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Admission Date: [**2131-6-28**] Discharge Date: [**2131-7-5**]
Date of Birth: [**2060-12-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Mr. [**Known lastname 2302**] is a 70 y.o. male with hx of Crohn's disease, afib,
dilated CMP and PE (on coumadin), who presents with
hematochezia/BRBPR in setting of INR 7.7.
Major Surgical or Invasive Procedure:
Colonoscopy w/ multiple Bx
History of Present Illness:
Patient had felt well during the last 2 weeks prior to
admission, although he had noticed slightly red/pink tinge to
his stool occasionally. Three days prior to admission, pt had
an INR of 2.7 at coumadin clinic. One day prior to presenation,
the patient self-started asacol from previous prescription
because worsening of rectal chrone's disease. On day of
presentation, pt began having dark red bloody BMs, had ~15
episodes before calling EMS. Upon ED arrival, had several
additional large bloody BMs. He received vitamin K SQ, 2 FFP,
and 2 PRBC for stabilization of bleeding. BP was stable
throughout.
Past Medical History:
1. Crohn's dz, found in [**2125**] on colonoscopy for anal fissure,
positive [**Doctor First Name **], been treated with Remicade
2. Rheumatoid arthritis
3. HTN
4. hx of renal calculus
5. s/p appendectomy
6. s/p TURP
7. s/p cholecystectomy
8. Recent pulmonary embolism- on coumadin since [**2-12**]
9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF
25%
10. Chronic left knee pain s/p meniscectomy, synovectomy, and
debridement of left knee [**2123**]
11. Recent gallstone pancreatitis [**2-12**]
12. Afib - [**2-12**] rate controlled on atenolol
Social History:
Married for 46 years and lives with wife. 3 children who all
live in area. No tobocco, h/o occasional ETOH, stopped drinking
in [**11-13**], denies h/o ETOH abuse. No illicit drugs.
Family History:
Father died at 62 from MI
Mother died at 52 of cirrhosis
No cancer or diabetes to patient's knowledge
No hisotry of clotting disorders
Physical Exam:
Exam afebrile, BP 100s/60s, 98%RA, HR 70s
NAD, alert and talkative
lungs clear
irreg, distant S1S2
abdomen soft
rectum with significant erythema/maceration, dark red blood in
vault,
Pertinent Results:
[**2131-6-28**] 10:00PM BLOOD WBC-8.0 RBC-3.50* Hgb-9.0* Hct-27.2*
MCV-78* MCH-25.7*# MCHC-33.1 RDW-16.1* Plt Ct-384
[**2131-6-28**] 10:00PM BLOOD Neuts-80.0* Lymphs-14.5* Monos-4.7
Eos-0.6 Baso-0.1
[**2131-6-28**] 10:00PM BLOOD PT-62.1* PTT-39.2* INR(PT)-7.7*
[**2131-6-28**] 10:00PM BLOOD Glucose-96 UreaN-20 Creat-1.6* Na-137
K-3.8 Cl-107 HCO3-23 AnGap-11
[**2131-6-28**] 10:00PM BLOOD CK(CPK)-58
[**2131-6-28**] 10:00PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2131-6-29**] 04:15AM BLOOD Calcium-7.7* Phos-3.5 Mg-1.6
EKG:
Baseline artifact. Regular rhythm with left anterior fascicular
block and right
bundle-branch block configuration, probably sinus rhythm. Since
the previous
tracing of [**2130-2-3**] the QRS width is wider and R wave reversal in
the lateral
precordial leads is more marked, related to axis or lateral
myocardial
infarction. Clinical correlation is suggested.
Brief Hospital Course:
## Hematochezia/Crohn's: Likely [**1-12**] combination of known Crohn's
and overanticoagulation most likely due to drug interaction of
coumadin w/ sasacol. Received 2Units FFP and 1 unit PRBC + vit
K. With drop of Hct as low as 23.6, 27.0 upon d/c. INR upon d/c
1.0. Underwent colonoscopy showing ulcer in proximal ascending
colon which wx bx to exclude ulcerated neoplasia, chrohn's dz
which was bx, and pseudopolyps in the descending colon and
sigmoid colon.
.
## ARF: likely hypovolemia in setting of GIB, Cr of 1.6 from
baseline of 1.0. Currently back to baseline.
.
## Paroxysmal atrial fibrillation: in sinus rhythm on [**Month/Day (2) 2304**].
- hold anticoag for now as risks outweigh benefits. Will be
restarted w/ f/u w/ PCP. [**Name10 (NameIs) **] control meds because of bleeding,
pt not in AF on [**Last Name (LF) 2304**], [**First Name3 (LF) **] restart BB w/ d/c to rehab facility.
## HTN: Meds held in setting of bleed, restarting OP meds w/ d/c
to rehab. Holding lasix [**1-12**] to continued dehydration [**1-12**] to
poor PO intake.
.
## DCM: appears euvolemic
- hold furosemide in setting of GI bleed
.
## h/o PE, LV thrombus:
- hold anticoag in setting of GI bleed, will restart as
outpatient.
Medications on Admission:
ASPIRIN 81 daily
ATENOLOL 50 daily
ATIVAN 0.5 [**Hospital1 **] prn anxiety
WARFARIN with goal INR [**1-13**]
CYANOCOBALAMIN 1,000 mcg daily
FUROSEMIDE 40 mg daily
LISINOPRIL 10 mg daily
Lidocaine-Hydrocortisone Ac 3-0.5 %--Thin film rectally daily
MVI
PLAQUENIL 200 mg [**Hospital1 **]
Tylenol #3 prn pain
ASACOL 1200 mg tid
PANTOPRAZOLE 40 mg daily
Discharge Medications:
1. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed for pain.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q4-6H
(every 4 to 6 hours).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Lower GI Bleed
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after an admission
for a lower gastrointestinal bleed. Because of significant
blood loss, you were stabilized throughout the admission with
transfusion of blood products and clotting proteins. You
underwent colonoscopy to evaluate for source of the bleeding.
It not only showed multiple areas of sick colon consistent with
your Chron's disease, but also a non-bleeding ulcer in the
bowel. Multiple biopsy's were taken, results pending. The most
likely cause of your bleeding is your very low ability to clot
due to a reaction between your blood thinner coumadin and the
asacol which you started. Both medications are being stopped,
and only restarted after discussion between your PCP and your
Gastroenterologist.
After being evaluated by Physical Therapy, it is felt that
you would benefit from a short stay in an acute rehab facility
to help improve your strength after this hospitalization.
Followup Instructions:
Follow up w/ Dr. [**First Name (STitle) 216**] in [**12-12**] weeks ([**Telephone/Fax (1) 1300**]
Follow up w/ Dr. [**Last Name (STitle) 2305**] in [**12-12**] weeks ([**Telephone/Fax (1) 2306**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
|
[
"42731",
"5849",
"4019"
] |
Admission Date: [**2193-2-19**] Discharge Date: [**2193-2-26**]
Date of Birth: [**2118-1-11**] Sex: M
Service: BLUMEGART INTERNAL MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old man
with a history of hypertension, type 2 diabetes mellitus, and
invasive adenocarcinoma of the gallbladder who is status post
recent admission for hemobilia and stent placement who
presented to the Emergency Department after one episode of
hematemesis. The patient noted on the evening prior to
admission he ate dinner and then later developed nausea with
emesis times one consisting of partially digested food. He
took Compazine. One hour later the patient was talking on
the phone and had another episode of nausea followed by
vomiting of brownish material with blood clots. He then came
to the Emergency Department where he was found to have a
hematocrit of 32 and INR of 1.3. Intravenous access was
difficult, and therefore, a right femoral central venous
catheter was placed, and the patient was line resuscitated.
Nasogastric tube was placed, and lavage was performed which
did not clear after 2 L of saline.
The GI Service was [**Name (NI) 653**], and the patient was
subsequently admitted to Blumegart for upper GI bleed in the
setting of invasive adenocarcinoma of the gallbladder. The
patient received approximately 2 L normal saline in the
Emergency Department, as well as intravenous Zantac.
PAST MEDICAL HISTORY: 1. Locally invasive gallbladder
adenocarcinoma diagnosed in [**2192-12-4**], on salvage
chemotherapy with 5FU and Leucovorin. 2. Hypertension. 3.
Type 2 diabetes mellitus. 4. Atrial and ventricular ectopy
on Amiodarone.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: ASA 81 mg p.o. q.d., Glyburide 5
mg p.o. q.d., Amiodarone 400 mg p.o. q.d., Lopressor 50 mg
p.o. b.i.d., Lasix 40 mg p.o. q.d., Compazine p.r.n.,
Imodium.
SOCIAL HISTORY: The patient lives with his wife and four
children. He denied alcohol, smoking, or intravenous drug
abuse. He is a retired librarian. The patient was born in
Barbados.
PHYSICAL EXAMINATION: Vital signs: The patient was
afebrile, with a heart rate of 68, blood pressure 130/76,
respirations 18, oxygen saturation 100% on room air.
General: The patient was an elderly man in no acute
distress. HEENT: Pupils equal, round and reactive to light.
Extraocular movements intact. The patient had a left-sided
ptosis. Oral mucosa moist and pale. Neck: Supple. No
jugular venous distention. No bruits. Chest: Clear to
auscultation bilaterally. Cardiovascular: Regular rhythm
with ectopy. Normal S1 and split S2. There was a 2 out of 6
systolic ejection murmur heard best at the left lower sternal
border. Abdomen: The belly was soft, mildly distended,
nontender, with normal bowel sounds. The liver span was 8
cm. There was no splenomegaly. The patient was guaiac
positive. Extremities: The patient had peripheral pulses
that were 2+ with mild pedal edema. The patient had a right
femoral line in place in his groin. Neurological: The
patient was grossly intact.
LABORATORY DATA: Initial studies indicated a white blood
cell count of 11.6, hematocrit 32.1, platelet count 270, with
a differential significant for 90% polys, 8% lymphocytes;
CHEM7 was remarkable only for a glucose of 286; INR 1.3; ALT
126, AST 162, alkaline phosphatase 331, total bilirubin 1.9.
Chest x-ray indicated no pneumonia or effusions.
Electrocardiogram indicated normal sinus rhythm at 64 with
right bundle branch block, a prolonged QTC at 493 msec.
HOSPITAL COURSE: The patient was admitted to Blumegart
Internal Medicine Firm for work-up of upper GI bleed. His
Aspirin was discontinued, and he was placed on intravenous
Protonix. On hospital day #2, the patient's hematocrit was
stable, and his liver function tests were trending down. He
received an upper endoscopy which indicated a normal
esophagus, clotted blood in the stomach, and erythema and
congestion of the duodenal mucosa with contact bleeding.
There was no active bleeding noted on exam. The patient was
therefore switched to p.o. Protonix.
The patient was transfused 2 U of packed red blood cells with
a pretransfusion hematocrit of 29.6 and a posttransfusion
hematocrit of 30.0; although this was thought to be an
inappropriate response to a transfusion, his hematocrit
remained stable, and no further transfusions were attempted
at that time.
On hospital day #3, the patient started to complain of
moderately severe epigastric tenderness with associated
nausea. He was then witnessed to have one episode of
hematemesis with approximately 50 cc of dark blood. He was
then noted to have melena with a substantial amount of maroon
colored stool. A repeat upper endoscopy was performed which
indicated red blood in the area of the papilla consistent
with hemobilia. The patient was also noted to develop atrial
fibrillation with a rapid ventricular response and rate in
the 150s. He was restarted on Lopressor with improved rate
control but remained in atrial fibrillation during the
remainder of his hospital stay.
The patient was then taken to the Interventional Radiology
Suite for emergent angiography of the celiac access which
revealed a right hepatic artery pseudoaneurysm. Multiple
coils were deployed proximally to the pseudoaneurysm, as well
as infusion of Gelfoam pledgets. The patient also received
coil and Gelfoam embolization distally to his right hepatic
artery pseudoaneurysm. The patient was then transferred to
the Medical Intensive Care Unit for monitoring overnight. He
remained hemodynamically stable, and his hematocrit remained
stable.
Blood cultures returned positive for gram-negative rods in 2
out of 2 bottles. This organism was later identified as
Klebsiella pneumonia which was pansensitive. The patient was
started on a two-week course of Ciprofloxacin and
Metronidazole.
On hospital day #4, the patient was returned to the floor in
stable condition; however, his hematocrit was noted to trend
down from 30 to 25 over the course of hospital day #5, and
the patient again received a transfusion of 2 U packed red
blood cells. The patient's posttransfusion hematocrit
remained stable at 30 for the remainder of his hospital stay.
On hospital day #7, the patient was evaluated by Physical
Therapy and was thought to benefit from an acute stay at an
inpatient rehabilitation hospital. At the time of this
dictation, it was planned that the patient will be discharged
to an acute rehabilitation setting for several days prior to
anticipated discharge to home. While the patient was
in-house, the Oncology Service was aware of his status, and
the patient is to follow-up with his oncologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] following discharge.
The patient remained afebrile with a normal white count and
resolving liver function tests during his hospital stay.
Following several conversations with the patient and his
family, it was clear that although the patient was aware of
his grim diagnosis, that he wished to remain FULL CODE for
the time being.
At the time of discharge, the patient remained in atrial
fibrillation with a ventricular rate of approximately 100.
Although he was maintained on Lopressor, it was felt that the
patient's rate control should not be increased given his risk
of continued bleeding.
DISCHARGE DIAGNOSIS:
1. Adenocarcinoma of the gallbladder with local invasion of
the liver.
2. Hemobilia with right hepatic artery pseudoaneurysm,
status post embolization.
3. Atrial fibrillation with rapid ventricular response.
4. Hypertension.
5. Type 2 diabetes mellitus.
DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg p.o. b.i.d. x 7
days, Flagyl 500 mg p.o. t.i.d. x 7 days, Lopressor 50 mg
p.o. b.i.d., Glyburide 5 mg p.o. q.d., Amiodarone 400 mg p.o.
q.d., Protonix 40 mg p.o. b.i.d.
DISPOSITION: It was planned that the patient will be
discharged to an acute rehabilitation facility.
FOLLOW-UP: He is to follow-up with Dr. [**Last Name (STitle) 1683**] within two
weeks and with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Oncology within one week.
CONDITION ON DISCHARGE: Improved.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2193-2-26**] 11:26
T: [**2193-2-26**] 11:41
JOB#: [**Job Number **]
|
[
"42731",
"25000",
"4019"
] |
Admission Date: [**2144-6-27**] Discharge Date: [**2144-6-29**]
Date of Birth: [**2062-7-8**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mr [**Known firstname **] [**Known lastname 112520**] is an unfortunate 81 year old man who presents
as a transfer from an outside hospital for unresponsiveness.
This is a very limited history that was obtained through his
health care proxy, his nephew [**Name (NI) 112521**] [**Name (NI) **] [**Telephone/Fax (1) 112522**]. He states
that this morning Mr. [**Known lastname 112520**] was awake at 8 am, took a shower and
at breakfast around 9 am, at that time he went back to take a
nap. His wife called him at 11:30 am, that he would not wake up
for her, he told her to let him sleep. She called at 2pm and 4
pm again that he wouldn't wake up. They thought he had
overheated and placed the air conditioning. At 7 pm he was not
responsive and they notified EMS who took him to an outside
hospital where he was transferred to [**Hospital1 18**] for further
evaluation.
.
ROS: unable to be performed.
Past Medical History:
diabetes, HTN
Social History:
former smoker and drinker, but none presently
Family History:
noncontributary
Physical Exam:
Vitals: T:97.6 P:86 R: 16 BP:104/61 SaO2:100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple,
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: does not open eyes.
-Cranial Nerves:pupils 2 mm and nonreactive, no dolls, no
corneals, + gag,
.
-Motor/sensory: decreased tone throughout, flicker withdrawal on
the right upper extremity at the bicep, otherwise no withdrawal
or posturing to noxious.
-ugpoing toes bilaterally
PHYSICAL EXAM AT TIME OF DEATH (11:59am)
GEN: lying in bed not moving
HEENT: mouth open, pupils fixed and non-reactive
CV: no heart beat ausculated or palpated
PULM: no breaths auscultated or palpated
EXT: cold and not moving
Pertinent Results:
ADMISSION LABS:
[**2144-6-26**] 10:30PM BLOOD WBC-7.0 RBC-4.19* Hgb-10.8* Hct-32.3*
MCV-77* MCH-25.8* MCHC-33.4 RDW-13.8 Plt Ct-269
[**2144-6-26**] 10:30PM BLOOD PT-12.7* PTT-31.9 INR(PT)-1.2*
[**2144-6-26**] 10:30PM BLOOD Fibrino-870*
[**2144-6-26**] 10:30PM BLOOD UreaN-35* Creat-2.3*
[**2144-6-27**] 01:07AM BLOOD ALT-23 AST-50* LD(LDH)-584* CK(CPK)-241
AlkPhos-61 TotBili-0.3
[**2144-6-26**] 10:30PM BLOOD Lipase-10
[**2144-6-27**] 01:07AM BLOOD CK-MB-2 cTropnT-0.03*
[**2144-6-27**] 01:07AM BLOOD Albumin-2.6* Calcium-7.9* Phos-3.5 Mg-2.2
LABS AT THE TIME OF EXPIRATION:
No labs were done on the day of pt's death as he was already
CMO.
REPORTS:
CXR [**2144-6-26**]:
IMPRESSION:
1. Nasogastric and endotracheal tubes in standard positions.
2. Opacity in the left lung base which could reflect infection,
atelectasis, or aspiration. Small left pleural effusion.
3. Right basilar atelectasis.
CT/CTA [**2144-6-26**]: CT head: edema and loss of grey-white matter
differentiation in BL ACA and right MCA distribution, suggestive
of infarction.
CTA: reconds pending. BL ICA are occluded, originating from the
cervical
segment just distal to bifrication. Vertibral arteries are
diminutive. Right MCA is occluded. Left MCA is patent, likely
filled from posterior
circulation. There is apparent wall thickening of the aortic
arch and great vessels, suggestive of arteritis.
Brief Hospital Course:
Mr [**Known firstname **] [**Known lastname 112520**] is an unfortunate 81 year old man who presented as
a transfer from an outside hospital for unresponsiveness. His
exam demonstrated nonresponsive to even noxious, nonreactive
pupils at 2 mm, + gag and a flicker of withdrawal to noxious in
the right bicep. His CT demonstrated vessel wall thickening of
all major vessels with bilateral clotted off ICAs and right
vert, but his left MCA appeared to be
getting collateral filling. There are hypodensities and loss of
[**Doctor Last Name 352**] white differentiation in the right ACA, MCA, PCA territory
and the left ACA territory. Given his poor prognosis, he was
made CMO by his family on [**6-27**] and terminally extubated. He
passed away on [**6-29**] at 11:59am. His HCP [**Name (NI) 112521**] [**Name (NI) **] ([**Telephone/Fax (1) 112522**])
was contact[**Name (NI) **] via voicemail and then his daughter [**Name (NI) **] was
reached and verbally notified via telephone.
Medications on Admission:
-lasix 20 mg daily
-crestor 20 mg daily
-metformin 850 mg [**Hospital1 **]
-tricor 145 mg daily
-metoprolol er 100 mg daily
-vitamin d2
-daily vites
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"25000",
"4019",
"2720"
] |
Admission Date: [**2200-10-12**] Discharge Date:
Date of Birth: [**2129-4-25**] Sex: M
Service: TRAUMA
DATE OF DISCHARGE: Pending.
HISTORY OF THE PRESENT ILLNESS: [**Known firstname 487**] [**Known lastname 36421**] is a
71-year-old man with the past medical history significant for
only hypercholesterolemia and no allergies. He was admitted
to the Trauma Service of [**Hospital1 69**]
after being struck with a car at about 40 miles per hour. He
had positive loss of consciousness at the scene, but his
[**Location (un) 2611**] Coma Scale was 15 upon arrival to trauma bay. Her
was perseverating and he was complaining of pain in the right
lower quadrant, right hip, and left chest. He was found to
have open laceration in the left parietal region. The blood
pressure, at the scene and upon arrival, was in the 90s.
Heart rate was 60.
He underwent trauma series in ER; CT of the head and T-spine,
CT of the chest and abdomen. His injuries included left
temporal-frontal laceration of the scalp, fracture of his
left radial diaphysis, multiple left rib fractures with
pulmonary contusion. He had splenic laceration. He had a
left inferior pubic ramus fracture. He received two units of
packed red blood cells in the ER and two liters of IV fluid
and two liters of crystalloids with little response of his
blood pressure. Therefore, he was taken to the operating
room for exploratory laparotomy and splenectomy. He was
transfused additional two units of packed red blood cells in
the operating room plus cell [**Doctor Last Name 10105**] and two units of FFP. He
was then transferred to the Surgical Intensive Care Unit.
HOSPITAL COURSE: (by system)
NEUROLOGICAL: The patient was on Morphine IV drip, which was
eventually weaned and he was changed to p.r.n. Morphine,
Clonidine. He was briefly on Haldol p.r.n. for agitation.
Because the cervical spine could not be cleared clinically,
he remained in cervical collar and he should remain in the
collar for a total of six weeks.
RESPIRATORY: The patient had a respiratory failure secondary
to the lung contusion. He also developed bilateral
pneumonia. Cultures from the sputum grew MRSA and
Enterobacter. He required placement of a left chest tube on
[**2200-10-16**]. At that time 950 ml of blood was evacuated via
the chest tube. Because of a slow wean, he required
percutaneous tracheostomy on [**2200-10-28**]. Since that time he
has been weaning slowly.
CARDIOVASCULAR: The patient had an episode of atrial
fibrillation with ventricular response in 130s on [**2200-10-17**].
Amiodarone drip was started, which was later changed to
Lopressor. He converted to normal sinus rhythm after
approximately six hours. He was ruled out for MI and
Cardiology consultation was obtained. He has remained stable
for the rest of his hospitalization course.
GASTROINTESTINAL: The patient was started on TPN early
postoperatively and later, on tube feeds. The tube feeds
were gradually advanced. He is currently receiving Impact
with fiber at 90 cc an hour. At the beginning of [**Month (only) **],
he had several liquid stools and he was repeatedly cultured
for C. difficile, but all of the cultures came back negative.
He is receiving tube feeds via a post pyloric feeding tube.
He will have a speech and swallow consultation before his
discharge.
GENITOURINARY: He has been diuresing well. His creatinine
has been stable throughout the hospitalization.
Because of TPN and multiple antibiotics, he was in positive
fluid balance, and he is being actively diuresed by Lasix.
INFECTIOUS DISEASE: The patient started spiking fevers
several days after admission and the white count was going up
to 30. He was pancultured several times, but the only
positive culture was MRSA and entercoccus from his sputum.
He underwent multiple CAT scans of his chest and abdomen,
which were all negative. He also underwent CT of his
sinuses, which showed some fluid in his sinuses. He
underwent a transmaxillary aspiration by ENT on [**2200-10-19**],
but the culture from this was negative. He was first started
on Levofloxacin, which was later changed to Vancomycin,
Levofloxacin, and Flagyl, given Staphylococcus aureus, MRSA
and bacteria in his sputum, he continued to spike fevers, and
Infectious Disease consultation recommend empiric change of
Levofloxacin for Zosyn. After the Vancomycin and Zosyn
therapy was initiated, the patient defervesced and his white
count went down. He will continue on Vancomycin and Zosyn
for a total of 14 days of Zosyn.
ENDOCRINE: The blood sugars were elevated while he was on
TPN and he was started on insulin drip. Sugars stabilized
when he was switched to enteral tube feeds and well
maintained by NPH insulin 20 units b.i.d. and regular insulin
sliding scale.
At the time of the dictation, he is doing well and he is
being weaned form a ventilator. He is able to communicate
with [**Name2 (NI) 36422**] valve. He should continue to wear his
cervical collar for a total of six weeks from the accident.
He will need back vaccines because of his splenectomy. He
will receive those just prior to his discharge. He still has
a left radial fracture, which will require operative
management by orthopedics. Therefore, he should continue to
wear a left upper extremity splint. Dr. [**Last Name (STitle) **], from
orthopedics should be contact[**Name (NI) **] at #[**Telephone/Fax (1) 5499**] for followup
one week after discharge.
MEDICATIONS AT THE TIME OF DICTATION
1. Aspirin 81 mg p.o.q.d.
2. Iron sulfate 325 mg p.o.t.i.d.
3. Heparin 5000 units subcutaneously b.i.d.
4. Clonidine patch 0.2 mg q week.
5. Epogen 40,000 units every Monday.
6. Nystatin powder.
7. Lopressor 50 mg p.o.b.i.d.
8. Lipitor 10 mg p.o.q.d.
9. Zantac 150 mg p.o.b.i.d.
10. Flovent.
11. Combivent.
12. Magnesium oxide 200 mg p.o.q.d.
13. Tums, two tabs p.o.q.d.
14. K-Dur 20 mEq p.o.q.d.
15. DTO 2 drops p.o.q.d.
16. Lasix 10 mg p.o.b.i.d.
17. NPH insulin 20 units subcutaneously b.i.d.
18. Regular insulin sliding scale.
19. He is getting Impact with fiber via his feeding tube at
90 mg per hour.
His complete list of medications will be updated on page 1.
He will be discharged to rehabilitation when a bed becomes
available.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Name8 (MD) 20287**]
MEDQUIST36
D: [**2200-11-7**] 13:45
T: [**2200-11-7**] 16:36
JOB#: [**Job Number 36423**]
|
[
"51881",
"42731"
] |
Admission Date: [**2152-12-21**] Discharge Date: [**2153-1-25**]
Service: General surgery -- Blue service.
NOTE: This is an interim summary.
CHIEF COMPLAINT: Malaise and low grade fevers and abdominal
pain.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is an 83 year old
female with past medical history significant for
gastroesophageal reflux disease, colon cancer, noninsulin
dependent diabetes mellitus, who is well known to the general
surgery blue service, as she underwent an antrectomy/vagotomy
with Bilroth II reconstruction as well as splenectomy and
partial pancreatectomy for a large bleeding duodenal ulcer on
[**2152-11-25**]. She recovered well from this previous surgery and
she was discharged to acute care rehabilitation on [**2152-12-8**]
with both a duodenostomy tube in the afferent limb of her
gastrojejunostomy and a feeding jejunostomy tube placed. She
was sent to the Emergency Department on [**2152-12-21**] with report
of fevers, abdominal pain and general malaise, as well as a
report of some purulent drainage from her former right upper
quadrant [**Location (un) 1661**]-[**Location (un) 1662**] drain site.
PAST MEDICAL HISTORY: Significant for gastroesophageal
reflux disease; colon cancer; ventral hernia; chronic
obstructive pulmonary disease; asthma; noninsulin dependent
diabetes mellitus; cataracts; arthritis; bleeding duodenal
ulcer.
PAST SURGICAL HISTORY: Right colectomy. Cataract surgery.
Ventral herniorrhaphy. Bilateral hip replacements.
Antrectomy/vagotomy with Bilroth II repair. Splenectomy.
Distal pancreatectomy.
MEDICATIONS AT HOME:
1. Lasix 40 mg q. a.m. and 20 q. p.m.
2. Atrovent.
3. NPH 10 units q. a.m.
4. Ambien 5 mg q h.s.
5. Lopressor 25 mg p.o. twice a day.
6. Zinc 20 mg p.o. q. day.
7. Flovent two puffs twice a day.
8. Paxil 20 mg p.o. q. day.
9. Protonic 40 mg p.o. twice a day.
10. Reglan 10 mg p.o. q.o.d.
11. Aldactone 25 mg p.o. twice a day.
PHYSICAL EXAMINATION: She is afebrile at 98.6; pulse 80;
blood pressure 125/55; respiratory rate 18; oxygen saturation
96% on three liters. She is sleepy, oriented, in no apparent
distress. She does have some scleral icterus. Lungs: She
has decreased breath sounds bilaterally. Heart: Regular
rate and rhythm with a normal S1 and S2. Her abdominal
examination is significant for softness and obese. There is
a 5 by 5 cm area that is tender, indurated and erythematous
surrounding the former right [**Location (un) 1661**]-[**Location (un) 1662**] drain site with
purulent drainage from the site. Some fluctuance inferior to
it. There is a duodenostomy tube with some serous drainage
from around the skin site and a feeding jejunostomy in good
position. The prior surgical incision is well healed with no
erythema or drainage. Rectal examination: No masses,
nontender. She is guaiac positive. Extremities: She has 1+
peripheral edema.
LABORATORY DATA: On admission, white count was 21.3 with a
left shift with 86% neutrophils; hematocrit of 40.5;
platelets of 355. Sodium of 149; potassium of 3.8; chloride
of 103; bicarbonate of 36; BUN 49; creatinine 1.4; sugar of
252. Her urinalysis shows positive nitrates and trace
leukocyte esterase. Her PT was 12.6; PTT was 23.2; INR was
1.1.
A CAT scan of the abdomen showed a large subcutaneous
collection of air and soft tissue. This collection did not
seem to involve the fascia. There were also signs of a
dilated afferent limb as well as some stranding in the area
around the end of the duodenostomy stump, indicating
possibility of a duodenal stump leak. In addition, the
radiologist noted the expected changes following a Bilroth II
reconstruction as well as a distal pancreatectomy and
splenectomy.
She had follow-up contrast studies, during which gastrografin
was injected into both the jejunostomy and duodenostomy
tubes. The J tube contrast study showed that the J tube was
in good position and there was no evident leak. However, the
duodenostomy contrast study showed a small amount of contrast
exiting from the duodenal stump, indicating a slight leak
from the duodenal stump.
It was determined that Ms. [**Known lastname **] had an angry abdominal wall
abscess which required emergent surgery. Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **], after consulting with Dr. [**Last Name (STitle) 957**], proceeded to
consent Ms. [**Known lastname **] to surgery and the patient was taken to the
operating room for treatment. Please refer to the previously
dictated operative note by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for the
specifics of this surgery. However, in brief, the surgery
had the following findings: 1.) A large subcutaneous abscess
was found almost immediately after opening the skin overlying
the abdomen, with about 400 to 500 ml of purulent debris
draining almost immediately. This purulent material was
washed out with high pressure saline and further inspection
revealed that there was a small fascial dehiscence of the
inferior aspect of Ms. [**Known lastname **] prior surgical wound.
Otherwise, Ms. [**Known lastname **] abdominal fascia was intact and once
this was repaired, two Penrose drains were placed to assist
with the drainage of the subcutaneous layer.
Intraoperatively, Ms. [**Known lastname **] had several episodes of
hypotension which required the administration of pressure
support. This, combined with the fact that the duodenal leak
appeared to be relatively minimal and would be unlikely to be
repaired by adjusting the duodenostomy tube precluded
additional intervention. It was decided that she would be
transferred to the Intensive Care Unit and managed
conservatively. In addition, the abdominal wound was packed
with Betadine soaked Kerlix and the Penrose drains assisted
with the drainage. Once this was completed, Ms. [**Known lastname **] was
transferred to the Intensive Care Unit, intubated and in good
condition. Wound cultures taken during this procedure
eventually grew out Vancomycin sensitive enterococcus,
pseudomonas, [**Female First Name (un) **] albicans, the anaerobe Prevotella, for
which Ms. [**Known lastname **] was put on intravenous antibiotics.
Ms. [**Known lastname **] Intensive Care Unit course was relatively
uncomplicated. She underwent hemodynamic monitoring with an
arterial line and Swan-Ganz catheter. She continued to have
twice daily dressing changes with wet to dry gauze of her
abdominal wound in the subcutaneous layer. TPN and tube
feeds were started on postoperative day number three and Mrs.
[**Known lastname **] actually began taking p.o. on postoperative day number
five. While in the Intensive Care Unit, Mrs. [**Known lastname **] also
received several red blood cell transfusions. On
postoperative day number six, Ms. [**Known lastname **] was transferred to
the floor, as she was doing very well. However, she bounced
right back to the Intensive Care Unit after she suffered an
episode of confusion, low grade fever and tachycardia. Blood
cultures were sent. Ms. [**Known lastname **] central venous access line
was changed; however. Electrocardiogram, chest x-ray and
arterial blood gases were all obtained; however, one of these
tests resulted in a diagnosis. This episode was attributed
to a reaction to the intravenous Dilaudid that Ms. [**Known lastname **] was
receiving for her dressing changes. This is in agreement
with the prior allergy to Percocet, noted from her prior
admission.
The second Intensive Care Unit stay was also uncomplicated
and on [**12-31**], which was postoperative day number nine,
Ms. [**Known lastname **] was transferred back to the floor. The rest of her
floor stay can be described in an organ system base fashion.
Neurologic: Ms. [**Known lastname **] was started on very small doses of
Demerol to assist with her dressing changes. By [**1-2**],
Ms. [**Known lastname **] was actually able to tolerate the dressing changes
without any narcotics. In addition, Ms. [**Known lastname **] was soon
started on her home dose of Paxil which she [**Known lastname 8337**] well.
Her pain, for the rest of her hospital stay of note was
easily controlled with Tylenol.
Cardiovascular: Ms. [**Known lastname **] was on her home dose of Lopressor,
25 mg twice a day for the rest of her hospital stay.
Respiratory: Ms. [**Known lastname **] did have some wheezing difficulties,
for which she continued on her Flovent. She also received
nebulizer treatments q. six and was oxygen saturation
requiring because of oxygen saturations down into the mid
80's; however, her oxygen saturation would quickly climb back
up with administration of oxygen via a shovel mask.
Gastrointestinal: During this time on the floor, Ms. [**Known lastname **]
has been sustained with a combination of parenteral and
enteral nutrition. Towards the beginning of the month, a
nitrogen balance was calculated and Ms. [**Known lastname **] was found to
have a nitrogen balance of -7.5, clearly catabolic. Ms.
[**Known lastname **] TPN was changed over. The protein was changed over
to HepatAmine, in the hopes that this would assist with
closing of her colocutaneous fistula. She was able to
increase the amount of protein in her TPN. In addition, Ms.
[**Known lastname **] also received tube feeds via her jejunostomy tube. She
received 1/2 strength Impact tube feeds plus fiber at 70%.
In an attempt to increase her protein intake, when she was
noted to be subcatabolic, these tube feeds were supplemented
with 30 grams of ProMod every day. She [**Known lastname 8337**] this
increase in protein very well and her subsequent nitrogen
balance was noted to be +2.
Hematology: There were no issues. Ms. [**Known lastname **] did not require
any more transfusions.
Infectious disease: After being treated for several days
with intravenous antimicrobials, Ms. [**Known lastname **] was noted to have
some low grade fevers on [**12-27**]. She was cultured and a urine
culture on that day ended up growing out [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**].
Ms. [**Known lastname **] was started on Voriconazole for this but she
subsequently had a dramatic increase in her creatinine. She
was switched back to Diflucan for several days; however, by
[**1-16**], Ms. [**Known lastname **] did not clear the [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] from
her urine and she was treated with Amphotericin B bladder
irrigation. On [**1-23**], urine culture, after her five day
course of bladder washings revealed that her urine had been
cleared of the fungus. Gradually, of note, no blood cultures
have come back positive and she has been discontinued from
all her intravenous and oral antibiotics as of [**1-25**].
Renal: As mentioned before, Ms. [**Known lastname **] had a poor reaction to
Voriconazole with rising creatinine. She [**Known lastname 53183**] well to
hydration and discontinuance of the Voriconazole. Throughout
the month of [**Month (only) 404**], she was actively diuresed with Lasix,
anywhere from 5 to 20 mg of intravenous Lasix a day. She
remained relatively stable with her weight. Baseline weight
was 72.7 kilograms. On [**1-23**], she was 80.4 kg, still 8
kg over her baseline weight. Finally with renal, her Foley
was discontinued on [**1-25**]. Ms. [**Known lastname **] [**Last Name (Titles) 8337**] this
well.
Musculoskeletal: Ms. [**Known lastname **] did injure her left wrist in the
middle of [**Month (only) 404**], on [**1-9**]. Ms. [**Known lastname **] had a wrist
x-ray obtained which did not show any fractures or any
pathology. A wrist splint was placed and Ms. [**Known lastname **] [**Last Name (Titles) 53183**]
well to Celebrex.
Skin care: It was noted on [**1-6**] or so, that Ms. [**Known lastname **]
had a small ulcer or area of induration on her sacrum. An
ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] and the patient received Duoderm
intermittently to help prevent development of a worse
decubitus ulcer.
Wound: Ms. [**Known lastname **] surgical wound has been packed on a twice
daily regimen, early morning on rounds and in the evening
after rounds by the surgical house officer. This is packed
with wet to dry Kerlix, covered over with four by fours and
abdominal pads and held together with [**Location (un) **] straps with
rubber bands holding them together. Her duodenostomy tubes
were also covered with ABD's. Her drainage has significantly
decreased from the beginning of her hospital stay. She still
does put out a small amount of greenish feculent material.
The current abdominal wound has a midline 2 by 3 cm defect at
its superior aspect. At the superior aspect of the defect,
one can see the prosthetic mesh from her prior umbilical
hernia repair. It is likely that this mesh is impeding the
ability of this wound to definitively heal. To the patient's
right, there is also another wound at approximately 10
o'clock. There is a subcutaneous tunnel connecting these two
which is also packed with the Kerlix. At 8 o'clock, there is
a Penrose drain. This is also connected to the subcutaneous
cavity. To the patient's left of the midline wound is a
small connection to another subcutaneous cavity. At the deep
layer of this cavity is a enterocutaneous fistula from which
the feculent material drains. It drains at approximately 5
to 10 cc per day. At the inferior aspect of this left sided
cavity, there is another Penrose drain which is sutured in
place as well. Above this cavity, Ms. [**Known lastname **] also has her
jejunostomy and duodenostomy tubes in place.
Discharge medications and discharge instructions will be
added at the end of Ms. [**Known lastname **] hospital stay. Her current
medication list includes:
1. Metoprolol 25 mg p.o. twice a day.
2. Protonic 40 mg p.o. q. day.
3. Sliding scale of insulin.
4. Glycerin suppositories prn.
5. Flovent 2 puffs twice a day.
6. Nebulizer treatments q. six hours.
7. Paxil 20 mg p.o. q. day.
8. Tylenol q. day.
9. Aldactone 25 mg p.o. twice a day.
10. Kaopectate 30 cc twice a day.
11. Imodium 2 mg p.o. twice a day.
12. Celebrex 200 mg p.o. q. day.
13. Lasix 10 mg intravenous twice a day.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2153-1-25**] 04:26
T: [**2153-1-25**] 04:36
JOB#: [**Job Number 54061**]
|
[
"5849",
"5119"
] |
Admission Date: [**2159-9-27**] Discharge Date: [**2159-9-30**]
Date of Birth: [**2094-9-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
s/p Cardiac Arrest
Major Surgical or Invasive Procedure:
Arterial line placement
Intubation
History of Present Illness:
65 yo M with history of pancreatic CA s/p Whipple [**1-/2159**], Afib,
CHF with LVEF 25-30%, and Type II DM who present s/p cardiac
arrest today. He originally presented to hospital as outpatient
for planned [**Year (4 digits) **], which was cancelled due to tachycardia,
relative hypotension, and inability to find oxygen sat. Patient
then left the hospital to go home and had a witnessed Vfib
arrest with intubation in field and epi down ETT. Was shocked
out of Vfib. FS at that time was 132.
.
*per phone conversation with patient's wife*
In last few weeks patient had been complaining to his wife that
he was more short of breath with exertion. Wife reports that
patient acted like he had given up on life as he had no
motivation to do even the smallest thing like change his
underwear. She notes that he was sleeping through most of the
day. Patient also may have been a bit more confusion lately.
Patient finished 6.5 weeks of radiation therapy last week.
Patient has also finished multiple cycles of gemcitabine
chemotherapy. Of note, wife is very angry about the fact that
patient was released to home from GI procedure suite today. She
resports that she feels it was inappropriate to send a
"half-dead" man home.
.
In the emergency department, vitals at presentation were: T
96.6, HR 112, BP 125/32, and intubated with O2Sat 100%. Patient
had multiple impaging procedures including negative CT head, CT
abd/pelvis showing large simple ascites, CTA chest without PE
but did show multiple right rib fractures and sternal fracture.
Currently being cooled (target reached at 33 C) and on a
midazolam drip. EKG without concern for STEMI, and cardiology
feels this is close to his baseline EKG. Prior to transfer to
the ICU vitals were: T 92 98, HR , BP 101/58, RR 25, O2Sat 100%
on AC mode Vt 560, f 22, PEEP 5, FiO2 100%.
Past Medical History:
Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy (Gemcitabine) was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above
Social History:
Lives in [**Location 13360**] with wife. Retired IT tech. Has one son
age 31, one daughter age 35 with special needs. No current or
past EtOH use, no current or past tobacco use.
Family History:
Mother h/o Breast Ca at early age. Father CAD. Brother died
from lung Ca, heavy smoker. Sister has dementia.
Physical Exam:
VS: T 33 C, HR 99, BP 100/59, RR 22, O2Sat 100%
VENT: AC with Vt 560, f 22, PEEP 5, FiO2 100%
GEN: Intubated and sedated, appears cachectic
HEENT: Scleral edema, PERRL 3->2 mm
NECK: EJ IV catheter at right neck
PULM: Anterior chest bruising
CARD: Tachycardic, nl S1, nl S2, no M/R/G
ABD: Largely obscured by placement of Artic Sun pads, though
BS+, soft, no grimace with palpation
EXT: Stage III ulcer on right heel, BLE with woody edema, BUE
[**11-25**]+ pitting edema
NEURO: Sedated, no rigidity of muscular tone
.
Pertinent Results:
Admission Labs
[**2159-9-27**] 11:17PM TYPE-ART TEMP-33 RATES-22/ TIDAL VOL-609
PEEP-5 O2-50 PO2-255* PCO2-22* PH-7.38 TOTAL CO2-14* BASE XS--9
-ASSIST/CON INTUBATED-INTUBATED
[**2159-9-27**] 11:17PM LACTATE-2.5*
[**2159-9-27**] 09:19PM TYPE-[**Last Name (un) **] PH-7.23* COMMENTS-GREEN TOP
[**2159-9-27**] 09:19PM LACTATE-2.6*
[**2159-9-27**] 09:19PM freeCa-1.04*
[**2159-9-27**] 09:07PM GLUCOSE-112* UREA N-33* CREAT-1.6* SODIUM-144
POTASSIUM-5.8* CHLORIDE-118* TOTAL CO2-16* ANION GAP-16
[**2159-9-27**] 09:07PM CK(CPK)-352*
[**2159-9-27**] 09:07PM CK-MB-55* MB INDX-15.6* cTropnT-0.73*
[**2159-9-27**] 09:07PM DIGOXIN-0.2*
[**2159-9-27**] 09:07PM WBC-9.8 RBC-3.10* HGB-9.6* HCT-30.4* MCV-98
MCH-30.8 MCHC-31.5 RDW-21.7*
[**2159-9-27**] 09:07PM PLT COUNT-191
[**2159-9-27**] 09:07PM PT-16.9* PTT-33.6 INR(PT)-1.5*
[**2159-9-27**] 08:10PM GLUCOSE-107* UREA N-34* CREAT-1.6* SODIUM-140
POTASSIUM-8.6* CHLORIDE-117* TOTAL CO2-16* ANION GAP-16
[**2159-9-27**] 08:10PM CK(CPK)-412*
[**2159-9-27**] 08:10PM CK-MB-53* MB INDX-12.9* cTropnT-0.63*
[**2159-9-27**] 08:10PM CALCIUM-7.7* PHOSPHATE-3.7 MAGNESIUM-1.4*
[**2159-9-27**] 03:21PM TYPE-ART TIDAL VOL-520 O2-100 PO2-329*
PCO2-30* PH-7.30* TOTAL CO2-15* BASE XS--9 AADO2-362 REQ O2-64
-ASSIST/CON INTUBATED-INTUBATED
[**2159-9-27**] 01:55PM URINE HOURS-RANDOM
[**2159-9-27**] 01:55PM URINE HOURS-RANDOM
[**2159-9-27**] 01:55PM URINE GR HOLD-HOLD
[**2159-9-27**] 01:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2159-9-27**] 01:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2159-9-27**] 01:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2159-9-27**] 01:38PM GLUCOSE-119* LACTATE-4.0* NA+-143 K+-5.7*
CL--118* TCO2-15*
[**2159-9-27**] 01:30PM UREA N-33* CREAT-1.7*
[**2159-9-27**] 01:30PM estGFR-Using this
[**2159-9-27**] 01:30PM estGFR-Using this
[**2159-9-27**] 11:59AM TYPE-ART PO2-294* PCO2-28* PH-7.39 TOTAL
CO2-18* BASE XS--6 INTUBATED-NOT INTUBA
[**2159-9-27**] 01:30PM FIBRINOGE-220
[**2159-9-27**] 01:30PM PLT COUNT-239
[**2159-9-27**] 01:30PM PT-16.4* PTT-33.4 INR(PT)-1.5*
[**2159-9-27**] 01:30PM WBC-6.7 RBC-3.38* HGB-10.4* HCT-33.3* MCV-99*
MCH-30.8 MCHC-31.3 RDW-21.8*
[**2159-9-27**] 01:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
Discharge Labs
[**2159-9-30**] 05:43AM BLOOD WBC-10.6 RBC-2.76* Hgb-8.6* Hct-26.8*
MCV-97 MCH-31.1 MCHC-32.0 RDW-21.8* Plt Ct-134*
[**2159-9-29**] 01:52AM BLOOD WBC-8.8 RBC-2.98* Hgb-9.3* Hct-29.2*
MCV-98 MCH-31.0 MCHC-31.7 RDW-21.8* Plt Ct-169
[**2159-9-28**] 04:46AM BLOOD WBC-9.4 RBC-3.20* Hgb-10.0* Hct-30.8*
MCV-96 MCH-31.3 MCHC-32.5 RDW-21.5* Plt Ct-177
[**2159-9-28**] 04:46AM BLOOD Neuts-95.6* Lymphs-1.8* Monos-2.4 Eos-0.1
Baso-0
[**2159-9-30**] 05:43AM BLOOD Plt Ct-134*
[**2159-9-29**] 01:52AM BLOOD Plt Ct-169
[**2159-9-28**] 12:54PM BLOOD PT-17.0* PTT-113.2* INR(PT)-1.5*
[**2159-9-28**] 04:46AM BLOOD Plt Ct-177
[**2159-9-30**] 05:43AM BLOOD Glucose-120* UreaN-39* Creat-2.1* Na-139
K-4.9 Cl-113* HCO3-18* AnGap-13
[**2159-9-29**] 07:49PM BLOOD Glucose-120* UreaN-39* Creat-2.0* Na-138
K-5.0 Cl-113* HCO3-18* AnGap-12
[**2159-9-29**] 04:04PM BLOOD Glucose-124* UreaN-39* Creat-1.9* Na-140
K-5.0 Cl-114* HCO3-19* AnGap-12
[**2159-9-29**] 01:52AM BLOOD Glucose-256* UreaN-37* Creat-1.7* Na-142
K-5.2* Cl-113* HCO3-16* AnGap-18
[**2159-9-28**] 04:46AM BLOOD ALT-31 AST-64* LD(LDH)-370* CK(CPK)-372*
AlkPhos-132* TotBili-1.0
[**2159-9-27**] 09:07PM BLOOD CK(CPK)-352*
[**2159-9-28**] 04:46AM BLOOD CK-MB-62* MB Indx-16.7* cTropnT-0.67*
[**2159-9-27**] 09:07PM BLOOD CK-MB-55* MB Indx-15.6* cTropnT-0.73*
[**2159-9-27**] 08:10PM BLOOD CK-MB-53* MB Indx-12.9* cTropnT-0.63*
[**2159-9-30**] 05:43AM BLOOD Calcium-7.8* Phos-4.5 Mg-1.9
[**2159-9-29**] 07:49PM BLOOD Calcium-7.7* Phos-4.5 Mg-2.0
[**2159-9-29**] 04:04PM BLOOD Calcium-7.6* Phos-4.1 Mg-2.0
[**2159-9-29**] 01:52AM BLOOD Calcium-7.9* Phos-4.2 Mg-2.1
[**2159-9-30**] 05:43AM BLOOD Phenyto-9.0*
[**2159-9-29**] 07:49PM BLOOD Phenyto-8.8*
[**2159-9-27**] 09:07PM BLOOD Digoxin-0.2*
[**2159-9-27**] 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2159-9-29**] 08:32AM BLOOD Type-ART Temp-36.1 Rates-12/14 PEEP-5
FiO2-30 pO2-110* pCO2-35 pH-7.34* calTCO2-20* Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2159-9-29**] 03:37AM BLOOD Type-ART Temp-35.0 Rates-[**10-25**] Tidal V-450
PEEP-5 FiO2-30 O2 Flow-6.3 pO2-92 pCO2-34 pH-7.33* calTCO2-19*
Base XS--6 Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-29**] 01:57AM BLOOD Type-ART Temp-34.3 Rates-[**10-26**] Tidal V-450
PEEP-5 FiO2-30 pO2-89 pCO2-31* pH-7.33* calTCO2-17* Base XS--8
Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-28**] 11:44PM BLOOD Type-ART Temp-33.6 Rates-[**10-29**] Tidal V-450
PEEP-5 FiO2-30 pO2-93 pCO2-28* pH-7.31* calTCO2-15* Base XS--10
Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-28**] 10:36PM BLOOD Type-ART Temp-33.3 Rates-[**10-27**] Tidal V-450
PEEP-5 FiO2-30 O2 Flow-6.2 pO2-132* pCO2-32* pH-7.27*
calTCO2-15* Base XS--10 Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-29**] 04:42PM BLOOD Lactate-1.8 Cl-114*
.
Reports
[**2159-9-27**]
Regular rhythm at 97 beats per minute. In leads V5-V6 there are
P waves so
this is probably sinus rhythm at 97 beats per minute. Marked low
voltage in the limb leads persists. The right bundle-branch
block pattern persists with a QRS duration which has widened to
158 milliseconds. There is poor R wave progression laterally and
low voltage in all leads. There are small Q waves in leads II,
III and aVF with ST segment elevation in those leads. Consider
acute inferior myocardial infarction.
.
[**9-27**] CT head w/o Contrast
IMPRESSION: No acute intracranial process.
.
[**2159-9-27**] Chest CT w contrast
. No central PE or dissection. Suboptimal evaluation of the
posterior
pulmonary circulation secondary to large bilateral pleural
effusions with
associated compressive atelectasis.
2. Focal small foci of gas in the anterior upper abdomen on the
last image of
non-contrast sequence. Free air cannot be excluded.
3. Large amount of abdominal ascites.
4. Multiple right and left rib fractures and a sternal fracture.
These may be
related to recent resuscitative efforts.
5. Ground-glass opacity in the right middle lobe may be a
pulmonary contusion
versus infection versus aspiration. This is new since [**2159-7-19**].
.
CT abdomen
Large volume ascites with no evidence of free air..
.
ECHO
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe
regional left ventricular systolic dysfunction with near
akinesis of the inferior and inferolateral walls and hypokinesis
of the remaining segments. The anterior septum contracts best
(LVEF 25-30%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The estimated cardiac index is depressed
(<2.0L/min/m2). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular cavity is dilated with moderate global free wall
hypokinesis. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Severe
(4+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2159-4-25**], the
estimated pulmonary artery systolic pressure is now highter.
.
[**9-29**] CXR
Cardiomegaly, large bilateral pleural effusions greater on the
right side with
associated atelectases are unchanged. ET tube, NG tube, and
right central
catheter remain in place. There is no pneumothorax.
Cardiomediastinal
silhouette is unchanged.
Brief Hospital Course:
65 yo M with history of pancreatic CA s/p Whipple [**1-/2159**], Afib,
CHF with LVEF 25-30%, and Type II DM who present s/p cardiac
arrest today. Is being cooled with Artic Sun.
#. Vfib cardiac arrest:
Most likely etiology was either new ischemia or automaticity
from old scar in setting of dilated ischemic cardiomyopathy with
LVEF of 25-30%. Patient's exam and history was consistent with
decompensated heart failure of at least several week duration.
Less likely cause of cardiac arrest would be digoxin toxicity
given patient recently started that medication and has history
of renal insufficiency. CTA chest was overall a poor study given
large pleural effusions, though no apparent PE or aortic
dissection. Patient fortunately had relatively rapid
defibrillation and [**Name (NI) **] during code. He was being cooled
followed by warmed on Artic Sun for neuro protection and has
reached temperature goal of 33 C. 48hr EEG showed possible
seizure activity consistent with ischemic injury; consult neuro
to evaluate EEG
Family meeting once warmed and off sedation to discuss goals of
care and prognosis, and it was decided to enact comfort care
measures.
.
#Hypotension: likely secondary to worsening heart failure in the
setting of fluid overload. N.epi and vasopressin as needed for
MAP > 60; phenylephrine PRN for additional pressure support
.
#. Acute on Chronic Kidney Injury:Most likely due to ATN in
setting of arrest
Mr [**Known lastname 4017**] wife and son decided they wanted to fully withdraw
care. Dr [**First Name (STitle) 1022**] met with them and answered all questions - pt was
extubated and all pressors were turned off. Placed on Morphine
for comfort. At approx. 12:45PM, I was notified by the nurse the
patient had passed away with his family at bedside.
