for a reactive airways component to her
pneumonia.
.
Congestive Heart failure: The patient presented as euvolemic to
slt dry. Her diuretics were held and can be restarted as needed
as the long-term care facility. She ruled out for MI and had no
significant events on telemetry.
.
Hypernatremia: This was likely related to low oral intake,
perhaps with a component of diabetes insipitus from her lithium.
Her calculated free water deficit was ~2 liters. She should
have daily electrolytes monitored as she has this deficit
replaced. Her first liter of replacement was ordered in the
discharge papers.
.
Schizoaffective disorder: She will remain on her home
medications.
.
Diabetes Mellitus type 2: The patient's blood sugars were
controlled with insulin sliding scale. As the patient's oral
intake improves, consideration should be made for a long acting
basal insulin.
.
FEN: Speech pathology recommendations as above. Free water
repletion as above.
.
Code status: DNR, DNI per patient's guardian.
.
Disposition: Discharged to return to long-term care facility.
Medications on Admission:
1. Heparin flush 100 units/1ml vial
2. Insulin regular sliding scale
3. Lasix 100 mg daily
4. Lithium carbonate 300 mg twice daily
5. Lorazepam 2 mg QID
6. Olanzapine 20 mg [**Hospital1 **]
7. Pantoprazole 40 mg daily
8. Sertraline 150 mg daily
9. Verapamil 80 mg [**Hospital1 **]
Discharge Medications:
1. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 6 days.
2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 6 days.
3. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: [**1-3**] neb Inhalation every
six (6) hours as needed for shortness of breath or wheezing.
4. LINE CARE
Midline care per protocol
5. Olanzapine 20 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day.
6. Lithium Carbonate 300 mg Tablet Sig: One (1) Tablet PO twice
a day.
7. Lorazepam 2 mg Tablet Sig: One (1) Tablet PO four times a
day.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO once a day.
10. Verapamil 80 mg Tablet Sig: One (1) Tablet PO twice a day.
11. D5W with Potassium Chloride 20 mEq/L Parenteral Solution
Sig: One (1) 1 liter Intravenous once a day for 1 doses: please
run at 80 cc/hr.
12. Insulin Regular Human 100 unit/mL Solution Sig: 0-8 units
Injection QACHS: per sliding scale
BS <150: 0 units
BS 151-200: 2 units
BS 201-250: 3 units
BS 251-300: 4 units
BS 301-350: 6 units
BS 351-400: 8 units
BS >400 [**Name8 (MD) 138**] MD.
13. Outpatient Lab Work
Daily electrolytes until serum sodium is corrected.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary:
Hospital Acquired pneumonia
hypernatremia
type 2 diabetes mellitus
Secondary:
Schizoaffective disorder
Hypertension
Discharge Condition:
stable. improved oxygenation on low flow nasal cannula.
Discharge Instructions:
You have been evaluated at treated for pneumonia. You were
given antibiotics and additional oxygen with good improvement.
You will continue to take antibiotics for 6 more days.
If you have any new or concerning symptoms particularly, chest
pain, shortness of breath, or fever to >100.5F; please seek
medical attention.
You will be evaluated by the physicians at the [**Hospital1 100**] Senior
Life.
Followup Instructions:
You will be evaluated by the physicians at the [**Hospital1 100**] Senior
Life.
|
[
"5070",
"2760",
"4280",
"496",
"25000",
"4019"
] |
Admission Date: [**2106-12-6**] Discharge Date: [**2106-12-15**]
Date of Birth: [**2022-6-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
hypotension, AMS
Major Surgical or Invasive Procedure:
PEG tube placement
History of Present Illness:
84F, h/o IDDM, dens fx in [**2106-9-27**] after fall w/ delayed spinal
cord injury (upper extremity weakness) in [**Month (only) 1096**], s/p halo
placement, presents from rehab facility with altered mental
status and hypotension. At baseline, per records, she is
oriented x2, speaks in full sentences. On admission she was
oriented x1 and was not speaking coherently. Her systolic blood
pressure at rehabilitation was 74, and she wsa started on Cipro
(Day 1 [**2106-12-3**]) for a UTI from an indwelling Foley.
.
In the ED, initial vs were: 100.9 103 99/66 18 97%. Exam showed
no focal neurologic deficits. She received 3L IVF with blood
pressure increase to the 100's. Dipped down again to 70s,
responded to fluids. Baseline reportedly around 90-100s. She was
noted to have a WBC 14.6, febrile to 100.9. Got vanc, zosyn. CT
head showed no acute process. Creat noted to be 1.7, up from
baseline 0.6. Had poor urine output in the ED (~100 cc over the
last few hours). Also noted to have trop 0.17, without chest
pain or EKG changes. Aspirin given. Guiaic negative. Heparin
drip ok'd by neurosurgery, however ultimately cards decided not
to start in the setting of no EKG changes, no chest pain, and
flat CK-MB.
VS on transfer: 95 96/50 16 98% RA
.
On admission to the the ICU, the patient received a CT
chest/spine which showed a non-displaced fracture of the
anterior and posterior arches of C1, and showed a Type II
fracture of the odontoid process that had improved alightment
and healing. Her blood cultures came back as gram positive cocci
in pairs and clusters, but this was felt to be a contaminent
since she did not have any leukocytosis or fever. Ortho was
consluted for left knee pain, and indicated that they did not
feel it was septic arthritis; joint not tapped. Renal was
consulted as the patient was anuric in the setting of a normal
renal U/S. TTE showed overall left ventricular systolic function
is normal, inconclusive for endocarditis, but did have some
mitral regurgitation. Renal recommended diuresing with
Metolazone and IV Lasix. G-tube placement complicated by the
fact that patient is in Halo, and wil lneed anesthia, but is a
difficult intubation. Family in meeting is ok to rescind DNR/DNI
one time if needed to place PEG tube. They would also be ok with
dialysis for short time if needed. Recently patient has been
even in I/Os. The patient has never had leukocytosis and fever,
and a source for infection was never locatlized. There was
concern from renal for ATN after hypotension from ischemia.
Past Medical History:
RA
GERD
HTN
DM 2
Depression
Social History:
married, lives with husband. no tobacco, occas etoh,
no drugs. ambulates with walker at baseline.
Family History:
N/C
Physical Exam:
General: Alert, no acute distress, oriented x 1. Unable to
answer most questions
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities, CN intact
Pertinent Results:
Admission Labs
[**2106-12-6**] 04:45PM BLOOD WBC-14.6* RBC-3.96* Hgb-11.8* Hct-35.0*
MCV-89 MCH-29.8 MCHC-33.7 RDW-14.8 Plt Ct-356
[**2106-12-7**] 05:00AM BLOOD Glucose-90 UreaN-23* Creat-1.9* Na-142
K-3.7 Cl-115* HCO3-18* AnGap-13
.
Pertinent Labs
[**2106-12-7**] 05:00AM BLOOD Glucose-90 UreaN-23* Creat-1.9* Na-142
K-3.7 Cl-115* HCO3-18* AnGap-13
[**2106-12-7**] 04:21PM BLOOD Glucose-68* UreaN-28* Creat-2.5* Na-144
K-4.3 Cl-118* HCO3-15* AnGap-15
[**2106-12-8**] 07:58AM BLOOD Glucose-160* UreaN-32* Creat-3.1* Na-142
K-3.9 Cl-112* HCO3-20* AnGap-14
[**2106-12-8**] 06:18PM BLOOD Glucose-166* UreaN-32* Creat-3.4* Na-141
K-3.8 Cl-110* HCO3-21* AnGap-14
[**2106-12-9**] 03:34AM BLOOD Glucose-107* UreaN-34* Creat-3.7* Na-141
K-4.0 Cl-109* HCO3-21* AnGap-15
[**2106-12-9**] 05:19PM BLOOD Glucose-91 UreaN-36* Creat-4.2* Na-142
K-4.1 Cl-110* HCO3-21* AnGap-15
[**2106-12-10**] 03:09AM BLOOD Glucose-90 UreaN-38* Creat-4.5* Na-141
K-3.7 Cl-108 HCO3-23 AnGap-14
[**2106-12-10**] 04:43PM BLOOD Glucose-225* UreaN-42* Creat-4.7* Na-142
K-3.9 Cl-107 HCO3-22 AnGap-17
[**2106-12-11**] 03:43AM BLOOD Glucose-122* UreaN-43* Creat-4.7* Na-145
K-3.6 Cl-109* HCO3-23 AnGap-17
.
[**2106-12-6**] 04:45PM BLOOD cTropnT-0.17*
[**2106-12-6**] 11:50PM BLOOD cTropnT-0.18*
[**2106-12-7**] 05:00AM BLOOD CK-MB-9 cTropnT-0.21*
[**2106-12-7**] 04:21PM BLOOD CK-MB-8 cTropnT-0.22*
[**2106-12-9**] 05:19PM BLOOD CK-MB-4 cTropnT-0.16*
[**2106-12-10**] 03:09AM BLOOD CK-MB-4 cTropnT-0.14*
.
[**2106-12-7**] 05:00AM BLOOD CRP-125.1*
.
Labs on Discharge:
Lactate:1.4
141 103 35
-------------<64
4.2 23 2.6
Ca: 8.5 Mg: 2.0 P: 4.3
10.4
9.6 >----<399
32.4
PT: 13.7 PTT: 23.1 INR: 1.2
Microbiology:
[**2106-12-6**] BLOOD CULTURE - GRAM POSITIVE COCCI IN PAIRS AND
CLUSTERS
[**2106-12-6**] URINE Culture - Negative, NGTD FINAL
1/10,14,14,15/11 BLOOD CULTURE - PENDING
Pertinent Reports
- CHEST (PA & LAT) Study Date of [**2106-12-6**] 6:11 PM
IMPRESSION: Low lung volumes, which accentuate the
bronchovascular markings, particularly at the lung bases. Given
this, patchy left base opacity may relate to atelectasis and
overlying soft tissue, although focal consolidation is not
excluded.
Mild blunting of the posterior costophrenic angles on the
lateral view could be due to pleural thickening or very trace
effusions.
.
- KNEE (AP, LAT & OBLIQUE) LEFT Study Date of [**2106-12-6**] 8:03 PM
IMPRESSION:
1. Depression of the lateral tibial plateau in the absence of a
joint
effusion or overlying soft tissue swelling. Recommend clinical
correlation for age of fracture, it may be subacute to chronic.
Recommend clinical correlation for point tenderness to further
assess acuity and consider cross section imaging as clinically
warranted.
.
- CT HEAD W/O CONTRAST Study Date of [**2106-12-6**] 9:00 PM
IMPRESSION: Severely limited examination secondary to the Halo
device. No evidence of gross acute intracranial hemorrhage.
.
- CHEST (PORTABLE AP) Study Date of [**2106-12-7**] 2:58 AM
FINDINGS: As compared to the previous radiograph, there is a
newly appeared retrocardiac and platelike left basal
atelectasis. No evidence of focal parenchymal opacity suggesting
pneumonia, with all limitations given positioning of the
patient. Borderline size of the cardiac silhouette. No evidence
of larger pleural effusions.
.
- RENAL U.S. Study Date of [**2106-12-7**] 1:59 PM
IMPRESSION: Grossly normal renal ultrasound.
.
- CT C-SPINE W/O CONTRAST Study Date of [**2106-12-7**] 2:34 PM
IMPRESSION: 1. Non-displaced fracture of the anterior and
posterior arches of C1. Possible mild interim healing along the
left posterior fracture line.
2. Type II fracture of the odontoid process demonstrates
improved alignment of the fracture fragments and possible
partial interval healing across the fracture line.
.
- CT CHEST W/O CONTRAST Study Date of [**2106-12-7**] 2:35 PM
IMPRESSION:
1. Kyphosis. Compression fracture of T12.
2. Bilateral pleural effusions and associated atelectasis with
very low likelihood of infectious process.
3. Extensive degenerative changes of the thoracic spine.
4. Coronary calcifications, hemodynamic significance is unclear.
.
- TTE (Focused views) Done [**2106-12-8**] at 9:35:42 AM FINAL
Overall left ventricular systolic function is normal (LVEF>55%).
The aortic valve is not well seen. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. The mitral valve leaflets are mildly
thickened. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. Mild to moderate ([**11-28**]+) mitral regurgitation is seen.
No masses or vegetations are seen on the tricuspid valve, but
cannot be fully excluded due to suboptimal image quality.
IMPRESSION: Suboptimal image quality. Extremely limited views.
Study inconclusive for endocarditis. Mild to moderate mitral
regurgitation. If clinically indicated, a TEE may be helpful in
evaluating for vegetations.
.
- CHEST (PORTABLE AP) Study Date of [**2106-12-11**] 2:55 AM
HISTORY: Volume overload, evaluate for change.
One limited AP view. Lung volumes are low and there is motion
artifact. An external stabilization device overlies the patient.
There is no definite focal consolidation. The retrocardiac area
is not well penetrated. Mediastinal structures appear stable.
IMPRESSION: Very limited study demonstrating no definite
interval change.
.
EKG: low voltage. sinus tach @ 110. LAD, normal intervals. TWI
III, aVF
- PERC G/G-J TUBE PLMT Study Date of [**2106-12-14**] 3:19 PM
Final Study Read Pending
- C-SPINE (PORTABLE) Study Date of [**2106-12-15**] 8:12 AM
Final Study Read Pending
- C-SPINE (PORTABLE) Study Date of [**2106-12-15**]
Final Study Read Pending
Brief Hospital Course:
84F with h/o IDDM, s/p dens fracture noted to have altered
mental status and hypotension, who was found to have acute renal
failure and elevated troponins, requiring admission to the MICU
for hypotension.
# Altered mental status: The patient at baseline is believed to
be alert and oriented x 2. Upon admission, vascular sources of
AMS were ruled out with a negative head CT, infectious sources
were ultimately ruled out with negative blood cultures, urine
cultures, a chest x-ray, as well as a surface Echo.
Toxic-metabolic favors certainly could have played a role, with
the patient's elevated troponin and cardiac injury leading to
poor perfusion of her kidneys, causing an elevation in renal
toxins. Her mental status improved to baseline during her last
few days in the ICU, as well as on the floor. The patient is
AAOx3, but apparently is AAOx2 at baseline, and she speaks in
full sentences upon her discharge from the hospital.
# NSTEMI - The patient is believed to have undergone an NSTEMI,
based on several factors. One, the patient's troponin rose
throughout her admission, peaking on [**2106-12-7**], but subsequently
tending down. We ended our tending of troponins as troponin
level was 0.17 in the setting of known appropriate medical
management of NSTEMI, in addition to lack of symptomatology of
ACS in the setting of renal injury which can elevate troponins.
Medical management was started with ASA, Statin, and BB. The
patient's ECHO on [**2106-12-8**] showed a normal EF, without any
obvious wall motion abnormalities or valvular vegetations. Mild
to moderate ([**11-28**]+) mitral regurgitation was seen. She was
discharged on medical management for an NSTEMI with ASA, Statin,
and BB.
.
# Acute renal failure/ATN: On presentation, Cr 1.7 from baseline
0.6. Cr trended upwards to a zenith of 4.7, but afterwards began
to trend down, such that on the day of her discharge, Cr was
2.6. The etiology was felt to be ATN secondary to kidney injury
from hypotension in the context of a presumed NSTEMI. The renal
team was involved in her care, and was diuresed in the ICU with
metolazone and furosemide. The patient and family were okay with
CVVH or HD should renal deem it necessary, but over the course
of her admission she auto diuresed, and her creatinine continued
to trend down. She will need close follow-up of her kidney
injury upon DC; per renal, she will follow-up in 2 week's time
with one of their physicians. Additionally, her ACE-inhibitor
can likely be restarted in 2 weeks time, per our renal
physicians as well.
# Hypotension: The patient was noted on presentation in the
nursing home to have SBPs in the 70s, with a baseline around
90s-100s. Upon arrival to our ICU, she again dripped into the
70s, but was fluid responsive. She initially received Vanc/Zosyn
as broad coverage for sepsis, but her blood cultures came back
positive x 1 for STAPHYLOCOCCUS, COAGULASE NEGATIVE in [**11-30**]
bottles, leading the infectious disease team to believe this was
a contaminant; antibiotics were DC'ed, and the patient
maintained her blood pressure well. Upon transfer to the floor,
the patient maintained her blood pressures in the 110s-130s.
# Nutrition: Per S&S, patient is not taking in adequate POs to
maintain nutrition, and they've recommended a PEG tube
placement. Family is in agreement. PEG was placed via IR on
[**2106-12-14**]. The patient tolerated the procedure well. Speech and
swallow also recommended a diet consisting of thin liquids, soft
solids. The patient recieved her PEG placement without issues,
and nutrition made recommendations which are included in the
patient's discharge instruction as to what her tube feeds should
be. Neurosurgery came by to cut out parts of the plastic HALO
such that her G-tube would be able to be visualized and
assessed.
# Dens fracture s/p halo placement: Patient remained in a HALO
per neurosurgery guidelines. They evaluated the patient and
signed off, given no neurosurgical
intervention required. The patient was recommended to have an
appointment in 1 month's time with Dr. [**Last Name (STitle) 739**].
Neurosurgery also came back to tighten the screws on the HALO on
the day of the patient's discharge, after finding that her HALO
was slightly loose.
# DM: Continue insulin sliding scale per in-house sliding scale,
may need to be adjusted at rehab post-tube feeds.
# HTN: Home lisinopril and hydralazine were held in the setting
of hypotension/acute renal failure. These medications can be
restarted by the PCP if clinically indicated once acute renal
failure has resolved.
# GERD: The patient was started on famotidine in house, but was
discharged on her home dose of ranitidine.
# Rheumatoid arthritis: Pain control with Tylenol PRN and
oxycodone PRN.
# Depression: The patient was continued on her home medication
regimen.
# Left knee pain: The patient has bilateral knee pain, which was
felt to be consistent with arthritis; we controlled this pain
in-house using Tylenol and oxycodone.
# Pending results
[**2106-12-11**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2106-12-10**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2106-12-10**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
- C-SPINE (PORTABLE) Study Date of [**2106-12-15**] 8:12 AM : Final read
pending
- PERC G/G-J TUBE PLMT Study Date of [**2106-12-14**] 3:19 PM : Final
read pending
- C-SPINE (PORTABLE) [**2106-12-15**] Final read pending
# PCP [**Name9 (PRE) 702**] Issues
- STRESS MIBI. The patient will require a STRESS MIBI as an
outpatient to ascertain if she has underwent an NSTEMI
- Follow Cr, and restart Lisinopril/Hydralazine if patient is
hypertensive, in the setting of a resolved ARF
- Please ensure patient goes to [**Hospital 4695**] clinic in 1 month's
time (appointment has been made)
- Please sure that patient goes to her Nephrology appointment as
well
- Closely monitor insulin requirements as the patient is
starting a new tube feeding regimen, described in the discharge
instruction.
Medications on Admission:
bisacodyl 10 daily
ciprofoxacin 500 [**Hospital1 **]
colace 100 mg po bid
heparin sq / currently on hold for peg placement
lisinopril 2.5 mg po daily
ranitidine 150 mg po bid
senna 10ml daily at bedtime
trazodone 12.5mg at hs
mvi
hydralazine 20mg po q 6 hrs prn snp >160
Discharge Medications:
1. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U
Injection three times a day.
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. trazodone 50 mg Tablet Sig: 0.25 Tablet PO at bedtime.
7. multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*0*
11. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*0*
12. clotrimazole 1 % Cream Sig: One (1) application Topical once
a day: apply to affected areas.
Disp:*1 bottle* Refills:*0*
13. insulin regular human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): Per Insulin Sliding
Scale Attached.
Disp:*10 ml* Refills:*0*
14. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO every four (4)
hours as needed for pain.
Disp:*15 Capsule(s)* Refills:*0*
15. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
16. multivitamin Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary Diagnosis:
- Non-ST elevation myocardial infarction
- Acute Tubular Necrosis
Secondary Diagnosis:
- Rheumatoid Arthritis
- GERD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 7188**], it was a pleasure taking care of you. You were
admitted to the hospital because you were found to have very low
blood pressure; you were in fact so ill that you needed to be in
the intensive care unit. While you were there, the doctors
noticed that some markers of damage to the heart were elevated,
and our concern was that your heart damage led to the heart not
pumping blood very well to the kidneys, which subsequently
damaged the kidneys. Because of this damage we started you on
several new medications to help to protect your heart.
Our speech and swallow specialists also looked at you, and while
they thought it was okay for you to continue swallowing the
foods that you normally have been, their concern was that you
are not taking enough nutrition by mouth. Because of this
concern, we placed a tube that goes from your skin directly into
your stomach, so that we can feed you even if you aren't able to
take food through your mouth. Our nutritions made
recommendations for the type of feeding that should go through
your G-tube.
.
When you leave the hospital
- STOP hydralazine 20 mg Daily every 6 (six) hours as needed for
SBP >160 (ask your physician about restarting this if your blood
pressure starts to become high)
- STOP lisinopril 2.5 mg Daily (You can consider restarting this
medication in 2 weeks)
- START Aspirin 81 mg Daily
- START Atorvastatin 80 mg Daily
- START Metoprolol Tartrate 25 mg twice a day
- START Insulin Sliding Scale (see attached, will need to be
adjusted as patient starting tube feedings)
- START oxycodone 2.5 mg every 4 hours as needed for pain
- START Tylenol 650 mg every 6 hours as needed for pain
- START a Multivitamin Capsule: Take One (1) Capsule once a
day
- START Clotrimazole 1 % Cream: Use one (1) application Topical
once a day to affected areas
We did not make any other changes to you medications, so please
continue to take them as you normally have.
- When you leave the hospital, you will need a STRESS MIBI
(stress test) Your primary care doctor can order this for you.
Followup Instructions:
You have an appointment to see your primary care doctor, Dr.
[**Last Name (STitle) 41076**]. He is currently on vacation, but his earliest available
appointment is [**2106-12-27**] at 2:45 PM, please meet him at
this time.
You have an appointment to see a nephrologist (kidney doctor),
on Monday [**2106-12-20**] at 3 PM with Dr. [**Last Name (STitle) 13219**] located
in the [**Hospital Ward Name 121**] Building on the [**Location (un) 453**].
Department: SPINE CENTER
When: THURSDAY [**2107-1-27**] at 10:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: THURSDAY [**2107-1-27**] at 9:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"41071",
"5845",
"5990",
"2762",
"2760",
"4280",
"53081",
"4240",
"311",
"V5867"
] |
Admission Date: [**2127-12-16**] Discharge Date: [**2128-2-5**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
unresponsive, hypoglycemia
Major Surgical or Invasive Procedure:
Intubation for unresponsiveness
History of Present Illness:
Mr. [**Known lastname **] is a 56 year-old man with DM1, ESRD, PVD, dCHF, and
recurrent admissions for hypoglycemia presents with hypoglycemia
requiring intubation for unresponsiveness and is transferred to
the MICU for further management.
.
He was recently discharged on [**2127-12-13**] after presenting with
lethargy and hypoglycemia. His course was complicated by left
sided subdural hematoma found in the setting of AMS evaluation,
and AV fistula clot requiring thrombectomy. He was due for
dialysis today but missed his session and per report was found
at home unresponsive. He was brought be EMS to the ED.
.
In the ED, vital signs were initially: 29C rectal 45 150/palp 20
95%nrb. He had an undetectable glucose level and was intubated
for agonal breathing with etomidate 20 mg iv and roc 10 mg iv
and was also given 1 amp calcium gluconate, 1 amp d50,
vanc/zosyn empirically, levothyroxine 37.5 mcg iv x 1,
solumedrol 125 mg iv x 1, and started on glucose drip. A right
femoral groin line ws placed semi-sterily. A bear hugger was
placed and temp rose to 29.7 after 1.5 hours. His ETT was pulled
back after a CXR demonstrated partial right main stem intubation
and he was transferred to the MICU for further evaluation.
.
In the MICU, the patient was extubated and his blood sugars were
controlled [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. Pt was warmed to good
effect. Vanc and zosyn was discontinued on [**2127-12-17**]. He was found
to have gram positive rods grow on [**2127-12-18**] 0500 in 1 anaerobic
bottle dated from [**2127-12-16**]. Speciation is pending. He also had
low grade temperatures (99.5) persistently. He was started on
Ampicillin 2 g IV Q12H, Ciprofloxacin 400 mg IV Q24H, and
Clindamycin 600 mg IV Q8H.
Past Medical History:
1. Type 1 diabetes with insulin autoantibody receptor syndrome
-since age 16 on insulin, followed by Dr. [**Last Name (STitle) 10088**]
[**Name (STitle) 21002**] hypoglycemic episodes, has required intubation for
altered MS in the past
-high level of anti-insulin Ab
-complicated by nephropathy
-complicated by retinopathy (s/p right eye laser surgery,
repeated [**8-2**])
-on immunosuppression ?? no records at [**Hospital1 18**]
2. End-stage renal disease on dialysis
3. Diastolic heart failure
4. Hypertension,
5. Hyperlipidemia
6. Peripheral vascular disease
7. Hypothyroidism
8. Anemia
9. Recent burn on his left upper extremity, now s/p skin graft
10. S/p left first toe distal phalangectomy in [**2127-9-28**]
11. Pancreatic lesions seen on an abdominal CT done in [**2127-5-28**]
Social History:
He states that he currently lives with his parents. Several
other relatives also live there at different times. He worked in
construction but was laid off. He denied alcohol tobacco, or
illicit drug use.
Family History:
Per OMR, history of DM (Type 1 and 2), RA and HTN.
Mother - Type 2 Diabetes [**Year (4 digits) **], Rheumatoid Arthritis
Maternal Aunt - Type 2 Diabetes [**Name (NI) **]
Nephew - Type 1 Diabetes [**Name (NI) **]
Physical Exam:
VS: 97.2 141/86 75 20 100%RA
General: Pleasant middle aged man in NAD. AOx3. Can say all days
of the week backwards.
HEENT: PERRL, EOMI, ETT
Neck: supple
Heart: RRR, no m/r/g
Lungs: CTAB, no rales, moderately reduced air-movement.
Abd: +BS, NTND, no rebound or guarding
Ext: no edema, no calf TTP
Neuro: CN 2-12 intact. moves all extremities, no pronator drift,
light touch sensation intact throughout
MSK: R toe s/p amputation, mild TTP, poor wound healing,
fibrinous exudate, foul smelling
Pertinent Results:
LABS ON ADMISSION:
[**2127-12-16**] 08:00AM BLOOD WBC-5.6 RBC-3.60* Hgb-10.3* Hct-32.3*
MCV-90 MCH-28.7 MCHC-32.1 RDW-15.0 Plt Ct-212
[**2127-12-16**] 11:40AM BLOOD Neuts-93.4* Lymphs-4.2* Monos-1.9*
Eos-0.3 Baso-0.1
[**2127-12-16**] 08:00AM BLOOD Plt Ct-212
[**2127-12-16**] 08:00AM BLOOD UreaN-28* Creat-5.9*#
[**2127-12-16**] 08:00AM BLOOD Lipase-44
[**2127-12-16**] 08:00AM BLOOD ALT-10 AST-21 LD(LDH)-226 AlkPhos-56
TotBili-0.2
[**2127-12-16**] 08:00AM BLOOD Albumin-3.6
[**2127-12-16**] 08:00AM BLOOD TSH-20*
[**2127-12-16**] 08:00AM BLOOD Free T4-1.3
[**2127-12-19**] 06:40AM BLOOD Cortsol-17.7
[**2127-12-16**] 08:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2127-12-16**] 11:40AM BLOOD Ethanol-NEG
.
LABS ON DISCHARGE:
.
STUDIES:
EKG [**2127-12-17**]: Sinus tachycardia, LAD, poor R-wave progression,
low voltage. Non-specific ST-T changes. When compared to prior
on [**2127-12-16**], QTc prolongation has improved to normal.
NCHCT ([**2127-12-16**]): Interval decrease in thin left subdural fluid
collection
overlying the left cerebral convexity posteriorly as well as an
improvement in
the local mass effect on subjacent sulci. No new acute
intracranial
hemorrhage, edema, or mass effect.
.
NCHCT ([**2127-12-19**]): Overall further improvement, with
near-complete resolution of the thin subdural fluid collection
layering over the posterior left cerebral convexity, and no new
acute intracranial process.
.
CXR [**12-16**] FINDINGS: In comparison with the study of earlier in
this date, the endotracheal tube has been pulled back so that
the tip now lies approximately 6 cm above the carina. There is
poor definition of the medial aspect of the left hemidiaphragm
with increased opacification in the retrocardiac region. This is
consistent with volume loss in the left lower lobe, related to
the prior low position of the endotracheal tube.
There is a suggestion of some patchy opacification in the right
mid lung zone, raising the possibility of aspiration pneumonia.
.
MICRO
Blood cultures ([**2127-12-16**]): CORYNEBACTERIUM SPECIES
(DIPHTHEROIDS) 1/2 bottles.
Blood culture ([**2127-12-18**]): No growth
Brief Hospital Course:
Mr. [**Known lastname **] is a 56 year-old man with DM1, ESRD, PVD, dCHF, and
recurrent admissions for hypoglycemia who presents with
hypoglycemia and unresponsiveness, called out from the MICU for
further management.
.
# Competency: Given the large number of life-threatening
hypoglycemic episodes, pt was evaluated by psychiatry, social
work, the medical team and was deemed to be incompetent in
managing his medical illness. The patient's family also satted
that they were unable to provide 24 hour supervision for the
patient and were no longer able to care for him. Therefore, the
process of guardianship was pursued. temporary limited
guardianship for the purposes of transfer to extended care
facility was assigned to the patient's son [**Name (NI) **] [**Name (NI) **]. The
patient's sister [**Name (NI) 1022**] [**Name (NI) 21004**] remains his health care proxy.
.
# Unresponsiveness: Has had these episodes last admission
thought to be related to interruption of consciousness syndrome
secondary to cerebral edema and frontal lobe dysfunction. This
edema was thought to be related to the chronic SDH. Seizure was
questioned but routine EEG negative. Differential diagnosis
included cerebral edema/fronal dysfx vs seizure, vs relative
hypoglycemia (given drop from 400s overnight to 130). CT head
and labs were ordered, neuro was consulted, EEG was scheduled,
however, pt refused any further work up, was made aware of risks
including death, and still refused. The patient had no further
episodes of unresponsivess the rest of this admission.
.
# Recurrent hypoglycemia: Thought to be multifactorial etiology
with combination of poor medication adherance, including
confusing levemer with short-acting, poor PO intake. Insulin
Antibody less likely to be a factor as the patient only had
several mild hypoglycemic episodes as an inpatient with blood
sugars in the 50s range, during which the patient remained
asymptomatic. The patient was followed by [**Last Name (un) **] consult
thorughout this admission and long-acting insulin and sliding
scale doses were adjusted. The patient still exhibited a wide
range of blood sugars ranging from 50s to 400s, but remained
asymptomatic throughout. [**Last Name (un) **] purposely used conservative
insulin scale to avoid hypoglycemic episodes.
.
# History of SDH: Found on head CT in [**11-4**] for evaluation for
agitation/AMS, thought to be secondary to a fall. Seen by
neurosurg and thought to be chronic, not intervened upon. Held
heparin. Ambulation was used for DVT prophylaxis. The patient
remained asymptomatic throughout the rest of his
hospitalization.
.
# Diabetes I: History of recurrent episodes of hypoglycemia. The
patient was continued on prednisone for insulin antibody
syndrome. Dose of prednisone decreased to 15mg daily. [**Last Name (un) **]
consulted and followed the patient throughout this admission.
We continued QID fingerticks and sliding scale. Continued
lantus (dose increased to 10 units QAM and 6 units QPM) as well
as humalog sliding scale. The patient will follow up at [**Last Name (un) **]
upon discharge.
.
# ESRD on HD: The patient received dialysis while inpatient on
his outpatient schedule every Tuesday, Thusday, Saturday. We
continued nephrocaps, calcitriol, and TID calcium carbonate.
The patient's medications were adjusted based on his renal
function. The patient will resume his outpatient dialysis upon
discharge at [**Location (un) **] [**Location (un) **] Dialysis Center, [**State 21005**], [**Location (un) **], [**Numeric Identifier 1415**]. He will continue to be followed by
his outpatient nephrologist Dr. [**First Name (STitle) **] [**Name (STitle) 4090**]. His next
outpatient HD session is on Saturday, [**2128-2-7**]. If the
patient is not able to receive HD at [**Last Name (un) 4029**] on Saturday, please
page Dr. [**Last Name (STitle) 4090**] by calling [**Telephone/Fax (1) 2756**] and arrange for HD at
[**Hospital1 18**].
.
# Left hallux amputation: The patient had a prior amputation of
left toe on prior admission and underwent closure pf left hallux
during this admissiojn by Podiatry. Betadine dressing were
changed daily and should continue to be changed upon discharge.
Sutures remain in place upon discharge. The patient may
continue to ambulate in his post-surgical shoe essential
distances. He will follow up with podiatry upon discharge.
.
# HTN: Pt was hypertensive on the floor because all his BP meds
were discontinued in the MICU. After restarting his home meds,
his pressures returned to normotensive.
We continued Metoprolol 50mg PO TID, diltiazem SR 180mg PO BID,
doxazosin 4mg PO HS
and minoxidil 5mg PO BID
.
# [**Doctor Last Name 933**] disease: we continued synthroid
.
# Hyperuricemia: we continued allopurinol
.
# Hyperlipidemia: we continued statin
Medications on Admission:
MEDICATIONS AT HOME (per [**2127-12-13**] d/c summary):
1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
3. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID
4. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
9. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H prn
11. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
capsule, Sustained Release PO BID (2 times a day).
12. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
qhs
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
daily
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
16. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One
(1)capsule, Delayed Release(E.C.) PO twice a day.
17. Insulin: Please resume you outpatient diabetes therapy.
Please
administer 3 units levemir under the skin, twice daily. Please
administer humalog according to the attached sliding scale.
18. Levemir 100 unit/mL Solution Sig: Three (3) units
Subcutaneous twice a day for 2 weeks.
19. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for n/v.
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
15. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
17. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Ten (10)
Subcutaneous QAM.
18. Insulin Glargine 100 unit/mL Cartridge Sig: Six (6)
Subcutaneous QPM.
19. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
21. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
22. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for toe pain.
23. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
24. Insulin Lispro 100 unit/mL Cartridge Sig: as directed units
Subcutaneous four times a day: Please check fingersticks QID and
administer insulin based on the attached sliding scale. .
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1459**] Care and Rehabilitation Ctr
Discharge Diagnosis:
PRIMARY:
1. unresponsiveness, likely secondary to hypoglycemic coma
2. hypoglycemia
.
SECONDARY:
1. Chronic kidney disease, stage V
2. Type I diabetes, with neuropathy and retinopathy and insulin
autoantibodies
3. Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Ambulates without assistance
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 69**] for an
episode of unresponsiveness felt to be from low blood sugars.
Your insulin medications were adjusted with assistance from the
[**Last Name (un) **] doctors. You also had an episode of unresponsiveness with
some shaking in the hospital, for which neurology input was
requested, but this was not felt to be seizure or other
neurologic disease.
.
While you were here, you continued to receive dialysis per your
usual schedule. After discharge, you will continue to receive
dialysis at [**Location (un) **] [**Location (un) **], your usual dialysis site.
.
Your son was chosen to be your legal guardian while you were in
the hospital. This is to make sure that you are able to go to
the appropriate rehab setting.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- We adjusted your dose of Insulin (Lantus and sliding scale).
- We started you on Simethicone QID: PRN for gas/bloating
- We decreased your doses of Prednisone to 15mg daily,
Prochlorperazine to 5mg every 6 hours as needed for
nausea/vomiting, Omeprazole to 20mg daily.
- We started you on Ulltram 50mg every 12 hours as needed for
toe pain
.
Please continue your other medications as prescribed.
.
Please keep your appointments below.
.
Please seek medical attention for lightheadedness, dizziness,
shaking, low blood sugars with symptoms, chest pain, abdominal
pain, shortness of breath, nausea/vomiting, or any other
concerning symptoms. Please also weigh yourself every morning,
and notify your primary care physician if your weight goes up
more than 3 lbs.
Followup Instructions:
You have the following appointments:
.
Department: PODIATRY
When: FRIDAY [**2128-2-20**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Name: [**Last Name (LF) 10088**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
When: Wednesday, [**3-3**], 8am
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Please call the above number and ask for [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21006**] if the
you need an appointment sooner because of poor blood sugar
control.
.
Completed by:[**2128-2-7**]
|
[
"51881",
"40391",
"4280",
"2449",
"2859",
"2724"
] |
Admission Date: [**2131-9-18**] Discharge Date: [**2131-9-25**]
Date of Birth: [**2061-7-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
hemoptysis associated with new right upper lobe lung mass
Major Surgical or Invasive Procedure:
bronchoscopy
embolization of bronchointercostal trunk
History of Present Illness:
70 year old male with new hemoptysis associated with new RUL
lung mass on [**8-2**]. In [**7-3**], patient complained of RUE/shoulder
pain progressing to slight increase in shortness of breath. On
CXR, RUL lung mass found. Patient treated with antibiotics for
post obstructive pneumonia on [**8-22**] to [**9-1**]. Patient has had
decreased activity over the past 2 months; can walk one flight
of stairs with resting at the top. Patient was scheduled to see
Dr. [**Last Name (STitle) 952**] at the thoracic clinic. However, this AM patient
awoke with coughing up blood. Patient brought to [**Hospital3 **]
Hospital and transferred to [**Hospital1 18**].
Past Medical History:
lung mass; MIx3, stents x2, bronchoscopy [**2131-9-11**]
Social History:
Lives in elderly nursing [**Hospital3 **], widow x 8 yrs, retired
janitor in school, no known occupational exposures, 1.5 ppd
smoker x 55yrs
Family History:
n/a
Physical Exam:
ROS
Neuro: Denies blurred vision
Resp: increased SOB, cough, hemoptysis
Cardio: no pedal edema
Abd: no issues
Ext: R. shoulder referred pain
PE
95.7 74 167/62 18 96%RA
GEN: healthy-appearing, elderly male
HEENT: neg. lymphadenopathy (cervical, suprclavicular, axilla)
RESP: CTA B/L
HEART: RRR
ABD: soft, NT/ND
EXT: no edema
Pertinent Results:
[**2131-9-25**] 07:50AM BLOOD WBC-12.1* RBC-4.44* Hgb-12.6* Hct-35.3*
MCV-80* MCH-28.3 MCHC-35.5* RDW-15.4 Plt Ct-373
[**2131-9-25**] 07:50AM BLOOD Plt Ct-373
[**2131-9-25**] 07:50AM BLOOD Glucose-88 UreaN-14 Creat-1.4* Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2131-9-22**] 03:32AM BLOOD ALT-11 AST-11 LD(LDH)-154 AlkPhos-113
Amylase-49 TotBili-0.4
[**2131-9-25**] 07:50AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.2
Bronchial Washings
[**2131-9-21**]
SPECIMEN RECEIVED: [**2131-9-20**] [**-6/3307**] BRONCHIAL WASHINGS
SPECIMEN DESCRIPTION: Received 20ml bloody mucoid fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: Heavy tobacco use with hemoptysis and RUL mass.
REPORT TO: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **]
DIAGNOSIS: NEGATIVE FOR MALIGNANT CELLS.
Rare epithelial cells, lymphocytes and neutrophils.
[**9-20**] PET CT
INTERPRETATION: There is focal abnormal uptake of FDG in a
cavitary right
apical mass with an SUVmax of 18.1. There is abnormal FDG uptake
in a right
hilar node (SUVmax 8.8) and in the left enlarged adrenal (SUVmax
of 4.21).
There is homogeneously increased FDG uptake in the left
iliopsoas likely due to
biomechanics.
Physiologic uptake is seen in the brain, heart and GI and GU
tracts.
The CT shows vascular calcifications, a left renal cyst (not
FDG-avid; 4.5 cm
diameter), a small right non-FDG-avid cyst and osteophytosis at
numerous spinal
levels.
IMPRESSION: Findings are consistent with a right apical lung
cancer metastatic
to a right hilar lymph node and possibly to the left adrenal
gland.
MRI ABDOMEN W/O CONTRAST [**2131-9-22**] 5:37 PM
MRI ABDOMEN W/O CONTRAST
Reason: MRI ADRENAL LEFT SIDE ONLY - please eval. for metastatic
lun
INDICATION: Metastatic lung cancer. Evaluate left adrenal
nodule.
TECHNIQUE: Noncontrast adrenal protocol was performed on a 1.5 T
magnet, including in phase and opposed- phased T1 weighted
images, as well as T2- weighted images of the adrenal glands.
FINDINGS: There is nodular thickening of both adrenal glands,
more prominent on the right than on the left. These both show
marked drop of signal on the opposed-phased images, consistent
with intravoxel fat. Visualized portions of the liver, spleen,
and pancreas appear unremarkable allowing for the technique.
Multiple renal cysts are present. There is bibasilar
atelectasis.
IMPRESSION: Bilateral adrenal hyperplasia, left greater than
right. No suspicious adrenal lesions are seen.
MR HEAD W & W/O CONTRAST [**2131-9-22**] 5:37 PM
MR HEAD W & W/O CONTRAST
Reason: Eval. for brain metastatic disease
Contrast: MAGNEVIST
CLINICAL INFORMATION: Patient with right upper lobe lung cancer
for further evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images were obtained before gadolinium. T1
sagittal, axial and coronal images were obtained following the
administration of gadolinium.
FINDINGS: The ventricles and extra-axial spaces are slightly
prominent but appropriate for patient's age. There is no midline
shift, mass effect or hydrocephalus identified. There is no
evidence of significant subcortical white matter ischemic
disease or acute infarct seen.
Following gadolinium no evidence of abnormal parenchymal,
vascular or meningeal enhancement identified. Small retention
cysts are seen in the left maxillary sinus.
IMPRESSION: No enhancing intracranial lesions are identified or
mass effect is seen.
CHEST (PA & LAT) [**2131-9-24**] 8:25 PM
CHEST (PA & LAT)
Reason: eval for consolidation.pna
HISTORY: Right upper lobe mass and elevated white count.
IMPRESSION: PA and lateral view compared to [**9-20**]:
Infiltration surrounding the cavitary lesion in the right lung
apex has improved revealing the multi-cameral quality of the
lesion and local pleural thickening.
Lung volumes are lower and there is interstitial abnormality at
the right base exaggerated by overlying soft tissue. This could
be early pneumonia or, under the appropriate circumstances, drug
reaction. I would recommend a repeat frontal view of maximal
inspiration to see if this is a real or an artifactual finding.
Heart size is normal. There is no pleural effusion.
Brief Hospital Course:
Patient was admitted to thoracic surgery. OSH results include
only a BAL: AFB neg., rare aspergillis. On HD2, bronchoscopy
showed scant bleeding from posterior segment of RUL; cytology
sent and no malignant cells found. On HD3 PET showed focal
abnormal uptake of FDG in a cavitary right apical mass, abnormal
FDG uptake in a right hilar node and in the left enlarged
adrenal gland. Patient then transferred to ICU because of 200c
hemoptysis on the floor. ID consulted to rule out TB. On HD4,
patient had embolization of bronchointercostal trunk, via rt
transfem approach. On HD5, patient was hemodynamically stable
and transferred to the floor. Patient had MRI of the head and
abdomen which showed b/l adrenal hyperplasia, left greater than
right. No suspicious adrenal lesions are seen. Patient had
negative AFB cultures, remained afebrile, and hemodynamically
stable. On HD8, patient was discharged back to the assisted care
facility.
Medications on Admission:
[**Last Name (LF) 4532**], [**First Name3 (LF) **], toprol 100',percocet,crestor
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
3. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
right upper lobe lesion
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] or your own pulmonologist
if you develop fever, chills, shortness of breath, chest pain.
call you cardiologist at home for a follow up appointment.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 170**]. Call for undate
regarding surgery week of [**2131-10-2**].
Cardiac evaluation prior to surgery by Dr [**Last Name (STitle) 69253**] [**Name (STitle) 69254**] office,
[**Location (un) 9101**], [**Telephone/Fax (1) 34149**]. They have been informed of this and will
call to arrange tests prior to surgery.
|
[
"412",
"2724"
] |
Admission Date: [**2143-1-7**] Discharge Date: [**2143-1-9**]
Date of Birth: [**2101-2-16**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 41-year-old female who
was found to have an "abnormal electrocardiogram" on routine
physical examination for which she was referred for further
workup. Echocardiogram performed in [**2142-10-23**] revealed
ASD for which she was referred for ASD closure.
PHYSICAL EXAMINATION: Vital signs: Heart rate 78, normal
sinus rhythm. Patient's weight is 150 pounds. Blood
pressure 111/55. General: No acute distress, appearing
stated age. Skin: No rashes. Well hydrated. HEENT:
Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Normal
buccal mucosa, no dentures. Neck: Supple, no
lymphadenopathy, no jugular venous distention, no tracheal
deviation, and no thyromegaly. Chest was clear to
auscultation bilaterally, no wheezes, rales, or rhonchi.
Heart: Regular, rate, and rhythm, positive S1, S2, no
murmurs or rubs. Abdomen is soft, nontender, nondistended,
normal bowel sounds, no guarding, rebound, or rigidity.
Extremities: Warm, positive mild bilateral lower extremity
edema. No cyanosis and no calf tenderness. Neurologic:
Cranial nerves II through XII are grossly intact. Positive
mild lordosis due to pain when walking from history of fallen
arches.
ELECTROCARDIOGRAM: 75, normal sinus rhythm, within normal
limits otherwise.
HOSPITAL COURSE: The patient had a history as noted above.
Echocardiography report done in [**Month (only) 359**] was consistent with a
large atrioseptal defect with a dilated right atrium and
right ventricle along with a large amount of left to right
flow, which was consistent with interatrial septum with
paradoxical septal motion.
The patient was taken to the operating room on the same day
of admission, [**2142-12-28**] at which time a minimally invasive
atrial-septal defect repair was performed without incident.
At the time of surgery, the patient had a chest tube placed.
Postoperatively, the patient did well and was extubated
without event. The patient was subsequently admitted to the
CSRU for careful observation. The patient remained in normal
sinus rhythm and was urinating adequately. Kefzol
perioperatively was continued postoperative day one.
The patient subsequently was found to be doing quite well and
her central line, A line, and Foley were discontinued. The
patient was placed on Lopressor. She was found to be stable
on postoperative day #1 in the pm and subsequently
transferred to the Cardiac Surgical floor, where she
continued to do well and the chest tube was taken out on
postoperative day #2 without event.
Physical therapy also had seen the patient and deemed her
safe for discharge to home. No further physical therapy was
needed at the time. The patient was discharged and
instructed about complications to look for.
DISCHARGE MEDICATIONS:
1. Percocet 1-2 tablets po q4-6h prn pain.
2. Lopressor 12.5 mg po bid.
3. Aspirin 325 mg po q day.
4. Fexofenadine 60 mg po bid.
5. Fluconazone 110 mcg two puffs [**Hospital1 **].
6. Salmeterol 1-2 puffs [**Hospital1 **].
7. Montilucast 10 mg po q day.
8. Protonix 40 mg po q day.
9. Colace 100 mg po bid.
CONDITION ON DISCHARGE: Good.
DISPOSITION: Home.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2143-1-9**] 15:39
T: [**2143-1-9**] 15:44
JOB#: [**Job Number 44907**]
|
[
"49390",
"53081"
] |
Admission Date: [**2118-12-1**] Discharge Date: [**2118-12-23**]
Date of Birth: [**2055-10-21**] Sex: F
Service: MEDICINE
Allergies:
Meperidine / Iodine
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
- EGD/Colonosocpy
- Angiography
- PICC line placement
History of Present Illness:
63 yo with hx of HTN, fibromyalgia, and breast cancer who was
admitted here 12/20-12-29 for acute pulmonary edema in setting
of NSTEMI s/p 2 stents in LCX and D1 complicated by strep
viridins tricuspid endocarditis. She was discharged with PICC
line to complete course of PCN and on coumadin, [**First Name3 (LF) **] and [**First Name3 (LF) 4532**].
Last night around 6pm first passed bright red blood about a cup
with clots of blood with some left sided abd pain, then passed 5
more movements with blood, minimal stool if any over night and 4
more bloody movements this am until she presented for
evaluation. She also noted today that she had similar substernal
chest pressure although less intense for an hour today that
resolved w/o intervention. Some minimal shortness of breath, no
fevers, chills, or other complaints. Given bleeding took other
home meds except [**First Name3 (LF) **] and coumadin today. Otherwise has been
complaint with home meds since d/c. Of note she has never had hx
of GI bleed or ulcers, but did have a colonoscopy over 5 yrs ago
with evidence of polyps which she has not followed up.
.
In ED no more bloody BMs, rec'd 10mg SC vitamin K, 2uFFP, 1uPRBC
and NGT attempts unsuccessful.
Past Medical History:
1. CAD s/p 2 drug eluding stents in LCX and D1
2. CHF ef 30-40% 3+TR, 1+MR, e/a 0.45
3. PVD s/p bifem bypass
4. s/p Right mastectomy, Breast Ca 20yrs ago
5. Hypertension
6. Fibromyalgia
7. Strep Viridans Endocarditis
8. PFO
Social History:
Quit smoking 3-4 years ago, previous 40 pack yr smoking hx, no
etoh, lives in SC, daughters are next of [**Doctor First Name **]
Family History:
Heart Disease
Physical Exam:
VS: T 96.3 P 59 BP 129/39 R18 Sat 100%RA
GEN: aao, nad
HEENT: assymetric pupils, +pallor conjuctiva, injected sclera
CHEST: CTAB no wheezes or crackles
CV: RRR, slight SEM at RLSB
ABD: soft, +tenderness to palpation of her left side to deep
palpation, +BS, rectal with bright red blood with small clots,
no stool in vault, +ext hemorrhoid
EXT: no edema, left PICC in place on left axilla
Pertinent Results:
Admission Labs:
[**2118-12-1**] 04:00PM PT-22.6* PTT-33.0 INR(PT)-3.7
[**2118-12-1**] 04:00PM PLT COUNT-331
[**2118-12-1**] 04:00PM WBC-8.5 RBC-3.09* HGB-8.4* HCT-25.3* MCV-82
MCH-27.1 MCHC-33.1 RDW-15.7*
[**2118-12-1**] 04:00PM CK-MB-NotDone cTropnT-<0.01
[**2118-12-1**] 04:00PM CK(CPK)-48
[**2118-12-1**] 04:00PM GLUCOSE-165* UREA N-27* CREAT-1.3* SODIUM-141
POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
[**2118-12-1**] 04:11PM HGB-8.7* calcHCT-26
[**2118-12-1**] 08:00PM PT-19.0* PTT-31.4 INR(PT)-2.5
[**2118-12-1**] 08:00PM PLT COUNT-305
[**2118-12-1**] 08:00PM ANISOCYT-1+ MICROCYT-1+
[**2118-12-1**] 08:00PM NEUTS-59.7 LYMPHS-31.9 MONOS-4.1 EOS-3.0
BASOS-1.2
[**2118-12-1**] 08:00PM WBC-7.7 RBC-2.52* HGB-7.0* HCT-20.6* MCV-82
MCH-27.8 MCHC-34.0 RDW-16.3*
[**2118-12-1**] 08:00PM LIPASE-16
[**2118-12-1**] 08:00PM ALT(SGPT)-10 AST(SGOT)-10 ALK PHOS-62
AMYLASE-35 TOT BILI-0.2
.
Discharge/Interval Data:
[**2118-12-23**] 04:58AM BLOOD WBC-7.8 RBC-3.57* Hgb-10.6* Hct-30.5*
MCV-86 MCH-29.6 MCHC-34.6 RDW-17.7* Plt Ct-271
[**2118-12-15**] 05:05AM BLOOD Neuts-67 Bands-0 Lymphs-24 Monos-5 Eos-2
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2118-12-13**] 05:10AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
[**2118-12-23**] 04:58AM BLOOD Plt Ct-271
[**2118-12-22**] 04:58AM BLOOD QG6PD-8.3
[**2118-12-20**] 05:40AM BLOOD Ret Aut-5.3*
[**2118-12-15**] 01:30PM BLOOD Ret Aut-3.5*
[**2118-12-23**] 04:58AM BLOOD Glucose-84 UreaN-16 Creat-1.3* Na-143
K-3.4 Cl-109* HCO3-27 AnGap-10
[**2118-12-23**] 04:58AM BLOOD LD(LDH)-1109* TotBili-1.0 DirBili-0.3
IndBili-0.7
[**2118-12-22**] 04:58AM BLOOD LD(LDH)-1283* TotBili-1.4 DirBili-0.3
IndBili-1.1
[**2118-12-21**] 03:25AM BLOOD LD(LDH)-1454* CK(CPK)-72 TotBili-2.7*
DirBili-0.4* IndBili-2.3
[**2118-12-20**] 05:40AM BLOOD LD(LDH)-1289* TotBili-1.1
[**2118-12-19**] 05:47AM BLOOD LD(LDH)-1336* TotBili-1.5
[**2118-12-17**] 04:37AM BLOOD ALT-20 AST-66* LD(LDH)-1580* AlkPhos-70
TotBili-1.9*
[**2118-12-16**] 05:07AM BLOOD LD(LDH)-1691* TotBili-1.4
[**2118-12-15**] 05:05AM BLOOD LD(LDH)-1898* TotBili-1.7*
[**2118-12-14**] 04:54AM BLOOD LD(LDH)-2135* CK(CPK)-227* TotBili-2.6*
[**2118-12-13**] 05:10AM BLOOD LD(LDH)-2100* CK(CPK)-230* TotBili-2.7*
DirBili-0.4* IndBili-2.3
[**2118-12-12**] 05:21AM BLOOD LD(LDH)-1855* CK(CPK)-228* TotBili-2.2*
DirBili-0.4* IndBili-1.8
[**2118-12-9**] 12:58PM BLOOD CK(CPK)-150*
[**2118-12-7**] 04:50AM BLOOD ALT-13 AST-23 LD(LDH)-210 AlkPhos-56
TotBili-0.6
[**2118-12-1**] 08:00PM BLOOD ALT-10 AST-10 AlkPhos-62 Amylase-35
TotBili-0.2
[**2118-12-21**] 03:25AM BLOOD cTropnT-<0.01
[**2118-12-20**] 05:42PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2118-12-20**] 11:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2118-12-9**] 12:58PM BLOOD CK-MB-3 cTropnT-<0.01
[**2118-12-7**] 03:38AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2118-12-6**] 11:26AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2118-12-6**] 03:12AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2118-12-5**] 05:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2118-12-4**] 05:05PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2118-12-4**] 09:01AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2118-12-4**] 04:07AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2118-12-4**] 01:37AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2118-12-2**] 04:41AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2118-12-2**] 12:05AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2118-12-21**] 03:25AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.8
[**2118-12-20**] 05:40AM BLOOD Hapto-<20*
[**2118-12-19**] 05:47AM BLOOD Hapto-<20*
[**2118-12-16**] 05:07AM BLOOD Hapto-<20*
[**2118-12-15**] 01:30PM BLOOD calTIBC-213* VitB12-379 Folate-8.5
Hapto-<20* Ferritn-1461* TRF-164*
[**2118-12-15**] 01:30PM BLOOD PEP-NO SPECIFI IgG-959 IgA-309 IgM-42
IFE-NO MONOCLO
[**2118-12-1**] 04:11PM BLOOD Hgb-8.7* calcHCT-26
[**2118-12-7**] 09:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- negative
.
Microbiology:
Blood cultures: [**12-2**], [**12-3**], [**12-16**] - No growth
Urine cultures: [**12-9**], [**12-10**], [**12-13**] contaminated, [**12-12**] No growth
H.Pylori - negative
.
Imaging:
CXR [**2118-12-1**]:
1. Left-sided PICC with tip at brachiocephalic/SVC junction.
2. Stable cardiomegaly with stable to slightly improved mild
congestive heart failure.
.
EKG [**12-1**]: Sinus bradycardia. Non-specific intraventricular
conduction delay. Left ventricular hypertrophy with associated
ST-T wave changes. Q waves in the inferior leads consistent with
prior infarction. Compared to the previous tracing Q waves in
the inferior leads are more apparent.
.
GI BLEEDING STUDY [**2118-12-2**]
GI BLEEDING STUDY
Reason: LOCALIZE GI BLEED
HISTORY: 63-year-old on Coumadin, now passing blood clots per
rectum.
DECISION:
INTERPRETATION: Following intravenous injection of autologous
red blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen for 90 minutes
were obtained.
Dynamic blood pool images show focal uptake of tracer in the
region of the
hepatic flexure within the initial 10 minutes of the study.
Tracer was then
seen throughout the transverse colon, and passing into the
descending colon. Blood flow images show normal flow. Bleeding
was first noticed at approximately eight minutes.
IMPRESSION: Findings consistent with bleeding originating in the
region of the hepatic flexure. This was communicated to Dr.
[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 3646**] at the completion of the study.
.
C1894 INT.SHTH NOT/GUID,EP,NONLASER [**2118-12-4**] 7:04 PM
Reason: please eval for site of bleeding
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
63 year old woman with BRBPR and blood loss anemai.
REASON FOR THIS EXAMINATION:
please eval for site of bleeding
CLINICAL INFORMATION: 63-year-old woman with lower GI bleed, had
positive nuclear scan, needs mesenteric arteriogram.
PROCEDURE/FINDINGS: The procedure was performed by Dr. [**First Name (STitle) 379**] [**Name (STitle) **]
and Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **], the attending radiologist was
present and supervising throughout the procedure.
After the risks and benefits were explained to the patient,
written informed consent was obtained. The patient was placed
supine on the angiographic table. Preprocedure timeout was
performed to confirm the patient's name, procedure and the site.
The right groin was prepped and draped in the standard sterile
fashion. The right common femoral artery was accessed with a
19-gauge needle after local administration of 1% lidocaine. A
0.035 Bentson guidewire was advanced into the abdominal aorta
under fluoroscopic guidance. The needle was exchanged for a
4-French sheath. The inner dilator was removed. The sheath was
connected to a continuous sidearm flush. A 4 French catheter was
advanced over the wire into abdominal aorta. The guidewire was
removed. The catheter was used to subsequently engage the origin
of celiac axis and superior mesenteric arteries. Selective
celiac and SMA arteriogram were performed at anterior-posterior
and lateral projections. There was no evidence of extravasation
of contrast. No inferior mesenteric artery was identified
secondary to aortic bypass graft.
Based on the diagnostic findings, no further intervention was
needed at this moment. The catheter and the sheath were removed.
Hemostasis was achieved by direct manual pressure for 20
minutes. The patient tolerated the procedure well and there were
no immediate complications.
IMPRESSION: Selective celiac axis, superior mesenteric
arteriogram demonstrated no extravasation of contrast.
.
GI BLEEDING STUDY [**2118-12-4**]
GI BLEEDING STUDY
Reason: P/W BRBPR-PLEASE ASSESS GI BLEED
HISTORY: bright red blood per rectum
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for 30 minutes were obtained. Dynamic
blood pool images show prompt appearance of tracer activity in
the right upper quadrant in a similar distribution to the prior
study. Blood flow images show tracer within the expected course
of the abdominal vasculature. Bleeding was first noticed at
approximately 3 minutes.
IMPRESSION: Tracer activity demonstrated in the right upper
quadrant beginning at approximately 3 minutes, in a similar
location compared to the prior study. Patient was promptly taken
to angiography when the bleeding was identified.
.
EKG [**12-4**]: Sinus bradycardia Short PR interval Nonspecific
intraventricular conduction defect Inferior infarct - age
undetermined
LVH with ST-T changes No change from previous
.
EKG [**12-7**]: Sinus bradycardia Short PR interval Nonspecific
intraventricular conduction defect Inferior infarct - age
undetermined LVH with ST-T changes No change from previous
.
EKG [**12-10**]: Atrial fibrillation with a mean ventricular response,
rate 118. Compared to the previous tracing of [**2118-12-9**] cardiac
rhythm is now atrial fibrillation.
.
RENAL U.S. [**2118-12-12**] 11:54 AM
RENAL U.S.
Reason: obstruction
[**Hospital 93**] MEDICAL CONDITION:
63 year old woman with CAD s/p MI, CHF, massive LGIB s/p 19
units of prbcs, now with ARF cr 0.8->1.9 in setting of labile
HTN. Also with ongoing hematuria.
REASON FOR THIS EXAMINATION:
obstruction
INDICATION: CAD, status post MI with acute renal failure in the
setting of labile hypertension, ongoing hematuria.
No prior studies are available for direct comparison.
FINDINGS: The right kidney measures 10.9 cm. The left kidney
measures 11.1 cm. There is a small roughly 4-mm nonobstructing
stone within the interpolar region of the right kidney. There is
no hydronephrosis. A small approximately 1 cm anechoic cyst is
demonstrated within the right parapelvic region. The bladder is
unremarkable.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Non-obstructing right renal stone.
.
INDICATIONS FOR CONSULT:
Investigation of transfusion reaction
CLINICAL/LAB DATA: The patient is a 63 year old female with a
history of
hypertension, coronary artery disease (NSTEMI with stent
placements in
[**10-31**]) peripheral vascular disease, pulmonary edema, breast
cancer and a
recent diverticular bleed at the splenic flexure who was
admitted for a
GI bleed and falling hematocrit. The patient has received 21
non-reactive red blood cell transfusions, 5 non-reactive plasma
transfusions and two non-reactive platelet trasnfusions. On
[**12-12**], the
patient received a unit of packed red blood cells (Hct was 28.2
to 29.3
on that date). Her vitals pre transfusion (14:45) were:
temp=97.9,
pulse=60, resp=18, BP=106/palp. At 18:30, after the patient had
received
375 cc, the patient was witnessed to have hematuria, which was
also
present before the transfusion, per the resident caring for the
patient.
Her vitals at that time were: temp=98.6, pulse=60, resp=16,
BP=154/80.
The patient had received percocet 30 minutes prior to the
transfusion.
Fever, chills/rigors, respiratory distress, chest pain, nausea
and
vomiting and back pain were not described. No clerical errors
were
detected.
LAB DATA:
RECIPIENT ABO/RH: B POSITIVE
UNIT (04FS82305) ABO/RH: B POSITIVE
Antibody screen: NEGATIVE
Plasma color pre and post transfusion: Icteric, copper-colored
LABS: post transfusion= 30.1
Other labs from [**2118-12-12**]: WBC=11.9, PLT=232
BUN=23, Creat=1.9, LD=1855, CK=228, total bili=2.2,
indirect=1.8, direct
bili=0.4, haptoglobin=<20.
Urine: color=red with 6-10 WBC and [**5-6**] RBC, prot/creat=1.6,
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: The patient
experienced
isolated hematuria 3 hours and 45 minutes after receiving 375 cc
of B
positive compatable blood. This hematuria was present
pre-transfusion.
The post transfusion antibody screen and DAT were negative and
the post
transfusion plasma had an icteric, copper color. No fever,
chills,
respiratory distress, hypotension or other signs of hemodynamic
instability were noted after the transfusion. The possiblility
of an immune intravascular hemolytic transfusion reaction with
this
clinical picture is highly unlikely. Non immune causes of
hemolysis
include mechanical (heart valve, roller pump), osmotic,
intrisnic red
cell defect. Repeat testing of antibody screen and direct
antiglobulin
test (DAT) would be warrented if continued hemolysis occurs
without
other found causes.
.
BAS/UGI AIR/SBFT [**2118-12-15**] 9:38 AM
BAS/UGI AIR/SBFT
Reason: obstruction, mass - cause for dysphagia
[**Hospital 93**] MEDICAL CONDITION:
63 year old woman with massive LGIB, CAD s/p MI, now with
hemolytic anemia, ARF, also with dysphagia to solids
REASON FOR THIS EXAMINATION:
obstruction, mass - cause for dysphagia
HISTORY: 63-year-old woman with massive lower GI bleed, CAD,
hemolytic anemia, acute renal failure, now with upper dysphagia
to solids.
FINDINGS: Barium passes freely through the esophagus. There is
no aspiration into the airway and no significant retention in
the valleculae or piriform sinuses. No structural abnormalities
are detected in the region of the pharynx and cervical
esophagus. There is a small axial hiatal hernia and a small
amount of gastroesophageal reflux was observed during the exam.
No definite Schatzki ring was observed, however, the barium
tablet delayed significantly at the gastroesophageal junction
before passing into the stomach. No esophageal mucosal
abnormalities were identified.
IMPRESSION: No abnormalities identified in the hypopharynx and
upper esophagus. Small axial hiatal hernia with associated
gastroesophageal reflux. Although no Schatzki ring was
identified, there was delayed passage of the 12.5 mm barium
tablet across the gastroesophageal junction.
.
EKG [**12-20**]: Sinus rhythm. Left atrial abnormality. Compared to the
previous tracing of [**2118-12-10**] cardiac rhythm now sinus mechanism.
Multiple other abnormalities persist without major change.
.
.
.
Gastroenterology:
1. Colonoscopy [**2118-12-4**]: Indications: Gastrointestinal bleeding
with positive tagged RBC scan at hepatic flexure
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was placed in the left
lateral decubitus position and the colonoscope was introduced
through the rectum and advanced under direct visualization until
the cecum was reached. The appendiceal orifice and ileo-cecal
valve were identified. Careful visualization of the colon was
performed as the colonoscope was withdrawn. The procedure was
not difficult. The quality of the preparation was poor.
Visualization of the whole colon was poor. The patient tolerated
the procedure well. The digital exam was normal. There were no
complications.
Limitations: Poor preparation of the whole colon due to
bleeding.
Findings:
Protruding Lesions Many semi-pedunculated non-bleeding polyps
of benign appearance and ranging in size from 4mm to 8mm were
found in the hepatic flexure. Three semi-pedunculated polyps of
benign appearance and ranging in size from 4mm to 7mm were found
in the transverse colon. A single mixed 7 mm non-bleeding polyp
of benign appearance was found in the sigmoid colon.
Excavated Lesions Multiple severe diverticula with extensive
openings were seen in the sigmoid colon , transverse colon,
hepatic flexure and ascending colon.
Other Extensive amount of blood was seen throughout the entire
colon. The cecum, appendiceal orifice, and ileocecal valve were
identified. Bilious, non-bloody fluid was seen coming from the
ileocecal valve suggesting that bleeding is localized distal to
the ileocecal valve. There was also fresh blood seen at the
hepatic flexure and less blood in general at the cecum/ascending
colon. A large adherent blood clot of was visualize at the
hepatic flexure. The blood clot was mobilized with irrigation
and with the colonoscope. Multiple diveriticula were seen
beneath the clot, but no active bleeding was seen. There were
also six polyps of [**3-4**] mm in size at the hepatic flexure. None
of the polyps was actively bleeding.
Impression: 1. Diverticulosis of the sigmoid colon , transverse
colon, hepatic flexure and ascending colon
2. Polyps in the hepatic flexure, transverse colon, and sigmoid
colon
3. A large adherent blood clot of was visualize at the hepatic
flexure. There were multiple diverticula and polyps underneath
and nearby the clot, respectively. Source of bleeding is most
consistent with diverticular bleed at the hepatic flexure.
Recommendations: Angiogram +/- selective embolization of
arteries supplying hepatic flexure.
Patient will need repeat colonoscopy for polypectomies after
acute GI bleeding has resolved.
Additional notes: The attending physician was present throughout
the entire procedure.
.
.
.
2. EGD: Indications: Dysphagia
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
Conscious sedation anesthesia. The patient was placed in the
left lateral decubitus position and an endoscope was introduced
through the mouth and advanced under direct visualization until
the second part of the duodenum was reached. Careful
visualization of the upper GI tract was performed. The vocal
cords were visualized. The procedure was not difficult. The
patient tolerated the procedure well. There were no
complications.
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Patchy erythema of the mucosa with no bleeding was
noted in the antrum. These findings are compatible with
gastritis.
Duodenum: Normal duodenum.
Impression: Erythema in the antrum compatible with gastritis
Otherwise normal egd to second part of the duodenum
Recommendations: Follow-up biopsy results
Check H. pylori serology
Esophageal manometry
Additional notes: The attending was present for the entire
procedure
.