.
[**2159-9-30**]
I examined the patient and he was not responsive to auditory or
tactile stimuli. I observed 1 minute of no breaths or
respiratory effort. I auscultated no breath sounds or heart
sounds for 1 minute. The patient did not have a corneal reflex
or pupilllary reaction to direct light bilaterally. I declared
the patient dead at 12:57 PM and notified his family who were in
the hallway outside the ICU. His wife and son denied a autopsy.
Medications on Admission:
per [**2159-9-4**] [**Hospital6 33**] discharge*
1) Atorvastatin 40 mg QHS
2) Lipase-Protease-Amylase 5,000-17,000-27,000 Capsule, TID
W/MEALS
3) Metoprolol Tartrate 25 mg PO DAILY
4) Trazodone 50 mg PO HS
5) Insulin Glargine 8 Units subcutaneous DAILY
6) Humalog 100 unit/mL 1-12 Units subcutaneous QID
7) Aspirin 81 mg PO DAILY
8) Pantoprazole 20 mg Q24H
9) Furosemide 40 mg Tablet PO DAILY
10) Digoxin 0.125 mg DAILY
11) Tamsulosin 0.4 mg DAILY
12) Ferrous gluconate DAILY
Discharge Medications:
Patient has passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient has passed away
Discharge Condition:
Patient has passed away
Discharge Instructions:
Patient has passed away
Followup Instructions:
Patient has passed away
|
[
"51881",
"5845",
"42731",
"25000",
"41401",
"V5867",
"5859",
"4280"
] |
Admission Date: [**2136-10-4**] Discharge Date: [**2136-10-21**]
Date of Birth: [**2067-8-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
BRBRP
Major Surgical or Invasive Procedure:
colonoscopy x2, EGD, mesenteric angiography.
s/p Right colon embolization by interventional radiology
History of Present Illness:
69 F with fibromyalgia, bipolar d/o, who was USOH until 3 days
PTA at which time she had a BM and noticed blood on the toilet
paper as well as in the toilet bowel. Her PCP was called, she
was seen the office and there was ? of a polyp. 1 day PTA, she
had one black stool. Later in the day, she went to the bathroom
after developing lower abd cramps. She saw red blood in her
stool and in the toilet bowel. The cramps were relieved with BM.
No N/V, eating and drinking well. +bloating/gas sxs. Unclear if
she has ever had c-scope in past.
.
In addition, the pt had a syncopal episode prior to arrival in
the ED after she had a BM this evening. The pt went to her
bedroom and "passed out." States she was out for 10 mins, no
head trauma. Had some right sided rib pain/under breast pain. No
CP, chest pressure, SOB, LH/dizziness prior. Came to ED via EMS.
.
In the ED, 97.4, 74, 144/80, 16, 96 % RA. Guiac + in the ED.
Anoscopy was unrevealing for source, limited exam. GI and
surgical services were made aware of the pt's case. NGL was
negative. Patient was admitted to medicine for w/u of GIB.
Past Medical History:
1. Bipolar disease
2. Fibromyalgia
3. Obesity
4. HTN
5. Sleep disorder, ?OSA
6. DM2?
Social History:
lives at home, no alcohol, no tobacco
Family History:
Non-contributory
Physical Exam:
Temp 97.4
BP 116/68
Pulse 81
Resp 22
O2 sat 97% RA
Gen - Alert, no acute distress, anxious and very talkative
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes dry, no sores
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally anteriorly; TTP under
right breast, no eccyhmosis
CV - Normal S1/S2, RRR, [**1-15**] SE murmur in axilla c/w MR, no rubs,
or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds, som discomfort with palp in lower abd, rectal deferred
as done in ED
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**1-21**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Pertinent Results:
On admission [**2136-10-3**]:
WBC-8.3 RBC-3.85* Hgb-11.7*# Hct-34.3*# MCV-89 MCH-30.4
MCHC-34.1 RDW-12.5 Plt Ct-227 Neuts-52.5 Bands-0 Lymphs-43.1*
Monos-3.3 Eos-0.8 Baso-0.2
PT-12.2 PTT-23.2 INR(PT)-1.0
Glucose-175* UreaN-25* Creat-0.7 Na-139 K-3.4 Cl-105 HCO3-24
AnGap-13 Calcium-8.0* Phos-2.9 Mg-2.1
CK(CPK)-69 CK-MB-NotDone cTropnT-<0.01
.
EKG: NSR 73, 1mm ST elev in v2, no TW changes, LAD, no change
compared to prior
Brief Hospital Course:
Assessment: 69 F with PMH GERD and ? hemorrhoids who presents
with 1 day of BRBPR after noting BRB on tissue 3 days PTA and
passing 1 large melanotic stool 1 days PTA. NGL in ED was
negative.
Hospital Course by problem:
.
#LGIB. Initial tagged RBC scan and colonoscopy did not reveal
active bleeding, and patient was transferred to floor for
observation and serial hematocrits. She was followed by the GI
service and by the surgical service during her stay. On the
floor she had an episode of bleeding with an SBP=50s (responded
to fluid), and was transferred back to the MICU. Her bleeding
then self-resolved and the plan was for a repeat colonoscopy.
The night before the planned procedure the pt had another
episode of bleeding, hypotension and tachycardia, and was
resuscitated with IVFs and PRBCs (16 units total by [**2136-10-15**]).
Repeat tagged RBC scan did not show a source of bleeding. She
underwent a rapid prep and had a colonoscopy the following day
which again did not show active bleeding. Since she had remained
hemodynamically stable with stable hematocrits for over 24 hours
she was transferred back to the floor with the plan to to a
repeat NGL and tagged scan in case of bleeding. Pt was made
aware of the possibility of need for surgery.
After transfer to the floor, the patient rebled again. She
was transferred back to the MICU for fluid and blood
resuscitation. On [**10-15**], she had another episode of BRBPR in the
MICU and was taken emergently for a tagged RBC scan, which was
negative. The morning of [**10-16**] a positive scan was reported and
she was taken emergently back to interventional radiology.
Initially no source was identified but pt rebled in IR and a
site in R colic artery was successfully embolized with coils.
She was observed in the MICU for another 12h and then
transferred to the medicine floor.
On the floor, her hematocrits were monitored and remained
overall stable at 28-29. She received one additional unit of
PRBCs for a Hct drop from 34 -> 28 (received a total of 26U
PRBCs over the course of her stay). She was kept NPO x 24h
after her embolization procedure due to some complaints of
nausea and abdominal tenderness and suspicion of potential bowel
ischmia from the surgical service. After that period she was
started on a clear diet and advanced as tolerated without event.
Her Hct and blood pressure remained stable until the day of
discharge.
.
#. Atrial fibrillation. On [**10-16**] the patient was had an episode
of AFib with RVR, HR = 160s. She responded to 5mg IV metoprolol
with HR -> 80s and auto-correction to NSR. She reported
palpitations during the episode but no other symptoms, and her
other vital signs remained stable. She did not have any further
episodes of AFib and remained in NSR during the rest of her
admission. Given her LGIB she was not discharged on
anti-coagulation or any other therapy for AFib.
.
# Hypertension. Her hypertension remained stable over the
course of her stay, with more problems with hypotension as
described above. The patient does not take any outpatient
anti-hypertensives and was not discharged on any new medications
for her hypertension.
.
#. Bipolar disorder/anxiety. The patient was followed by the
psychiatry service throughout her stay. Her home treatments
consist of only herbal supplements. She remained fairly anxious
duing her admission but did well on ativan 0.5mg tid. Her mood
improved after her final transfer to the floor and she was
discharged on prn ativan with instructions to arrange follow-up
with her outpatient psychiatrist.
.
# Fibromyalgia. Pt complained of right sided chest wall
discomfort, L shoulder pain, hip pain/LBP over the course of her
admission. She was treated successfully with tylenol, heating
pads, and bengay.
.
# Code status: FULL CODE.
.
# Other/Dispo. The patient was discharged home with services
when her hematocrits and vital signs had remained stable for
several days. She was evaluated by PT who cleared her as safe
for home. She was able to consume a low-residue diet (given for
her diverticulosis) and did not have any signs or symptoms of
lower GI bleeding.
.
Medications on Admission:
maalox prn
pepcid
MVI
Herbs- [**Last Name (LF) 25697**], [**First Name3 (LF) **]-E
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. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID PRN as
needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Lower gastrointestinal bleed
Atrial Fibrillation
Discharge Condition:
good
Discharge Instructions:
Continue your home medications/supplements/vitamins.
If you experience new bloody stools or black stools,
lightheadedness, or dizziness, or other new and concerning
symptoms, please call your doctor or come to the emergency room.
Followup Instructions:
1. Follow up with your primary care doctor in the next [**12-11**]
weeks.
2. Follow up with your psyciatrist and therapist ASAP.
3. Follow up with gastroenterology -- we made an appointment
with Dr. [**Name (NI) 9890**] on [**10-31**] at 2:00 PM. The office
is located in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**]. You need to
call them prior to your appointment ([**Telephone/Fax (1) 8892**] to register.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2136-10-22**]
|
[
"42731",
"5990",
"4019"
] |
Admission Date: [**2131-8-10**] Discharge Date: [**2131-8-12**]
Date of Birth: [**2060-5-13**] Sex: M
Service: NME
CHIEF COMPLAINT: Convulsive status epilepticus.
HISTORY OF PRESENT ILLNESS: A 71-year-old man with known
metastatic brain cancer from non-small cell lung cancer, who
now presents with convulsive status epilepticus. He was
diagnosed with lung cancer on [**2131-2-1**] after he presented
with cough and hemoptysis. CT of the chest still showed a
left upper lobe mass and mediastinal lymphadenopathy. Fine
needle biopsy of the left upper lobe mass on [**2131-2-16**] showed
poorly differentiated non-small lung cancer. He was at Stage
3B.
He then underwent neoadjuvant and carboplatin and Taxol with
concurrent chest radiation. A restaging FDG-PET scan on
[**2131-6-19**] showed decreased uptake at the left lobe, but his
PET scan also staying the same of taking the right temporal
brain. MRI on [**2131-6-24**] showed three brain mets, which
include one with greater than 3 cm in diameter at the right
posterior temporal lobe, one at the right insula, and the
third one at the right singlet gyrus region. He was
asymptomatic from the brain tumors.
On [**2131-6-30**], he experienced nausea, fatigue, slurring of
speech, confusion, and hiccups. He came to our Emergency
Department at [**Hospital1 69**] on
[**2131-6-30**]. His symptoms promptly resolved after starting
Decadron. The posterior right temporal region was completely
resected by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2131-7-3**]. The pathology was
consistent with non-small cell lung cancer. He completed a
course of Decadron uneventfully and is now scheduled for
radiosurgery.
Today, he appeared lethargic and apparently confused per
family. At 5 p.m., he went to the bathroom and exited with
his pants down and confused. Family called 911. By the time
EMS arrived, he generalized, shaking left upper and lower
extremities. He was brought to [**Hospital1 188**], where he arrived with eye deviation to the left and
generalized tonic-clonic seizure. The seizure broke after 2
mg Ativan x1. He was loaded with Dilantin and the seizure
stopped shortly thereafter. He is not in stable condition,
although he is snoring with transmitted upper airway sounds.
PAST MEDICAL HISTORY: Lung cancer.
Hypertension.
MEDICATIONS AT HOME: Hydrochlorothiazide.
ALLERGIES: None.
SOCIAL HISTORY: He lives with his wife, who is the
healthcare proxy. According to his daughter, he stated he
did not wish to be resuscitated.
EXAM UPON ADMISSION: Blood pressure 157/66, pulse 115,
respiratory rate 32, and 99 percent on 100 percent FIO2. He
has moderate upper airway obstruction, which improved with
oral airway. Heart has regular, rate, and rhythm. Lungs are
clear to auscultation bilaterally. Abdomen is soft and
nontender. Extremities showed no clubbing, cyanosis, or
edema. On neurologic exam, his eyes are closed and he did
not open to stimulation. There is no spontaneous movement.
Cranial nerves, his pupils are equal, round, and reactive to
light with sharp optic disc margins. He has a dolls and corneal
reflex. His gag and cough are intact. His face appears
symmetric. On motor exam, withdraws to pain with his legs.
However, there is no movement with his arms. His toes are
upgoing bilaterally.
HOSPITAL COURSE: Patient will continue on Dilantin and then
awoke to be transferred from the ICU to the floor. He was
also given Decadron to decrease any possible swelling in his
brain. He did have a MRI of the brain, which showed the ring-
enhancing lesion in the right posterior temporal region with
increased surrounding edema since the MRI study on [**2131-7-30**].
The enhancing lesion in the right subinsular region, left
cerebellar hemisphere appeared unchanged compared to prior
study. There is no midline shift or hydrocephalus seen on
the insula.
When patient awoke, he had a little bit of neglect, which
then improved throughout the hospital course. His neurologic
exam was completely normal by the time he was discharged. He
is to continue on his Decadron and Dilantin until he is to
see Dr. [**Last Name (STitle) 724**] in the [**Hospital 746**] Clinic.
DISCHARGE DIAGNOSES: Status epilepticus.
Metastatic brain cancer from non-small cell lung cancer.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Decadron 6 mg p.o. q.i.d.
3. Dilantin 100 mg p.o. t.i.d.
4. Tylenol prn.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home.
FOLLOW UP: Patient is to followup with Dr. [**Last Name (STitle) 724**] in one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6600**], [**MD Number(1) 6601**]
Dictated By:[**Last Name (NamePattern1) 11265**]
MEDQUIST36
D: [**2131-8-13**] 21:12:45
T: [**2131-8-14**] 05:11:31
Job#: [**Job Number **]
|
[
"4019",
"2720"
] |
Admission Date: [**2119-9-20**] Discharge Date: [**2119-9-28**]
Date of Birth: [**2040-7-6**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy (x2)
History of Present Illness:
79 y.o male with hx of severe COPD recently treated at [**Hospital 40576**] for SBO and LLL pneumonia, discharged on [**9-14**],
returned on [**9-15**] to ED with hemoptysis, was treated in ED for
pneumonia with Tequin and discharged home. On [**9-19**] pt had
another episode of hemoptysis at home associated with syncope.
Admitted again to [**Hospital6 302**], intubated, CT showed
cavitation on the L side and b/l pneumothoracies R>L,
pneumomediastinum, L pleural effusion and evidence of aspiration
on right. B/L chest tube placed and bronchoscopy was performed
which showed b/l lower lobe bleeding. On [**9-20**] patient
trasferred to [**Hospital1 18**] for further management of hemoptysis with
possible endobronchial ablative therapy.
Past Medical History:
PMH:
COPD with FEV1 1.4
Lipomas, several removed "many years ago"
SBO
Colon polyps, s/p L colectomy.
glaucoma
Cholecystecomy
Social History:
Lives with wife. Former [**Name2 (NI) 1818**] for 30 years, but quit 18 years
ago.
Family History:
Father with liver cancer.
Mother with cancer- unknown.
Physical Exam:
Tm: 97.1, Tc:97.0, BP: 109-160/31-62, P: 58-79, RR: 21(17-26),
O2: 90% on 4l nc
Gen: NAD, AAOx3
HEENT: perrla, eomi, mmm
Neck: no jvd, no lad
Chest: rrr, nl s1s2, no m/r/g
Lungs: Bronchial breath sounds throughout, rales at Left lower
lung field
Abd: soft, nt, nd, normal bowel sounds
Extremities: multiple soft/firm/mobile/nontender/subcutaneous
nodules at forearm b/l, UE with non pitting edema r>l, LE with
edematous knees, edematous feet, 2+ peripheral pulses.
Back: multiple subcutaneous nodules as described above
Pertinent Results:
CT chest/abd/pelvis-IMPRESSION:
1. Bilateral lower lobe consolidation with possible cavitation
on the left. On the right, there is obstruction of the right
lower lobe bronchus with appearance suggesting possible hilar
mass surrounding this bronchus.
2. Large left sided pleural effusion with component of
loculation.
3. Right sided pneumothorax and right chest wall dissecting
subcutaneous air. Dissection of air is likely the explanation
for free air seen in the intraperitoneal space within the
abdomen.
4. Multiple cystic lesions of the pancreas. Findings may relate
ot diffuse IPMT. Further evaluation with MRCP could be
performed.
5. 5.1 x 6.5 cm well delineated cystic lesion in the left upper
quadrant.
this may represent a exophytic renal cyst, peritoneal inclusion
cyst from prior surgery, another pancreatic cyst, or possibly a
duplication cyst.
*
Bronchial brushings and washings- negative for malignant cells,
no positive cultures, no positive fungal culture
*
[**Hospital6 302**] sputum from suction- gram [**Last Name (un) **] with GP cocci
in pairs, culture with yeast only
Brief Hospital Course:
Upon transfer to [**Hospital1 18**] pt had bronchoscopy which revealed clot
in anterior segment RUL. Blood clot was removed and BAL gram
stains and cultures negative. Shortly after procedure pt had
recurrent hemoptysis and was transferred to MICU. Pt was
evaluated and found to have a cavitating pneumonia along with
likely superimposed aspiration pneumonia. He was continued on
Zosyn started at OSH and Vancomycin was started secondary to
spike following intervention of Bronch. On [**9-22**] a second
bronchoscopy was performed, multiple clots and fresh blood was
found which resolved with flushing. Both brochoscopies
determined the most likely bleeding site to be the bronchial
artery of the RUL. Pt arrived to [**Hospital1 18**] with b/l pneumothoracies,
which are resolving though a small right loculated pocket
remains. Chest tube was removed [**9-22**]. Pt was extubated [**9-23**] and
was saturating 95% on 2l NC on transfer to floor. While in the
MICU required minimal blood support with 2 u PRBC and fluid
boluses to bring up blood pressure. Also c/b episode of
hypertension to 160's treated with hydralazine. Upon transfer to
floor all cultures were obtained, without a single positive
bacterial culture noted. Vancomycin was discontinued. Pt
required IV fluids to resolve orthostatic hypotension. Pt was
noted on several occasions, particularly at night, to desaturate
to approximately 83-86% for a matter of minutes. At these times
he responded to suction and nebulizers, and it is felt that
these episode are due to mucous plugging. He was started on
guafenesin to treat this. Towards the end of hospitalization,
interventional pulmonary performed a thoracentesis and was able
to drain 1400cc of serosangiunous fluid. The gram stain and
fluid analysis are not suggestive of empyema, but this fluid is
exudative and due to higher than normal ,ynphocyte % could be
related to lymphoma, therefore it will be absolutely essential
to follow cytology from this fluid which is currently pending.
He will be discharged to rehabilitation for physical therapy and
to complete a 14 day course of Zosyn. As on out patient it will
be essential to work up incidental finding, CT abd showed
retroperitoneal air and a 7x5 cm soft tissue mass.
Medications on Admission:
Advair 500/50
Spiriva
alphagan eye drops
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5503**] [**Hospital1 **] Convalescent Home - [**Location (un) 5503**]
Discharge Diagnosis:
Pneumonia
Pneumothorax
Discharge Condition:
stable
Discharge Instructions:
Please return to the emergency room if you develop increased
shortness of breath, fever, hemoptysis, or other concerning
symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 57752**] at
the appointment scheduled for [**Last Name (LF) 2974**], [**10-13**] at 9am.
Please schedule an appointment with your pulmonologist Dr.
[**Last Name (STitle) 18199**].
Completed by:[**2119-9-28**]
|
[
"51881",
"5070",
"496",
"5119"
] |
Admission Date: [**2169-10-20**] Discharge Date: [**2169-10-30**]
Service: MEDICINE
Allergies:
Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol /
Lisinopril / Diovan / Percocet / Ciprofloxacin
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Temporary dialysis line placement
Tunneled dialysis line placement
History of Present Illness:
88F with hx sCHF (EF 40%), CAD, dyslipidemia, HTN, DM, HL who
presents with sudden onset shortness of breath today. She was at
an appointment for an EMG of her hand; when she was laid flat
she experienced sudden onset shortness of breath that has
continued. also c/o mild b/l leg edema. Denies chest pain,
fevers, nausea, vomiting, diarrhea, abdominal pain. She is not
on home O2. She endorses increased fatigue for the last 2 days,
as well as dry cough at night and occasional wheezing. She notes
mild leg swelling. She is on torsemide 100mg PO daily and
metolazone twice a week. Dry weight from last CHF exacerbation
in [**Month (only) 958**] is 164lb.
In the ED
EKG: SR 68, QRS 104, NA, Q III (old), STD 1, avl, V5/6
Labs - crit drop from prior 28 (pt says she has been having
bleeding from hemorrhoids); Cr bumped from prior 2.8 guiaic -
neg
BNP [**Numeric Identifier 389**] (chronically elevated)
UA- dirty
CXR - diminished lung volumes, diffuse edema, cardiac silhouette
enlarged but stable
Patient given lasix 80mg IV and [**Numeric Identifier 9847**], developed [**Last Name (LF) **], [**First Name3 (LF) **] given
Benadryl
On arrival to the floor, patient still has some SOB, no CP, UOP
500ml.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he 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,
DOE, palpitations, syncope or presyncope.
Past Medical History:
- Dyslipidemia
- Hypertension, difficult to control on multiple agents
- Diabetes Mellitus since [**95**] years, on insulin
- Frequent exacerbations of CHF in the past (most recent [**4-21**])
- CAD with multiple cardiac interventions in the past, including
balloon angioplasty of the RCA in [**2157**], stenting of the ostial
RCA with two overlapping BMS in [**3-/2167**], stenting of the
proximal LAD with BMS in 05/[**2168**].
- Peripheral arterial disease
a.) Left common iliac and external iliac artery stenting in
4/[**2164**].
b.) left superior femoral artery angioplasty complicated by
dissection, requiring stent placement in 5/[**2166**].
- Renal Insufficiency
- Appendicitis treated sx
- Bladder suspension by sx
- GERD
- Hyperparathyroidism ([**2162**])
- Colonic Polyps in [**2157**]
- Catarct sx in both eyes
- BL Hearing impaired, uses hearing aids
Social History:
The patient currently lives [**Location 107650**] [**Location (un) **] with her
[**Age over 90 **] year old husband whom she has been married to for 63 years.
She has 1 son. At baseline she walks with a walker, she is
otherwise independent in all ADLs.
Tobacco: None
EtOH: None
Illicits: None
Family History:
-Father: heart problems, DM
-Mother: heart problems
-4 brothers: CAD, one with stroke
Physical Exam:
ADMISSION EXAM:
VS: T=96.6 BP=152/63 HR=73 RR=20 O2 sat= 92%2LNC weight 79.1kg
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of [**9-20**] cm.
CARDIAC: RR, normal S1, S2. +S3 No m/r. No thrills, lifts. No
S4.
LUNGS: bilateral wheezes in upper lung fields. Crackles 1/2 up
lung. Resp were unlabored, no accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ edema b/l to ankles. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
DISCHARGE EXAM:
VS: 98.9; 130-148/49-83; 58-76; 16; 93%RA
I/O: 670/525 Weight: 75.1kg
GENERAL: NAD. AAOx3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with no JVP elevation
CARDIAC: RR, normal S1, S2. +S3 No m/r. No thrills, lifts. No
S4.
LUNGS: Minimal crackles at lung bases, R>L. No wheezes, no
rhonchi. Resp were unlabored, no accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace edema b/l to ankles. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
[**2169-10-20**] 03:10PM BLOOD WBC-6.0 RBC-2.26* Hgb-7.8* Hct-22.4*
MCV-99*# MCH-34.3* MCHC-34.5 RDW-14.9 Plt Ct-148*
[**2169-10-20**] 03:10PM BLOOD Neuts-85.5* Lymphs-7.8* Monos-5.8 Eos-0.9
Baso-0.1
[**2169-10-20**] 03:10PM BLOOD PT-12.3 PTT-26.7 INR(PT)-1.0
[**2169-10-20**] 03:10PM BLOOD Plt Ct-148*
[**2169-10-21**] 08:56AM BLOOD Ret Aut-2.0
[**2169-10-20**] 03:10PM BLOOD Glucose-306* UreaN-137* Creat-3.2* Na-137
K-4.1 Cl-96 HCO3-26 AnGap-19
[**2169-10-21**] 08:56AM BLOOD LD(LDH)-326* CK(CPK)-80 TotBili-0.6
DirBili-0.4* IndBili-0.2
[**2169-10-20**] 03:10PM BLOOD proBNP-[**Numeric Identifier 42619**]*
[**2169-10-20**] 03:10PM BLOOD cTropnT-0.47*
[**2169-10-21**] 08:56AM BLOOD CK-MB-6
[**2169-10-21**] 05:17AM BLOOD Albumin-3.6 Calcium-9.0 Phos-5.4*#
Mg-3.1*
[**2169-10-21**] 08:56AM BLOOD Hapto-137
[**2169-10-23**] 05:50AM BLOOD calTIBC-246* Ferritn-849* TRF-189*
[**2169-10-20**] 03:25PM BLOOD Lactate-1.1
[**2169-10-21**] 08:21AM BLOOD Type-ART pO2-261* pCO2-45 pH-7.43
calTCO2-31* Base XS-5
[**2169-10-23**] 10:05AM BLOOD Type-ART pO2-124* pCO2-42 pH-7.46*
calTCO2-31* Base XS-6
Urine Culture
URINE CULTURE (Final [**2169-10-23**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CXR [**2169-10-20**]:
FINDINGS: Lung volumes are diminished. There is diffuse
interstitial and alveolar edema and engorgement of the [**Year (4 digits) 1106**]
pedicle. Calcified plaque is seen at the aortic arch. The
cardiac silhouette is enlarged but stable accounting for patient
and technical factors. No definite large effusion is noted.
Limited evaluation of the left costophrenic angle due to the
enlarged cardiac silhouette. There is no pneumothorax.
IMPRESSION: Heart failure. Recommend repeat radiography after
appropriate diuresis to assess for underlying infection
CT head [**2169-10-21**]:
IMPRESSION: No acute intracranial process.
CXR [**2169-10-22**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant change. The distribution of the pre-existing
parenchymal opacities, likely caused by pulmonary edema, is
changed but its overall severity has not decreased. Unchanged
appearance of the cardiac silhouette. Unchanged mild
retrocardiac atelectasis.
ECHO [**2169-10-23**]:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild to moderate regional left ventricular systolic dysfunction
with hypokinesis of the distal half of the septum and anterior
wall, distal inferior wall and apex. The apex is not aneurysmal.
The remaining segments contract normally (LVEF = 40 %). No
masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild to moderate
([**2-12**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD (mid-LAD distribution).
Mild-moderate mitral regurgitation. Pulmonary artery
hypertension.
Compared with the prior study (images reviewed) of [**2168-9-16**],
regional dysfunction is similar, though global LVEF is now more
depressed. Aortic stenosis is no longer suggested.
DISCHARGE LABS:
[**2169-10-30**] 07:00AM BLOOD WBC-7.6 RBC-3.26* Hgb-10.6* Hct-31.0*
MCV-95 MCH-32.4* MCHC-34.1 RDW-15.9* Plt Ct-289
[**2169-10-30**] 07:00AM BLOOD Glucose-138* UreaN-74* Creat-2.3* Na-137
K-3.9 Cl-97 HCO3-28 AnGap-16
[**2169-10-30**] 07:00AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.3
Brief Hospital Course:
88F with hx sCHF (EF 40%), CAD, HTN, DM, HL, CKD presents with
sudden onset shortness of breath on the day of admission while
laying flat for a study, found to have acute on chronic heart
failure.
# Acute on chronic systolic heart failure: Patient presents with
symptoms consistent with heart failure exacerbation. CXR shows
pulm edema. Likely [**3-15**] to progressive renal failure and
increasing resistance to diuresis. Has low salt diet at her
[**Hospital3 **]. Cognizent of fluid intake restrictions.
Recent increase of metolazone 2.5mg weekly to biweekly as
outpatient. On the first night on the floor, she was -700cc
from 80mg IV Lasix + 100mg IV torsemide + 2.5mg metolazone. On
the morning of [**10-21**], patient O2 saturation decreased to 85% on
2LNC. Improved with additional torsemide, neb treatment, NRB,
eventually sats in mid 90s on facemask. In the setting of
progressive end-stage renal failure, resistance to diuresis, and
altered mental status (see below), patient was transferred to
CCU for urgent dialysis. She underwent dialysis daily from [**10-21**]
to [**10-24**] with improvement in fluid status (-1.5L each session),
satting mid 90s on 3LNC. Attempted to diurese with torsemide on
[**10-25**] and [**10-26**] while off dialysis with limited urine output (only
100-200cc to 100mg IV torsemide). Patient received additional
dialysis on [**10-27**] and [**10-30**], with plans for permanent dialysis
(see below). All diuretics were stopped due to ineffectiveness.
Patient discharge weight was 75.1kg and appears clinically
euvolemic.
# Hypoxia: On [**10-21**], patient developed increasing O2 requirement
responsive to increased FiO2. Desat into 85% on 2LNC, improving
to 95% on facemask. ABG showed normal pCO2. Most likely from
V/Q mismatch from pulmonary edema. Other considerations include
PE given immobilized state for many days. However, patient was
not tachycardic with no significant LE edema or pain.
Aspiration pneumonia also possible, but patient afebrile, no
leukocytosis. TRALI was another consideration, but patient not
tachycardic, no acute increase in O2 requirement within hours of
pRBC transfusion. Hypoxia improved with dialysis and
improvement in fluid status. O2 sats in mid 90s on room air on
discharge.
# Altered mental status- Per patient's family, she has had
progressively worsening intermittent solmnolence for past [**2-12**]
weeks, being difficult to arouse from sleep for hours during the
day on several occasions. On [**10-21**] around noon time, patient
developed worsening solmnolence. CT head negative (has h/o
recent falls). Uremia was likely cause of altered mental status
given progressive CKD, and history of intermittent solmnolence.
Anemia and heart failure could be contributing to solmnolence.
Infectious process may also be contributing- has UTI.
Gabapentin toxicity in the setting of worsening CKD also a
[**Last Name (LF) **], [**First Name3 (LF) **] Gabapentin was DCed. Decision was made to transfer
patient to the CCU for dialysis. Mental status improved after
multiple days of dialysis and 3 units of pRBC (see below).
Patient AAOx3 on discharge.
# Anemia: Baseline in high 20s in [**2169-9-11**]. Hct 22.8 on
admission. Guaiac negative in the ED. Has history of recent
hemorrhoid bleed. When blood bank attempted to type/screen
blood, found to have new autoantibodies concerning for warm
agglutinins. However, hemolysis labs were negative. Blood sent
to Red Cross in an attempt to find good match. Patient
transfused total 3units pRBC and Hct stable at 28-20. EPO given
at dialysis on [**10-27**] and [**10-30**].
# CORONARIES: Stable CAD. No chest pain. Chronically elevated
troponins in the setting of CKD.
# CKD: elevated Cr. to 3.2 (baseline high 2.7-2.9). Urgent
dialysis started on [**10-21**] (see per above) for uremia and fluid
overload. Last dialysis session PM of [**10-30**].
# UTI: UA dirty in the ED. Asx. H/o multiple UTI, E. coli
resistent to [**Date Range **]. Started ceftriaxone treatment on [**10-20**].
Culture and sensitivity showed E. coli only resistant to
Ampicillin. Patient treated with 5-day course of ceftriaxone.
# HL: Simvastatin decreased to 20mg daily [**3-15**] interactions with
amlodipine. LDL 54 in 03/[**2169**].
# Transitional issues:
Patient had Quantiferon-TB Gold result pending at time of
discharge. Result needed once patient moving to community
dialysis center.
Medications on Admission:
allopurinol 200 mg daily
amlodipine 10 mg daily
budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/Actuation HFA
Aerosol Inhaler 2 puffs po twice a day
Calcitriol 0.25 mcg Capsule Monday, Wednesday and Friday
Carvedilol 12.5 mg twice a day
Clopidogrel [Plavix] 75 mg daily
fluticasone 50 mcg Spray
gabapentin 300 mg at bedtime; 100mg twice during the day
Hydralazine 75 mg TID
Isosorbide dinitrate 20 mg TID
lidocaine [Lidoderm] 5 % (700 mg/patch) Adhesive Patch
Metolazone 2.5 mg twice once a week
Nitroglycerin [Nitrolingual] 0.4 mg/dose Spray, Non-Aerosol
As directed Every 5 minutes X 3 as needed for Chest painnr
polyethylene glycol 3350 17 gram/dose Powder
Prednisone 5 mg 1 Tablet(s) by mouth once a day Take 3 tabs x
5days 2 x 5, 1 x 5days then discontinue. [**2169-7-13**]
simvastatin 40 mg daily
torsemide 100 mg daily
tramadol 50 mg [**Hospital1 **]
ASA 81mg daily
cholecalciferol (vitamin D3) 2,000 unit Tablet
Docusate sodium [Colace] 100 mg Capsule twice a day
ferrous sulfate 134 mg (27 mg) Tablet daily
miconazole nitrate [Athlete's Foot] 2 % Powder
to buttocks and groin three times a day (started in rehab)
NPH insulin human recomb [Humulin N Pen] 100 unit/mL (3 mL)
Insulin Pen 16 units daily
nr sennosides [Senna Herbal Laxative] 12 mg 1 Capsule
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
4. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. hydralazine 100 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
7. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. nitroglycerin 0.4 mg/dose Spray, Non-Aerosol Sig: One (1)
spray Translingual as directed as needed for chest pain: may
repeat every 5 minutes up to 3 times.
10. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as
needed for constipation.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
13. Vitamin D-3 2,000 unit Tablet Sig: One (1) Tablet PO once a
day.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
15. ferrous sulfate 134 mg (27 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
16. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for constipation.
17. miconazole Powder Sig: One (1) Miscellaneous three
times a day: to affected buttock or groin area.
18. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
Sixteen (16) unit Subcutaneous once a day.
19. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
20. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
21. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
22. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY:
Acute on chronic CHF
CKD on dialysis
Uremia
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure taking care of you during your
hospitalization. You were admitted to us because you had
shortness of breath and heart failure exacerbation.
Your kidneys were failing and you became very drowsy because of
toxin buildup in your system that your kidneys were not able to
filter.
You started hemodialysis, which helped take off fluids from your
lungs and toxins from your blood. You will continue having
dialysis at the dialysis center after you leave the hospital.
We made the following changes to your medications:
STARTED Sevelamer
STARTED Nephrocaps
INCREASED Hydralazine to 100mg three times a day
INCREASED Carvedilol to 25mg twice a day
DECREASED Allopurinol
DECREASED Simvastatin
STOPPED Torsemide
STOPPED Metolazone
STOPPED Gabapentin
STOPPED Tramadol
Followup Instructions:
Department: RHEUMATOLOGY
When: THURSDAY [**2169-11-2**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2169-11-13**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2169-11-16**] at 2:30 PM
With: DR. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
Completed by:[**2169-10-30**]
|
[
"5990",
"40391",
"5849",
"4280",
"41401",
"2724",
"25000",
"V5867"
] |
Admission Date: [**2131-7-6**] Discharge Date: [**2131-7-14**]
Date of Birth: [**2058-7-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
coronary aretery bypass grafts x 4
(LIMA-LAD,SVG-dg,SVG-OM,SVG-PDA) [**2131-7-6**]
History of Present Illness:
This 72 year old white male with known coronary artery disease
has had recurrent palplitations and dyspnea. A stress test was
positive and a cardiac csatheterization reveled triple vessel
disease. He was referred for revascularization for which he is
now admitted.
Past Medical History:
hypertension
fatty liver
noninsulin dependent diabetes mellitus
paroxysmal atrial fibrillation
s/p appendectomy
Social History:
dental exam within 6 months
lives with his wife. 50-100 pk year history prior to 16 years
ago
rare ETOH use
parttime truck driver,retired fireman
Family History:
father and brother with coronary disease in 50s
Physical Exam:
Pulse: 73 sr Resp: 16 O2 sat: 98% RA
B/P Right: 195/94 Left: 184/97
Height: 66" Weight: 155
General: WDWN in NAD
Skin: Warm, dry and intact
HEENT: NCAT, PERRL, EOMI, sclera anicteric, OP benign. Teeth in
good repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, I/VI Systolic ejection murmurbest heard at
right sternal border.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit Right: + Bruit Left: None
Pertinent Results:
[**2131-7-10**] 01:00AM BLOOD WBC-5.4 RBC-3.05* Hgb-9.2* Hct-26.5*
MCV-87 MCH-30.0 MCHC-34.6 RDW-14.5 Plt Ct-209
[**2131-7-10**] 01:00AM BLOOD Glucose-146* UreaN-13 Creat-0.7 Na-135
K-3.8 Cl-101 HCO3-27 AnGap-11
[**2131-7-6**] 12:27PM BLOOD UreaN-13 Creat-0.7 Cl-109* HCO3-23
[**2131-7-11**] 05:05AM BLOOD WBC-5.6 RBC-3.58* Hgb-10.4* Hct-30.9*
MCV-87 MCH-29.2 MCHC-33.7 RDW-14.8 Plt Ct-300
[**2131-7-12**] 09:10AM BLOOD PT-17.1* PTT-51.4* INR(PT)-1.5*
[**2131-7-11**] 05:05AM BLOOD Glucose-157* UreaN-12 Creat-0.7 Na-135
K-3.8 Cl-100 HCO3-24 AnGap-15
[**2131-7-13**] 04:50AM BLOOD PT-24.5* PTT-54.3* INR(PT)-2.3*
[**2131-7-12**] 06:00PM BLOOD PTT-65.7*
[**2131-7-12**] 09:10AM BLOOD PT-17.1* PTT-51.4* INR(PT)-1.5*
[**2131-7-13**] 04:50AM BLOOD UreaN-14 Creat-0.9 Na-137 K-3.9 Cl-103
[**2131-7-8**]
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W&W/O
CONTRAST Clip # [**Clip Number (Radiology) 40079**]
Reason: evaluate for R MCA stroke
1. Multiple punctate acute infarcts bihemispherically in
watershed
distribution, many more on the right than on the left.
2. High-grade proximal right internal carotid artery stenosis.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
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.
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the aortic arch.
There are complex (>4mm) atheroma in the descending thoracic
aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
pericardial effusion.
POST_BYPASS:
Biventricular normal systolic function. LVEF 55%. Trivial MR.
Mild AI.
Intact thoracic aorta.
Brief Hospital Course:
On [**2131-7-6**] Mr.[**Known lastname 40080**] was taken to the Operating Room and
underwent coronary artery revascularization x 4 (left internal
mammary artery grafted to the left anterior descending
artery/Saphenous vein grafted to the Diag/Obtuse
Marginal/Posterior descending artery). Please refer to
Dr[**Last Name (STitle) **] operative report for further details. The patient
tolerated the procedure well and was weaned from bypass on Neo
Synephrine and Propofol in sinus rhythm. He was transferred to
the CVICU for further invasive monitoring. He awoke
neurologically intact, weaned from his drips and was extubated
without incident postoperative night. CTs were removed per
protocol and subsequently temporary pacing wires. Beta
blockers/Statin/aspirin and diuresis were initiated. POD 3 he
was transferred to the floor for further monitoring. Physical
Therapy was consulted to evaluate his strength and mobility.
On POD 2 he was noted to have mild weakness on the left hand and
arm and left neglect with visual field cut. A neurology consult
was obtained and a head CT suggested a right lucunar infarct of
indeterminate age. A MRA demonstrated multiple watershed
punctate infarcts, more so on the right than left.
Mr.[**Known lastname 40080**] was transferred back to the CVICU for closer
monitoring and CVA evolution. Physical therapy continued to work
with him and by POD6 he had only minor residual weakness of the
left arm.
Vascular surgery saw him and anticoagulation was begun with ASA,
Plavix and a Heparin infusion, followed by Coumadin. He will be
followed after discharge and the 90% right carotid stenosis
addressed after recovery from his cardiac surgery.
He went into rapid atrial fibrillation on post operative day 6
and converted to sinus rhythm with 20 mg IV Lopressor.
Lopressor was titrated up and he remained in sinus rhythm for
the remainder of his hospital course.
Arrangements were made for Coumadin follow up with Dr. [**First Name (STitle) 3646**].
His target INR is 2-2.5. First draw to be done by VNA [**7-15**] with
results called to [**Telephone/Fax (1) 40081**]. POD# 8 he was cleared by Dr.
[**Last Name (STitle) 914**] (Dr.[**Name (NI) 5572**] colleague) for discharge to home with
VNA/OT. All follow up appointments and precautions were advised.
Medications on Admission:
Atnelolo 50mg daily
ASA25mg daily
vitamin
Glyburide 5mg AM/2.5 mg in PM
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day: one
tablet in AM(5mg), [**2-3**] tablet in PM(2.5mg).
Disp:*60 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): two tablets twice a day for two weeks, then one
tablet twice daily for two weeks, then one tablet daily.
Disp:*100 Tablet(s)* Refills:*2*
9. Outpatient [**Name (NI) **] Work
PT/INR on 6/***, then prn. Call results to ****
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: INR goal of [**3-6**].5 for atrial fibrillation. Coumadin
will be dosed by Dr. [**First Name (STitle) 3646**] .
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x4
paroxysmal atrial fibrillation
cerebrovascular disease
s/p right hemispheric stroke
hypertension
s/p appendectomy
fatty liver
noninsulin dependent diabetes mellitus
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with oral analgesics
Incisions:
sternal - healing well, no erythema or drainage
Leg/Left - healing well, no erythema or drainage. Edema:none
Discharge Instructions:
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.
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**]).
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on Thurs., [**8-9**] at 1:30pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12816**] ([**Telephone/Fax (1) 12817**]) in [**2-3**]
weeks
Cardiologist: Dr. [**First Name (STitle) 3646**] in [**2-3**] weeks [**Telephone/Fax (1) 21903**]
Vascular :[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], call in [**4-5**] weeks
Neurology: Dr.[**Last Name (STitle) **], call in [**4-5**] weeks
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Labs: PT/INR for Coumadin ?????? indication: s/p Multiple punctate
acute infarcts bihemispherically in watershed distribution, many
more on the right than on the left. 90% right carotid stenosis.
Goal INR: 2-2.5
First draw: [**2131-7-15**]
Results to: Dr. [**First Name (STitle) 3646**]
phone: [**Telephone/Fax (1) 40081**]
Completed by:[**2131-7-14**]
|
[
"41401",
"42731",
"25000",
"4019"
] |
Admission Date: [**2183-7-28**] Discharge Date: [**2183-8-2**]
Date of Birth: [**2121-4-10**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Hematuria.
Major Surgical or Invasive Procedure:
Left nephroureterectomy.
History of Present Illness:
Mr [**Known lastname **] is a 64 year old gentleman with a remote tobacco
history who presented with hematuria. Initially, there were
episodes of gross hematuria, left flank pain and left lower
quadrant pain. Workup revealed suspicious urine cytology,
positive NMP22 test. Cystoscopy and retrograde studies performed
at an outside hospital were normal. Ureteroscopy was performed
which showed a left renal pelvis tumor. MRI scan confirmed these
findings and did not show significant metastatic disease. After
appropriate consent, the patient decided that surgical therapy
would be the most appropriate route. All questions were answered
prior to proceeding.
Past Medical History:
1. Ischemic heart disease
2. MI history, in [**2163**], [**2171**] with a CABG and 2 stents in [**2177**]
3. 2 shoulder surgeries
4. lumbar lamis [**2157**]
5. stomach surgery for ulcers
Social History:
Previous smoking history of 10 pack years (recently quit). He is
married and occasionally takes alcohol. He denies any
recreational drug usage.
Family History:
Noncontributory.
Physical Exam:
General: well nourished, well appearing, resting comfortably,
without any apparent distress. He is orientated to time, person
and place.
CVS: regular rate and rhythm, audible prosthetic valve sounds.
Chest: clear to auscultation bilaterally.
GIT: soft, nontender and nondistended.
Extremities: no abnormalities detected.
Pertinent Results:
[**2183-8-2**] 08:15AM BLOOD WBC-7.4 RBC-2.89* Hgb-9.2* Hct-27.4*
MCV-95 MCH-32.0 MCHC-33.8 RDW-14.3 Plt Ct-144*
[**2183-8-1**] 06:16AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.3* Hct-27.6*
MCV-92 MCH-30.9 MCHC-33.6 RDW-14.0 Plt Ct-128*#
[**2183-7-31**] 03:03AM BLOOD WBC-9.1 RBC-2.86* Hgb-9.2* Hct-26.2*
MCV-92 MCH-32.2* MCHC-35.1* RDW-13.9 Plt Ct-85*
[**2183-8-2**] 08:15AM BLOOD Glucose-95 UreaN-26* Creat-1.5* Na-141
K-4.0 Cl-106 HCO3-26 AnGap-13
[**2183-8-1**] 06:16AM BLOOD Glucose-85 UreaN-31* Creat-1.5* Na-141
K-4.3 Cl-106 HCO3-24 AnGap-15
[**2183-7-31**] 03:03AM BLOOD Glucose-93 UreaN-24* Creat-1.8* Na-140
K-4.4 Cl-107 HCO3-26 AnGap-11
[**2183-7-30**] 02:56AM BLOOD Glucose-95 UreaN-22* Creat-1.8* Na-139
K-4.7 Cl-108 HCO3-25 AnGap-11
Brief Hospital Course:
Mr [**Known lastname **] was admitted on [**2183-7-28**] for his surgical
procedure. His procedure was scheduled for the same day.
Preoperatively, consent was obtained, and he was prepared for
surgery. In the operating room, the patient was prepped and
draped in the usual sterile fashion after induction of general
anesthetic and placement of a Foley catheter. Throughout the
surgery, there were no complications.After completion of the
procedure, The patient was transferred stable to the intensive
care unit. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was the attending surgeon of
record and was present and scrubbed throughout the entire
procedure. In the ICU, Mr [**Known lastname **] was in a considerable amount of
pain, and was heavily sedated and confused. He was given
intravenous pain medication, and later became more calm and
awake. He had no new issues or complaints. On occassion, he
would have no recall of his surgery, but had no other symptoms
including chest pain, nausea or vomiting. Over the course of the
next two days, he began to become more aware of his
surroundings. His nasogastric tube and chest tubes were removed,
and his pain medications kept at an optimal level. He was
transfered to the floor on the [**Hospital Ward Name 516**] of [**Hospital1 18**] where he was
started on a regular diabetic diet after he passed flatus, and
changed to oral pain medications. He continued to progress very
well, although it was noted that he became confused when given
doses of morphine (and hence, the dosages of morphine was kept
at a minimal level).
Medications on Admission:
1. aspirin
2. avapro
3. isosorbide
4. lipitor
5. toprol
6. zetia
7. nisapan
8. cholestryamine
Discharge Medications:
1. Ciprofloxacin 500 mg
2. Colace 100 mg
3. Hydromorphone 4 mg
4. Acetaminophen 325 mg
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 5450**] VNA
Discharge Diagnosis:
Left transitional cell carcinoma of the renal pelvis.
Discharge Condition:
Stable.
Discharge Instructions:
The pain medicine you are given can make you drowsy. Do not
drive or operate heavy machinery while on medication.
If you have medical symptoms including a high fever, chest pain,
shortness of breath, please see your physician or return to the
Emergency Department as soon as possible.
You may continue your home medications, and those prescribed by
your surgeon while in hospital. You are also being prescribed an
antibiotic, for which you are meant to start the day BEFORE your
follow-up appointment and continue for 3 days.
Followup Instructions:
Please arrange a follow-up appointment with Dr. [**First Name (STitle) **] [**Name Initial (MD) **]
[**Name8 (MD) **], M.D. by calling ([**Telephone/Fax (1) 4276**].
Completed by:[**2183-8-2**]
|
[
"V4581",
"412"
] |
Admission Date: [**2142-6-21**] Discharge Date: [**2142-6-26**]
Date of Birth: [**2072-11-22**] Sex: F
Service: NEUROSURGERY
Allergies:
Nut Sup, Glucose Intolerant #1 / Spironolactone / Bactrim DS /
Fluarix [**2135**]-[**2136**] (PF)
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Residual Pituitary Adenoma
Major Surgical or Invasive Procedure:
[**2142-6-21**] Right Craniotomy for resection of pituitary ademona
History of Present Illness:
69yo woman with pituitary lesion who underwent a subtotal
transphenoidal resection in 2/[**2140**]. Pathology was
c/w ACTH secreting pituitary adenoma. MRI [**12-11**] showed residual
adenoma centered in the supracellar cistern with radiologic
compression on the optic apparatus.
On her last visit it was recommended that she have an open
resection to decompress the optic apparatus. The patient wanted
to wait and have an reconsultation with Radiation oncology.
Patient denies visual problems, heat intolerance, breast
leakage, wt loss or gain.
Past Medical History:
Diabetes, hypertension , GERD, glaucoma, cataract, hypokalemia,
(+)PPD s/p INH, AV reentrant and nodal tachycardia, left knee
OA,
ectopic pregnancy surgery, tubal ligation, appendectomy,
parathyroidectomy, knee surgery
Social History:
No tob/etoh. Lives independently with husband. [**Name (NI) 1403**] FT in
environmental services here at [**Hospital1 **].
Family History:
Mother died in childbirth, Father 98 and only hard of hearing; 4
children, daughter with MS.
Physical Exam:
On Admission:
Gen: AF VSS;
WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: no adventicious sounds
Cardiac: RRR to auscultation
Abd: Soft, NT
warm peripherals
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: . Strength full power [**5-5**] throughout. No pronator drift
Sensation: Intact to light touch; no paresthesias
Symmetric brisk reflexes
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger bilaterally
No extrapyramidal signs
On Discharge:
Pertinent Results:
MRI Brain [**6-21**]:
Surgical planning study with surface markers demonstrates a
sellar and suprasellar mass suggestive of residual pituitary
neoplasm. No
other abnormalities are seen. No hydrocephalus or enhancing
brain lesions are identified.
CT Head [**6-21**] post-op
1. Expected post-surgical changes with bilateral prefrontal
pneumocephalus and a small amount of blood products layering
along the right frontal dural surface.
2. No evidence of intraparenchymal hemorrhage.
MRI Brain Post-op [**6-22**]:
1. No evidence of residual enhancement within the resection
bed. Recommend continued followup after the immediate
postoperative changes have resolved.
2. Normal postoperative appearance after right craniotomy
without evidence of large postoperative hemorrhage
Brief Hospital Course:
[**Known firstname 99759**] [**Known lastname 174**] was admitted to the Neurosurgery service after
right craniotomy for resection of residual pituitary adenoma.
Postoperatively she was admited to the Neuro-ICU for frequent
neuro checks and blood pressure control less than 140.
Endocrinology service was consulted. Postoperative head CT
showed expected post-operative changes. She was monitered with
frequent labs and UAs and her urine output was monitered closely
for signs of DI. She had increasign sodiums overnight on [**6-21**]
into [**6-22**], endocrinology did not feel that she required DDAVP or
vasopressin. She was started on IV fluids and her urine output
and lab valuyes continued to be closely monitoried. On [**6-22**] she
underwent an MRi scan of teh brain to assess for post-operative
change which showed no evidence of residual enhancement within
the resection bed. Endocrine recommended hydrocortisone 40mg in
am and 20mg in pm, then on [**6-23**] she should recieve 20mg in am
and 10mg in pm. She may drink to thirst. D5W was discontinued
and q6h labs were continued. She was albe to be OOB and dangle
her feet at the edge of the bed. On [**6-24**], a-line was removed and
foley d/c'ed. Hydorcortisone was decreased to 20mg in am and no
dose in pm.
On [**6-25**], cortisol level was drawn and was 12.9. She remains in
stable condition, ambulating independently and reports no
drainage. She was transferred to the floor and PT/OT consulted.
She recieved on dose of 20mg hydrocortisone in the am. Her
cortisol level was normal, so hydrocotisone was discontinued.
She was cleared by PT and nursing was working with her and
stairs. Patient felt unsteady on her feet and requested that she
have more time in the hospital.
On [**6-26**], patient was doing well. She was ambulating
independently and felt more comfortable being discharged home
today. She was discharged home and should follow up with
endocrine in one week and neurosurgery in 4 weeks.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amlodipine 10 mg PO DAILY
2. Aprepitant 40 mg PO ONCE Duration: 1 Doses
3 hours prior to preop
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Metoprolol Succinate XL 200 mg PO DAILY
6. Potassium Chloride 30 mEq PO DAILY Duration: 24 Hours
Hold for K >4.0
7. Valsartan 320 mg PO DAILY
8. Bisacodyl 10 mg PO DAILY:PRN Constipation
9. Calcium Carbonate 600 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Fish Oil (Omega 3) Dose is Unknown PO DAILY
Discharge Medications:
1. Outpatient Lab Work
seurm and urine NA, serum osm and urine osm
2. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*90
Capsule Refills:*0
3. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-1**] Capsule(s) by mouth every four (4) hours
Disp #*60 Capsule Refills:*0
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Valsartan 320 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Vitamin D 1000 UNIT PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
10. Calcium Carbonate 600 mg PO DAILY
11. Bisacodyl 10 mg PO DAILY:PRN Constipation
12. Amlodipine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pituitary adenoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-10**] days(from your date of
surgery) a wound check. This appointment can be made with the
Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need an MRI of the brain with or without gadolinium
contrast.