Brief Hospital Course:
Patient is a 63 yo woman w/ CAD, labile HTN, CHF (mildly
depressed EF, 1+AR, 2+MR), Afib, PVD, FM, breast CA in
remission, s/p NSTMI in [**10-31**] c/b pulmonary edema, s/p 2 stents
to D1 and LCx (failed), also c/b strep viridans endocarditis
admitted with massive GI bleed. Patient was d/ced on [**2118-11-24**]
w/PICC line to complete course of PCN. Patient had episode of GI
bleed w/BRBPR in setting of taking [**Date Range **], Coumadin. Patient's hct
on admission was 25->20. Patient received a total of 19 units of
pRBCs , 2 units of FFP, and reversed with 10 mg SC Vit K for
this episode of GI bleeding. At that time patient also had
substernal chest pressure x 1 hr that resolved spontaneously.
Patient is s/p 2 positive tagged cell scan at hepatic flexure
and colonoscopy showing a clot at the hepatic flexure. Angiogram
was negative, last bleed on [**2118-12-5**]. Surgical evaluation felt
that patient was not a surgical candidate at the time. Patient
was then stabilize in terms of GI bleeding and maintained a
stable Hct >30. She was transferred to the regular medicine
floor at that time. On the floor, the patient had labile HTN
with BP ranging 180s-200s. Her blood pressure medications were
held in the setting of GI bleed. Patient was restarted on most
of her outpatient meds including ACEI. She dropped her pressures
to the 140s range. She subsequently had an increase in Cr. to a
max of 2.4 on [**2118-12-13**]. Renal consultation was placed and it was
felt that the initiation of an ACE along with relative
hypotension was the cause for this increase. ACEI was
discontinued and the patient's medications where tapered for a
goal SBP of 160s. Upon discharge the patient's Cr. was 1.3 and
she is scheduled for renal follow up regarding the possibility
of using an ACEI in the future. Patient also started to develop
brown urine around this time. Her Hct drifted below 30 without
any evidence of ongoing GI bleeding (although she remained
guaiac +). Patient was transfused several more units of blood
over the following days to a total of 25 units since admission.
With these transfusions, however, the patient did not
substantially increase her Hct and persistently remained with a
Hct ~25-26. Her urine remained dark and the workup for hemolysis
began since patient had elevated LDH to [**2112**], haptoglobin <20
and elevated bilirubin to ~2.5. Patient never experienced any
fevers, chills, flank pain however and her Cr. continued to
improve. Hematology was consulted since the etiology for this
hemolysis remained unclear. DDx included delayed transfusion
reaction (immune vs. non immune), G6PD deficiency given patient
had received 1x Sulfa for +U/A. Urine hemosiderin was
persistently negative suggesting an extravascular process. [**Doctor Last Name 17012**]
body preparation was negative and G6PD assay was within normal
limits. Her blood smear remained inconclusive with rare
schistocytes, bite cells and spherocytes. It was also postulated
that the patient may be hemolyzying due to sulfa drugs since she
also received lasix with her blood transfusion. A trial of lasix
however did not induce further hemolysis. Upon discharge, the
patient's Hct is stable ~30 with clear urine. She is scheduled
for follow up with Hematology at [**Hospital3 **].
.
In terms of her individual medical problems:
.
1. Lower GI bleed: Patient bled in the setting of a supra
therapeutic INR and while taking [**Hospital3 **] post MI and hx of A.fib.
She did not have a history of bleeding had a colonoscopy with
polyps over 5 yrs ago without any follow up. She was guaiac
negative prior to starting heparin on last admission. Her bleed
was found to be secondary to diverticula located at the hepatic
flexure. Her last bleed was on [**12-5**] without any further episodes.
Her hematocrit was maintained >30 given her recent history of
myocardial infarction, this required a total of 19 units of
blood while she was monitored in the intensive care unit. She
was also treated with Vit K and 2 units of FFP. Two tagged red
cell scans localized the bleed to the hepatic flexure. She also
had colonoscopy confirming diverticular disease. Patient is
advised to return to the ED immediately with any blood per
rectum. She will likely need surgical intervention should this
occur again. At the time of admission, however the patient was
felt to be nonoperable. Interventional Radiology also performed
angiography but was unwilling to perform embolization due to the
risk of necrosis. Importantly, patient was taken off Coumadin
and continued on [**Month/Day (4) **]/[**Month/Day (4) **] as per Cardiology consultation.
Patient has been tolerating a diet for several days prior to
discharge. She is also continued on a bowel regimen to maintain
soft stool.
.
2. CAD s/p NSTEMI: Patient was considered high risk for ischemia
given her massive LGIB and recent MI. She experience one episode
of CP with the bleed without EKG changes, CE negative. Patient
then remained stable throughout admission. Later on patient
experience chest tightness with shortness of breath in the
setting of Hct ~25. There were no new EKG changes and CE were
negative x 3. Upon discharge she is chest pain free. She is to
continue taking [**Last Name (LF) **], [**First Name3 (LF) **], beta blocker. She is scheduled for
Cardiology follow up as an outpatient.
.
3. Labile HTN: Patient with severe HTN with hx of flash
pulmonary edema and hypertensive emergencies. She was initially
taken off all outpatient meds given her large GI bleed. Once
stabilized and transferred to the floor, her usual medications
were restarted including CCB, ACEI, Hydral PO, clonidine patch,
Imdur. Her blood pressures varied b/w 120s-190s. At this stage
her Cr. began to increase and it was felt that relative
hypotension was the cause along with initiation of the ACEI. As
such, permissive hypertension was allowed with goal SBP ~ 160.
Upon discharge, however, with recovery of her Cr, she was
controlled more closely with BP ~130-140. She is discharged on
Toprol, Amlodipine, and Imdur. Her clonidine path, Hydral and
ACEI and Aldactone were all discontinued. She will be evaluated
in the nephrology clinic about the possibility of re adding and
ACEI. She may also still need po Hydralazine for optimum
control. Patient received a renal MRI/MRA to rule out stenosis
that was negative on the right and unable to assess on the left
due to artifact from aorto-[**Hospital1 **] iliac stenting.
.
4. Atrial Fibrillation/Flutter: Patient had transient episode
during her last admission, spontaneously converted to sinus
rhythm and was started on Coumadin, and sent out on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts monitor and was to have an outpatient EP study. Given her
massive GI bleed Coumadin was discontinued. Patient also had
some short runs of SVT to 150s on [**12-13**]. Beta blocker was up
titrated per EP recommendations. She did not experience any
further episodes. She is scheduled for EP follow up to determine
the need for ongoing anticoagulation. She is currently in Sinus
Rhythm.
5. ARF. Cr peak at 2.4 trending down to 1.3 on Discharge. Her Cr
began to rise prior to her episode of hemolysis. Likely
secondary to starting ACEI as well as relative hypotension,
?exacerbated by hemolysis. Her dose of Statin was temporarily
decreased to 40 mg daily (Atorvastatin) since this could have
been exacerbating her renal failure. She is not longer taking
and ACEI.
.
6. Hemolytic Anemia. Evidence of hemolysis with increased LDH,
low hapto, increased T. bili, ?delayed transfusion rx vs. G6PH
deficiency, drug reaction, infectious (Bactrim for UTI). Patient
s/p transfusion reaction screen - no evidence of immune mediated
hemolysis however could be false negative. Other work up was
also negative including [**Doctor Last Name 17012**] body smear, urine hemosiderin, non
specific blood smear. Upon discharge the etiology remains
unclear. Hct currently stable ~30. She is scheduled for
Hematology follow up.
The patient should have a micro coombs assay sent as outpatient
as the clinical suspicion for a COOMBS + alloimmune hemolytic
anemia remaisn high as the patient seemed to only hemolyze in
the setting of red cell transfusion. Said another way, we think
the negative DAT ( coombs test) may be a false negative.
7. CHF: Evidence of both systolic and diastolic dysfunction with
mildly reduced EF. No active issues during this admission, no
evidence of fluid overload. Lasix was given between blood
transfusions to prevent overload. Patient was continued on beta
blocker and Imdur.
.
8. Strep Viridans endocarditis/thrombus: Unclear based on [**Doctor Last Name 113**]
results (no vegetations) on prior admission, surveillance
cultures negative. She was started on Penicillin to complete a
course of antibiotics on last admission and d/ced home with
PICC. Upon admission to the MICU, PCN was discontinued.
Surveillance cultures were negative and as such she was not
restarted on penicillin. Patient is scheduled for ID follow up
as an outpatient.
.
9. Shortness of Breath. Patient experienced intermittent
episodes of shortness of breath, primarily wit
ambulation/exertion and SVT. Beta blocker was up titrated with
good control. Likely [**12-29**] to deconditioning and long hospital
stay. She was r/out for MI. O2 sats remained good.
.
10. Dysphagia. Patient complained of dysphagia to solids. Barium
swallow was performed which showed showing distal narrowing and
delayed emptying at the level of the GE junction (see results
section). EGD was performed that did not show any
lesions/masses, not consistent with achalasia. + gastritis. H.
pylori testing was negative. Her dysphagia was thought to be
secondary to a [**Month/Day (2) **] disorder. Patient was continued on a
soft mechanical diet. An esophageal manometry study is scheduled
as an outpatient.
.
11. Thrombocytopenia: Likely secondary to massive red cell
transfusion. Resolved spontaneously.
.
F/E/N: Cardiac diet/soft mechanical, monitored and replaced
lytes as needed
.
Prophylaxis: Venodynes, no heparin, [**Hospital1 **] PPI then tapered to
daily, bowel reg prn
.
Patient was a full code throughout.
.
Access: PICC, 1 PIV (Note: Post-mastectomy, can only use left
arm)
Medications on Admission:
- [**Hospital1 **] 75mg qd
- Lipitor 80mg qd
- [**Hospital1 **] 325mg qd
- Pantoprazole 40mg qd
- Warfarin 5mg qd
- Lasix 20mg qd
- Lisinopril 40 [**Hospital1 **]
- Toprol xl 100mg qd
- Hydralazine 50mg q6hrs
- Spironolactone 25mg qd
- Imdur 120mg qd
- Norvasc 10mg qd
- Clonidine 0.1mg/24hr patch(Tues)
- Ipratropium 2puffs qid
- Sertraline 25mg qd
- Penicillin G Potassium 3,000,000 units q4hrs
- Oxycontin 10mg q12
- Oxycodone-Acetaminophen 5-325 mg prn PO Q4-6H
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*150 Tablet(s)* Refills:*0*
4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
10. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
11. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
12. 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*
13. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*qs 1* Refills:*2*
15. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Physician [**Name9 (PRE) **] [**Name9 (PRE) **]
Discharge Diagnosis:
1. Lower GI bleed
2. Coronary Artery Disease s/p Non ST Elevation Myocardial
Infarction
3. Atrial Fibrillation/SVT
4. Hypertension
5. Congestive Heart Failure
6. Thrombocytopenia
7. Acute Renal Failure
8. Hemolytic Anemia
Discharge Condition:
Good - BP under better control, chest pain free, no further
hemolysis, renal function stable and improved
Discharge Instructions:
Please take all of your medications as directed
Please go to your local clinic/doctor's office to get your blood
drawn (Complete Blood Count and Chemistry Panel) and have the
results sent/faxed to your Primary Care Doctor.
Please return to the hospital or contact your physician if you
have any headache/dizziness, chest pain/pressure, difficulty
breathing or any other complaints.
***If you see any evidence of bleeding in your stool
immediatedly go to the nearest emergency room
Followup Instructions:
You have the following appointments scheduled. It is very
important that you see a doctor shortly after your discharge. We
have made an appointment for you to see a general medicine
doctor here at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**]. You should also follow up with you
own primary care doctor, please make sure to see them within one
week of discharge. Please take your discharge summary with you
to this appointment so that they know what happened in the
hospital.
1. Gastroenterology: Provider: [**Name10 (NameIs) 2166**] ROOM GI ROOMS
Date/Time:[**2118-12-28**] 12:00 to perform a [**Year/Month/Day **] study.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7217**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2118-12-28**]
12:00
2. Infectious Diseases - Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2118-12-29**] 11:00 AM
3. Gastroenterology: [**2119-1-3**] 02:30p Dr. [**First Name (STitle) **] [**Doctor Last Name **]. To follow up
your [**Doctor Last Name **] study. Phone ([**Telephone/Fax (1) 8892**]
4. Hematology: Date: [**2119-1-23**] 09:30a Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] L. Phone: ([**Telephone/Fax (1) 31457**]
5. General Medicine [**2119-1-26**] 01:30p Dr. [**Last Name (STitle) 11183**],[**First Name3 (LF) **] -
[**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **]. [**Hospital 191**] MEDICAL UNIT
6. Cardiology: Date: [**2119-1-9**] 04:00p Dr. [**Last Name (STitle) **] CARDIOLOGY
Phone: ([**Telephone/Fax (1) 9530**]
7. Kidney specialist. [**2119-1-26**] 03:00p Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] K. RENAL
DIV-Phone: ([**Telephone/Fax (1) 773**]
Completed by:[**2118-12-23**]
|
[
"5849",
"4280",
"42731",
"2875",
"2851",
"V4582",
"4019"
] |
Admission Date: [**2174-1-29**] Discharge Date: [**2174-3-1**]
Date of Birth: [**2094-12-18**] Sex: F
Service: NEUROSURGERY
Allergies:
Meperidine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
[**2174-1-29**] Cerebral Angiogram with coiling of L supraclinoid ICA
aneurysm
[**2174-1-29**] Right fronatl External ventricular drain
[**2174-2-1**] Cerebral angiogram
[**2174-2-6**] Right frontal External ventricular drain re-placed
[**2174-2-8**] Left frontal external ventricular drain placement
[**2174-2-25**] Left frontal VP shunt
[**2174-2-28**] PEG
History of Present Illness:
HPI: 79yo F w/ h/o HTN found down this AM w/ altered mental
status and unwitnessed fall. Was found by husband on floor, with
urinary incontinence noted. Last seen normal on evening of
[**1-29**].
Was evaluated on [**1-29**] in ED for nausea, vomiting, and headache
and was stable and discharged at that time. On arrival to ED
patient is non-vocal and is unable to provide history.
Past Medical History:
HTN, HLD
Social History:
Social Hx: per OMR no tobacco, occasional alcohol
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
GCS 8 E: 2 V:1 Motor 5
O: T: 100.5 BP: 126/85 HR: 90 R 14 O2Sats 100% RA
Neuro: lethargic, non-vocal, not following commands, EO to
noxious, pupils 2->1.5 bilaterally, +corneal, +gag, moving all
extremities spontaneously w/ strength, localizing noxious
stimuli, toes upgoing bilaterally, no clonus
ON DISCHARGE
Patient is generally lethargic, but opens eyes to voice. PERRL 3
to 2mm bilaterally EOM I.
Moves all extremities spontaneously.
Cranial incision closed with nyelon sutures.
Pertinent Results:
[**1-30**] CTA:
1. Head CT shows diffuse subarachnoid hemorrhage and
hydrocephalus.
2. CT angiography demonstrates a 6-mm aneurysm arising from the
left internal carotid artery C6 segment, pointing superiorly
with a 4-mm neck. No other aneurysms are seen.
[**1-30**] Cerebral Angio:
Successful embolization of the supraclinoid left internal
carotid artery
aneurysm.
[**1-30**] CT C-spine: No fractures
[**1-31**] CT head: Interval increase in the amount of blood in the
occipital horns of the lateral ventricle, the third ventricle
and the fourth ventricle with a small amount of blood adjacent
to the catheter opening in the right frontal [**Doctor Last Name 534**].
[**2-1**] CTA Head: IMPRESSION:
1. Stable diffuse subarachnoid hemorrhage involving both
hemispheres with
redistribution and resolution of the intraventricular component.
2. Evolution of scattered infarcts in the left fetal origin PCA
vascular
territory and left frontal lobe which are most likely embolic in
nature.
3. Diffuse narrowing of left PCA and bilateral distal A2 and M3,
M4 branches. In conjunction with the more recent CT performed at
the time of this report, this finding appears largely related to
technical issues, though an actual component of peripheral
vasospasm appears to be present.
4. Further decrease of the ventricular size with stable position
of right
frontal ventriculostomy catheter.
[**2-2**] ECHO: IMPRESSION: Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
[**2-2**] CTA Head: IMPRESSION:
1. Evolving scattered infarcts, involving the left PCA territory
as well as small lacunar area in the left frontal corona
radiata.
2. Mild spasm involving the left PCA and bilateral anterior and
middle
cerebral artery terminal branches.
3. Unchanged appearance of extensive subarachnoid hemorrhage
with relatively small intraventricular component.
4. Stable size and configuration of ventricles.
[**2-2**] Angio- / Cerebral
FINDINGS: Left common carotid artery arteriogram shows filling
of the left
internal carotid artery along the cervical, petrous, cavernous
and
supraclinoid portion. The previously coiled supraclinoid
aneurysm stays
obliterated. The MCA is normal in caliber along with the
internal carotid
artery and the fetal PCA. The anterior cerebral artery is
smaller in caliber consistent with a right dominant A1.
Right common carotid artery arteriogram again demonstrates that
the right
internal carotid artery fills well along the cervical, petrous,
cavernous and supraclinoid portion. The anterior and middle
cerebral arteries fill well. The anterior cerebral artery is
seen to be dominant and supplies both hemispheres.
IMPRESSION: [**Known firstname 6739**] [**Known lastname **] underwent cerebral angiography which
revealed no
evidence of vasospasm. The previously coiled aneurysm continues
to stay
obliterated.
[**2174-2-4**] LENIES
CONCLUSION: No evidence of DVT in right or left lower extremity.
[**2174-2-8**] CT BRAIN:
IMPRESSION: New focus of air in the frontal [**Doctor Last Name 534**] of the right
lateral
ventricle with otherwise stable exam.
[**2174-2-8**] CT BRAIN:
Diffuse subarachnoid hemorrhage is largely stable from prior
exam.
Ventriculostomy catheter has been removed. Intraventricular
hemorrhage has
significantly progressed from study obtained 11 hours prior, now
extending
into and filling the right lateral, third and fourth ventricles.
In addition, the ventricles appear increased in size. For
example, frontal horns of the lateral ventricles currently
measure 4.2 cm in diameter, previously 3.6 cm (2:11). The third
ventricle measures 1.4 cm, previously 1.1 cm (2:12). A locule of
gas involving the frontal [**Doctor Last Name 534**] of the right lateral ventricle is
unchanged (2:12). Focal hyperattenuation with surrounding
hypodensity along the previous ventriculostomy tract, likely
represents hemorrhage with surrounding edema (2:13). Small
subgaleal hematoma, soft tissue edema and a burr hole overlying
the right frontal area is unchanged, likely post-procedural.
[**2174-2-9**] CT BRAIN:
IMPRESSION:
1. Similar extent of diffuse subarachnoid hemorrhage and
right-predominant
intraventricular hemorrhage.
2. Interval placement of left frontal approach shunt catheter
with significant improvement in degree of lateral
ventriculomegaly, more on the left.
3. No new hemorrhage, major infarct, or increased mass effect.
[**2174-2-11**] CT Head:
IMPRESSION:
1. Interval increase in dilatation of the occipital [**Doctor Last Name 534**] of the
left lateral ventricle with increase in the amount of blood
pooling in this region.
2. Persistence of subarachnoid hemorrhage, and persistence of
blood products in the right ventricle as well at the right
frontal lobe.
3. Persistence of hypodensity in the left occipital lobe
consistent with a
chronic infarction.
[**2174-2-12**] CXR
REASON FOR EXAMINATION: Ventilation-acquired pneumonia in a
patient with
subarachnoid hemorrhage.
AP radiograph of the chest was compared to [**2174-2-8**].
The ET tube tip is 3.5 cm above the carina. The Dobbhoff tube
tip is in the stomach. Heart size is normal. Mediastinum is
stable. The PICC line tip is at the level of mid SVC. Right
lower lobe opacity has progressed consistent with either
atelectasis or infectious process. Upper lungs are essentially
clear. No appreciable pleural effusion or pneumothorax is seen
[**2174-2-12**] LEFT SHOULDER
REASON FOR EXAMINATION: Trauma, shoulder swelling.
Two limited views of the left shoulder were reviewed.
There is chronic widening of the left acromioclavicular joint,
8.6 mm. There is no acute fracture or dislocation.
Radiology Report CT Chest, ABD & PELVIS WITH CONTRAST Study Date
of [**2174-2-18**] 1:47 PM
IMPRESSION:
1. Mild dependent bibasilar atelectasis. Ground glass opacity at
the right
lung base may represent aspiration in the appropriate clinical
setting. No
consolidative pneumonia.
2. 7-mm ground-glass nodule at the right apex. If the patient
has no risk
factors for malignancy, followup with dedicated chest CT is
recommended at
6-12 months. If the patient has risk factors for malignancy
(e.g. smoking),
dedicated chest CT is recommended in [**4-12**] months.
3. No evidence of infection in the abdomen or pelvis.
4. Massive amount of stool in the rectum.
5. Nonobstructing stone in the left kidney.
Head CT [**2174-2-19**]:
IMPRESSION:
1. Interval increase in dilatation of the ventricular system,
consistent with progressive hydrocephalus.
2. Interval decrease in quantity of multi-compartmental
intracranial
hemorrhage, as described above.
3. No new intracranial hemorrhage, acute large vascular
territorial
infarction, or central herniation.
Head CTA [**2174-2-21**]:
IMPRESSION:
1. Slight decrease in ventricular size which remains still
dilated.
2. CT angiography shows unchanged appearance of the vascular
structures
compared with [**2174-2-6**], but minimal diffuse vasospasm is seen
compared to the CT of [**2174-2-1**]. No occlusion is seen
Head CT [**2174-2-23**]:
1. Moderate ventricular dilation, minimally increased since the
recent CTA
study. Correlate with catheter function and position.
Intraventricular
hemorrhage as before. No new areas of hemorrhage identified.
2. Left frontal lucent calvarial lesion is unchanged since
[**2174-1-29**] and since the MR [**First Name (Titles) 767**] [**2164-12-13**] and
likely benign.
Head CT [**2174-2-28**]
1.Decreased amount of air in the ventricles and in the left
frontal lobe
surrounding the catheter .
2. No evidence of new hemorrhage or other acute intracranial
process.
Brief Hospital Course:
Ms. [**Known lastname **] was found to have a left superclinoid aneurysm and
obstructive hydrocephalus. A right frontal EVD was placed
emergently and the patient subsequently went to the angio suite
for coiling of her aneurysm. Post coiling the patient was
placed on a heparin drip for 12 hours and transported intubated
to the ICU.
ICU course:
[**1-31**] Patient remained stable, on examination she was moving all
four extremities spontaneously. Her EVD stopped working for a
period of time, a CT was obtained that showed a Clot at the end
of her EVD. She recieved 2mg of IT TPA which desolved the clot
and she started to drain normally.
[**2-1**] TCD w increased velocities on left dista MCA, minimal
respons to commands with no motor weakness. Pressing to SBP 140
[**2-2**] Cerebral angiogram negative for vasospasm, ECHO with EF>55
and normal biventricular function
[**2-3**] febrile to 102, blood/urine/CSF cultures sent. Off
pressors now, Dilantin changed to Keppra and ASA started
On [**2-4**], The evd was at 15 and open. The patient had a fever
spike to 102 and was cultured by icu team. A picc line was
placed.
On [**2-5**], The EVD was raised drain to 20. Transcranial doppler
studies were consistent with mild vasospasm in the left MCA,
borderline vasospasm in the Right MCA. lower extremity
ultrasound of the bilateral lower extremity was performed and
were negative.
On [**2-6**], The EVD stopped draining CSF. TPA 2mg was instilled
to the EVD catheter. The Aspirin and keppra ws discontinued. A
ChestXRay was performed which was suggestive of mid/upper lung
emphysema. The Hematocrit was 26 and the patient was transfused
with 1 unit of PRBCs.
On [**2-6**], A CTA of the Head was performed and showed NO vasospasm.
The EVD stopped draining at 1100 and TPA not given due to small
hemorhage noted along the EVD tract. The EVD removed and large
clot noted in the distal end of the EVD catheter and replaced in
same tract without difficulty. The EVD was raised to 20 and
open.
She remained stable and the EVD catheter stopped functioning.
It was left open at 10 cm if H20. It was then intermittently
functioning for a day or so and her vetricular size remained
stable as did her clinical exam. She had the right frontal EVD
removed on [**2-8**]. It was noted some hours afterwards that her
clinical exam had changed. CT imaging demonstrated large new
intraventricular hemorrhage. She was re-intubated and a left
sided External Ventricular drain was placed. Follow up imaging
diplayed worsening hemorrhage. Her drian remains functional and
her exam stabilized. On [**2-10**], patient had low grade fevers with
episodes of tachycardia and tachypnea. She was tranfused with
PRBCs for low hct. Cultures were sent. She continued to spike
and patient was more lethargic on examination. Sputum culture
was positive and she was placed on vanc/zoysn for presumed VAP.
On [**2-11**] a CT of the head was performed which was stable, her EVD
was raised to 20 and she was started on salt tabs for
hyponatremia. On the weekend of the 8th she fever spiked to
102.8 / her abx were switched to Nafcillin for RLL PNA. She
remains intubated at present.
A re-clamping trial occured on the 9th and she failed within 5
hours. Her drain was re-opened. On [**2-15**] she appeared more
lethargic in the AM but seemed to perk up late morning. Early
afternoon, she once again appeared lethargic. She was noted to
be tachpenic and working to breathe, she was afebrile. Her EVD
was dropped to 15cm. An ABG was sent which showed a PO2 of 66. A
repeat NA was 127 and 3% saline was started at 20 cc/hr.
Patient had persistant fevers on [**2-17**] and [**2-18**] despite
antibiotics. An ID consult was consulted for further
recommednations. A CT of the chest , abdomen, and pelvis was
performed and consistent with Mild dependent bibasilar
atelectasis. Ground glass opacity at the right lung base may
represent aspiration, but no
consolidative pneumonia, 7-mm ground-glass nodule at the right
apex. If the patient has no risk factors for malignancy,
followup with dedicated chest CT is recommended at 6-12 months.
If the patient has risk factors for malignancy (e.g. smoking),
dedicated chest CT is recommended in [**4-12**] months. No evidence of
infection in the abdomen or pelvis and a non-obstructing stone
in the left kidney.
Patient was started on Cipro on [**2-20**] for a UTI, her Dilantin was
found to be supertheraptic, and put on hold, she had an EEG that
was negative initially but then some subclinical seizures were
noted on EEG on [**2-21**] into [**2-22**] and she was started on Keppra.
Speech therapy came by for an initial evaluation and recommended
a video swallow when patient is able to travel out of the ICU.
On [**2-23**], her exam remained unchanged, EEG [**Location (un) 1131**] from [**2-22**] into
[**2-23**] was improved but showed rare seizure activity. Her Keppra
was increased to 500mg [**Hospital1 **]. There was no further seizure
activity noted. Her exam remained unchanged. On [**2-24**] CSF was
sent and showed no sign of infection. On [**2-25**], she underwent a
surgical placement of a L VP shunt. She received one unit of FFP
and platelets in the OR intraop. There were no complications and
her VP shunt was programmed to 1.0.
She underwent a PEG placement on [**2-28**] without complications. A
CT of the head was performed that showed persistant enlarged
ventricles. Her shunt settings were dialed down to .5.
Patient was medically stable and screened for rehab and
discharged to [**Hospital 100**] rehab on [**3-1**].
Medications on Admission:
Lipitor 10,
Diovan 160,
vit D3 1000u,
MVI,
ranitidine 150
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO HS (at
bedtime).
3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
4. potassium chloride 20 mEq Packet Sig: One (1) Packet PO PRN
(as needed).
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth care.
6. methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
9. sodium chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day): Please monitor Na level and wean off if NA
consistantly above 130.
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection twice a day.
11. insulin regular hum U-500 conc Injection
12. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
SAH
L supraclinoid ICA aneurysm
Interventricular hemorrhage
Hydrocephalus
Fever
Urinary tract infection / complicated
Left Thalamic Lacunar Infarct
Anemia requiring transfusion
Hyponatremia
Altred mental status
Ventilator aquired Pneumonia
protien/calorie malnutrition
Dysphagia
Seizures
Lethargy
Aphasia
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Generally non verbal except with family
Discharge Instructions:
What to report to office:
?????? Changes in vision (loss of vision, blurring, double
vision, half vision)
?????? Slurring of speech or difficulty finding correct words to
use
?????? Severe headache or worsening headache not controlled by
pain medication
?????? A sudden change in the ability to move or use your arm or
leg or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow
or green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please have a CT of the head performed here at [**Hospital1 18**] for our
review, you will not be seen in our office at this time.
Your sutures on your head should be removed on [**2-8**]. This can
be done by a practitioner at your rehab facility.
Please follow-up with Dr [**First Name (STitle) **] in 4wks with a MRI/MRA ([**Doctor Last Name **]
protocol). Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Please follow up with your primary care physician regarding the
CT of the Chest/Abdomen/and pelvis findings which included a
7-mm ground-glass nodule at the right apex. If you have no risk
factors for malignancy, followup with dedicated chest CT is
recommended at 6-12 months. If you have risk factors for
malignancy (e.g. smoking), dedicated chest CT is recommended in
[**4-12**] months.
Completed by:[**2174-3-1**]
|
[
"2760",
"5990",
"2761",
"2859"
] |
Admission Date: [**2192-3-17**] Discharge Date: [**2192-3-21**]
Service: Coronary care unit
HISTORY OF PRESENT ILLNESS: This is a 78-year-old male with
a history of coronary artery disease, back pain, and
hypertension who presents with intermittent chest pain and
nausea since two days prior to admission, who was transferred
from [**Hospital3 **] for further care. The patient is status
post cardiac catheterization on [**2192-3-5**], for
exertional angina and chest tightness with radiation to his
jaw and arms. At that time he had a left ventricular
ejection fraction of 45%, a right-dominant system with
3-vessel disease, showing a discrete 90% right left
ventricular lesion, a 20% to 30% proximal left anterior
descending artery, 70% D1, 60% D2, and 90% to 95% ramus
intermedius lesion. He had no interventions at that time.
He was medically managed with aspirin, nitroglycerin patch,
and atenolol. He had a previous exercise stress test in
[**2191-11-16**] in an outside system that showed possibly
inferior ischemia. The patient self-discontinued his
nitro-paste two days prior to admission because of a
headache. The patient subsequently developed sustained
substernal chest pain all day prior to admission and
presented to [**Hospital3 **]. The patient also had back pain
at the time and states that sometimes his back pain can
trigger the chest pain. He had some mild nausea and
diaphoresis, some mild lightheadedness, and radiation to the
jaw. Electrocardiogram there showed a paced rhythm. The
patient was given aspirin and nitroglycerin. His blood
pressure dropped to 50/32. He was given IV fluids with his
blood pressure recovering. The patient continued to have
chest pain intermittently, initially [**8-24**] to [**9-24**] and
improving to [**2-25**] to [**3-24**] with nitroglycerin. At one point,
the patient's heart rate was noted to go from 20 down into
the 20s and 30s; although, this was not recorded, and there
was no evidence of pacer activations, so there was a
suspicion of pacer failure/pacer capture. Again, the patient
was started on a nitroglycerin drip, but his systolic blood
pressure dropped to the 80s, and nitroglycerin was
discontinued. The patient was started on heparin and
Integrilin with an initial creatine kinase of 247, and a MB
fraction of 30, and a MB index of 12%. His troponin was less
than 0.3. The patient was transferred to the [**Hospital1 346**] for further care.
PAST MEDICAL HISTORY:
1. Back pain with lumbosacral spondylosis.
2. Chronic right knee arthritis for which he tapes Ultram.
3. Hypertension.
4. Reactive airway disease.
5. Benign prostatic hypertrophy, status post transurethral
resection of prostate.
6. Macular surgery.
7. Coronary artery disease with chronic bradycardia. He
had a DDD pacemaker placed for advanced AV block in [**2191-10-16**] when he presented with fatigue and bradycardia.
8. He is status post cholecystectomy.
9. He has peptic ulcer disease with no history of
gastrointestinal bleeding.
10. He has B12 deficiency.
MEDICATIONS ON ADMISSION: Included atenolol, nitroglycerin
patch, Vioxx, Valium p.r.n., Ultram p.r.n., albuterol p.r.n.,
Atrovent p.r.n.
ALLERGIES: He has an allergy to CODEINE.
MEDICATIONS ON TRANSFER: Include Integrilin, atenolol,
aspirin, and heparin, Flovent.
SOCIAL HISTORY: He is a retired electrical engineer. He is
married with three children. Lives with a friend by the name
of [**Name (NI) 26196**] [**Name (NI) 5108**] (phone number [**Telephone/Fax (1) 29895**]). He has two
daughters and a son. His health care proxy is his daughter,
[**Name (NI) 553**] [**Name (NI) **] (phone number [**Telephone/Fax (1) 29896**]). He has no smoking
history. He is full code but would not want to prolong
course of support.
PHYSICAL EXAMINATION: On physical examination he was alert,
awake, and in no acute distress. He was 6 feet 4 inches and
98 kg. Temperature of 97.7, heart rate of 60, blood pressure
of 121/67, respiratory rate of 17. He was
normocephalic/atraumatic. Pupils were equal, round and
reactive to light. Cranial nerves were grossly intact. Neck
was supple. His carotids were 2+ with no bruits. He had no
significant jugular venous distention. Heart had a regular
rate and rhythm with distant heart sounds. No murmurs, rubs
or gallops were audible. Lungs were clear to auscultation
bilaterally. His abdomen was soft, nontender, and
nondistended with normal active bowel sounds. Extremities
showed no clubbing, cyanosis or edema. He had 2+ distal
pulses. Right groin previous catheterization site had no
bruits or hematoma.
LABORATORY/RADIOLOGY: Electrocardiogram on admission showed
a rate of 60 with atrial ventricular pacing. There appeared
to be approximately one QRS of slightly different morphology,
suggesting the possibility of failed pacer capture.
Chest x-ray showed no congestive heart failure, no effusions,
and no consolidations.
Troponin was less than 0.3. Serial creatine kinases were 174
with a MB index of 6%, 111 with a MB of 6, and 129. He had
a white blood cell count of 6.8, hematocrit of 45, platelets
of 243.
HOSPITAL COURSE: The patient was admitted with what appeared
to be unstable angina. He did rule in for a myocardial
infarction with small MB leak. The patient was stabilized
with Integrilin and heparin. The patient was continued on
beta blocker with Lopressor. His lipid levels were checked
and were found to be in good range. His Integrilin was
subsequently discontinued, and the patient remained stable.