?????? Please follow up with Endocrine in 1 week. You can
schedule this appointment by calling [**Telephone/Fax (1) 1803**].
Completed by:[**2142-6-26**]
|
[
"4019",
"25000",
"53081"
] |
Admission Date: [**2144-6-27**] Discharge Date: [**2144-7-8**]
Date of Birth: [**2088-4-18**] Sex: M
Service: MEDICINE
Allergies:
Coreg
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
RLE stump wound infection, urinary tract infection and altered
mental status
Major Surgical or Invasive Procedure:
[**2144-7-6**] debridement, primary closure R BKA
[**2144-7-1**] debridement right BK stump
failed lumbar puncture times three
History of Present Illness:
Mr. [**Known lastname **] is a 56 year-old man with a history of kidney
transplant x 2, DM, bilateral BKA with RLE non-healing ulcer
(right BKA in [**2144-5-21**]), who presents from rehab with AMS. Of
note, he was recently discharged on [**2144-6-13**] after being admitted
with a CHF exacerbation; at that time, he also had a wound VAC
placed on his right stump and was treated with two weeks of
vancomycin for an enterococcus wound infection. He was doing
well at his nursing home until the day prior to admission when
he was noted to have worsening mental status. He was also found
to have a UTI and was started on imipenem. On the day of
admission, he was found standing next to his bed on his stumps
and was combative and noncooperative with nursing home staff,
pulling out both his PICC and foley. He was then transferred to
the ED for further evaulation.
.
In the ED, initial vs were: T 99.2 P 51 BP 141/83 R 18 O2 97%ra
sat. He was given vancomycin and zosyn, later spiked a
temperature to 102.9 rectal which resolved with PR tylenol, and
was placed in wrist restraints for combativeness. His right BKA
was draining purulent material and vascular was consulted, with
a recommendation to start broad spectrum antibiotics. He was
also noted to have diarrhea and an abdominal CT was performed to
rule out colitis or an abdominal process, with an initial read
that was negative. Because of his history of VRE, he was also
given linezolid and then ceftriaxone 2g/acyclovir 50 mg x 1 to
cover for meningitis. An LP was attempted (3 passes) but was
unsuccessful. He was admitted to the MICU because of his severe
agitation and concern that he would fail management on the
floor.
.
On the floor, he was agitated but intermittently cooperative
with interview and exam.
Past Medical History:
- CHF with Known EF 25-35%
- PVDF with a right foot nonhealing ulcer s/p right SFA-to-DP
bypass graft, a nonreverse saphenous vein in [**2134**], a left BKA
in [**2133**], R BKA [**2144-5-21**]
- ESRD secondary to his diabetes s/p failed LLRT in [**2116**], second
LRRT in [**2135**] (stable)
- CAD s/p myocardial infarction, s/p angioplasty with stent
placement
- HTN
- CVA [**2131**]
- type 1 insulin dependent diabetes with triopathy
- GERD
- Hyperlipidemia on a statin
- left AVF fistula
- Chronic diarrhea [**3-9**] to ? diabetic autnomic neuropathy
- Recent [**First Name9 (NamePattern2) **] [**Doctor Last Name **]. Enterococcus stump infection, on [**Doctor Last Name **]
Social History:
Lives alone, recently in a rehab facility. Has an intermittent
smoking history of approximately 20-30 packyears. Smoked 1
cigarette today. Denies EtOH or other drug use.
Family History:
M: Colon Ca
F: Prostate Ca
Physical Exam:
Vitals: T: 98 BP: 128/70 P: 80 R: 18 O2: 97%ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: 2+ RLE edemma, no edema LLE. R BKA stump with erythema, s/p
vac dressing removal, 3 cm ulcerated wound on anterior stump,
base of stump also with ulcertation, erythema, and purulent vs
fibrinous appearing material.
Pertinent Results:
[**2144-6-27**] 06:00PM URINE COMMENT-SPERM SEEN
[**2144-6-27**] 06:00PM URINE RBC-0-2 WBC-[**12-25**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2144-6-27**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2144-6-27**] 06:00PM NEUTS-80.2* LYMPHS-14.2* MONOS-4.8 EOS-0.7
BASOS-0
[**2144-6-27**] 06:00PM WBC-7.2 RBC-3.44* HGB-10.0* HCT-30.9* MCV-90
MCH-29.0 MCHC-32.3 RDW-14.9
[**2144-6-27**] 06:00PM CK-MB-NotDone
[**2144-6-27**] 06:00PM cTropnT-0.14*
[**2144-6-27**] 06:00PM LIPASE-7
[**2144-6-27**] 06:00PM ALT(SGPT)-11 AST(SGOT)-24 CK(CPK)-83 ALK
PHOS-263* TOT BILI-0.4
CT HEAD [**2144-6-27**]:
IMPRESSION: No acute intracranial pathology including no
hemorrhage.
CT ABDOMEN PELVIS [**2144-6-28**]:
1. Cardiomegaly, small pericardial effusion and small bilateral
pleural
effusions, body wall edema. Findings likely secondary to volume
overload.
2. Small amount of gas in bladder, mild bladder wall thickening
and
perivesical stranding may be seen in the setting of infection.
Recommend
clinicalcorrelation.
3. Bilateral atrophic native kidneys are in place. Transplanted
kidney is
noted within the right lower quadrant area.
4. Cholelithiasis with no evidence of cholecystitis.
5. Extensive atherosclerosis with prior right SFA stenting.
KNEE XRAY [**2144-6-29**]:
The patient is status post right-sided below-the-knee
amputation. There is
soft tissue gas in an ulcer adjacent to the distal tibial stump.
However, the
cortical margins are unchanged and preserved since the previous
study.
Underlying osteomyelitis is likely given the development of the
ulcer
extending to exposed bone (best seen on the lateral view). There
is increase
in the soft tissue swelling since the prior study. Vascular
calcifications
are identified.
OPERATIVE REPORT [**2144-7-1**] DEBRIDEMENT:
PREOPERATIVE DIAGNOSIS: Nonhealing right BKA stump
POSTOPERATIVE DIAGNOSIS: Nonhealing right BKA stump
ASSISTANT: [**First Name8 (NamePattern2) 5045**] [**Last Name (NamePattern1) 29242**], M.D.
REASON FOR PROCEDURE: Mr. [**Known lastname **] is a 56-year-old male who
underwent right below-the-knee amputation a bout a month ago.
He
was found standing next to his bed on his BKA stumps at rehab,
confused and combative and was admitted to [**Hospital1 18**] for stump
infection and MS changes. The decision was made to debide the
stump back to viable bone and soft tissue. The procedure was
discussed in detail and the patient signed an informed consent
prior to the procedure.
OPERATIVE NOTE: The patient was taken to the operating room
and the right leg was prepped and draped in the usual sterile
fashion. A spinal block was performed and level was confirmed.
A
ronjour was then used to trim the tibia to healthy, bleeding
bone
which only required removal of about 1cm of distal tibia. Skin
and soft tissue was also debrided to healthy tissue. There was
a
pocket between the anterior and posterior compartments that
contained a 20cc fluid collection. This fluid was sent for
aerobic and anaerobic cultures. Hemostasis was achived and a
occlusive negative pressure dressing was placed with continuous
suction at 100mmHg.
The patient's indwelling foley catheter was removed at the
request of the primary team.
The patient awoke from MAC sedation, tolerated the procedure
well, and was taken to the PACU uneventfully.
The estimated blood loss of the procedure minimal.
Complications: none
Brief Hospital Course:
Patient is a 56 year old male s/p kidney transplant x 2, DM1,
bilateral BKA with RLE stump who presented with AMS secondary to
sepsis from UTI and osteomyleitis from stump site infection.
Patient is s/p multiple debridements and primary closure done by
vascular surgery currently on tobramycin.
.
# Right BKA stump infection / Osteomyelitis - S/p BKA procedure
in [**5-14**] by vascular surgeon, Dr. [**Last Name (STitle) 1391**]. On previous admission
[**2144-6-13**], pt had a wound VAC placed on his right stump and was
treated with two weeks of vancomycin for an (VSE) enterococcus
wound infection. Previously this infection cultured out VRE and
required treatment with linezolid, but ID not recommending any
antibiotics at this time. Initially presented with overlying
cellulitis, responded well to 5 days of CTX that was given for
UTI. Contributed to altered mental status on initial
presentation. Was found to have osteo in the stump and underwent
surgical debridement on [**7-1**]. Wound vac was changed on [**7-3**].
Went to OR today for primary clousure. Patient is to continue
[**Hospital1 **] wet to dry dressings. Patient had wound vac placed by
vascular surgery and to have outpatient follow up. Patient is
having tobramycin given at 240mg IV, first day on [**2144-7-3**],
initially dosed Q48H but will be dosed per through levels, <1.0.
Pain medication regimen adjusted, percocet PO and dilaudid PO
for breakthru pain. ID will assist in medication dosing.
.
# Resolved Altered mental status: On intial exam and at time of
admission to unit and at time of my initial exam on the floor,
patient had altered mental status. At ECF, patient was agitated
and pulling out lines. Patient is calm at this time. AMS was
thought to be in the setting of infection from UTI vs wound
infection. Other causes were considered including, Meningitis
less likely given absence of nuchal rigidity and photobia. Had
failed LP x3, was placed on meningitis ppx with
linezolid/ctx/acyclovir until cleared by neuro with exam with no
focal deficits. Head CT negative. Agiation initially required
physical and pharmacological restriants. Currently, alert and
oriented times three and full insight but has waxing and [**Doctor Last Name 688**].
Patient may benefit from outpatient psych.
.
# Resolved Urinary tract infection - [**6-24**] from rehab had
pan-sensitive E coli UTI that was being treated with imipeniem
for unclear reasons. Had foley placed in ED. Patient's repeat UA
on [**6-29**] was clean, IV ceftriaxone was stopped after 5d course.
.
# Stage 2 sacral decubti - stable, not superinfected
.
# Chronic diarrhea - has been worked up throughly by GI in the
past. C diff negative again on this admission. Symptomatic
treatment with loperamide
.
# Kidney Transplant/Acute renal failure: Status post failed LLRT
in [**2116**], second LRRT in [**2135**], and on prednisone, tacrolimus and
sirolimus as outpatient. Had tacrolimus dose decreased from 4 mg
to 2 mg po bid during last admission. Transplant team following.
Cr above baseline of 1.4. Function progressively improving.
Continued tacrolimus and prednisone. Renal transplant to follow
up as outpatient to determine restarting serolimus.
.
# chronic sCHF/CAD, EF 25%: Had troponin leak on this
presentation, but setting of ARF. Completed ROMI. Echo from
[**2144-6-5**] shows severe regional left ventricular systolic
dysfunction, c/w multivessel CAD. Mild mitral regurgitation.
Moderate pulmonary hypertension. Had CHF AE admission on [**2144-6-13**].
CAD s/p myocardial infarction, s/p angioplasty with PCI.
Continue aspirin 81, metoprolol, atorvastatin.
.
# Diabetes mellitus, type 1, moderately controlled: continue
ISS. [**Last Name (un) **] assisting but not formally consulting since he is
dictating his own insulin dosages.
.
# ? hx of skin ca - unclear diagnosis. Patient should have
outpatient derm for hx of skin cancers and now off serolimus.
.
# HTN - well controlled on diruetics and metoprolol
.
# CVA in [**2131**] - cont ASA 81
.
# GERD - on pantoprazole 40mg PO daily
.
# Code: DNI/DNR, discussed with patient
Medications on Admission:
Loperamide 2 mg PO q8hr
Flomax 0.4mg PO qHS
Atorvastatin 20mg PO Daily
Finasteride 5mg PO Daily
Sirolimus 1mg PO Daily
Aspirin 81mg PO Daily
Metoprolol 12.5 mg PO BID
Isosorbide mononitrate 60mg PO Daily
Pantoprazole 40mg PO Daily
Furosemide 80mg IV Daily
Furosemide 40mg PO Daily
Tacrolimus 2mg PO BID
Morphine 4-8mg IV prn pain
Prednisone 4mg PO Daily
KCl 20 mEq PO Daily
Alprazolam 0.5mg PO TID
Percocet q6hr prn
Glargine 8u SQ Daily
Lispro ISS
Pacrelipase 1cap PO w/ meals and qHS
Imipenem 500mg IV q8hr
Haldol 5mg PO q4hr prn
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for anxiety.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
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. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for breakthru pain.
17. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20)
units Subcutaneous at bedtime.
18. Humalog 100 unit/mL Cartridge Sig: per sliding scale units
Subcutaneous four times a day.
19. Sodium Polystyrene Sulfonate 15 g/60 mL Suspension Sig: Two
(2) mg PO ONCE (Once) for 1 doses.
20. Tobramycin Sulfate 40 mg/mL Solution Sig: One [**Age over 90 11578**]y
(180) mg Injection Q48H (every 48 hours) for 6 weeks: course
finishes on [**2144-8-17**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] health care east region
Discharge Diagnosis:
Primary:
R BKA stump infection with osteomyelitis and closure
resolved urinary tract infection
resolved altered mental status
.
Secondary:
Stage 2 sacral decubti
chronic sCHF EF 25%
Chronic diarrhea
s/p renal transplant
Diabetes mellitus, type 1, moderately controlled
Discharge Condition:
stable, on antibiotics
Discharge Instructions:
You were admitted for an infection of your right BKA stump and
the underlying bone and a urinary tract infection causing
altered mental status. You initially were treated in the
intensive care unit for your mental status and were given
ceftriaxone antibiotic for you urinary tract infection for five
days. You underwent two surgical procedures, on [**2144-7-1**]
debridement right BK stump and [**2144-7-6**] debridement, primary
closure R BKA. You had a wound vac placed to improve wound
healing. Your blood sugars were better controlled as your
insulin regimen was increased. You are to continue Tobramyicin
as your antibiotic for six weeks for the treatment of your bone
infection.
.
Please take all medications as prescribed and go to all
scheduled follow up appointments. Your dosage of tobramycin will
be adjusted based on trough levels. Sirolimus was stopped.
.
Please return to the hospital if you develop altered mental
status, fevers, or another infection at your stump site. Please
be compliant with your diabetic diet and take your insulin as
per your sliding scale.
.
Follow up:
Dr. [**Last Name (STitle) 1391**] - Vascular surgery on [**2144-8-12**] at 1:00pm at [**Last Name (NamePattern1) **]. Suite 5C in [**Hospital Unit Name **].
.
Renal transplant:Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2144-7-30**] 9:20
.
Dermatology:Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2144-9-8**] 1:15
.
Infectious Disease: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2144-8-14**] 9:30
Followup Instructions:
Dr. [**Last Name (STitle) 1391**] - Vascular surgery on [**2144-8-12**] at 1:00pm at [**Last Name (NamePattern1) **]. Suite 5C in [**Hospital Unit Name **].
.
Renal transplant:Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2144-7-30**] 9:20
.
Dermatology:Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2144-9-8**] 1:15
.
Infectious Disease: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2144-8-14**] 9:30
Completed by:[**2144-7-8**]
|
[
"0389",
"5849",
"5990",
"99592",
"4280",
"41401",
"V4582",
"412",
"4168",
"5859",
"53081",
"V5867",
"2724"
] |
Admission Date: [**2189-11-23**] Discharge Date: [**2189-12-5**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This 80 year old white female
was transferred in from the cardiac catheterization
laboratory from Dr. [**Last Name (STitle) **] office for an episode of chest
pain and EKG changes. She has a known history of mild aortic
stenosis, atrial fibrillation, diastolic heart failure,
hypertension and reports progressive chest pain occurring
interrupted he cold weather and on stairs and with activity.
Two weeks prior to admission, she had pain in her chest which
radiated to her arm. She is now admitted for Cardiac
Catheterization.
PAST MEDICAL HISTORY:
1. Significant of a history of mild aortic stenosis.
2. History of low back pain.
3. History of heart failure.
4. Atrial fibrillation.
6. History of hypertension.
7. History of glaucoma.
8. Status post arthritis, status post right total hip
replacement.
9. History of gastroesophageal reflux disease.
disconnected....
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2189-12-4**] 17:44
T: [**2189-12-4**] 22:49
JOB#: [**Job Number 92796**]
|
[
"41401",
"42731",
"4241",
"4280",
"412"
] |
Admission Date: [**2120-2-26**] Discharge Date: [**2120-3-1**]
Date of Birth: [**2040-3-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Rare dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2120-2-26**] Three Vessel CABG (LIMA-LAD, SVG-OM, SVG-> PDA)
History of Present Illness:
This is an 80-year-old patient with a recent episode of left arm
weakness who was investigated further and was found to have a
positive stress test. Further angiogram showed severe
triple-vessel disease with 80% left anterior descending and 90%
circumflex and 100% right coronary artery. The LV function was
well maintained with an ejection fraction of 60%, and he was
electively admitted for coronary artery bypass grafting.
Past Medical History:
Hypercholesterolemia
HTN
DJD
BPH
CRI
Chronic periodontal disease
AAA s/p endovascular stent [**2-28**]
Social History:
Retired teacher. Lives with wife. Remote smoking history. Denies
alochol use.
Family History:
Brother with MI at age 50
Physical Exam:
GEN: WDWN man in NAD
HEENT: Unremarkable
NECK: Supple, no JVD
LUNGS: Clear
HEART: RRR, Nl S1-S2
ABD: Benign
EXT: Warm, well perfused, no edema, no varicosities.
NEURO: Nonfocal
Pertinent Results:
[**2120-3-1**] 07:50AM BLOOD Hct-29.6*
[**2120-2-29**] 08:05AM BLOOD WBC-9.4 RBC-3.20* Hgb-10.0* Hct-28.7*
MCV-90 MCH-31.2 MCHC-34.9 RDW-13.9 Plt Ct-190
[**2120-3-1**] 07:50AM BLOOD UreaN-24* Creat-1.2 K-3.9
[**2120-2-29**] 08:05AM BLOOD Calcium-9.2 Phos-2.1* Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 65882**] was admitted to the [**Hospital1 18**] on [**2120-2-26**] for elective
surgical management of his coronary artery disease. He was taken
directly to the operating room where he underwent coronary
artery bypass grafting to three vessels. Please see operative
note for detail. Postoperatively he was taken to the cardiac
surgical intensive care unit for monitoring. On postoperative
day one, Mr. [**Known lastname 65882**] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. He was then transferred to the step down unit for
further recovery. Mr. [**Known lastname 65882**] was gently diuresed towards his
preoperative weight. His drains and pacing wires were removed
per protocol without complication. He remained in a normal sinus
rhythm without atrial or ventricular arrhythmias. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. Beta blockade, aspirin and
a statin were resumed. As his blood pressure remained elevated,
an ace inhibitor was eventually started and titrated for optimal
blood pressure control. Over several days, Mr. [**Known lastname 65882**]
continued to make steady progress and clinical improvements. He
was discharged to home on postoperative day four. His blood
pressure ranged between 110-140/60-70's on discharge and he was
in a normal sinus rhythm, rate in the 60's to 80's with first
degree AV block. His incisions were clean, dry and intact
without drainage. He will continue to require gentle diuresis as
he remained about 10 pounds above his preoperative weight.
Medications on Admission:
Lipitor 10mg QD
Aspirin 81mg QD
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days: please take with KCL.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days: please take with Lasix.
Disp:*28 Capsule, 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. 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*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
CAD - s/p CABG
Hypercholesterolemia
HTN
DJD
BPH
CRI
Chronic periodontal disease
AAA s/p endovascular aortic stent
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
one week.
4) No driving for 1 month or while on narcotics.
5) No lifting greater then 10 pounds for 10 weeks.
6) You may wash incision and pat dry. No swimming of bathing
until wound has healed.
7) No lotions, creams or powders to wound until it has healed.
8) Take lasix for one week as directed
9) Please call with any questions or concerns.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**First Name (STitle) **] in [**11-27**] weeks.
Follow-up with Dr. [**First Name (STitle) **] in 2 weeks. ([**Telephone/Fax (1) 65883**].
Please call all providers for appointments.
Completed by:[**2120-3-1**]
|
[
"41401",
"4019",
"2720"
] |
Admission Date: [**2195-11-19**] Discharge Date: [**2195-11-25**]
Date of Birth: [**2169-8-12**] Sex: F
Service: SURGERY
Allergies:
Cetacaine Anesthetic
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Left lower extremity pain
Major Surgical or Invasive Procedure:
Thrombolysis of Left Lower Extremity Deep Vein Thrombosis
1. Ultrasound-guided puncture of left common femoral vein.
2. Advancement of catheter to inferior vena cava
bifurcation.
3. Inferior venacavogram.
4. Serial venacavogram of left proximal lower extremity.
5. Stent placement at left common iliac vein, left external
iliac vein.
6. AngioJet mechanical and tissue plasminogen activator-
based thrombolysis of left common iliac vein, left
external iliac vein and bifurcation of inferior vena
cava.
History of Present Illness:
26F w/ UC s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**] and multiple complications which resulted
in a prolonged (~3month) hospital stay presents with new L-sided
DVT. We are consulted for management of the new DVT. Of note
during her last hospitalization she was diagnosed with a RLE
DVT,
and due to upcoming surgery, an IVC filter was placed. Since
that time she presented to an outpatient Hematologist to find
that she was a heterozygote for Factor V Leiden, and over this
past weekend she noted pain in her left anterior thigh.
Concerned over her hypercoagulable results and thigh pain, the
hematologist referred her for a BLE U/S, demonstrating a DVT
from
the L CFV to the calf. Notably the patient is without
phlegmasia, has minimal pain, and is tolerating her ADL's
without
much pain.
Past Medical History:
PMH: Ulcerative colitis s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**]; DVT of right superficial
femoral-popliteal vein [**8-14**]; Factor V Leiden heterozygous
PSH: as above; IVC filter placement [**8-14**]
Social History:
Originally from [**State 33977**], recently an MBA grad student at BU.
Denies tobacco. Social EtOH.
Family History:
Mother with [**Name2 (NI) **] s/p colectomy at age 33, brother with [**Name2 (NI) **]
relatively well-controlled. Maternal aunt with rheumatoid
arthritis. No colon ca.
Physical Exam:
Gen - tall, thin female in NAD
Pulm - CTAB
CV - Tachy rr, no m/g/r
Abd - +BS, soft, NTND, ostomy with flatus and stool
Extrem - RLE warm, +AT/PT, without swelling, LLE warm, +AT/PT,
without swelling, venopuncture site c/d/i
Pertinent Results:
[**2195-11-19**] WBC-7.7 Hct-32.6*
[**2195-11-20**] WBC-5.8 Hct-24.0*
[**2195-11-21**] Hct-28.0*
[**2195-11-22**] WBC-4.0 Hct-27.0*
[**2195-11-23**] WBC-2.7* Hct-25.1*
[**2195-11-24**] WBC-2.9* Hct-26.1*
[**2195-11-24**] Immunology (CMV) CMV Viral Load-PENDING
[**2195-11-19**] Duplex of lower extremities
IMPRESSION:
1. Unremarkable venous Doppler right lower extremity.
2. Extensive deep vein thrombosis involving the entire left
lower extremity
to the level of the common femoral veins.
Brief Hospital Course:
The patient was admitted to the Colorectal surgery service on
[**2195-11-19**] with an extensive left lower extremity DVT. She was
transferred to the [**Date Range **] service on HD 2 and underwent stent
placement and thrombolysis of the clot. The patient tolerated
the procedure well. Post operatively she continued thrombolysis
with TPA for 6 hours and was placed on a heparin drip for
further anticoagulation. Because of a Hct drop during the
procedure the patient was transfused two units of PRBC's and had
an apropriate rise in Hct. On POD 1 she was switched to lovenox
and transferred back to the Colorectal service because of mild
bleeding from her ostomy site.
Neuro: Post-operatively, the patient received Dilaudid PO, and a
lidocaine patch with good effect and adequate pain control.
CV: The patient was tachycardic throughout her hospitalization.
She was in the 110's to 120's when lying down and could go up to
the 150's with ambulation. A cardiology consult was placed and
an Echo was recommended to evaluate for a PE or any congenital
abnormalities. The Echo was unremarkable and the cardiologist
mentioned that her tachycardia is likely in response to her
prolonged illness, acute issues and deconditioning and that this
requiress further treatment of her underlying illness.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced on POD 1, which
was tolerated well. She was briefly made NPO during POD 2 when
she had mild bleeding from her ostomy, which resolved on its
own. She was made NPO for a possible scope by GI. Because the
bleeding resolved, GI decided not to scope her and instead
follow her Hct, and trend her LFT's which trended down
throughout this admission. Intake and output were closely
monitored.
ID: Post-operatively, the patient did not require antibiotics.
The patient's temperature was closely watched for signs of
infection. She did have a decreased WBC count this admission and
an ID consult was obtained. Dr [**Last Name (STitle) 2148**] thought that her
decreasing WBC count may be due to prolonged administration of
Valsyte. On POD 3, the Valsyte was stopped and her WBC was
monitored for 48 hours. Her WBC count [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 87477**]. Because
she had been treated for over a month with the medicaiton it was
though that she had an adequate duration of treatment. A CMV
viral load was obtained during this hospitalization. It was not
back at the time of discharge.
Prophylaxis: The patient received Plavix and Lovenox post
operatively. Given her history of Factor V Leiden, and multiple
DVT's, she will likely need long term anticoagulation. She will
continue these medications for the duration recommended by the
[**Last Name (NamePattern1) 1106**] surgery team and will follow up with them in one
month's time. She was encouraged to get up and ambulate as early
as possible.
At the time of discharge on POD 5, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
CYCLOBENZAPRINE - (Prescribed by Other Provider) - 10 mg Tablet
- 1 Tablet(s) by mouth once a day as needed for pain
HYDROCORTISONE ACETATE - (Prescribed by Other Provider) - 30 mg
Suppository - 1 rectally at bedtime prn
LIDOCAINE [LIDODERM] - (Prescribed by Other Provider) - 5 %
(700
mg/patch) Adhesive Patch, Medicated - 1 - 2 patches Topical once
a day applied to back Patch can stay in place for 12 hours and
should be removed for 12 hours
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for pain
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
PROPRANOLOL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth 1 twice a day
VALGANCICLOVIR [VALCYTE] - (Prescribed by Other Provider) - 450
mg Tablet - 2 Tablet(s) by mouth daily
ZOLPIDEM - 10 mg Tablet - One Tablet(s) by mouth at bedtime as
needed for sleep. (Fill if unable to fill prescription for
Ambien
CR)
ZOLPIDEM [AMBIEN CR] - 12.5 mg Tablet, Multiphasic Release - One
Tablet(s) by mouth at bedtime.
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet
-
2 Tablet(s) by mouth every 8 hours as needed for pain
CALCIUM CARBONATE - (Prescribed by Other Provider) - Dosage
uncertain
LOPERAMIDE - (Prescribed by Other Provider) - 1 mg/5 mL Liquid
-
5 - 10 ml by mouth 3 times a day
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for Pain for 5 days: Please do not drive or
drink alcohol while taking this medication.
Disp:*40 Tablet(s)* Refills:*0*
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for Pain for 2 weeks.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please take for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
4. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 1 months.
Disp:*21 * Refills:*0*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
6. trazodone 50 mg Tablet Sig: .[**4-4**] Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO
every eight (8) hours as needed for pain for 2 weeks.
Disp:*0 Tablet(s)* Refills:*0*
8. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO once a
day as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
9. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO four times a
day.
10. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TU) for 2 months.
Disp:*8 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left common iliac vein deep venous thrombosis.
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 a large vein thrombosis.
You required thrombolysis on this clot while admitted. You will
need to continue anticoagulation to prevent a recurrent clot.
You have follow-up appointments with Dr. [**Last Name (STitle) 3407**] made as written
below. You will need to continue your plavix and lovenox for 30
more days. Please monitor the puncture site on his leg for
bleeding or increased bruising, call Dr. [**Last Name (STitle) 3407**] or Dr. [**Last Name (STitle) 4488**]
office if you have any concerns or questions or go to the
emergency room if the following symptoms are severe: increased
swelling, increased pain, numbness in the leg, bluish/purple
coloring in the leg, or decreased sensation. You should keep
your left leg ace wrapped from foot to thigh or wear a thigh
high compression stalking until your follow-up appointment with
Dr. [**Last Name (STitle) 3407**]. Please avoid lifting anything greater than 10 lbs
for the next 5 days. You will need to be on anticoagulation for
the next year, this will be either be lovenox on coumadin with a
baby aspirin and will be decided with Dr. [**Last Name (STitle) 87478**] and [**Doctor Last Name 2148**]. If
you develop any rectal spotting of blood please call Dr. [**Last Name (STitle) 4488**]
office for advice, if the bleeding is severe go to the emergency
room. You have a supply of lovenox at home from previous
prescriptions, as the medication is so expensive you may use
these syringes but you are now taking 60mg and you will need to
waste the lovenox to the 0.6 line. I am giving you an
prescription to make up for the 10 days you are short, with this
prescription you will not need to waste. If you have any
problems with this please call the office for a new
prescription. Please check the expiration date on the lovenox
syringes you are using at home prior to use.
You no longer need to that the valgancyclovir for CMV treatment.
You developed a low white blood cell count from this medication.
Your most recent count is 2.8. You will see Dr. [**Last Name (STitle) 2148**] in
clinic next thursday for a lab draw to check your white blood
cell count. Please see the appointment time listed below. He
will also monitor the lab values for your blood while on the
lovenox. You will also be seeing him for your hematology needs.
While you were here you were also seen by cardiology to evaluate
your tachycaardia you have developed since your surgery. You had
an echocardiogram which was normal expcept for a small amount of
fluis around your heart which the cardiology department thinks
is not [**Last Name **] problem and that your tachycardia will improve as you
become more conditioned. They believe the tachycardia is related
to deconditioning. Please call the office if you feel as though
you have worsening shortness of breath, chest pain, worsening
fast heart rate that does not return to normal with rest.
Continue to Monitor
Please continue to monitor your ileostomy output and take
immmodium as needed. Call the office with any issues with your
ileostomy. Please continue to change the dressing on your
abdomen daily, apply a dry sterile gauze to the [**Last Name **].
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-13**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
You should follow the directions from your GI doctor about the
vitamin D, you only need to take the capsule 1 time a week for 8
weeks and then preceed as you were instructed by Dr. [**Last Name (STitle) 6925**].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2195-12-3**] 11:00, infectious disease/hematology, lab
(white blood cell count and PT check) at this appointment.
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2195-12-25**]
8:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2195-12-25**]
8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2195-12-25**] 9:00
Please call Dr[**Doctor Last Name **] office for a follow up appointment
following your visits with the [**Doctor Last Name 1106**] surgeons.
Completed by:[**2195-11-25**]
|
[
"42789",
"V5861"
] |
Admission Date: [**2131-3-15**] Discharge Date: [**2131-3-24**]
Date of Birth: [**2074-6-16**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old
male with hypertension, hypercholesterolemia, diabetes who
underwent coronary artery bypass graft on [**2131-3-8**]
which was a left internal mammary artery to left anterior
descending and an saphenous vein graft to obtuse marginal.
Apparently at the time the right coronary artery was
difficult to mobilize due to pericardial adhesions, so the
patient had a stenting of the right coronary artery and right
PLV with praxis DES. The patient did well postoperatively
and was discontinued on [**2131-3-14**]. The next evening,
the patient awoke with shortness of breath, orthopnea and
chest pain. The patient went to [**Hospital 41498**] Hospital where he
was treated for congestive heart failure and transferred to
[**Hospital6 256**] for further evaluation.
PAST MEDICAL HISTORY: Diabetes, hypercholesterolemia,
hypertension, coronary artery bypass graft/stent as noted.
ALLERGIES: Amoxicillin which gives him a rash.
MEDICATIONS ON ARRIVAL: Lopressor b.i.d., Colace, Aspirin
325 q.d., Plavix 75 q.d., Lasix 40 q.d., [**Doctor First Name 233**]-Ciel 20 q.d.,
insulin 70/30 25 units b.i.d.
SOCIAL HISTORY: No tobacco, occasional ethanol.
FAMILY HISTORY: Mother deceased, myocardial infarction at
age 46.
PHYSICAL EXAMINATION: Vital signs on arrival revealed 138/81
blood pressure, heart rate 92, respiratory rate 16, sating
96% on 2 liters. Physical examination on arrival revealed
patient lying flat in bed in no acute distress. Cardiac, no
jugulovenous distension, regular rate and rhythm, no murmurs,
rubs or gallops. Respiratory: Chest with median sternotomy,
clean, dry and intact. Mild rales bilaterally. Abdomen,
soft, no tenderness to palpation. Right groin without
hematoma, no bruits. 2+ lower extremity edema bilaterally.
LABORATORY DATA: Electrocardiogram showed normal sinus
rhythm at 88 beats/minute, slight ST depression, moderate AVL
with no significant change from the electrocardiogram done on
[**3-12**]. Laboratory data on arrival revealed creatinine
kinase 223, troponin .36 and MB fraction of CK was 18.
Sodium was 137, potassium was 4.3, chloride 101, carbon
dioxide 27, BUN 17, creatinine .8, glucose was 230. White
blood count was 11, hematocrit was 24.9 and platelets were
323.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**]
Service for further evaluation and probable repeat
catheterization to assess the surgery that had been done just
weeks prior. The catheterization was performed which showed
a widely patent saphenous vein graft to obtuse marginal and
left internal mammary artery to left anterior descending.
However, this showed an in-stent thrombosis of the praxis
stent to the PVLR. During the catheterization, there was an
unsuccessful attempt to reopen this thrombosis. No
ventriculography was done at this time.
Cardiovascularly, the patient's last ejection fraction of
40%, now with new insult to the right posterior lateral
artery from an in-stent rethrombosis. An echocardiogram from
[**3-16**], showed an ejection fraction of 25%. While in-house
the patient was continued on Lasix and his beta blocker and
an ACE inhibitor was added. It was attempted to decrease the
amount of fluid as he was in congestive heart failure. For
this rethrombosis, there was no acute intervention at this
point. There was thought that a small area of myocardium
will infarct and that only medical management is possible at
this point. The patient will be on Aspirin and Plavix along
with beta blockers. The patient will start a statin with
plans to check lipids once the acute event is over. During
the stay there were no additional electrocardiogram changes
and the CK peaked around 800 and his troponin peaked around
5. The patient continued to experience nausea as his anginal
symptom throughout his hospital stay until the last few days.
Also during this stay, the patient became hypotensive while
receiving blood for a low hematocrit. The patient was
started on Dopamine 2.5. Due to the tenuous nature of his
blood pressure, the Dopamine was increased to 5. At this
point the patient developed some ectopy and the Dopamine was
reduced down to 2.5. In order to diurese the patient
Natrecor was started the following day. Due to the fact that
the patient's blood pressure remained labile, the patient was
transferred to the CCU for further hemodynamic analysis. In
the CCU the patient had a internal jugular catheter placed
and a Swan-Ganz catheter placed as well. The patient's
pulmonary capillary wedge pressure at this point was 18. The
plan at this time was to continue the Captopril, Metoprolol,
Lasix and follow the intakes and outputs. In the CCU there
was very little need for pressors and the patient was off of
pressors altogether the following day which is the reason he
returned to the floor. After returning to the floor from the
CCU the patient became much more stable with improving
physical function. The patient diuresed well. The patient
worked with physical therapy and cardiophysical therapy to
the point where he was able to earn a 5 out of 5 cardiac
score in hopes of going home with [**Hospital6 407**].
Diabetes, the patient remained on his normal outpatient
regimen during his stay in the hospital. He also was on a
standing insulin sliding scale for any other hypo or
hyperglycemic event. There were no events during his stay.
Heme, the patient was transfused 3 units total while in the
hospital secondary to a low hematocrit. The desired
hematocrit was 20 to 30 of which it stayed for the rest of
this time.
Gastrointestinal, the patient apparently had coffee ground
emesis times one during his hospital stay and was put on
Protonix intravenously b.i.d. The patient did not have
recurrence of this episode.
There were no other major events during the hospital stay and
the patient will be going home with [**Hospital6 1587**] or to rehabilitation.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with [**Hospital6 407**] or
rehabilitation.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Hypertension.
3. Diabetes mellitus.
4. Status post coronary artery bypass graft with in-stent
rethrombosis.
5. Myocardial infarction.
6. Hypercholesterolemia.
DISCHARGE MEDICATIONS
1. Aspirin 325 p.o. q.d.
2. Atorvastatin 80 mg p.o. q.d.
3. Captopril 25 mg p.o. q.d.
4. .................. 75 mg p.o. q.d.
5. Docusate sodium 100 mg p.o. b.i.d.
6. Furosemide 80 mg p.o. q. AM
7. Furosemide 40 mg p.o. q. PM
8. Levofloxacin 500 mg p.o. q. 24
9. Lisinopril 20 mg p.o. q.d.
10. Metoprolol XL 50 mg p.o. q.d.
11. Pantoprazole 40 mg p.o. q. 12 hours.
FOLLOW UP: The patient will follow up with his primary
cardiologist as well as his primary care physician within the
next week to ten days for additional adjustments in
medications or regimen.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-611
Dictated By:[**Last Name (NamePattern1) 7170**]
MEDQUIST36
D: [**2131-3-22**] 18:46
T: [**2131-3-22**] 19:01
JOB#: [**Job Number 107666**]
|
[
"41071",
"4280",
"9971",
"5070",
"41401",
"25000",
"2859"
] |
Admission Date: [**2199-2-2**] Discharge Date: [**2199-3-6**]
Date of Birth: [**2127-9-21**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 71 year old
gentleman who was in his usual state of good health until
9:00 PM on the day of admission when he was eating dinner and
developed the worse headache of his life. He went to [**Hospital **]
Hospital where they found a subarachnoid hemorrhage. The
patient denies nausea, vomiting, chest pain or shortness of
breath. The headache is currently is [**3-28**].
PAST MEDICAL HISTORY: Hypertension and foot surgery in the
past.
ALLERGIES: No known allergies.
PHYSICAL EXAMINATION: Temperature was 98, blood pressure
137/100, respiratory rate 18, saturations 100 percent, heart
rate 72. HEENT - Pupils equal, round and reactive to light,
2 down to 1.5. Extraocular movements were full. Lungs -
Clear to auscultation bilaterally. Cardiovascular - Regular
rate and rhythm. Abdomen - Soft, non-tender, positive bowel
sounds. Extremities - No edema. Neurologic - Prefers eyes
closed, awake, alert and oriented times three and following
commands. Speech was fluent. Comprehension was intact. He
had no drift. His smile was symmetric. His strength was [**5-23**]
in all muscle groups. His reflexes were 2 plus throughout
and his toes were downgoing and visual fields were full.
He was admitted to the neurosurgical service in the ICU for q
one hour neuro checks. He underwent an angiogram which
showed a ruptured ACA aneurysm which he had coiled on
[**2199-2-3**]. On [**2-4**] postoperatively being recovered in the ICU,
he had several episodes of bradycardia down into the 40's and
ventricular bigeminy. The bradycardia was felt to be related
to vagal activity after his hemorrhage and was treated
conservatively with telemetry. The patient was asymptomatic
in terms of blood pressure problems. The patient had a
repeat head CT on [**2199-2-4**] which showed no new hemorrhage.
The ventricles were slightly smaller. The patient was
extubated on [**2199-2-5**]. He had an echocardiogram which showed
an ejection fraction of 55 percent, 1 plus AR and trivial MR.
The patient had a head CT on [**2-5**] that was stable or improved
from [**2-4**]. His neurologic status remained stable. The
patient had a ventricular drain placed at the time of
admission. On [**2199-2-8**] the patient had a repeat angiogram
which showed a stable appearance of the aneurysm with
moderate spasm in the right A1 segment. The patient's blood
pressure was kept in the 150-190 range and CVP 8-10 range.
The patient's ventricular drain was at 10 cm above the
tragus. The patient was neurologically stable and intact.
On [**2-7**] the patient had a chest x-ray which showed mild to
moderate volume overload and the patient spiked to 102.9. He
was continued cefazolin 1 gram IV q eight hours for
ventricular drain prophylaxis and drain cultures showed 2
plus polys but no organisms from CSF sent on [**2-8**]. On [**2-6**]
CSF showed 1 plus polys and no organisms.
On [**2199-2-10**], the patient spiked to 103. Urinalysis was
negative. CSF cultures continued to be negative. Blood
cultures were pending. The chest x-ray showed resolving
perihilar edema and new bibasilar opacities and right small
pleural effusion. The patient also was hyponatremic and was
having sodium checks every six hours. The patient was
started ceftriaxone and vancomycin prophylactically and
continued to have no positive cultures.
On [**2199-2-13**], the patient had a CTA which again showed
vasospasm of the right A1 segment of the anterior
circulation. The patient's blood pressure continued to be
kept in the 150-190 range.
The patient's temperature resolved and all cultures were
negative to date. Ceftriaxone and vancomycin were
discontinued on [**2199-2-13**]. The patient was continued on
cephazolin 1 gram IV q eight for drain prophylaxis. The
chest x-ray showed no consolidation and less atelectasis on
[**2199-2-13**]. The patient had his ventricular drain changed to a
lumbar drain on [**2199-2-13**] and the drain was clamped. The
patient was transferred to the Step-Down Unit on [**2199-2-17**].
The patient had the lumbar drain removed after a head CT
showed a stable size of the ventricles with the ventricular
drain clamped for 24 hours. On [**2199-2-20**] the patient had an LP
and opening pressure was 22 and 30 cc of CSF was sent. The
patient had serial LP's done to assess for high opening
pressures with the last being on [**2199-2-26**] with an opening
pressure of 21 and closing pressure of 9. The patient was
then scheduled for a VP shunt placement, however, the
patient's neurologic status remained stable and no VP shunt
was placed. The patient remained neurologically intact and
was followed by physical therapy and occupational therapy and
found to be stable for discharge to home on [**2199-3-6**].
Medications at the time of discharge include Metoprolol 12.5
mg PO BID, Keppra 1,000 mg PO BID, lansoprazole 30 mg PO q
day and insulin for sliding scale.
The patient's condition was stable at the time of discharge.
He will follow up with Dr. [**Last Name (STitle) 1132**] in two weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2199-3-6**] 12:19:15
T: [**2199-3-6**] 14:01:50
Job#: [**Job Number 59535**]
|
[
"2761",
"5180",
"5119",
"4019",
"25000",
"3051"
] |
Admission Date: [**2154-3-2**] Discharge Date: [**2154-3-5**]
Date of Birth: [**2135-7-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
18M history of intermittent asthma, tobacco abuse presents with
asthma exacerbation. Patient states that he started developing a
cold last night at work with rhinorrhea, dry cough, and
headache. He started to also having wheezing, but did not have
his inhaler present while at work. When he came home, he
utilized his inhaler; however, this did not relieve his symptoms
of shortness of breath and wheezing. He states that he has
significant significant shortness of breath with wheezing.
He denies fever, cough, myalgias, chest pain, or other symptoms
except as above.
He also denies sick contacts. [**Name (NI) **] denies receiving flu
vaccination this year. He states that tobacco abuse has been
weaned down in past few months but actively smoking. He denies
any occupational exposures, changes in household (carpet
cleaning, new pets/animals, etc).
At baseline, he states that his asthma has been present since
childhood. He has required ER visits 2-3 times over the past
five years. He has never been hospitalized or required PO
prednisone.
.
In the ED inital vitals were, 00:35 5 98.5 118 165/97 18 95% ra
A CXR was performed that showed no acute cardiopulmonary
process. He was given multiple nebulizer treatments and
prednisone 60 mg PO x 1. His initial peak flow was 150. Repeat
after 3 nebs was 200.
Initial exam showed poor air movement and diffuse wheezing. He
was able to speak in complete sentences and was not in
respiratory distress with no accessory muscle usage.
He was intially placed in observation for nebulizer treatments
every two hours. However while he was in observation, he
triggered for pulse oximetry [**Location (un) 1131**] of 88 % on room air. On
repeat exam, his lungs were very tight with poor air movement.
He was given magnesium 2 mg. He received continuous nebulized
albuterol for an hour and on repeat exam, he still have poor air
movement. He was subsequently admitted to the MICU for continued
asthma exacerbation and poor peak flow measurements.
Labs on transfer were significant for WBC 13.4, Hgb 16.6, Plt
340 with neutrophilia and lymphopenia. Chem panel was within
normal limits except hyperglycemia.
VS on transfer: 110 19 152/101 94% on neb, peak flow 200.
.
On arrival to the ICU, patient was able to relate above history.
He was in no acute respiratory distress. He was given continuous
albuterol nebs, 3 L of LR given tachycardia and hypovolemia. ABG
on 5 L NC and 50 % FM showed pH 7.42, pCO2 35, pO2 70, HCO3 23,
lactate 4.6. RRV screen was performed, and he was placed on
influenza precautions. A sputum culture was also obtained.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Asthma
Onset after birth. Triggers are cold and exercise. He uses his
albuterol inhaler excluding exercise about 1x/week. He does not
see a pulmonary doctor. He has never been intubated or
hospitalized for asthma attack before.
- Tobacco abuse
He currently smokes [**4-25**] cigs/day
Social History:
Patient lives with his mother. [**Name (NI) **] works as a club bouncer. He
drinks alcohol sporadically and denies a history of alcohol
abuse. He denies illicit drug usage. He states that his home
does have a cat/dog but no other recent changes.
Family History:
Mother has asthma
Physical Exam:
ADMISSION PHYSICAL EXAM
General Appearance: No acute distress, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Mallampati [**3-24**],
difficult to assess oropharynx
Lymphatic: Cervical WNL
Cardiovascular: Heart sounds distant. No murmur.
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: , speaking in complete sentences, good air
movement , mild inspiratory squeks, no expiratory wheeze
Abdominal: Soft, Non-tender, No(t) Distended, Obese
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Warm
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Pertinent Results:
Labs:
[**2154-3-2**] 02:25PM BLOOD WBC-13.4* RBC-5.96 Hgb-16.6 Hct-49.6
MCV-83 MCH-27.9 MCHC-33.5 RDW-13.5 Plt Ct-340
[**2154-3-2**] 02:25PM BLOOD Neuts-87.8* Lymphs-10.0* Monos-1.7*
Eos-0.3 Baso-0.2
[**2154-3-3**] 03:29AM BLOOD WBC-16.4* RBC-5.59 Hgb-15.5 Hct-46.0
MCV-82 MCH-27.8 MCHC-33.7 RDW-13.6 Plt Ct-332
[**2154-3-4**] 01:30AM BLOOD WBC-20.8* RBC-5.56 Hgb-15.9 Hct-46.4
MCV-83 MCH-28.6 MCHC-34.4 RDW-13.6 Plt Ct-351
[**2154-3-2**] 02:25PM BLOOD Glucose-167* UreaN-13 Creat-1.0 Na-136
K-4.3 Cl-102 HCO3-22 AnGap-16
[**2154-3-3**] 05:00AM BLOOD Glucose-157* UreaN-11 Creat-0.9 Na-137
K-4.3 Cl-104 HCO3-22 AnGap-15
[**2154-3-4**] 01:30AM BLOOD Glucose-138* UreaN-15 Creat-0.9 Na-137
K-4.3 Cl-102 HCO3-22 AnGap-17
[**2154-3-3**] 05:00AM BLOOD CK-MB-4 cTropnT-<0.01
[**2154-3-3**] 10:01AM BLOOD CK-MB-4 cTropnT-<0.01
[**2154-3-3**] 04:55PM BLOOD CK-MB-3 cTropnT-<0.01
[**2154-3-2**] 10:39PM BLOOD Calcium-9.4 Phos-2.9 Mg-1.9
[**2154-3-3**] 10:01AM BLOOD Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2154-3-2**] 04:51PM BLOOD Type-ART pO2-70* pCO2-35 pH-7.42
calTCO2-23 Base XS-0 Comment-NEBULIZER
[**2154-3-2**] 10:58PM BLOOD Type-[**Last Name (un) **] pO2-34* pCO2-42 pH-7.39
calTCO2-26 Base XS-0
[**2154-3-3**] 03:47AM BLOOD Type-[**Last Name (un) **] Temp-36.3 Rates-/18 pO2-61*
pCO2-37 pH-7.43 calTCO2-25 Base XS-0 Intubat-NOT INTUBA
Comment-HIGH FLOW
[**2154-3-2**] 04:51PM BLOOD Lactate-4.6*
[**2154-3-3**] 03:47AM BLOOD Lactate-2.6*
[**2154-3-3**] 04:18PM URINE bnzodzp-NEG barbitr-NEG cocaine-NEG
amphetm-NEG
MICRO:
[**2154-3-2**] 3:38 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final [**2154-3-3**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to Respiratory Virus Identification for further
information.
[**2154-3-2**] 7:06 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2154-3-2**]**
GRAM STAIN (Final [**2154-3-2**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2154-3-2**]):
TEST CANCELLED, PATIENT CREDITED.
[**2154-3-2**]:
STUDY: PA and lateral chest radiograph.
COMPARISON: None.
FINDINGS: The cardiomediastinal and hilar contours are normal.
The lungs are clear. There is no pleural effusion or
pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
[**2154-3-3**]:
AP radiograph of the chest was reviewed in comparison to
[**2144-3-2**].
Heart size and mediastinum are stable. Lungs are essentially
clear. There is no evidence of pneumothorax or pneumomediastinum
demonstrated on the current examination. Bibasal opacities are
noted and might reflect small areas of atelectasis, new since
the prior study that might also reflect compromised aeration
through compromised airways or fatigue of inspiration
musculature, please correlate clinically.
CTA w/ and w/out contrast ([**2154-3-3**]):
IMPRESSION:
1. No evidence of acute aortic syndrome or pulmonary embolus.
2. Areas of atelectasis in the lingula, and right lower lobe.
Brief Hospital Course:
=====================
Brief Hospital Summary
=====================
18M history of intermittent asthma, tobacco abuse presents with
asthma exacerbation, likely secondary to a respiratory viral
illness.
# Asthma exacerbation with Hypoxemia: Respiratory distress most
likely secondary to asthma exacerbation likely in the setting of
a viral upper respiratory infection especially given inspiratory
squeaks. Pt has no hx of sickle cell, no anemia and no family
members w/ sickle cell. Patient moving air, without wheeze. No
evidence for pneumonia. Peak flow in the ED was <150 but is now
up to 300. Still requiring nasal cannula 6L. Looks comfortable.
WBC increasing, likely [**2-21**] steroids. Patient's oxygenation
improves with large breaths (inspiratory effort), so encouraging
peak flows and inspiratory spirometry. Continuing albuterol q
3-4 hr and ipratropium q 6 hr. Initially gave
MethylPREDNISolone Sodium Succ 60 mg IV Q8H with GI prophylaxis
and SSI, and now are transitioning to PO prednisone 40mg.
Guaifenasen with codine for cough provided. Start ibuprofen PRN
and standing tylenol for chest pain. Pt will need pulmonary
follow-up at discharge. Would recommend flu and PNA vaccinations
before d/c. Lactic acidosis likely secondary to respiratory
muscle use and albuterol. Upon call-out to medical floor,
patient saturating 91% on 6L nasal cannula, improving with deep
breaths and cough. Patient continued to improve to 93% RA with
ambulation. Patient was feeling better on prednisone.
- Discharged to complete steroid taper of Prednisone
- Initiated on Flovent and continued on Albuterol
- PCP and Pulm follow up arranged
# Tobacco abuse: Patient in pre-contemplative state of tobacco
cessation. Advised to quit smoking and provided counseling.
continued to encourage smoking cessation throughout
hospitalization.
# Tachycardia: Etiology likely secondary to albuterol and
hypovolemia. ECG showing non-specific ST-T changes. Pt w/ some
chest pain, likely secondary to pleurisy. Troponin negative x3.
CTA neg for PE
# Leukocytosis: Etiolology likely secondary to steroid
administration given neutrophilia and lymphopenia. Do not
suspect superimposed bacterial infection
Medications on Admission:
- albuterol prn wheezing/SOB
Discharge Medications:
1. prednisone 10 mg Tablet Sig: 1-4 Tablets PO once a day: as
follows:
4 pills (40mg) [**3-6**]
2 pills (20mg) [**2060-3-6**]
1 pill (10mg) [**2062-3-9**]
STOP.
Disp:*12 Tablet(s)* Refills:*0*
2. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough: do use with alcohol or
driving.
Disp:*100 ML(s)* Refills:*0*
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours: until symptoms
improved. then as needed after that.
Disp:*1 inhaler* Refills:*1*
4. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day: wash mouth off with water afterwards.
Disp:*1 inhaler* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with shortness of breath and low oxygen as a
result of an acute asthma flare. This was likely triggered by a
viral syndrome. With treatment your oxygen and symptoms
improved.
You will be given Prednisone to taper of the next few days. You
will also be given an inhaled steroid to take twice daily, and
albuterol. Please take your albuterol 2 puffs every 4-6 hours
for the next few days until your symptoms resolve, then as
needed thereafter.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] O.