On [**3-19**], the patient was brought to the cardiac
catheterization laboratory where lesions were found that were
essentially similar to the previous cardiac catheterization;
however, the ramus intermedius lesion received angioplasty
and was stented. The patient was started on a short course
of Integrilin and also started on aspirin and Plavix. His
Lopressor dose was increased, and ACE inhibitor lisinopril
was also started. The patient recovered well and was up and
walking with no subsequent chest pain or other symptoms.
The electrophysiology service was also consulted to examine
the patient's pacemaker given the possible report of failed
pacer capture, and the patient was found to be in good
condition with good capture and no other problems.
DISCHARGE DISPOSITION: The patient was discharged to follow
up with his primary cardiologist.
MEDICATIONS ON DISCHARGE:
1. Imdur 30 mg p.o. q.d.
2. Lisinopril 2.5 mg p.o. q.d.
3. Lopressor 25 mg p.o. b.i.d.
4. Plavix 75 mg p.o. q.d. for one month.
5. Aspirin 325 mg p.o. q.d.
6. Atenolol.
7. Nitroglycerin patch.
8. Vioxx.
9. Valium p.r.n.
10. Ultram p.r.n.
11. Albuterol p.r.n.
12. Atrovent p.r.n.
[**Last Name (LF) **],[**Name8 (MD) 870**] M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 1546**]
MEDQUIST36
D: [**2192-3-21**] 12:53
T: [**2192-3-22**] 03:59
JOB#: [**Job Number 2654**]
|
[
"41071",
"41401",
"49390",
"4019"
] |
Admission Date: [**2110-7-22**] Discharge Date: [**2110-8-13**]
Date of Birth: [**2049-10-10**] Sex: M
Service: SURGERY
Allergies:
Flagyl
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Increasing creatinine value on labs, increasing confusion,
nausea and diarrhea since d/c from hospital on [**7-11**]
Major Surgical or Invasive Procedure:
Open J tube on [**2110-8-12**] placed after several attempts at
[**Last Name (un) 1372**]-duodenal tubes pulled or clogged
History of Present Illness:
60 y/o male s/p OLT on [**2110-5-13**] with several hospitalizations
since transplant for incisional wound issues, nausea, poor
appetite and confusion who now presents 11 days post last
admission with increasing creat on labs, increasing confusion
and still having nausea and diarrhea in spite of switching from
Cellcept to Myfortic. On last admission, confusion slowly
resolved. A neuro consult had been obtained at that time and he
was ruled out for cerebral bleed. IV Vitamins, hydration,
decreased Prograf dosing and starting thyroid replacement for
TSH of 12 were also done and improvement in MS was seen. Since
the discharge, he has continued with nausea, poor PO intake
(Feeding tube was self d/c'd by patient)and has seen an increase
in creatinine to 2.7. Liver enzymes have been stable, UC
negative. No fever or chills.
Past Medical History:
ETOH cirrhosis, s/p OLT [**2110-5-13**] (with mesh closure)
DM II
HTN
h/o C diff
s/p esophageal dilatation
Basal cell CA
Lumbar DJD
Failure to Thrive
Social History:
Lives in [**Location **] with wife in single family home
H/O ETOH abuse
Family History:
Non Contrib
Physical Exam:
On Admission:
VS: 96.9, 105, 135/65, 20, 96% RA
Gen: Appears confused
Oriented x1
CV: RRR, 2+ radial pulses
Pulm: CTA bilaterally
Abd: Diffusely tender with guarding
Pertinent Results:
[**2110-7-22**] 11:00PM GLUCOSE-91 UREA N-10 CREAT-2.6*# SODIUM-138
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-19* ANION GAP-16
[**2110-7-22**] 11:00PM ALT(SGPT)-23 AST(SGOT)-51* ALK PHOS-107
AMYLASE-16 TOT BILI-0.3
[**2110-7-22**] 11:00PM LIPASE-15
[**2110-7-22**] 11:00PM WBC-3.4* RBC-3.40* HGB-9.9* HCT-28.8* MCV-85
MCH-29.1 MCHC-34.3 RDW-15.7*
[**2110-7-22**] 11:00PM PLT COUNT-192
[**2110-7-22**] 11:00PM PT-13.9* PTT-34.3 INR(PT)-1.2*
Brief Hospital Course:
Patient admitted with increasing confusion from baseline,
increasing creat, nausea and diarrhea. S/P OLT in [**4-29**] for ETOH
cirrhosis and coming from rehab center where he has been a
patient since discharge [**7-11**].
Initial therapy was given with IV fluids for likelydehydration,
Head CT done showing no acute intracranial hemorrhage or mass
effect. Abd/Pelvis CT were done showing bilateral pleural
effusions, pericardial effusions, Status post OLT, reduced size
of anterior abdominal wall collection and reduction in size of
right adrenal hematoma.
Liver U/S showed patent vessels, normal blood flow.
It was noted that patient was having difficulty swallowing
pills, and in general was "orally defensive". Swallow eval not
done as patient confused and could not cooperate with testing.
Kept NPO.
EGD on [**7-24**] showed normal esophagus, normal stomach and normal
duodenum and an NJ tube was placed for feeding at this time.
On the evening of [**7-25**] patient found to be coughing and then
vomited mucous, coarse breath sounds noted. Increased resp rate
with low O@ sats and tachycardia noted with slight fever and
when not improved the patient was moved to ICU, intubated.
Bronchoscopy on [**7-26**] showed normal secretions and no gross mass.
Vanco and Meropenem started for coverage after pan-culture.
Sputum cultures, and bronchalveolar lavage did not grow
significant organisms. In light of illness at that time patient
continued with meropenem, vanco and addition of ambisome and
Cipro.
While in ICU patient received CVVH for worsening kidney
function/metabolic acidosis.
LP also performed which was negative.
By [**7-28**] patient off pressors, CVVHD stopped for one day and then
restarted on [**7-29**] for fluid management. Creat maximum value 2.8
Patient noted to continue to have pulmonary edema with bilateral
pleural effusions.
Antibiotics changed to Vanco, meropenem, and prophylactic
fluconazole, gancyclovir and bactrim. Patient continued on tube
feeds.
Initially failed weaning, and then was successfully extubated on
[**8-1**] and then transferred back to floor on [**8-3**].
Mental status slowly improving at this time. Creat slowly
falling.
Swallow eval done [**Last Name (un) 7162**] at this time and this time diet advanced
to regular solids and thin liquids, calorie counts and
aspiration precautions.
PT evaluated and found to require PT training 2-3x/week and
recommended d/c to rehab as part of planning.
Due to patient pulling out several dobhoff feeding tubes, a J
tubes was surgically placed on [**8-6**].
On [**8-7**], patient again transferred to ICU following episode of
vomiting with tachycardia and question of aspiration. Patient
also intermittently confused.
At this time patient on Vanco and Zosyn for questionable
aspiration PNA. Short stay in ICU and then transferred back to
regular floor.
TPN was started in addition to tube feed through J tube. Patient
is to continue on strict aspiration precautions.
Received 5 units Packed RBCs over the hospital course for
anemia. Continues on PO Iron and Erythropoietin
Zoloft, which had been d/c'd on admission due to confusion was
restarted.
Mental status continued to improve, patient assessed by social
work and may require further outpatient evaluation.
Will complete antibiotic course with 2 days of PO Augmentin, all
other antibiotics have been completed. TPN was weaned as of [**8-12**]
and he will continue on Tube feeds.
Liver enzymes remained normal during this hospitalization.
Immunosuppression regimen stable.
Medications on Admission:
[**Last Name (un) **], mmf750'', protonix 40', valcyte 450', bactrim ss', fluc
400', colace 100", zoloft 100', levaquin 500 x 4 more days, ISS
Discharge Medications:
1. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
QID (4 times a day) as needed.
3. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): See sliding scale.
6. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
9. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension Sig:
Ten (10) ML PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
12. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
16. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: One (1) PO Q8H (every 8 hours) for 2 doses.
18. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day:
Please check Potassium level q Monday and Thursday with
transplant labs.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p OLT [**4-29**]
aspiration pneumonia
sepsis
failure to thrive
ATN (resolving)
Discharge Condition:
Stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if you experience any of the following
symptoms: fever,chills, nausea, vomiting, diarrhea, pain over
the liver or at the feeding tube site, jaundice, an increase in
abdominal girth or any other symptoms concerning to you.
Have labs drawn every Monday and Thursday and have them faxed to
[**Telephone/Fax (1) 697**]. CBC, Chem 10, AST,ALT, Alk Phos, Albumin, T Bili
and trough Rapamune Level
Continue Tube Feeds per order
Completed by:[**2110-8-13**]
|
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"0389",
"99592",
"5845",
"78552",
"51881",
"5070",
"2762",
"4280",
"2760",
"2761",
"2875",
"25000",
"4019",
"2859"
] |
Admission Date: [**2118-5-19**] Discharge Date: [**2118-5-25**]
Date of Birth: [**2043-6-6**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
S/p Total Hip Replacement
Major Surgical or Invasive Procedure:
total hip replacement
History of Present Illness:
This is a 74 year old male with PMH significant for HTN, CAD,
diastolic dysfunction, moderate pulmonary hypertension with an
estimated PASP of 41 mm Hg on last ECHO in [**4-4**], OA,
hyperlipidemia, DM2, who was admitted to the MICU for
post-operative monitoring following a L THA revision. Of note,
the patient was recently admitted to [**Hospital1 18**] from [**4-13**] - [**4-18**],
during which time he underwent left total hip arthroplasty on
[**4-13**]. Post-operative course was complicated by development of
AMS, left-sided facial droop, and left sensory neglect. Pt was
seen by the neurology service at that time and was diagnosed
with CVA. Per report he had good functional recovery with just
minimal left sided weakness. He was started on Lovenox and
[**Month/Year (2) **] following that admission in addition to aspirin 325mg
which he was taking previously.
.
The patient did well after discharge until [**2118-5-13**] when he
presented to orthopedic clinic following a fall at home. X-rays
at that time showed a periprosthetic fracture with the Accolade
femoral stem rotated and a displaced fracture of the left
greater trochanter. He was made non-weight bearing and was
scheduled for surgical revision on [**2118-5-19**]. It is unclear what
blood thinners the patient was on prior to surgery, although it
seems that the Lovenox had been discontinued a few days prior.
It is unclear if and when his aspirin and [**Name (NI) **] were
discontinued prior to surgery. Unfortunately, the surgery was
complicated by a large amount of blood loss and hemodynamic
instability requiring Levophed 0.1 mcg/kg/min and phenylephrine.
Anesthesia was attempting to wean the phenylephrine prior to
transfer to the ICU. Orthopedics consulted trauma surgery to
assist in the OR given the amount of bleeding. Per OMR, he
required 12 units of pRBCs, 14 units of FFP, and a 6 pack of
platelets intraoperatively. He was kept sedated with propofol
and small bolus doses of ketamine and fentanyl during the
procedure. He remained intubated at time of transfer to the
ICU. He did not have a central line, but has good peripheral
access and an A-line.
.
On arrival to the MICU, initial vs were: T=96.4, P=49,
BP=103/61, R=10, O2 sat=100% on vent. Patient was intubated, off
of sedation, and minimally responsive. Phenylephrine was weaned
off due to bradycardia to the 30s.
Past Medical History:
hypertension, coronary artery disease, osteoarthritis, elevated
cholesterol, diabetes, and occasional anxiety; tonsillectomy
Social History:
Retired, lives with wife. [**Name (NI) 4084**] smoked and does not drink
alcohol
Family History:
Brother died at age 59 unexpectedly, cause unknown. Grandmother
with diabetes.
Physical Exam:
General: a/o x 3.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Bradycardic, 2/6 SEM radiating to the left axilla
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. LBM [**2118-5-25**].
GU: Condom cath to drainage bag [**1-26**] scrotal edema
Neuro: Intact with no focal deficits
LLE:
* Incision healing well with staples
* Thigh full but soft
* No calf tenderness
* 5/5 strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
[**2118-5-20**]:
CT head w/contrast:
1. No acute intracranial hemorrhage. If there is concern for
acute
infarction, an MRI with DWI can be obtained for further
evaluation.
2. Multiple paranasal sinus disease, likely relates to the
endotracheal
intubation.
[**2118-5-25**] 07:00AM BLOOD WBC-6.2 RBC-3.20* Hgb-9.6* Hct-28.8*
MCV-90 MCH-30.1 MCHC-33.4 RDW-15.1 Plt Ct-201
[**2118-5-24**] 04:34AM BLOOD WBC-7.2 RBC-3.28* Hgb-9.9* Hct-29.1*
MCV-89 MCH-30.2 MCHC-34.1 RDW-15.8* Plt Ct-155
[**2118-5-23**] 05:14AM BLOOD WBC-7.4 RBC-2.97* Hgb-8.9* Hct-26.9*
MCV-91 MCH-30.0 MCHC-33.2 RDW-15.5 Plt Ct-145*
[**2118-5-22**] 05:52PM BLOOD WBC-9.7 RBC-3.28* Hgb-9.9* Hct-28.9*
MCV-88 MCH-30.2 MCHC-34.2 RDW-15.8* Plt Ct-139*
[**2118-5-22**] 11:33AM BLOOD WBC-9.7 RBC-3.07* Hgb-9.3* Hct-27.3*
MCV-89 MCH-30.2 MCHC-34.0 RDW-15.7* Plt Ct-120*
[**2118-5-22**] 04:23AM BLOOD WBC-9.0 RBC-3.16* Hgb-9.6* Hct-28.2*
MCV-89 MCH-30.3 MCHC-33.9 RDW-15.6* Plt Ct-103*
[**2118-5-21**] 10:58PM BLOOD WBC-9.4 RBC-3.16* Hgb-9.4* Hct-27.9*
MCV-89 MCH-29.9 MCHC-33.8 RDW-15.5 Plt Ct-100*
[**2118-5-21**] 05:37PM BLOOD WBC-10.0 RBC-3.45* Hgb-10.5* Hct-29.8*
MCV-86 MCH-30.3 MCHC-35.1* RDW-15.7* Plt Ct-105*
[**2118-5-21**] 12:48PM BLOOD WBC-10.4 RBC-3.54* Hgb-10.7* Hct-30.8*
MCV-87 MCH-30.2 MCHC-34.8 RDW-15.7* Plt Ct-97*
[**2118-5-21**] 03:11AM BLOOD WBC-10.0 RBC-3.41* Hgb-10.6* Hct-30.5*
MCV-89 MCH-30.9 MCHC-34.6 RDW-15.6* Plt Ct-92*
[**2118-5-20**] 05:19PM BLOOD WBC-11.8* RBC-3.64* Hgb-11.1* Hct-31.5*
MCV-86 MCH-30.4 MCHC-35.2* RDW-15.4 Plt Ct-103*
[**2118-5-20**] 04:01AM BLOOD WBC-9.9 RBC-2.93* Hgb-8.9* Hct-25.5*
MCV-87 MCH-30.5 MCHC-35.0 RDW-16.3* Plt Ct-124*
[**2118-5-19**] 03:51PM BLOOD WBC-10.0# RBC-3.74* Hgb-11.2* Hct-31.5*
MCV-84 MCH-29.9 MCHC-35.5* RDW-15.9* Plt Ct-82*#
[**2118-5-19**] 10:40AM BLOOD WBC-5.1 RBC-3.28* Hgb-9.6* Hct-28.2*
MCV-86 MCH-29.2 MCHC-34.0 RDW-16.3* Plt Ct-169
[**2118-5-19**] 09:15AM BLOOD WBC-3.7*# RBC-2.69* Hgb-7.9* Hct-23.8*
MCV-88 MCH-29.4 MCHC-33.3 RDW-16.3* Plt Ct-233
[**2118-5-25**] 07:00AM BLOOD PT-18.1* PTT-30.7 INR(PT)-1.6*
[**2118-5-24**] 04:34AM BLOOD PT-16.1* PTT-30.1 INR(PT)-1.4*
[**2118-5-23**] 05:14AM BLOOD PT-17.2* PTT-32.8 INR(PT)-1.5*
[**2118-5-22**] 05:52PM BLOOD PT-16.5* PTT-31.2 INR(PT)-1.5*
[**2118-5-22**] 04:23AM BLOOD PT-14.7* PTT-30.5 INR(PT)-1.3*
[**2118-5-25**] 07:00AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-140
K-3.4 Cl-103 HCO3-30 AnGap-10
[**2118-5-24**] 04:34AM BLOOD Glucose-116* UreaN-17 Creat-0.8 Na-142
K-3.5 Cl-107 HCO3-29 AnGap-10
[**2118-5-23**] 05:14AM BLOOD Glucose-138* UreaN-23* Creat-0.9 Na-144
K-3.7 Cl-111* HCO3-28 AnGap-9
[**2118-5-22**] 05:52PM BLOOD Glucose-145* UreaN-21* Creat-1.0 Na-144
K-3.9 Cl-113* HCO3-27 AnGap-8
[**2118-5-20**] 04:01AM BLOOD ALT-6 AST-28 LD(LDH)-242 AlkPhos-51
TotBili-0.4
[**2118-5-25**] 07:00AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.6
[**2118-5-24**] 04:34AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.5*
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. This is a 74 year old male with PMH significant for HTN, CAD,
diastolic dysfunction, moderate pulmonary hypertension with an
estimated PASP of 41 mm Hg on last ECHO in [**4-4**], OA,
hyperlipidemia, DM2, who was admitted to the MICU
post-operatively while still intubated and sedated for
hemodynamic monitoring following a left THA revision complicated
by a large amount of blood loss and hemodynamic instability
requiring two pressors.
2. [**Hospital Unit Name 153**] course: The patient had extensive blood loss requiring
12 units of pRBCs, 14 units of FFP, and a 6 pack of platelets.
He was also on Levophed and phenylephrine to maintain his blood
pressures. There was concern for CVA or neurogenic shock as his
blood pressures have varied widely from 80s-180s systolic, he is
bradycardic, however CTA head was negative. Central line was
placed and levophed continued for low pressures. He received
another 1 unit of PRBC and 1 unit of platelets. He was also
noted to have ST elevations on EKG likely in setting of demand
ischemia related to hypotension and blood loss in setting of
CAD.
Patient was extubated POD2. Aspirin and [**Hospital Unit Name 4532**] held, coumadin
was started on POD 3 for DVT ppx. Ancef was continued until
removal of JP drains on POD3.
3. POD 4 - Hct 26.9 -> Transfused 1 unit PRBCs
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received lovenox for DVT prophylaxis starting on the morning of
POD#1. The foley was removed on POD#2 and the patient was
voiding independently thereafter. The surgical dressing was
changed on POD#2 and the surgical incision was found to be clean
and intact without erythema or abnormal drainage. 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 acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the wound was benign.
The patient's weight-bearing status is PARTIAL (50%) weight
bearing on the operative extremity at all times with
posterior/trochanter off precautions.
Mr. [**Known lastname 634**] is discharged to rehab in stable condition.
Code: Full
Contact: [**Name (NI) **] [**Name (NI) 634**] (wife) [**Telephone/Fax (1) 99629**](h), [**Telephone/Fax (1) 99630**] (c);
[**First Name4 (NamePattern1) **] [**Known lastname 634**] (daughter) [**Telephone/Fax (1) 99631**]; [**First Name4 (NamePattern1) 553**] [**Known lastname **]
(daughter) [**Telephone/Fax (1) 99632**]
Medications on Admission:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily). (recently discontinued)
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for Pain.
5. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice
a day for 3 weeks: AFTER completing all lovenox syringes, please
take as directed with food. you may resume your preoperative
dose after completing this regimen.
6. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO DAILY (Daily).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): was held on [**4-17**] and [**4-18**].
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. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM for 6 weeks: Goal INR 2-2.5
Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*1*
8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
L hip greater trochanteric periprosthetic fracture with stem
rotation
Hypotension
Hypovolemia
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out by the visiting nurse (VNA) or rehab
facility three
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your coumadin for six (6)
weeks to help prevent deep vein thrombosis (blood clots). Goal
INR 2-2.5. [**Male First Name (un) **] STOCKINGS x 6 WEEKS. To be followed by PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] after discharge from rehab (Phone: [**Telephone/Fax (1) 6699**], Fax:
[**Telephone/Fax (1) 66415**]).
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in three (3) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at three weeks
after surgery.
12. ACTIVITY: PARTIAL (50%) weight bearing on operative
extremity. Posterior and trochanter off precautions. No
strenuous exercise or heavy lifting until follow up appointment.
Physical Therapy:
LLE PWB (50%) at all times
2 crutches or walker at all time
Posterior/trochanter off precautions
Mobilize
HIGH fall risk
Treatments Frequency:
Dry sterile dressing daily as needed for drainage
Wound checks
Ice as tolerated
Staple removal POD 21 ([**2118-6-9**]) - replace with steristrips
TEDs x 6 weeks
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2118-6-17**] 11:00
Completed by:[**2118-5-25**]
|
[
"2762",
"2851",
"V5861",
"4168",
"25000",
"V4582",
"412",
"4019",
"2724",
"4280"
] |
Admission Date: [**2195-10-14**] Discharge Date: [**2195-10-23**]
Date of Birth: [**2133-8-29**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Left parietal mass removal
History of Present Illness:
Patient is a 62 year old woman who presents to [**Hospital1 18**] for
evaluation after having a 2 minute witnessed tonic clonic
seizure
while at work. She was post-ictal upon EMS arrival and was not
reponding to any commands but was protecting her airway. She was
trasnferred to [**Hospital1 18**] for further care and in the ER while being
evaluated she had another seizure. She had a CT of the head that
showed a left parietal brain lesion and neurosurgery was
consulted. Prior to arriving to consult on the patient she was
intubated and sedated for airway protection. Unable to obtain
review of systems given patients recent intubation and no family
available to dicuss.
Past Medical History:
Poorly differentiated Nodular Lymphoma, >20years ago in pelvis,
s/p XRT, in remission
Hypertension
Hyperlipidemia
CKD, baseline creat 1.2-.14
Anemia, unclear etiology (extensive w/u with labs, BMB, GI w/u
neg, may be [**3-11**] CKD)
s/p TAH/BSO for pelvic mass/metrorrhagia '[**85**]
Thyroiditis
Social History:
The patient lives in [**Location 669**] with her Husband and son. She is
employed in the Cafeteria of the [**Location (un) 86**] Public School.
Tobacco: [**6-12**] cigarettes daily x 20 years
Family History:
Mother - Died age 86 from CAD
Father - Died in 80s from "poisoned ETOH"
- no family history of Gastrointestinal disease
Physical Exam:
PHYSICAL EXAM:
Gen: intubated, sedated
HEENT: Pupils: PERRL EOMs unable to obtain
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intuabted, sedated, no commands
Orientation: unable to obtain
Language: unable to assess
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally.
III, IV, VI: unable to assess
V, VII: unable to assess
VIII: unable to assess
IX, X: unable to assess
[**Doctor First Name 81**]: unable to assess
XII: unable to assess
Motor: MAE
Sensation: unable to assess
Toes downgoing bilaterally
Coordination: unable to assess
Pertinent Results:
[**10-14**] CT head noncontrast: 2-cm rounded hypodensity in the left
parietooccipital region concerning for underlying intra-axial
mass with edema
[**10-14**] MRI with and without contrast: 3 x 2.8 cm cystic mass with
internal enhancing mural nodule
[**10-15**] CT Torso with and without contrast: Scattered enlarged and
necrotic lymph nodes
[**10-15**] CTA head: Hypoattenuating left parietal lesion is
redemonstrated,
suspicious for neoplasm. Narrowing of left supraclinoid ICA.
[**10-16**] Postop CT head: 1. Post-surgical changes from left parietal
craniotomy including mild frontoparietal pneumocephalus,
post-operative hemorrhage and subcutaneous air. 2. Minimal
subfalcine herniation. No sign of transtentorial or tonsillar
herniation. 3. No hemorrhage outside of the surgical bed or
evidence of acute large territorial infarction.
[**10-17**] Postop MRI with and without contrast: 1. Two small foci of
contrast enhancement along the inferior margin of the left
occipitoparietal surgical cavity. Recommend continued follow-up.
2. Stable 4-mm enhancing lesion in the left precentral cortex
with slow diffusion, which has similar signal characteristics to
the resected larger mass.
Discharge Labs: [**2195-10-21**] 06:00AM
WBC-9.5 RBC-3.04* Hgb-9.2* Hct-27.3* MCV-90 Plt Ct-184
Glucose-88 UreaN-20 Creat-0.9 Na-138 K-3.8 Cl-105 HCO3-24
AnGap-13
Brief Hospital Course:
[**Known firstname **] [**Known lastname 104205**] was intubated in the emergency department for
seizure control and admitted to the Neurosurgery service for Q1
hour neuro checks. She was continued on Dilantin for seizures.
MRI with and without contrast was performed and demonstrated a
large cystic lesion in the left posterior temporal lobe. CT
torso performed for metastatic work up demonstrated multiple
enlarged scattered and necrotic lymph nodes. On [**10-16**] she remained
intubated and was prepared to be taken to the OR for resection
of her lesion. She had an MRI WAND study and CTA for operative
planning and was taken to the operating room for resection on
the afternoon of [**10-16**]. Post-operatively she was transferred
intubated to the ICU.
Her post operative course was notable for agitation, controlled
with propofol, and then extubation on [**10-18**], with mild post
extubation confusion. She developed hyponatremia which resolved
with PO fluid intake. She was then transferred to the general
medicine service. She had no further seizures throughout the
remainder of her hospital stay.
The patient's biopsy results were consistent with metastatic
carcinoma, likely of lung origin. Given she was already seen at
the [**Hospital3 328**] for her prior lymphoma and her anemia, she
preferred to pursue further evaluation and treatment there. She
was scheduled to see Dr.[**Last Name (STitle) **] one week after discharge at the
recommendation of Dr.[**Last Name (STitle) 3315**]. She will have a phenytoin level
checked prior to this appointment. She was instructed to pick up
a CD with all of her imaging results on the [**Location (un) **] of the
[**Hospital Ward Name 23**] building next week prior to her follow-up appointments;
arrangements were made for her pathology slides to be sent to
Dr[**Last Name (STitle) 104206**] office. She was continued on Phenytoin and Decadron
for seizure prophylaxis and instructed not to drive or return to
work until seen by Dr.[**Last Name (STitle) **].
The patient was also noted to have a new thyroid nodule which
will need to be followed-up as an outpatient. She was maintained
on half of her home dose of Atenolol and her Lisinopril was
held; she maintained good blood pressures on this regimen and
was instructed to follow-up with her PCP for repeat blood
pressure checks.
Medications on Admission:
Lisinopril 20 mg po daily
Omeprazole 20 mg po daily
Atenolol 100 mg po bid
Levothyroxine 50 mcg po daily (last filled in [**8-17**])
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day): Please have a phenytoin level
checked at your visit with Dr.[**Last Name (STitle) 724**].
Disp:*180 Tablet, Chewable(s)* Refills:*0*
3. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): This is a lower dose than you were taking previously.
Disp:*60 Tablet(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): Continue this
medication whie you are taking Decadron (your steroid).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
Please have a dilantin level checked on Tuesday, [**10-27**]
prior to your visit with Dr.[**Last Name (STitle) **].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left Parietal Tumor
Metastatic Carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with seizures and were found
to have a brain mass that is thought to be a metastatic
carcinoma that may have originated in your lung. You underwent
resection of the mass and were started on two new medications,
Dilantin and Decadron, to prevent further seizures. You will
need to follow-up with a neuro-oncologist at [**Hospital3 328**] for
further management of these medications and your underlying
cancer.
The following instructions are related to your recent surgery:
Exercise should be limited to walking; no lifting, straining, or
excessive bending.
You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine. Please take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at
Dr.[**Last Name (STitle) **] office at 08:30 on the [**Location (un) **] in the [**Hospital3 328**]
Yawkey Building.
You are being sent home on a steroid medication. These
medications can cause stomach irritation. Make sure to take
your steroid medication with meals, or a glass of milk.
Clearance to drive and return to work will be addressed at your
office visit with your neuro-oncologist.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Please follow-up with your new neuro-oncologist, Dr.[**Last Name (STitle) 53939**]
[**Name (STitle) **], at the [**Hospital3 328**] on Thursday, [**10-29**] at 9:00AM.
You should have a Dilantin level checked 30 minutes before this
visit as noted above. Please also keep the following appointment
with your primary care doctor.
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Specialty: Internal Medicine
When: Wednesday [**10-28**] at 9:30am
Location: [**Hospital6 9657**] PHYSICIAN GROUP
Address: [**Location (un) **] [**Apartment Address(1) 25389**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 24396**]
|
[
"51881",
"2760",
"40390",
"2724",
"5859"
] |
Admission Date: [**2184-1-8**] Discharge Date: [**2184-1-21**]
Date of Birth: [**2184-1-8**] Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname 70056**] was the 1.135 kilogram product of a
28-6/7 week gestation born to a 38 year-old gravida I, para
0, now I mother. Prenatal screens: A positive, antibody
negative, hepatitis surface antigen negative, RPR
nonreactive, rubella immune, GBS unknown, CF and HIV
negative. [**Hospital 37544**] medical history notable for advanced
maternal age, chronic hypertension, oral HSV-1 and previous
LEEP procedure. Maternal medications include labetalol and
prenatal vitamins. This pregnancy conceived by IVF.
This pregnancy was complicated by pregnancy-induced hypertension
and preeclampsia. Fetal studies notable for 2 vessel cord with
normal fetal echo done at [**Hospital3 1810**]. Normal fetal
survey and normal triple screen. Amniocentesis was not
performed. Mother was being followed by Dr. [**Last Name (STitle) **] at
[**Hospital3 **]. Routine follow up for preeclampsia
revealed a platelet count of 50,000, prompting transfer to
[**Hospital1 69**] for further care.
Infant was delivered by cesarean section. Mother received general
anesthesia. Infant emerged with slight tone and grimace but
poor respiratory effort. He required positive pressure
ventilation but due to persistent apnea, required intubation in
the delivery room. Apgars were 4 and 7.
PHYSICAL EXAMINATION ON ADMISSION: Weight 1.135 kilograms,
less than 25th percentile. Length 38.5 cm, 50th percent. Head
circumference 27.75 cm, greater than 50th percentile. Pink,
intubated, nondysmorphic. Anterior fontanel soft and flat.
Ears normal set, Palate intact. Neck supple with intact
clavicles. Lungs: Poor aeration but on own but good equal
aeration with bag mask ventilation. Cardiovascular: Regular rate
and rhythm. No murmurs. 2+ femoral pulses. Abdomen soft, no
hepatosplenomegaly. GU: Normal preterm male, testes down
bilaterally. Patent anus. No sacral or back anomalies.
Extremities: Pink and well perfused.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Known lastname **]
[**Known lastname **] was admitted to the Neonatal Intensive Care Unit
intubated. He received a total of 2 doses of surfactant and
was extubated by day of life #3. He remained on CPAP until
[**1-16**] at which time he transitioned to room air and has
been stable on room air since that time. He was started
empirically on caffeine citrate on day of life 8 and
continues on caffeine citrate for management of apnea and
bradycardia of prematurity. He is currently receiving 7 mg
p.o. q daily.
Cardiovascular: Infant has been without issue.
Fluids and electrolytes: Birth weight was 1.135 kilograms.
Discharge weight is 1120g. Infant was initially started on 100
cc per kilo per day of D10W. Enteral feedings were initiated on
day of life #2. Infant achieved full enteral feedings by day
of life #10. He is currently receiving 150 cc per kilo per
day of breast milk 24 calorie, tolerating that well. Most
recent set of electrolytes were done on [**1-18**], had a
sodium of 134, potassium of 5.7, chloride of 101 and total
CO2 of 23.
GI: Peak bilirubin was on day of life #3 of 6.4/0.4. He was
treated with phototherapy which was discontinued on [**1-15**]. His most recent bilirubin was done on [**1-18**] of
4.4/0.3.
Overnight, prior to discharge, infant with heme positive trace
stool noted. Abdominal exam normal and no aspirates/spits. Will
continue to follow clinically.
Hematology: Hematocrit on admission was 47.5. He did not
require any transfusions during this hospital course.
Infectious Disease: Initial CBC had an ANC of 918, white count
was 3.4, platelet count of 191, 27 polys, 0 bands, 63 lymphs. A
repeat CBC on day of life #2 was corrected nicely with a white
count of 7.7, platelet count of 188, 27 polys, 0 bands, 63
lymphs. Infant received a total of 48 hours of ampicillin and
gentamicin which were discontinued with a 48 hour blood culture,
which was negative.
Neuro: Infant has been appropriate for gestational age. Head
ultrasound was performed on day of life #8 and was within
normal limits. A repeat head ultrasound at DOl #30 and term
postmenstrual age is recommended.
Audiology hearing screen has not been performed but should be
done prior to discharge.
Ophthalmology: Patient has not been examined as of yet.
CONDITION AT DISCHARGE: Stable, but critical.
DISCHARGE DISPOSITION: To [**Hospital3 **].
NAME OF PRIMARY PEDIATRICIAN: [**Doctor First Name **] Kemony, [**Hospital1 **].
CARE RECOMMENDATIONS: Continue caloric density to maintain a
weight gain of 30 grams per kilogram per day.
Medications:
1. caffeine citrate at 7 mg p.o. P/G q day.
2. Ferinsol 0.2 mg q day= 4mg/kg/day
3. Vitamin E 5 international unis po q day.
Car seat positioning screening: Not yet performed but will need
to be done prior to discharge home.
State Newborn Screen: Was sent most recently on [**2184-1-12**] and results are pending at this time.
IMMUNIZATIONS RECEIVED: Infant has not received any
immunizations.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis shoulder
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
contacts and out of home care givers.
DISCHARGE DIAGNOSES:
1. Former 28-6/7 week infant.
2. Respiratory distress syndrome, resolved.
3. Rule out sepsis with antibiotics, resolved.
4. Two vessel cord.
5. Apnea and bradycardia of prematurity.
6. Hyperbilirubinemia, resolved
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2184-1-19**] 22:56:29
T: [**2184-1-20**] 09:04:35
Job#: [**Job Number 70057**]
|
[
"7742",
"V290"
] |
Admission Date: [**2143-7-28**] Discharge Date: [**2143-8-9**]
Service: MEDICINE
Allergies:
Heparin Agents / Bee Pollens
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
Hypoxia, hypotension
Major Surgical or Invasive Procedure:
arterial line l radial artery
l IJ CVL attempt
l femoral line placement and removal
intubation
extubation
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] year old female with hx of HIT leading to
bilateral AKAs, ESRD ([**2-11**] HIT) on HD, was recently brought in by
son for [**Name2 (NI) 15780**] to 87-91% on [**7-23**] L pleural effusion was noted
on CXR and pt was given a 7 day course of Levaquin 250 mg and
Albuterol Nebs. She returns today after son noted hypoxia again
at home. States she was very lethargic yesterday after dialysis
which she has at home. She was tachy to the 120s and son gave
her metoprolol but brought her in after she coughed up a large
amount of phlegm. He states she has been more confused -
baseline knows her name and where she is, but not date.
.
Of note, 2 of her daughters came down with similar symptoms with
fevers and sputum production within the past week and were
prescribed avelox.
.
In the ED, initial vs were: 102.4 rectal, 119, 79/50, 20, 99 on
2L. Patient was given vanc/zosyn, started on levafed for
hypotension as low as 60s/40s and received 3.5 L IVF in ED. CT
abd/pelvis without acute intraabdominal pathology. She was
transfered to the MICU for further management.
.
Review of sytems obtained from son:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain (other than
targeted with dialysis. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denied shortness of breath. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits.
Past Medical History:
- HIT resulting in thrombosis in LE s/p L AKA [**2142-1-25**], R AKA on
[**2142-4-18**]
PVD
- R fem-DP bypass w/ saphenous graft [**2141-9-26**] - unable to
revascularize toes
- CAD, s/p MI last fall (NSTEMI related to HIT?)
- ESRD, dialysis dependent since [**7-/2141**]
- h/o anemia, renal
- osteodystrophy, MWF schedule
- GERD, on protonix
- Hypothyroidism, on levothyroxine
- Baseline Tachycardia to 110s
- mild global LV dysfunction on echo [**1-/2142**] (EF 45-50%)
- Rapid A fib (post-op [**4-17**]) s/p electric cardioversion
Social History:
Lives with his son in [**Name (NI) 10022**] MA who is her primary caregiver.
She does not smoke, drink alcohol or do drugs. She has not
traveled outside MA.
Family History:
Noncontributory
Physical Exam:
On arrival to MICU:
Vitals: T: 96.8 BP: 129/46 P: 109 R: 32 O2: 100% on 3L
General: somnolent but arousable to noxious stimuli, oriented
x0, no acute distress
[**Name (NI) 4459**]: Sclera anicteric, MMM
Neck: supple, JVP flat, no LAD
Lungs: bibasilar crackles.
CV: Irregularly irregular, [**1-15**] murmur at LSB. No rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Upper extremities without palpable pulses, R IJ tunnelled
dialysis catheter, L femoral line. Bilateral lower extremity AKA
Pertinent Results:
[**2143-7-27**] 06:20PM WBC-9.6 RBC-4.06* HGB-11.9* HCT-43.6 MCV-107*
MCH-29.3 MCHC-27.3* RDW-17.2*
[**2143-7-27**] 06:20PM NEUTS-76.5* LYMPHS-15.8* MONOS-7.0 EOS-0.4
BASOS-0.3
[**2143-7-27**] 06:20PM PLT COUNT-322
.
[**2143-7-27**] 06:20PM PT-41.7* PTT-34.9 INR(PT)-4.4*
.
[**2143-7-27**] 06:20PM GLUCOSE-102 UREA N-27* CREAT-3.4* SODIUM-147*
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-29 ANION GAP-16
.
[**2143-7-28**] 02:32AM CALCIUM-8.2* PHOSPHATE-4.3# MAGNESIUM-2.1
.
CXR: IMPRESSION: Persistent left basilar opacity likely
reflective of effusion and atelectasis/pneumonia. A small right
pleural effusion. Markedly limited exam.
.
CT abd Pelvis: ***Wet Read*** Bilateral pleural effusions, not
significantly changed. Very small perihepatic fluid. Small
amount of free pelvic fluid, slightly increased since prior
study of 8/[**2142**]. otherwise, no significant change.
.
EKG: A-fib rate 115, nl axis, ST depressions in I, aVL and V4-V6
with TWI in V4-6 all from prior ECG.
.
[**2143-8-9**] 04:26AM BLOOD WBC-11.0 RBC-2.66* Hgb-7.6* Hct-27.0*
MCV-102* MCH-28.7 MCHC-28.2* RDW-16.6* Plt Ct-212
[**2143-8-8**] 05:16AM BLOOD WBC-13.7* RBC-2.66* Hgb-7.7* Hct-27.5*
MCV-104* MCH-28.9 MCHC-27.9* RDW-16.3* Plt Ct-178
[**2143-7-27**] 06:20PM BLOOD WBC-9.6 RBC-4.06* Hgb-11.9* Hct-43.6
MCV-107* MCH-29.3 MCHC-27.3* RDW-17.2* Plt Ct-322
[**2143-8-9**] 04:26AM BLOOD PT-29.3* PTT-71.8* INR(PT)-2.9*
[**2143-7-27**] 06:20PM BLOOD PT-41.7* PTT-34.9 INR(PT)-4.4*
[**2143-7-29**] 02:30PM BLOOD PT-88.6* PTT-46.8* INR(PT)-10.8*
[**2143-8-9**] 04:26AM BLOOD Glucose-194* UreaN-11 Creat-1.0 Na-134
K-4.7 Cl-100 HCO3-23 AnGap-16
[**2143-8-8**] 11:33AM BLOOD Glucose-212* Na-133 K-4.6 Cl-100 HCO3-24
AnGap-14
[**2143-7-27**] 06:20PM BLOOD Glucose-102 UreaN-27* Creat-3.4* Na-147*
K-3.9 Cl-106 HCO3-29 AnGap-16
[**2143-7-27**] 06:20PM BLOOD cTropnT-0.20*
[**2143-7-28**] 02:32AM BLOOD CK-MB-3 cTropnT-0.17*
[**2143-7-28**] 09:30AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2143-7-29**] 02:30PM BLOOD D-Dimer-824*
[**2143-8-1**] 10:53AM BLOOD Cortsol-19.1
[**2143-8-1**] 12:34PM BLOOD Cortsol-40.0*
[**2143-7-28**] 02:32AM BLOOD TSH-3.9
.
Echo:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is severe global left ventricular hypokinesis
(LVEF = 20 %). The estimated cardiac index is depressed
(<2.0L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. There is moderate
thickening of the mitral valve chordae. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Severe aortic stenosis. Severe global left
ventricular systolic function. Mildly dilated right ventricle
with global hypokinesis. Depressed cardiac index.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] yo woman with hx of HIT, ESRD on HD, s/p b/l
AKA presents with respiratory failure secondary to ?pneumonia,
complicated by heart failure and inability to wean off pressors
or ventilator. Due to the lack of response to treatment,
patient was made comfort measures only on [**8-9**] and terminally
extubated.
.
Respiratory failure. Patient was treated intiially with 8 days
of vanco/cefepime for Pneumonia. DFA for flu negative. There
was difficulty weaning from ventillator in spite of aggressive
fluid removal with CVVH and treatment of pneumonia. Pt was
terminally extubated on [**8-9**] and expired about 20 minutes later.
.
Shock. Patient presented with what was thought to be septic
shock due to pneumonia. She was treated with 8 days of
vanco/cefepime for VAP, however, it was difficult to wean her
levophed dose. She subsequently developed a rising leukocyosis
thought to be secondary to a line infection which was positive
for enterococcus. She was treated with lenozolid for this.
Finally, she was felt to have an element of cardiogenic shock
given her echo showed severe aortic stenosis which per
cardiology was not seconary to sclerosis of the valve but rather
due to impaired filling in the setting of CAD and A. fib with
RVR. Her hemodynamics never normalized and she required ongoing
titration of her pressors, both levophed and vasopressin. Three
days prior to death, her a-line dysfunctioned and we (as well as
anesthesia) were unable to place another one. We did not have a
reliable blood pressure [**Location (un) 1131**] the last two days of
hospitalization.
.
Enteroccus line infection. Tip of femoral line positive for
enteroccus. Line was removed on [**8-3**] and plan was to treat
until [**8-12**], pt expired prior to completion of treatment.
.
Heart failure/functional AS. Patient's most recent echo which
was performed during her hospital stay showed severe AS, but per
cardiology, likely functional due to CAD and poor filling times
in setting of tachycardia. She was loaded with digoxin for rate
control. She underwent CVVH for volume removal. As above, she
never stabalized hemodynamically.
.
HIT. HIT was diagnosed in [**12/2141**] and complicated by thrombus
in bilateral lower extremities requiring amputations. She was
initially supertherapeutic, likely in setting of abx and
coumadin interaction. Her couamdin was held and FFP was given
for an OG placement and attempted CVL placement. She was placed
on agratroban when INR was below 2, and coumadin was held for
the rest of the hospitalization.
.
ESRD on HD. She was started on CVVH for volume removal during
her ICU stay. It was continued throughout expect for a few days
in the middle when we thought her tachycardia may have been to
volume depletion. It was restarted, later.
.
Anemia. Her anemia was felt to be due to chronic disease, blood
loss from blood draws and procedures, and guiaic positive
stools. Her Hct remained stable.
.
CAD. Patient had NSTEMI in [**2142**]. An echo was performed during
her hospital stay and showed an EF of 20% on most recent echo.
Beta-blockers were held due to her need for pressors. Aspirin
was held as she was on argatroban drip. She was continued on a
statin. She would benefit from revascularization, but she is
likely not a candidate for CABG.
.
Hypothyroid. She was continued on levothyroxine during her
hospital stay. Her TSH was checked and was normal during her
ICU stay.
.
Communication: [**Name (NI) **] son [**Name (NI) **] [**Name (NI) **] (dentist) - [**Telephone/Fax (1) 68653**]
.
Goals of care. Family meeting was held on [**2143-8-8**] to discuss of
goals of care. Family recognizes that patient would not want to
be trached and in a chronic vent facility. It was explained to
the family that patient required too much ventillator support to
be extubated. The family agreed to patient DNR with a plan of
withdrawal of care when the family was gathered. On [**8-9**], she
was extubated with her family in the room. She expired about 20
minutes later. Time of death 10:40am.
Medications on Admission:
Aspirin 81 mg DAILY
Metoprolol Tartrate 12.5 mg PRN for HR > 120
Toprol XL 25 mg daily
Warfarin 1 mg as directed Daily
Atorvastatin 20 mg DAILY
Pantoprazole 40 mg DAILY
Levothyroxine 75 mcg DAILY
Lidocaine-Prilocaine 2.5-2.5 % Cream [**Hospital1 **] prn pain.
Camphor-Menthol 0.5-0.5 % QID prn itching.
Folic Acid 1 mg DAILY
Cyanocobalamin 500 mcg DAILY
Vitamin B1 and B12 daily
Sevelamer HCl 800 mg TID W/MEALS
Midodrine 2.5 mg PRN prior to dialysis
NTG SL prn chest pain
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmomary Arrest
Respiratory Failure
Acute on Chronic Systolic Heart Failure
End stage renal disease
Pneumonia
Enterococcus Line Infection
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2143-8-9**]
|
[
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"4280",
"42731",
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"412",
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"2449",
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"V5861"
] |
Admission Date: [**2175-4-9**] Discharge Date: [**2175-4-13**]
Date of Birth: [**2126-9-26**] Sex: F
Service: ICU
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
female with a history of poorly differentiated adenocarcinoma
of the lung with diffuse metastases to the liver, pelvis, and
brain (status post carboplatin and Taxol radiation therapy
'Arissa') who was found to have brain metastases (status post
resection) in [**2175-2-14**] who had been recently started on
Navelbine salvage who presented on [**2175-4-10**] with
hypotension, mild disseminated intravascular coagulation,
acute renal failure, and supraventricular tachycardia.
The patient's supraventricular tachycardia was responsive to
adenosine, and the patient was volume resuscitated in the
Emergency Department. She was treated broadly with
ampicillin, levofloxacin, and Flagyl and was admitted to the
Feniard Intensive Care Unit.
The patient's hypotension resolved overnight and was thought
largely secondary to volume depletion and possibly sepsis.
At that time, she was made do not resuscitate/do not intubate
by her husband. [**Name (NI) **] mental status was intermittent and
confused. She was transferred to the floor where she
improved for a few days.
On [**4-12**], she developed agitation and further confusion;
requiring Haldol. The patient was noted to develop stridor
and tachycardia. Multiple nebulizer treatment were tried
without affect. The patient was given Benadryl 25 mg p.o.
times two and Cogentin 2 mg times two for suspected laryngeal
dystonia from Haldol. The patient was given Pepcid 20 mg
intravenously times one and dexamethasone 10 mg intravenously
for a potential allergic reaction with no improvement. The
patient was unable to speak secondary to distress.
Ear/Nose/Throat was consulted and found no upper airway
obstruction and normal cords. The patient was admitted to
the Feniard Intensive Care Unit for a trial of [**Hospital1 **]-level
positive airway pressure.
PAST MEDICAL HISTORY:
1. Poorly differentiated lung adenocarcinoma diagnosed in
[**2173-4-16**] with three right upper lobe lesions; treated
with Taxol and carboplatin. The patient was found to have
new lung nodules, liver metastases, and pelvis metastases in
[**2174-5-16**]. She was given radiation therapy and then
Arissa. Over the course of [**2174-9-16**] to [**2175-9-16**] the patient was found to have increasing liver function
tests and noted to have worsening liver metastases. In [**2175-1-14**], she was found to have brain metastases and underwent
right frontal lobe resection with two smaller metastases
remaining in [**2175-2-14**]. The patient was started on
Navelbine salvage.
2. Reactive airway disease and emphysema.
3. Right thyroidectomy for colloid nodule.
4. Iron deficiency anemia.
5. Gastritis with Helicobacter pylori.
6. Depression.
7. History of abnormal PAP smear.
8. History of whole body image.
9. History of axillary abscess.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Atrovent meter-dosed inhalers.
2. Haldol 0.5 mg p.o. twice per day as needed.
3. Neutra-Phos two packets p.o. three times per day.
4. Sucralfate 1 g four times per day.
5. Dapsone 4 mg intravenously twice per day.
6. Iron 325 mg p.o. once per day.
7. Vitamin K 10 mg p.o. once per day.
8. Docusate 100 mg p.o. twice per day.
9. Lidoderm patch as needed.
10. Senna one tablet p.o. twice per day.
11. Lactulose 30 cc p.o. three times per day.
CODE STATUS: The patient is do not resuscitate/do not
intubate.
SOCIAL HISTORY: The patient has a 20-pack-year history of
smoking. Occasional alcohol use.
FAMILY HISTORY: Brain cancer, thyroid cancer, coronary
artery disease, hypertension, and asthma.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 98, blood pressure was 150/70,
respiratory rate was 28, heart rate was 125, and oxygen
saturation was 92% on 4 liters. Generally, the patient was
an ill-appearing female in moderate respiratory distress.
Head, eyes, ears, nose, and throat examination revealed
extraocular movements were intact. Mucous membranes were
dry. Neck examination revealed no lymphadenopathy. Audible
stridor on expiration was heard. Cardiovascular examination
revealed tachycardia. Normal first heart sounds and second
heart sounds. No murmurs, rubs, or gallops. The lungs were
clear with the exception of decreased breath sounds up to
halfway up the right lung field and one quarter of the way up
the left lung field. The abdomen was firm, distended, and
nontender with normal active bowel sounds. Extremity
examination revealed no edema. On neurologic examination,
the patient was acutely agitated.
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratory findings revealed the patient had a white blood
cell count of 12.3, hematocrit was 33.1, and platelets were
163. INR was 2. Chemistry-7 revealed sodium was 144,
potassium was 3.7, chloride was 109, bicarbonate was 19,
blood urea nitrogen was 28, creatinine was 0.8, and blood
glucose was 129. Anion gap was 17. The patient had a
fibrinogen of 143. D-dimer was greater than [**2171**]. FBE was
80 to 160. ALT was 213, AST was 737, alkaline phosphatase
was 497, and total bilirubin was 2.9. Calcium was 7.8,
phosphate was 2.3, and magnesium was 2.6. Lactate was 12.5.
Free calcium was 1.15.
PERTINENT RADIOLOGY/IMAGING: On chest x-ray the patient had
a large right pleural effusion with a question of left lower
lobe atelectasis.
IMPRESSION: The patient is a 48-year-old female with a
history of poorly differentiated lung cancer with diffuse
metastases to the liver, pelvis, and brain; status post
carboplatin, Taxol, radiation therapy, Arissa, and metastases
resection (on Navelbine salvage) who presented with
hypotension, mild disseminated intravascular coagulation,
acute renal failure, and lactic acidosis who now returned to
the Feniard Intensive Care Unit with acute respiratory
distress.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. PULMONARY ISSUES: The patient with a question of acute
stridor with an unchanged chest x-ray.
The differential diagnosis initially included a dystonic
reaction from Haldol or an allergic reaction. However, the
patient did not respond to Cogentin, Benadryl, steroids, or
H2 blockers; and Ear/Nose/Throat ruled out any upper airway
swelling or laryngeal spasms.
Thus, it was thought that the patient had a fixed
obstruction; perhaps some lymph nodes or lung cancer which
became clinically evident as wheezing or stridor in the
setting of increased mini-ventilation from progressive
metabolic acidosis. Heliox was attempted without success,
and the patient was started on [**Hospital1 **]-level positive airway
pressure with no real improvement in her symptoms. She was
not any more responsive on [**Hospital1 **]-level positive airway pressure
and required morphine for some sedation to enable her to work
with the [**Hospital1 **]-level positive airway pressure. Her respiratory
status did not improve clinically.
2. NEUROLOGIC ISSUES: The patient with mental status
changes in the setting of diffusely metastatic breast cancer
with liver involvement and hepatic encephalopathy as well as
hypoxia and worsening acidosis with hypercarbia. Her mental
status did not improve despite the aggressive measures in the
Intensive Care Unit.
3. GASTROENTEROLOGY ISSUES: The patient with rapidly
progressive liver failure; likely secondary to metastatic
non-small-cell lung cancer with diffuse involvement.
Progressive metabolic lactic acidosis was likely secondary to
hepatic failure.
4. HEMATOLOGY/ONCOLOGY ISSUES: The patient with metastatic
lung cancer diffusely spread to liver, [**Hospital1 500**], and brain.
Nearing the end-stage on salvage Navelbine. The patient had
ongoing evidence of disseminated intravascular coagulation.
The overall prognosis, according to the patient's primary
oncologist, was uniformly poor.
5. CODE ISSUES: The patient presented with progressive lung
cancer diffusely metastatic which was refractory to multiple
chemotherapeutic regimens, brain metastases resection, and
radiation therapy. She developed worsening respiratory
failure in the setting of progressive lactic acidosis,
pleural effusions, respiratory acidosis, and altered mental
status.
After discussing the patient's uniformly poor prognosis with
her oncologist, as well as her husband (who was her health
care proxy), the decision was made to make the patient
comfort measures only. The patient expired with family at
the bedside.
CONDITION AT DISCHARGE: Expired.
DISCHARGE STATUS: The patient expired.
DISCHARGE DIAGNOSES:
1. Respiratory failure.
2. Poorly differentiated metastatic non-small-cell lung
cancer.
3. Progressive metabolic lactic acidosis.
4. Right pleural effusion.
5. Liver failure.
6. Acute renal failure.
7. Disseminated intravascular coagulation.
8. Supraventricular tachycardia.
9. Reactive airway disease.
[**Last Name (LF) **], [**First Name3 (LF) **] N. 12-981
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2175-4-13**] 11:58
T: [**2175-4-15**] 05:05
JOB#: [**Job Number 100596**]
cc:[**Last Name (NamePattern4) 100597**]
|
[
"5849",
"51881",
"2762",
"5119"
] |
Admission Date: [**2136-5-26**] Discharge Date: [**2136-5-31**]
Date of Birth: [**2057-6-27**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
woman with the sudden onset of a headache who then fell to
the ground. She was taken to [**Hospital3 **] where she
was awake, alert and oriented times three. At 1:00 p.m. her
mental status declined, and she was intubated. A head
computer tomography showed a subarachnoid hemorrhage. She
was given Mannitol, vecuronium, Versed, and labetalol and
transferred to [**Hospital1 69**] for
further management.
PAST MEDICAL HISTORY: Diabetes, arthritis, myocardial
infarction, and congestive heart failure. .
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: The patient had
corneal, gag, and localized to pain in the right side greater
than the left, and withdrew her lower extremities. Her toes
were downgoing bilaterally. She was afebrile, her pulse was
69, her blood pressure was 165/117, her respiratory rate was
25, and her saturations were 100 percent. Her eyes were
closed. The neck was supple. She had no carotid bruits.
Cardiovascular examination revealed a regular rate and
rhythm. The chest was clear to auscultation bilaterally.
The abdomen was soft, nontender, and nondistended.
Extremities revealed no clubbing, cyanosis, or edema.
PERTINENT RADIOLOGY-IMAGING: Her chest x-ray showed no
infiltrate.
Electrocardiogram revealed a normal sinus rhythm with ST
elevations.
A noncontrast head computer tomography showed a subarachnoid
hemorrhage (right greater than left) with blood in the basal
cisterns.
A computer tomography showed a left middle cerebral artery
aneurysm next to the clip site.
SUMMARY OF HOSPITAL COURSE: Neurologically, her eyes were
closed. Her pupils were 6 mm down to 4 mm and reactive. She
had positive doll's eyes. Her face was symmetric. She had
corneal and gag. She localized in the left upper extremity
at 3/5 and on the right [**2-23**]. Sensation was intact to light
touch. Her reflexes were [**3-22**] throughout. The toes were
upgoing.
On [**2136-5-27**] the patient opened her eyes to voice. The
pupils were 3 mm down to 2 mm and reactive. She was
localizing to pain in all four extremities. She was
following commands. Squeezing right greater than left. On
[**5-27**], she underwent an angiogram which showed a left
internal carotid artery aneurysm with an occlusion of the
right internal carotid artery. The patient had an occluded
right internal carotid artery, occluded left subclavian with
subclavian seal syndrome, and poor collateral circulation.
On [**5-28**], the patient underwent an angiographic stent and
coiling. However, it was not possible to deploy the stent
due to the patient's tortuous vessels and aneurysm morphology.
Vascular Surgery was consulted on [**2136-5-30**] as the patient
had lost both pulses in her lower extremities. She was taken
emergently to the Operating Room for a thrombectomy and
postoperatively had dopplerable dorsalis pedis and posterior
tibial pulses bilaterally. The patient had good pulses in
her lower extremities on postoperative day one, however, the
patient did drop her pressure and then lost the pulses in her
lower extremities.
The family approached the physicians in the Intensive Care
Unit regarding making the patient comfortable given the
patient's poor prognosis. The patient was extubated, and the
patient passed away on [**2136-5-31**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2136-7-9**] 13:47:41
T: [**2136-7-9**] 17:12:14
Job#: [**Job Number 55433**]
|
[
"4280",
"412"
] |
Admission Date: [**2108-6-7**] Discharge Date: [**2108-6-9**]
Date of Birth: [**2052-5-31**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
CC:[**CC Contact Info 70329**]
Major Surgical or Invasive Procedure:
intubation
R leg femoral artery thrombectomy
CVL placement
History of Present Illness:
The patient is a 56 year old female patient with a history of
anterior
communicating artery anuerysm of 6mm X 6mm X 3mm s/p clipping
[**2108-5-10**] admitted to Dr.[**Name (NI) 9034**] service on neurosurgery from
[**2108-5-10**] to [**2108-5-25**] complicated by UTI, ? partial nephrogenic
diabetic insipidus ([**Month/Day/Year **] 158 on desmospressin which was
stopped on [**2108-5-18**], followed by endocrine) right femoral and
external iliac dissection post angiogram with emergent
thrombectomy of right iliac, common femoral and superficial
femoral arteries with endarterectomy of the right common femoral
artery and Dacron patch angioplasty, right external iliac artery
stent, and four compartment right lower extremity fasciotomies,
as well as left basal ganglia, left frontal infarct (possibly
secondary to intraoperative parenchymal retraction), and
posterior left frontal infarct thought likely secondary to
embolic phenomena during angiogram who presented from [**First Name9 (NamePattern2) 58991**]
[**Hospital1 656**] today after being found unresponsive. A CT of the head
was performed which showed (per neurosurgery report, no
copies/report in patient chart from ED):
.
" No evidence of hemorrhagic stroke of CT. L ACA and MCA areas
of infarct still present."
.
Neurosurgery was consulted in the ED and noted possible tremors
in LUE ?seizure and ?new LLE weakness but felt there were no
acute neurosurgical issues.
.
.
In the ED, Vanco 1 gm IV, cefepime 2 gm IV given for ?empiric
sepsis for a fever of 100.8. Also, noted to have K of 5.7->5.9,
give 10 units IV insulin with 1 amp of D50. No other meds given
for hyperkalemia normal appearing EKG with no acute changes.
.
Also, newly elevated LFTs noted in ED:
.
ALT 519, AP 506, LDH 801. Bili 0.5. During last admit, ALT, AST
in 70, 50s range.
.
A right upper quadrant ultrasound was performed which showed:
.
No intra or extra-hepatic biliary dilatation. CBD is 5 mm.
Portal vein is patent. No ascites. s/p chole.
Labs were otherwise significant for the following:
Past Medical History:
*Polycystic kidney disease
*HTN
*MI(unknown age)
*hyperlipidemia
*bipolar disorder
*Anterior communicating aneurysm s/p elective clipping [**2108-5-10**]
left basal ganglia, left frontal infarct (possibly secondary to
intraoperative parenchymal retraction), and posterior left
frontal infarct [**1-27**] emboli from CT-A of head with resulting CN
III palsy, right sided hemiplegia
* right femoral and external iliac dissection post angiogram
[**2108-5-10**] with emergent thrombectomy of right iliac, common
femoral and superficial femoral arteries with endarterectomy of
the right common femoral artery and Dacron patch angioplasty,
right external iliac artery stent, and four compartment right
lower extremity fasciotomies
* Nephrogenic DI, followed by endocrine
*h/o recent UTI during last admit [**2108-5-10**] to [**2108-5-25**]
Social History:
Lived with husband previously, no EtOH, 60 pack years tob.
Transferred from acute care rehab facility.
Family History:
non-contributory
Physical Exam:
Initial PEX:
Tc = 99.6 Tm = 100.8 in ED P=108 BP = 106/75 RR = 27 99% on 4
liters O2
.
Gen - Non-responsive to verbal stimuli
HEENT - Pupils responsive to light, left eye >dilated than right
(documented as old), anicteric, no head trauma, pursed lip
breathing
Heart - RRR, no M/R/G
Lungs - CTAB (anteriorly)
Abdomen - Soft, NT, ND, decreased breath sounds, no
hepatosplenomegaly, G tube
Ext - RUE erythematous, swollen, hemiplegic on right side, moves
LUE spontaneously, no spontaneous movement of LLE, retracts LLE
to painful stimuli
Back - Unable to assess
Skin - Warm, erythematous blanching rash on chest, abdomen
Neuro - CN III ? palsy in left eye, LLE no spontaneous movement,
R sided hemiplegia, brisk LLE DTRs, positive [**Name2 (NI) **]
bilaterally, left upper extremity tremor with pill-rolling
Pertinent Results:
RUQ U/S [**6-8**]: IMPRESSION: Status post cholecystectomy. No intra-
or extra-hepatic biliary dilatation.
.
Head CT [**6-8**]: CONCLUSION: No evidence of hemorrhage. Evolving
acute infarction in the left frontal lobe, new since the study
of [**5-21**], this region was obscured on the earlier examination
of [**6-8**].
.
CT abd/pelvis [**6-9**]:
1. Large acute hemmorage within the right biceps femoris and
surrounding soft tissues. The largest pocket of acute hemorrhage
measures 4.2 cm in greatest dimension with a fluid-fluid level
within.
2. Large wedge shaped hypoattenuating region within the right
lobe of the liver consistent with an infarct suggesting an acute
portal vein thrombosis.
3. Trace pericardial effusion.
.
Head CT [**6-8**]:
1. No evidence of acute intracranial hemorrhage or new major
vascular territorial infarct.
2. Continued evolution of large left ECA and MCA infarcts with
mild edema and minimal subfalcine herniation (approximately 2
mm).
3. Stable appearance of left frontal craniotomy and aneurysm
clips in the suprasellar region.
.
Brief Hospital Course:
Hospital course:
Her mental status change was thought secondary to old and
concern for new R stroke given new L hemiparesis. Followed by
neuro, neurosurg and vascular teams. Head CT showed new left
large frontal CVA. Pt with unresponsive pupils, blunted
reflexes, tachypnea, labile BP. Was intubated for airway
protection given her mental status. Neurology evaluated patient
but was not able to examine her off propofol given her
instability. On HD#1 she was found to have a cold ischemic RLE
and she was evaluated by vascular surgery who took her
immediately to the angio suite for a thrombectomy. They were
able to restore her flow. Given her multiple arterial clots
(CVA and RLE arterial clot) and her drop in platelets, HITT was
suspected and all heparin products were stopped. She was
started on lepirudin given her LFT abnormalities. She developed
bleeding into her RLE thigh given her recent intervention and
she was aggressively transfused. Her BP remained labile and
required pressors to maintain adequate CPP. On HD#2, she
continued to deteriorate with continued bleeding into her thigh.
Vascular surgery did not feel she was an adequate candidate for
a re-operation. She was aggressively hydrated, maintained on
pressors, and hyperventilated to prevent further acidosis.
Given her deteriorating hemodynamic status, as well as her very
poor long term neurologic prognosis given her large stroke and
complications, her family decided to convert her to comfort
measures only on [**6-9**] at 6pm. Her pressors, fluids, and
transfusions were stopped adn family was present at her bedside.
She was kept on propofol, and a morphine gtt was added for
comfort. She expired at 11:30pm. Her family was notified and
declined an autopsy.
Medications on Admission:
. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate [**Month/Year (2) **] 50 mg/5 mL Liquid Sig: [**12-27**] PO BID (2 times a
day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection every eight (8) hours.
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO BID (2 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed: To groin intertrigo.
9. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at
bedtime) for 7 days.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
CVA
suspected HITT
RLE arterial thrombus
ARF
Liver infarct
Respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2108-6-10**]
|
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"5849",
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"4019",
"2724",
"2767"
] |
Admission Date: [**2180-5-5**] Discharge Date: [**2180-5-16**]
Date of Birth: [**2180-5-5**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 39 and 1/7
weeks gestational age infant transferred to the NICU at the
request of Dr. [**Last Name (STitle) 49694**], for a consultation regarding hypotonia
and dysmorphic features.
MATERNAL HISTORY: A 32 year old gravida III, para I, now II,
woman with past obstetrical history notable for spontaneous
abortion in [**2176**], and spontaneous vaginal delivery at 41
weeks in [**2177**], a son alive and well.
PAST MEDICAL HISTORY: Noncontributory.
FAMILY HISTORY: Noncontributory.
PRENATAL SCREENS: O positive, antibody negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative, GBS negative, triple screen charted as "normal".
PREGNANCY HISTORY: Last menstrual period [**2179-8-6**], for
estimated date of confinement [**2180-5-11**], estimated gestational
age 39 and 1/7 weeks. Eighteen week ultrasound normal and
consistent with dates. Mother complained of decreased fetal
movement throughout pregnancy. A 34.6 week ultrasound showed
reduced fetal movement but normal amniotic fluid volume and
umbilical flow. Pregnancy otherwise uncomplicated. Repeat
cesarean section under epidural anesthesia. No maternal
intrapartum fever or fetal tachycardia. Rupture of membranes
at delivery yielding clear amniotic fluid.
NEONATAL COURSE: NICU not in attendance at delivery. Apgar
eight at one minute and nine at five minutes. No
resuscitative interventions by report. NICU consultation
requested given antenatal findings and postnatal physical
findings.
PHYSICAL EXAMINATION: Saturation 92% in 21% FIO2. Blood
pressure 68/38, mean 51, heart rate 145, respiratory rate 38,
temperature 95.9, birth weight 3350 grams. Anterior
fontanelle soft, open, flat. Epicanthal folds, redundant
nuchal folds, no macroglossia, palate intact. No nasal
flaring. Chest - no retractions, good breath sounds
bilaterally and no crackles. Cardiovascular - well perfused,
regular rate and rhythm, femoral pulses normal. S1 and S2
normal, no murmur. The abdomen is soft, nondistended, thin
umbilical cord, no organomegaly, no masses, bowel sounds
active, anus patent. Genitourinary normal penis, left testis
undescended, right testis descended. Central nervous system
- responsive to stimuli, tone decreased, generalized. Moving
all limbs symmetrically. Suck/roof/gag/grasp/Moro normal.
Integument normal. Musculoskeletal - bilateral single palmar
creases, short digits. Spine, hips, clavicles are normal.
HOSPITAL COURSE:
1. Cardiovascular - A cardiac evaluation and a cardiac
consult was performed due to an initial oxygen requirement,
comfortable tachypnea, and an enlarged cardiothymic silouette.
Four extremity blood pressures were within normal limits, an
EKG was normal for age, a hyperoxia challenge revealed a paO2
of 273. A cardiac consult was obtained and an echocardiogram
was performed. The echocardiogram revealed patent foramen
ovale, small patent ductus arteriosus, right ventricular
hypertension, qualitatively good biventricular systolic
function and very small inferior pericardial effusion.
The cardiology service would like to see baby [**Name (NI) 49695**] in 1
month in the cardiology clinic. At that time a repeat
echocardiogram will be done to ensure closure of the PDA and
evaluate pulmonary pressures.
2. Respiratory - The patient initially required oxygen at
approximately 300cc flow with approximately 30 to 60% FIO2.
The oxygen requirement was due to central hypotonia, shallow
respirations and bilateral lobe atelectasis. There was
probably also mild increased pulmonary pressures early in his
course that partly contributed to the oxygen requirment.
His respirations and chest excursion steadily improved and on
day of life six, he transitioned to low flow nasal cannula.
On day of life nine he transitioned to room air where he
currently remains. He has had no apnea and/or bradycardia
episodes.
3. FEN - The patient briefly required intravenous fluids but
promptly advanced to full enteral feeds which he tolerated
without difficulty. He is currently po ad lib with Enfamil 20
(with Fe).
Birthweight 3350 gms, L 20.25 in, HC 33.5 cm.
Discharge weight 3335 gms, L 56 cm, HC 34.5 cm.