Location: [**Hospital3 **] HEALTH CENTER
Address: [**State **], [**Location (un) **],[**Numeric Identifier 38978**]
Phone: [**Telephone/Fax (1) 14167**]
Appt: [**Month (only) 956**]
- please call the day after discharge to confirm appointment
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2154-4-29**] at 2:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: MONDAY [**2154-4-29**] at 2:30 PM
With: DR. [**Last Name (STitle) 5528**] / DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
***You have also been placed on the wait list and will be called
at home once a sooner appt is available.
|
[
"2762",
"3051"
] |
Unit No: [**Numeric Identifier 76608**]
Admission Date: [**2181-1-1**]
Discharge Date: [**2181-1-6**]
Date of Birth: [**2181-1-1**]
Sex: M
Service: NB
DATE OF INTERIM SUMMARY: [**2181-1-3**]
This Baby [**Name (NI) **] [**Known lastname **] number 2 is the former 2.895 kg product
of a 36 and [**4-11**] week gestation pregnancy, now day of life
number 2.
HISTORY OF PRESENT ILLNESS: This is the former 2.895 kg
product of a 36 and [**4-11**] week twin gestation pregnancy, born
to a 27 year-old, gravida 2, para 0 now 2 woman. Estimated
date of delivery was [**2181-1-24**]. Prenatal labs: Blood type A
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group beta strep status
unknown. The pregnancy was reportedly unremarkable with
normal fetal survey times two. The mother presented with
rupture of membranes of twin A and spontaneous labor. She was
taken for Cesarean section delivery. Rupture of membranes of
this twin #2 was at the time of delivery. There was no
maternal fever noted and mother received antibiotics for
group beta strep prophylaxis beginning 3 hours prior to
delivery. There was no clinical concern for chorioamnionitis.
This twin emerged vigorous with Apgars of 8 at 1 minute and 8
at 9 minutes. Work of breathing was noted in delivery room
prompting evaluation by neonatology and eventual admission to
the Neonatal Intensive Care Unit.
Anthropometric measurements upon admission to the Neonatal
Intensive Care Unit: Weight 2.895 kg, 50 to 75th percentile.
Head circumference 34 cm, 50 to 70th percentile. Length 19
inches.
PHYSICAL EXAMINATION: Weight 2.905 kg. General:
Nondysmorphic, non distressed, near term male in room air.
Oxygen saturations 100%. Head, ears, eyes, nose and throat:
Fontanel soft and flat. Ears and nares normal. Palate
intact. Neck supple, no lesions. Chest: Breath sounds clear
and equal, well aerated. Comfortable respirations.
Cardiovascular: Regular rate and rhythm. No murmur. Normal
S1 and S2. Femoral pulses +2. Abdomen: Soft, nontender,
nondistended. No hepatosplenomegaly. No masses. Active
bowel sounds. Cord on and drying. Genitourinary: Normal
male. Testes descended. Anus patent. Extremities, hips and
back normal. Neuro: Appropriate tone and activity.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: RESPIRATORY: This infant was admitted to the Neonatal
Intensive Care Unit for respiratory distress. He was placed
on continuous positive airway pressure with significant
improvement. His max ventilatory support was continuous
positive airway pressure of 6 and oxygen requirement of less
than 30%. He was able to wean off the CPAP within 16 hours
and transition to room air. He continued in room air for the
rest of his Neonatal Intensive Care Unit admission. At the
time of admission, he was breathing comfortably in room air
with oxygen saturations 98 to 100% and respiratory rate of 40
to 60 breaths per minute.
CARDIOVASCULAR: An intermittent murmur was noted during the
first few hours of life but resolved. Baseline heart rate is
150 to 170 beats per minute with a recent blood pressure of
60/34 mmHg, mean arterial pressure of 42 mmHg.
FLUIDS, ELECTROLYTES AND NUTRITION: This infant was
initially maintained n.p.o. and on IV fluids. Enteral feeds
were started on day of life one and were well tolerated. At
the time of transfer, he is ad lib feeding Enfamil 20. Serum
glucoses have been normal. Weight on the day of transfer is
2.905 kg. Wt on d/c home 6 lb 1 oz (2760 gm).
INFECTIOUS DISEASE: Due to his respiratory distress and the
unknown group beta strep status of his mother, this infant
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
IV ampicillin and gentamycin. The blood culture remains no
growth as of d/c home (abx d/c'd after 48 hrs) .
HEMATOLOGY: Hematocrit at birth was 38%. This infant did not
receive any transfusions of blood products.
GASTROINTESTINAL: Serum bilirubin wnl (6.6 at 60hrs) .
NEUROLOGIC: This infant has maintained a normal neurologic
exam during Neonatal Intensive Care Unit admission and there
were no neurologic concerns at the time of transfer.
SENSORY:
Audiology: BAERS passed b/l .
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 34561**], [**Hospital1 1474**], MA.
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: Ad lib p.o. feeding, Enfamil 20 calories per
ounce formula.
2. Medications: None.
1. Iron and vitamin D supplementation:
Iron supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age. All infants
fed predominantly breast milk should receive Vitamin D
supplementation at 200 i.u. (may be provided as a multi-
vitamin preparation) daily until 12 months corrected age.
1. Car seat position screening is recommended prior to
discharge.
2. State newborn screen due to be sent on day of life 3.
3. Immunizations: No immunizations administered thus far.
4. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
DISCHARGE DIAGNOSES:
1. Near term infant at 36 and 5/7 weeks gestation.
2. Twin #2 of twin gestation.
3. Transitional respiratory distress --resolved.
4. Evaluation for sepsis, ruling out with antibiotics.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 71194**]
Dictated By:[**Name8 (MD) 75740**]
MEDQUIST36
D: [**2181-1-3**] 04:32:46
T: [**2181-1-3**] 05:26:46
Job#: [**Job Number 76609**]
|
[
"V290",
"V053"
] |
Admission Date: [**2165-8-1**] Discharge Date: [**2165-8-7**]
Date of Birth: [**2107-11-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
SOB/cough
Major Surgical or Invasive Procedure:
[**2165-8-1**]
Right thoracotomy and diaphragmatic plication.
History of Present Illness:
Mr. [**Known lastname 6330**] is a 56M who is s/p R sternothoracotomy, radical
thymectomy and en-bloc RML wedge resection w/ sacrifice of R
phrenic nerve [**2164-1-30**] and R VATS decortication, bronchoscopy
with BAL & RUL wedge for pneumonia and a loculated pleural
effusion with gram-positive cocci on [**2164-7-18**]. He has been
followed
with symptoms of DOE with 1 flight but was on
Prednisone at that time. He weaned off Prednisone as of
[**2164-12-9**]
but his symptoms were about the same. He also admitted to right
shoulder and arm aches/tingling since his Prednisone came off.
He has a history of arthritis in his lower back and hips and
denies any trauma to his right shoulder. He takes Aleve or
Motrin and the pain decreases but then returns. He presents now
for diaphragmatic plication.
Past Medical History:
Stage [**Doctor First Name 690**] mixed type AB thymoma s/p resection and chemoradiation
Hypertension
Hyperlipidemia
Social History:
Cigarettes: nonsmoker
ETOH: occasional alcohol use
Drugs: no illicit drug use
Exposure: Admits to some exposure to dust/sand/cement at work,
possibly silicosis. Otherwise, no exposures to asbestos.
Travel history: He has traveled to [**State 4565**], but denies any
recent travel overseas
Family History:
non-contributory
Physical Exam:
BP: 133/85. Heart Rate: 79. Weight: 238.3. Height: 72.5. BMI:
31.9. Temperature: # (no [**Location (un) 1131**]). Resp. Rate: 16. Pain Score:
0.
O2 Saturation%: 98.
Chest left lung clear, absent breath sounds at right base and
diminished BS in R upper lobe. Dull to percussion on right.
Wounds well healed.
CV: RRR
Abd: soft, NT, ND, BS +
Ext: warm, no edema, +2 pulses
Pertinent Results:
[**2165-8-1**] 08:17AM HGB-13.2* calcHCT-40 O2 SAT-98
[**2165-8-1**] 08:17AM GLUCOSE-121* LACTATE-1.5 NA+-135 K+-4.7
CL--101
[**2165-8-1**] 09:28AM HGB-13.8* calcHCT-41 O2 SAT-99
[**2165-8-5**] CXR :
1. Stable appearance of loculated right basilar pneumothorax.
No new
pneumothorax status post right medial chest tube removal.
2. Persistent right hilar and upper lobe lung opacities. There
is a
suggestion that opacity surrounding a circular structure,
however, this may be due to a combination of radiation fibrosis
and atelectasis. If there is concern for acute pulmonary
process, chest CT would be better able to delineate anatomy
[**2165-8-6**] CXR :
Interval removal of right-sided chest tube. Otherwise
essentially unchanged chest radiograph from prior imaging.
Brief Hospital Course:
Mr. [**Known lastname 6330**] was admitted to the hospital and taken to the
Operating Room where he underwent a right thoracotomy and
diaphragmatic plication. He tolerated the procedure well and
returned to the SICU in stable condition. He maintained stable
hemodynamics and his pain was controlled with an epidural
catheter. He remained intubated for the first 24 hours to assure
full expansion of the right lung.
He weaned and extubated easily and was transferred to the
Surgical floor on [**2165-8-3**].
He underwent vigorous pulmonary toilet including incentive
spirometry and his chest xray showed a small basilar
pneumothorax. This was controlled with his chest tubes, which
were initially placed to suction. POD #3 his chest tubes were
switched to water seal and his pneumothorax remained stable. On
POD #4, he had one chest tube removed, with a stable
pneumothorax post removal. He also had his foley, epidural, and
PCA removed and was switched to PO pain medication. He had
increased pain afterwards and we adjusted his regimen
accordingly. On POD #5, he had his second chest tube pulled,
with an unchanged post-removal CXR. He was also weaned off of O2
at rest. Unfortunately his saturations on room air with activity
remained at 88% therefore he will continue to use his home
oxygen as he increases his activity. His incision was healing
well and he was up and walking independently. He was discharged
to home on [**2165-8-7**] and will follow up in the Thoracic Clinic in
2 weeks.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Losartan Potassium 50 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Pravastatin 80 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D 50,000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Multivitamins 1 TAB PO DAILY
3. Vitamin D 50,000 UNIT PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Senna 2 TAB PO HS:PRN constipation
6. Aspirin 81 mg PO DAILY
7. Atenolol 25 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Pravastatin 80 mg PO DAILY
10. Ibuprofen 400 mg PO Q8H:PRN pain
11. OxycoDONE (Immediate Release) 10-15 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-18**] tablet(s) by mouth every four (4) hours
Disp #*150 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right diaphragmatic paralysis.
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 lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 1000 mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2165-8-20**] at 8:30 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) 470**] of the [**Location (un) 40900**] for a chest xray
Completed by:[**2165-8-7**]
|
[
"4019",
"2724"
] |
Admission Date: [**2135-1-18**] Discharge Date: [**2135-1-24**]
Date of Birth: [**2083-1-21**] Sex: F
Service: MEDICINE
Allergies:
Betadine / Nitroglycerin Transdermal / Gabapentin / Cilostazol /
Colestipol
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
TUNNELED LEFT FEMORAL LINE PLACEMENT
History of Present Illness:
51 year old female with history of Insulin dependent DM s/p
Kidney Transplant x3, Pancreas transplant x2, orthostatic
hypotension, CIDP on IVIG, severe PVD with tunneled femoral line
presented via EMS after calling out for help to the janitor in
her building who then called 911. The patient had been in her
usual state of health (per the husband) although complained of
some sinus congestion over the past few weeks. She does not
remember the events today other then calling for help. When EMS
arrived she was mentating fine but hypotensive to 90s, HR 150s
and fever 100.3. On arrival to ED has had normal mental status
but moaning, rigoring and uncomfortable. Vitals on admission to
ED were T100.3 HR 136 BP 127/85 RR 21 98%RA. Labs notable for
WBC 3.6, Lactate 3.0 CK 18. She received 3L IVF, Imipenem; and
125mg Methylprednisolone. CT abdomen/pelvis negative, CT
Head/neck notable for maxillary sinusitis, renal transplant
ultrasound neg, U/A negative, blood cultures were sent.
.
After fluid rescucitation pts BP improved initially to SBP 130s
but drifted back to 110s; HR improved from 150->109 O2 sat
97%RA. She was subsequently admitted to the MICU for further
management.
.
Currently, the patient [**First Name3 (LF) **] any pain. She does not remember
any of the events that occured today. She [**First Name3 (LF) **] any
lightheadedness, palpitations prior to the event. She does
report sinus congestion which has required use of nasal steroids
over past few days. She reports purulent drainage from ostomy
that has been seen by her ostomy nurse. [**First Name (Titles) 4273**] [**Last Name (Titles) 5162**]/chills.
She [**Last Name (Titles) **] any CP, SOB, abdominal pain, urinary frequency, does
report large volume stools unchanged from the past few months.
Reports normal appetite.
Past Medical History:
PMH:
DM1 w triopathy
ESRD
legally Blind
HTN
hyperlipdemia
CAD
asthma
VRE
left hip fx [**12-30**], s/p closed reduction
hx of herpes zoster - treated
b/l dysplastic knee
hx of pneumonia
hx of toxic megacolon
chronic inflammatory demylinating polyneuropathy
seizures [**2132-8-5**] on Keppra
osteoporosis
PSH:
s/p angioplasty of her below-knee popliteal artery and
posterior tibial artery on [**2133-8-28**] for gangrenous ulcers of her
left foot.
s/p angioplasty of proximal anastomosis of vein bypass graft [**3-25**]
s/p Right below-knee popliteal to distal peroneal bypass
graft with reversed saphenous vein graft [**2132-5-6**]
s/p CABGx2 LIMA-LAD,SVG-PDA [**2-21**]
s/p Simultaneous Kidney Pancreas Tx - [**Location (un) 5944**] [**2-22**]
s/p Tx nephrectomy [**8-25**]
s/p subtotal colectomy with ileostomy for toxic megacolon [**10-26**]
failed renal transplant secondary to renal torsion, [**2-23**]
s/p CRT #2 [**9-29**]
s/p ex lap, LOA, resection of ileorectal anastmosis and
ileoprostosmy [**7-28**]
s/p lap PD cath placement [**9-27**]
s/p removal of PD catheter [**9-29**]
s/p ex lap w revision of ileostomy [**7-29**]
s/p parastomal hernia repair [**7-29**]
s/p cyso for removal of ureteral stent,
s/p multiple RIJ and tunnel catheters for HD
s/p CRT #3 [**2132-9-24**]
Social History:
lives with husband. She formerly smoked quit in [**2107**]. Used to be
a cardiac nurse. Is able to walk around the house with a walker
or cane.
Family History:
Adopted, unknown
Physical Exam:
-- per admitting resident --
Vitals - HR 110 SBP 132/79, SpO2 96%
GENERAL: Sitting up in bed in NAD, eating lunch
HEENT: anicteric, EOMI
CARDIAC: grade II systolic murmur loudest at upper sternal
border
LUNG: clear bilaterally
ABDOMEN: normal bowel sounds, colonostomy in place with
green-brown liquid output, no surrounding erythema
EXT: dressing on lower extremity ulcers, clean and dry no
erythema
NEURO: A+O X 3
Pertinent Results:
ADMISSION LABS
[**2135-1-18**] 12:30PM BLOOD WBC-3.6*# RBC-3.85* Hgb-13.8 Hct-39.9
MCV-104* MCH-36.0* MCHC-34.7 RDW-16.6* Plt Ct-154
[**2135-1-18**] 12:30PM BLOOD PT-13.0 PTT-27.6 INR(PT)-1.1
[**2135-1-18**] 12:30PM BLOOD Glucose-104* UreaN-10 Creat-1.1 Na-134
K-3.7 Cl-98 HCO3-25 AnGap-15
[**2135-1-18**] 12:30PM BLOOD ALT-22 AST-29 CK(CPK)-18* AlkPhos-138*
[**2135-1-18**] 12:30PM BLOOD Albumin-4.2 Calcium-9.4 Phos-1.9* Mg-1.7
[**2135-1-18**] 12:36PM BLOOD Lactate-2.0 K-3.7
CT HEAD: (PRELIM READ)
No intracranial hemorrhage or edema. No fracture. Bilateral
maxillary sinus disease concerning for acute sinusitis.
CT CSPINE: (PRELIM READ)
1. No fracture or malalignment of the cervical spine.
2. Multilevel degenerative disc disease, particularly at C4-5
and C5-6,
similar to MRI [**2134-5-24**].
CT ABDOMEN/PELVIS:
1. Cholelithiasis.
2. Suboptimal evaluation of bowel just proximal to the left
lower quadrant
ostomy due to the lack of oral contrast and post-operative
anatomy; therefore, infection is impossible to exclude.
RIGHT UPPER QUADRANT US:
Normal resistive indices and waveforms with no evidence of
hydronephrosis.
Somewhat limited exam and main renal artery could not be
assessed.
TTE: Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are moderately thickened.
Significant aortic stenosis is present (not quantified). The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
An 3.7 cm long echogenic mass is present in the inferior vena
cava extending past the orifice of the cava, approximately 1 cm
into the right atrium. This most likely represents thrombus
Compared with the findings of the prior study (images reviewed)
of [**2135-1-19**], the mass present in the right atrium is
significantly reduced in size, and is now seen to be contiguous
with mass in the inferior vena cava, most likely representing
thrombus.
Brief Hospital Course:
51 yo female s/p renal tx X3 (most recent CRT [**9-29**]) and panc X2
(most recent [**2-27**]), severe PVD, HTN presents with rigors/[**Month/Year (2) 5162**]
and mental status changes.
# Sepsis / GPC Bactermia: Patient presented with fever,
tachycardia and hypotension. initial evaluation with CXR
negative, CT abdomen unrevealing, U/A negative, Renal Ultrasound
unrevealing, Lactate 2.0, LFTs unremarkable. Patient does have
history of VRE Peritonitis as well as an indwelling tunneled
femoral line which was suspected as most likely source; CT did
show maxillary sinusitis and pt did have recent complain of a
persistant "head cold" per her husband. On day #1 patients blood
cultures grew GPCs later speciated to CoNS,
methicillin-resistant. She was treated initially with
Vancomycin and Imipenem but this was subsequently narrowed to
vancomycin only. Her tunneled line was removed and a new left
femoral line was placed. Ideally, we would have had a line-free
period in which her blood cultures would clear, but owing to
very difficult IV access the left femoral line was replaced the
same day as the prior line. Blood cultures promptly cleared the
day that the old femoral line was pulled. In addition, a TTE
was done which showed a thrombus in her right atrium. She will
continue vancomycin for a four week course and follow up with ID
in transplant clinic.
.
# Mental Status change- Patient with acute MS changes although
events not clear at this time. Per her husband, pt has altered
MS every time her BP drops. BP was low on EMS arrival. Pt does
have labile BPs and takes both BB and fludrocortisone prn to
manage her pressures. It is possible that infection
precipitation hypotension causing the MS changes. CT head was
negative. MS improved upon arrial to ICU with control of BP.
.
# Right Atrial thrombus - Pt had TTE done given positive blood
cultures; thrombus in RA and IVD found; started on heparin,
switched to Lovenox bridge to coumadin. Uncertain whether
thrombus formation was [**1-25**] tunneled line. Patient will continue
anticoagulation and follow up with cardiology.
.
# S/P Kidney/Pancreas Transplant - Pt's creatinine slightly
above baseline on admission; likely prerenal given
hypotension/sepsis. She was continued on Azathioprine and
prednisone. Tacrolimus levels were high during admission, so it
was redosed to a lower dose at discharge.
.
# h/o Hypertension/Orthostatic Hypotension
- Toprol and Florinef held initially but resumed after BP stable
.
# CAD - ACE and BB continued
.
# Blindness [**1-25**] DMI: stable, She continued her home drops.
- Cyclosporine 0.05% gtts; one in each eye QID
- Acular 0.5% drops 1 gtt os q3D
- Loteprednol Etabonate 0.2% drops 1 gtt ou [**Hospital1 **]
Medications on Admission:
Albuterol prn
Alendronate 70mg qsunday
Azathioprine 50mg daily
Astelin spray
Klonopin 0.5mg [**Hospital1 **]
Creon 3 capsules with each meal
Cyclosporine 0.05% gtts; one in each eye QID
Desipramine 150mg daily
Famotidine 20mg daily
Florinef [**12-25**] tabsl q4 hrs prn for BP
Fluticasone spray [**12-25**] sprays daily
Folic acid 1mg daily
Heparin 1000u/ml solution; 3.4cc to red port, 3.6cc blue port
Hydrocortisone 2.5% cream
Ipatropium Bromide [**12-25**] sprays per nostril [**Hospital1 **] prn
Acular 0.5% drops 1 gtt os q3D
Loteprednol Etabonate 0.2% drops 1 gtt ou [**Hospital1 **]
Toprol XL 75mg daily
Pred Forte 1% drops 1 gtt os q3d
Prednisone 5mg daily
Prograf 03mg SL mg [**Hospital1 **]
Bactrim 400mg/80mg daily
Effexor 37.5mg [**Hospital1 **]
Ambien 5mg 1-2tabs prn
aspirin 325mg daily
Loratidine 10mg qam
MVI
Sodium Bicarbonate 650mg [**Hospital1 **]
Imuran 50mg daily
Discharge Medications:
1. Vancomycin 1,000 mg Recon Soln Sig: 1250 (1250) mg
Intravenous once a day for 26 days: Started [**2135-1-21**], stops
[**2135-2-18**] for total 4 week course.
Disp:*QS for course specified * Refills:*0*
2. Line Care
Please flush line with 10cc saline, followed by 2ml of 10
unit/ml Heparin (20 units of heparin) daily and after infusion /
draw (SASH and PRN)
3. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection
ASDIR for 6 weeks: Please flush with 10ml saline before and
after medication infusion.
Disp:*QS * Refills:*0*
4. Heparin Flush 10 unit/mL Kit Sig: Two (2) ml Intravenous
ASDIR for 6 weeks: Please instill 2ml (20 units) after infusion.
Disp:*QS * Refills:*0*
5. Outpatient Lab Work
Please obtain vancomycin trough level before dose administered
on [**2135-1-26**], fax results to ([**Telephone/Fax (1) 1353**], to the attention of
Dr. [**Last Name (STitle) 724**].
6. Outpatient Lab Work
Please draw CBC with differential, BUN, and creatinine weekly on
[**2135-1-26**], [**2135-2-2**], and [**2135-2-9**]. Fax results to Dr. [**Last Name (STitle) 724**] at ([**Telephone/Fax (1) 10739**].
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
on Sunday.
9. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Azelastine 137 mcg Aerosol, Spray Sig: One (1) NU Nasal [**Hospital1 **]
(2 times a day).
11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Creon Oral
13. Desipramine 150 mg Tablet Sig: One (1) Tablet PO once a day.
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Fludrocortisone 0.1 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for blood pressure.
16. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Ipratropium Bromide 0.03 % Spray, Non-Aerosol Sig: [**12-25**]
Nasal [**Hospital1 **] (2 times a day) as needed for rhinorrhea.
19. Ketorolac 0.5 % Drops Sig: One (1) gtt OS Ophthalmic q3d.
20. Alrex 0.2 % Drops, Suspension Sig: One (1) gtt OU Ophthalmic
[**Hospital1 **] (2 times a day).
21. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO QPM (once a day
(in the evening)).
22. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO QAM (once a day
(in the morning)).
23. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
24. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
Disp:*180 Capsule(s)* Refills:*0*
25. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
26. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
27. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
28. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*28 syringes* Refills:*0*
29. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic QID (4 times a day).
30. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) gtt
os Ophthalmic q3d.
31. Warfarin 1 mg Tablet Sig: 2.5 Tablets PO once a day: Adjust
as ordered to maintain INR 2.0 - 3.0.
Disp:*75 Tablet(s)* Refills:*0*
32. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
33. Outpatient Lab Work
Please draw INR on [**2135-1-26**] and fax to [**Company 191**] Anticoagulation
Management Service at [**Telephone/Fax (1) 3534**].
34. Outpatient Lab Work
Please draw tacrolimus level on [**2135-1-26**] and fax results to Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 21335**].
35. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
36. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
37. Multivitamins with Iron Tablet Sig: One (1) Tablet PO
once a day.
38. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
SEPSIS
LINE INFECTION / BACTEREMIA (COAG NEGATIVE STAPH)
INTRA-ATRIAL THROMBUS
Discharge Condition:
Hemodynamically stable, afebrile, alert and oriented per
baseline.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with fever and with low blood
pressure. We found a bacterial infection in your blood that
likely started from your permanent femoral line. We also found
evidence of blood clots in the right side of your heart and
started blood thinners.
With the assistance of IR, a new line was placed on your left
side. Additionally during your hospitalization, a large blood
clot was noted near the right side of your heart. You were
started on blood thinners (anticoagulation) to prevent this clot
from spreading. You tolerated anticoagulation and the
antibiotics very well and have not had signs of persistant
infection at this time.
The following medications were changed during your
hospitalization:
ADDED enoxaparin (Lovenox) to thin your blood in the short-term
until you reach an adequate level of warfarin in your blood
ADDED warfarin for use as a longer-term blood thinner
ADDED vancomycin to treat your infection
CHANGED tacrolimus to achieve appropriate blood levels of this
medication
Followup Instructions:
You are scheduled to follow up in the transplant infectious
disease clinic with Dr. [**Last Name (STitle) 724**] on [**2135-2-8**], at 10AM.
This appointment will be on the [**Location (un) 436**] of the [**Hospital Unit Name **].
You can contact his office to reschedule this appointment if
needed by calling ([**Telephone/Fax (1) 3618**]. We would want you to follow
up with him between 2-3 weeks after discharge.
You are scheduled to meet with the cardiologist, Dr.[**Doctor Last Name 3733**],
on [**2135-2-8**] at 2:20 PM. This appointment will be on
the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Center. You can contact his office
to reschedule this appointment if needed by calling ([**Telephone/Fax (1) 3942**]. We would want you to follow up with him around 3
weeks after discharge.
We would like you to follow up with your transplant
nephrologist, Dr. [**Last Name (STitle) **], on [**2135-2-16**], at 8:30 AM.
You can contact her office to reschedule this appointment if
needed by calling ([**Telephone/Fax (1) 3618**]. We would want you to follow
up with her between 2-3 weeks after discharge.
Additionally, you will need periodic laboratory work done while
you are on the vancomycin. These results will be faxed to Dr.
[**Last Name (STitle) 724**] and your vancomycin dose may be changed if needed as a
result.
Your warfarin blood levels will be followed by the [**Company 191**]
Anticoagulation Management Service. The levels will be drawn as
coordinated between this service and your visiting nurse, and
your warfarin dosage will be adjusted accordingly. You will be
asked to discontinue your Lovenox (enoxaparin) injections once
your warfarin level has been therapeutic for at least 24 hours.
If you have any questions, please call the [**Company 191**] line at
[**Telephone/Fax (1) 250**].
Please schedule a follow up appointment with your primary care
doctor, Dr. [**Last Name (STitle) 9006**], within 1 month of discharge. You can set up
an appointment with his office by calling ([**Telephone/Fax (1) 1300**].
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2135-1-25**]
|
[
"4019",
"2724",
"49390"
] |
Admission Date: [**2163-9-17**] Discharge Date: [**2163-9-24**]
Date of Birth: [**2097-6-16**] Sex: M
Service: SURGERY
Allergies:
Percocet / Flexeril / Meclizine / Fosamax / Mirtazapine
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Metastatic neuroendocrine tumor to the liver.
Major Surgical or Invasive Procedure:
[**2163-9-17**] Orthotopic deceased donor liver [**Month/Day/Year **] (piggyback)
portal vein-to-portal vein anastomosis, common bile
duct-to-common bile duct with no T- tube, common hepatic artery
(recipient) to proper hepatic artery (donor).
History of Present Illness:
Per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] preoperative note as follows:
66-year-old male who underwent a partial gastrectomy,
pancreatectomy,
and splenectomy with wedge resection of hepatic metastases
for a pancreatic neuroendocrine tumor in [**2160-12-1**]. He
was subsequently evaluated at [**Hospital1 18**] for his extensive liver
metastases. He was evaluated and found to be a suitable
candidate for liver transplantation and was placed on the
list. He has undergone radiofrequency ablation and
transarterial chemoembolization for control of his local
disease. He has had no evidence of disease outside the
liver. The patient has provided informed consent and now
returns to the operating room for orthotopic deceased donor
liver [**Hospital1 **]. The donor was a 36-year-old male with a
history of recent incarceration and heavy alcohol use in the
past who was viewed as a high-risk recipient. The details of
the donor were discussed with the patient and he agreed to
proceed.
Past Medical History:
- [**12-8**] diagnosed with well differentiated pT3, N1,M1 pancreatic
neuroendocrine cancer
- underwent partial gastrectomy, pancreatectomy and splenectomy
with wedge resection of hepatic metastases
- Pathology - 3.5x3.0x2.0cm pancreatic tail tumor with invasion
of the peripancreatic fat, splenic hilum, and stomach wall. The
margins were free of tumor but two/two splenic lymph nodes were
positive and there was extranodal extension into the perinodal
adipose tissue and lymphatic, blood vessel and perineural
invasion.
- tumor cells were synaptophysin positive, chromogranin
positive, and positive for the keratin cocktail and beta catenin
- CT [**3-9**] and [**4-9**] showed new and enlarging [**Hospital1 **]-lobar liver
lesions up to 3 cm
- non-diagnostic biopsy of adrenal mass
- [**4-8**] started octreotide
- [**5-9**] chemoembolization
- [**7-9**] chemoembolization
- [**10-9**] chemoembolization
- TACE on [**2162-2-17**]
- Follow up CT on [**2162-4-21**] with interval new lesions.
.
PAST MEDICAL HISTORY:
- hepatitis (unknown type) at age 8, resolved
- hypothyroidism dx about [**2155**]
- GERD
- osteoporosis/osteopenia dx [**2152**] (s/p full endocrine w/u as per
pt) due to hypercaliuric hypocalcemia for which pt takes
calcium supplements and HCTZ.
- s/p splenectomy. Received vaccinations post splenectomy
(Pneumovax, meningococcus and hemophilus influenza as per note
by Dr. [**First Name (STitle) **]
- Laminectomy in [**2140**]
Social History:
Pastor in a Lutheran [**Doctor Last Name 9995**] Church. Married with six children,
two of whom live at home. One beer night. No smoking.
Family History:
Brother was recently diagnosed with nasopharyngeal SCC.
Physical Exam:
T: 97.6 P: 97 BP: 148/92 RR: 18 O2sat: 98% RA
General: awake, alert, NAD
HEENT: NCAT, EOMI, anicteric
Heart: RRR, NMRG
Lungs: CTAB, normal excursion, no respiratory distress
Abdomen: soft, NT, ND, no mass, small epigastric incisional
hernia
Pelvis: deferred
Extremities: WWP, no CCE, no tenderness
Studies:
Serum electrolytes:
pending
CBC:
pending
Coags:
pending
HAV Ab ([**2163-7-20**]): negative
HBsAg ([**2163-7-20**]): negative
HBsAb ([**2163-7-20**]): negative
HBcAb ([**2163-7-20**]): negative
HCV Ab ([**2163-7-20**]): negative
Pertinent Results:
[**2163-9-23**] 06:05AM BLOOD WBC-10.3 RBC-3.97* Hgb-12.3* Hct-33.6*
MCV-85 MCH-31.0 MCHC-36.7* RDW-14.2 Plt Ct-189
[**2163-9-21**] 05:55AM BLOOD PT-12.3 PTT-22.0 INR(PT)-1.0
[**2163-9-23**] 06:05AM BLOOD Glucose-124* UreaN-19 Creat-0.9 Na-138
K-4.0 Cl-103 HCO3-29 AnGap-10
[**2163-9-23**] 06:05AM BLOOD ALT-264* AST-69* AlkPhos-129 TotBili-0.8
[**2163-9-23**] 06:05AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.9
[**2163-9-22**] 05:50AM BLOOD tacroFK-7.4
[**2163-9-18**] Liver Duplex/US:
IMPRESSION:
1. Normal appearance of the liver [**Month/Day/Year **], without evidence
of biliary
dilatation or perihepatic fluid collection.
2. Normal hepatic vasculature.
Brief Hospital Course:
On [**2163-9-17**], he underwent orthotopic deceased donor liver
[**Date Range **] (piggyback) portal vein-to-portal vein anastomosis,
common bile duct-to-common bile duct with no T-tube, common
hepatic artery (recipient) to proper hepatic artery (donor). Two
JP drains were placed. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please
refer to operative note for details.
Postop, he went to the SICU intubated for management. LFTs
increased as expected. Liver duplex was WNL. He was extubated
and sips were started. LFTs decreased daily. JP output was
non-bilious. JPs were removed without incident and insertion
sites sutured.
Diet was advanced and tolerated. He experienced some elevated
glucoses for which he received sliding scale insulin. [**Last Name (un) **] was
consulted and recommended low dose long acting insulin as well
as short acting insulin. He did well with teaching.
He was ambulatory. Incision pain was well controlled with
Dilaudid. Incision was intact with staples without
redness/drainage. His chief complaint was back discomfort from
the hospital mattress.
Immunosuppression consisted of CellCept that was well tolerated.
Steroids were tapered to prednisone 20mg qd per protocol.
Prograf was initiated on postop day 1. Doses were titrated per
trough levels.
Vital signs were stable. He felt well and was discharged to home
with VNA services.
Medications on Admission:
Levothyroxine 175 mcg daily
Octreotide 40 mg Q28D
KCl 10 mEq daily
Calcium carbonate-vitamin D3 500 mg (1,250 mg)-200 unit TID
Cholecalciferol 3,000 unit daily
Diphenhydramine 25 mg QHS
Ibuprofen PRN pain
MVI daily
Omega-3 fatty acids-fish oil 300 mg-1,000 mg daily
Metamucil [**2-3**] capsules daily
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
follow printed taper schedule.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO prn: every 4
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. insulin lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous four times a day.
Disp:*1 bottle* Refills:*2*
11. NPH insulin human recomb 100 unit/mL Suspension Sig: Three
(3) units Subcutaneous once a day.
Disp:*1 bottle* Refills:*2*
12. Kayexalate Powder Sig: Three (3) teaspoons PO prn: as
needed for high potassium mix 4tsp with water. DO NOT take
unless directed to by [**Month/Day (3) **] center .
13. Calcium+D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO three times a day.
14. FreeStyle System Kit Kit Sig: One (1) kit Miscellaneous
once a day.
Disp:*1 kit* Refills:*1*
15. Do not take:
Motrin/Ibuprofen/Advil/Aleve
16. tacrolimus 1 mg Capsule Sig: Six (6) Capsule PO Q12H (every
12 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Metastatic neuroendocrine tumor to the liver.
hyperglycemia from steroids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the [**Hospital 1326**] Clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, inability to
tolerate food, fluids or medications, increased abdominal pain,
yellowing of skin or eyes or other concerning symptoms.
Monitor the incision for redness, drainage or bleeding
Have your labwork drawn every Monday and Thursday with results
to the [**Telephone/Fax (1) **] clinic at [**Telephone/Fax (1) 697**]. CBC, Chem 10, AST,
ALT, T Bili, Alk Phos, Albumin and trough prograf level
You may shower with soap and water, pat dry. No tub
baths/swimming
No driving while taking pain medication
No heavy lifting (nothing heavier than 10 pounds)/straining
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2163-9-28**] 1:00
Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2163-9-28**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2163-10-5**] 3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"53081",
"2449"
] |
Admission Date: [**2173-3-30**] Discharge Date: [**2173-4-5**]
Date of Birth: [**2138-1-19**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 35 year-old
female with a past medical history significant for previous
myocardial infarction, known coronary artery disease and a
previous stent to the right coronary artery who presents as a
transfer for acute myocardial ischemia and cardiac
catheterization.
PAST MEDICAL HISTORY: Coronary artery disease, previous
myocardial infarction, previous stent, arthritis, carpal
tunnel syndrome.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin, Atenolol, Lipitor,
Calcitrel, magnesium and calcium supplements.
HOSPITAL COURSE: The patient was transferred to our facility
and admitted to the Medical Service where she underwent a
cardiac catheterization, which revealed a right dominant
system with significant obstruction of two vessels and left
main disease. The left main had a 60% osteal lesion, left
anterior descending coronary artery had a 60% mid vessel
stenosis and the left circumflex had minimal luminal
irregularities throughout its course and was otherwise
normal. Right coronary artery 60% stenosis of his proximal
stent and 90% mid vessel stenosis. Ejection fraction of
approximately 60%. Based on these findings a stat
Cardiothoracic Surgery consult was obtained and the patient
was deemed appropriate for surgery. On [**2173-4-2**] she was
taken to the Operating Room where she underwent a coronary
artery bypass graft times three. The patient's grafts were
left internal mammary coronary artery to left anterior
descending coronary artery, saphenous vein to posterior
descending coronary artery, and left radial to the obtuse
marginal. The patient tolerated this procedure well without
complications.
Postoperatively, she was transferred to the Cardiothoracic
Intensive Care Unit where she was maintained on intravenous
drips. She was extubated and did well in this immediate
period. She had an air leak on her chest tube, which was
left in for two additional days. The remainder of her
Intensive Care Unit course was uneventful and she was
transferred to the floor off drips still with her chest
tubes. By postoperative day four the patient's air leak was
resolved. Chest x-ray demonstrated no pneumothorax and her
chest tube was removed. She continued to do well working
with physical therapy and tolerating a regular diet and on
postoperative day five will be discharged home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS: Metoprolol 12.5 mg po b.i.d., Lasix
20 mg po q day, K-Ciel 20 milliequivalents po q day, ASA 325
mg po q.d., Zantac 150 mg po b.i.d., Colace 100 mg po b.i.d.,
Plavix 75 mg po q day, Imdur 60 mg po q day, and Dilaudid 2
mg po q 4 to 6 hours prn for pain.
The patient will follow up with her primary care physician
and with CT Surgery in two to four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2173-4-5**] 08:17
T: [**2173-4-5**] 08:42
JOB#: [**Job Number 38175**]
|
[
"41401",
"4019",
"2720",
"412",
"V4582",
"V1582"
] |
Admission Date: [**2170-7-4**] Discharge Date: [**2170-7-9**]
Date of Birth: [**2100-3-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2170-7-5**]
Redo Sternotomy/Aortic Valve Replacement #23 mm porcine
History of Present Illness:
70 year old gentleman with history of CABG in [**2153**] now with
aortic stenosis which has been followed by serial
echocardiograms. In [**2169-8-10**], he noticed dyspnea and chest
tightness with exertion which resolves with rest. An
echocardiogram was performed at that time which showed moderate
to severe aortic stenosis with an aortic valve area of 0.9cm2
with a peak/mean gradient of 59/39mmHg respectively. He elected
to winter in [**State 108**] and address his aortic stenosis upon his
return. He would prefer a percutaneous aortic valve replacement.
He was seen by Dr. [**Last Name (STitle) **] in clinic to discuss an aortic valve
replacement. He now presented for pre-op cardiac catheterization
and aortic valve replacement.
Cardiac Catheterization: Date:[**2170-7-4**] Place:[**Hospital1 18**]
LMCA: distal 80%
LAD: TO after D1
LCx: TO proximal
RCA: 60-70% proximal
Radial to OM: widely patent
LIMA-LAD: widely patent; left sternal border
RIMA-RCA: nearly atretic, retrograde flow
3 vessel disease with patent LIMA and radial grafts; Residual
ischemic targets D1 and RCA.
Past Medical History:
Past Medical History:
Coronary artery disease
Hypertension
Hyperlipidemia
Neuropathy (chest/abdomen- following previous CABG)
Paralyzed right hemidiaphram after CABG
brachial plexis injury left arm after CABG
Aortic insufficiency/stenosis
Benign Prostatic Hyperplasia
GI Bleed - [**2167**] ? related to motrin
Aflutter
Past Surgical History;
A.Flutter ablation [**12-15**]
CABG [**2153**]
Bilateral Rotator Cuff
Melanoma excised from back
Bilateral cataract surgery
Past Cardiac Procedures
Surgery: CABG x 3 @ [**Hospital 794**] Hospital with Dr.[**Last Name (STitle) **] Date: [**2153**]
Social History:
Race: Caucasian
Last Dental Exam: [**5-/2170**], dental clearance obtained
Lives with: wife
Contact:[**Name (NI) 1258**] (wife) Phone #[**Telephone/Fax (1) 112348**]
Occupation: Semi-retired business owner
Cigarettes: Smoked no [] yes [X] last cigarette 30 yrs ago
Other Tobacco use:denies
ETOH: < 1 drink/week [] [**1-16**] drinks/week [] >8 drinks/week [x]
[**12-11**] glasses of wine at night
Illicit drug use:Denies
Family History:
Father died at 74 from "heart disease"
Physical Exam:
Pulse:70 Resp:16 O2 sat: 98%/RA
B/P Right: 177/79 Left: 164/72
Height:5'[**67**]" Weight:212 lbs
General: NAD
Skin: Dry [x] intact [x] well healed sternotomy
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade _3/6___
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema [] _trace
left radial artery harvest
left open GSV harvest, ankle to 3"below knee
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: cath site Left:+1
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: 2+ Left: harvested
Carotid Bruit Right: Left:
radiation of cardiac murmur
Pertinent Results:
[**2170-7-5**]
LEFT ATRIUM: No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Severe symmetric LVH. Normal LV cavity
size. Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (area 0.8-1.0cm2). Mild (1+) AR.
MITRAL VALVE: Mild mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Prebypass:
No thrombus is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. There is severe
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+)
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
Post bypass:
Well seated bioprosthetic valve seen in the aortic position with
no perivalvular leak. Aorta is intact post decannulation.
Biventricular systolic function is unchanged. Rest of the
examination is unchanged.
.
[**2170-7-9**] 05:20AM BLOOD WBC-7.5 RBC-3.11* Hgb-10.0* Hct-30.7*
MCV-99* MCH-32.3* MCHC-32.7 RDW-13.4 Plt Ct-177
[**2170-7-8**] 04:33AM BLOOD WBC-9.7 RBC-3.18* Hgb-10.4* Hct-31.2*
MCV-98 MCH-32.7* MCHC-33.4 RDW-13.4 Plt Ct-131*
[**2170-7-9**] 05:20AM BLOOD PT-12.6* INR(PT)-1.2*
[**2170-7-9**] 05:20AM BLOOD Glucose-121* UreaN-21* Creat-0.8 Na-141
K-4.4 Cl-104 HCO3-31 AnGap-10
[**2170-7-8**] 04:33AM BLOOD UreaN-15 Creat-0.8 Na-142 K-4.2 Cl-106
[**2170-7-7**] 03:42AM BLOOD Glucose-146* UreaN-14 Creat-0.8 Na-135
K-4.4 Cl-100 HCO3-28 AnGap-11
[**2170-7-9**] 05:20AM BLOOD Mg-2.0
[**2170-7-8**] 04:33AM BLOOD Mg-2.0
[**2170-7-7**] 03:42AM BLOOD Mg-1.9
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2170-7-5**] where the patient underwent Re-do
sternotomy and aortic valve replacement
with a 23 mm Bicor Epic Tissue valve.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. He
developed brief, non-sustained periods of afib which were
treated with increased betablocker and oral amiodarone. He was
started on coumadin. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. BuPROPion 75 mg PO DAILY
2. Clonazepam 0.5 mg PO Q8H:PRN anxiety
3. Gabapentin 800 mg PO TID
4. Nitroglycerin SL 0.4 mg SL PRN chest pain
5. Omeprazole 20 mg PO EVERY OTHER DAY
6. Simvastatin 40 mg PO DAILY
7. Terazosin 2 mg PO HS
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion 75 mg PO DAILY
3. Clonazepam 0.5 mg PO Q8H:PRN anxiety
4. Gabapentin 800 mg PO TID
5. Simvastatin 40 mg PO DAILY
6. Terazosin 2 mg PO HS
7. Acetaminophen 650 mg PO Q4H:PRN PAIN/TEMP
8. Amiodarone 400 mg PO BID
400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, the 200mg daily
RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
9. Metoprolol Tartrate 100 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 100 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*0
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
RX *Endocet 5 mg-325 mg [**12-11**] tablet(s) by mouth q4-6h Disp #*40
Tablet Refills:*0
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*40 Tablet Refills:*0
12. Nitroglycerin SL 0.4 mg SL PRN chest pain
13. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Tablet Refills:*0
14. Furosemide 40 mg PO BID Duration: 1 Weeks
RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
15. Potassium Chloride 20 mEq PO Q12H
Hold for K+ > 4.5
RX *Klor-Con 20 mEq 1 packet by mouth twice a day Disp #*14
Tablet Refills:*0
16. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary Diagnosis:
Aortic Stenosis
Secondary Diagnosis:
Coronary artery disease
Hypertension
Hyperlipidemia
Neuropathy (chest/abdomen- following previous CABG)
Paralyzed right hemidiaphram after CABG
brachial plexis injury left arm after CABG
Aortic insufficiency/stenosis
Benign Prostatic Hyperplasia
GI Bleed - [**2167**] ? related to motrin
Aflutter s/p ablation [**12-15**]
CABG [**2153**]
Bilateral Rotator Cuff
Melanoma excised from back
Bilateral cataract surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Edema 1+
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check: [**2170-7-17**] at 10:00a [**Hospital Ward Name **] Office Building [**Hospital Unit Name **]
Surgeon: Dr. [**Last Name (STitle) **] on [**2170-8-15**] at 1:45p
Cardiologist: Dr. [**Last Name (STitle) **] [**2170-7-20**] at 4:00p [**Hospital3 **] office
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 4249**] in [**3-15**] weeks [**Telephone/Fax (1) 112349**]
Dr. [**Last Name (STitle) 4249**] will manage anti-coagulation
**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:[**2170-7-9**]
|
[
"4241",
"42731",
"2724",
"41401",
"V4581",
"4019"
] |
Admission Date: [**2135-7-16**] Discharge Date:
Date of Birth: [**2059-9-25**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: (per Medical Intensive Care Unit
admission note) The patient is a 75 year old male with
alcoholic cirrhosis, ascites, edema, multiple
gastrointestinal bleeds from Grade I varices, and lower
gastrointestinal bleed from diverticula and hemorrhoids.
Today, he noted explosive diarrhea, dark and melanotic per
patient, about every two hours, and he came to the Emergency
Department. He was started on Motrin four times a day times
four days for gouty flare. He complained of lightheadedness
but denied fever or chills, nausea or vomiting, chest pain,
shortness of breath, hematemesis, bright red blood per
rectum.
He had a colonoscopy on [**2135-7-7**], for bleeding, with
polyps. He had a resection at that time and was also noted
to have diverticula with internal hemorrhoids. He is
quasi-transfusion dependent for packed red blood cells in two
days. Nasogastric lavage was negative in the Emergency
Department.
PAST MEDICAL HISTORY:
1. Cirrhosis secondary to alcohol.
2. Atrial flutter status post cardioversion and
arteriovenous node ablation.
3. Coronary artery disease status post coronary artery
bypass graft, left internal mammary artery to left anterior
descending, saphenous vein graft to obtuse marginal stent
[**38**]/[**2132**].
4. History of multiple gastrointestinal bleeds.
5. Diverticulosis.
6. Multiple colonic polypectomies.
7. Esophageal varices [**4-18**], Grade I.
8. History of telangiectasias stomach.
9. Chronic renal insufficiency with baseline creatinine 1.5
to 1.8.
10. History of urosepsis.
11. Right esotropia.
12. Hemorrhoids.
13. Gout.
14. History of peptic ulcer disease in [**2132**].
15. History of cellulitis of left leg.
MEDICATIONS ON ADMISSION:
1. Nitroglycerin patch.
2. Protonix 40 p.o. q. day.
3. Lactulose 30 mg p.o. q. day.
4. Lopressor 50 mg p.o. twice a day.
5. Lasix 40 mg p.o. twice a day.
6. Aldactone 35 mg p.o. twice a day.
7. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mg p.o. q. day.
SOCIAL HISTORY: Married; quit alcohol. Thirty pack year
smoking history.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 97.1 F.; blood pressure
126/44; heart rate 70. In general, an elderly male in no
apparent distress. HEENT: Mucous membranes were moist.
Lungs clear to auscultation bilaterally. Cardiovascular is
regular rate and rhythm, Grade III/VI systolic murmur at left
upper sternal border. Abdomen soft, obese, nontender,
nondistended, positive bowel sounds. Extremities with no
pedal edema. Neurological: Alert, pleasant conversant.
LABORATORY ON ADMISSION: White blood cell count 3.8,
hematocrit 25.5, platelets 106, 72% neutrophils, 18%
lymphocytes, 6% monocytes, 2% eosinophils. Sodium 135,
potassium 4.4, chloride 99, carbon dioxide 26, BUN 40,
creatinine 3.0 from baseline of 1.5 to 1.8. Glucose 122, INR
1.1.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for gastrointestinal bleed and multiple
bleeding sources. Gastroenterology was consulted who
recommended beginning Octreotide, taking a right upper
quadrant ultrasound and transfusing as needed.
The patient had an esophagogastroduodenoscopy performed on
[**2135-7-17**], which revealed Grade I esophageal varices
without evidence of recent bleed. Small fundic polyp; biopsy
was not performed as he is currently undergoing evaluation
for gastrointestinal bleed and this can be re-evaluated at
the time of next esophagogastroduodenoscopy.
The patient then underwent colonoscopy on [**7-18**], which
revealed diverticulosis of the sigmoid colon. There were
large nonbleeding rectal veins and varices noted; otherwise
normal colonoscopy to the cecum. There was no source clearly
obtained from study.
The patient was transfused to maintain hematocrit greater
than 30. The plan was discussed regarding the possibility of
performing capsule endoscopy, however, given the patient's
reluctance for surgery, the decision was made to not pursue
further work-up and to transfuse only as needed.
The patient remained hemodynamically stable with a normal
hematocrit.
2. HEMATOLOGY: The patient with a long standing
pancytopenia seen evidenced one year ago. He also had acute
blood loss anemia as described above. Reticulocyte count was
performed which revealed an appropriate bone marrow response
to ongoing anemia with a reticulocyte index of only 1.5. His
platelets remained low but as he had stopped bleeding, he did
not require any platelet transfusions. He was not on any
heparin products. Pt really is against invasive aproach and it
was felt that even if aggressive w/u including bone marrow bx,
the likelyhood of finding a reversible cause was very unlikely so
no further w/u will be pursue.
3. INFECTIOUS DISEASE: On [**2135-7-19**], the patient spiked a
fever to 103.3 F. Urinalysis was positive for trace
leukocytes, 11 to 20 white blood cells, moderate bacteria
with zero to two white blood cell casts, so he was started on
Levofloxacin 250 mg p.o. q. day times seven day course. He
was not on a Foley catheter.
Chest x-ray, blood cultures and urine cultures were obtained
prior to initiating antibiotics. Blood cultures ultimately
revealed Staphylococcus aureus. The patient was initially
started on Vancomycin until the sensitivities returned
showing Methicillin sensitive Staphylococcus aureus and he
was changed to oxacillin to complete a two week course.
He had a transesophageal echocardiogram which showed no
evidence of endocarditis and the decision was made not to
pursue a transesophageal echocardiogram given that he is
clinically stable. His urine culture initially came showing
fecal contamination. A repeat urine culture sent after
initiation of Levofloxacin ultimately showed no growth.
He was given a PICC line and sent to rehabilitation for
intravenous Oxacillin times a two week course.
4. CARDIOVASCULAR SYSTEM: The patient has a history of
coronary artery disease with coronary artery bypass graft,
diastolic dysfunction. His aspirin was held given the bleed.
His beta blocker was also held given the bleed, however, it
was restarted on discharge to rehabilitation.
5. RENAL: The patient was admitted with a creatinine of
3.0, however, with intravenous fluids, creatinine improved
and ultimately he was discharged with a creatinine of 1.1,
below baseline.
DISCHARGE DIAGNOSES:
1. Melena.
2. Anemia secondary to blood loss.
3. Acute renal failure, prerenal.
4. Cirrhosis of liver, alcoholic.
5. Esophageal varices, Grade I.
6. Methicillin sensitive Staphylococcus aureus bacteremia.
7. Pancytopenia.
8. Leukopenia.
9. Thrombocytopenia.
10. Chronic obstructive pulmonary disease.
11. Gout.
12. Diastolic congestive heart failure.
DISCHARGE MEDICATIONS:
1. Acetaminophen p.r.n.
2. Pantoprazole 40 mg p.o. q. 12 hours.
3. Maalox p.r.n.
4. Ambien p.r.n.
5. Oxycodone p.r.n. gout pain.
6. Albuterol inhaler q. six hours.
7. Levofloxacin 250 mg p.o. q. 24 hours, last dose 06/09,
for a seven day course.
8. Lactulose 30 mg p.o. q. day.
9. Lasix 20 mg p.o. twice a day.
10. Spironolactone 25 mg p.o. twice a day.
11. Colchicine 0.6 mg p.o. q. day.
12. Oxacillin two grams intravenously q. six hours times 14
days, with last dose [**2135-8-1**].