4. Hematology - The patient initial complete blood count
showed a white blood cell count of 19.0 with a differential
of 79 polys, 5 bands and 14 lymphocytes. His hematocrit was
63.0, and his platelet count was 234,000.
He had mild physiologic hyperbilirubinemia with a bilirubin
of 11.6 on day of life four which clinically improved. He
never needed phototherapy.
5. Infectious disease - No issues.
6. Genetics - Given the constellation of admission physical
findings, a cytogenetics evaluation was sent. The analysis
revealed trisomy 21. Of the 11 lymphocytes that were
studied, all had trisomy 21, therefore showing no to minimal
mosaicism.
To further evaluate the degree of mosaicism, we have requested
that the cytogenetics lab evaluate a greater number of cells
(closer to 30). Results are pending.
The family was referred to the Down Syndrome clinic at
[**Hospital3 1810**] and Dr. [**Last Name (STitle) **]. They have already met
with Dr. [**Last Name (STitle) **].
Finally, the family has expressed interest in genetic
counseling to determine risk of Trisomy 21 in future children.
This should be done throught the Genetics service at
[**Hospital3 1810**]. The general genetics team met with the
family prior to discharge to discuss counseling and future
testing.
7. Social - The parents were very attentive and involved in
his care throughout his hospitalization. Our staff attempted
in as much as we could to answer all their questions and
concerns. We also recruited the help of the Down Syndrome
Clinic at [**Hospital3 1810**] and had mother meet and speak
on the telephone on several occasions with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and
Dr. [**Last Name (STitle) **] on [**2180-5-16**].
8. Sensory - Audiology - Hearing screening was performed as
automated auditory brain stem responses. The patient's
hearing was referred and he will need further testing at a
later date with Audiology at [**Hospital3 1810**].
9. Psychosocial - [**Hospital1 69**]
social work was involved with the family. The contact social
worker is [**Name (NI) **] and she can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
PRIMARY CARE PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 732**], [**Hospital3 2358**]
Medical Center. Telephone number [**Telephone/Fax (1) 49696**]. Fax
[**Telephone/Fax (1) 49697**].
CARE AND RECOMMENDATIONS:
1. Feeds at Discharge - Enfamil 20 p.o. ad lib.
2. Medications - None.
3. Car Seat Position Screening - Passed.
4. State Newborn Screening Status - Sent per protocol with no
notification of abnormal results.
5. Immunizations Received - Hepatitis B vaccination [**2180-5-16**].
6. Follow-Up Appointments (Parents to arrange specific
appointment date and times):
a. Pediatrician - Dr. [**First Name (STitle) 732**], [**2180-5-19**].
b. Genetics/Down Syndrome Clinic/Dr. [**Last Name (STitle) **] - in 1
month, telephone [**Telephone/Fax (1) 49698**].
c. Cardiology - in 1 month, telephone [**Telephone/Fax (1) 46235**].
d. Audiology - [**Hospital3 1810**] ([**Last Name (un) 9795**] 11), telephone
[**Telephone/Fax (1) 48318**].
e. Early Intervention Program (EIP) - Family support
EIP, telephone [**Telephone/Fax (1) 44332**].
f. VNA - [**Location (un) 86**] VNA, telephone [**Telephone/Fax (1) 37525**]. Fax
[**Telephone/Fax (1) 49699**].
DISCHARGE DIAGNOSES:
1. Trisomy 21.
2. Respiratory distress and oxygen requirement, resolved.
3. Patent ductus arteriosus.
4. Referred hearing screen.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **],M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 44694**]
MEDQUIST36
D: [**2180-5-12**] 14:12
T: [**2180-5-12**] 16:21
JOB#: [**Job Number 49700**]
|
[
"V053",
"V290"
] |
Admission Date: [**2135-9-21**] Discharge Date: [**2135-9-30**]
Date of Birth: [**2068-1-20**] Sex: M
Service: CARDIOTHORACIC SURGERY
CHIEF COMPLAINT: The patient presented with increased
shortness of breath with exertion and severe dyspnea on
exertion on occasion.
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
myocardial infarction and received care here at the [**Hospital6 1760**]. He has a long history of
angina and shortness of breath for several years prior to
this myocardial infarction. Additionally, the patient has a
long-standing history of angina and shortness of breath times
five years and prior myocardial infarction and angioplasty
with stent. His symptoms had progressed to more severe
would sleep sitting up. These symptoms have been taking
place for some time as stated above.
Cardiac catheterization completed on [**2135-9-12**], showed
severe AS, aortic valve area of 0.7, 90% left anterior
descending lesion, 50% circumflex lesion, right coronary
artery with mild disease. Echocardiogram dated on [**2135-9-7**], showed an ejection fraction of 15%, left ventricular
dysfunction, multiple wall motion abnormalities, moderate AS,
1+ AI, 1+ MR, 4.2 cm dilated ascending aorta, small
pericardial effusion.
PAST MEDICAL HISTORY: Myocardial infarction with
percutaneous transluminal coronary angioplasty and stent in
[**2129**]. Myocardial infarction in [**2135-8-30**]. GI bleed and
gastroesophageal reflux disease on H. pylori therapy.
Insulin-dependent diabetes mellitus. Hypertension.
Congestive heart failure. Hiatal hernia. Obesity.
PAST SURGICAL HISTORY: Tonsillectomy and adenoidectomy.
MEDICATIONS ON ADMISSION: Protonix 40 q.d., Clarithromycin
500 mg p.o. b.i.d., Amoxicillin 1 g p.o. b.i.d. to be taken
over a 14-day course for H. pylori, Zestril 2.5 mg q.d.,
Atenolol 50 mg q.d., Lasix 80 mg p.o. q.a.m., Insulin 70/30
[**3-5**] U in the morning and 12 U in the evening.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
LAST DENTAL EXAM: No new dental issues.
FAMILY HISTORY: His father died of stroke at age 48. Mother
died at 82 of Alzheimer's.
SOCIAL HISTORY: Shoe repairman. He lives with his wife. [**Name (NI) **]
quit smoking approximately 30 years ago. He has occasional
alcohol use. No cocaine abuse.
REVIEW OF SYSTEMS: He was stable appearing. Appropriate
mood. Otherwise the remainder of his review of systems is
negative.
PHYSICAL EXAMINATION: Vital signs: Heart rate 85,
respirations 10, blood pressure 130/70, height 7', weight 211
lb. General: The patient was an obese gentleman with a
large abdomen, dry scaly skin of the
bilateral lower extremities. HEENT: Normal buccal mucosa.
Pupils equal, round and reactive to light. Extraocular
movements intact. No carotid bruits. No jugular venous
distention. He did have a murmur that was radiating to
bilateral neck. Lungs: Clear to auscultation without
persistent cough. Abdomen: Firm, nontender, nondistended.
Hypoactive bowel sounds. No hepatosplenomegaly noted.
Extremities: No clubbing or cyanosis. There was 2+ pedal
edema bilaterally.
LABORATORY DATA: Electrocardiogram showed left ventricular
hypertrophy in sinus rhythm at 88. There was some slight ST
elevation in V1-V3. This was consistent with his
presentation for likely acute anterior myocardial infarction.
The patient was seen by the CT Surgery Service and admitted
to be worked up for coronary artery bypass grafting and
aortic valve replacement by Dr. [**Last Name (STitle) **]. On [**2135-9-22**],
went to the Operating Room and underwent coronary artery
bypass grafting times one with saphenous vein to the left
anterior descending, as well as aortic valve repair with #21
mm [**Company 1543**] mosaic porcine valve. This was done under
general endotracheal anesthesia. Dr. [**Last Name (STitle) 72**] assisted Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in this procedure. He left the Operating Room with an
arterial line and Swan-Ganz catheter and intra-aortic balloon
pump which was placed in the right groin intraoperatively,
two ventricular and two atrial wires, two mediastinal and one
left pleural tube. Cardiopulmonary bypass time was 160 min
with a cross-clamp time of 87 min.
The patient came out with a mean arterial pressure of 71,
with a CVP of 15, and PAD of 27. He was being AV paced at a
rate of 74. He was on Dobutamine at 10 mcg/kg/min, Levophed
0.07 mcg/kg/min, Insulin drip at 6 U/hr, and Propofol at 10
mcg/kg/min. On postoperative day #.., the patient's
inotropic support was serially weaned. He was ultimately
started on slow diuresis. Beta-blockers were added slowly.
Postoperatively he was out of bed ambulating. His chest
tubes were discontinued on postoperative day #3. Ultimately
the patient went to the floor by postoperative day #3. He
was otherwise deemed well and tolerating a diet. His pacing
wires were removed. Lopressor, Lasix, and Aspirin were
titrated. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultation was obtained to control his
blood glucose. He was started back on his preoperative NPH
regimen. His blood glucose immediately was controlled.
By postoperative day #6, the patient was deemed appropriate
and stable for discharge.
DISCHARGE MEDICATIONS: Lisinopril 2.5 mg p.o. q.d., Lasix 20
mg p.o. b.i.d., x 5 days, K-Dur 20 mEq p.o. b.i.d. x 5 days,
both of these medications are to be reviewed as an outpatient
to be compared to his preoperative Lasix requirement,
Protonix 40 mg p.o. q.d., Lopressor 12.5 mg p.o. b.i.d.,
Aspirin 325 mg p.o. q.d., Percocet 5/325 [**12-1**] tab p.o. q.[**3-5**]
p.r.n., Colace 100 mg p.o. b.i.d., Insulin 70/30 [**3-5**] U in the
morning, 12 U in the evening, sliding scale Insulin as
directed.
DISCHARGE INSTRUCTIONS: The patient should consume a
diabetic, heart-healthy diet, and have Accuchecks q.i.d. with
a goal blood glucoses to be between 120 and 160.
Additionally the patient should be out of bed and ambulating.
He should received chest physical therapy every six hours as
needed. Wound checks should be performed, and drainage
should be reported to the on-call Cardiothoracic Surgery
house staff.
FOLLOW-UP: The patient should follow-up with Dr. [**Last Name (STitle) **] in
approximately 2-3 weeks from the time of discharge. He can
pursue cardiac rehabilitation at the aforementioned
rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting times one,
saphenous vein graft to left anterior descending, as well as
aortic valve replacement with a porcine valve as stated above
completed on [**2135-9-22**], done for critical AS, as well
as coronary artery disease.
2. Diabetes.
3. Hypertension.
4. Hyperlipidemia.
5. Gastroesophageal reflux disease.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2135-9-27**] 15:26
T: [**2135-9-27**] 13:53
JOB#: [**Job Number 33273**]
|
[
"4241",
"4280",
"41401",
"25000",
"53081",
"4019"
] |
Admission Date: [**2178-8-6**] Discharge Date: [**2178-8-9**]
Date of Birth: [**2139-8-22**] Sex: M
Service: MEDICINE
Allergies:
Indinavir / Ritonavir / Stavudine / Lamivudine
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Increased cough x1 week and fevers
Major Surgical or Invasive Procedure:
1.) Intubated secondary to hypoxic respiratory failure.
Successfully extubated.
2.) Lumbar puncture
3.) Central line placement
4.) Transfused 2 units pRBC
History of Present Illness:
38 yo male with hx of HIV/AIDS (diagnosed in [**2170**]; [**3-26**] had
CD4=5, Viral load = 100K [off HAART]),disseminated [**Doctor First Name **], candidal
esophagitis, recurrent PCP, [**Name10 (NameIs) 15925**] started on HAART [**2178-7-10**]
(had been held prior [**12-24**] LFT abnormalities while on
clarithromycin and ethambutol for disseminated [**Doctor First Name **]), who
presents w/ increased dry cough x 5 days, fever, L-sided
abdominal pain and RUQ pain. Pt noted began having fevers
approximately 1 week ago associated with this worsening dry
cough. Day after onset of symptoms he had an outpt appointment
with his primary care physician at which time they got a CXR
which was normal. Pt noted worsening of these symptoms
throughout the week until presentation. States this is similar
to the symptoms he has had in the past when he was diagnosed
with PCP.
[**Name10 (NameIs) **] note, pt had been on bactrim prophylaxis for PCP which was
[**Name Initial (PRE) **]/ced [**12-24**] LFT abnormalities (as mentioned above). He was then
started on pentamadine INH PCP prophylaxis which he recieved his
first dose of 5 weeks PTA - was scheduled to get his 2nd
pentamadine prophylaxis the week PTA but did not make
appointment.
Pt also noted onset of L-sided abdominal pain and RUQ pain day
PTA. He does report diarrhea, which he describes as "loose
stools" approximately 5 times/day, but he has had this ever
since restarting the HAART therapy in [**Month (only) **]. Denies any blood
in the stool. Denies nausea.
ROS otherwise negative for chest pain/pressure, sick contacts,
sob, dysuria, weight changes.
Past Medical History:
1. HIV/AIDS, CD4 nadir 5.
2. History of recurrent PCP.
3. Eczema.
4. HSV.
Social History:
Mr. [**Known lastname 174**] was diagnosed around [**2169**] with HIV and has been on
HAART intermittently since then. He lives with his partner,
[**Name (NI) **], who is HIV negative, in [**Location (un) 686**] w/ one roommate. He was
recently laid off from his job in an accounting firm and is
currently unemployed and w/o insurance or a way to pay for
medications. A case manager is looking into his options. He has
had problems w/ noncompliance w/ his meds, though he expresses
the desire to start taking them again. His parents and 3 of 5
siblings live in the area, with whom he states he has a good
relationship. He started smoking cigarettes 6 yrs ago and
smokes 1 PPD. He has used crystal meth for 2 yr when he goes
clubbing, but denies other drug use, though cocaine and ecstasy
use are recorded in some records. He does not drink EtOH.
Family History:
- father MI [**35**], living
- paternal grandomother- MI [**50**]
- maternal grandmother- DM
Physical Exam:
Vitals - T 98.7, HR 78, BP 127/68, RR 20, O2 98% 2L
General - awake, alert, NAD
HEENT - PERRL, EOMI, OP clear w/out thrush/lesions, [**Year (2 digits) 5674**]
Neck - no cervical LAD
Heart - RRR +S1, S2, no M/R/G
Lungs - scattered rhonci at bases b/l, otherwise CTA
Abd - tender to palpation in LUQ, LLL, RUQ - difficult to assess
as patient was voluntary guarding, although no noted involuntary
guarding, rebound. + BS x 4 Q
Ext - no edema in LE b/l
Skin - no noted rashes
Neuro - A+Ox3
Pertinent Results:
Labs on admission:
[**2178-8-5**] 11:49PM BLOOD Type-ART pO2-66* pCO2-28* pH-7.47*
calHCO3-21 Base XS--1 Intubat-NOT INTUBA
[**2178-8-5**] 02:15PM BLOOD WBC-7.1 RBC-3.31* Hgb-9.3* Hct-27.4*
MCV-83 MCH-28.0 MCHC-33.8 RDW-19.7* Plt Ct-220
[**2178-8-5**] 02:15PM BLOOD Neuts-77* Bands-3 Lymphs-10* Monos-5
Eos-0 Baso-0 Atyps-5* Metas-0 Myelos-0
[**2178-8-5**] 02:15PM BLOOD Glucose-102 UreaN-15 Creat-0.6 Na-127*
K-4.1 Cl-94* HCO3-24 AnGap-13
[**2178-8-5**] 02:15PM BLOOD ALT-19 AST-39 LD(LDH)-247 AlkPhos-548*
Amylase-33 TotBili-3.7* DirBili-2.5* IndBili-1.2
[**2178-8-5**] 02:15PM BLOOD Albumin-2.5* Calcium-7.8* Phos-2.9 Mg-2.0
On tranfer to MICU:
[**2178-8-6**] 06:43PM BLOOD Type-ART pO2-347* pCO2-23* pH-7.17*
calHCO3-9* Base XS--18
[**2178-8-6**] 06:51PM BLOOD Type-ART pO2-132* pCO2-33* pH-7.10*
calHCO3-11* Base XS--18
[**2178-8-6**] 07:40PM BLOOD Type-[**Last Name (un) **] pO2-61* pCO2-28* pH-7.24*
calHCO3-13* Base XS--13
[**2178-8-6**] 07:44PM BLOOD Type-ART pO2-484* pCO2-25* pH-7.32*
calHCO3-13* Base XS--11
[**2178-8-6**] 11:01PM BLOOD Type-ART Temp-34.4 Rates-16/ Tidal V-650
PEEP-5 FiO2-50 pO2-224* pCO2-28* pH-7.42 calHCO3-19* Base XS--4
Intubat-INTUBATED Vent-CONTROLLED
[**2178-8-7**] 01:35AM BLOOD Type-ART Temp-36.2 Rates-/20 Tidal V-600
PEEP-5 FiO2-40 pO2-179* pCO2-29* pH-7.42 calHCO3-19* Base XS--3
Intubat-INTUBATED
On Discharge:
[**2178-8-9**] 05:33AM BLOOD WBC-3.4* RBC-3.60* Hgb-10.3*# Hct-30.6*
MCV-85 MCH-28.8 MCHC-33.9 RDW-19.2* Plt Ct-292
[**2178-8-9**] 05:33AM BLOOD Glucose-152* UreaN-16 Creat-0.6 Na-132*
K-3.8 Cl-104 HCO3-20* AnGap-12
[**2178-8-8**] 03:19AM BLOOD ALT-27 AST-40 CK(CPK)-20* AlkPhos-491*
TotBili-1.4
[**2178-8-9**] 05:33AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.0
Micro data:
[**2178-8-5**] Urine cx - negative
[**2178-8-5**] Blood cx - NGTD
[**2178-8-6**] Blood cx - NGTD
[**2178-8-6**] Fungal blood cx - NGTD
[**2178-8-6**] urine cx - negative
[**2178-8-6**] CSF fluid - cryptococcal Ag negative, LP unimpressive,
cx NGTD
[**2178-8-7**] Blood cx - NGTD
[**2178-8-7**] Fungal blood cx - NGTD
[**2178-8-7**] CMV viral load - pending
[**2178-8-8**] Blood cx - NGTD
[**2178-8-8**] CMV viral load NGTD
Imaging:
[**2178-8-5**] CXR: No focal consolidation appreciated. Questionable
diffuse and symmetric haziness could relate to technique, but
infection such as PCP cannot be excluded.
[**2178-8-6**] CT Thorax:
1. Prominent interstitial markings in both lungs, more
pronounced in the lower lobes consistent with given history of
PCP [**Name Initial (PRE) 2**].
2. Free fluid in the pelvis.
3. Apparent thickening of the sigmoid bowel wall. This could be
secondary to under distension. However, inflammatory/infectious
process can give similar appearance.
[**2178-8-6**] C-Spine study: No fracture identified
[**2178-8-5**] RUQ U/S: Normal son[**Name (NI) 493**] appearance of the liver.
There is no biliary dilatation as clinically questioned. There
is mild dilatation of the common duct, which is likely secondary
to the patient's status of cholecystectomy. Dilated splenic vein
raises possibility of portal hypertension
[**2178-8-8**] MRI head: Mild age inappropriate prominence of sulci and
ventricles and subtle increased periventricular hyperintensities
could be secondary to HIV encephalopathy. There is no enhancing
lesion or acute infarct seen.
Brief Hospital Course:
The patient is a 38yo man with HIV/AIDS (last CD4 count = 5 and
last viral load = 100K in [**2178-3-22**] when off of HAART, currently
back on HAART), history of recurrent PCP infections, not on PCP
prophylaxis on admission who presented with increased cough and
fevers x 5 days. Was febrile on admission to 101-102, with CXR
on admission c/w PCP infection, had ABG with PaO2 = 66 also c/w
PCP. [**Name10 (NameIs) **] was started on Bactrim and 40 mg prednisone [**Hospital1 **] given
PaO2. On night of admission, Pt was found down and seizing at
the bedside and code was initiated for hypoxic respiratory
failure and patient was intubated and transferred to ICU. Pt's
seizure was thought to be secondary hypoxia in the setting of
the pt's likely PCP infection coupled with ambulation off of
oxygen.
Pt. was admitted to the MICU on [**2178-8-6**] s/p respiratory failure
and seizure. BP was low initially in the MICU, requiring
pressors and concerning for sepsis vs secondary to medications
used for intubation. Therefore he was initially started on
vancomycin and zosyn which were subsequently d/ced after no
further signs of infection, and was maintained throughout MICU
stay on Bactrim and steroids. He received an LP in the MICU
that was notable for no WBCs or RBCs. MICU course significant
for CXR which showing diffuse haziness with no consolidation, CT
showing prominent interstial markings in lungs, free fluid in
the pelvis and thickening of the sigmoid wall (?concerning for
infectious colitis), C-spine was negative for fractures. Blood
cultures, fungal blood cultures, Cryptococcal antigen (in serum
and CSF), CMV viral load were all sent and were negative or no
growth to date on discharge. Pt was quickly weaned off
levophed and extubated, and returned to regular medicine floor.
On medicine floor, patient maintained on Bactrim and Steroids.
Oxygenation was measured at > 96% on RA. Prior to discharge,
patient had ambulatory oxygenation which was > 96%. Patient was
discharged with instructions to complete 21 day course of
Bactrim and prednisone taper (40mg [**Hospital1 **] x 5 days, 40mg QD x 5
days, 20mg QD x 5 days) and with instructions to follow up with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in clinic.
In terms of the abdominal CT that demonstrated ? Sigmoiditis, pt
had complained of abdominal pain on admission with RUQ U/S that
ruled out any biliary process, and abdominal pain quickly
resolved on admission, without complaints of worsening diarrhea
from baseline. Therefore no further work up was performed as an
inpatient with plans to address as an outpatient as needed.
Pt was also anemic on admission, with Hct = 27, dropping to 25
during hospital course. Etiologies thought to include [**Doctor First Name **]
marrow suppression vs. anemia of chronic disease. Pt was
transufed 2 units of packed red blood cells with appropriate
bump of Hct and was discharged with Hct = 30.6.
Patient also with hyponatremia to 127 on admission (baseline Na
= 133-138). As patient appeared euvolemic on exam, this was
thought secondary to SIADH likely [**12-24**] to PCP [**Name Initial (PRE) 1064**].
Hyponatremia resolved during hospitalization and treatment of
PCP and patient was discharged with Na = 132.
In terms of pt's HIV/AIDS, maintained on HAART therapy
throughout hospital course, LFTs monitored and showed elevated
T. bili and Alk phos (c/w immune reconstitution syndrome per Dr.
[**Last Name (STitle) **] but flat transaminases. Of note, pt with MRI prior to
discharge which showed some changes that could be c/w HIV
encephalopathy. Patient was agitated prior to d/c, but at
baseline per previous caregivers. [**Name (NI) **] remained alert and
oriented x 3 without mental status changes throughout hospital
course.
Medications on Admission:
Clarithromycin 500mg [**Hospital1 **]
Ethambutol 500mg QD
Kaletra 3 tabs [**Hospital1 **]
Zerit 30mg [**Hospital1 **]
Truvada 1tab QD
Amphotericin B swish and swallow
Folic Acid 1mg QD
Cyanocobalamin 100mcg QD
Discharge Medications:
1. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Lopinavir-Ritonavir 133.3-33.3 mg Capsule Sig: Three (3) Cap
PO BID (2 times a day).
3. Stavudine 30 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Ethambutol 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ethambutol 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2)
Tablet PO TID (3 times a day) for 21 days: Complete 21 day
course, through [**8-27**] (began course on [**8-7**]).
Disp:*qs Tablet(s)* Refills:*0*
10. Amphotericin B 100 mg/mL Suspension Sig: Twenty (20) mg PO
QID (4 times a day): 5 mL wash, 4 times/day.
11. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO SEE other
instructions for 21 days: 40mg [**Hospital1 **] [**Date range (1) 3697**]
40mg QD [**Date range (1) 15926**]
20mg QD [**Date range (1) 15927**].
Disp:*qs Tablet(s)* Refills:*0*
12. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1.) PCP [**Name Initial (PRE) 1064**]
2.) Hypoxic respiratory failure
Discharge Condition:
Stable. Patient oxygenating well on room air at rest.
Ambulating oxygenation is good. On Bactrim and Prednisone.
Discharge Instructions:
1.) Please contact physician if increased cough, shortness of
breath, fevers > 100.4, change in mental status, any other
questions or concerns
2.) Please take medications as directed
3.) Please follow up with appointments as instructed
Followup Instructions:
1.) Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2178-8-11**] 1:30
2.) Provider: [**Name10 (NameIs) **] [**Name8 (MD) 15928**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2178-11-19**] 9:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
"51881"
] |
Admission Date: [**2124-10-17**] Discharge Date: [**2124-10-26**]
Date of Birth: [**2073-9-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain and wide complex tachycardia
Major Surgical or Invasive Procedure:
EP study
internal cardiac defibrillator placed
History of Present Illness:
51M with CAD s/p PCIX2 to the LCx ([**2117**],[**2121**]), systolic CHF
(EF=40% in [**2121**]) and T2DM, COPD on home O2, who was transfered
from OSH after multiple shocks for wide-complex tachycardia.
.
Patient was noted to have the onset of chest pain the night
prior to admission, he subsequently called 911, EMS found him in
resp distress, diaphoretic, WCT on monitor @ 180??????s, Shocked
biphasic sync 70 and 100 without effect and was brought to
[**Hospital3 7571**]Hospital. At [**Location (un) **] ED he received Amio 150mg
IV x 2 , Shocked biphasic sync 100, 100, 150, 200, Calc
chloride, Insulin, bicarb
Adenosine 6 & 12. None of these interventions terminated his WCT
and he was then given a metoprolol IV with reported improvement
in his heart rate to the 100s. Of note, he has a known LBBB
documented at prior admission to [**Hospital1 18**] in [**2121**]. Never lost
peripheral pulses, remained responsive to voice throughout.
Patient had also recieved Aspirin PR. At OSH noted to be hypoxic
to the 80s and CXR was consistent with pulmonary edema. Nasal
intubation was attempted X2 but patient did not tolerate, then
intubated with etumidate, reportedly had copious secretions on
intubation. Bedside echo ?????? dilated LV,minimal septal/lateral
contractility, hypok at apex. No pericardial effusion. BP's
subsequently labile at 80's-100's.
A right groin line was attempted which was found to be in the
femoral artery and was subsequently removed, he reportedly
received a dose of Unasyn for this + suspected aspiration.
.
On admission to [**Hospital1 18**] ED, patient was intubated/vented on
fent/versed, CMV FiO2: 100% PEEP: 18 RR: 24 Vt:470, initial
vitals were 129 97/70 81%.
- CXR showed diffuse bil alveolar infiltrates consistent with
florid pulmonary edema.
- Chem 7, CBC showed WBC 19.0, hyperglycemia to 433 but was
otherwise unremarkable. WBC = 19.0
- ECG (my read) shows regular tachycardia 110 with leftish axis
WNL and LBBB morphology which is consistent with his prior
baseline and without precordial concordence. Rythm looks like
sinus tachycardia, as P waves identified consistent with prior
tracing with PR = 0.16.
- given 10units of IV insulin
.
.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
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:
Diabetes,
Hypertension
CAD (s/p PCI with stents to LCX in [**2117**], s/p cardiac
cath [**2121**], which showed in-stent restenosis of patient's prior
LCx
stent, and underwent thrombectomy and re-stenting. )
sys+diast CHF ([**2121**] ECHO showed akinesis of the basal
inferolateral wall and mild global hypokinesis of the remaining
segments (LVEF=40%).
Chronic LBBB
HLD
Social History:
+EtOH - per son, drinks fifth of vodka every few days
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Physical Exam on Admission:
General: sedated, intubated, following commands
HEENT: sclera anicteric. PERRL. Conjunctiva pink, no pallor or
cyanosis.
Neck: supple, difficult to assess JVP but no ovious JVD. No
carotid bruits.
Cardiac: distan regular heart sounds
Lungs: Bil diffuse insp crackles on all lung fields
Abd: soft, NTND, No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominal bruits.
Ext: cool hands and feet, with mildly dusky bil fingertips. No
c/c/e. No femoral bruits. Right groin hematoma appears stable,
s/p attempted femoral line in OSH.
Skin: No stasis dermatitis, ulcers, scars
Pulses: therapy DP + radials palpable bilaterally
Physical Exam on Discharge:
T 98.4, normotensive, not tachycardic, not tachypnic
General - Mr. [**Known lastname 8271**] is a well-appearing 51 y/o male found
resting in bed in NAD.
HEENT - PERRL, EOMI, sclera anicteric, MMM
Neck - no JVD, no lymphadenopthy
Chest - upper left chest ICD placed - dressing c/d/i, no warmth
or erythema, mild tenderness to palpation
CV - normal RRR, S1 and S2 audbile, no m/r/g
Resp - CTAB, no wheezes, ronchi, rales
GI - soft, NTND, + BS
Ext - no c/c/e, 2+ DP pulses
Pertinent Results:
Labs On Admission:
[**2124-10-17**] 06:50AM BLOOD WBC-19.5* RBC-4.83 Hgb-15.9 Hct-47.5
MCV-98 MCH-32.9* MCHC-33.5 RDW-12.7 Plt Ct-291
[**2124-10-17**] 09:21AM BLOOD Neuts-85.8* Lymphs-7.2* Monos-6.2 Eos-0.6
Baso-0.3
[**2124-10-17**] 06:50AM BLOOD PT-11.4 PTT-30.4 INR(PT)-1.1
[**2124-10-17**] 06:50AM BLOOD Fibrino-295
[**2124-10-17**] 09:21AM BLOOD Glucose-396* UreaN-18 Creat-1.1 Na-144
K-4.7 Cl-110* HCO3-22 AnGap-17
[**2124-10-17**] 09:21AM BLOOD ALT-100* AST-171* CK(CPK)-526*
AlkPhos-132* TotBili-0.3
[**2124-10-17**] 06:50AM BLOOD Lipase-19
[**2124-10-17**] 09:21AM BLOOD Calcium-8.6 Mg-2.1
[**2124-10-17**] 09:21AM BLOOD VitB12-558
[**2124-10-17**] 06:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2124-10-17**] 08:22AM BLOOD pO2-104 pCO2-54* pH-7.18* calTCO2-21 Base
XS--8
[**2124-10-17**] 03:15PM BLOOD Lactate-4.3*
Cardiac Enzymes:
[**2124-10-17**] 09:21AM BLOOD CK-MB-22* MB Indx-4.2 cTropnT-0.09*
[**2124-10-17**] 03:00PM BLOOD CK-MB-28* MB Indx-4.8 cTropnT-0.19*
[**2124-10-17**] 11:10PM BLOOD CK-MB-24* MB Indx-4.7 cTropnT-0.28*
[**2124-10-17**] 03:00PM BLOOD CK(CPK)-582*
[**2124-10-17**] 11:10PM BLOOD CK(CPK)-506*
CXR [**2124-10-17**]: 1. Severe diffuse bilateral airspace opacities
might represent pulmonary edema, pulmonary hemorrhage or
widespread infection. Further assessment with chest CT is
recommended.
2. Endotracheal tube ending 4.8 cm above the carina
ECHO [**2124-10-17**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF = 15 %) secondary to akinesis of the
entire posterior wall, and hypokinesis (with regional variation)
of the rest of the left ventricle - basal segments relatively
well-preserved. No masses or thrombi are seen in the left
ventricle. The right ventricular free wall is hypertrophied.
Right ventricular chamber size is normal. with depressed free
wall contractility. The aortic valve is not well seen. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
CXR [**2124-10-18**]:
IMPRESSION: Almost complete resolution of bilateral diffuse
airspace
opacifications consistent with diagnosis of pulmonary edema.
Cardiac MRI [**2124-10-20**]:
Mildly enlarged left atrium and normal size right atrium.
Increased left
ventricular cavity. Thinned and akinetic antero-basal and
mid-basal antero-lateral walls. Moderately hypokinesis of the
other ventricular segments with probable dyssynchrony also
present. Transmural late gadolinium enhancement of the
antero-basal and mid-basal antero-lateral wall, consistent with
fibrosis or scar, and low likelihood of contractile recovery
after revascularization. No evidence of late gadolinium
enhancement in the other, hypokinetic, left ventricular
segments. Normal right ventricular cavity size and function.
The ascending aorta, descending aorta and main pulmonary artery
were normal. No significant aortic or mitral regurgitation. No
pericardial effusion.
ECHO [**2124-10-25**]: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Overall left ventricular systolic function is severely depressed
(LVEF= 25 %). There is global hypokinesis with akinesis of the
inferior wall. A left ventricular mass/thrombus cannot be
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Regional and global left ventricular systolic
dysfunction. Normal right ventricular systolic function. No
pathologic valvular abnormalities identified.
CXR [**2124-10-26**]: As compared to the previous radiograph, the
patient has been
extubated and the nasogastric tube has been removed. In the
interval, the
patient has received a pacemaker, the generator is in left
pectoral position, the course of the leads is unremarkable, the
tip of the lead projects over the right ventricle. There is no
evidence of complications such as pneumothorax. No evidence of
pulmonary edema. No pleural effusions.
Labs on Discharge:
[**2124-10-26**] 06:58AM BLOOD WBC-6.1 RBC-3.67* Hgb-11.8* Hct-34.0*
MCV-93 MCH-32.2* MCHC-34.7 RDW-12.2 Plt Ct-188
[**2124-10-26**] 06:58AM BLOOD Glucose-158* UreaN-16 Creat-0.9 Na-136
K-4.2 Cl-103 HCO3-25 AnGap-12
[**2124-10-26**] 06:58AM BLOOD Mg-2.0
Brief Hospital Course:
51M with CAD s/p PCIX2 to the LCx ([**2117**], [**2121**]), systolic CHF
(EF=40% in [**2121**]) and T2DM, COPD on home O2, who developed chest
pain 1 day prior to admission was then treated by EMS and OSH ED
with multiple shocks and meds for a stable wide-complex
tachycardia which was not terminated, subsequently intubated for
hypoxia and pulmonary edema and transferred to [**Hospital1 18**]. Patient
now s/p ICD placement.
# Wide-complex tachycardia: SVT with abarrancy vs. sinus
tachycardia. SVT less likely given failure to convert with
adenosine. ECG on admission consistent with sinus tachycrdia +
LBBB. Most likely this is tachycardia secondary to heart
failure, pulmonary edema and possibly COPD exacerbation.
Ischemia nevertheless should be ruled out given his history.
Cardiac enzymes were trended to peak, at third set when CK and
CKMB reached plateau. An ECHO was obtained that showed overall
left ventricular systolic function is severely depressed (LVEF =
15 %) secondary to akinesis of the entire posterior wall, and
hypokinesis (with regional variation) of the rest of the left
ventricle - basal segments relatively well-preserved. The
patient then had a cardiac MRI to map out area of scar prior to
EP study. He was then taken for an EP study where it became
clear that this was indeed VT. However, there was difficulty
finding focus with voltage map and was unable to induce VT. Pt
kept having PVCs and may be coming from an epicardial focus.
Therefore he was taken the next day to have an ICD placed. He
was then started on a 3 day course of antibiotics. CXR after
procedure showed leads in correct place and without
complication. He was discharged the day after ICD placed.
# Resp distress: CXR on admission consistent with pulmonary
edema. Patient with known systolic CHF with LVEF = 40% per echo
[**2121**]. Unclear trigger for decompensation. ? of contributing
underlying COPD exacerbation +/- pneumonia (may have had
aspiration during his dramatic intubation). The patient was
intubated at OSH prior to admission. The patient was diueresed
with lasix. The patient was successfully extubated on HOD 2. The
patient's respiratory status remained well throughout the
remainder of his hospitalization.
# CHF: The patient had an EF of 40% in [**2121**]. ECHO on admission
showed EF of 15%, likely secondary to myocardial stunning. He
was given IV Furosamide 40mg x 2 on day of admission. Diueresed
for a goal -1.5 to 2 L net negative until euvolemic. We
continued to diurese pt until he was euvolemic. He was
discharged on a regimen of 40 mg PO lasix. Repeat ECHO the day
before discharge showed EF of 25%. The patient was started on BB
and ACE-I.
# CORONARIES: initially presented with CP, has history of Lcx
instent restenosis in [**2121**]. Cardiac enzymes were initially
trended and were initially elevated and trop up t 0.28 with
elevated but flat CK and CKMB. However, the enzymes were hard to
interpret given shocks. The patient was continued on home
aspirin and started on metoprolol, lisinopril, and atorvastatin.
# Diabetes: The patient came in with a previous diagnosis of
diabetes, however had not been taking his insulin for about 1
year. While in the hospital his glucose was trended and covered
with ISS and long acting insulin adjusted accordingly. He was
discharged on a regimen of 20 units of glargine in the AM.
Diabetic education was provided prior to discharge.
# Non-compliance: The patient has a h/o non-compliance and was
only taking an aspirin prior to coming to the hospital. He
reported insulin, but when re-evaluated he hadn't taken this in
one year. Diabetic education was provided as well as it was
stressed the importance of his new medications and following up
with the scheduled appointments as well as establishing care
with primary care doctor. Additionally social work met with the
patient. He was set up with a home VNA prior to discharge to
provide medication teaching, diabetes teaching, and education.
# Alcohol Abuse: The patient had no signs or symptoms of alcohol
withdrawal throughout the hospitalization. Education was
provided and the patient was informed that it is strongly
advised that he stop drinking.
Transitional Issues:
- The patient will need to establish with primary care doctor
whom he reports he has never seen. He was instructed that it is
very important for him to establish care.
- Patient will need diabetes management optimized
- Patient will follow up in device clinic and with cardiologist.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 325 mg PO DAILY
2. Humalog 75/25 45 Units Breakfast
Humalog 75/25 45 Units Dinner
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
2. Atorvastatin 40 mg PO HS
RX *atorvastatin 40 mg one tablet(s) by mouth dailiy Disp #*30
Tablet Refills:*2
3. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 75 mg PO DAILY
hold for BP<100, HR<60
RX *metoprolol succinate 50 mg 1.5 tablet(s) by mouth daily Disp
#*45 Tablet Refills:*2
6. Cephalexin 500 mg PO Q6H Duration: 2 Days
RX *cephalexin 500 mg one capsule(s) by mouth four times a day
Disp #*8 Capsule Refills:*0
7. Diabetes Supplies
glucose test strips
needles
Disp: one month supply
Refil: 2
8. Glargine 20 Units Breakfast
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) inject
subcutaneously 20 Units before breakfast Disp #*2 Each
Refills:*0
9. Diabetes Supplies
Glucometer
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Acute on Chronic Systolic congestive heart failure
Coronary artery disease
Ventricular tachycardia
Diabetes
Chronic Obstructive Pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Last Name (Titles) 8273**],
You had a irregular looking tachycardia at [**Hospital3 7569**] and
it was shocked multiple times. You needed a breathing tube to
get enough oxygen and you were transferred to [**Hospital 18**] hospital for
further management. You were admitted to the CCU. We do not feel
that you had a heart attack. An electrophysiology study showed
the rhythm was ventricular tachycardia. An internal cardiac
defibrillator was placed that will shock you internally if this
dangerous rhythm happens again.
While you were here we worked to control your sugar level. We
started you on a long acting insulin that you will take once a
day. However, it is very important that you follow up with your
primary care physician to get your diabetes under better
control.
Your heart is weaker after the shocks and you are at risk for
fluid accumulation in your legs and lungs. Weigh yourself every
morning, call your heart doctor if weight goes up more than 3
lbs in 1 day or 5 pounds in 3 days.
An ICD (defibrilator) was placed. No baths or swimming for one
week, no driving for one week until after you are seen in the
device clinic. Do not lift your left arm or lift more than 5
pounds with your left arm for 6 weeks.
It is extremely important that you quit drinking alcohol. This
makes your heart weaker and works against the medicines that you
are taking.
It was a pleasure caring for you,
Your [**Hospital1 **] doctors
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2124-11-2**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CVI [**Location (un) **], [**Apartment Address(1) **]
When: MONDAY [**2124-11-13**] at 2:00 PM
With: [**Last Name (un) 1918**] [**Doctor Last Name **] [**Telephone/Fax (1) 11767**]
Building: [**Location (un) 20588**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
It is recommended that you establish care with a Primary Care
Physician. [**Name10 (NameIs) 357**] call and schedule an appointment within the
next week.
Name: VENKAT,[**Name8 (MD) 84507**] MD
Address: [**Doctor Last Name 75454**]., [**Location (un) **],[**Numeric Identifier 43359**]
Phone: [**Telephone/Fax (1) 84508**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2124-10-27**]
|
[
"4280",
"496",
"4019",
"25000",
"2724",
"412",
"V4582",
"V1582"
] |
Admission Date: [**2183-2-12**] Discharge Date: [**2183-2-20**]
Date of Birth: [**2119-5-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
SSCP
Major Surgical or Invasive Procedure:
[**2183-2-12**] Emergent CABG x 3 (OM, PDA, LIMA)
History of Present Illness:
Mr. [**Known lastname 66075**] is a 63 year old male with no PMH who presented to
an OSH on [**2-12**] with severe SSCP, r/i for IMI.
Past Medical History:
None.
Social History:
Has not had medical care in over 15 years.
Physical Exam:
P 100 BP 117/73 PA 40/24
Neuro awake, alert
CV RRR, IABP
Resp CTAB ant/lat
Abd Soft/NT/ND +BS
Extrem 2+pulses t/o, no varicosities, warm w/o edema
Pertinent Results:
[**2183-2-20**] 07:38AM BLOOD Hct-33.2*
[**2183-2-19**] 12:55PM BLOOD WBC-10.0 RBC-3.72* Hgb-11.2* Hct-32.7*
MCV-88 MCH-30.1 MCHC-34.2 RDW-14.4 Plt Ct-212
[**2183-2-19**] 12:55PM BLOOD Plt Ct-212
[**2183-2-20**] 07:38AM BLOOD UreaN-19 Creat-0.8 K-4.2
[**2183-2-12**] 01:54AM BLOOD ALT-21 AST-35 AlkPhos-54 TotBili-0.3
[**2183-2-12**] 01:54AM BLOOD %HbA1c-5.5 [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
Cardiac catheterization on [**2-12**] revealed a 99% LM and 3VD, an
IABP was placed. Mr. [**Known lastname 66075**] was taken emergently to the
operating room on [**2-12**] where he underwent a CABG x 3 witha
LIMA->LAD, SVG->OM1 and SVG->LPDA. After surgery he was
transferred to the ICU in critical but stable condition with the
IABP in place and on milrinone, propofol and phenylephrine. He
was extubated by POD 2. He was placed on amiodarone for
ventricular ectopy. His IABP was dc'd on POD 2. He remained on
milrinone until POD 5. He was seen in consultation by cardiology
for post MI as well as heart failure management. He was
transferred to the floor on POD 6. He underwent an
echocardiogram on [**2-20**] to evaluation LV function and assess need
for an ICD, which showed a slightly improved LVEF of 35%. On
POD 8 Mr. [**Known lastname 66075**] was 2kg above his preop weight with good
exercise tolerance, no SOB, or Chest pain. His blood pressure
was stable. His sternotomy and leg incision were clean, dry,
and intact without evidence of infection. He was discharged
home on POD 8 with services in good condition, cardiac diet,
sternal precautions, and instructed to follow up with his
PCP/cardiologist in [**11-25**] weeks. He will follow up with Dr.
[**Last Name (STitle) **] in four weeks.
Medications on Admission:
None.
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
5. Atorvastatin 10 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:*40 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400 mg (2 tabs) daily for 1 weeks then 200 mg (1 tab)daily.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incisions or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting or driving.
Shower, no baths, no lotions creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Cardiologist 2 weeks
PCP 2 weeks
Completed by:[**2183-2-20**]
|
[
"41401"
] |
Admission Date: [**2167-7-22**] Discharge Date: [**2167-7-26**]
Date of Birth: [**2115-11-9**] Sex: M
Service: MED
INTERIM SUMMARY
DATE OF DISCHARGE FROM INTENSIVE CARE UNIT: [**2167-7-26**].
CHIEF COMPLAINT: Fever, cellulitis, adenitis and
hypotension.
HISTORY OF PRESENT ILLNESS: A 51-year-old male, without any
significant past medical history, who was transferred from an
outside hospital for cellulitis and adenitis that was not
responsive to antibiotics, resulting in hypotension. The
patient stated that he was in his usual state of health until
Tuesday, [**2167-7-14**] when he first noted some left upper
groin pain. The groin pain became progressively worse over
the next several days, and also he noted an area of erythema.
He developed fevers on [**2167-7-19**]. He went to an outside
hospital Emergency Department the following day. At that
time, he was diagnosed with cellulitis and adenitis, and was
given 2 gm of ceftriaxone, and was discharged to home. He
continued to have persistent fevers to 103 and returned the
following morning to the outside hospital Emergency
Department where he was admitted for cellulitis and adenitis.
He was started on Ancef, but developed a diffuse erythroderma
rash the day after initiation of Ancef therapy, which was
felt to be due to a drug rash. On [**2167-7-22**], the day of
transfer to [**Hospital6 256**], the patient
was still persistently spiking fevers, had an elevated white
blood cell count with a bandemia, and became hypotensive
despite IV antibiotics, including vancomycin, clindamycin and
Levaquin. His blood pressure dropped to 70 systolic, and he
was given IV fluids and started on peripheral dopamine. At
this time, arrangements were made to transfer the patient to
[**Hospital6 256**]. On arrival to [**Hospital6 1760**], the patient was no longer on
the dopamine drip and was normotensive with blood pressure's
in the 100's to 110's/60's to 70's.
The patient reported that 3 to 4 days prior to the onset of
his symptoms on [**7-14**], he had been doing work at a family
member's house and had been trying to close-off openings that
rodents were using to get into a house. He also, at that
time, removed a dead squirrel from the chimney. He noted
that during his work that day there were a lot of bugs and
spiders. He, however, does not remember being bitten by any
insect. The patient lives in a heavily wooded area, has deer
in his backyard, and also has a pet dog. He has not had any
recent travel outside of [**Location (un) 3844**]. He has had no sick
contacts.
PAST MEDICAL HISTORY: History of prior wrist and hand
surgery.
ALLERGIES: Possible allergy to Ancef causing a rash.
MEDICATIONS: None.
MEDICATIONS ON TRANSFER:
1. Vancomycin.
2. Clindamycin.
3. Levaquin.
4. Zofran.
5. Vicodin.
FAMILY HISTORY: No family history of early coronary artery
disease, or diabetes.
SOCIAL HISTORY: The patient has a remote tobacco history.
He quit smoking in the [**2133**]'s. He drinks occasionally only
socially. The patient lives in [**Location (un) 3844**] with his wife
and children. He has a dog and lives in a heavily wooded
area.
PHYSICAL EXAM ON ARRIVAL: Temperature 98.6, heart rate 106,
blood pressure 108/67, respiratory rate 24, oxygen saturation
96 percent on 2 liters.
GENERAL: In no acute distress, alert and oriented x 3.
HEENT: Pupils equal, round and reactive to light. Supple
neck. Clear oropharynx. No cervical lymphadenopathy.
Anicteric sclerae. Extraocular muscles intact. No facial
asymmetry.
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR EXAM: Tachycardic, irregular.
ABDOMEN: Soft, nontender, normoactive bowel sounds, no
hepatosplenomegaly.
EXTREMITIES: No lower extremity edema. 2 plus dorsalis
pedis pulses and posterior tibialis pulses bilaterally.
LEFT GROIN: With several large, palpable subcutaneous
nodules and an erythema over the left upper thigh extending
from several inches above the knee to just below the inguinal
crease. The area of erythema was warm and tender to
palpation. The subcutaneous nodules were nontender to
palpation.
NEUROLOGIC EXAM: Cranial nerves II through XII intact
bilaterally. Strength 5/5 in upper and lower extremities
bilaterally.
LABORATORY DATA: White blood cell count 19.8 with 94 percent
polys, 0 bands, 3 percent lymphs, hematocrit 35.3, platelets
201, INR 1.3, PTT 30.7, ESR 100, reticulocyte count 1.7,
sodium 137, potassium 3.8, chloride 103, bicarbonate 21, BUN
12, creatinine 0.7, ALT 64, AST 27, LDH 81, CK 153, alkaline
phosphatase 127, amylase 12, total bilirubin 1.7, direct
bilirubin 1.0, lipase 12, troponin-T less than 0.01, albumin
3.3, uric acid 3.0, haptoglobin 328, TSH 0.36, Lyme serology
160:[**2167**], negative.
CHEST X-RAY: Showed increased interstitial markings,
possibly suggesting fluid overload.
EKG: Showed sinus tachycardia with first degree AV block
with a PR interval of 0.218.
HOSPITAL COURSE:
1. GROIN ERYTHEMA AND SUBCUTANEOUS NODULES: The patient's
groin erythema was clinically consistent with a
cellulitis. Given the patient's possible allergy to
Ancef, he was continued on IV vancomycin and clindamycin.
Blood cultures were sent which did not reveal any
organism. The patient remained hemodynamically stable and
did not require any further pressors. The subcutaneous
nodules had been previously ultrasounded and sampled with
fine needle aspiration at the outside hospital on the day
of admission. The ultrasound at the outside hospital
revealed only lymphadenopathy. The Gram stain showed 2
plus polys but no organisms.
A repeat ultrasound at [**Hospital6 256**]
showed only left groin enlarged lymph nodes. No evidence of
an abscess or fluid collection. The surgical service was
consulted for biopsy of the left upper thigh lymph nodes, as
the patient continued to spike fevers and had a persistently
elevated white blood cell count despite vancomycin and
clindamycin. An excisional biopsy was attempted; however, no
lymph node was obtained.
After approximately 3 to 4 days, the patient's cellulitis was
clinically improving, he was no longer spiking fevers, and
his white blood cell count was decreasing. Given his
extremely low risk for MRSA, and the fact that his cultures
did not reveal any organisms, the patient's antibiotic
coverage was changed to PO clindamycin.
There was also concern for possible streptococcal infection
with his diffuse erythroderma rash, possibly representing the
rash seen as scarlet fever. The patient never reported any
pharyngitis, but given his complaints of diffuse arthralgias,
myalgias, migrating neuropathic pain, there was some concern
of rheumatic fever, as the patient had 2 ASO screens
performed which were both negative.
1. MYALGIAS, ARTHRALGIAS AND NEUROPATHIC PAIN: The patient
complained of bilateral shooting neuropathic-like pain,
migrating arthralgias, swelling in the fingers and toes,
and pleuritic chest pain. Given the patient's exposure to
multiple insects and animals, there was initially concern
over tick-borne illnesses, including Lyme disease and
tularemia. Tularemia titers were sent to the State Lab
and were pending at the time of transfer out of the
intensive care unit. The patient was started on
doxycycline to cover tularemia and Lyme disease. However,
with the patient's clinical improvement on antibiotics, it
was felt that his clinical course was not consistent with
tularemia. The patient did develop a significant amount
of pleuritic chest pain that was relieved with NSAIDS and
IV Toradol. He also developed a pericardial friction rub.
An echocardiogram revealed a normal ejection fraction and
no pericardial effusion, and Lyme titers were initially
negative. However, given the patient's clinical evidence
of pericarditis, newly prolonged PR interval, and
migratory arthralgias and neuropathic pain, there was a
significant concern for Lyme disease and Lyme carditis
despite lack of serologic evidence. Therefore, the
decision was made to complete a 1 month course of
doxycycline, and to repeat Lyme serologies in [**2-6**] weeks.
On [**2167-7-26**], the patient was transferred out of the
intensive care unit to the general medical floor. The
remainder of this discharge summary will be dictated by the
covering intern on the general medicine floor.
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], [**MD Number(1) 24326**]
Dictated By:[**Last Name (NamePattern1) 18139**]
MEDQUIST36
D: [**2167-7-27**] 12:52:10
T: [**2167-7-27**] 13:58:13
Job#: [**Job Number 55595**]
|
[
"0389"
] |
Admission Date: [**2190-8-16**] Discharge Date: [**2190-8-20**]
Date of Birth: [**2111-5-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 79 year-old female with h/o hypothyroidism, CVA in
[**2186**], HTN, hyperlipidemia who presents with weakness,
palpitations, and feeling presyncopal when upright. She reports
weight loss over last few months, dropping two dress sizes since
[**Month (only) 116**], with minimal PO intake over the past few days. She denies
diarrhea, BRBPR, fevers, chills, SOB, chest pain. She has no
history of colonoscopy.
.
In the ED, VS T 97.2 BP 108/44 HR 74 RR 16 POx 100% on RA.
Orthostatics positive by HR and BP dropping to 84/36 on
standing. Guaiac positive stool in ED. NG leavage negative.
Patient received 2 units FFP, 2 units PRBCs, 10mg po and 1mg IV
vitamin K, IV Protonix, and 1500cc NS. GI contact[**Name (NI) **] in the [**Name (NI) **]
with plan for colonscopy/EGD when INR reversed. 2 large bore IVs
placed.
.
ROS: The patient denies any fevers, chills, nausea, vomiting,
abdominal pain, diarrhea, constipation, melena, hematochezia,
chest pain, shortness of breath, orthopnea, PND, lower extremity
edema, cough, urinary frequency, urgency, dysuria, gait
unsteadiness, focal weakness, vision changes, headache, rash or
skin changes.
Past Medical History:
B12 Deficiency
Hypertension
Hyperlipidemia
S/P CVA [**2186**] without residual deficits
Hypothyroidism
Cataract surgery [**2188**]
Social History:
lives w/husband in [**Name (NI) 10059**]. Denies etoh, tobacco, drugs. Retired
flight attendant.
Family History:
CAD in parents, sibling. [**Name (NI) 10060**] mom, sister.
Physical Exam:
Vitals: T: 98.5 BP: 108/54 HR:77 RR:18 O2Sat: 100% on RA
GEN: Pale, in no acute distress
HEENT: NCAT, EOMI, PERRL, sclera anicteric, conj pallor, no
epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses, no rebound or
guarding
EXT: No C/C/E
NEURO: A&Ox3. Interactive and appropriate.
SKIN: No jaundice, cyanosis. No ecchymoses. Dry, cracked skin
throughout.
Pertinent Results:
[**2190-8-16**] 11:50AM PT-25.2* PTT-26.1 INR(PT)-2.5*
[**2190-8-16**] 11:50AM PLT COUNT-342
[**2190-8-16**] 11:50AM NEUTS-77.5* LYMPHS-17.7* MONOS-3.9 EOS-0.6
BASOS-0.3
[**2190-8-16**] 11:50AM WBC-11.4* RBC-1.92*# HGB-6.0*# HCT-17.7*#
MCV-92 MCH-31.4 MCHC-34.0 RDW-17.1*
[**2190-8-16**] 11:50AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-1.8
[**2190-8-16**] 11:50AM CK-MB-NotDone
[**2190-8-16**] 11:50AM cTropnT-<0.01
[**2190-8-16**] 11:50AM LIPASE-66*
[**2190-8-16**] 11:50AM ALT(SGPT)-22 AST(SGOT)-30 CK(CPK)-50 ALK
PHOS-53 TOT BILI-0.3
[**2190-8-16**] 11:50AM estGFR-Using this
[**2190-8-16**] 11:50AM GLUCOSE-104 UREA N-43* CREAT-1.2* SODIUM-140
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-29 ANION GAP-12
[**2190-8-16**] 01:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2190-8-16**] 01:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2190-8-17**] CT abd/pelvis)
IMPRESSION:
1. Large infiltrative mass arising from the lesser curvature of
the stomach,
with possible invasion of the left hepatic lobe and pancreas -
findings are
consistent with extensive gastric malignancy. There is also
omental caking
and intra- abdominal fluid consistent with intraperitoneal
metastases.
2. Multiple large gallstones within a non-distended gallbladder.
3. Prominence of the CBD with mild intrahepatic biliary ductal
dilatation,
without definite distal CBD obstruction. Clinical correlation is
recommended.
4. Small bilateral pleural effusions.
[**8-17**] Pathology:
Stomach mass biopsy:
1. Adenocarcinoma, diffuse cell type.
2. Immunostains of the tumor are positive for cytokeratin
cocktail and focally positive for CD68 with satisfactory
controls.
3. Special stains (PAS-D and mucicarmine) of the tumor cells
are faintly positive for mucin.
4. Chronic mildly active inflammation of the adjacent mucosa.
[**Doctor Last Name 6311**] stain is negative for H. pylori, with satisfactory
control.
Brief Hospital Course:
This is a 79 year-old female with a history of HTN, embolic CVA
on coumadin, hypothyroidism who presented with weakness,
palpitations, orthostasis and unintentional weight loss found to
have +guaiac stools and HCT of 17 in ED. Patient with very low
hematocrit, elevated INR of 2.5 on admission and blood in her
stool raised initial concern of active GI bleeding, possibly due
to undiagnosed malignancy. The patient was transfused 4 units
PRBC in ICU and underwent upper endoscopy revealing large
gastric adenocarcinoma with CT revealing evidence of likely
metastatic spread to left hepatic lobe, pancreas and omental
caking.
# Metastatic gastric adenocarcinoma)
The patient was seen by the GI, oncology, radiation oncology and
palliative care services. The patient repetedly stated that she
did not any aggressive interventions. She did not want IR
embolization if she had a rapid GI bleed. She is not currently
a candidate for palliative radiation XRT per radiation oncology.
She will f/u with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**] of palliative care. She did not
want hospice at this time.
# Anemia of acute blood loss) Stable after PRBC transfusions.
# Palpitations: Patient currently without palpitations, issue
appears to have resolved. Likely initially secondary to
hypotension and orthostasis given poor PO intake. Unlikely to be
hyperthyroid given elevated TSH. Troponins negative x2.
# Hypotension: Patient currently normotensive (resolved)
# CVA: Embolic CVA in [**2186**], on coumadin. INR 2.5 on admission
which is within goal range, however in setting of significant GI
bleed from her gastric cancer permanently discontinued her
coumadin and aspirin.
# Hypertension: patient on atenolol and hctz as outpatient.
Restarted on discharge.
.
# Hyperlipidemia:
- continue home statin
.
# Hypothyroidism: Patient has been on levothyroxine for some
time. TSH 7 which is slightly elevated. appears that patient on
100 of levothroxyine at home 6 times a week, will change to
daily in the setting of elevated TSH, would also consider
uptitration of medication
-cont levothyroxine as above
Medications on Admission:
Coumadin 5 mg qd except 2.5 mg on Sunday
atenolol 50mg PO qd
HCTZ 25mg po qd
atorvastatin 40mg PO qd
levothyroxine 100mcg PO 1tab qd 6d/week
ASA 81mg PO qd
folic acid .4mg PO qd
cyanocobalamin 1,000mcg/ml sln, 1cc every other mo.
Ca-citrate+ vitamin D+ Mag (OTC)
Omega 3 fatty acid (OTC)
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO every
other month: OF NOTE, PATIENT WAS receiving cyanocobalamin 1000
mcg/ml sln every other month.
7. omega three Sig: One (1) tab once a day: take per home
dose.
8. Calcium Citrate + D with Mag 250-40-5-125 mg-mg-mg-unit
Tablet Sig: One (1) Tablet PO once a day: take per prior home
dosing.
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Gastric Adenocarcinoma
GI Bleed
Anemia, Acute Blood Loss
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to Emergency Department if having active bright red blood
from the rectum, dizziness, abdominal pain, protracted nausea
and vomitting.
Followup Instructions:
Patient to arrange f/u appointment with PCP [**Last Name (NamePattern4) **] 2 week Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 4775**].
Patient to f/u with palliative care [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10061**]
office to call patient with appointment.
|
[
"2851",
"2449",
"4019",
"2724",
"V5861"
] |
Admission Date: [**2156-9-14**] Discharge Date: [**2156-10-4**]
Date of Birth: [**2116-3-20**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
Dialysis on [**2156-9-14**] for acidosis and hypokalemia
Intubation
PICC line placement
History of Present Illness:
40-year-old female DM2 transferred from [**Hospital 1562**] Hospital for
severe acidosis from ? DKA, altered mental status, and
respiratory failure. Patient presented to the outside hospital
with altered mental status and agitation. She was noted to be
hypotensive. Initial labs revealed elevated lipase. As the
patient became more agitated, she was intubated for airway
protection. She was given 6 L of NS with levophed at 3 mcg/min
started and increased to 25 mcg/min. Vent settings on transfer
were SIMV 12/500/1/5. She was given KCl 10 mEq x 2. She was
transferred to [**Hospital1 18**] for further management.
Labs prior to transfer were lactate 0.8, alcohol < 10, lipase
1027, CK 86, cTropnT < 0.010, amylase 553, ALP 173, GGT 107, AST
50 ALT 58, Na 123, K 4, Cl 93, HCO3 3, BUN 42, Cr 1.05, Glc 685,
Mg 2.7, Ph 4.4, Gap 30. CBC WBC 35.9, Hgb 13.2, Plt 97, 8 %
bands.
In the ED, initial VS were: 82 95/51 22 100%
Patient received intubated from OSH. 7.5 ETT secured @ 22cm
@lips. Initial vent settings were FiO2: 100% PEEP: 5 RR: 14 Vt:
500
Initial ABG was pH 6.74 pCO2 33 pO2 385 HCO3 5. Based on ABG
results RR increased to 22 and FiO2 decreased to 40%.
A RIJ and left femoral a-line was placed in the ER.
Past Medical History:
Insulin dependent diabetes mellitus
Social History:
Patient lives in [**Location **]. Her father is an internist and is
currently here visiting while she is in the hospital.
Tobacco: [**8-1**] pack year smoking history in the [**2134**]. Quit for 10
years, recent relapse, but now without smoking for 6 months.
EtOH: Socially; 2 drinks/month.
IVDU: Denies.
Family History:
Diabetes in multiple family members.
Denies family history of seizures and strokes.
Physical Exam:
Admission Physical Exam:
General Appearance: Intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, atraumatic, IJ line in
place
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), no murmurs
Peripheral Vascular: pulses present throughout
Respiratory / Chest: clear bilaterally
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: no peripheral edema
Skin: Warm
Neurologic: intubated, sedated
Physical Exam on Discharge:
Vitals: afebrile, hemodynamically stable
General: Awake, cooperative, NAD.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Speech was not dysarthric. Able to follow both midline
and appendicular commands. The pt. had good knowledge of current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 5 5 4+ 5 3 3 5 5 5 5 2 5 3
R 5 5 5 5 5 5 5 5 5 4 2 5 3
-Sensory:decreased in L 5 to midshin b/l, decreased at L ulnar
n distribution from 5th digit to wrist
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2156-9-14**] 12:52AM BLOOD WBC-37.36* RBC-4.25 Hgb-12.4 Hct-38.5
MCV-91 MCH-29.1 MCHC-32.1 RDW-14.0 Plt Ct-67*
[**2156-9-14**] 04:00AM BLOOD Neuts-59 Bands-8* Lymphs-16* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-11*
[**2156-9-14**] 12:52AM BLOOD PT-11.5 PTT-27.2 INR(PT)-1.1
[**2156-9-14**] 04:00AM BLOOD Glucose-568* UreaN-33* Creat-1.1 Na-134
K-2.1* Cl-109* HCO3-LESS THAN
[**2156-9-14**] 12:52AM BLOOD ALT-92* AST-129* AlkPhos-149* TotBili-0.4
[**2156-9-14**] 12:52AM BLOOD Lipase-612*
[**2156-9-14**] 04:00AM BLOOD cTropnT-<0.01
[**2156-9-14**] 12:52AM BLOOD Calcium-6.3* Phos-2.3* Mg-2.1
[**2156-9-19**] 09:00PM BLOOD calTIBC-221* Ferritn-293* TRF-170*
[**2156-9-14**] 04:00AM BLOOD %HbA1c-13.1* eAG-329*
[**2156-9-14**] 12:52AM BLOOD Triglyc-488*
[**2156-9-14**] 04:00AM BLOOD Acetone-SMALL Osmolal-336*
[**2156-9-14**] 04:00AM BLOOD TSH-1.2
[**2156-9-14**] 04:00AM BLOOD Cortsol-91.5*
[**2156-9-14**] 01:57PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2156-9-14**] 04:00AM BLOOD HCG-<5
[**2156-9-20**] 04:00PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2156-9-20**] 04:00PM BLOOD PEP-TRACE ABNO IgG-857 IgA-174 IgM-76
IFE-MONOCLONAL
[**2156-9-14**] 12:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2156-9-14**] 01:57PM BLOOD HCV Ab-NEGATIVE
[**2156-9-14**] 01:12AM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5
FiO2-100 pO2-385* pCO2-33* pH-6.74* calTCO2-5* Base XS--33
AADO2-294 REQ O2-55 -ASSIST/CON Intubat-INTUBATED
[**2156-9-14**] 12:53AM BLOOD Glucose-500* Na-137 K-2.7* Cl-118*
calHCO3-3*
[**2156-9-14**] 12:52AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2156-9-14**] 12:52AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2156-9-14**] 12:52AM URINE RBC-<1 WBC-0 Bacteri-FEW Yeast-NONE Epi-1
[**2156-9-14**] 12:52AM URINE Mucous-RARE
[**2156-9-14**] 12:52AM URINE UCG-NEGATIVE
[**2156-9-14**] 12:52AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Relevant Labs:
[**2156-9-29**] 05:10AM BLOOD ESR-99*
[**2156-9-26**] 12:05PM BLOOD ESR-103*
[**2156-9-29**] 05:10AM BLOOD Ret Aut-8.5*
[**2156-9-20**] 07:24AM BLOOD Ret Aut-0.6*
[**2156-9-20**] 07:24AM BLOOD calTIBC-211* Hapto-286* Ferritn-256*
TRF-162*
[**2156-9-20**] 04:00PM BLOOD VitB12-1251*
[**2156-9-14**] 04:00AM BLOOD %HbA1c-13.1* eAG-329*
[**2156-9-15**] 07:55AM BLOOD Triglyc-276*
[**2156-9-14**] 04:00AM BLOOD TSH-1.2
[**2156-9-14**] 04:00AM BLOOD Cortsol-91.5*
[**2156-10-1**] 03:18AM BLOOD HIV Ab-PND
[**2156-9-14**] 01:57PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2156-9-24**] 05:21AM BLOOD ANCA-NEGATIVE B
[**2156-9-29**] 05:10AM BLOOD b2micro-1.5
[**2156-9-20**] 04:00PM BLOOD PEP-TRACE ABNO IgG-857 IgA-174 IgM-76
IFE-MONOCLONAL
[**2156-10-1**] 03:18AM BLOOD HIV Ab-PND
RPR [**2156-9-20**]: negative
Lyme [**2156-9-20**]: negative
[**2156-9-18**] 8:22 pm BLOOD CULTURE Source: Venipuncture.
MICRO:
[**2-1**] blood cultures:
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
STUDIES:
ECHO ([**2156-9-14**])
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and hyperdynamic global biventricular systolic
function. No valvular pathology or pathologic flow identified.
CT Head Non-con ([**2156-9-14**]):
IMPRESSION: No evidence of acute intracranial pathology.
CT Abd/Pelvis ([**2156-9-14**]):
1. Visualized lung bases show bilateral trace pleural effusions
with adjacent opacification which likely represents atelectasis;
however, a component of aspiration versus infectious process
such as pneumonia cannot be completely excluded.
2. Minimal edema within the fat in the groove between the
pancreas and
duodenum which may represent focal acute pancreatitis with
extension of edema to the pericholecystic region.
3. Multiple transient intussceptions are noted along the jejunum
(uncertain significance).
4. Significantly fatty liver.
ECHO ([**9-21**]):
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
No vegetation seen (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2156-9-14**],
findings are similar. The heart rate is now slower.
EMG [**2156-9-23**]
Abnormal study. There is electrophysiologic evidence for an
acute, severe, sensorimotor polyneuropathy affecting the
bilateral lower extremities. Although this neuropathy appears to
have axonal features, a demyelinating pathology cannot be
entirely excluded due to the absence of distal sensorimotor
responses. In addition, there is evidence for a severe, acute
ulnar neuropathy at the left elbow. A right lumbosacral
polyradiculopathy cannot be entirely excluded.
EMG [**2156-9-30**]
Taken together with the results of [**9-23**], the findings are
most consistent with severe, acute bilateral sciatic
neuropathies. Given the clinical history and evidence for left
ulnar neuropathy, a compressive etiology for these neuropathies
is most likely.
MRI L spine w/o contrast
FINDINGS: Intervertebral disc heights and signals are
maintained. There is no signal abnormality in the cord.
Vertebral body heights are maintained and show normal signal.
Imaged portions of the soft tissues are unremarkable. A small
disc buldge is present at L5-S1 with very minimal compression of
the thecal sac, but no contact with traversing nerve roots.
IMPRESSION: Very minimal disc buldge of L5-S1. If there is
concern for
polyneuritis, post gadolineum imaging can be obtained.