13. Metoprolol 50 mg p.o. twice a day.
14. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. q. day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8829**], M.D. [**MD Number(1) 8830**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2135-7-23**] 17:44
T: [**2135-7-23**] 20:44
JOB#: [**Job Number 10386**]
|
[
"5849",
"496"
] |
Admission Date: [**2152-4-25**] Discharge Date: [**2152-5-1**]
Date of Birth: [**2086-10-5**] Sex: F
Service: NEUROLOGY
Allergies:
Imdur
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
HA, Loss of Coordination
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 65 yo woman with a h/o Infiltrating ductal breast
cancer (Stage II) s/p right mastectomy and 4 cycles chemo also
with CAD s/p CABG who presents with 5 days of "excruciating"
headache and lack of coordination. Patient notes that she was
working on a computer five days ago when she had an acute onset
of severe, constant headache localized to the top of her head.
She notes that she has not had a similar headache before, noting
that it was the worst headache of her life. She tried Tylenol
and Motrin with no improvement. She notes that the HA worsens
when standing and when bending over. She notes that since the
headache, she has been veering to the left and walking into
objects on the left despite being able to see them.
On the day of admission, she was bending over and lost her
balance and was not able to get back into position on her own.
She was, therefore, brought to the [**Hospital1 18**] ED by her daughter.
She denies N/V/D, photophobia, phonophobia, visual changes,
hearing changes, fevers, chills, weight loss, dysuria, vertigo,
dysarthria, aphasia, dysphagia, weakness, numbness, and
incontinence but notes night sweats for the last 5 days.
Past Medical History:
Infiltrating ductal breast cancer (Stage II) diagnosed in [**11-3**]
- right mastectomy for a 3.7cm breast tumor which was grade III
and ER negative, PR negative, and Her2/neu negative. Has
finished four cycles of Taxotere and Cytoxan.
CAD with CABG years ago and prior to that stents which she says
were removed with the CABG,
Hypertension
Hypercholesterolemia
Congestive heart failure
DM Type II (last Hgb A1c 6.2 in [**12-3**])
H.pylori
Esophageal webbing
Ovarian cyst
Social History:
Patient is married and lives with her husband who has diabetes
and is disabled in [**Location (un) 669**]. She has four children in their 50's.
One of her daughter's has been helping her at home since she
has not been able to cook or take care of herself. She owns a
travel agency. Patient quit smoking cigarettes 11 years ago,
but smoked a half pack a day for 20 years. She denies alcohol
use or illegal drug use. She feels safe at home. Her health
care proxy is her daughter [**Name (NI) 6177**] [**Name (NI) 5903**]. Her home number is
[**Telephone/Fax (1) 14958**].
Family History:
The patient denies family history of malignancies in her uterus,
breast, colon, ovary, or cervix. Grandmother and Grandfather
both had diabetes, otherwise everyone is healthy.
Physical Exam:
T- 97.8 BP- 150/90 HR- 81 RR- 19 O2Sat 98 RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
and
appropriate affect. Oriented to person, place, and says [**2152-4-10**]
for date. Attentive, says [**Doctor Last Name 1841**] backwards x 4, but then says its
hurting her head. Attentive with exam. Speech is fluent with
normal comprehension and repetition; naming intact. No
dysarthria. [**Location (un) **] intact. Registers [**2-28**], recalls [**2-28**] in 1
minute. No right left confusion. No evidence of apraxia or
neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Left field cut. Could not see discs secondary to
cataracts. Extraocular movements intact bilaterally, no
nystagmus. Sensation intact V1-V3. Facial movement symmetric.
Hearing intact to finger rub bilaterally. Palate elevation
symmetrical. Traps normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift. No asterixis
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 * * 5 * 4+ * * 5 * 5 *
L 5 5 5 * * 5 * 4+ * * 5 * 5 *
* Patient had severe exacerbation of headache on motor testing,
so portions were deferred.
Sensation: Intact to light touch and cold throughout. Perhaps
some extinction to DSS but only one out of three tries.
Reflexes:
+1 and symmetric throughout BUE. Absent knees and ankles.
Toes up bilaterally
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: Narrow based, mildly unsteady and wobbles twice. Does not
seem to veer to one side.
Romberg: deferred as patient's headache was exacerbated by
standing and could not comply.
Pertinent Results:
[**2152-4-25**] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2152-4-25**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
[**2152-4-25**] 03:00PM URINE RBC-0 WBC-[**3-1**] BACTERIA-FEW YEAST-FEW
EPI-[**6-6**] TRANS EPI-[**3-1**]
[**2152-4-25**] 03:00PM URINE HYALINE-0-2
[**2152-4-25**] 11:26AM PT-12.1 PTT-23.0 INR(PT)-1.0
[**2152-4-25**] 10:06AM GLUCOSE-116* UREA N-16 CREAT-0.9 SODIUM-142
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-20* ANION GAP-21*
[**2152-4-25**] 10:06AM CALCIUM-10.3* PHOSPHATE-4.4 MAGNESIUM-2.2
[**2152-4-25**] 10:06AM WBC-11.9* RBC-4.29 HGB-12.3 HCT-37.2 MCV-87
MCH-28.6 MCHC-33.0 RDW-16.1*
[**2152-4-25**] 10:06AM NEUTS-86.3* LYMPHS-8.8* MONOS-3.2 EOS-1.5
BASOS-0.2
CTH: [**4-25**]: IMPRESSION:
1. Multiple high-attenuation foci in bilateral cerebral
hemispheres. Differential diagnosis includes hemorrhagic,
hypervascular or adenocarcinomatous metastases.
2. There is a 6.8 mm leftward subfalcine herniation with early
uncal herniation.
MRI brain: [**4-26**]:
FINDINGS: There is extensive metastatic disease with multiple
rounded rim- enhancing lesions in all lobes of the brain. The
largest lesions include: A 1 x 0.9 cm mass at the left frontal
vertex, 2 x 1.6 cm mass in the right parietal lobe, 1.6 x 1.4 cm
mass in the right lentiform nucleus, 1.3 x 1.2 cm mass in the
right temporal cortex, 1.9 x 1.7 cm mass in the left cerebellar
hemisphere, and 1.5 x 1.2 cm mass in the right cerebellar
hemisphere, as well as multiple subcentimeter lesions. There is
moderate vasogenic edema, with severe extensive edema in the
right frontal and parietal lobes surrounding the right parietal
and right lentiform nucleus lesions. Mass effect and effacement
of the right lateral ventricle as well as subfalcine herniation
with 9 mm of leftward midline shift are stable from prior CT.
The suprasellar cisterns are poorly visualized and there is
distortion of the interpeduncular cistern. Nearly all of the
lesions demonstrate hypervascularity and hemorrhage.
IMPRESSION: Innumerable hypervascular and hemorrhagic metastases
throughout the cerebral and cerebellar hemispheres with
extensive edema in the right frontal and parietal lobes and
evidence of subfalcine and early uncal herniation.
CXR: [**4-26**]: Left lower lobe mass as described highly suspicious
for metastatic spread.
Brief Hospital Course:
Pt did well during stay. Pt started on decadron 4 Q6hrs. With
question of worsening diplopia, pt'd decadron was increased to 4
Q4hrs. Pt had whole brain radiation started on [**4-26**] (with goal
10 days of treatment). Neuro oncology evaluated her and will
follow her in brain tumor clinic (Dr. [**Last Name (STitle) 724**].Pt with diplopia
worse with lateral gaze to either direction suggestive of
bilateral VIth nerve palsies. Pt was given patch with relief.
Her headache significantly improved with analgesia and steroids.
Pt was evaluated by physical therapy who felt that she would
initially benefit from rehab, however her exam improved and she
was felt to be safe to go home with home PT and OT.
Medications on Admission:
Allopurinol - 100 mg Tablet - 2 (Two) Tablet(s) daily
Amlodipine [Norvasc] - 5 mg Tablet - 1 daily
ATORVASTATIN CALCIUM - 80MG daily
Clopidogrel [Plavix] - 75 mg Tablet - once daily
Colchicine - 0.6 mg Tablet - 1 (One) Tablet(s) by mouth once a
day as needed for pain
Furosemide - 20 mg Tablet - 1 Tablet(s) by mouth once a day
Insulin Glargine [Lantus] - 100 unit/mL Solution - 20 units HS
Insulin Lispro [Humalog] sliding scale
Levothyroxine [Levoxyl] - 100 mcg Tablet - 1 (One) Tablet(s) by
Lisinopril - 40 mg Tablet - 1 Tablet(s) by mouth daily
Metoprolol Tartrate - 50 mg Tablet - 2 Tablet(s) by mouth qam
and
Nitroglycerin - 0.4 mg Tablet, Sublingual - 1 (One) Tablet(s)
Aspirin - (Prescribed by Other Provider) - 325 mg Tablet - 1
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QPM
(once a day (in the evening)).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Insulin Regular Human Injection
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. Dexamethasone 4 mg Tablet Sig: Four (4) Tablet PO Q4H.
Disp:*120 Tablet(s)* Refills:*1*
Discharge Disposition:
Home with Service
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
breast cancer
multiple brain lesions - likely metastatic breast cancer
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
please follow up with primary care provider and primary
oncologist.
please follow up with Dr. [**Last Name (STitle) 724**] in ([**Telephone/Fax (1) 6574**]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 10662**]
Date/Time:[**2152-6-20**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2152-9-27**] 10:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2152-9-27**]
10:00
Please follow up with Dr. [**Last Name (STitle) 724**] ([**Telephone/Fax (1) 6574**]. His office will
contact you with appointment.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
|
[
"4280",
"V4581",
"25000",
"2720"
] |
Admission Date: [**2140-1-16**] Discharge Date: [**2140-1-23**]
Date of Birth: [**2088-2-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Jaundice, fever
Major Surgical or Invasive Procedure:
ERCP and sphincterotomy
Percutaneous drainage of subhepatic biloma
History of Present Illness:
51-year-old man who underwent laparoscopic cholecystectomy on
[**2140-1-10**] presented to the office on [**2140-1-16**] with jaundice and
fever. He was admitted placed on antibiotics and sent for ERCP
in [**Location (un) 86**] and admitted after the procedure for further treatment
Past Medical History:
Mitral valve prolapse
Social History:
Noncontributory
Family History:
Noncontributory
Physical Exam:
Discharge exam:
Afebrile, vital signs stable
NAD, A&Ox3
RRR
CTAB
Abd soft, NT, ND, +BS. Drain site c/d/i, yellow/green fluid in
gravity bag.
Pertinent Results:
Admission Labs
[**2140-1-16**] 01:16PM BLOOD WBC-14.5* RBC-3.60* Hgb-11.0* Hct-32.2*
MCV-89 MCH-30.6 MCHC-34.3 RDW-13.9 Plt Ct-166
[**2140-1-16**] 01:16PM BLOOD Glucose-136* UreaN-13 Creat-0.6 Na-136
K-4.5 Cl-102 HCO3-20* AnGap-19
[**2140-1-16**] 01:16PM BLOOD ALT-389* AST-94* LD(LDH)-228 AlkPhos-122*
Amylase-14 TotBili-1.7*
[**2140-1-16**] 01:16PM BLOOD Lipase-10
[**2140-1-16**] 01:16PM BLOOD Albumin-2.4* Calcium-7.5* Phos-1.4*
Mg-1.6
Discharge Labs
[**2140-1-23**] 07:15AM BLOOD WBC-8.1 RBC-3.97* Hgb-11.9* Hct-34.6*
MCV-87 MCH-30.0 MCHC-34.4 RDW-13.7 Plt Ct-391
[**2140-1-22**] 06:15AM BLOOD Glucose-111* UreaN-12 Creat-0.7 Na-136
K-4.3 Cl-102 HCO3-24 AnGap-14
[**2140-1-22**] 06:15AM BLOOD ALT-67* AlkPhos-115 Amylase-101*
TotBili-0.9
[**2140-1-22**] 06:15AM BLOOD Lipase-105*
Brief Hospital Course:
HD1: Admitted to ICU for observation, made NPO, Foley placed,
started on Vancomycin, Levaquin, Flagyl. Placed on IV Lopressor
for blood pressure control. ERCP Findings: The CBD was not
dilated and there was one questionable filling defect within.
After filling the CBD with contrast a leak from the duct of
luschka was identified.
HD2: Was stable overnight, fevers resolved, was transferred to
floor. Gallbladder fossa fluid collection assessed as too small
for drainage.
HD3: Foley d/c'd. Vancomycin stopped.
HD4: RUQ US: Within the gallbladder fossa, a 2.7 x 3.1 x 2.5 cm,
ovoid, anechoic
fluid collection is present. This collection is unchanged in
size from the
previous CT examination from four days previously. Levaquin and
flagyl changed to PO.
HD5: Biloma aspirated by interventional radiology; 10cc bile
returned and sent for gram stain and culture. Gram stain: no
microorganisms. Culture: no growth.
HD6: WBC and LFTs failed to decrease as expected. Abd CT: large
L-sided peri-hepatic fluid collection.
HD7: Interventional radiology placed a drainage catheter in a
different fluid collection with return of bile, no signs of
infection/abscess. Fluid sent for gram stain (no
microorganisms) and culture (no growth). Postprocedure was
advanced to clears.
HD8: Uneventful course overnight. Diet advanced to regular. WBC
count decreased from 15.6 to 8.1. Discharged home with VNA and
drain care teaching.
Medications on Admission:
None
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Duct of Luschka Biliary leak
E. Coli Bacteremia
Biloma requiring percutaneous drainage
Discharge Condition:
Good
Discharge Instructions:
-Call if you have any questions or concerns.
-Call if you have any of the following symptoms:
-Fever >101.4 or chills
-Intractable nausea or vomiting
-Increasing abdominal discomfort/pain
-Intolerance to tube feeding regimen
-Dizziness or increasing weakness
-Your drain output suddenly changes color or the amount of
drainage significantly increases or decreases
Followup Instructions:
Please call Dr. [**First Name (STitle) 2819**] for a follow-up appointment in 1 week.
Completed by:[**2140-1-25**]
|
[
"4240"
] |
Admission Date: [**2118-11-14**] Discharge Date: [**2118-11-20**]
Date of Birth: [**2075-8-18**] Sex: M
Service:
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This 47 year old male underwent
coronary bypass grafting times three in [**2118-6-9**], and now
has onset of shortness of breath and increasing fatigue since
[**2118-8-10**]. He had an echocardiogram which showed three
to four plus mitral regurgitation and he is now admitted, was
seen preoperatively by Dr. [**Last Name (Prefixes) **] for mitral valve
replacement. Cardiac catheterization showed venous left
anterior descending coronary artery with 70 to 80 percent
stenosis, vein graft to the obtuse marginal two with 80
percent stenosis, patent vein graft to the posterior
descending coronary artery, ejection fraction 25 to 30
percent, occluded left coronary artery, global hypokinesis,
three to four plus mitral regurgitation, 100 percent native
left anterior descending coronary artery, 70 to 80 percent
native circumflex and obtuse marginal one 99 percent lesion.
Echocardiogram showed global hypokinesis, inferior akinesis,
ejection fraction 30 percent, three to four plus mitral
regurgitation and trace tricuspid regurgitation.
PAST MEDICAL HISTORY: Status post coronary artery bypass
graft times three in [**2118-6-9**].
Elevated lipids.
Hypertension.
Ankle surgery.
ICD placement 11/[**2117**].
Percutaneous transluminal coronary angioplasty with stents
times three in [**2118-8-10**].
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. daily.
2. Lisinopril 10 mg p.o. daily.
3. Toprol 25 mg p.o. daily.
4. Lipitor 40 mg p.o. daily.
5. Plavix 75 mg p.o. daily.
6. Bupropion SR 150 mg p.o. twice a day for smoking
cessation.
7. Vitamin B1 10 mg p.o. daily.
ALLERGIES: He had no known allergies.
SOCIAL HISTORY: The patient is currently unemployed. He had
a thirty pack year history of smoking four to five cigarettes
a day right at this time although the patient admits that he
is cutting down. He also admits to a couple of beers per
week.
Cardiac MR performed [**2118-10-13**], showed a left ventricular
ejection fraction of 55 percent, a forward left ventricular
ejection fraction of 30 percent, right ventricular ejection
fraction of 59 percent, moderate to severe mitral
regurgitation, mild to moderate tricuspid regurgitation and
descending thoracic aorta diameter was 29 with global
hypokinesis.
Preoperative laboratories were as follows: Urinalysis was
negative. ALT 24, AST 23, alkaline phosphatase 112, total
bilirubin 0.5, total protein 8.5, albumin 4.9, globulin 3.6,
hemoglobin A1C 5.7 percent. Prothrombin time 12.8, partial
thromboplastin time 28.2 and INR 1.0. Sodium 137, potassium
4.5, chloride 99, bicarbonate 25, blood urea nitrogen 22,
creatinine 1.1 with a blood sugar of 78. White blood cell
count 8.9, hematocrit 43.8. Electrocardiogram showed sinus
bradycardia at 59 beats per minute. Chest x-ray showed
interval placement of right ventricular ICD lead, as well as
decreasing left base lung atelectasis.
PHYSICAL EXAMINATION: On examination, the patient is five
feet nine inches tall, 190 pounds, oxygen saturation 96
percent in room air, in sinus rhythm at 67 beats per minute
with a blood pressure of 133/86. He came into the office in
no apparent distress. His skin was warm and dry with normal
skin tone. Extraocular movements were intact. No jugular
venous distention or carotid bruits. Lungs were clear
bilaterally. His heart was regular rate and rhythm with S1
and S2 tones and grade II/VI systolic ejection murmur heard
best at the apex. His abdomen was soft, round, nontender,
nondistended, with positive bowel sounds. Extremities were
warm and well perfused with no edema. He had no varicosities
apparent. He was alert and oriented times three and
appropriate and grossly neurologically intact. He had
bilateral two plus dorsalis pedis, posterior tibial and
radial pulses. No carotid bruit was heard.
HO[**Last Name (STitle) **] COURSE: The patient was seen preoperatively on
[**2118-11-11**], in the office and was admitted for his surgery on
[**2118-11-14**]. Dr. [**Last Name (Prefixes) **] performed a redo sternotomy with
mitral valve replacement with 27 millimeter [**Last Name (un) 3843**]-
[**Doctor Last Name **] bioprosthesis. The patient was transferred to the
Cardiothoracic Intensive Care Unit in stable condition on a
Lidocaine drip of 2 mg a minute, Neo-Synephrine drip at 0.3
mcg/kg/minute, Epinephrine drip at 0.01 mcg/kg/minute and
titrated Propofol drip. On postoperative day number one, the
patient had a blood pressure of 109/65, remained ventilated
in sinus rhythm at 73 beats per minute on an Epinephrine drip
at 0.01, Neo-Synephrine drip at 0.6 and insulin drip at 2
units per hour and Lidocaine drip at 2.0. Epinephrine was
discontinued during the day. Swan remained in and the
patient remained intubated and sedated. When he was off
sedation, he was moving all extremities. He had coarse
breath sounds bilaterally with the plan to extubate him and
try and cut back on his drips in preparation for extubation.
He was also seen by electrophysiology service. His ICD
detectors were turned off. The patient was left on VVI.
They evaluated his pacer and then did postoperative
interrogation. Detection was turned on and VVI was set at 40
and it was determined that the ICD single chamber was
normally functioning. On postoperative day number two, the
patient had been extubated and an ejection fraction of
approximately 40 percent. Blood pressure 103/60 and sinus
rhythm in the 70s, oxygen saturation 97 percent on nasal
cannula. Started Aspirin and his oral Plavix as well as
Lasix diuresis. Neo-Synephrine was weaned to off. He
started on low dose beta blockers. Chest tubes and Swan-Ganz
were discontinued and his Precedex was discontinued. The
patient ask for a pain service consultation. This was
determined by the team to be placed on the back burner at the
time. The patient was making adequate urine. His
postoperative hematocrit was 26, and a chest x-ray was
ordered. On postoperative day number three, he continued
Plavix, Lopressor and Lasix and he was off all drips. He was
changed over to Toprol. His chest tubes were discontinued
and his pacing wires were discontinued. The patient
continued to have a slight oxygen requirement and he was
transferred out to the floor. He was also started on Flomax.
Foley was replaced for retention and was left in. Repeat
chest x-ray showed a right lung base effusion. The patient
had an oxygen requirement. Beta blocker was changed over to
Toprol. The patient was transferred out to the floor later
in the day. The patient was transferred out to the floor and
began to work with physical therapy. He was also seen by
case management in an effort to get him to improve his
pulmonary toilet and start increasing his activity level.
His creatinine remained stable at 0.9. He was on Toprol XL
at 25 and continued with his Plavix. His p.o. intake was
limited. The patient was managed with p.o. pain medications
on the floor, continued to work with physical therapy, made
excellent progress on postoperative day number five. He
continued with Flomax and he was encouraged to ambulate and
increase his p.o. intake. His pacing wires were discontinued
without any incident and discharge planning was begun. The
patient was also started on Thiamine and was receiving some
Dilaudid p.r.n. for pain, as well as starting on some Flovent
and Combivent to aid in his pulmonary status. The patient
also was given a little bit of Ativan to help him with his
Dilaudid, to decrease his anxiety and increase his pain
relief. He had some right basilar crackles and was getting
nebulizer treatments as previously stated. He continued to
improve on the floor. On postoperative day number six, his
weight was down to 87.2 kilograms and he was hemodynamically
stable. He was doing very well and was discharged to home
with VNA services. He was noted to have a small ridge noted
on his incision but this was not deemed to be necessary to
hold up his discharge and he was discharged to home on
[**2118-11-20**].
DISCHARGE DIAGNOSES: Status post redo sternotomy and mitral
valve replacement.
Status post coronary artery disease [**2118-6-9**].
Elevated lipids.
Hypertension.
Ankle surgery.
ICD placed 11/[**2117**].
Percutaneous transluminal coronary angioplasty with three
stents 09/[**2117**].
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient was instructed to follow-
up with Dr. [**Last Name (Prefixes) **] and see him in the office at
approximately four weeks postoperatively for his
postoperative surgical visit. He was also instructed to
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12300**] for his postoperative visit
in one to two weeks, [**Telephone/Fax (1) 58104**].
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. twice a day for seven days.
2. Potassium Chloride 20 mEq p.o. twice a day for seven days.
3. Colace 100 mg p.o. twice a day.
4. Enteric Coated Aspirin 81 mg p.o. one daily.
5. Plavix 75 mg p.o. daily.
6. Dilaudid 2 mg tablets, dispense one to two tablets p.o.
p.r.n. q4-6hours for pain as needed.
7. Albuterol/Ipratropium 103/118 mcg aerosol two puffs
inhalation q6hours.
8. Fluticasone Propionate 110 mcg aerosol two puffs twice a
day inhalation.
9. Ibuprofen 600 mg p.o. q6hours as needed for pain.
10. Metoprolol 50 mg p.o. sustained release one daily.
11. Tamsulosin Hydrochloride 0.4 mg sustained release
p.o. daily at bedtime.
12. Bupropion 150 mg sustained release p.o. twice a day
for smoking cessation.
CONDITION ON DISCHARGE: Again, the patient was discharged
home in stable condition on [**2118-11-20**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2119-1-31**] 16:47:43
T: [**2119-1-31**] 20:25:44
Job#: [**Job Number 58105**]
|
[
"4240",
"V4581",
"V4582",
"412"
] |
Admission Date: [**2167-3-28**] Discharge Date: [**2167-4-10**]
Service: MEDICINE
Allergies:
Heparin Agents / Lipitor
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
R IJ central line placement
History of Present Illness:
81 F presents from [**Hospital1 **] with fever, hypotension, and altered
mental status. Pt s/p CABG [**5-29**] c/b bowel ischemia s/p
resection with ileostomy with high level of output resulting in
intermittent dehydration. Pt had PICC placed recently for TPN
to improve nutritional status before closure of ileostomy
shceduled for [**4-13**]. On admission, pt c/o nonproductive cough.
Denied dysuria, abdominal pain, nausea/vomiting, diarrhea, chest
pain, back pain, or SOB.
In the [**Name (NI) **], pt was given vancomycin 1g x1, levofloxacin 500mg IV
x1; a Foley was placed, Ucx and BlCx sent. Pt was given 2L NS.
BP was 93/28 on arrival, decreased to 82/39. Code sepsis was
called, and pt was transferred to [**Hospital Unit Name 153**].
Past Medical History:
- 3V CABG [**5-29**]
- Mesenteric ischemia s/p resection and temportary ileostomy
- Short gut syndrome
- HIT
- Depression
Social History:
Denied ETOH, tobacco, IVDA. Currently lives at [**Hospital **] rehab in
preparation for ileostomy reversal. Family actively involved in
care
Family History:
NC
Physical Exam:
Gen: awake, alert, mild respiratory distress
HEENT: PERRL, EOMI, MM dry
Neck: JVP flat, no cervical LAD
CV: irregular, nl S1/S2, no m/r/g
Pulm: diffusely wheezy, no crackles
Abd: soft, NT/ND, ostomy patent, draining brown liquid stool
Ext: warm, no edema
Skin: no rashes
Pertinent Results:
Admission labs:
electrolytes: GLUCOSE-102 UREA N-28* CREAT-1.3* SODIUM-140
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-2.1
LFTs: ALT(SGPT)-16 AST(SGOT)-30 AMYLASE-44 LIPASE-14
CBC: WBC-7.6 RBC-3.40* HGB-10.0* HCT-28.8* MCV-85 MCH-29.6
MCHC-34.8 RDW-14.7 PLT COUNT-185
NEUTS-83.5* BANDS-0 LYMPHS-10.7* MONOS-4.0 EOS-1.7 BASOS-0.1
LACTATE-1.6
Imaging:
[**3-27**] CXR: No acute cardiopulmonary abnormality identified.
[**3-30**] CXR: There is new bilateral lower lobe infiltrates and
effusions with volume loss in the left lower lobe as well. There
is hazy bilateral vasculature with vascular redistribution. It
is unclear how much of this process due to CHF or if there is an
underlying infectious infiltrate. Dual-lead pacemaker is
unchanged. Right subclavian line tip is in the superior vena
cava.
IMPRESSION: New bilateral lower lobe infiltrates and effusion.
Micro:
[**3-27**] Blood Cx: 4/4 bottles with coag neg Staph:
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
[**3-28**] PICC tip with coag negative Staph, same sensitivities as
above
[**3-28**] UCx: Enterococcus:
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
VANCOMYCIN------------ <=1 S
[**3-28**], [**3-31**] blood cultures NGTD
.
CXR [**4-5**]: Interval resolution of previously seen congestive
heart failure. Small, persistent, bilateral effusions.
.
Tunneled Cath placement [**4-6**]: Successful placement of a
10-French double-lumen tunneled central venous catheter by way
of the right internal jugular vein with tip in the superior vena
cava. The catheter can be used immediately.
Brief Hospital Course:
1. Sepsis - Pt was admitted to the [**Hospital Unit Name 153**] and was administered
approximately 5L IV fluid for hypotension. Pt required levophed
support for 24 hours and was subsequently weaned off pressors.
Cortisol stimulation test was normal. CXR was without
infiltrate; UCx grew Enterococcus and [**4-28**] blood cultures grew
coag negative Staph with same sensitivity profile as coag neg
Staph from PICC tip. Pt was initially treated broadly with
Zosyn and Vanco; once sensitivities returned from blood cultures
and PICC tip, antibiotics were reduced to Vancomycin alone, to
continue for 14 days total (last dose [**2167-4-11**]). Patient remained
hemodynamically stable and afebrile on the floor.
.
2. Congestive heart failure - Patient was fluid overloaded on
exam after aggressive resuscitation in the setting of sepsis.
Pt autodiuresed well and lung exam improved through hospital
course. Patient was weaned off supplemental oxygen on the floor,
and continued to oxgenate well on room air.
.
3. s/p bowel resection with ostomy, short-gut syndrome - PICC
line had initially been placed for nutritional optimization
prior to reversal of ostomy planned for later this month at [**Hospital1 2025**].
Ileostomy had high-ouput drainage; in discussion with patient's
PCP at [**Name9 (PRE) 2025**], numerous medical interventions had been tried
without success. Patient was continued on Ranitidine [**Hospital1 **], and
Lansoprazole added to regimen for GERD-type symptoms with good
effect. Once access was obtained (R IJ tunneled cath), TPN was
cycled, first over 24 hours, now 12 hours overnight.
.
4. Coronary artery disease s/p CABG - Given high output from
ileostomy, patient was not on ACE or BB as she was prone to
dehydration and BPs ran asymptomatically low at baseline. Pt was
continued on aspirin. Patient with statin allergy -
rhabdomyloysis on prior administration. Patient without coronary
issues on this admission.
.
5. Depression - continued on outpatient Amitriptyline 15
.
6. Access - A right subclavian was placed while in ICU which was
subsequently dc'd after hemodynamically stable. PICC was removed
shortly after admission as it was the etiology of sepsis. After
surveillance cultures were negative x72 hours, PICC replacement
was attempted but unsuccessful due to subclavian stenosis on
right, and left was not engaged due to presence of pacemaker.
Cardiology was curbsided and they recommended against PICC
placement on left. Patient then received double-lumen tunneled R
IJ via Interventional Radiology on [**2167-4-6**].
.
7. PPX
Patient with history of Heparin-induced thrombocytopenia, NO
heparin products were administered. Patient was given
Fondaparinux for DVT prophylaxis.
.
8. CODE: FULL
Medications on Admission:
ASA 81 mg po qd, elavil 12.5 mg po qhs, Alphagan gtt, Citracel+D
1 tab po tid, folate 1 mg po qd, arixtra 2.5 mg SC qhs, MVI 1
tab po qd, zantac 150 mg po qd, loperamide 2mg po q8h prn
Discharge Medications:
1. Amitriptyline 25 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
10. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 5 days.
11. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY
(Daily).
13. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 24H (Every 24 Hours) for 1 days. Recon Soln(s)
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Principal:
1. Methicillin Sensitive Coagulase Negative Staph Line Sepsis.
2. Enteroccocus Urinary Tract Infection.
3. Diastolic Heart Failure.
4. Malnutrition - Moderate Degree.
5. High Ouput Ileostomy.
6. Stage III Chronic Kidney Disease.
Secondary:
1. Coronary Artery Disease s/p CABG.
2. Perioperative bowel ischemia s/p resection.
3. Short-Gut Syndrome with Ileostomy.
4. Immune Mediated Heparin Induced Thrombocytopenia.
5. Dual Chamber Pacemaker.
6. Gastroesophageal Reflux Disease.
7. Depression.
8. S/P Cholecystectomy.
9. Statin associated Rhabdomyolysis.
Discharge Condition:
feeling well, no oxygen requirement, without pain
Discharge Instructions:
1. Please take all medications as prescribed
2. Please make all follow-up appointments
3. Patient will need nutrition follow-up at [**Hospital1 2025**] for TPN
4. Patient on Vancomycin for line sepsis - last dose [**2167-4-11**]
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66248**] as needed [**Telephone/Fax (1) 66249**]
Completed by:[**2167-4-10**]
|
[
"99592",
"5990",
"78552",
"4280",
"V4581"
] |
Admission Date: [**2131-6-21**] Discharge Date: [**2131-6-22**]
Date of Birth: [**2066-10-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Unresponsiveness, hypoglycemia
Major Surgical or Invasive Procedure:
Patient was intubated.
History of Present Illness:
54 yo F with ho DM2, HTN, PVD, OSA, aortic stenosis (1.2 cm),
RBBB/LAFB on EKG, PAF, h/o PE s/p IVC filter, adrenal mass,
gastric & colonic polyps, s/p CCY, admitted on [**6-12**] to
[**Hospital3 **] with anorexia and weakness x 2days. In the
10 days prior to admission her FS had been in the 500s. Also,
about 2-3 weeks prior to admission was started on bactrim for
possible LE cellulitis. Per her family she had anorexia and
elevated blood sugars and presented to OSH, where she was
admitted. She was found to have elvated LFTs which were thought
to be secondary to bactrim. She had an abdominal US with min
ascites but no ductal dilation or stones, but was started on
cipro for possible cholecystitis then referred for ERCP for
unclear reasons, but procedure aborted due to afib with RVR to
140??????s. She was started on heparin and continued her on
amiodarone and diltiazem and digoxin was added. She became
increasingly confused per her family and was started on
lactulose. In terms of her labs, WBC 14 AST 135, ALT 239,
alkphos 154, bili 10.7 (trending up from 4.4 on admission), alb
1.7. Creatinine range 1.1 to low 2.0s and was trending up prior
to transfer. AST and ALT remained stable but t bili increased to
10 and lipase 172. She became thrombocytopenic the day prior to
transfer and heparin was d/c'd give concern for HIT. Her HRs
110s-120s. ABG 7.33/22/74 on RA. Was switched from cipro to
aztreonam and vanco.
Originally was transferred here for work-up of her hepatitis,
then became unresponsive in the ambulance and FS found to be 25.
On arrival to the ED she was agonally breathing with a thready
pulse. She was given 1 amp of D50 and 1 amp HCO3 and was
intubated. She was hypotensive was briefly on peripheral
dopamine and an emergent femoral line was placed and she was
started on levophed. An attempt at an a-line was made in both
radial arteries as well as femoral, but was unsuccessful. Her
VBG was 7.11/46/107 on AC with unclear settings and lactate 6.9.
Her ECG showed a RBBB ? afib versus flutter with variable block.
She was given 5 L NS, 1 liter LR, 2 amps D50, 2 amps HCO3,
insulin, kayexalate, vancomycin, levofloxacin and flagyl. CXR
revealed no PNA or CHF, CT abdomen with hepatomegaly, ascites,
bilateral pleural effusions, pericardial effusion, anasarca and
no biliary dilitation. CT head was negative. She was transferred
to the ICU for further management.
Past Medical History:
DM2
OSA on CPAP
aortic stenosis (1.2 cm)
RBBB/LAFB on EKG
PAF
h/o PE s/p IVC filter
adrenal mass
gastric & colonic polyps
s/p CCY
LE cellulitis
developed hepatitis while on Bactrim
PVD
Echo in [**9-2**] with EF 75%
Social History:
Lives with daughter. Quit smoking 10 years ago, no ETOH, no
drugs.
Family History:
father with gastric cancer
Physical Exam:
General: Obese, intubated and sedates
HEENT: sceral icterus, PERRL
Abd: obese
Ext: chronic venous stasis changes, 3x4 cm ulcertion on the
medial aspect of right leg
Pertinent Results:
Patient expired,
Brief Hospital Course:
Patient entered [**Hospital Unit Name 153**] with hypoglycemia and agonal breathing s/p
intubation with shock, liver failure and renal failure. She
became markedly hypotensive despite being on 2 pressors and
being intubated. At this juncture, the family decided on
providing comfort measures only at which point a decision was
made to extubate the patient. She expired shortly thereafter.
Medications on Admission:
NPH 18 [**Hospital1 **]
Digoxin 125 mcg po qday
Lacthytrim
oscal 500 mg Po BID
lactulose 30 ml Po QID
vanco 1.5 g IV daily
aztreonam 1 gram Q12H
tylenol 650 q4h PRn (received 2 doses)
Diltiazem ER 180 mg po qday
Duoneb
Discharge Disposition:
Expired
Discharge Diagnosis:
Fulminant Hepatic Failure with associated cardiac arrest
Discharge Condition:
Patient Expired.
Completed by:[**2131-6-22**]
|
[
"5849",
"2762",
"5119",
"32723",
"4241",
"42731",
"2767"
] |
Admission Date: [**2190-12-22**] Discharge Date: [**2190-12-26**]
Date of Birth: [**2133-5-7**] Sex: M
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Syncope. Subsequent workup for the
syncopal episode revealed aortic disease.
HISTORY OF PRESENT ILLNESS: No previous cardiac history,
syncope in [**2190-7-7**]. Following the syncopal episode he
saw a neurologist, a neurosurgeon and finally a cardiologist.
A cardiac echocardiogram done from the cardiologist revealed
a normal ejection fraction and two mobile plaques in the
aortic arch more distal then the left subclavian.
PAST MEDICAL HISTORY: Significant for hypercholesterolemia,
hypertension and gastric reflux. He also has ruptured disc
for which he is awaiting surgery.
PAST SURGICAL HISTORY: Four mouth extractions, knee surgery
and a tonsillectomy.
MEDICATIONS PRIOR TO ADMISSION: Zestril 10 mg q.d., Lipitor
80 mg q.d., Plavix 75 mg q.d., Wellbutrin SR 150 mg b.i.d.,
Combivent inhaler q 6 hours, Ambien 10 mg q.h.s. and Roxicet
5/325 prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in an apartment with a
friend up three flights of stairs. Occupation, he is a
material manager. Tobacco use positive, down to five
cigarettes a day. ETOH use three drinks per day, more on the
weekends and occasional marijuana use.
PHYSICAL EXAMINATION PRIOR TO ADMISSION: Heart rate 102.
Blood pressure 163/88. Respiratory rate 22. Height 5'7".
Weight 160 pounds. General, male in no acute distress. Skin
few superficial lesions on his legs. HEENT is unremarkable.
Neck is supple with some decreased flexion. Chest is clear
to auscultation bilaterally. Heart regular rate and rhythm.
No murmur noted. Abdomen slightly distended, soft, nontender
with positive bowel sounds. Extremities are warm and well
perfuse. Left foot slightly pale compared with the right.
Varicosities none. Neurological grossly intact.
LABORATORY DATA: White blood cell count 9.3, hematocrit
39.4, platelets 314, PT 11.2, PTT 24.2, INR 0.9, sodium 139,
potassium 4.0, chloride 99, CO2 24, BUN 12, creatinine 1.0.
Chest x-ray no infiltrates or effusions. No pneumothorax.
HOSPITAL COURSE: The patient is a direct admission to the
Operating Room on [**12-22**]. At that time he underwent an
aortic arch endarterectomy. He tolerated the operation well
and was transferred to the Operating Room to the
Cardiothoracic Intensive Care Unit.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2190-12-24**] 10:32
T: [**2190-12-24**] 12:03
JOB#: [**Job Number 37688**]
|
[
"496",
"2720",
"4019",
"53081",
"3051"
] |
Admission Date: [**2124-10-10**] Discharge Date: [**2124-10-17**]
Date of Birth: [**2058-2-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Remicade
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
increasing SOB/DOE
Major Surgical or Invasive Procedure:
[**2124-10-10**] redo MVR ([**Street Address(2) 17009**]. [**Male First Name (un) 923**] porcine)/ TV repair (28 mm CE
MC3 annuloplasty ring)
History of Present Illness:
66 year old RN who underwent mitral valve repair in [**2123-7-30**]
at [**Hospital1 756**] and
Women??????s Hospital. She has reported increasing shortness of
breath and dyspnea on exertion. She can become short of breath
with as little as conversing with someone. She is profoundly
dyspneic with one flight of stairs. She also reports
progressive fatigue and though she continues to work, she feels
as though she is pushing herself. Further evaluation with
echocardiogram and
right heart cardiac catheterization have revealed findings
consistent with mitral stenosis. She also appears to have
moderate to severe tricuspid regurgitation. Based upon the
findings, she was referred for cardiac surgical intervention.
Past Medical History:
Possible TIA - transient right visual field deficit
Dyslipidemia
Asthma/Restrictive Lung Disease
Psoriatic arthropathy
Hypothyroidism, Thyroid Nodule - benign
Mild gastroparesis
Stress incontinence
Gastroesophageal reflux disease
Ulcerative colitis - GI Bleed in [**Month (only) 216**]/[**2124-8-29**]
Right lung nodule - stable, not enlarging
Osteoporosis
Past Surgical History:
- s/p Mitral valve repair on [**2123-8-12**] at [**Hospital1 756**] and
Women??????s with a 32-mm [**Doctor Last Name 405**]-[**Doctor Last Name **] ring
implantation...****difficult intubation followed cardiac arrest
during induction******Postop course complicated by atrial
fibrillation and pleural effusion requiring tap
- s/p Tubal ligation
- s/p Tonsillectomy and adenoidectomy
- s/p Right knee meniscus repair
- s/p Left Hip Arthroscopy
Social History:
married with three grown children. She
is [**Name8 (MD) **] RN, currently working in the cath lab here at [**Hospital1 18**]. She
does not smoke or drink.
Family History:
no premature coronary disease
Physical Exam:
Height: 62" Weight: 148lbs
General: middle aged female in no acute distress
Skin: Dry [x] intact [x] - hemangioma noted on chest and
forehead
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: bilateral varicosities noted
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2124-10-16**] 05:35AM BLOOD WBC-9.4 RBC-3.34* Hgb-9.9* Hct-29.5*
MCV-88 MCH-29.5 MCHC-33.5 RDW-15.4 Plt Ct-251#
[**2124-10-10**] 02:02PM BLOOD WBC-13.3*# RBC-2.45*# Hgb-7.1*#
Hct-22.4*# MCV-91 MCH-29.1 MCHC-31.9 RDW-15.4 Plt Ct-187
[**2124-10-13**] 02:04AM BLOOD PT-13.3 PTT-27.4 INR(PT)-1.1
[**2124-10-10**] 02:02PM BLOOD PT-16.6* PTT-36.2* INR(PT)-1.5*
[**2124-10-16**] 05:35AM BLOOD UreaN-10 Creat-0.6 Na-135 K-5.2* Cl-101
HCO3-28 AnGap-11
[**2124-10-11**] 03:11AM BLOOD Glucose-122* UreaN-14 Creat-0.8 Na-140
K-5.0 Cl-113* HCO3-22 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 10900**] L. [**Hospital1 18**] [**Numeric Identifier 94277**]
(Complete) Done [**2124-10-10**] at 11:23:06 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]
[**Last Name (LF) **], [**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: [**2058-2-17**]
Age (years): 66 F Hgt (in): 62
BP (mm Hg): / Wgt (lb): 148
HR (bpm): BSA (m2): 1.68 m2
Indication: Congestive heart failure. Mitral valve disease.
Shortness of breath.
ICD-9 Codes: 424.90, 428.0, 786.05, 440.0, 394.0
Test Information
Date/Time: [**2124-10-10**] at 11:23 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 #: 2009AW-:01 Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.5 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Mitral Valve - Pressure Half Time: 160 ms
Mitral Valve - MVA (P [**12-31**] T): 1.2 cm2
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast in the
body of the LA. No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Low normal LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Increased transmitral gradient. Small vegetation
on mitral valve. Moderate valvular MS (MVA 1.0-1.5cm2) Mild (1+)
MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Moderate
[2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The patient appears to be in sinus rhythm.
patient. See Conclusions for post-bypass data
Conclusions
Pre-bypass:
No spontaneous echo contrast is seen in the body of the left
atrium. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
The right ventricular cavity is mildly dilated with normal free
wall contractility.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen.
The gradient across the mitral valve is increased (peak = 17
mmHg and mean 8mm of Hg). There is a echodense, mobile 2 to 3mm
mass on the posterior leaflet close to the previously placed
mitral ring suggestive of pannus formation. These findings can
explain the increased gradients across the mitral valve and
mitral valve area of 1.2. There is moderate valvular mitral
stenosis (area 1.0-1.5cm2). Mild (1+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen and the
tricuspid annulus diameter of 4 cm in end diastole. There is no
flow reversal in the hepatic veins.
There is no pericardial effusion.
Post Bypass
Normal biventricular systolic function.
LVEF 40 to 55%.
There is a ring in the tricuspid position with residual mild TR.
The ring is stable and functioning well. The gradients across
the tricuspid valve is normal.
There is a mitral prosthesis, stable and functioning well. There
is no periprosthetic leak.
Thoracic aorta is intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician
?????? [**2117**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Mrs. [**Known lastname **] was taken to the operating room on [**2124-10-10**] and
underwent a redo-sternotomy/Mitral Valve Replacement (#25mm
St.[**Male First Name (un) 923**] Porcine)/Tricuspid Valve repair (#28 CE MC3 Annuloplasty
ring) with Dr.[**Last Name (STitle) **].Cross calmp time= 124 minutes.
Cardiopulmonary Bypass time= 151 minutes. Please refer to
Dr[**Last Name (STitle) **] operative report for further details. She was
transferred to CVICU intubated and sedated in critical but
stable condition. She awoke neurologically intact and was
extubated without difficulty on postoperative night. She was
started on Beta-blockers/diuresis/ASA/Statin initiated. POD2 she
was transfused 2 unit PRBC for a HCT of 22 to 27. All lines and
drains were discontinued in a timely fashion.She remained in
CVICU for hypotension and when hemodynamically stable on POD#3
she was transferred to the step down unit for further
monitoring. Physical therapy was consulted for evaluation of
strength and mobility. Aggressive pulmonary toilet and nebs were
given. She continued to progress and was cleared for discharge
to home by Dr.[**Last Name (STitle) **] on POD# 7.All follow up appointments were
advised.
Medications on Admission:
Lipitor 20 qd, Protonix 40 [**Hospital1 **], Levoxyl 75 qd,
Atenolol 25 qd, Aspirin 325 qd, Albuterol MDI, Fluticasone nasal
spray, Flovent MDI, Atrovent MDI, Sulfsalazine 1000mg TID, FeSO4
325mg qd, MVI, ?Asacol 400 tid
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
MR /TR s/p redo MVR/TV repair
prior possible TIA - transient right visual field deficit
Dyslipidemia
Asthma/Restrictive Lung Disease
Psoriatic arthropathy
Hypothyroidism, Thyroid Nodule - benign
Mild gastroparesis
Stress incontinence
Gastroesophageal reflux disease
Ulcerative colitis - GI Bleed in [**Month (only) 216**]/[**2124-8-29**]
Right lung nodule - stable, not enlarging
Osteoporosis
Discharge Condition:
stable
Discharge Instructions:
no driving for one month and off all narcotics
no lifting greater than 10 pounds for 10 weeks
no lotions, creams, powders or ointments on any incision
shower daily and pat incisions dry
call for fever greater than 100.5, redness, drainage, or
erythema
Followup Instructions:
see Dr. [**Last Name (STitle) 4390**] in [**12-31**] weeks
see Dr. [**Last Name (STitle) **] in [**2-1**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
please call for all appts.
Completed by:[**2124-10-17**]
|
[
"5119",
"5990",
"4280",
"53081",
"49390",
"2724",
"2449"
] |
Admission Date: [**2145-1-14**] Discharge Date: [**2145-1-22**]
Date of Birth: [**2061-9-27**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vasotec / Pletal
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with angioplasty and drug eluting stent
to left main coronary artery and left anterior descending artery
History of Present Illness:
83 yo with hx of AS s/p bioprosthetic AVR x 2, RIMA to RCA in
[**7-/2130**] presented to [**Hospital3 17921**] Center on [**1-12**] with CP. She
reported worsening of indeigestion with heartburn X 2 weeks with
the episodes of [**2145-1-20**] dull chest discomfort becoming more
constant. She was put on a PPI by her PCP without effect. Over
several days her sxs have become worse with burning chest
discomfort without associated SOB. She has 6 pillow orthopnea
from 3 due to worse sxs at night. Her chest discomfort is worse
with activity. Day prior ([**1-11**]) to admission she developed
severe heartburn and CP which radiated to both arms with
numbness and tingling of both arms as well. It was associated
with SOB, diaphoresis, lightheadedness, and eventual vomiting.
She has also had increasing fatigue and weakness. She called EMS
at that point and was relieved with oxygen.
.
Initial OSH EKG showed: old RBBB with new TWI in V2-V3 and III
and increased diffuse ST depressions. ST elevations in aVR.
Initial troponin was 0.1 which increased to 1.85 on [**1-13**] at
720am. She was started on IV heparin on the am of [**1-12**].
.
Patient had CP at 330 am on [**1-13**] relieved by increasing nitro
gtt.
Cardiac catheterization on [**1-13**] showed 98% discrete distal left
main disease, 90% proximal/mid/distal RCA, patent RIMA-distal
RCA, 85% mid right external iliac stenosis. LAD and circumflex
were poorly visualized. She was started on a nitro gtt, high
dose liptor, lopressor and norvasc. She was given Lasix IV for
evidence of CHF on CXR and an elevated BNP to 2810. She is +1.2
L due to IVF for renal protection.
.
She had a Hct drop from 34 to 28 which was rechecked and 24 on
day of transfer. Her creatinine was elevated at 1.8 (basline
unknown).
.
On the floor, patient had developed [**9-26**] chest discomfort while
on a heparin gtt and nitro gtt, which could not be put to max
dose due to limitations to what can be administered on the
general wards. The patient's chest discomfort relived on its
own.
.
Additionally, patient was found to have BRBPR on rectal
examination, although no bloody bowel movements.
.
On transfer, patient is CP free.
Past Medical History:
Cardiac Risk Factors: +Hypertension
- Aortic Stenosis: unknown valve area:
- AVR with periprostheic AR
- RIMA to RCA [**2130-8-2**]
- PVD with venous stripping RLE remote and intermittent
claudication
- basal cell carcinoma
- renal insufficiency stage III-IV [**2144-10-9**]: 1.82 baseline;
[**2142**]: 1.39, 1.48
- ACD
- GERD
- IBS
- b/l cataracts [**8-/2134**]
Colonscopy <5 years ago negative and told to return in 10 years;
Colonscopies previously with polyps
Social History:
Widowed with currently 3 living children. She lives alone in an
apartment and does own ADLs.
Hx of tobacco use (25 pack-years, quit >10 years ago). No etoh.
Uses a cane.
Family History:
Strong CAD with entire mother's side having heart problems. She
is [**12-27**] children and 6 siblings have died of heart related
problems. She also has a son who died of a sudden MI at age 52.
Physical Exam:
Gen: NAD. Oriented x3. Mood, affect appropriate. Speaking
comfortably in full sentences.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink.
Neck: Supple with JVP of 8 cm.
CV: Nondisplaced PMI. RR, normal S1, S2. 3/6 SEM radiating to
carotids.
Chest: Resp were unlabored, no accessory muscle use. Crackles at
bases b/l L>R.
Abd: Soft, NTND. No HSM or tenderness.
Ext: Trace LE pitting edema. b/l femoral bruits. Warm and well
perfused. 2+ DPs.
Pertinent Results:
[**2145-1-14**] 02:00PM WBC-8.5 RBC-2.73* HGB-8.5* HCT-25.1* MCV-92
MCH-31.2 MCHC-33.9 RDW-12.8
[**2145-1-14**] 02:00PM NEUTS-76.7* LYMPHS-17.0* MONOS-4.3 EOS-1.6
BASOS-0.4
[**2145-1-14**] 02:00PM CK(CPK)-26*
[**2145-1-14**] 02:00PM CK-MB-NotDone cTropnT-0.26*
[**2145-1-14**] 02:00PM PT-12.3 PTT-29.6 INR(PT)-1.0
[**2145-1-14**] 02:00PM GLUCOSE-101* UREA N-38* CREAT-1.7* SODIUM-139
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-34* ANION GAP-12
[**2145-1-14**] 09:54PM CALCIUM-8.4 PHOSPHATE-2.2* MAGNESIUM-2.5
[**2145-1-20**] 02:39PM DIPSTICK URINALYSIS: Blood Neg, Nitrite
Neg, Protein Tr, Glucose Neg, Ketone Neg, Bilirub Neg, Urobiln
Neg, pH 6.5, Leuks Lg
MICROSCOPIC URINE EXAMINATION RBC 1, WBC 54, Bacteria Few, Yeast
None, Epi 0
[**2145-1-20**] 2:39 pm URINE CULTURE (Preliminary): GRAM NEGATIVE
ROD(S). >100,000 ORGANISMS/ML.
.
[**2145-1-14**] ECG: Normal sinus rhythm, rate 78. Right bundle branch
block. Non-specific inferolateral repolarization changes. No
previous tracing available for comparison.
.
[**2145-1-14**] Arterial duplex lower extremity u/s: There is
significant calcified plaque bilaterally within the right and
left common femoral and superficial femoral arterial
distributions, now with elevated velocities within the
superficial femoral arteries bilaterally.
.
[**2145-1-14**] CT abdomen pelvis: 1. No evidence of retroperitoneal
hemorrhage.
2. Multiple well-circumscribed bilateral renal lesions, some of
which may
represent simple cysts, though with some incompletely
characterized and
correlation with prior imaging is recommended, and if no prior
imaging is
available, a renal ultrasound can be performed on a non-emergent
basis for
further evaluation. 3. Extensive atherosclerotic calcification
and disease with associated luminal narrowing that is
incompletely assessed on this non-contrast imaging study.
.
[**2145-1-15**] TTE: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function.
Aortic valve bioprosthesis with thickened leaflets and
abnormally-elevated gradients. Mild calcific mitral stenosis.
Moderate to severe mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension.
.
[**2145-1-18**] Cardiac catheterization: 1. Limited coronary angiography
in this right dominant system demonstrated three vessel disease.
The LMCA had a distal 90% stenosis. The LAD had a 90% mid vessel
stenosis. The RCA was not injected. 2. Abdominal aortography
revealed mild bilateral renal artery stenosis. The iliac
arteries were severely calcified and tortuous with a 70% right
and 60% left common iliac stenosis. 3. Successful PTCA and
stenting of the LMCA with a 4.5 x 13mm Ultra bare metal stent
which was postdilated to 5.0mm. Final angiography revealed no
residual stenosis, no angiographically apparent dissection, and
TIMI 3 flow. 4. Successful PTCA and stenting of the mid LAD with
a 3.0 x 15mm Vision bare metal stent which was postdilated to
3.5mm. Final angiography revealed no residual stenosis, no
angiographically apparent dissection, and TIMI 3 flow.
.
Renal Ultrasound [**2145-1-22**]
IMPRESSION:
1. Bilateral simple cysts measuring up to 1.7 cm.
2. Number of echogenic foci in the lower pole of the left
kidney, the largest
measuring 0.6 cm consistent with stone.
3. Bilateral small amount of pleural effusion.
4. Small amount of ascites.
Brief Hospital Course:
83 year-old female with past medical history of AS, CAD s/p 1V
[**Hospital **] transferred from OSH with 98% left main disease s/p BMS to
LMCA and mid LAD. She was transferred back to [**Hospital **] hospital in
[**Location (un) 3844**] on [**2145-1-22**] for further care because it is closer to
home, so that her family can visit her more easily.
#. CAD: The patient presented from an outside hospital with
severe left main stenosis of 98%. The patient underwent a
catheterization at the outside hospital. She was transfused 1u
pRBC to a goal of 30. She was weaned off the nitroglycerin drip
and her blood pressures were controlled with metoprolol tartrate
and hydralazine. She was on high dose atorvastatin. She had back
pain and had a CT abdomen and pelvis which was negative for RP
bleed. Her EKG was stable from the OSH and she was monitored on
telemetry. She underwent a high risk PCI with a bare metal stent
placed in the LMCA and LAD. She was maintained on aspirin and
plavix. Plavix should be continued for at least a month and
should only be stopped by her cardiologist. Aspirin should be
continued indefinitely and should only be stopped by her
cardiologist. She was discharged on a beta blocker and
hydralazine. When her kidney function returns she may warrant
addition of an ACE inhibitor to regimen. She will need an
appointment with her cardiologist in the near future that has
been scheduled.
#. Acute on chronic kidney disease: The patient has an unclear
baseline creatinine, which may be around 1.4. The patient had a
dye load from the OSH and a dye load during her catheterization
procedure and developed an acute kidney injury about 48hours
after the procedure, which appears to be Contrast-Induced
Nephropathy. Her UA and microscopy show rare eosinophils, which
is concerning for cholesterol emboli, however, no systemic signs
of this. Her FENa was suggestive of a pre-renal picture. Her
creatinine increased to 3.4 at the day of transfer. She was
given 1.5L of IV fluid without response in creatinine. She may
benefit from a nephrology consult on transfer. She should also
follow up with her nephrologist as well in the near future. A
renal ultrasound showed no hydronephrosis or obstruction but did
show a number of echogenic foci in the lower pole of the left
kidney, the largest
measuring 0.6 cm consistent with stone.
#. Hyponatremia: The patient developed hyponatremia when her
creatinine began to worsen. Her low sodium was 121. She was
given 1.5L NS with elevation of her sodium to 126. She was
started on salt tablets briefly with elevation of her sodium to
127. This will need to be closely monitored.
#. Guaiac positive stool: The patient presented with a history
of dark stools. She also had a dark stool which was guaiac
positive in house. She was transfused 1 u of pRBC the day of
discharge for a hematocrit of 26. She remained hemodynamically
stable. She should remain on aspirin and plavix due to recent
stent placement but EGD may be indicated if hct cont to fall.
#. Urinary Tract Infection: The patient had a positive UA and
urine culture with gram negative rods, sensitivities pending.
She has had a foley place intermittently and thus should
continue with a 7 day course of antibiotics. She was transferred
on ceftriaxone with day 1 being [**2145-1-22**]. She should see her
primary care phsyician in the near future.
#. Urinary retention: The patient had a post void bladder scan
with 350cc of urine remaining in her bladder. A foley catheter
was placed. The foley catheter had been removed and the patient
was urinating without difficulty at discharge.
#. Hypertension: She was well controlled on metoprolol tartrate
and hydralazine. ACE inhibitor should be considered when her
kidney function improves.
#. Peripheral vascular disease: Stable. Held pentoxifylline.
#. Code Status: Patient was Full Code during this
hospitalization.
#. Family contact: Daughter [**Name (NI) **] at [**0-0-**] cell
Medications on Admission:
at home:
Pentoxifylline 400mg TID
Toprol Xl 50mg daily
Enalapril 5 mg daily
Lasix 40mg daily
ASA 81 mg daily
Ferrous sulfate 325mg daily
Tylenol #3 one daily
on transfer:
IV nitroglycerin at 180 mg/min (850)
IV Heparin at 850 U/hr
Norvasc 5mg daily
Acetylcysteine 1200 mg Q12H
Metoprolol 25mg Q6H
Lipitor 80mg daily
Plavix load [**1-13**] 300mg, now on 75mg daily
Enalapril 5mg daily
Ferrous sulfate 325mg daily
Lasix 40mg daily (on hold)
MVI daily
protonix 40mg [**Hospital1 **]
Pentoxifylline 400mg TID
Tylenol #3, 1 tab daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for acid
reflux.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours): Hold HR< 60.
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day): Hold SBP < 100.
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever: Max 3 grams per day.
11. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn,
dyspepsia.
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
15. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
16. Ceftriaxone 1 gram Piggyback Sig: One (1) gram Intravenous
once a day for 7 days: First day [**2145-1-22**], last day [**2145-1-28**].
17. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
18. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Coronary Artery Disease
Hypertention
Acute on Chronic Kidney Disease
Acute Blood Loss Anemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had a high risk cardiac catheterization and a bare metal
stent was placed in your left main coronary artery. The
procedure went well but you received a large amount of contrast
that has caused your kidneys to stop working. We have given you
fluid to support your kidneys and have been following your
electrolytes closely. A kidney ultrasound was done and results
are pending at this time. You also are losing some blood in your
stool and have received 2 units of blood to treat your anemia.
You will need to stay on aspirin and Plavix for at least one
month and possibly longer. Do not stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s without speaking to Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] about
this. You risk having another fatal heart attack if you stop
taking aspirin and plavix.
.
Medication changes:
1. Start taking aspirin and Plavix every day to prevent the
stent from clotting off
2. Stop taking Enalapril and lasix until kidney function
improves.
3. Stop taking Pentoxifylline until your kidney function
improves.
4. Metoprolol Succinate changed to Metoprolol tartrate while
hospitalized
5. Start Hydralazine and Amlidipine to control your blood
pressure.
6. Start Famotidine to prevent bleeding in your stomach
7. Start Ceftriaxone to treat your urinary tract infection
8. Start Heparin SC to prevent blood clots
9. Start Trazadone to help you sleep at night
10. Start Atorvastatin to control your cholesterol
11. You were started on colace, bisacodyl for your constipation
Followup Instructions:
Primary Care:
[**Last Name (LF) 85865**],[**First Name3 (LF) 275**] N. Phone: [**Telephone/Fax (1) 85866**] Date/time: Please make an
appt to see 1 week after discharge from Catholic [**Hospital1 107**]
.
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 85867**] Date/time: Please keep
your scheduled appt.
|
[
"41071",
"5849",
"2761",
"5990",
"2851",
"41401",
"4280",
"4168",
"5859",
"40390",
"4240",
"V4581",
"V1582"
] |
Admission Date: [**2144-9-15**] Discharge Date: [**2144-9-24**]
Date of Birth: [**2067-6-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11839**]
Chief Complaint:
Respiratory distress.
Major Surgical or Invasive Procedure:
Thoracentesis [**2144-9-14**].
Bronchoscopy with stent placement [**2144-9-14**].
Bronchoscopy with stent removal [**2144-9-15**].
Thoracentesis with pigtail drain placement [**2144-9-16**].
Removal of pigtail [**2144-9-22**]
picc line placement [**2144-9-14**]
History of Present Illness:
77 year old man with h/o stage IB (pT2aN0Mx) Squamous NSCLC s/p
right lower [**Month/Day/Year 3630**] wedge resection ([**2144-2-8**]), presenting with
lung/pleural and rib mets with extrinsic and intrinsic
compression. He presented [**2144-9-14**] for rigid and flexible
bronchoscopy, initially planned as a day/ambulatory procedure.
Flexible bronchoscope showed patent distal airways. A Stent was
placed at the [**Hospital1 **]. Balloon dilatation perfomed with-in the stent.
Patency of distal airways confirmed. Estimated blood loss was
minimal.
.
In [**Name (NI) 13042**], pt was hypoxemic after extubation to 88-91% on room air
(does not use oxygen at home). Blood pressure 89/70. He remained
well-appearing and mentating post-operatively and ambulating
with the RN around the [**Name (NI) 13042**]. Planned thoracentesis was performed
at [**Name (NI) 13042**] bedside, with 2.2L drained from the right pleural space
with subjective improvement in symptoms. Post-procedure CXR
without pneumothorax. Given his vital signs, the patient was
planned for admission overnight with telemetry and continuous
pulse oximetry observation. He was placed on 10L non-rebreather
initially for desaturations into the low 80s and then
transitioned to 4L shovel mask, gradually to 4L nasal cannula
with neb treatments and mucinex.
.
Pt received IVF without improvement in his blood pressures. His
blood pressures improved with attempted A-line, peripheral
placements to peak SBP100. While awaiting MICU bed, the patient
had labs drawn (within normal limits, WBC 6.7 --> 10), blood
cultures sent, received Vancomycin/Cefepime. In discussions with
IP, second CXR while in [**Name (NI) 13042**] suggestive of RML/RLL collapse
after procedures with planned flex bronch by IP in the morning.
.
He was admitted from the [**Name (NI) 13042**] to the MICU due to concerns about
his respiratory status. He was taken back to the OR for another
rigid/flex bronch. Attempt was made to reposition the stent
more proximally, which did not improve RML/RLL aeration and
obstructed the RUL, so stent was removed. LMA
removal/extubation occurred right away, but bipap was initially
required upon transfer to ICU after this procedure. A pigtail
was also placed for continued drainage of R sided effusion.
Oxygen has been weaned down to nasal cannula, BP remained stable
and t transferred to th eOncology floor on [**2144-9-17**].On th
eoncology floor pt reports he feels quite well, feels breathing
significantly improved. No chest pain, nausea/abdominal pain.
Has had occasional cough with yellow sputum, no blood. Stable
weight, no edema, no orthopnea.
All other ten point ROS was negative.
Past Medical History:
obesity, hypertension, CAD s/p CABG, hyperlipidemia, anemia,
polyclonal gammopathy, osteoarthritis, hypogonadism, renal
insufficiency, BPH, allergic rhinitis, skin cancer, and ischemic
optic neuropathy, L orbital pseudotumor s/p biopsy. s/p wedge
resection of RLL as above.
.
ONCOLOGIC HISTORY:
-- In [**12/2141**], he was seen in the ophthalmology clinic for
worsening right eye blindness and headache.
-- In [**2-/2142**] CTA revealed complete occlusion of the right ICA
and patent ACOM, and moderate stenosis of the right vertebral
artery.
-- In early [**2143**], he was reevaluated for persistent headaches
and progressive visual loss. Imaging revealed a retroorbital
lesion. On MRI and MRA imaging studies NSMC: An ill-defined
mass in the right posterior orbit encasing the optic nerve
extending into the right cavernous sinus with thrombosis of the
RCA inside the cavernous sinus.
-- On [**2143-5-28**], he was seen by neurosurgery for evaluation.
-- On [**2143-5-24**], given the concern for lymphoma, a CT of chest,
abdomen, and pelvis was performed to assess for other lesions.
This revealed a 1 cm right lower [**Year (4 digits) 3630**] pulmonary nodule with
irregular margin concerning for primary lung cancer or
metastatic disease. Otherwise, on imaging was found no evidence
of lymphoma, a 6-mm bladder diverticulum.
-- On [**2143-6-12**], PET CT scan revealed 24 x 22 mm right
retroorbital soft tissue mass which is FDG avid (SUV maximum 5)
with FDG avid retrobulbar fat. In the right lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] FDG
avid 14-mm solitary nodule (SUV maximum 7.1) otherwise no
evidence of distant FDG avid disease.
-- On [**2143-7-30**], biopsy of the orbital apex lesion showed a
mixed inflammatory picture, it was not diagnostic lymphoma.
-- On [**2143-11-5**], PET CT noted a 2.2 cm right lower [**Year (4 digits) 3630**] nodule
with a SUV maximum 8.24 with no FDG avid mediastinal, hilar, or
axillary lymphadenopathy. Again noted was the FDG avid right
retroorbital soft tissue density.
-- On [**2144-2-14**], he underwent a right lower [**Year (4 digits) 3630**] wedge
resection, which revealed squamous cell carcinoma (2.5 x 2 x 1.5
cm) grade 2 moderately differentiated T2a N0 Mx tumor which was
invading the visceral pleura and had lymphovascular invasion.
Level 7 and 9 lymph nodes were negative for malignancy.
A few days prior to his six-month followup visit, he noticed
being increasingly short of breath.
-- On [**2144-8-18**], CT of the chest revealed new right-sided
effusions and new 3-mm nodules in the left upper and lower
lobes, suspicious.
-- On [**2144-8-20**], 2 liters of pleural fluid were drained from
his right lung, which was negative for malignant cells.
-- On [**2144-8-31**], PET CT revealed stable retroorbital soft
tissue fullness. A 3.4 cm right lower [**Year (4 digits) 3630**] FDG avid nodule
(maximum SUV is 30), FDG avid lymph nodes in the right perihilar
region measuring largest 2.5 x 1.4 x 5 cm maximum SUV 30
associated with marked narrowing of the bronchus intermedius,
obstruction of the lower [**Year (4 digits) 3630**] bronchus with distal patency, and
marked narrowing of the origin of the middle [**Year (4 digits) 3630**] bronchus.
There were 2 FDG avid pleural soft tissue masses on the right
measuring 2.8 x 3.2 cm (maximum SUV 36) and another nodule
measuring 3.9 x 4.2 cm (maximum SUV 19) along with pleural
posterior to the right costophrenic angle highly suspicious for
metastatic deposits. In addition to right pleural effusion,
there is bronchovascular thickening in the right lower [**Year (4 digits) 3630**]
suspicious for lymphangitic spread of disease. The three
nodules which are seen in the previous study remain unchanged.
There are postoperative changes
consistent with right lung wedge resection. There are two FDG
avid rib metastases, anterior fourth rib (maximum SUV 37) and
posterior eighth rib (maximum SUV 17) and a right sacral
metastasis (maximum SUV 26).
-- On [**2144-9-3**], Dr. [**Last Name (STitle) **] performed bronchoscopy. Fine needle
aspirate of the right upper lope endobronchial mass and right
bronchus intermediate mass both revealed squamous cell
carcinoma, non-small-cell carcinoma.
Social History:
Previously with relatively active lifestyle. He enjoys fishing,
boating, gardening, and walks with his wife. 60 pack year
smoking history, quit 20 years ago.
Family History:
Positive for hypertension, renal failure, and possibly CAD in
his mother. [**Name (NI) **] family history of diabetes or malignancies.
Physical Exam:
On transfer from MICU to oncology:
T97.3, 130/56, HR 73, R20, 92% on 4L NC
Alert, appropriate, breathing comfortably, no distress.
HEENT: small healing lac on lower lip on R. PERRL and
anicteric. Slight R eyelid droop. OP clear.
Neck: obese, supple, no JVD elevation appreciated, no
adenopathy.
Heart: regular, slightly distant, no m/r/g.
Chest: symmetric expansion. R side diminished throughout
particularly at post base, with expiratory rhonchi. L side
clear.
Abdomen: +BS, soft, NT/ND.
Extrem: warm, PICC site LUE benign. 1+ pitting LE edema. No
clubbing.
Neuro: alert. [**6-11**] UE/LE strength bilat.
Pertinent Results:
On Admission:
[**2144-9-14**] 06:46PM BLOOD WBC-10.7# RBC-3.74* Hgb-11.1* Hct-33.5*
MCV-90 MCH-29.7 MCHC-33.1 RDW-14.4 Plt Ct-358
[**2144-9-14**] 06:46PM BLOOD Glucose-102* UreaN-21* Creat-1.1 Na-139
K-4.5 Cl-105 HCO3-25 AnGap-14
[**2144-9-14**] 06:46PM BLOOD Calcium-8.4 Phos-4.3 Mg-1.9
[**2144-9-15**] 06:40PM BLOOD Type-ART pO2-62* pCO2-64* pH-7.20*
calTCO2-26 Base XS--3
[**2144-9-15**] 05:34AM BLOOD Lactate-1.2
.
Lactate Trend:
[**2144-9-15**] 05:34AM BLOOD Lactate-1.2
[**2144-9-15**] 06:40PM BLOOD Lactate-0.7
[**2144-9-15**] 08:54PM BLOOD Lactate-0.7
[**2144-9-15**] 10:25PM BLOOD Lactate-0.6
[**2144-9-16**] 11:50AM BLOOD Lactate-0.6
[**2144-9-16**] 05:33PM BLOOD Lactate-0.7
.
Labs at transfer from MICU to Floor:
[**2144-9-17**] 03:15AM
WBC-8.3 RBC-3.17* Hgb-9.4* Hct-28.2* MCV-89 MCH-29.5 MCHC-33.2
RDW-14.2 Plt Ct-275
Glucose-96 UreaN-13 Creat-0.9 Na-138 K-4.4 Cl-104 HCO3-26
AnGap-12
Calcium-8.7 Phos-2.6* Mg-2.1
O2 Flow-4 pO2-71* pCO2-49* pH-7.38 calTCO2-30 Base XS-2
.
Reports:
[**2144-9-15**] CT CHEST: IMPRESSION:
1. New collapse of the entire right lung is explained by tumor
impinging on the right upper [**Month/Day/Year 3630**] bronchus and occlusion of the
bronchus intermedius stent by secretions, partially bloody.
2. Moderate right pleural effusion, stable volume since [**8-17**],
despite large, interval thoracentesis, may contain minimal
bleeding.
3. Right pleural metastasis, increased since [**2144-8-21**].
4. New moderate left basilar atelectasis and a small left
pleural effusion.
.
[**2144-9-17**] CXR: IMPRESSION:
1. Left approach PICC terminating within the right atrium.
2. Only mild improvement in dense opacification of the right
hemithorax with aeration of only the right upper [**Month/Day/Year 3630**]. There is
still a large right pleural effusion demonstrating loculated
components. No evidence of pneumothorax.
.
[**2144-9-18**]: LUE U/S:Non-occlusive thrombosis of the left basilic
vein (superficial vein).
.
Brief Hospital Course:
77yo man with stage IV squamous cell CA of the lung and CAD
admitted for dyspnea, respiratory distress, and a obstructive
right lung collapse. Bronchial stent was attempted [**2144-9-14**] by
Interventional Pulmonary, but the stent became occluded and was
not able to be reopened. So it was removed [**2144-9-15**]. Pus from
the obstructed bronchus was noted. Thoracentesis drained ~2.2
lit. He was transferred out of the ICU 0n [**2144-9-17**].
.
# Hypoxia: Due to obstructive right lung collapse, progressive
NSCLC, and post-obstructive bacterial pneumonia. Stent placed
[**2144-9-14**], removed [**2144-9-15**]. Right-sided pig-tail placed, continues
to drain. Radiation Oncology consulted for XRT to relieve
bronchial obstruction. Pt completed antibiotics
(ceftriaxone/azithromycin) for post-obstructive pneumonia and
also received PRN nebs. On d/c sats in high 90's on 4 lit NC and
able to amnbualte with assistance comfortably..
.
# NSCLC: Pt started XRT to relieve bronchial obstruction on
[**2144-9-24**] and plan for 10 day treatemnt total dose 3000cGy. He is
scheduled to see Dr [**Last Name (STitle) **], his medical oncologist, after
completion of radiation treatment or earlier as needed.
.
# Hypotension: Pt became hypotensive after the treatment. He did
require pressors in the ICU. On th efloor he did have a few
brief episodes of asymptomatic hypotension ( systolic to 80's).
Am cortisol level was 12.2 and a cosyntropin test was negative
for adrenal insufficiency.ECG was unremarkable and pt was also
monitored on telemetry, which was uneventful. Blood cutures were
obtained and remained sterile. Orthostatics also negative. 48
hrs prior to discharge blood pressure remained stable.
# Non-occlusive thrombosis of left basilic vein: Pt developed
LUE pain and swelling . U/S of LUE revealed a non-occlusive
thrombosis of left basilic vein, which was the site of teh picc
line. The pain and swelling resolevd spontaneously adn the picc
line was removed.
.
# Anemia: Anemia panel c/w anemia of inflammation.Pt did receive
1 unit of PRBCS during hospital stay with appropriate response.
.
# Urinary retention: Pt had a foley cath placed prioir to
transferto teh Oncology floor. Initiail voiding trial
unsuccessful and foley was replaced . 1 dose of tamsulosin was
given but not tolerated due to low blood pressures. After d/w
urology a second trial was attempted and successful.
.
# CAD: Aspirin held for procedures and restarted a t a dose of
81 mg.
.
# Hyperlipidemia: Continued outpatient statin.
.
# Pain: Pain was well controlled with acetaminophen as needed.
.
# FEN: Regular diet.
.
# GI PPx: Started a PPI and bowel regimen.
.
# DVT PPx: Heparin SC.
.
# Precautions: None.
.
# CODE: FULL.
Medications on Admission:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet
SL PRN CP.
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
candidiasis.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H as
needed for pain.
.
Medications on transfer from ICU to oncology:
- HSQ 5000 units TID
- Atorvastatin 20 mg daily
- Mucinex 600 mg [**Hospital1 **]
- Atrovent neb Q6H
- Albuterol neb Q6H PRN
- Nitro SL prn
- APAP prn
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. guaifenesin 600 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day) for 5 days.
3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea or wheeze.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for sob/wheezing.
5. petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for To lip abrasion.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 8**]
Discharge Diagnosis:
1. Shortness of breath.
2. Pleural effusion (fluid in the lung space).
3. Collapsed right lung.
4. Post-obstructive pneumonia (lung infection due to a blocking
tumor).
5.Hypoxia (low oxygen levels).
6.Hypotension
7.urinary retension
8.anemia
9.basilic vein non-occlusive thrombosis ( superficial clot)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for shortness of breath. This
was due to a collapsed right lung from a blocking tumor. The
pulmonary physicians attempted to open up the lung by inserting
a stent into the airway. Unfortunately, after multiple
attempts, this did not work, so the stent was removed. Fluid
from the right lung was removed and a drain was left in place.
After the procedure you became hypotensive and you were
transferred to the intensive care unit. You were placed on
antibiotics for pneumonia (lung infection) and continued to
need oxygen.You were transferred to the oncology floor when
stabilized. Antibiotics were continued and you were monitored
closely.You received one unit of red blood cells You were
evaluated by radiation oncology and you underwent mapping for
radiation treatment which was started today( [**2144-9-24**].
Change in medications:
aspirin decreased to 81 mg
albuterol neb treatments as needed for shortness of breath
/cough.
pantoprazole
Followup Instructions:
1. Radiation oncology: [**2144-9-25**].
2.Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2144-10-15**] at 9:30 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: THURSDAY [**2144-10-15**] at 9:30 AM
With: DR. [**First Name8 (NamePattern2) 2801**] [**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
|
[
"5180",
"2724",
"V4581",
"V1582"
] |
Admission Date: [**2167-12-22**] Discharge Date: [**2167-12-30**]
Date of Birth: [**2123-12-7**] Sex: F
Service: MICU GREEN TEAM
CHIEF COMPLAINT: Hypoxia, status post right middle lobe
wedge resection.
HISTORY OF PRESENT ILLNESS: This is a 44-year-old female,
with a history of primary pulmonary hypertension diagnosed in
[**2167**], presenting with progressive dyspnea on exertion over
the past year. The patient states that the dyspnea has
worsened since [**2167-3-7**], for which she was admitted four
months later with a diagnosis of dyspnea. She was initially
treated with Flolan, given her diagnosis of primary pulmonary
hypertension. Echo and cardiac catheterization were notable
for increased pulmonary artery hypertension. At that time,
the patient also had a normal wedge pressure, normal LV
function, normal biventricular diastolic function, and a
normal ejection fraction.
The patient was admitted primarily for work-up of new chest
x-ray and chest CAT scan findings which were diffuse
bilateral ground glass opacities, bibasilar thickening of the
interlobar septa with honeycombing. The concern was that the
patient may have had a secondary diagnosis in addition to her
primary pulmonary hypertension. Therefore, the patient was
admitted to have a right lobe wedge resection performed for
pathologic studies. The differential at the time of this
surgery primarily included pulmonary [**Last Name (un) **]-occlusive disease
versus pulmonary capillary hemangiomatosis. At the time of
admission, the patient was status post chest tube removal.
She complained of pleuritic right-sided chest and back
discomfort. She also noted feeling short of breath. She was
persistently nauseated, and she had vomited bilious emesis x
1 on the day of transfer to the MICU. The patient also noted
a cough productive of dark blood 2-3 times a day.
Additionally, the patient felt orthopneic. Chest x-ray upon
transfer to the MICU was notable for a new right lower lobe
infiltrate consistent with air space disease, most likely
lung injury.
PAST MEDICAL HISTORY:
1. Primary pulmonary hypertension.
2. Herniated disk at L4-L5 diagnosed in [**2166-3-7**].
3. Rosacea.
4. Status post ex. lap 2 years ago to evaluate abdominal
pain.
5. History of negative Holter evaluation.
ALLERGIES: Penicillin causes hives.
MEDICATIONS ON TRANSFER:
1. Flolan continuous infusion.
2. Potassium chloride 60 mEq qd.
3. Lasix 240 mg po qd.
4. Vitamin D 800 U qd.
5. Digoxin 0.125 po qd.
6. Elavil 50 mg po q hs.
7. Coumadin had been discontinued as of [**2167-12-9**].
SOCIAL HISTORY: The patient is an ex-tobacco user of
approximately 28-pack year. She quit in [**2166-11-4**]. She
works as a registered nurse [**First Name (Titles) **] [**Hospital3 **]. She lives
with her children and husband. She reports occasional
alcohol use, but denies IV drug abuse. At baseline, the
patient is on 4 liters nasal cannula at home. Her code
status is full.
FAMILY HISTORY: Negative for any pulmonary processes.
Father is deceased from Alzheimer's disease and pneumonia.
Mother is alive and well. There is a family history of
coronary artery disease.
PHYSICAL EXAM ON TRANSFER TO MICU: Notable for vital signs -
T-max 99.8??????F, blood pressure ranged systolic 84-123/45-91,
heart rate range 103-140, respiratory rate 24, 89-95% on 4 L
nasal cannula and shovel mask. Her intake and output history
upon transfer: She had 2,050 ml/3,425 ml. Exam was notable
for anicteric sclerae. Her oropharynx was clear. Her neck
exam - JVP approximately 10 cm at 45??????, no bruits. Pulmonary
exam - decreased breath sounds at bases, no crackles, no
wheezes. Cardiac exam - regular, tachycardia, S1, S2, II/VI
systolic murmur at the left sternal border. Abdominal exam
benign. Extremity exam - 1+ pretibial edema, 2+ dorsalis
pedis bilaterally, positive clubbing of the upper digits, no
calf tenderness, no swelling. Neurologic exam grossly
intact.
STUDIES [**2167-10-5**]: Echocardiogram - ejection fraction
55-60%, right ventricular dilatation, moderate global right
ventricular hypokinesis, moderate pulmonary systolic
hypertension.
[**2167-11-4**] CARDIAC CATHETERIZATION: Right ventricular
filling pressures 55/7, pulmonary artery pressure 55/26, with
a mean of 39, mean wedge 6, left ventricular pressure 81/10,
cardiac output 4.9, cardiac index 2.8, pulmonary vascular
resistance 536.
RADIOGRAPHIC STUDIES: As mentioned, CAT scan notable for
ground glass opacities bibasilar. Chest x-ray notable for a
new right lower lobe infiltrate.
HOSPITAL COURSE BY PROBLEM - 1) PRIMARY PULMONARY
HYPERTENSION, STATUS POST RIGHT LOWER LOBE WEDGE RESECTION
FOR WORK-UP OF NEW RADIOGRAPHIC LUNG FINDINGS AND PROGRESSIVE
DYSPNEA ON EXERTION: The patient was initially treated with
Flolan with a short course of inhaled nitric oxide treatment
in the setting of her acute dyspnea. Symptomatically, the
patient improved and was able to be weaned off nitric oxide
after a 48-hour course. The patient's pathology was notable
for evidence of pulmonary capillary hemangiomatosis. Given
the overall poor prognosis in this diagnosis, the patient was
maintained on supportive regimen including Flolan,
doxycycline for its presumed effects on decreased
metalloproteinase activity, and lasix to further reduce
preload in the setting of increased filling pressures on the
right side. The patient's chest x-ray did not change
remarkably. However, symptomatically she improved. Her
cough became dry without any evidence of hemoptysis. The
patient's hematocrit was stable. Her oxygen saturation
improved while weaning her O2 requirement. Additionally, the
patient's exercise tolerance increased during her hospital
course, and upon transfer to the regular floor, the patient
was able to ambulate without feeling short of breath.
2) CARDIAC: From an ischemia standpoint, the patient did not
have any active issues. She, however, did remain tachycardic
throughout her hospital course, but denied any symptoms of
chest discomfort, and did not have any evidence of ischemia
on her EKG. The patient did have a recent cardiac
catheterization from [**2167-11-4**] which did not reveal any
evidence of critical stenoses in her coronary arteries.
From a pump perspective, the patient's ejection fraction was
55-60%. She did have evidence of increased right ventricular
filling pressures and moderate right ventricular hypokinesis.
The patient was maintained on lasix with very impressive
diuresis. She was maintained on her PO regimen and was
approximately negative 10 liters for her length of stay in
the ICU. The patient was continued on her digoxin with her
dig level at 0.6 on transfer to the MICU. Follow-up level is
pending.
From a rhythm perspective, the patient was persistently sinus
tachycardic. This was presumed to be in relation to
diuresis, as well as her Flolan treatment which is a common
side-effect. The patient was asymptomatic, however.
Therefore, she was not aggressively treated for this, and her
EKG did not reveal any abnormalities. For this reason, the
patient was maintained on tele.
3) HEMATOLOGIC: The patient initially was on Coumadin for
her primary pulmonary hypertension. However, in the setting
of an acute bleed in the right lung, her Coumadin was held
and continues to be held upon transfer to the floor. Her
hematocrit remained stable, and her chest x-ray did not
change in appearance.
4) GI: The patient did not have any active issues. She was
maintained on a bowel regimen with normal bowel movements
which were reportedly guaiac negative.
5) POSTOPERATIVE PAIN AND BACK PAIN: The patient, at
baseline, has back pain in relation to her disk disease for
which she takes amitriptyline. In the setting of having had
her chest surgery, she was given morphine sulfate on a prn
basis, as well as po percocet, to which the patient reported
adequate pain control. Thereafter, the patient was
maintained on Tylenol treatment prn for her pain.
6) PROPHYLAXIS: The patient was maintained on a proton pump
inhibitor, as well as heparin subcu tid.
DISPOSITION: To the floor with follow-up with Dr. [**Last Name (STitle) **]
for potential treatment of her primary pulmonary hypertension
and pulmonary capillary hemangiomatosis. Additionally, the
patient is on the lung transplant waiting list. Addendum to
follow with the team on service.
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**], M.D. [**MD Number(1) 1178**]
Dictated By:[**Last Name (NamePattern1) 1600**]
MEDQUIST36
D: [**2167-12-30**] 10:56
T: [**2167-12-30**] 12:01
JOB#: [**Job Number 45782**]
|
[
"4280",
"2851",
"V5861"
] |
Admission Date: [**2129-11-18**] Discharge Date: [**2129-11-23**]
Date of Birth: [**2052-12-2**] Sex: F
Service: MEDICINE
Allergies:
Captopril / Digoxin Immune Fab
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
fevers, MRSA bacteremia
Major Surgical or Invasive Procedure:
1. PICC line placement [**11-21**]
2. Sternal wound culture [**11-18**]
History of Present Illness:
76 y/o female s/p recent d/c from [**Hospital1 **] on [**11-6**] following
complicated course involving pericardial tissue AVR and MAZE for
aortic stenosis and refractory afib [**9-17**], intermittent CHF and
renal failure now being re-admitted for ?sternal cellulitis and
MRSA bacteremia. Admitted late [**8-17**] for aortic valve repair w/
surgery initially delayed secondary to acute renal failure and
volume overload, treated w/ natrecor. Underwent magna
pericardial tissue AVR for AS and MAZE for afib. Post-op course
c/b recurrent afib and tenous volume status resulting in
intermittent CHF and ARF and several episodes of respiratory
failure requiring intubation. At one point, pt treated w/
milrinone in [**9-17**] after intubated for respiratory distress and
then extubated on [**10-3**] w/ metabolic alkalosis treated w/ diamox.
Continued to revert into afib on multiple occasions and thought
to exacerbate CHF. Labile blood pressures resulting in
hypotension w/ ACEi and bradycardia w/ digoxin. During
remainder of hospital course, again managed for CHF and resp
failure and ultimately underwent trach and PEG. All told, during
hospital course, diuresed 15 liters negative.
Transferred to [**Hospital **] rehab on [**11-10**] and initially remained
stable. Apparently, spiked fever on [**11-13**] to 103.5 and was noted
to be w/ increased resp distress and WBC also increased. CXR w/
reported b/l infiltrates. Started on Zosyn for ?infiltration but
sputum, blood cultures found positive for MRSA and started on
Vancomycin [**11-16**]. On [**11-17**], c/o substernal CP and noted to have
significant erythema at sternal incision site. Transferred to
[**Hospital1 18**] for further evaluation.
Past Medical History:
1. Aortic stenosis s/p AVR [**9-17**] as above
2. Presumed diastolic dysfunction
3. Recurrent afib s/p MAZE [**9-17**]
4. Pulmonary HTN
5. Chronic respiratory failure s/p trach
6. s/p PEG
7. type 2 dm
8. CVA [**42**] years ago
9. hypothyroid
10. Chronic renal insuffiency, baseline 1.3
Social History:
coming from [**Hospital1 **] rehab
Family History:
+DM
+CV
Negative for premature coronary disease. No other obvious
etiology of cardiomyopathy per pt and family.
Physical Exam:
gen: debilitated elderly female, appearing frustrated,
comfortable on trach ventilation
heent: JVP to ear at 60 degrees, MMM, OP clear, erythema/pain to
palpation at site of sternal wound
cv: s1, s2, irregularly irregular
pulm: cta anteriorly
abd: J tube w/ mild erythema but no discharge. no tender to
palpation.
extre: 1+ pitting le edema
Pertinent Results:
[**2129-11-18**] 03:22PM GLUCOSE-57* UREA N-28* CREAT-1.2* SODIUM-146*
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-30* ANION GAP-12
[**2129-11-18**] 03:22PM CALCIUM-8.7 PHOSPHATE-2.5*# MAGNESIUM-2.1
[**2129-11-18**] 03:22PM WBC-6.5 RBC-3.16* HGB-9.1* HCT-28.5* MCV-90
MCH-28.9 MCHC-32.1 RDW-16.3*
[**2129-11-18**] 03:22PM NEUTS-65.2 LYMPHS-24.1 MONOS-6.5 EOS-3.8
BASOS-0.5
[**2129-11-18**] 03:22PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
[**2129-11-18**] 03:22PM PLT COUNT-268
[**2129-11-18**] 03:22PM PT-17.7* PTT-33.7 INR(PT)-2.0
Brief Hospital Course:
1. MRSA bacteremia: 2/2 bottles from OSH + for MRSA. Given
recent bioprosthetic aortic valve [**9-17**], concerns about potential
for endocarditis. Pt also had erythema and pain around site of
sternum. Pt followed by both ID and CT surgery. Started on iv
vanc and rifampin and gent given concerns for endocarditis.
However, blood cultures remained neg [**Hospital 54708**] hospital course.
TTE and TEE both performed which were negative for vegetations.
ID recommended d/c of rifampin and prolonged course of IV
vancomycin x 4 weeks at 1g q 48 hrs. Meanwhile, sternal incision
was cultured w/o significant growth.
1a;)?Sternal wound infection: no evidence of osteo on ct and
evaluated by CT w/o evidence of fluctuance concerning for
abscess. Cultures of deep sternal wound w/ minimal growth.
Recommended wet to dry normal saline dressing changes [**Hospital1 **].
2. Chronic respiratory failure: continued on current vent
settings of SIMV PS.
3. CHF: Continued on low dose Coreg. In addition, pt was felt to
mild overloaded on exam and diuresed w/ IV lasix 80 mg x 2 w/
good response. She will continue w/ lasix 40 mg po bid. She
should have creatinine and weight followed closely.
4. Anemia: Hct remained relatively stable [**Hospital 44644**] hospital course
w/ transfusion 1 unit prbc.
5. CRI: creatinine stable throughout hospital course.
6. AFib: rate controlled w/ coreg and continued on
anti-coagulation w/ coumadin.
7. Access: new RUE PICC placed on [**11-20**] for delivery iv abx.
8. Rash: Macular erythematous rash thought secondary to rifampin
that was d/c'd.
Medications on Admission:
lantus 10 units qhs, lumigan eye gtts. Coreg 3.12 mg by mouth
2x/day, Colace 100 mg by mouth 2x/day, Synthroid 100 mcg by
mouth 1x/day, Flagyl 100 mg IV 3x/day, Remeron 15 mg by mouth
every evening, Zantac 150 mg by mouth 2x/day, Vancomycin 1 gram
IV every day, coumadin 3.5 mg by mouth every evening, lasix 80
mg IV as needed for weight greater than 152 lbs.
Discharge Medications:
1. Warfarin Sodium 1 mg Tablet Sig: 3.5 Tablets PO HS (at
bedtime).
2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
10. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: insulin
sliding scale sliding scale Subcutaneous four times a day:
please follow pre-existing insulin sliding scale.
11. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) solution
Intravenous 48 hrs for 4 weeks: to finish on [**12-16**].
12. Outpatient Lab Work
please check vancomycin trough following third dose - goal is
for trough 15-17.
Please check inr/ptt two times per week and chem 7(sodium,
potassium, bicarbonate, chloride, bun, creatinine) 2x/week
13. tubefeeding
Ultra-cal full strength at 65 cc/hour. Check residuals q 4 hours
and hold for residual greater than 100 cc. Please flush tube w/
water 100 cc every 6 hours
14. outpatient respiratory vent
SIMV respiratory rate 12
Tidal volume 500
Pressure Support 15
PEEP 5
FiO2 - 0.30
15. Outpatient Lab Work
blood cultures - 2 sets to be drawn 1 week after completion of
anti-biotics
16. wound care
please normal saline wet to dry dressing changes to sternal
wound [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
MRSA bacteremia resolved
s/p PICC line placement
CHF stable
Atrial fibrillation
Discharge Condition:
fair
Discharge Instructions:
3lbs.
2. Please continue IV vancomycin 1 g every 48 hours until [**12-16**].
Please check vancomycin trough after 3rd dose and goal for
trough 15-17. Please check blood cultures 1 week after
completiion of abx.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SURGERY LMOB 2A Follow-up appointment should
be in 2 weeks
|
[
"4280",
"42731",
"4168",
"25000",
"2449"
] |
Admission Date: [**2123-7-8**] Discharge Date: [**2123-7-23**]
Service: MED
Allergies:
Oxycodone
Attending:[**First Name3 (LF) 3513**]
Chief Complaint:
CHANGE IN MENTAL STATUS, UTI, SEPTIC SHOULDER
Major Surgical or Invasive Procedure:
PROCEDURE: Attempted closed reduction, left glenohumeral
joint. Irrigation and debridement, open, of left glenohumeral
joint
Open anterior reconstruction, left shoulder (modified Bankart
procedure).
History of Present Illness:
86 y.o. female. Admission in mid [**Month (only) **] for septic left
shoulder(MRSA), discharged to rehab on Vanco via PICC and now
presents (after an initial work-up at [**Hospital6 **]) with
change in mental status, dislocated left shoulder, and decreased
urinary output. She was transferred at the request of her
daughter given that she receives most of her care at [**Hospital1 18**]. She
was A/Ox3 at home. She was found to have +UTI, 6 of 6 bottles of
gram negative rods, Negative Head CT. Vancomycin was continued
dosed by level and levofloxacin given empirically. Her shoulder
pain responded well to low dose morphine. On [**7-13**] went to
surgery for shoulder debridement, irrigation and placement. On
[**7-14**] transferred to MICU overnight for hypotension, GI bleed
(had guaiac + black stool), refused c-scope, now Guaiac
negative. Gram negative rods determined to be Enterobacter, [**7-15**]
meropenem started. Pt's mental status markely improved
throughout the course of the Abx and post-surgical intervention.
She will needed extended Abx tx as an outpt and significant PT
follow-up for her shoulder. To be placed in Rehab.
Past Medical History:
CAD (MIBI reversible defect ant/apical not intervened)
CHF (EF 55% with diastolic failure from HTN)
Afib (now in sinus on amio)
CRI (BLC 1.7)
Venous stasis, DVT (s/p IVC filter)
LGIB, diverticulosis
Left Hip replacement
Right TKR
pacer
Social History:
Lives in [**Location **]. Family very involved in her care. No ETOH, Tob,
drugs. Enjoys gospel music and church.
Family History:
unsure of parent's cause of death
Physical Exam:
T97.3, BP106/72, P80, R18, O2sat100%RA
HEENT: left eye cataract, EOMI, right eye PERRL, poor
dentition, No OP erythema, no LAD
CHEST: CTAB anteriorly
HEART: RRR, NL S1/S2
ABD: obese, BS+, NT, ND
EXT: 1+ pitting edema b/l, left anterior shoulder dislocation,
warm, pulses 2+ (radial,DP)
NEURO: AxOx1, 5+ strength throughout(except left upper
extremity could not be examined secondary to pain), reflexes 2+
throughout (except left upper extremity could not be examined
secondary to pain). Difficult to assess Pt's sensation given MS
change.
Pertinent Results:
[**2123-7-8**] 12:24AM LACTATE-1.9
[**2123-7-8**] 11:11AM SED RATE-125*
[**2123-7-8**] 11:11AM PT-13.9* PTT-29.9 INR(PT)-1.3
[**2123-7-8**] 11:11AM PLT COUNT-373
[**2123-7-8**] 11:11AM WBC-9.0 RBC-3.10* HGB-9.1* HCT-29.3* MCV-95
MCH-29.2 MCHC-30.9* RDW-14.2
[**2123-7-8**] 11:11AM VANCO-24.0*
[**2123-7-8**] 11:11AM CRP-24.01*
[**2123-7-8**] 11:11AM ALBUMIN-2.3* CALCIUM-8.7 PHOSPHATE-4.0
MAGNESIUM-1.8
[**2123-7-8**] 11:11AM GLUCOSE-79 UREA N-56* CREAT-2.2*# SODIUM-135
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-21* ANION GAP-19
[**2123-7-8**] 11:55AM URINE RBC->1000* WBC-0 BACTERIA-NONE
YEAST-MANY EPI-0
[**2123-7-8**] 11:55AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2123-7-8**] 11:55AM URINE COLOR-BROWN APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2123-7-8**] Blood Cx: ENTEROBACTER CLOACAE 1 of 1 bottles
[**2123-7-9**] Blood Cx: ENTEROBACTER CLOACAE 2 of 2 bottles
[**2123-7-10**] Blood Cx: no growth
[**2123-7-17**] Blood Cx: pending
Sensitivities set1 set2 set3
CEFEPIME-------------- 16 I <=1 S 2 S
CEFTAZIDIME----------- 32 R =>2 S 4 S
CEFTRIAXONE----------- =>64 R =>64 R =>64 R
CIPROFLOXACIN--------- 2 I =>4 R
GENTAMICIN------------ <=1 S 4 S =>16 R
LEVOFLOXACIN---------- 1 S 4 I 4 I
MEROPENEM------------- 0.5 S <=0.25 S <=0.25 S
PIPERACILLIN---------- =>128 R =>128 R =>128 R
TOBRAMYCIN------------ 8 I 8 I =>16 R
TRIMETHOPRIM/SULFA---- =>16 R =>16 R =>16 R
[**2123-7-9**] Shoulder Joint Cx: ENTEROBACTER CLOACAE
SENSITIVITIES: MIC expressed in MCG/ML
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 32 I
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
[**2123-7-8**] URINE CULTURE (Final [**2123-7-9**]): YEAST.
10,000-100,000 ORGANISMS/ML
[**2123-7-9**] URINE CULTURE (Final [**2123-7-10**]): YEAST.
10,000-100,000 ORGANISMS/ML
LT. SHOULDER MRSA PT WAS ON VANCO,MEREPENIM,& KEFZOL.
[**2123-7-13**] Shoulder swab: GRAM STAIN (Final [**2123-7-13**]): 2+ ([**1-11**]
per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN. WOUND CULTURE (Final [**2123-7-15**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH
Brief Hospital Course:
This is an 86 year-old female recently admitted in mid [**Month (only) **] with
septic L shoulder (coag + staph) on vanco via Picc, s/p left
shoulder washout and TEE negative for endocarditis. Admitted
from [**Hospital1 756**] after found to have UTI and altered MS and
transferred here at request of daughter and found to have L
shoulder dislocation, reduced 1 at [**Hospital1 112**] and 2 at [**Hospital1 18**] ED. At
nursing facility patient also found to have altered mental
status, decreased urine output, and azotemia.
Mental status change/ID: Subsequently, patient found to have
Enterobacter bacteremia with sensitivity only to meropenam.
Patient's mental status improved significantly with IV
antibiotics with some baseline waxing and [**Doctor Last Name 688**]. Recently Mrs.
[**Known lastname 101651**], in addition to her medical issues, suffered the loss of
her husband. This grieving and possible depression has lead to
some withdrawal. Would recommend appetitite stimulants,
possible anti-depressants at discretion of physicians at
[**Hospital1 **] to help with mentation.
**Most importantly, patient will need continued vanco for MRSA
until [**2123-7-29**] and meropenem Enterobacter Cloace until [**2123-8-24**].
She has been blood culture surveillance negative since initial
cultures and has been afebrile with declining WBC.
Shoulder dislocation: s/p debridement, open anterior
reconstruction, and aspiration
of her left shoulder joint now in sling. Patient's course has
been very complicated, with multiple dislocations, now a chronic
dislocation and severe pain. Ortho at [**Hospital1 18**] feels that
continued surgical options are limited and recommend sling, with
good pain control. Patient will need further evaluation, most
likely at [**Hospital6 **] for further options of
management.
CHF with EF 55% with diastolic dysfunction: Patient with
respiratory distress during this admission. Gentle diuresis of
Lasix 20 mg PO every other day has kept her in good fluid
balance. Currently her blood pressure has dropped to 80's/40/s
with good response to fluid but she has maintained hemodynamic
stability after her GI bleed (see below)
GI bleed with anemia: patient hemodynamcially stable, with
stable crits after a brief lower Gi bleed, likely secondary to
diverticulosis -guaiac +, black stool, but patient did not want
colonoscopy. Her goal crit is >30.
Atrial fibrillation: Has been in sinus on amio. Not on coumadin
secondary to Gi bleed.
CAD: h/o abnormal pMIBI in [**2120**]. Had intermittent Chest pain on
[**7-12**] with ECG demonstrating t-wave inversions in anterior leads.
Per cards fellow, patient was not ruled out, ASA held due to
bleed. Beta-blocker maintained, with occasional holding for low
BP's. will not rule out. holding ASA secondary to bleed. Now
stable, without chest pain or associated symptoms.
Pain: pain is now well controlled on current regimen. Would
recommend continuation.
Nutrition: Patient with decreased PO intake over past 2 days
prior to discharge. Likely secondary to grieving/depression
with loss of her husband. Would consider appetite stimulants,
anti-depressants at discretion of treating physician at
[**Name9 (PRE) **]/Dr. [**First Name (STitle) 3510**].
Code status: DNR/DNI
Disposition: Patient to go to [**Hospital1 **] with close f/u with Dr.
[**First Name (STitle) 3510**]. She will likely need further eval by orthopoedics,
possibly at [**Hospital6 **] for further care of shoulder
dislocation.
Medications on Admission:
Nitroglycerin SL 0.3 mg SL ASDIR one tab q5min prn for chest
pain nte 3 tabs
Pantoprazole 40 mg PO Q24H
Nystatin Oral Suspension 5 ml PO QID
Sarna Lotion 1 Appl TP TID
Lumigan 1 drop OD qhs
Amiodarone HCl 200 mg PO QD
Metoprolol 25 mg PO BID
Simvastatin 40 mg PO QD
Polysaccharide Iron Complex 150 mg PO QD
Docusate Sodium 100 mg PO BID
Senna 1 TAB PO BID:PRN
Bisacodyl 10 mg PO QD:PRN
Aspirin 325 mg PO QD
Discharge Medications:
Vancomycin HCl 1000 mg IV Q48H
Meropenem 1000 mg IV Q12H
Pantoprazole 40 mg IV Q24H
Heparin 5000 UNIT SC Q12H
Nitroglycerin SL 0.3 mg SL ASDIR one tab q5min prn for chest
pain nte 3 tabs
Morphine Sulfate 0.5-2 mg IV Q3-4H:PRN
Nystatin Oral Suspension 5 ml PO QID
Sarna Lotion 1 Appl TP TID
Lumigan 1 drop OD qhs
Amiodarone HCl 200 mg PO QD
1. Vancomycin HCl 1000 mg IV Q48H
2. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic qhs
().
Disp:*qs 1 month* Refills:*2*
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*qs 1 month* Refills:*0*
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*qs 1 month* Refills:*0*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
Disp:*5 Tablet, Sublingual(s)* Refills:*2*
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection Q12H (every 12 hours).
Disp:*60 injection* Refills:*2*
8. Morphine Sulfate 0.5-2 mg IV Q3-4H:PRN Pain
9. Pantoprazole 40 mg IV Q24H
10. Meropenem 1000 mg IV Q12H
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO QOD.
Disp:*15 Tablet(s)* Refills:*2*
12. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
1. Vancomycin HCl 1000 mg IV Q48H
2. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic qhs
().
Disp:*qs 1 month* Refills:*2*
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*qs 1 month* Refills:*0*
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*qs 1 month* Refills:*0*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
Disp:*5 Tablet, Sublingual(s)* Refills:*2*
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection Q12H (every 12 hours).
Disp:*60 injection* Refills:*2*
8. Morphine Sulfate 0.5-2 mg IV Q3-4H:PRN Pain
9. Pantoprazole 40 mg IV Q24H
10. Meropenem 1000 mg IV Q12H
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO QOD.
Disp:*15 Tablet(s)* Refills:*2*
12. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
1. Vancomycin HCl 1000 mg IV Q48H
2. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic qhs
().
Disp:*qs 1 month* Refills:*2*
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*qs 1 month* Refills:*0*
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*qs 1 month* Refills:*0*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
Disp:*5 Tablet, Sublingual(s)* Refills:*2*
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection Q12H (every 12 hours).
Disp:*60 injection* Refills:*2*
8. Morphine Sulfate 0.5-2 mg IV Q3-4H:PRN Pain
9. Pantoprazole 40 mg IV Q24H
10. Meropenem 1000 mg IV Q12H
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO QOD.
Disp:*15 Tablet(s)* Refills:*2*
12. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Mental status change
Sepsis (shoulder + UTI)
shoulder dislocation
atrial fibrillation
coronary aretery disease,
hyperension
Discharge Condition:
stable
Discharge Instructions:
If Pt experiences significant mental status changes, CP, SOB,
palpitations, GI bleeding she should seek immediate medical
attention.
Followup Instructions:
--on MEROPENEM for ENTEROBACTER CLOACAE (6/6 bottles) continue
until [**2123-8-24**]
--on VANCOMYCIN for MRSA continue until [**2123-7-29**]
--check CBC w/ diff, creatinine, vanco trough, AST, ALT once a
week as outpt and Fax results Dr. [**Last Name (STitle) 17444**] ([**Telephone/Fax (1) 1419**])
--call/page Dr. [**Last Name (STitle) 17444**] before discharge so he can make f/u appt
in his clinic, he will follow the sensitivities to gram neg
rods.
|
[
"4280",
"42731",
"5990",
"40391"
] |
Admission Date: [**2147-7-22**] Discharge Date: [**2147-7-26**]
Date of Birth: [**2074-6-25**] Sex: F
Service: MED
Allergies:
Penicillins / Compazine / Benadryl / Dilantin / Reglan /
Klonopin / Depakote / Neurontin / Lamictal / Lithium
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
acute SOB,tachycardia, fever, and witnessed seizure
Major Surgical or Invasive Procedure:
PICC placement
Arterial line
History of Present Illness:
73F PMH bipolar d/o, sz d/o, depression, CVA x2, and recent
humerus fracture s/p screw placement ([**7-17**]) presents with acute
SOB and witnessed seizure. Pt was found in bed tachypneic with
RR 40, Sat 60%, and HR 160's. She had 1 1-min seizure in amb on
the way to the hospital that resolved on its own, and sat 100%
on bag mask. Pt [**Name (NI) **] 105 PR, received Tylenol. Upon arrival at
the [**Name (NI) **], pt given 1 mg Ativan and intubated for post-ictal airway
protection. ABG on 100% NRB prior was 7.03/89/281. S/P
intubation on AC 450x22, FiO2 50%, PEEP 5, MV 8.7 - ABG
7.49/30/145. On minimal sedation-Propofol. Received 5L fluids,
Vanco 1g and CTX 2g for possible meningitis. Temp decr to 99.2,
BP 140/85, HR 108. Ortho consulted about possible septic joint:
recommended humerus films and CT humerus to r/o necrotizing
fascitis. Pt has past drug overdoses and medication abuse with
ETOH.