Skeletal Survey
LATERAL SKULL: No focal lytic or blastic lesions are seen.
BILATERAL HUMERI: There is a portion of a central venous
catheter seen in the right arm. There are no focal lytic or
blastic lesions or significant degenerative changes.
THORACIC SPINE: No compression deformities are seen. There is
minimal
spurring at the anterior aspect of several lower thoracic
vertebral bodies. Visualized lung fields are clear. There is a
central venous catheter with distal lead tip at the cavoatrial
junction.
LUMBAR SPINE: There are five non-rib-bearing lumbar-type
vertebral bodies. There is no compression deformity. Minimal
spurring at the L4 and L5 vertebral bodies are seen anteriorly.
AP PELVIS AND BILATERAL FEMORA: No focal lytic or blastic
lesions are seen. The sacroiliac joints are grossly within
normal limits. Bilateral hip joint spaces demonstrate mild
spurring in the superolateral aspect, consistent with early
degenerative changes.
IMPRESSION:
No focal lytic or blastic lesions in the skeleton to indicate
definite
myelomatous deposits.
Sural biopsy: final report pending at time of discharge. Prelim
read was normal.
Labs on Discharge: (most recent)
[**2156-10-1**] 03:18AM BLOOD WBC-3.7* RBC-3.08* Hgb-8.9* Hct-27.4*
MCV-89 MCH-29.0 MCHC-32.7 RDW-15.8* Plt Ct-327
[**2156-9-29**] 05:10AM BLOOD PT-11.5 PTT-25.9 INR(PT)-1.1
[**2156-10-1**] 03:18AM BLOOD Glucose-121* UreaN-14 Creat-0.5 Na-137
K-4.7 Cl-103 HCO3-27 AnGap-12
[**2156-9-29**] 05:10AM BLOOD ALT-45* AST-35 LD(LDH)-200 AlkPhos-81
TotBili-0.3
[**2156-9-29**] 05:10AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.7 Mg-1.9
Brief Hospital Course:
40F unknown past medical history with Insulin dependant DM2
transferred to [**Hospital1 18**] for severe acidosis and hypokalemia in
setting of DKA. Patient managed in the MICU for 6 days with
resolution of her acidosis noted. Patient was called out to the
floor on hospital day 6 after being stable on SubQ insulin.
Course complicated by new sensory-motor polyneuropathy of left
upper extremity and bilateral lower extremities. Transfered to
neurology service after EMG concerning for axonal neuropathy on
hospital day 11, ultimately determined to be a compressive
neuropathy vs. multiple root radiculopathy.
# Severe acidosis likely DKA
Patient has severe acidosis on ABG with both primary metabolic
non-gap and gap acidoses with superimposed respiratory acidosis.
Etiology of primary metabolic non-gap acidosis may be from NS
volume resuscitation, diarrhea, or other etiologies. The likely
cause of the anion gap acidosis is DKA with no other apparent
MUDPILES etiologies based on urine/serum toxicology. Osmolar gap
initially 51, so methanol, polyethylene glycol or other
exogenous substance may explain extra osmoles that would not be
accounted for by DKA alone. Patient started on Insulin drip and
Bicarb which were rate limited so as not to drop K+ faster than
it could be repleted. Over the course of hospital day 1 patient
was noted to have progressive improvement of her acidosis. In
setting of severe acidosis and osmolar gap, patient received a
single episode of hemodialysis. In the evening of hospital day
1 the patient's anion gap was noted to re-open to 24, patient
was given additional IV fluids and insulin drip was continued
with resolution of anion gap noted on repeat Chem7. Patient
tolerated a PO diet on hospital day 4 and was started on SubQ
insulin. Following initiation of SubQ insulin the insulin drip
was discontinued. The patient was observed in the MICU following
discontinuation of the insulin drip and her anion gap was noted
to remain closed. Once the patient was fully awake she endorsed
poor medication compliance with regards to her insulin. She
states that she was on vacation prior to onset of DKA and that
she did not utilize her insulin at all during a period of time
during her vacation making medication non-compliance the most
likely etiology of her DKA. After transfer to the general
medicine, her blood sugars remained in the 120-250 range and she
was kept on Lantus 50 units in the am and humalog sliding scale.
She was followed closely by the [**Last Name (un) **] service. Insulin dose
on discharge was Lantus 40qam and 16qhs along with sliding
scale. Instructed patient about importance of insulin
compliance and establishing care with a primary care doctor upon
return to [**State 4565**].
# Leukocytosis/hypothermia/MRSA bacteremia
Initial concern for hypothermic sepsis given marked
leukocytosis. Careful skin exam did not reveal any skin/soft
tissue infection. CXR showing ? atelectasis vs. developing LL
infiltrate after fluid resuscitation. CT Abdomen could suggest
colitis although indefinite. Host factors include DM2 - no
recent healthcare exposure- vancomycin/cefepime/flagyl given
empirically as patient critically ill pending culture results.
Patient's antibiotics discontinued on hospital day 3 as all
cultures acquired were negative. On hospital day 5, repeat CXR
concerning for new pneumonia and UA concerning for UTI. Repeat
cultures sent and patient re-started on vanc and cefepime.
Cultures sendt [**9-18**] noted to grow out gram positive cocci in
clusters, central line discontinued and patient continued on
vanc and cefepime. She remained on Vancomycin after confirmed
MRSA bacteremia to complete a 2 week course ending [**2156-10-2**]. A
PICC was placed [**2155-9-22**] via IR guidance after an initial failed
attempt. She also had a TTE which did not show evidence of
vegetation, thus low suspicion of endocarditis. She completed a
course of Vancomycin per recommendations of the infectious
disease team on [**2156-10-3**].
# ? Pancreatitis
The patient had elevated pancreatic enzymes, which may reflect
either pancreatitis or increased pancreatic enzyme activities in
the setting of DKA. Her abdominal exam appears to be bengin. A
CT Abd/pelvis showed bowel wall thickening mainly involving the
proximal small bowel (duodenum and jejunum) which could
represent peristalsis, enteritis (such as infectious,
inflammatory or ischemic) with mild blurring of pancreatic
margins with minimal mesenteric stranding. It also shows
multiple transient intussusception of jejenum, little bit of
fluid in mesenetery and pancreas consistent with ? focal
pancreatitis. Patient was evaluated by surgery for questionable
CT abdomen findings, no surgical intervention indicated per
surgery. TG mildly elevated, but unclear if high enough to have
precipitated pancreatitis. Ca within normal limits; no evidence
of CBG/gallstone pancreatitis on CT Abd. As patient's mental
status improved appeared to be in pain with apparent tenderness
to palpation of epigastrum, in setting of elevated lipase we
have increased suspiscion of pancreatitis as cause of pain and
possibly as etiology of DKA. Treated with IV Dilaudid PRN pain.
Patient subsequently noted to have improvement of pain and
tenderness likely representing resolution of acute pancreatitis
episode. There was no further abdominal pain/tenderness while
on the floor.
# Respiratory failure
Patient was intubated secondary to depressed mental status for
airway protection. Patient passed spontaneous breathing test on
hospital day two and was extubated. No further respiratory
distress.
# Shock
Patient likely had septic shock from underlying infection,
hypovolemic shock from osmotic diuresis in setting of DKA. Doubt
cardiogenic or distributive shock. Her opening CVP was 11 with
good urine output, normal lactate, and exam consistent with good
perfusion. ScVO2 is ~ 90 suggestive of likely tissue
mitochondrial dysfunction in setting of severe acidosis. She has
been responsive to IVF resuscitation. By hospital day 2 patient
was noted to have improvement in hemodynamics and was weaned off
of phenylephrine.
# Elevated LFTs
Patient had mild elevated LFTs at OSH and on admission at [**Hospital1 18**].
Uncertain etiology - abdominal CT not showed elevated Tbili or
other overt abnormalities. Could be from toxidrome vs. early
shock liver given hypotension or other causes. Patient's LFTs
were trended and returned to baseline.
# Thrombocytopenia
Admission platelets with thrombocytopenia. Etiology is likely
marrow suppresion from acute sepsis/illness. No evidence of
sequestration or destruction - firinogen and coagulation is
within normal limits speaking against DIC. Was noted to have
improvement of platelet count during ICU stay. Normal platelet
counts while on the floor. She was seen by heme/onc who
recommended a skeletal survey which was normal. Also
recommended HIV, which is pending at time of discharge.
Considered bone marrow biopsy, but deferred given abnormalities
likely in setting of acute illness. Asked patient to seen a
hematologist/oncologist in 3 months and have them re-check SPEP,
free kappa/lambda chains. Also, re-consider a bone marrow biopsy
if values have not normalized.
#Anemia: She developed normocytic anemia during this
hospitalization (Hgb 12.5 -> 8.4). This was likely secondary to
volume repletion. B12, folate, and Iron studies within normal
limits. No evidence of active bleeding. Would continue to
follow H/H, although it has remained stable.
# Severe acute axonal sensory-motor polyneuropathy
Patient was in ICU for 6 days. Intubated and sedated. Then
extubated and off sedation and noted tingling in her hands and
feet. She couldn't "wiggle her ankles". Her exam was most
notable for an Left Ulnar neuropathy and difficulty with TA [**2-29**]
bilateralas well as weakness of the toe flexors. Did not fit
distribution. Differential was initially critical illness
neuropathy, mononeurotis multiplex. EMG looked like a severe
acute axonal sensorimotor polyneuropathy intially. Confirmed
that the left wrist was an ulnar neuropathy. Had repeat EMG
which showed bilateral sciatic nerve neuropathies, probably
compression from position. Also possible that she has a
multiple root lumbosacral radiculopathy. Currently, strength and
sensation improving as per discharge exam. Does have painful
tingling in her lower extremities, likely nerve pain with
regeneration, which responds well to Gabapenin and tylenol with
codeine. Since patient has bilateral foot drop, had orthotics
made for her. She will follow up with neurology as an
outpatient once she returns to [**State 4565**].
TRANSITIONAL ISSUES:
- follow up with PCP regarding fatty liver on ultrasound, high
triglycerides, hepatitis serology
- 3 months from now (early [**Month (only) 1096**]) you should see a
hematologist/oncologist and ask them to check these labs: SPEP,
free kappa/lambda chains. Also, re-consider a bone marrow biopsy
if values have not normalized.
- HIV and final report of sural nerve biopsy pending at time of
discharge
- patient will follow up with a new PCP and neurologist upon
return to [**State 4565**].
Medications on Admission:
Lantus 40 units SC daily
Discharge Medications:
1. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*180 Capsule Refills:*2
2. Glargine 40 Units Breakfast
Glargine 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [Accu-Chek Active Test] QAHS Disp
#*1 Not Specified Refills:*2
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 40
Units before BKFT; 16 Units before BED; Disp #*2 Not Specified
Refills:*2
RX *blood-glucose meter [Accu-Chek Active Care] Before every
meal and at bedtime QAHS Disp #*1 Kit Refills:*1
RX *insulin lispro [Humalog KwikPen] 100 unit/mL Up to 25 Units
per sliding scale four times a day Disp #*2 Not Specified
Refills:*2
RX *lancets [Accu-Chek Multiclix Lancet] QAHS Disp #*1 Not
Specified Refills:*1
3. Miconazole Powder 2% 1 Appl TP TID:PRN groin rah
RX *miconazole nitrate [Anti-Fungal] 2 % apply to affected area
three times a day Disp #*1 Tube Refills:*0
RX *miconazole nitrate [Anti-Fungal] 2 % three times a day Disp
#*1 Tube Refills:*1
4. Acetaminophen w/Codeine [**1-26**] TAB PO Q4H:PRN pain
please hold for rr <12, sedation
RX *acetaminophen-codeine 300 mg-30 mg 1 tablet(s) by mouth
every four (4) hours Disp #*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
diabetic ketoacidosis
bilateral sciatic neuropathies vs. multiple root lumbosacral
radiculopathy
secondary diagnosis:
diabetes mellitus type I
Critical illness polyneuropathy
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 Ms. [**Known lastname 4566**],
It was a pleasure taking care of you. You were admitted to the
[**Hospital1 69**] for a severe case of
diabetic ketoacidosis. You were initially stabilized in the
intensive care unit (ICU). We found that you had a blood stream
infection and treated you with intravenous antibiotics.
You had a weakness of your ankles and left arm that we
investigated. We biopsied several of your nerves and did EMGs.
We determined that the cause of your weakness was due to
compression of the scitic and ulnar nerves as you are at risk
for this with your diabetes. During the hospital stay, your
strength and sensation gradually began to improve. We think
this will continue to improve over the next year. We started
you on Gabapentin (Neurontin) for the pain. When you return to
[**State 4565**] it is important that you schedule an appointment with
a neurologist.
Also it is CRITICAL that you follow up with your primary care
doctor for STRICT management of your diabetes as we do not want
you to become ill from the high sugars as you did this time. You
MUST check your blood sugars regularly and [**Last Name (un) **] your insulin.
You had some abnormal blood counts so we asked the
hematology/oncology team to evaluate you. They recommended an
x-ray of your body which was quite normal. Most likely, these
abnormalities were in the setting of acute illness. 3 months
from now (early [**Month (only) 1096**]) you should see a
hematologist/oncologist and ask them to check these labs: SPEP,
free kappa/lambda chains. Also, re-consider a bone marrow
biopsy if values have not normalized.
We have made the following changes to your medications:
START
Gabapentin 200mg three times per day for nerve pain
Tylenol with codeine up to every 4 hours as needed for pain
Miconazole powder as needed for rash
Insulin sliding scale
INCREASE
Lantus to 40 units in the morning and 16 units at bedtime
On discharge, please schedule appointments with a neurologist, a
primary care doctor as soon as possible. Also, schedule an
appointment with a hematologist/oncologist in early [**Month (only) 1096**].
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
On discharge, please schedule appointments with a neurologist
and primary care doctor as soon as possible.
Also, schedule an appointment with a hematologist/oncologist in
early [**Month (only) 1096**]. Please ask them to check the tests mentioned
above.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
Completed by:[**2156-10-4**]
|
[
"2875",
"2760",
"V5867",
"4019",
"V1582"
] |
Admission Date: [**2169-11-8**] Discharge Date:[**2169-12-3**]
Date of Birth: [**2169-11-8**] Sex: M
Service: NB
[**Known lastname **] [**Known lastname 41684**], boy number 2, was born at 33 and 6/7 weeks
gestation to a 36-year-old, gravida 1, para 0 now 3 woman.
The mother's prenatal screens were blood type A positive,
antibody negative, Rubella immune, RPR nonreactive, hepatitis
surface antigen negative and group B strep unknown. This
pregnancy was achieved with in [**Last Name (un) 5153**] fertilization with
subsequent trichorionic, triamniotic triplets. The pregnancy
course was otherwise unremarkable until the assessment of
intrauterine growth restriction of triplet number one. On
the day of delivery, assessment of that triplet yielded a
biophysical profile of [**3-5**], prompting the decision to
deliver. The infant emerged vigorous. Apgars were 8 at 1
minute and 9 at 5 minutes.
Birth weight was 2260 grams. Birth length 44 cm. Birth head
circumference 32 cm.
The admission physical examination reveals a pre-term infant
with mild respiratory distress. Anterior fontanelle soft and
flat. Palate intact. Nondysmorphic facies. Mild subcostal
retractions, intermittent grunting. Good air entry. Heart
was regular rate and rhythm, no murmurs. Femoral pulses
present. Abdomen soft and nontender. No hepatosplenomegaly.
Normal phallus. Testes descended bilaterally. Age
appropriate tone and reflexes.
HOSPITAL COURSE BY SYSTEMS: Respiratory status: [**Known lastname **]
required nasopharyngeal continuous positive airway pressure
for the first five days of life when he reached nasal cannula
oxygen and then weaned to room air and dialyzed to number six
where he has remained since that time. He had a few episodes
of apnea bradycardia, the last one occurring on day of life
number five. On examination, his respirations are
controlled. Lung sounds are clear and equal.
Cardiovascular status: He has remained normotensive
throughout his NICU stay. His heart has a regular rate and
rhythm and no murmur.
Fluid, electrolyte and nutrition status: Fluid electrolyte
and nutrition status: At the time of discharge, his weight
is 2725 grams. His length is 47.5 cm. Head circumference
32.5 cm.
Enteral feeds were begun on day of life number four and
advanced without difficulty to full volume feeding by day of
life number eight. At the time of discharge, he was eating
26 calorie/ounce breast milk or formula made with formula
powder and corn oil. He is breast feeding well, and mother
has an adequate milk supply.
Gastrointestinal status: He was treated with phototherapy
from day of life five until day of life number six. His peak
bilirubin occurred on day of life number five, and it was a
total of 10.4, direct 0.4.
Genitourinary status: He was circumcised on [**2169-11-30**], and the area is healed.
Hematology: [**Known lastname **] has received no blood product transfusions
during his NICU stay. His last hematocrit on [**2169-11-17**] was 42.
Infectious disease status: [**Known lastname **] was started on ampicillin
and gentamicin at the time of admission for sepsis risk
factors. The antibiotics were discontinued after 48 hours
when the blood cultures were negative, and the infant was
clinically well. On day of life number five, he presented
with a cellulitis in his left arm at the area of an
intravenous infiltrate. At that time, he was treated with
vancomycin and gentamicin for seven days. The blood cultures
did remain negative.
Audiology: Hearing screen was performed with automated
auditory brain stem responses, and the infant passed in both
ears.
Psychosocial appearance has been very involved in the
infant's care throughout his NICU stay. The infant was
discharged in good condition.
The infant was discharged home with his parents.
Primary pediatric care will be provided by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 8071**]
in [**Hospital1 3597**], [**State 350**]. Telephone number [**Telephone/Fax (1) 43314**].
RECOMMENDATIONS AFTER DISCHARGE: Feedings: Breast feeding
ad-lib and supplementing with 26 calorie/ounce formula or
breast milk made with 4 calories/ounce of Similac powder and
2 calories/ounce of corn oil.
MEDICATIONS: Tri-Vi-[**Male First Name (un) **] 1 mL p.o. daily.
The infant passed a car seat position screening test.
The last State Newborn Screen was sent on [**2169-11-21**].
He received his first hepatitis B vaccine on [**2169-11-28**].
RECOMMENDED IMMUNIZATIONS:
1. Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infant to meet any of the following
three criteria: (1) Born at less than 32 weeks, (2) born
between 32 and 35 weeks with two of the following:
daycare during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings, or (3) with chronic lung disease.
2. Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of a child's life,
immunization against influenza is recommended for
household contacts and out-of-home caregivers.
FOLLOW UP APPOINTMENTS: [**Hospital6 407**] of
Partner's Home Care. Telephone number [**Telephone/Fax (1) 38388**].
DISCHARGE DIAGNOSES:
1. Sepsis ruled out.
2. Status post respiratory distress syndrome.
3. Status post apnea of prematurity.
4. Status post circumcision.
5.
Status post cellulitis.
6. Status post hyperbilirubinemia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2169-12-3**] 00:48:12
T: [**2169-12-3**] 01:49:25
Job#: [**Job Number 57129**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2121-2-16**] Discharge Date: [**2121-2-20**]
Date of Birth: [**2052-5-29**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Percocet /
Demerol / Meperidine / Strawberry
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
headache, unsteadiness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 68 RHF w/ hx HLD and osteoporosis, presents to the ER now
with a L frontal IPH. Her first sx began 3 days ago when she
experienced a sudden, but not not particularly intense frontal
HA
(~[**4-7**]). It was non-throbbing. She cannot recall what she was
doing at the time, but it was "nothing intense." She took 2 baby
ASA (162 mg total) for the pain, and the HA resolved over 2
hours. The following day, she reports feeling her balance was
off, which was also noticed by her husband. She has difficulty
describing this further, but denies falling to one side or the
other (or any falls at all), and denies walking as though drunk.
She endorses some sense of dysequilibrium as if on a boat. This
symptom has been improving over the last 2 days to the point
where is it barely perceptible, but because this symptom has
persisted, her husband convinced her to get evaluated at the
[**Hospital1 **] ER. There, a NCHCT showed the L frontal IPH. Platelets
and
INR were normal. She had a UTI and was given one dose of
Levofloxacin, and was transferred to [**Hospital1 18**]. She denies any other
VC, focal weakness, sensory change, ataxia, or difficulty
producing or understanding language. She states her
daughter-in-law feels her speech is a bit slower than usual, but
without dysarthria.
Past Medical History:
osteoporosis
HLD
appy
C/S x 2
sx for deviated septum
B/L LE vein stripping
Social History:
Former nurse, retired. Lives with husband and spends days
taking care of 11-mo old grandson. Drinks ~2x/month. Denies
tobacco or drug use.
Family History:
Mother with stroke, CAD, DM. Father with fatal aortic
aneurysm. Brother w/ CAD. Sister with breast CA.
Physical Exam:
T- BP- HR- RR- O2Sat
98.7, 62, 129/62, 14, 99%RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple,
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no c/c/e; equal radial and pedal pulses B/L.
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and month/year, but states
date is 16th (acutally 21st). Attentive, says [**Doctor Last Name 1841**] backwards.
Speech is fluent with normal comprehension and repetition;
naming
intact, except for "hammock." No dysarthria. [**Location (un) **] intact.
Only abnormality in describing Cookie Picture is that she
describes a "blanket" hanging over the sink, rather than saying
water is overflowing. Registers [**1-29**], encodes [**1-1**] at 30 sec and
recalls [**12-1**] in 5 minutes, and [**1-1**] with both semantic cues and
mult choices. No right left confusion. No evidence of apraxia
or
neglect. Makes some mistakes in Luria testing in both UE. Jumps
early once on go/no-go testing, but largely otherwise complies.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation to moving
fingers. Extraocular movements intact bilaterally, no nystagmus.
Sensation intact V1-V3. Facial movement symmetric. Hearing
intact to finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, and proprioception
throughout.
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: Narrow based, steady. some unsteadiness on tandem gait.
Romberg: Negative
Pertinent Results:
OSH labs reviewed. CBC, Chem-7, Ca, EtOH, coags, Utox normal. UA
cloudy w/ 40-50 WBC's and 4+ bact.
Imaging
NCHCT [**2121-2-16**] (prelim)
Prior OSH CT not available for comparison. 4.7 x 3.3 cm acute
IPH
left
frontal lobe with surrounding edema. Minimal 3mm rightward
midline shift.
acute intraventricular hemorrhage in dependent portions of both
occipital
horns. ? h/o coagulopathy, coumadin use, trauma, underlying mass
can not be
excluded
[**2121-2-16**] 06:25PM PT-13.3 PTT-25.2 INR(PT)-1.1
[**2121-2-16**] 06:25PM PLT COUNT-189
[**2121-2-16**] 06:25PM NEUTS-70.4* LYMPHS-23.4 MONOS-5.6 EOS-0.4
BASOS-0.2
[**2121-2-16**] 06:25PM WBC-9.9 RBC-4.20 HGB-12.4 HCT-36.1 MCV-86
MCH-29.4 MCHC-34.2 RDW-13.0
[**2121-2-16**] 06:25PM CK-MB-2
[**2121-2-16**] 06:25PM cTropnT-<0.01
[**2121-2-16**] 06:25PM GLUCOSE-121* UREA N-13 CREAT-0.6 SODIUM-134
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-23 ANION GAP-14
CTA head/neck [**2121-2-16**]
1. Intraparenchymal hemorrhage in the left frontal lobe, without
evidence of an underlying vascular malformation or aneurysm.
There has mild increase in the size of the intraparenchymal
hematoma, with stable appearance of the intraventricular
extension. There is also local mass effect and stable mild
rightward midline shift.
2. Unremarkable CTA of the head and neck, without evidence of an
underlying vascular malformation or aneurysm. There is no
evidence of hemodynamically significant stenosis or dissection.
3. Periapical lucency involving the left maxillary first molar,
for which
correlation with dental examination is recommended.
4. Mucosal sinus disease, predominantly involving the frontal
and ethmoid air cells.
MRI +/- [**2-17**];
IMPRESSION:
1. Left intraparenchymal hematoma, with intraventricular
extension, with mild increase in the degree of rightward midline
shift.
2. There is no evidence of an underlying mass lesion or abnormal
enhancement. No other focus of abnormal enhancement is
identified to suggest metastatic disease.
3. Scattered foci of susceptibility artifact are noted. Given
the
distribution and pattern, these may represent microhemorrhage
related to
hypertension or prior trauam. Amyloid angiopathy is less likely.
4. Multiple confluent areas of white matter signal abnormality
are a
nonspecific finding, but likely represent the sequela of chronic
microangiopathy given the patient's age.
Brief Hospital Course:
Ms. [**Known lastname 1274**] is a 68 year old woman with history of dyslipidemia
and osteoarthritis who presented with a left frontal
intraparenchymal hemorrhage with intraventricular extension.
The etiology of the bleed includes amyloid angiopathy vs.
underlying AVM or mass. She was admitted to the neurological
ICU for monitoring.
.
Hospital course by problem;
.
1. Neurology; The patient was admitted to the neurology ICU
overnight for q1h neurochecks. Her HOB was maintained > 30
degrees, SBP was maintained 120-160 with MAP < 110. She was
started on keppra 500 mg [**Hospital1 **] for seizure prophylaxis which
should be continued through [**2-23**]. On HD#2 the patient was
clinically doing well and transferred to the floor. Given the
possibility of AVM (although not seen on CTA) she underwent an
angiogram on [**2-19**] which showed no sign of AVM, however she was
incidentally noted to have a small (2mm) PComm aneurysm for
which she should undergo a repeat MRA in 1 year. For her
frontal hemorrhage she will have a repeat MRI prior to her
Neurology follow-up appointment in 6 weeks.
.
2. ID; The patient was found to have a urinary tract infection
prior to transfer and was started on levofloxacin. Urinalysis
and urine culture here are currently pending. She completed a
three day course
.
3. CV; the patient was monitored on telemetry. Her blood
pressure remained well-controlled and she was continued on her
home statin.
.
Medications on Admission:
Liver oil pills, 1200 mg Qday
Lipitor 10 mg Qday
Fosamax 70 mg Qweek
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Intraparenchymal hemorrhage
Secondary: Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted following a headache and gait instability.
You were found to have a small hemorrhage in your brain. You
underwent an angiogram which showed no sign of vascular
malformation
Medication changes:
Continue Keppra through [**2-23**]
If you notice any of the concerning symptoms listed below,
please call your doctor or return to the nearest emergency
department for further evaluation.
Followup Instructions:
Neurology: Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2121-3-24**] 2:00
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] on [**2-27**] at 10:30. Phone [**Telephone/Fax (1) 4475**]
|
[
"5990",
"2724"
] |
Admission Date: [**2189-12-29**] Discharge Date: [**2190-1-8**]
Date of Birth: [**2142-11-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Benadryl
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
abdominal wound drainage
Major Surgical or Invasive Procedure:
[**2189-12-29**] EGD, revision of gastrostomy tube
History of Present Illness:
47F with h/o obesity hypoventilation syndrome, sleep apnea on
CPAP, COPD, recently discharged to rehab on [**2189-12-24**]. She had
been admitted for COPD exacerbation and MRSA PNA, failed to wean
from ventilation, and, on [**2189-12-15**], underwent tracheostomy and
open gastrostomy tube placement with Dr. [**Last Name (STitle) **]. On
[**2189-12-21**], she returned to the OR for fascial dehiscence. Prior to
discharge, she was tolerating goal tube feeds without difficulty
and her incision was intact. She was transferred back to [**Hospital1 18**]
on [**2189-12-29**] with gastric contents draining from her abdominal
incision.
Past Medical History:
PMH: h/o childhood asthma, morbid obesity, obesity
hypoventilation syndrome, sleep apnea, COPD, hyperlipidemia,
DMII, HTN
PSH: tracheostomy, gastrostomy tube ([**2189-12-15**]); abdominal wash
out, closure of fascial dehiscence ([**2189-12-21**])
Social History:
1 PPD smoker. Lives w/husband.
Family History:
non-contributory
Physical Exam:
On admission:
99.5 92 131/93 27 98%TM
Gen: NAD
HEENT: NC, EOMI, MMM
Neck: midline trachea with tracheostomy in place
CVS: RRR, nl S1S2, no m/r/g
Pulm: coarse breath sounds diffusely, diminished breath sounds
at b/l bases
Abd: obese, soft, diffuse tenderness, no peritoneal signs,
midline surgical incision, open superiorly with brown gastric
drainage
Ext: no c/c/e
On discharge:
98.9 88 126/71 20 93%TM
Gen: NAD
HEENT: NC, EOMI, MMM
Neck: midline trachea with tracheostomy in place
CVS: RRR, nl S1S2, no m/r/g
Pulm: CTA b/l
Abd: obese, soft, NT, ND, +BS, midline incision with VAC
dressing (last changed [**1-8**]), no leak, G tube without erythema
Ext: no c/c/e
Pertinent Results:
On admission:
[**2189-12-30**] 12:52AM BLOOD WBC-15.8* RBC-3.80* Hgb-12.2 Hct-37.0
MCV-97 MCH-32.1* MCHC-32.9 RDW-12.5 Plt Ct-560*
[**2189-12-30**] 12:52AM BLOOD PT-12.8 PTT-24.9 INR(PT)-1.1
[**2189-12-30**] 12:52AM BLOOD Glucose-157* UreaN-16 Creat-0.7 Na-142
K-4.2 Cl-99 HCO3-37* AnGap-10
[**2189-12-30**] 12:52AM BLOOD Calcium-9.8 Phos-5.1* Mg-2.3
[**2189-12-30**] 01:03AM BLOOD Type-ART pO2-85 pCO2-63* pH-7.39
calTCO2-40* Base XS-9
On discharge:
[**2190-1-7**] 04:10PM BLOOD WBC-9.6 RBC-3.42* Hgb-11.0* Hct-32.9*
MCV-96 MCH-32.3* MCHC-33.5 RDW-13.2 Plt Ct-258
[**2190-1-7**] 04:10PM BLOOD Glucose-131* UreaN-9 Creat-0.5 Na-141
K-4.4 Cl-100 HCO3-34* AnGap-11
[**2190-1-7**] 04:10PM BLOOD Calcium-9.4 Phos-3.9 Mg-2.0
Brief Hospital Course:
Patient was admitted with gastric contents draining from
abdominal wound. She was started on vancomycin and Zosyn and was
taken to the OR. On EGD, the G tube was found to be leaking and
was replaced. Please see operative note for further details.
Postoperatively, she was transferred to the TSICU. On POD 1, she
was transferred to the floor. On POD 2, tube feeds were started.
Nutrition was consulted for recommendations on tube feeds. On
POD 3, the wound was opened and a VAC dressing was placed. On
POD 4, her regular insulin sliding scale and Glargine were
restarted with improved glucose control. On POD5, her vanco and
Zosyn were d/c'd. She was started on Augmentin. On POD 6, her
VAC was changed and her wound was debrided. On POD 8, she was
evaluated by Speech & Swallow and cleared for regular diet. Her
trach was deemed too large for a Passy Muir valve. Plans were
made to downsize it; however, later in the day, she had an
episode of mucous plugging, for which a Code Blue was called,
and which resolved following suctioning. On POD 7, as she had
tolerated regular diet, her tube feeds were discontinued. On POD
8, the VAC dressing was changed and the wound debrided. It was
clean with serosanguinous drainage. She was stable for discharge
to rehab. She will complete a 7 day course of Augmentin on
[**2190-1-9**].
Medications on Admission:
Humalin SS, Combivent q6h, Crestor 10', Diovan 160', Colace,
fentanyl patch 25 mcg q72h, MVI, SQH, Lantus 60", miconazole
powder, Beclovent 2puffs", Senna, Tylenol, diazepam 2 prn,
Atrovent q6h prn, MOM prn, morphine 4 q3h prn
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Date Range **]: One (1)
Injection TID (3 times a day).
2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Date Range **]: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
3. Fentanyl 75 mcg/hr Patch 72 hr [**Date Range **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Miconazole Nitrate 2 % Powder [**Date Range **]: One (1) Appl Topical PRN
(as needed).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Lactulose 10 gram/15 mL Syrup [**Date Range **]: Fifteen (15) ML PO BID (2
times a day) as needed for constipation.
7. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: Five (5) ML PO BID (2
times a day).
8. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Date Range **]: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: crushed
.
9. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution [**Date Range **]: Ten (10) ML PO TID (3 times a day) for 2
days: through [**2190-1-9**].
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day:
.
11. Hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for breakthough pain: crushed
.
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
13. Insulin
Insulin SC Fixed Dose Orders
Glargine 60 Units qHS
Regular Insulin SC Sliding Scale QACHS
Glucose Regular Insulin Dose
0-60 mg/dL [**11-18**] amp D50
61-110 mg/dL 0 Units
111-160 mg/dL 30 Units
161-200 mg/dL 33 Units
201-240 mg/dL 36 Units
241-280 mg/dL 39 Units
281-310 mg/dL 42 Units
311-350 mg/dL 45 Units
351-400 mg/dL 48 Units
> 400 mg/dL Notify M.D.
14. Morphine Sulfate 2-4 mg IV DAILY PRN DRESSING CHANGE
15. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Month/Day (2) **]:
2.5mg/3 ML Inhalation Q2H (every 2 hours) as needed.
16. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: 0.02% Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
17. Lorazepam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times
a day) as needed: crushed.
18. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day (2) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
s/p trach, open G tube ([**12-15**]); c/b dehiscence s/p abdominal
washout and fascial closure ([**12-21**]); s/p EGD, revision of
gastrostomy tube ([**12-29**]); morbid obesity; hypoventilation
syndrome; OSA (home CPAP); COPD; DM2; HTN; hyperlipidemia
Discharge Condition:
Afebrile, vital signs stable, tolerating regular diet (cleared
for PO by speech & swallow), deconditioned and requires
intensive physical therapy.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101.5 or chills
-Trach complications, difficulty with ventilation
-Abdominal wound complications (e.g. increased or purulent
drainage, erythema)
-G-tube complications
Wound VAC dressing change Q3D
Right PICC line flush per protocol
Followup Instructions:
On the day of appointment with Dr. [**Last Name (STitle) **], take off VAC
dressing and apply wet to dry gauze. Reapply VAC upon return
from clinic.
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2190-1-12**] 10:30
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2190-1-21**] 10:30
Completed by:[**2190-1-8**]
|
[
"2724",
"25000",
"4019"
] |
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