Past Medical History:
Depression-s/p ECT [**2147**]; CVAx2; s/p appy; TAH/BSO; Subtotal
Colectomy; Nl Cors ([**5-29**])-EF 65%; Chronic Abd Pain;
Osteoporosis; Grade III esophagitis-nl EGD in [**6-29**]; HTN;
Migraine; PMR; Sjogren's; Seizure d/o; Bipolar; PTSD; h/o SA
Social History:
Pt was born in [**Country 2559**] to [**Hospital1 **] parents, put in concentration
camp at age 10 for a year, and prior to that in work camps. Pt
has 1 living brother in [**Name (NI) **]. Married, and divorced in [**2113**].
Daughter, 46, refuses to stay in contact with her. Currently,
has a legal guardian, [**Name (NI) 2411**] [**Name (NI) 9192**] (HCM) [**Telephone/Fax (1) 69964**] cell.
Family History:
Father died diabetes complications. Mother died of melanoma.
Physical Exam:
VS (ED): T 105 P 108 BP 148/84 R 22 p/t intubation
Vent: AC 450x22 FiO2 50%, PEEP 5 -> ABG 7.49/30/145
PE: G: Intubated, sedated
H: Pupils non-reactive (L<R), Neck stiff-able to lift pt up
by head, NC/AT, No JVD, No [**Doctor First Name **]
L: Coarse BS BL, no w/r/c
H: tachy, Nl S1, S2, no M/R/G
A: Soft, NT, ND, BS+
E: 2+ distal pulses, good cap refill ~2 sec, warm, dry
LUE: staple in place in wound, appears C/D/I, no
erythema, mildly warmer over site. 2+ pitting edema distal to
arm.
Neuro: Intubated, sedated. No Babinski
Pertinent Results:
[**2147-7-25**] 04:05AM BLOOD WBC-16.7* RBC-3.11* Hgb-9.0* Hct-27.8*
MCV-89 MCH-29.0 MCHC-32.5 RDW-14.9 Plt Ct-256
[**2147-7-24**] 03:25AM BLOOD WBC-14.3* RBC-3.44* Hgb-10.0* Hct-30.7*
MCV-90 MCH-29.0 MCHC-32.5 RDW-14.8 Plt Ct-248
[**2147-7-23**] 04:00AM BLOOD WBC-15.5* RBC-4.02* Hgb-11.6* Hct-36.7
MCV-91 MCH-28.9 MCHC-31.7 RDW-14.7 Plt Ct-279
[**2147-7-22**] 07:14PM BLOOD WBC-14.8* RBC-4.08* Hgb-12.0 Hct-36.7
MCV-90 MCH-29.4 MCHC-32.6 RDW-14.7 Plt Ct-295
[**2147-7-22**] 04:00PM BLOOD WBC-14.4* RBC-4.03* Hgb-12.1 Hct-36.2#
MCV-90# MCH-29.9 MCHC-33.4# RDW-14.7 Plt Ct-258
[**2147-7-22**] 09:46AM BLOOD WBC-22.3*# RBC-4.67 Hgb-13.4 Hct-46.9#
MCV-101*# MCH-28.7 MCHC-28.6*# RDW-14.3 Plt Ct-327#
[**2147-7-22**] 07:14PM BLOOD Neuts-64.4 Lymphs-32.2 Monos-2.7 Eos-0.3
Baso-0.3
[**2147-7-22**] 04:00PM BLOOD Neuts-75.1* Lymphs-21.6 Monos-3.0 Eos-0.1
Baso-0.3
[**2147-7-22**] 09:46AM BLOOD Neuts-54 Bands-0 Lymphs-24 Monos-8 Eos-2
Baso-0 Atyps-12* Metas-0 Myelos-0
[**2147-7-22**] 07:14PM BLOOD Hypochr-1+
[**2147-7-22**] 04:00PM BLOOD Hypochr-1+
[**2147-7-22**] 09:46AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Burr-1+
[**2147-7-25**] 04:05AM BLOOD Plt Ct-256
[**2147-7-24**] 03:25AM BLOOD Plt Ct-248
[**2147-7-23**] 04:00AM BLOOD Plt Ct-279
[**2147-7-22**] 07:14PM BLOOD Plt Ct-295
[**2147-7-22**] 04:00PM BLOOD Plt Ct-258
[**2147-7-22**] 04:00PM BLOOD PT-12.4 PTT-22.1 INR(PT)-1.0
[**2147-7-22**] 09:46AM BLOOD Plt Smr-NORMAL Plt Ct-327#
[**2147-7-22**] 09:46AM BLOOD PT-13.2 PTT-20.5* INR(PT)-1.1
[**2147-7-22**] 09:46AM BLOOD Fibrino-571*
[**2147-7-23**] 04:00AM BLOOD ESR-0
[**2147-7-25**] 04:05AM BLOOD Glucose-122* UreaN-11 Creat-0.8 Na-141
K-3.7 Cl-110* HCO3-19* AnGap-16
[**2147-7-24**] 03:25AM BLOOD Glucose-145* UreaN-11 Creat-0.7 Na-134
K-3.3 Cl-103 HCO3-17* AnGap-17
[**2147-7-23**] 10:02AM BLOOD K-4.5
[**2147-7-23**] 04:00AM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-139
K-3.3 Cl-107 HCO3-22 AnGap-13
[**2147-7-22**] 07:14PM BLOOD Glucose-117* UreaN-11 Creat-0.7 Na-143
K-4.4 Cl-112* HCO3-20* AnGap-15
[**2147-7-22**] 04:00PM BLOOD Glucose-133* UreaN-11 Creat-0.7 Na-143
K-3.2* Cl-110* HCO3-20* AnGap-16
[**2147-7-22**] 09:46AM BLOOD Glucose-231* UreaN-16 Creat-1.2* Na-144
K-5.4* Cl-103 HCO3-15* AnGap-31*
[**2147-7-22**] 09:46AM BLOOD ALT-13 AST-55* LD(LDH)-679* CK(CPK)-98
AlkPhos-184* TotBili-0.4
[**2147-7-22**] 09:46AM BLOOD Lipase-18
[**2147-7-22**] 09:46AM BLOOD CK-MB-4 cTropnT-0.07*
[**2147-7-25**] 04:05AM BLOOD Mg-1.7
[**2147-7-24**] 03:25AM BLOOD Calcium-8.3* Phos-1.9* Mg-1.5*
[**2147-7-23**] 04:00AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.1
[**2147-7-22**] 07:14PM BLOOD Albumin-2.9* Calcium-7.9* Phos-3.1
Mg-1.3*
[**2147-7-22**] 04:00PM BLOOD Calcium-7.9* Phos-2.6*# Mg-1.3*
[**2147-7-22**] 09:46AM BLOOD Calcium-9.6 Phos-5.7*# Mg-1.8
[**2147-7-22**] 09:46AM BLOOD Osmolal-307
[**2147-7-23**] 10:02AM BLOOD CRP-17.85*
[**2147-7-25**] 11:50AM BLOOD Vanco-5.3*
[**2147-7-23**] 10:02AM BLOOD Vanco-25.9*
[**2147-7-22**] 09:46AM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-14.9
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2147-7-22**] 09:46AM BLOOD GreenHd-HOLD
[**2147-7-24**] 11:49AM BLOOD Type-ART Temp-36.2 O2-90 pO2-149*
pCO2-25* pH-7.46* calHCO3-18* Base XS--3 AADO2-481 REQ O2-80
Intubat-NOT INTUBA
[**2147-7-24**] 06:07AM BLOOD Type-ART O2-70 pO2-71* pCO2-23* pH-7.46*
calHCO3-17* Base XS--4 Intubat-NOT INTUBA
[**2147-7-24**] 05:12AM BLOOD Type-ART Temp-37.7 O2-35 O2 Flow-6
pO2-66* pCO2-26* pH-7.31* calHCO3-14* Base XS--11 Intubat-NOT
INTUBA Vent-SPONTANEOU
[**2147-7-23**] 01:16AM BLOOD Type-ART Temp-38.7 O2-40 pO2-125* pCO2-35
pH-7.38 calHCO3-22 Base XS--3
[**2147-7-22**] 10:53PM BLOOD Type-ART Temp-38.1 Rates-/24 Tidal V-420
PEEP-5 O2-40 O2 Flow-12 pO2-149* pCO2-26* pH-7.46* calHCO3-19*
Base XS--2 Intubat-INTUBATED Vent-SPONTANEOU
[**2147-7-22**] 04:13PM BLOOD Type-ART Tidal V-400 O2-50 pO2-223*
pCO2-25* pH-7.52* calHCO3-21 Base XS-0 Intubat-INTUBATED
[**2147-7-22**] 12:24PM BLOOD Type-ART PEEP-5 O2-100 pO2-145* pCO2-30*
pH-7.49* calHCO3-23 Base XS-1 AADO2-555 REQ O2-90
Intubat-INTUBATED
[**2147-7-22**] 10:04AM BLOOD Type-ART pO2-281* pCO2-89* pH-7.03*
calHCO3-25 Base XS--9
[**2147-7-24**] 06:07AM BLOOD Lactate-3.8*
[**2147-7-24**] 05:12AM BLOOD Lactate-9.7*
[**2147-7-22**] 10:53PM BLOOD Lactate-1.7
[**2147-7-22**] 04:13PM BLOOD Lactate-2.2*
[**2147-7-22**] 12:24PM BLOOD Lactate-2.5* K-3.3*
[**2147-7-22**] 09:54AM BLOOD Lactate-1.3
[**2147-7-24**] 06:07AM BLOOD O2 Sat-96
Brief Hospital Course:
Pt intubated and admitted to ICU. LP performed, normal findings
r/o meningitis. Pt put on Vanco and CTX, and blood, urine,
sputum cultures obtained. Pt extubated without complications.
Ortho consulted, determined low likelihood of infection wound
infection. Pt experienced episode of aggitation in AM, fever
spike and tachycardia. Re-cultured and bolused with fluid. UC
returned E.Coli [**Last Name (un) 36**] to everything, other cultures were still
pending. Psychiatry consulted and recommended holding Seroquel
and Trazodone, avoiding Benzos if possible, giving Fentanyl only
for obvious pain, and using Haldol ladder (1mg, 1/2 hr wait,
then 2mg, then 1/2 hr, then 5mg, 10mg, then if no relief 10mg
and 0.5 mg Ativan). Pt lost access and required PICC insertion
as pt had no PO intake. Pt is d/c with PICC in place for
completion of Ab (CTX) course for UTI. Psychiatrist, [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 16471**], encouraged to restart Seroquel and Trazodone upon d/c
and recovered MS, if no PO intake can use Haldol IV as
equivalent to Seroquel. No IV anti-depressent available if pt
can't take PO Celexa. As per ortho, staples should be removed in
4 days, pt should follow up with Dr. [**First Name (STitle) **] in [**1-27**] weeks. On
morning of d/c, patient had 3 episodes of watery diarrhea, stool
sent for CDiff toxin. Need to f/u results so pt can be started
on appropriate ab.
Medications on Admission:
Acetominophen, Percocet, [**Last Name (LF) 98369**], [**First Name3 (LF) **], Seroquel, Trazodone,
Citalopram, Ambien, Fentanyl patch, Prednisone
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
8. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
Q2-3H (every 2-3 hours) as needed for Agitation.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 10283**] Center - [**Location (un) **]
Discharge Diagnosis:
Urinary tract infection, Delirium
Discharge Condition:
Stable
Discharge Instructions:
continue antibiotics, follow up CDiff toxin results
Followup Instructions:
As needed
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"0389",
"5990",
"51881",
"4019"
] |
Admission Date: [**2153-12-24**] Discharge Date: [**2153-12-29**]
Date of Birth: [**2078-3-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2153-12-24**] Coronary artery bypass grafting x2 with a left internal
mammary artery graft to the left anterior descending and reverse
saphenous vein graft to the ramus intermedius branch.
History of Present Illness:
Mr. [**Known lastname 3075**] is a 75-year-old male with worsening anginal
symptoms who underwent catheterization that showed left main
disease and left-sided disease and is presenting for
revascularization.
Past Medical History:
Coronary Artery Disease, Hypertension, Hyperlipidemia, Post
Traumatic Stress Disorder, Prior Knee Replacement, Prior Hernia
Repair
Social History:
Denies tobacco and ETOH.
Family History:
Denies premature CAD.
Physical Exam:
Vitals BP 144/57, HR 54, R 16, SAT 100% on RA
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2153-12-28**] 08:15AM BLOOD Hct-31.2*
[**2153-12-26**] 07:25AM BLOOD WBC-13.2* RBC-3.43* Hgb-10.8* Hct-32.1*
MCV-94 MCH-31.4 MCHC-33.6 RDW-14.6 Plt Ct-146*
[**2153-12-28**] 08:15AM BLOOD UreaN-18 Creat-1.0 K-4.6
[**2153-12-27**] 07:10AM BLOOD Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 3075**] was admitted and underwent two vessel coronary
artery bypass grafting by Dr. [**Last Name (STitle) **]. Intraoperative
echocardiogram was notable for depressed LV function with an
ejection fraction of 40-45%, and mild mitral regurgitation. Post
bypass, his LV function remain unchanged but his mitral
regurgitation improved to trace. The operation was otherwise
uneventful, and he was brought to the CSRU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated. He weaned from intravenous therapy without
difficulty. Diuresis was initiated and he transferred to the
telemetry floor on postoperative day one. Beta blockade was
initially withheld secondary to systolic BP in the 100's and
bradycardia. Over several days, beta blockade was resumed and
advanced as tolerated. He remained in a normal sinus rhythm
without evidence of atrial or ventricular dysrythmias. He
continued to make clinical improvements with diuresis and made
steady progress with physical therapy. He was cleared for
discharge to home on postoperative day five. At discharge, his
BP was 120-130's/ 60-70 with a HR of 70's(sinus) and room air
saturations of 98%. His discharge chest x-ray showed only small
bilateral pleural effusions.
Medications on Admission:
Toprol XL, Lipitor, Aspirin, Paxil
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Health Visiting RN ([**State 1727**])
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG, Hypertension,
Hyperlipidemia, Post Traumatic Stress Disorder, Prior Knee
Replacement, Prior Hernia Repair
Discharge Condition:
Good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not swim or take a bath for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
do not lift anything heavier than 10 pounds for 1 month
do not drive for 1 month
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in [**3-16**] weeks
follow up with Dr. [**Last Name (STitle) 22889**] in [**1-14**] weeks
follow up with Dr. [**Last Name (STitle) 11679**] in [**1-14**] weeks
Completed by:[**2154-2-13**]
|
[
"41401",
"4240",
"4019",
"2724"
] |
Admission Date: [**2118-1-10**] Discharge Date: [**2118-1-20**]
Date of Birth: [**2054-6-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
xferred from [**Hospital 1727**] Medical center for managment of meningitis
Major Surgical or Invasive Procedure:
PICC line placement
Chest tube placement (left)
History of Present Illness:
63F xferred from [**Hospital 1727**] Medical center for managment of
meningitis.
.
The illness began on [**12-24**] with flu-like sx, + malaise, +
neck pain, +headache, +subjective fevers/chills, + fatigue, +
bilateral knee pain. Per report, patient visited her grandkinds
on [**2117-12-19**], one of whom had bronchitis and sore throat but was
tested negative for strep. Patient was getting progressively
worse, increased drowsiness, +changes in gait. On [**12-26**],
patient collapsed (witnessed--legs weakened, her husband caught
her, patient was drowsy but did not lose conscousness)--not
syncopal episode. At that time, patient c/o increasing neck and
back pain. Pt taken to [**Hospital 15961**] hospital, where meningitis
was suspected, and the patient was started on vanc/ctx/steroids.
Head CT was negative for bleed. EKG per report showed incomplete
LBBB. Cardiac enzymes were negative per report. Reports are
incomplete, but apparently the patient was intubated for airway
protection given her mental status. She was then transferred to
[**Hospital 1727**] Medical Center essentially in a near-comatose condition.
LP was performed and was profoundly positive for strep meningits
and she was started on ctx 2gm IV q12 H. Per report, MIC was
found to be 0.032, which was thought to be sufficient in tx
meningtiis. She was stabilized and extubated, but not clear the
exact course of events. In addition, she received platelets and
2U PRBCs for hct of 22.7. She was also found to be guiaiac +.
.
The patient was improving from 12th till [**1-6**] with
increased awareness, increased mental status, working with PT
and OT. Pt was afebrile. On evening on 22nd, pt once again
became lethargic, spiked to 101.6, so vancomycin was also added.
Pt's family contact[**Name (NI) **] [**Name2 (NI) **] [**Doctor Last Name **] and xfer to [**Hospital1 18**] was
arranged.
.
Upon arrival, to the [**Name (NI) 153**], pt's VSS. Afebrile, but without IV
access.
.
MICU Course:
[**1-10**]: Neuro consulted. Vanc added given fevers.
[**1-11**]: [**Female First Name (un) **] performed -> transudate, c/b PTX requiring CT. LENIs
neg. MRI spine with cord enhancement C3-T2.
[**1-12**]: CT put to water seal, no leak, small residual apical PTX
on CXR. Arthrocentesis
Past Medical History:
L wrist surgery
chronic sinus infections, no antibiotics
Social History:
baseline lives with husband, independent, was working as an
administrator prior to this illness, no tobacco, no etoh, no
IVDU. has 1 dog and 2 cats at home.
Family History:
mother had "unstable blood pressure" and died of a cva. Father
had [**Name2 (NI) 18007**] and died of CHF at age 80,
Physical Exam:
HEENT: PERRLA, EOMI. + meningismus, + neck stiffness. impaired
neck flexion, head rotation.
RESP: CTAB, no rales or ronchi
CV: S1, S2, RRR. no MRG
ABD: +BS. soft, slightly distended. per report patient has not
had stool. no hepatosplenomegaly.
EXT: significant for swollen, warm L knee, 1+ pitting edema L
leg up to knee
NEURO: pt is awake and alert, responding to questions
appropriately. deaf, not able to communicate verbally. patient
has hearing loss. otherwise, cranial nerves intact. proximal UE
strength 1/5. Prox LE strenth [**11-19**]. Bilateral upgoing babinsky.
very stiff in the neck. unable to flex neck.
SKIN: no rashes.
Pertinent Results:
[**2118-1-10**] 02:02PM WBC-13.0* RBC-3.85* HGB-11.5* HCT-35.3*
MCV-92 MCH-30.0 MCHC-32.6 RDW-16.2*
[**2118-1-10**] 02:02PM NEUTS-90.7* LYMPHS-0* MONOS-7.2 EOS-1.0
BASOS-0 ATYPS-1.0* NUC RBCS-1*
[**2118-1-10**] 02:02PM PLT COUNT-463*
[**2118-1-10**] 02:02PM PT-11.7 PTT-22.7 INR(PT)-1.0
[**2118-1-10**] 02:02PM GLUCOSE-109* UREA N-20 CREAT-0.8 SODIUM-139
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
[**2118-1-10**] 02:02PM ALT(SGPT)-47* AST(SGOT)-29 LD(LDH)-288* ALK
PHOS-228* TOT BILI-0.5
TTE:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular
wall motion is normal. 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. Trace aortic
regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The
estimated pulmonary artery systolic pressure is normal. There is
no
pericardial effusion.
IMPRESSION: No valvular vegetations seen. If clinically
indicated, a TEE may be better to exclude a small valvular
vegetation.
MRI HEAD ([**1-14**])
IMPRESSION:
1. Multiple bilateral subcortical white matter infarctions, up
to 10 days old, which is suggestive of vasculitis in the setting
of meningitis.
2. Extensive leptomeningeal edema and enhancement, consistent
with meningitis.
3. Irregularities in the distal M1 segment of the right middle
cerebral artery and at the origin of the left posterior cerebral
artery, which may represent atherosclerosis or vasculitis.
Please note that small-vessel vasculitis may be occult on MRA.
4. No evidence of cerebral abscess or subdural empyema.
RIGHT KNEE FILM:
IMPRESSION:
1. There are mild osteoarthritic changes worst in the medial
compartment.
2. The large joint effusion seen on [**1-10**] has markedly improved.
[**1-14**] CXR:
There is no appreciable left pneumothorax or pleural effusion.
Left posterior pleural drains still in place. Left lower lobe
consolidation is stable. Lungs otherwise clear. Heart size is
normal. Thoracic aorta is very tortuous but not dilated. Tip of
the left PIC catheter projects over the left brachiocephalic
vein.
There is no positive micro data from this hospital.
Brief Hospital Course:
1) PNEUMOCOCCAL MENINGITIS:
At OSH, pt was started on broad spectrum abx with ctx, vanco and
amp. Once cultures returned for pneumococcus, this was narrowed
to Ctx only. However, after a period of improvement, pt
worsened again around [**1-5**] with fever and lethargy. Vanco was
restarted at this time though no focus of infection was
identified. This was discontinued again on [**1-12**].
ID consultation obtained, and CTX was deemed appropriate
therapry. She was initially on 2grams q12hours. Day#1 was
[**12-27**]. MRI with multiple subacute infarcts and concerned for
vasculitis/embolic disease. She was started on ASA. Surface
echo showed no evidence of endocarditis. A TEE was attempted to
definitively rule this out but the pt could not tolerate it
under conscious sedation and it was felt the risk of doing in
under general anesthesia outweighed the benefit given low
suspicion. The patient's delerium and mental status improved on
a daily basis so no further workup was pursued for these brain
lesions as they were likely secondary to vasculitis from
infection. Her Ctx dose were changed to 2g once a day. Her
carotid US was negative.
.
2) SEPTIC ARTHRITIS of b/l knees:
Initially discovered at OSH where arthrocentesis was
performed.This was treated with antibiotics as above. Once
arrived to [**Hospital1 18**], rheumatology was consulted. Repeat
arthrocentesis showed improved cell counts. She was also
improving clinically with decreased effusions, pain. She will
complete a 6 week course of ceftriaxone for this. Pain control
with tylenol.
.
3) PNEUMOTHORAX:
While in MICU, here pt had a diagnostic left thoracentesis given
fevers. The pleural fluid was transudative but the procedure
was complicated by pneumothorax. A chest tube was placed for
several days and taken out on [**1-15**] without event. The patient
has poor healing of skin at the site and is getting wound care
but respiratory status is stable and post CT films show no PTX.
.
4) DELERIUM:
The workup was as above for meningitis and brain lesions. She
also had TSH, B12, RPR sent which were unremarkable. Her
delerium was partly due to hearing loss and subsequent
disorientation. However, it improved throughout the admission
on a daily basiss.
.
5) HEARING LOSS:
Likely sensineural secondary to meningitis. Formal audiology
testing can be done as an outpatient.
.
6) ANEMIA: Workup consistent with anemia from acute
inflammation. Hct was stable.
.
7) RASH: Several days prior to discharge pt developed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
rash on her thighs. IT was thought Ctx could be the culprit.
She was started on H2B and benadryl with complete resolution.
The histamine blockers were stopped without recurrence.
.
8) CONSTIPATION:
Pt will need continued bowel regimen and possibly enemas as she
remains constipated.
Medications on Admission:
At home: none
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One [**Age over 90 1230**]y
(150) mg PO BID (2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
5. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) gram Intravenous Q24H (every 24 hours) for 17 days.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Pneumococcal meningitis, septic athritis, delerium
Discharge Condition:
Good.
Discharge Instructions:
1. Take medications as prescribed.
2. Follow up as below.
3. You will attended to by physicians at rehab--please address
any medical concerns with them or Dr. [**Last Name (STitle) **].
Followup Instructions:
INFECTIOUS DISEASES: Provider: [**First Name8 (NamePattern2) 7618**] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2118-2-1**] 10:00
PCP: [**Name10 (NameIs) **] you leave rehab, you should follow up with your
primary care doctor, Dr. [**Last Name (STitle) **], in 1 to 2 weeks.
RHEUMATOLOGY: Please call ([**Telephone/Fax (1) 1668**] to make an appointment
to follow up with a rheumatologist regarding the septic
arthritis in your knees. The doctor that you saw you was Dr.
[**Last Name (STitle) **] but you can see any doctor.
If you need to see an audiologist for hearing testing here,
please call ([**Telephone/Fax (1) 18008**] to make an appointment.
|
[
"5119",
"2859"
] |
Admission Date: [**2156-7-14**] Discharge Date: [**2156-7-24**]
Date of Birth: [**2085-3-31**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
male with a history of coronary artery disease, status post
myocardial infarction times four, coronary artery bypass
graft with multiple PCA interventions, atrial fibrillation,
congestive heart failure with several recent admissions
presenting with syncope. At the time of initial interview
the patient was unable to give further events secondary to
Ativan administration, although the following day the patient
described a syncopal event on the couch witnessed by his
wife. [**Name (NI) **] denied chest pain or shortness of breath throughout
the episode. While in the Emergency Room the patient had
multiple episodes of V tach lasting at least 16 seconds which
were witnessed by the RN who stated patient's eyes rolled
back in his head. The patient does have an implantable
defibrillator that did not fire and received 150 mg of
Amiodarone in the Emergency Room.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, had a coronary artery bypass graft in [**2133**] which was
[**Year (4 digits) 5659**] to LAD, continuous to OM1, RCA, [**6-/2154**] had PTCA with stent
to the [**Last Name (LF) 5659**], [**First Name3 (LF) **] graft. In [**2146**] had PTCA again to [**Year (4 digits) 5659**] to OM
and RCA. Congestive heart failure had a recent admission to
[**Hospital1 69**]. [**4-1**] had instent
stenosis with stent to the [**Month/Year (2) 5659**] to RCA and EF was 15% at that
time. [**2156-7-1**] a cath showed [**Year (4 digits) 5659**] to RCA 99% with PTCA
done, patent [**Year (4 digits) 5659**] to LAD and [**Year (4 digits) 5659**] to OM1. The patient has
automatic implanted defibrillator secondary to cardiac arrest
that occurred in [**2153**]. Also has benign prostatic
hypertrophy.
MEDICATIONS: On admission, Aspirin 325 mg, Lasix 80 mg in
the morning, 40 mg at night, Zestril 2.5 mg, Toprol XL 12.5,
Lipitor 10 mg, Coumadin 2 mg, Proscar 5 mg, Ticlid 250 mg
[**Hospital1 **], home oxygen 2 liters and initial blood pressure 94/61,
pulse 74, respirations 20, 100% on two liters. In general
the patient is sleepy, arousable to pain, anicteric, heart
was regular, 2/6 systolic murmur. Chest, decreased breath
sounds at the bases with decent air exchange. Abdomen,
positive bowel sounds, nontender, nondistended. Extremities
showed [**12-3**]+ edema to the mid calf.
LABORATORY DATA: Hematocrit 39.9, white count 10.5, platelet
count 116,000, sodium 134, potassium 5.0, chloride 99, CO2
30, BUN 67, creatinine 2.1, glucose 125, initial CK 77 with
troponin of 1.2. Chest x-ray showed increased perihilar
haziness, bibasilar opacities suggestive of pulmonary edema.
EKG initially showed a left bundle branch block at 82.
HOSPITAL COURSE:
1. The patient was admitted to the floor and placed on
telemetry for syncope and V tach arrest. The patient was
continued with the diuresis of IV Lasix. The next day the
patient was taken to the EP lab for ablation of his V tach
focus and mapping of his V tach. The day before the patient
received adjustment of his pacer, defibrillator settings to
shock at a lower rate. On the morning after the ablation,
the patient was found to be less oriented, not saturating
well, cyanotic toes and was transferred to the CCU for
administration of Milrinone. While in the CCU the patient
received 24 hours of Milrinone without much response. After
two days the patient was called out to the floor. On the
floor the patient continued in congestive heart failure. An
echo done previously on this admission had showed an EF
around 10%. The patient was started on a Natrecor drip and
was evaluated for receiving a biventricular pacer. The
patient received the pacer and on the day after continued to
do well. A repeat echo showed an EF of [**9-19**]%. The patient
was mentating well and was no longer as cyanotic and was
saturating well off oxygen. None of these events were
thought to be ischemic. Elevated enzymes post ablation were
thought secondary to the ablation itself and came down
appropriately.
2. Pulmonary: Patient had congestive heart failure
throughout his admission, had good response to Natrecor,
Lasix, Spironolactone was started to increase this diuresis.
Of note, the patient also had episodes of sleep apnea with O2
sats down to 89% and we avoided giving him Ambien for the
rest of his admission.
3. Hematology: A) Thrombocytopenia - The patient's platelet
count started dropping during his CCU stay. It was monitored
and had a nadir in the 70's. We were considering
discontinuing anti-platelet agents if the downward trend
continued, although patient very much needed his Ticlid for
his stents. No signs of symptoms of bleeding were noted.
B) Leukocytosis - patient accidentally received a dose of
Solu-Medrol while initially on the floor due to a nursing
error. Although the white count remained elevated, there
were no signs or symptoms of other systemic infections.
4. Infectious Disease: The patient had thrush throughout
his admission. He was tried on Clotrimazole troches and
Nystatin swish and swallow although still complained of mouth
burning with some visible thrush. On the day of his
discharge he was started on Diflucan 200 mg po the first day,
then 100 mg a day after.
CODE STATUS: The patient's code status changed during this
admission. He was initially full code and after careful
discussion with his family, was changed to DNR/DNI.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. V tach.
3. Syncope.
4. Congestive heart failure exacerbation secondary to
ventricular tachycardia and ischemic cardiomyopathy.
5. Benign prostatic hypertrophy.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q d, Lipitor 10 mg
po q d, Finasteride 5 mg po q d, Ticlid 250 mg po bid,
Amiodarone 400 mg a day until [**8-21**], then 200 mg a day,
Protonix 40 mg a day, Tylenol 325 to 650 mg po q 4-6 hours
prn, Nystatin oral suspension 5 ml po qid, Spironolactone 25
mg po q d, Viscus Lidocaine 2%, 20 ml po tid prn, Ambien 5 mg
po h.s., Captopril 6.25 mg po tid, Lasix 80 mg IV bid,
Fluconazole 100 mg po q day for 7 days, Carvedilol 3.125 mg
po bid.
FOLLOW-UP: In Device Clinic in one week. The patient has an
appointment at Device Clinic [**2156-8-23**] at 11 a.m. on [**Hospital Ward Name 23**]
[**Location (un) **] and can call to confirm at [**Telephone/Fax (1) **]. He should
also be brought back for ICD testing. Patient to follow-up
with Dr. [**Last Name (STitle) 2912**] or coverage in one week.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: To rehabilitation.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2917**]
Dictated By:[**Last Name (NamePattern1) 6834**]
MEDQUIST36
D: [**2156-7-24**] 09:24
T: [**2156-7-24**] 09:32
JOB#: [**Job Number 24431**]
|
[
"4280",
"2875",
"42731",
"V4581"
] |
Admission Date: [**2154-3-31**] Discharge Date: [**2154-4-2**]
Date of Birth: [**2120-11-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
33M PMH ESRD on HD, HTN p/w epigastric abdominal pain,
nonradiating, nausea/vomiting starting one day prior to
admission. The patient has been unable to tolerate PO,
including his home medications. He complains of loose stools
for one day, now resolved. The patient's mother and sister have
had similar symptoms. The patient also complains of orthopnea,
DOE, and nonproductive cough, consistent with his prior episodes
of fluid overload due to missing dialysis. The patient missed
HD Friday due to a friend's funeral.
.
In the ED, initial VS: T: 97.1 BP: 186/48 HR: 78 RR: 20 O2:
100%RA. EKG with new TWI V5-V6, although consistent with
reciprocal changes from patient's known LVH, and no evidence of
peaked T waves. The patient's blood pressure increased to up to
256/162. The patient received Ondansetron 4 mg, Insulin 10
units with dextrose, Calcium gluconate 1 amp IV, Kayexalate 30
gm, NIFEdipine CR 60 mg, Labetolol 10 mg IV x 2. The patient's
blood pressure remained elevated and the patient was started on
Labetolol gtt. Chest x-ray showed mild congestion. The patient
was thought to be lethargic and CT head performed and negative.
.
On arrival to the floor, the patient denies abdominal pain,
nausea.
.
ROS: Negative for fevers, chills, chest pain, headache,
weakness, numbness. Otherwise negative in detail.
Past Medical History:
1. ESRD on HD thought due to hypertensive nephropathy, started
on dialysis in [**12/2152**]; going to [**Location (un) **] Dialysis Unit at [**Location (un) 76539**], and follows with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 76540**]; saw Dr.
[**Last Name (STitle) **] here in [**2153-11-29**].
2. Hypertension, diagnosed in [**2147**] when he had a medical exam
during incarceration.
3. Status post appendectomy.
4. Recent admission for right flank pain 1/[**2153**].
5. Medication noncompliance.
Social History:
He used to work as a plasterer, but is now on disability.
tobacco - 1PPD x 14 years, recently decreased to
two cigarettes a day. + alcohol use, + cocaine - last use
[**2153-11-27**],
denies any intravenous drugs.
Family History:
Father - dead at age 36 from unknown cancer
Mother - alive, 56, + HTN
maternal grandmother - on hemodialysis for end-stage renal
disease.
- The patient has a younger sister and an older brother,
both alive and well.
- son - 7, alive and well
Physical Exam:
T: 97 BP: 165/114 (equal bilaterally) P: 82 RR: 20 SaO2: 100% 4L
NC
General: NAD
HEENT: Sclera anicteric, PERRL, OP clear without lesions
NECK: Supple, JVD 5 cm, RIJ tunnelled catheter without erythema
CV: RRR, no MRG
Pulm: CTAB
Abd: NABS, soft, NTND, no HSM, no masses
Ext: No CCE
Skin: Warm, no rashes
Neuro: AAOx3, CN II-XII intact, MAEW
Pertinent Results:
EKG: NSR at 77, axis 0, NI with QTc 433. LVH per voltage
criteria. TWI III and aVF (old), JPE V2-V4 (old), TWI V5-V6
(old) but c/w reciprocal changes from LVH.
.
CHEST (PA & LAT) Study Date of [**2154-3-31**]
IMPRESSION:
Cardiomegaly, mild congestion.
.
CT HEAD W/O CONTRAST Study Date of [**2154-3-31**]
(my read) No ICH or mass effect.
Brief Hospital Course:
33M PMH ESRD on HD presenting with hypertensive urgency,
nausea/vomiting after missing dialysis.
.
# Hypertensive urgency: Hypertension in the setting of inability
to tolerate his medications due to nausea and the patient
missing his last session of dialysis. Initially started on
labetalol gtt in the MICU. Without evidence of end organ
ischemia, with negative CT head, no ECG changes, cardiac enzymes
negative. He was continued on his outpt regimen (BB, ACEI), CCB
was titrated up prior to discharge.
.
# Hyperkalemia: Resolved with Kayexalate. Rreceived Insulin 10
units with dextrose, Calcium gluconate, Kayexalate 30 gm in ED.
He underwent HD per his outpt regimen.
.
# ESRD on HD: Thought to be secondary to due to hypertensive
nephropathy. Resumed on outpt schedule of MWF HD.
.
# Nausea/Vomiting: Resolved. Recent sick contacts suggesting
viral gastroenteritis. Also likely component of uremia. LFT and
lipase unremarkable (laboratories slighly hemolyzed). Ruled out
for MI with enzymes. Symptoms improved on discharge.
Medications on Admission:
Calcium Acetate 667 mg TID
Lisinopril 40 mg [**Hospital1 **]
Metoprolol Succinate 100 mg DAILY
Nifedipine 60 mg SR [**Hospital1 **]
Sevelamer HCl 1600 mg TID
Terazosin 1 mg QHS
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
5. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO once a day.
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Hypertensive urgency
End stage renal disease on hemodialysis
Hyperkalemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with high blood pressures. You were treated
initially with intravenous blood pressure medications. You were
then started on oral blood pressure medications that you
normally take at home. You also had hemodialysis on Monday.
Please note that your nifedipine was increased. Also note that
your sevelamer was increased as well. Please take all of your
other medications as directed. In addition, we have made
several appointments for you. It is important that you attend
these appointments. Please see below. It is also extremely
important that you take all of your blood pressure medications.
If you have any of the following symptoms, please return to the
emergency room or see your PCP:
[**Name10 (NameIs) **] pain, shortness of breath, palpitations, or any other
serious concerns.
Followup Instructions:
We have set you up with a primary care doctor in our clinic
because you did not have one. We have also set up an
appointment for you to be evaluated by Dr. [**First Name (STitle) **] for
evaluation for hemodialysis access placement:
Dr. [**First Name (STitle) **]:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2154-5-2**] 3:40
.
Your new primary care doctor appointment:
[**2154-5-8**] 02:00p [**Last Name (LF) 6401**],[**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **]
[**Hospital6 29**], [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
.
Please attend your dialysis tomorrow as previously scheduled.
Completed by:[**2154-5-6**]
|
[
"2767"
] |
Admission Date: [**2142-10-4**] Discharge Date: [**2142-10-17**]
Date of Birth: [**2110-3-5**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
TBI s/p MCC
Major Surgical or Invasive Procedure:
[**10-4**] R ICP bolt placement
[**10-11**] perc trach / PEG
History of Present Illness:
32M s/p MCC. Found unconscious but breathing at scene with blood
tinged sputum. Brought to [**Hospital1 18**] and was moving extremities x4,
non-verbal but not protecting airway. Intubated in the field. CT
revealed bilateral IPH.
Past Medical History:
PMH: none
PSH: adenoidectomy, tonsillectomy, knee arthroscopy
Social History:
Noncontributory
Family History:
Noncontributory
Physical Exam:
VS: T 100, HR 96, BP 123/61, RR 27, SaO2 96% TM40%
Gen: A/Ox2
HEENT: trach in place, midline, no surrounding erythema
CV: RRR, no M/R/G
P: coarse breath sounds throughout
GI: PEG in place, soft, no rebound, no guarding, nondistended
GU: foley in place
Ext: WWP, No edema, abrasions to RLE
Pertinent Results:
[**2142-10-16**] 01:58AM BLOOD WBC-13.1* RBC-3.17* Hgb-9.4* Hct-27.5*
MCV-87 MCH-29.7 MCHC-34.2 RDW-13.9 Plt Ct-854*
[**2142-10-4**] 01:40PM BLOOD WBC-13.5* RBC-4.43* Hgb-13.5* Hct-40.0
MCV-90 MCH-30.5 MCHC-33.8 RDW-12.7 Plt Ct-269
[**2142-10-16**] 01:58AM BLOOD Glucose-121* UreaN-21* Creat-0.6 Na-137
K-4.5 Cl-102 HCO3-26 AnGap-14
[**2142-10-5**] 01:55AM BLOOD Glucose-129* UreaN-8 Creat-0.9 Na-136
K-4.0 Cl-105 HCO3-20* AnGap-15
[**2142-10-4**] 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT head [**10-4**]:
FINDINGS: This study is technically limited due to motion
artifact. There are multiple foci of intraparenchymal hemorrhage
seen within the grey-white matter junction of the left frontal
lobe and right frontal lobe towards the vertex, as well as the
left basal ganglia and left internal capsule. A tiny focus of
extra-axial hemorrhage adjacent to the right frontal
intraparenchymal
hemorrhage also is likely present suggestive of subarachnoid
blood. Thin hyperdensity layering along the left tentorium may
represent a tiny subdural hemorrhage. There is no evidence of
edema, mass effect or shift of normally midline structures. The
[**Doctor Last Name 352**]-white matter interface is well preserved with no evidence
of acute major vascular territorial infarct. The ventricles and
sulci are normal in size and configuration.
The extracalvarial soft tissues show right frontal scalp and
periorbital hematoma. Multiple facial fractures are identified
of the right superior lateral orbital wall and inferolateral
orbital wall. There is a fracture of the floor of the right
orbit with a displaced fragment displaced in the right maxillary
sinus without herniation of extraocular musculature.
Opacification in the right maxillary sinus and right ethmoid air
cells suggests hemorrhage from the multiple facial fractures.
The skull base is intact without fracture. The bilateral globes
are intact with lenses in place bilaterally.
No retrobulbar hematoma present.
IMPRESSION:
1. Multiple intraparenchymal hemorrhages compatible with diffuse
axonal injury.
2. Tiny extra-axial hemorrhage noted adjacent to the right
frontal intraparenchymal hemorrhage, likely subarachnoid blood.
Small subdural hemorrhage layering over the left tentorium.
3. Facial fractures as described above. A dedicated
maxillofacial CT would be recommended when possible for further
evaluation.
CThead [**10-5**]:
FINDINGS: Right frontal parenchymal hemorrhage with a
fluid-fluid level seen dependently is redemonstrated, unchanged
in size. Foci of left frontal and temporal parenchymal
hemorrhage are also redemonstrated, also appearing unchanged.
There is no new intracranial hemorrhage, edema, mass effect, or
vascular territorial infarction. Ventricles and sulci are
unchanged in size
and in configuration. An intracranial bolt is visualized, placed
via a right frontal approach.
Osseous structures are notable for a comminuted fracture
involving the superolateral corner of the right orbit anteriorly
with adjacent extraconal hematoma slightly impinging on the
globe. Additionally, there is a comminuted right orbital floor
fracture with a fallen osseous fragment, though no evidence of
entrapment of the inferior rectus extraocular muscle. A
minimally displaced fracture is also visualized in the right
anterior maxillary sinus wall. There is expected near total
opacification of the right maxillary sinus. The pterygoid
plates, and zygomatic arches are intact. The lamina papyracea
are intact. The nasal septum is intact, and notable for a
moderate-sized rightward nasal septal spur. There is a minimally
displaced right nasal bone fracture. Note is made of partial
opacification of ethmoidal air cells bilaterally, greater on the
right than left as well as moderate mucosal thickening in the
left maxillary sinus, sphenoid sinus and frontal sinuses. The
sphenoid sinus contains a single dominant septum which
terminates near the midline.
IMPRESSION:
1. Bilateral parenchymal hemorrhage as described above, similar
to the most recent comparison study.
2. Right facial fractures as characterized above.
CThead [**10-8**]
FINDINGS: Again seen are multiple evolving intraparenchymal
hematomas, without significant interval change in size since the
prior study of [**2139-10-6**]. There is mild interval increase in the
edema surrounding these hemorrhagic contusions, especially
surrounding the large hematoma in the right frontal vertex. The
large right frontal vertex hematoma now measures 2.8 x 2.3 cm,
which allowing for differences in technique is unchanged since
the prior study 3.0 x 2.2 cm. Mild effacement of the right
frontal hemispheric sulci, is more prominent since the prior
study. No significant shift of midline structures is seen.
Multiple parenchymal hematomas in the left frontal lobe, left
caudate nucleus, basal ganglia, temporal lobe, are again
redemonstrated. No new intracranial hematoma is seen. The
ventricles and sulci are unchanged in appearance. There is no
intraventricular extension of hemorrhage. The basal cisterns are
normal. Multiple facial fractures including right superolateral
orbital fracture, right orbital floor fracture are again
redemonstrated. There is diffuse opacification of the right
maxillary, right ethmoid sinuses, with air-fluid levels in both
sphenoid sinuses.
IMPRESSION:
1. Evolving intraparenchymal hematomas, without significant
interval change in size. Mildly increased surrounding edema and
mass effect.
2. No evidence of transtentorial herniation. No new parenchymal
hematomas.
LUE duplex [**10-7**]
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of left internal
jugular, subclavian, axillary, brachial veins were performed.
There is normal compressibility, flow and augmentation
throughout. The left cephalic and basilic veins are normal.
IMPRESSION: No evidence of DVT in the left upper extremity.
MR [**Last Name (Titles) **] [**10-8**]:
FINDINGS: Cervical vertebrae reveal normal height, signal
intensity and alignment. Craniocervical junction appears normal.
Cervical spinal cord reveals normal morphology and signal
intensity. Pre- and paravertebral and posterior paraspinal soft
tissues appear unremarkable. Fluid signal is seen within the
oropharynx and around the endotracheal tube, likely secondary to
intubation.
There is no spinal canal or neural foraminal narrowing seen.
Intervertebral discs are normal in height and signal
intensities. There is no evidence of ligamentous injuries.
IMPRESSION: Unremarkable MRI of the cervical spine.
LENI [**10-12**]
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of bilateral common
femoral, superficial femoral, popliteal, posterior tibial and
peroneal veins were performed. There is normal compressibility,
flow and augmentation.
IMPRESSION: No evidence of DVT.
CT torso [**10-14**]
FINDINGS:
CHEST: The visualized portion of the thyroid is unremarkable.
There is no axillary, hilar, or mediastinal lymphadenopathy. A
tracheostomy tube is in place. The aorta is of a normal caliber
along its course without evidence of injury. The pulmonary
artery shows no large central filling defect. There is no
pericardial effusion.
Assessment of fine detail of the lungs is slightly limited by
mild motion artifact. Bibasilar consolidations have worsened
compared to prior study. Additionally, the previously described
right lower lobe anterior basal segment contusion demonstrates a
more confluent well-rounded appearance, possibly representing
rounded atelectasis or a focal area of diaphragmatic eventration
(2:45), measuring 26 x 17 mm. There is no large pleural effusion
or pneumothorax.
ABDOMEN: A gastrostomy tube is in place. Extensive streak
artifact is seen from the oral contrast administered as well as
from excreted IV contrast in the renal collecting systems. There
is no evidence of extraluminal contrast or free air. There is no
perihepatic or perisplenic fluid. The kidneys enhance with and
excrete contrast symmetrically. The visualized portion of large
and small bowel show significant colonic fecal load. The aorta
shows no evidence of injury.
BONES: Again are seen fractures of the anterior portions of the
left second and third ribs as well as the anterior portions of
the right second, third, fourth, fifth, and sixth ribs.
IMPRESSION:
1. Worsening bibasilar consolidations as described above.
2. Status post PEG tube placement without evidence of free air
or extraluminal contrast.
3. Multiple rib fractures as described above.
Brief Hospital Course:
The patient was admitted to the Trauma Surgical Intensive Care
Unit for evaluation and treatment of polytrauma following MCC.
Attending of record was Dr. [**Last Name (STitle) **] of the Acute Care Surgical
Service.
Injuries at time of admission:
- RUL pulm contusion
- multifocal areas of probable aspiration
- b/l rib fxs(2nd, 3rd L, 5th on R)
- intraparenchymal hem L frontal lobe
- focus of SAH at R frontovertex
- R inf+sup orbit floor [**Last Name (LF) **], [**First Name3 (LF) **] sinus fx
- R non-displaced rad/uln fx
On [**10-4**] the patient underwent placement of R bolt for ICP
monitoring which went well without complication (reader referred
to the Operative Notes for details). Patient arrived to the
Trauma Surgical Intensive Care Unit NPO, on IV fluids, with a
foley catheter, and fentanyl for pain control. The patient was
hemodynamically stable.
Neuro: TBI with subsequent MRI concerning for [**Doctor First Name **]. The patient
received intermittent mannitol with good effect and fentanyl
with adequate pain control. ICPs remained stable and bolt was
subsequently dc'd. Subsequent head CT demonstrated stable ICH.
Pt completed course of seizure prophylaxis. Pt's baseline mental
status gradually improved throughout hospitalization with
patient interactive and following some commands with family
members.
CV: The patient arrived to the ICU hemodynamically stable in
sinus rhythm without pressor requirement.
Pulmonary: The patient arrived to the ICU intubated and was
subsequently extubated without complication and comfortable on
trach mask with blow-by throughout the remainder of his
admission. Concern for RUL, RML, RLL, LUL aspiration PNA with
negative sputum cultures. VAP protocol initiated with serial CXR
and completion of antibiotic course.
GI/GU/FEN: The patient was made NPO with IV fluids. Due to
impaired mental status and concern for inability to protect
airway with PO intake and subsequently underwent PEG placement
for definitive enteral access through which he received tube
feeds at goal. Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Wound care: Incisional wounds were regularly monitored for
signs of infection of which there were none.
Antibiotics: The patient received vancomycin/cefepime/cipro for
VAP protocol and completed antibiotic course during this
admission with >24 hours aefbrile at time of discharge.
Endocrine: The patient's blood sugar was monitored throughout
this admission. Insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots during this admission and was encouraged to get
up and ambulate as early as possible.
Disposition: Discharge to rehabilitation facility.
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
8. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for agitation.
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1)
Tablet PO DAILY (Daily).
14. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever/pain.
15. ChlorproMAZINE 25 mg IV Q4H:PRN hiccups
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
30M s/p MCC p/w TBI/[**Doctor First Name **], facial fxs, R rad/ulna fx, mult rib fxs
req intubation in ED s/p trach/peg
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-29**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
Please follow-up in [**Hospital 2536**] clinic within 1 week of discharge. Call
([**Telephone/Fax (1) 2537**] with any questions and to schedule an appointment
Completed by:[**2142-10-17**]
|
[
"51881",
"5070",
"2859"
] |
Admission Date: [**2189-1-6**] Discharge Date: [**2189-1-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Abdominal pain, dysuria.
Major Surgical or Invasive Procedure:
Central line placement [**2189-1-6**]:
History of Present Illness:
83yo man w/ Alzheimers, BPH h/o UTIs, s/p recent R hip fx &
ORIF with gamma nail on [**2188-12-28**] who presented w/ "shaking
chills & abd pain x 1 day. In the ER, temp 103.3, rectal temp
>104, HR 120, BP 140s/40s and lactate 4.4. Sepsis protocol was
initiated and a RIJ was placed. He was started on vanc, zosyn
and flagyl and recieved 3 L of fluid. UA showed evidence of UTI.
CT abdomen was negative for acute pathology. CT head did not
show an ICH. CXR film did not show an infiltrate. Lactate
subsequently came down to 2.1.
.
He was initially admitted to the [**Hospital Unit Name 153**] for urosepsis. 4 out of 4
blood cultures returned Ecoli (R to pcn, unasyn) otherwise
pan-sensitive. Vanco,Zosyn discontinued. Started on Cipro
antibiotics. Repeat surveillance cultures from [**1-7**], [**1-9**] negative
to date. Also started on flagyl and PO vancomycin empirically
for cdiff (cdiff negative x 2 thus far [**1-6**] and [**1-8**]).
.
[**Hospital Unit Name 153**] course also complicated by new afib with RVR, felt to be in
setting of infection. Treated initially with dig load, and
diltiazem, b-blocker for rate control. digoxin, dilt
subsequently discontinued due to hypotension. Currently
controlled on PO lasix, in normal sinus rythm
.
Given HD stability, called out to floor on [**2189-1-10**].
Past Medical History:
bladder diverticulum
renal cysts
BPH
recurrent UTIs (pansensitive Klebsiella and E. Coli)
TIA '[**79**]
depression
[**1-7**]+ AR/1+ MR, EF >55% on echo from [**6-9**]
Social History:
Italian speaking, understands and speaks some english. Lives at
home with his wife. [**Name (NI) **] 3 children. Denies tob/drug use. Drinks
[**1-7**] glass wine per day.
Family History:
NC
Physical Exam:
VS: T 98.6, BP 112/57, HR 82, RR 20, 95% 3L O2 NC
GEN: awake, alert, primary italian speaking, no acute distress
HEENT: EOMI. MMM. OP clear
NECK: supple. no jvd
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: right lower extremity with echymosis extending from hip
laterally down entire leg to dorsum of foot. also w/ 2+ dorsal
edema b/l
NEURO: no focal deficits
Pertinent Results:
[**2189-1-6**] 11:28PM HCT-24.2*
[**2189-1-6**] 10:21PM TYPE-ART PO2-102 PCO2-32* PH-7.38 TOTAL
CO2-20* BASE XS--4
[**2189-1-6**] 10:21PM LACTATE-2.2*
[**2189-1-6**] 09:09PM TYPE-ART TEMP-36.7 O2-50 O2 FLOW-15 PO2-95
PCO2-34* PH-7.36 TOTAL CO2-20* BASE XS--5 INTUBATED-NOT INTUBA
VENT-SPONTANEOU COMMENTS-SHOVEL
[**2189-1-6**] 09:09PM freeCa-1.05*
[**2189-1-6**] 09:55AM GLUCOSE-129* UREA N-23* CREAT-1.0 SODIUM-142
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16
[**2189-1-6**] 09:57AM HGB-9.5* calcHCT-29
[**2189-1-6**] 05:47PM WBC-30.6*# RBC-2.33* HGB-7.2* HCT-22.0*
MCV-95 MCH-31.1 MCHC-32.9 RDW-14.5
CT Abd/Pelvis with IV contrast [**2189-1-15**]:
IMPRESSION:
1. No CT evidence of colitis, as clinically questioned. No
evidence of
intra-abdominal infection.
2. Increasing liquefaction of right thigh hematoma;
superinfection cannot be excluded.
3. New patchy opacities in the right middle lobe and the
lingula, raising the possibility of aspiration.
4. Multiple bilateral renal cysts.
CT abd/pelvis [**2189-1-6**]:
IMPRESSION:
1.9-cm hematoma in the medial compartment of the right thigh,
likely related to right femoral neck fracture and ORIF.
2.Mild anasarca.
3. No evidence for intra-abdominal infection.
4. Multiple bilateral renal cysts.
5. Bibasilar atelectasis.
CT head [**2189-1-6**]:
IMPRESSION: No acute intracranial hemorrhage and no evidence of
acute
intracranial process.
Brief Hospital Course:
Problem list
1) E.coli Bacteremia/Urosepsis)
2) ducubitus ulcer
3)c. diff infection
4) delirium
Please see HPI for brief summary of ICU events. E.coli was
sensitive to cipro and patient was to complete a 2 week course
of cipro to be stopped on [**2189-1-21**]. Unfortunately he was
persistently delirious despite antibiotic treatment for the
urosepsis as well as his c. diff infection. He developed
intermittent oligoarthritis that was aspirated by orthopedics.
The initial aspiration revealed no evidence of infection or
arthropathy. Repeat aspiration showed evidence of pseudogout.
The patient cotinued to spike fevers with intermittent episodes
of hypotension and no improvement in his mental status with low
grade fevers and leukocytosis. Due to the patient's poor mental
status his nutritional intake was poor. The family refused NGT
or J-tube placement for intermittent feedings. Multiple family
meetings were held and it was decided by the entire family with
myself and his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**], in attendance that the patient
would be made CMO per his previously stated wishes. The patient
was placed on a morphine gtt and passed away peacefully later
that day.
Medications on Admission:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Memantine 5 mg Tablet Sig: One (1) Tablet PO qd ().
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Continue until [**2189-1-28**].
8. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Continue until [**2189-1-28**].
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID
10. Enoxaparin 40 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q24H
11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
13. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1) bag
Intravenous Q12H (every 12 hours): Continue until [**2189-1-21**]. Stop
on [**2189-1-21**].
14. Docusate 100 mg po bid
Senna one tab po bid prn
Bisacodyl 10 mg supp prn
Tylenol 650 mg po q6 prn
Oxycodone 5 mg o q 6h prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Urosepsis with E.coli bacteremia
Clostridium Difficile
decubitus ulcer
Discharge Condition:
expired
|
[
"5990",
"2851",
"42731",
"4019"
] |
Admission Date: [**2127-1-16**] Discharge Date: [**2127-1-17**]
Date of Birth: [**2073-7-29**] Sex: F
Service: .
REASON FOR ADMISSION: status post sepsis and respiratory
failure; transfer from outside hospital in [**State 108**].
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old
female with a history of multi-system neurological atrophy,
neurogenic bladder plus Shy-[**Last Name (un) **] syndrome who was visiting
[**State 108**] when she was admitted to the hospital with sepsis
secondary to urinary tract infection with subsequent
complicated hospital course requiring intubation. She is now
transferred to [**Hospital1 69**] to be
closer to home.
She presented in [**Last Name (LF) 84064**], [**First Name3 (LF) 108**] on [**2127-1-5**], with
hypotension, sepsis and urinary tract infection. Urine
cultures and blood cultures were positive for Proteus which
was later on found to be sensitive to Levofloxacin. The
patient initially was treated with Zosyn there prior to the
culture results and was given stress dosed steroids, thought
to be an adrenal insufficiency at the same time. The
hypotension had resolved. The patient's antibiotics were
changed to Unasyn but failure to wean from ventilator with
failed extubation times one and at that point was
re-intubated there. She had a tracheostomy performed. Tube
feeds were also started via an NG tube. At that point, the
patient's family requested the patient to be transferred from
[**State 108**] to [**Hospital1 69**] to be closer
to home.
She denies any pain or discomfort. Her husband says that the
patient was walking with a walker, swimming with Physical
Therapy prior to this acute illness.
PAST MEDICAL HISTORY:
1. Questionable Shy-[**Last Name (un) **].
2. Multi-system atrophy.
3. Cesarean section times two.
4. Obstructive sleep apnea on BiPAP.
5. Autonomic dystrophy.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Mysoline.
2. Zoloft.
3. Sinemet.
4. Ritalin.
5. Ditropan.
6. Florinef.
MEDICATIONS ON TRANSFER:
1. Prednisone 5 mg twice a day.
2. Regular insulin sliding scale.
3. Ferrous sulfate.
4. Prozac 20 q. day.
5. Albuterol and Atrovent.
6. Lovenox 40 q. day.
7. Unasyn 3 q. day.
8. Tube feed.
9. Protonix.
10. Morphine p.r.n.
11. Nystatin.
12. Clotrimazole.
SOCIAL HISTORY: She has had a history of cocaine and
marijuana use in college years. She is a social drinker.
She has two children; husband is very supportive.
FAMILY HISTORY: Father with myocardial infarction. Mother
with [**Name2 (NI) 499**] cancer at age 80.
Her ventilation settings on admission were AC-502, 0.3, 14 x
550, PEEP of 5.
PHYSICAL EXAMINATION: Temperature of 99.0 F.; blood pressure
of 116/61; heart rate 88; respiratory rate 14; O2 saturation
93%. HEENT: Moist mucous membranes, anicteric. Flattened
neck veins. Generally a middle aged woman in no acute
distress, responds by shaking head and blinking
appropriately. Chest clear to auscultation bilaterally.
Heart is regular rate and rhythm with no murmurs, rubs or
gallops. Abdomen is soft, obese, nontender. Bowel sounds
were present in four quadrants. Extremities with no
cyanosis, clubbing or edema; no ulcers. One plus dorsalis
pedis pulses bilaterally. Back with no skin breakdown.
Neurologic: Myoclonus, alert, unable to talk secondary to
tracheostomy but appropriately responding; moving all four
extremities.
LABORATORY: At outside hospital a [**1-5**] urine culture showed
greater than 100,000 Proteus mirabilis which was sensitive to
Ampicillin, Cefixime, Bactrim, Ciprofloxacin and
Levofloxacin. On [**2127-1-5**], blood cultures also showed
Proteus mirabilis which was sensitive to Levofloxacin,
Bactrim, Imipenem, two out of three bottles. On [**1-12**], blood
cultures negative times two sets.
TSH 0.74. On [**1-12**] her labs were sodium of 140, potassium
4.6, chloride 103, bicarbonate 29, BUN 12, creatinine 0.6.
Glucose 187, calcium 8.8, white blood cell count 10.3,
hematocrit 32.5, platelets 274.
HOSPITAL COURSE: Being admitted is a 53 year old female with
multisystem neurological atrophy status post sepsis secondary
to urinary tract infection, now resolved; failure to wean
from ventilator status post tracheostomy.
1. RESPIRATORY FAILURE: The patient was initially ventilated
with AC and while here was switched over to pressure support and
tolerating well. On pressure support, the patient is
tolerating brief periods of tracheostomy collar at outside
hospital; likely secondary to weakness. Her NIF was measured at
-14cmH20. She has no secretions. Electrolytes specifically
phosphate checked and repleted as needed to expedite the
extubation.
Chest x-ray at [**Hospital1 69**] showed
proper positioning of the NG tube and her tracheostomy tube
and on obvious infiltrate. Her urinary tract infection
sepsis was relatively resolved and leukocytosis resolved. No
acute febrile episode. Her Proteus infection sepsis was
treated with a 14 day course. She received her 13th day
course while at [**Hospital1 69**]. She
would require two more days including today.
2. MULTI-SYSTEM NEUROLOGICAL ATROPHY: Restarting her
Sinemet for her tremors, Midodrine for autonomic dysfunction.
3. DEPRESSION: For her depression, she was continued on her
Prozac.
4. FLUIDS, ELECTROLYTES AND NUTRITION: She was continued on
tube feeds and electrolytes were repleted while here and
regular insulin sliding scale.
PROPHYLAXIS: On proton pump inhibitor, Pneumoboots and
subcutaneous heparin.
She is a Full Code.
Communication was discussed with the husband.
DISPOSITION: She was pending to be transferred to [**Hospital1 **].
Will appreciate [**Hospital1 296**] transfer.
DISCHARGE DIAGNOSES:
1. Respiratory distress.
2. Tracheostomy.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: She is transferring to [**Hospital **]
[**Hospital **] Hospital for further care and extubation.
DISCHARGE MEDICATIONS FROM [**Hospital1 **]:
1. Levofloxacin which would have one more day of dose of 500
p.o. q. 24 hours.
2. Carbidopa / Levodopa 2500, one tablet p.o. times five
more days.
3. Insulin Regular sliding scale.
4. Fluoxetine 20 mg p.o. q. day.
5. Albuterol, ipratropium 6 puffs inhaled q. six hours.
6. Heparin 5000 units subcutaneously q. eight hours.
7. Ferrous sulfate 325 mg p.o. q. day.
8. Lansoprazole 30 mg NG q. day.
9. Docusate 100 mg p.o. twice a day.
10. Methylphenidate 5 mg p.o. times five days.
11. Fludrocortisone 0.1 mg p.o. q. day.
12. Midodrine 7.5 mg p.o. three times a day.
13. Primidone 25 mg p.o. q. h.s.
The patient is discharged in stable condition.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Name8 (MD) 6112**]
MEDQUIST36
D: [**2127-1-17**] 12:47
T: [**2127-1-17**] 16:23
JOB#: [**Job Number 100275**]
|
[
"51881",
"0389",
"5990",
"311"
] |
Admission Date: [**2102-9-16**] Discharge Date: [**2102-9-19**]
Date of Birth: [**2050-2-1**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Ibuprofen / Gabapentin / Egg
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Unresponsiveness and altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation performed at OSH
Extubated on [**2102-9-17**]
History of Present Illness:
52 y.o. F with h/o polysubstance abuse, including alcohol and
benzodiazapines, and cirrhosis c/b encephalopathy, presenting to
[**Hospital1 18**] from [**Hospital6 302**] after being found unresponsive
the morning of admission. The patient was at her inpatient
detoxification facility, [**Hospital 22870**] [**Hospital3 **] (section 35). This AM,
she was found to be completely nonresponsive but her VS were
stable. She was breathing and snoring per report. There is a ?
of left facial droop, but has since resolved per report (cannot
find any written documentation in chart). Initially, she was
brought to [**Hospital6 302**] for evaluation where she was
intubated for airway protection and sedated and paralyzed with
etomidate and succinylcholine. Narcan x 1 given at OSH without
effect. Rectal temp at OSH noted to be 93.8 and bear hugger was
placed. OSH labs were significant for WBC 3.2, Hct 28, INR 1.4,
ammonia 66 and tox screen + for benzos. Her CT head was
negative. Zosyn x 1 given. She was transferred to [**Hospital1 18**] for
further evaluation.
.
On arrival to [**Hospital1 18**] ED, VS: T 98.2 HR 62 BP 108/62 RR 14 RR 100%
on vent. Per ED resident, the patient was able to withdraw from
painful stimuli but would not open her eyes on initial
evaluation but then would wake up a little if yells in her ear
and made some purposeful movements during LP. OG was placed with
bilious fluid. CT head was reviewed with [**Hospital1 18**] radiologists and
was negative. LP performed and unremarkable with 1 WBC. Given
cefepime x 1, vancomycin x 1, and ampicillin x 1 for possible
meningtis. CXR performed that showed ? RLL infiltrate. Labs
remarkable for normal LFTs except for total bili of 1.7,
hematocrit of 27.8, platelets of 57 and WBC of 4.5 with 6 bands.
Lactate 1.6. INR elevated at 1.7. Urine tox positive for
benzodiazapines. Serum tox negative. UA with large blood, [**7-4**]
WBC, but no nitrites or leukoesterase. Blood culture, urine
culture, and CSF culture sent. Vent settings 600 x 14 with FiO2
50% and PEEP 5.
.
Of note, pt recently hospitalized at OSH from [**8-31**] - [**9-4**] for
altered mental status and was found to have SBP with 1070 WBCs.
Pt signed out AMA but was given prescription for Vantin 200 mg
[**Hospital1 **] for SBP.
.
ROS: Unable to ascertain due to sedated and intubated
.
Past Medical History:
Polysubstance abuse (opiate, benzodiazapine, and alcohol
dependence): recently switched from Klonopin to Ativan, which
she takes 0.5 mg TID; also took oxycodone 5 mg daily.
Cirrhosis, c/b hepatic encephalopathy, ascites, and esophageal
varices
Diabetes Mellitus, Type 1
Neuropathy
Thrombocytopenia
Depression
Anxiety
Social History:
Reportedly sober for five years. Lives in apartment for disabled
persons. Lives alone. Unemployed and on disability. Educated
through grade nine. History of cocaine use with last use in
[**5-/2102**] although tox screen was + 8/[**2102**]. Mother of 5 grown
children and grandmother to 5 grandchildren
Family History:
Father and brother with alcohol and chemical dependence.
Physical Exam:
Vitals: T: 97.6 BP: 120/89 HR: 76 RR: 20 O2Sat: 100% on vent
Wt: 70.2 kg
GEN: somnolent but responsive to loud voice, making purposeful
movements
HEENT: PERRL, anicteric, no LAD, ETT in place
CHEST: CTAB anteriorly, no w/r/r
CV: RRR, nl S1, S2, no m/r/g
ABD: distended, nontender, + fluid wave, NABS
EXT: 2+ pitting edema to knees bilaterally, no c/c
NEURO: somnolent but responds to loud voice, moving all
extremities
SKIN: no rashes noted
RECTAL: stool in vault. guiaic negative.
Pertinent Results:
[**2102-9-16**] 04:30PM BLOOD WBC-4.5 RBC-3.21* Hgb-9.5* Hct-27.8*
MCV-86 MCH-29.4 MCHC-34.0 RDW-19.8* Plt Ct-57*
[**2102-9-17**] 06:28AM BLOOD WBC-4.1 RBC-2.92* Hgb-8.9* Hct-26.1*
MCV-89 MCH-30.4 MCHC-34.0 RDW-20.4* Plt Ct-56*
[**2102-9-17**] 06:28AM BLOOD Neuts-78* Bands-6* Lymphs-7* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2102-9-16**] 04:30PM BLOOD Neuts-84* Bands-6* Lymphs-5* Monos-2
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2102-9-17**] 06:28AM BLOOD Glucose-103 UreaN-28* Creat-0.7 Na-146*
K-4.0 Cl-115* HCO3-21* AnGap-14
[**2102-9-17**] 06:28AM BLOOD ALT-24 AST-35 LD(LDH)-186 AlkPhos-78
TotBili-1.1 DirBili-0.4* IndBili-0.7
[**2102-9-16**] 04:30PM BLOOD DirBili-0.5*
[**2102-9-16**] 04:30PM BLOOD ALT-24 AST-37 LD(LDH)-206 CK(CPK)-76
AlkPhos-84 TotBili-1.7*
[**2102-9-17**] 06:28AM BLOOD Albumin-2.6* Calcium-7.5* Phos-3.4 Mg-2.0
[**2102-9-16**] 04:30PM BLOOD Iron-189*
[**2102-9-16**] 04:30PM BLOOD calTIBC-256* Ferritn-63 TRF-197*
[**2102-9-16**] 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2102-9-16**] 10:43PM BLOOD Type-ART Rates-/11 Tidal V-618 PEEP-5
FiO2-40 pO2-162* pCO2-32* pH-7.48* calTCO2-25 Base XS-1
Intubat-INTUBATED Vent-SPONTANEOU Comment-PS-8
[**2102-9-16**] 10:43PM BLOOD Lactate-1.3
[**2102-9-16**] 04:35PM BLOOD Glucose-80 Lactate-1.6 K-3.5
.
CXR [**2103-9-16**]: The tip of the ET tube is approximately 27 mm from
the carina. The tip of the NG tube is not visualized, although
the NG tube follows an intra- abdominal course suggestive of
placement in the stomach. There is diffuse increased density
over the right hemithorax, due to a posteriorly placed large
pleural effusion. The left lung is clear.
.
CXR [**2102-9-17**]: Comparison is made with prior study performed the
day earlier. Opacification of the right hemidiaphragm is due to
large layering pleural effusion, unchanged from prior study and
associated with atelectasis. Cardiomediastinal silhouette is
unchanged. ET tube tip is 2.8 cm above the carina. NG tube tip
is out of view below the diaphragm. The left lung is grossly
clear.
Brief Hospital Course:
52 y.o. F with h/o polysubstance abuse, including alcohol and
benzodiazapines, and cirrhosis c/b encephalopathy, presenting to
[**Hospital1 18**] from OSH after being found unresponsive with altered
mental status the morning of admission.
.
# Altered mental status: Patient arrived in the ICU intubated
but responding to painful stimuli. CT head in the ED showed no
acute pathology. Meningitis or SBP were intial concerns, but LP
done in the ED was unremarkable, and diagnostic paracentesis
showed only 93 WBC. The patient remained afebrile and without
leukocytosis. Given her history of polysubstance abuse and her
positive urine drug screen (benzodiazepines) one concern was for
benzodiazepine toxicity however she was given Ativan at her
previous facility and this, hepatic encephalopathy was thought
to be more likely. Cefepime/vancomycin for empiric coverage of
SBP, q2 hour neuro checks overnight and monitored her vital
signs closely. She became progressively more responsive
overnight and was successfully extubated in the morning. Her
mental status returned to baseline and she did not require
oxygen to keep 02 sat>95%. EKG did not show any increased QT,
she remained afebrile and her WBC count stayed low. She started
tolerating POs and was given lactulose and her other po
medications. She had a good mental status throughout the rest of
her admission.
# Cirrhosis: Likely secondary to alcohol history, although
unable to ascertain as no records at [**Hospital1 18**]. INR and bili
elevated, but trended down overnight. We monitored daily LFTs
and coags, continued lactulose TID when taking PO, and continued
nadalol. aldactone and lasix. She had a foley placed to monitor
I&O and weighed her daily. She also underwent a therapeutic
paracentesis during this hospital stay.
# Diabetes: While the patient was ventilated, we put her on
SSI, but changed her to NPH once taking PO.
.
# Anemia: Her HCT was 27.6 on arrival, and trended down to 23.9
after multiple fluid boluses. She appears to have chronic
anemia, and no overt signs of bleeding (guaiac negative stool).
Hct remained stable.
.
# Thrombocytopenia: Her Platelet count was in the 50s, likely
[**2-25**] liver disease and possibly marrow suppression from alcohol.
No evidence of bleeding. We held heparin and checked platelet
counts daily.
.
# Polysubstance abuse: Pt was section 35'd in inpatient
detoxification facility prior to coming to [**Hospital1 18**]. Serum and
urine tox only notable for benzodiazapines. We consulted SW and
talked to her rehab facility. Apparently she has been off her
benzodiazepine taper since [**9-14**] and was not noted to ingest any
substance there. She was put on a CIWA scale here, but did not
need it. The sectioned 35 was revoked by the rehabilitation
facilty with paper documentation provided to our hospital.
Medications on Admission:
Nadolol 20 mg daily
Aldactone 25 mg [**Hospital1 **]
Vitamin K 50 mg daily
Protonix 40 mg daily
Lasix 40 mg daily
Folic Acid 1 mg daily
Ferrous sulfate 325 mg [**Hospital1 **]
Lantus 40 units SC qhs
Humalin R sliding scale
Benadryl 50 mg qhs prn
Prozac 10 mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1)
PO BID (2 times a day).
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc
Discharge Diagnosis:
1) hepatic encephalopahy
2) Cirrhosis
3) Ascites
Discharge Condition:
Stable
Discharge Instructions:
Please return to the emergency room should you develop a change
in mental status, shortness or breath, fever, or abdominal pain
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2102-10-17**] 2:50
|
[
"5119",
"4019",
"2859"
] |
Admission Date: [**2111-9-9**] Discharge Date: [**2111-9-22**]
Date of Birth: [**2065-9-12**] Sex: M
Service: Neurosurgery
HISTORY: The patient is a 45-year-old gentleman with severe
headache, nausea, and vomiting, while at work on [**2111-9-9**].
Paramedics were called. The patient had a systolic blood
pressure of over 300. He was transferred to [**Hospital1 346**]. He had no complaints of trauma,
loss of consciousness, diplopia, blurry vision, or weakness.
PAST MEDICAL HISTORY: History includes hypertension, for
which the patient has been noncompliant with medications
times four months. The patient has had heavy alcohol use.
PAST SURGICAL HISTORY: The patient is status post a motor
vehicle accident with surgery of his abdomen.
PHYSICAL EXAMINATION: The patient was drowsy, but easily
arousable. Temperature was 95.2. Heart rate 92. Blood
pressure 249/140. Respiratory rate 18. Saturations were
98%. The patient was oriented times three. Head was
atraumatic. Pupils were 4-mm and reactive to light
bilaterally. Neck had no JVD, no lymphadenopathy. Chest was
clear to auscultation. Cardiac S1 and S2. Abdomen: Large
midline old healed incision, soft, nontender, positive bowel
sounds. Extremities: The patient was moving all four
extremities. Extremities were warm, no edema, no
discoloration, positive pulses. Neurological examination
reveals that the patient was drowsy and oriented times three.
Pupils as before. Cranial nerves III, IV and VI had right
limited gave with nystagmus on right lateral gaze. The
cranial nerves V and VII revealed no facial sensation or
motor deficit. Cranial nerves IX, X, and XII tongue midline,
no fasciculations, uvula central. Motor strength: The
patient was [**4-11**] in all muscle groups, sensation to pinprick
was equal bilaterally, reflexes 2+ throughout. Toes were
downgoing.
LABORATORY DATA: Labs reveal the white count of 10.7,
hematocrit 42.3, platelet count 161, PT 12.0, PTT 21.6, INR
1.0; sodium 141; K 2.9; 100, CO2 29; BUN 18; creatinine 1.1;
glucose 98; CPK on admission 376; MB 6; troponin was less
than .3. Head CT showed right periventricular hemorrhage
adjacent to the 4th ventricle with interventricular
hemorrhage and supratentorial hydrocephalus. Incidental note
of effusion of C2 to C3 vertebral bodies in the past. The
patient had a ventricular drain placed on [**2111-9-9**]. He was
monitored in the Surgical Intensive Care Unit and started on
Nipride and IV Labetalol to keep his systolic blood pressure
less than 140.
The patient had a repeat head CT on [**2111-9-14**], which showed
no enlargement of the ventricles with the drain being clamped
for twenty-four hours. The patient's drain was removed on
10/[**Numeric Identifier 30092**]. The patient was transferred to the regular floor
on [**2111-9-16**]. He was neurologically intact, awake, alert,
and oriented times three with no drift, moving all
extremities. EOMs were full. Smile was symmetrical. The
patient had problems with nausea and vomiting, most likely to
cerebellar bleed. The patient was started on bowel
medications. The patient had a bowel movement, but nausea
and vomiting continued, mostly likely due to cerebellar
bleeding, which would resolve with time.
The patient remained neurologically intact. He was started
on a regular diet. He was voiding spontaneously. He was
seen by the Departments of Physical Therapy and Occupational
Therapy and found to require rehabilitation prior to
discharge to home.
MEDICATIONS ON DISCHARGE:
1. Zantac 150 mg p.o.b.i.d.
2. Lopressor 150 mg p.o.t.i.d.
3. Norvasc 10 mg p.o.q.d.
4. Hydralazine 60 mg p.o.t.i.d.
5. Captopril 50 mg p.o.t.i.d.
6. Spirolactone 25 mg p.o.b.i.d.
7. Tylenol 650 p.o.q.4h.p.r.n.
8. Ativan .5 mg p.o.q.8h.p.r.n.
9. Colace 100 mg p.o.b.i.d.
10. Milk of Magnesia 15-30 mg p.o.q.h.s.p.r.n.
11. Reglan 10 mg p.o.t.i.d. with meals.
CONDITION ON DISCHARGE: The patient's condition was stable
at the time of discharge. The patient will be discharged to
rehabilitation with followup with Dr. [**Last Name (STitle) 6910**] in [**9-20**]
days.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 30093**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2111-9-22**] 10:23
T: [**2111-9-22**] 11:05
JOB#: [**Job Number 24890**]
|
[
"4019"
] |
Admission Date: [**2129-7-22**] Discharge Date: [**2129-8-3**]
Date of Birth: [**2073-2-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
acute mental status changes, fevers
Major Surgical or Invasive Procedure:
[**2129-7-26**]
1. Coronary artery bypass grafting x 2 with left internal
mammary artery to left anterior descending artery and
reverse saphenous vein graft to the obtuse marginal
artery.
2. Pericardial patch of aortomitral curtain abscesses x 2.
3. Aortic valve replacement with a 25 mm On-X mechanical
valve, serial number [**Serial Number 112311**], reference number [**Serial Number 42227**].
4. Mitral valve replacement with a 27/29 mm On-X mechanical
valve
,serial #[**Serial Number 112312**], reference number [**Serial Number **].
History of Present Illness:
Mr. [**Known lastname **] is a 56 year old man who was admitted with acute mental
status change with word finding difficulties x 2 days, fever to
103, no headache neck pain. Per patient the symptoms got worse
today when he was out in the junkyard in the heat working.
Patient thought he had heat stroke. No chest pain. Complaining
of his chronic R shoudler pain at chronic level. His head CT
and chest x-ray were negative. Patient was given vancomycin,
zosyn, ampicillin and ceftriaxone. He was noted to have
leukocytosis of 13.2, a negative urine for blood, positive
troponin of 2.9 (their upper limit neg is 0.3).
Past Medical History:
Hypertension
Social History:
No alcohol, no tobacco, currently on disability. No recent sick
contacts. [**Name (NI) **] recent travel.
Family History:
Patient claims no conditions run in family
Physical Exam:
#ADMISSION PHYSICAL EXAM:
VS T 98.2 BP 112/60 HR 86 RR 16
GEN: Alert, oriented to person place, and month/year, no acute
distress
HEENT: NCAT, MMM, EOMI, sclera anicteric, some injection of left
sclera, OP clear
NECK: supple, no LAD
PULM: Good aeration, mild expiratory wheeze
CV: S1/S2, no murmurs auscultated
ABD: soft, non-tender, distended, umbilical hernia, normoactive
bowel sounds
EXT: WWP, right arm in sling, 2+ pulses palpable bilaterally, no
c/c/e
NEURO CNs [**1-31**] intact, no Kernig or Brudzinski signs, motor
function grossly normal
SKIN: erythematous papules and tumors in area of left axilla
Pertinent Results:
[**2129-7-26**] TEE:
Pre-Bypass:
The left atrium is normal in size.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction in the inferior wall.
Right ventricular chamber size and free wall motion are normal.
The aortic root, arch, and descendcing aorta are mildly dilated.
There are simple atheroma throughout the aorta.
The aortic valve is bicuspid. There is a probable vegetation on
the aortic valve. An aortic annular abscess is seen. There is an
aoritc root abcess cavity measuring 1.1cmx0.5cm adjacent to the
anterior mitral valve leaflet.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
Post Bypass #1:
Patient is AV paced on phenylepherine infusion. Aortic
prosthesis is well seated witout paravalular leaks. Peak
gradient 20, mean 12 mm Hg. There is a [**1-23**]+ jet of eccentric MR
directed posteriorly. Jet improves to [**12-24**]+ when pacing paused
and sbp <100, but worsens to 3+ in sinus rhythm with SPB 120.
Post Bypass #2:
Patient is AV paced (later a paced) on phenylepheine infusion.
There is a mechanical posthesis in the Mitral valve position
with normal washing jets and good leaflet motion, but without
paravalular leaks. Mean gradient 5 mm Hg. Aortic valve
prosthesis unchanged. Aortic contours unchanged. LVEF preserved
and at baseline. Remaining exam unchanged. All findings
discussed with Dr. [**Last Name (STitle) **] at the time of the exam.
[**2129-8-2**] 06:26AM BLOOD WBC-11.2* RBC-2.89* Hgb-8.6* Hct-27.1*
MCV-94 MCH-29.9 MCHC-31.8 RDW-15.3 Plt Ct-326#
[**2129-8-2**] 06:26AM BLOOD PT-26.0* PTT-54.9* INR(PT)-2.5*
[**2129-8-1**] 04:20AM BLOOD PT-26.4* PTT-45.3* INR(PT)-2.5*
[**2129-7-31**] 12:07PM BLOOD PT-25.3* PTT-51.0* INR(PT)-2.4*
[**2129-8-2**] 06:26AM BLOOD Glucose-132* UreaN-36* Creat-1.7* Na-140
K-4.4 Cl-105 HCO3-27 AnGap-12
[**2129-8-1**] 04:20AM BLOOD Glucose-138* UreaN-32* Creat-1.5* Na-137
K-4.3 Cl-102 HCO3-28 AnGap-11
[**2129-7-31**] 12:06PM BLOOD UreaN-30* Creat-1.5* Na-141 K-4.3 Cl-103
Brief Hospital Course:
Mr. [**Known lastname **] is a 56 year old man with a history of hypertension who
presented to an outside hospital on [**2129-7-24**] with acute mental
status changes and fevers, transferred to [**Hospital1 18**] for further
workup. A lumbar puncture was performed which showed elevated
WBCs in the aseptic meningitis range with a monocytic
predominance, cultures negative. On admission he also had acute
kidney injury, elevated liver function tests, a troponin of 0.3
and a total creatinine kinase of [**2116**] (troponin was felt
secondary to rhabdo by cardiology). Initially he was treated as
bacterial meningitis on
vancomycin/ceftriaxone/ampicillin/acyclovir. His hospital course
was significant for MSSA bacteremia, vanc/CTX discontinued per
infectious disease, septic right shoulder s/p washout in the
operating [**2129-7-25**], also for transient diplopia likely due
to multiple septic emboli seen on MRI, diplopia now resolved.
Remained on nafcillin/acyclovir as HSV PCR. He was getting
routine EKGs daily for PR monitoring in setting of possible
endocarditis. A TEE confirmed aortic vale vegetation and aortic
root abscess. During his cardiac catheterization he developed
heart block and a temporary wire was placed. He went urgertly
to the operating room and underwent : 1)Coronary artery bypass
grafting x 2 with left internal mammary artery to left anterior
descending artery and reverse saphenous vein graft to the obtuse
marginal artery. 2)Pericardial patch of aortomitral curtain
abscesses x 2.
3) Aortic valve replacement with a 25 mm On-X mechanical valve,
serial number [**Serial Number 112311**], reference number [**Serial Number 42227**]. 4) Mitral valve
replacement with a 27/29 mm On-X mechanical valve serial
#[**Serial Number 112312**], reference number [**Serial Number **]. Please see operative note for
further details.
Overall the patient tolerated the long procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He was initally
on Neosynepherine and in AJR with occasional PAC's. This drug
was weaned off and he maintained a junctional rhythm but with
stable hemodynamics. He extubated POD#1 without difficulty. The
patient was neurologically intact. He returned to SR with
frequent PAC's, Beta blocker was started slowly on POD#3. CT and
PW were remove wihtout difficulty. He was very fluid overloaded
and was started on lasix. His creatine rose to 1.7 and diureses
was adjusted. He tranferred to the floor on POD#6. On the floor
he developed rapid afib and was started on Amiodarone. Presently
he is in rate controlled afib. He was started on anticoaulation
for double mechanical valve goal INR 3.0-3.5. He was febrile in
the post-op period and was pan cultured, all cultures returned
negative. His shoulder culture grew out MSSA and he was followed
by infectious disease, the nafacillin was continued which he
will need to remain on for total of 6 weeks from surgery. The
acyclovir was discontinued. His right shoulder wound remained
clean, dry, and intact. He developed a decubitus to coccyx/left
upper buttocks area. The patient was evaluated by the physical
therapy service for assistance with strength and mobility, he is
weak and deconditioned. By the time of discharge on POD 8 the
patient needed assistance with walking. The upper pole of his
sternum drained small amount of serosanguinous drainage and
should be painted daily with betadine until resolved. His pain
is controlled with oral analgesics. The patient was discharged
to North Eastern [**Hospital1 **] in [**Location (un) 701**] in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Lisinopril Dose is Unknown PO DAILY
Discharge Medications:
1. Furosemide 40 mg PO BID Duration: 2 Weeks
titrate per creatinine and toward goal pre-op weight of 147kgs
2. Potassium Chloride 40 mEq PO DAILY Duration: 2 Weeks
Hold for K >4.5, titrate per lasix dose
3. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
4. Aluminum Hydroxide Suspension [**3-31**] mL PO Q4H:PRN heartburn
5. Amiodarone 400 mg PO DAILY
take 400mg daily for one week, then decrease to 200mg daily
ongoing
6. Aspirin EC 81 mg PO DAILY
if extubated
7. Calcium Carbonate 500 mg PO QID:PRN indigestion
8. Docusate Sodium 100 mg PO BID
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
11. Nafcillin 2 g IV Q4H
12. Oxycodone-Acetaminophen (5mg-325mg) [**11-22**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**11-22**] tablet(s) by mouth
every four hours Disp #*40 Tablet Refills:*0
13. Pantoprazole 40 mg PO Q12H
14. Senna 2 TAB PO BID
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
16. Warfarin MD to order daily dose PO DAILY
for double mechanical valves
17. Warfarin 10 mg PO ONCE Duration: 1 Doses
titrate for goal INR of [**1-22**].5 for double mechanical valves
18. Simvastatin 10 mg PO DAILY
19. Metoprolol Tartrate 75 mg PO TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Endocarditis
Aorto-mitral curtain abscess
Coronary Artery Disease
Hypertension
Sebaceous cysts
hernia umbilical
Past Surgical History:
Right shoulder w/ rotator cuff tear s/p repair 4years ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - superior pole with serosanguinous drainage,
no erythema
Edema 2+
Discharge Instructions:
While on Nafcillin will need weekly CBC, BUN/Cre
Place mepilex to ulcer at coccyx. Frequent turning.
Paint sternal incision daily with betadine until sternal
drainage abates
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**8-11**] 10:30 [**Telephone/Fax (1) 170**]
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**9-8**] 1PM [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] (orthopedics for shoulder) [**8-23**] 2:45 ([**Telephone/Fax (1) 112313**]
Please call to schedule the following:
Wound check [**2129-8-11**] at 10:00am
Cardiologist: Dr [**Last Name (STitle) **] in 3 weeks (office will call patient)
Primary Care in [**2-24**] weeks
Infectious Disease: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-8-16**] 10:45
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for double mechanical valves
Goal INR 3-3.5
First draw day after discharge
Then please do daily INR checks until INR stabilized and then
decrease as directed by rehab
On discharge from rehab, please arrange INR follow-up with
primary care physician or cardiologist
Completed by:[**2129-8-3**]
|
[
"5849",
"2875",
"42731",
"4019",
"41401",
"2720",
"2859",
"4240"
] |
Admission Date: [**2174-2-4**] Discharge Date: [**2174-2-17**]
Date of Birth: [**2129-4-22**] Sex: F
Service: NEUROSURGERY
Allergies:
Erythromycin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
[**2-5**]: Diagnostic angiogram and coil embolization of PCOM
aneurysm
History of Present Illness:
44 yo female w/ no significant PMHx who was taking a shower
two weeks ago and developed an acute onset 10 out of 10 headache
at the back of her head that traveled forward. She went to the
bedroom and laid down. She noted that the pain was worse and
throbbing when she stood up. The patient was bedridden for a
week managing her symptoms. She saw a chiropractic who
performed neck manipulation. She felt slightly better. Today
she had a massage and her head "exploded" again. Massage
therapist called
an ambulance and pt brought to [**Hospital3 **] where CT head
showed SAH. She was then transferred to [**Hospital1 18**] for further
management.
Past Medical History:
previous ruptured pcomm aneurysm
Social History:
Married, resides at home. Jehovah's wittness.
Family History:
non-contributory
Physical Exam:
Exam on Admission:
Vitals: T 98.1; BP 118/76; P 84; RR 16; O2 sat
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: + meningismus
Extremities: no c/c/e.
Neurological Exam:
Mental status: awake, alert, attentive. Fluent speech with no
paraphasic or phonemic errors. Adequate comprehension. Follows
simple and multi-step commands.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**3-30**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift. Full
strength.
Sensation: intact to light touch.
Reflexes: 2+ symmetric
Exam on Discharge:
As above. Neurologically Intact
Pertinent Results:
Labs on Admission:
[**2174-2-4**] 07:57PM [**Year/Month/Day 3143**] WBC-11.9* RBC-4.59 Hgb-14.2 Hct-40.4
MCV-88 MCH-
Labs on Discharge:
COMPLETE [**Year/Month/Day 3143**] COUNT WBC RBC Hgb Hct MCV MCH M CHC RDW Plt
Ct
[**2174-2-17**] 04:30AM 6.8 4.24 13.5 39.9 94 31.8 33.9 13.2 405
------------------
IMAGING:
------------------
CTA Head [**2-4**]:
CT angiography of the head demonstrates approximately 6 mm right
posterior
communicating artery aneurysm extending posteriorly and having a
bilobed
appearance. No other distinct aneurysms are identified. There is
no vascular occlusion or stenosis seen.
IMPRESSION: 6 to 7 mm right posterior communicating artery
aneurysm with
bilobed appearance pointing posteriorly. No other aneurysms
seen. No
vascular occlusion or stenosis identified.
IMPRESSION:
1. Subarachnoid hemorrhage.
2. Right posterior communicating artery aneurysm measuring 6 mm.
No
vascular occlusion or stenosis seen.
[**Known lastname 86671**],[**Known firstname **] [**Medical Record Number 86672**] F 44 [**2129-4-22**]
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2174-2-14**] 1:11 PM
Final Report
INDICATION: 44-year-old woman with subarachnoid hemorrhage,
status post
aneurysm coiling and subsequent vasospasm. Please perform CT
perfusion to
evaluate for vasospasm.
TECHNIQUE: Contiguous axial images were obtained through the
brain without
contrast material. Subsequently, axial perfusion CT images were
obtained
during infusion of Omnipaque IV contrast. Sequentially, rapid
axial imaging was performed through the brain during infusion of
Omnipaque intravenous contrast. Images were processed on a
separate workstation with display of mean transit time, relative
cerebral [**Name2 (NI) **] volume, and relative cerebral [**Name2 (NI) **] flow maps for
the CT perfusion study and maximum intensity projection images
for the CTA maps.
COMPARISON: CTA of the head from [**2174-2-11**], CT of the head
from [**2-5**], [**2173**]. Angiogram of the head from [**2174-2-5**] and CTA of
the head from [**2174-2-4**].
FINDINGS:
CT OF THE HEAD: Compared to the prior studies, there is almost
complete
resolution of the subarachnoid hemorrhage. There is unchanged
hypodensity in the left basal ganglia, likely representing
prominent Virchow-[**Doctor First Name **] space or old lacunar infarct.
CTA OF THE HEAD: Again seen are high-attenuation artifats
secondary to
coiling of a left PCOM aneurysm. The previously described
vasospasm of the M1 segment of the right MCA has resolved with a
normal caliber of the right MCA. The left middle cerebral
artery, anterior cerebral arteries, and bilateral posterior
cerebral arteries are normal without evidence of vascular
abnormalities.
CT PERFUSION: Mean transit time, cerebral [**Doctor First Name **] volume and
cerebral [**Doctor First Name **]
flow images are normal.
CONCLUSION:
1. The CT perfusion maps are normal without evidence of delayed
transit time, reduced [**Doctor First Name **] flow or [**Doctor First Name **] volume.
2. The CTA images of the head demonstrate resolution of the
right M1 MCA
vasospasm.
3. Compared to prior studies, the subarachnoid hemorrhage has
almost
completely resolved.
4. Unchanged left basal ganglia hypodensity, likely representing
a prominent Virchow-[**Doctor First Name **] space or old lacunar infarct.
_____________________________________________
Final Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: 44-year-old female with history of
subarachnoid
hemorrhage.
COMPARISON: None.
FINDINGS: PA and lateral views of the chest are obtained. The
lungs are
clear without focal consolidation. No pleural effusion or
evidence of
pneumothorax is seen. The cardiac and mediastinal silhouettes
are
unremarkable.
IMPRESSION: No acute cardiopulmonary process.
_______________________________________________________________
[**Known lastname 86671**],[**Known firstname **] [**Medical Record Number 86672**] F 44 [**2129-4-22**]
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2174-2-11**] 4:41 PM
Final Report
EXAM: CTA of the head.
CLINICAL INFORMATION: Patient with subarachnoid hemorrhage and
status post
PCom aneurysm coiling, for further evaluation to exclude
vasospasm.
TECHNIQUE: Axial images of the head were obtained without
contrast.
Following this using departmental protocol, CT angiography of
the head was
acquired. Comparison was made with the previous CTA examination
of [**2174-2-4**].
FINDINGS: Since the previous MRI examination, the patient has
undergone
coiling of the aneurysm in the region of right posterior
communicating artery. Artifacts are seen in this region which
limits the evaluation of surrounding vascular structures. There
is now mild-to-moderate right-sided middle cerebral artery
vasospasm identified without occlusion or obliteration of the
lumen of the artery. The vascular structures in both sylvian
regions are well maintained. The left middle cerebral artery and
the anterior cerebral arteries as well as the posterior
circulation arteries are well maintained without vasospasm.
The CT head obtained before contrast demonstrate interval
decrease in
subarachnoid hemorrhage. The ventricular size has also slightly
decreased. Prominent perivascular space is again identified.
IMPRESSION:
1. Head CT shows interval decrease in subarachnoid [**Year (4 digits) **]. A coil
artifact is seen in the right paraclinoid region.
2. CT angiography of the head demonstrates interval coiling of
the aneurysm. The area of the aneurysm coiling is obscured by
surrounding streak artifacts.
3. Mild-to-moderate right middle cerebral artery M1 segment
vasospasm is
identified which appears nonocclusive. The remaining vascular
structures are well maintained.
_
_
_
________________________________________________________________
[**Known lastname 86671**],[**Known firstname **] [**Medical Record Number 86672**] F 44 [**2129-4-22**]
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2174-2-14**] 1:11 PM
Final Report
INDICATION: 44-year-old woman with subarachnoid hemorrhage,
status post
aneurysm coiling and subsequent vasospasm. Please perform CT
perfusion to
evaluate for vasospasm.
TECHNIQUE: Contiguous axial images were obtained through the
brain without
contrast material. Subsequently, axial perfusion CT images were
obtained
during infusion of Omnipaque IV contrast. Sequentially, rapid
axial imaging was performed through the brain during infusion of
Omnipaque intravenous contrast. Images were processed on a
separate workstation with display of mean transit time, relative
cerebral [**Name2 (NI) **] volume, and relative cerebral [**Name2 (NI) **] flow maps for
the CT perfusion study and maximum intensity projection images
for the CTA maps.
COMPARISON: CTA of the head from [**2174-2-11**], CT of the head
from [**2-5**], [**2173**]. Angiogram of the head from [**2174-2-5**] and CTA of
the head from [**2174-2-4**].
FINDINGS:
CT OF THE HEAD: Compared to the prior studies, there is almost
complete
resolution of the subarachnoid hemorrhage. There is unchanged
hypodensity in the left basal ganglia, likely representing
prominent Virchow-[**Doctor First Name **] space or old lacunar infarct.
CTA OF THE HEAD: Again seen are high-attenuation artifats
secondary to
coiling of a left PCOM aneurysm. The previously described
vasospasm of the M1 segment of the right MCA has resolved with a
normal caliber of the right MCA. The left middle cerebral
artery, anterior cerebral arteries, and bilateral posterior
cerebral arteries are normal without evidence of vascular
abnormalities.
CT PERFUSION: Mean transit time, cerebral [**Doctor First Name **] volume and
cerebral [**Doctor First Name **]
flow images are normal.
CONCLUSION:
1. The CT perfusion maps are normal without evidence of delayed
transit time,
reduced [**Doctor First Name **] flow or [**Doctor First Name **] volume.
2. The CTA images of the head demonstrate resolution of the
right M1 MCA
vasospasm.
3. Compared to prior studies, the subarachnoid hemorrhage has
almost
completely resolved.
4. Unchanged left basal ganglia hypodensity, likely representing
a prominent
Virchow-[**Doctor First Name **] space or old lacunar infarct.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
On [**2174-2-4**] Patient presented to [**Hospital3 **] for what she
described as an explosion in her head while receiving a massage.
A Head CT was done and it was found that she had a SAH. She
was then transferred to [**Hospital1 18**] for further management. On exam
at [**Hospital1 18**] she had no neurological deficits and after repeating a
scan and obtaining a CTA it was determined she likely had an
aneurysm 2 weeks prior and had rebled. She was admitted and on
[**2-5**] she underwent cerebral angiogram for diagostics and was
found to have a posterior communicating artery aneurysm which
was coiled. At post-angio check on the 13th she had severe
headache. a CT Head was obtained which was stable. On the
morning of [**2-7**] it was noted that following the removal of her
arterial line she complained of some numbness and tingling in
her left hand. anesthesia saw her and reported that this is
most likely temporary and is related to irriation of the radial
nerve due to the insertion of the arterial line. She remained
stable in the ICU on spasm watch as of [**2174-2-8**]. She continued to
complain of a slight headache while in the ICU but as of [**2-11**]
her exam remained nonfocal. CTA showed vasospasm in R MCA and
ACA, but patient remained nonfocal. Her [**Date Range **] pressure
parameters were increased to 16-200 and she was to remain in the
ICU.
Her repeat imaging was without vasospasm. Her HHH therapy was
backed off and she remained stable. She was transfered to the
floor. She has been ambulating independantly and will be
discharged home on Nimodipine to complete a 21 day course.
Medications on Admission:
Vitamin D
Discharge Medications:
1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 10 days.
Disp:*120 Capsule(s)* Refills:*0*
2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-27**]
Tablets PO Q4H (every 4 hours) as needed for headach.
Disp:*50 Tablet(s)* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Atraumatic SAH
PCOM aneurysm
cerebral vasospasm
Discharge Condition:
Neurologically Stable
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
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 call [**Telephone/Fax (1) **] for an appointment to be seen by Dr
[**First Name (STitle) **] in 4 weeks. You will need a MRI/MRA at that time, 'per
[**Doctor Last Name **] Protocol'. You will need an Angiogram in 3 months
******* you will need to continue to take Nimodipine for aprox.
10 days from the date of your discharge, when you run out of the
perscription is the end of your treatment with this medication.
Completed by:[**2174-2-17**]
|
[
"5990"
] |
Admission Date: [**2166-12-24**] Discharge Date: [**2167-1-9**]
Date of Birth: [**2086-4-16**] Sex: F
Service: SURGERY
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
GENERAL SURGERY: [**2167-1-4**]
1. Inferior vena cava filter
2. Exploratory laparotomy with extensive enterolysis
3. Drainage of retroperitoneal hematoma.
4. Hartmann resection of the sigmoid colon with end-descending
colostomy and Hartmann pouch.
VASCULAR SURGERY: [**2167-1-5**]
Axillary-bifemoral graft
History of Present Illness:
80F s/p multiple endovascular procedures at OSH complicated by
retroperitoneal hematoma, transferred for additional care, now
with persistent abdominal distension. Patient was transferred on
[**2165-12-24**] after prolonged course at OSH requiring multiple
endovascular and open surgical procedures for left common iliac
aneurysm and associated complications of retroperitoneal
hematoma and femoral embolus. During this course, patient had
intermittent episodes of abdominal pain and nausea, but not very
bothersome. Patient reports that prior to her surgeries, she
visited the ER several times for abdominal pain and nausea, with
occasional vomiting of bilious fluid. She has never required NG
decompression for management of these episodes. During her
current admission, CT scan performed to evaluate her hematoma
and surgical sites revealed significant small bowel dilation.
Her abdomen was noted to be distended, however she was not
nauseated or in pain. A concurrent work up for possible
periampullary mass prompted NGT placement for decompression and
subsequent ERCP. However, since placement on [**2165-12-25**], the patient
has had persistently high bilious NG output, averaging
approximately a liter daily. She remains without abdominal pain.
She has not had a bowel movement in at least 5 days and starting
passing a very small amount of flatus today. She has been NPO
and on TPN. She denies recent constipation, change in stool
caliber, melena, and
malaise. She had a normal colonscopy 5 years ago. She feels
weakened and depressed by her prolonged course.
Past Medical History:
Afib, hydronephrosis, diastolic CHF, L common iliac aneurysm,
HTN, hyperlipidemia, GERD, breast cancer s/p mastectomy, chronic
nausea and bloating
Social History:
Minimal alcohol use. Denies smoking tobacco. Main support are
son and daughter who is a pediatric neurologist
Family History:
Mother - pancreatic cancer at 67yrs, Brother - gall bladder
cancer at 62 years
Physical Exam:
Expired
Pertinent Results:
[**2167-1-8**] 01:53PM BLOOD WBC-16.7* RBC-3.93* Hgb-11.9* Hct-33.2*
MCV-84 MCH-30.2 MCHC-35.8* RDW-16.7* Plt Ct-28*
[**2167-1-8**] 01:53PM BLOOD Plt Smr-VERY LOW Plt Ct-28*
[**2167-1-8**] 09:34AM BLOOD PT-23.7* PTT->150* INR(PT)-2.3*
[**2167-1-8**] 01:53PM BLOOD Glucose-69* UreaN-32* Creat-0.9 Na-138
K-4.3 Cl-108 HCO3-19* AnGap-15
[**2167-1-8**] 02:52AM BLOOD ALT-76* AST-202* LD(LDH)-1414*
AlkPhos-141* TotBili-10.2* DirBili-6.5* IndBili-3.7
[**2167-1-6**] 10:42AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.019
[**2167-1-6**] 10:42AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-TR Ketone-TR Bilirub-SM Urobiln-NEG pH-6.5 Leuks-LG
[**2167-1-6**] 10:42AM URINE RBC->182* WBC->182* Bacteri-MOD
Yeast-NONE Epi-0 TransE-7
Brief Hospital Course:
Mrs. [**Known lastname 84273**] is an 80-year old female transferred from an OSH
after multiple endovascular procedures for left common iliac
aneurysm and associated complications of retroperitoneal
hematoma complicated by retroperitoneal hematoma and femoral
embolus, transferred for additional care.
Patient had a prolonged ileus and intestinal, colonic and left
ureteral compression by the hematoma, finally requiring an
exploratory laparotomy with Hartmann's procedure.
On POD1 patient had acute ischemia to bilateral lower
extremities and CTA showing occlusion of the aortobifem graft,
needing to go emergently to the OR for ax-bifem
bypass graft to revascularize the lower extremities.
Postoperatively patient did poorly with persistent pressor
requirements, progressive renal failure, liver failure and
possibly a spinal cord infarct not able to move the lower
extremities.
On POD 3 from the last operation patient was not making
substancial improvements and given the multiorgan failure and
poor overall prognosis, the family decided to make her CMO.
Patient was extubated on [**2167-1-8**] in the afternoon and died about
12 hours later on [**2167-1-9**] at 02:25 am. Report of death was
completed.
Patient's family (daughter) were at the bedside and notified.
The admitting office was notified and no need for a Medical
Examiner call was necessary.
The family did not ask for an autopsy.
Medications on Admission:
MiraLax, Fragmin 10,000 units daily for 10 days, Cardizem CD 240
daily, lisinopril 20 daily, Coumadin 5 daily, furosemide 40
daily, digoxin 125 MWF, atenolol 50 daily, omeprazole 20 daily,
Ascriptin 325 daily while Coumadin and Fragmin on hold
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2167-1-14**]
|
[
"53081",
"4280",
"0389",
"99592",
"2761",
"2762",
"5849",
"2767",
"2724",
"42731",
"V5861",
"4019"
] |
Admission Date: [**2146-4-22**] Discharge Date: [**2146-4-26**]
Date of Birth: [**2101-11-17**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 44-year-old gentleman
who has a 3-month to 4-month history of exertional angina
described as chest tightness with tingling in both of his
forearms and wrists. The patient underwent a stress test in
[**2146-3-10**] which was positive, and he was referred for
cardiac catheterization.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Positive tobacco (half a pack per day).
3. Idiopathic thrombocytopenia purpura.
4. Status post appendectomy.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS ON ADMISSION: Lipitor 20 mg by
mouth once per day.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was taken to
the Cardiac Catheterization Laboratory on [**2146-4-11**]. In
the Laboratory, the patient was found to have an ejection
fraction of 52 percent, 60 percent left main ostial lesion,
80 percent proximal left anterior descending lesion, 100
percent left circumflex lesion, with normal left ventricular
filling pressures.
The patient was referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for coronary
artery bypass grafting. The patient returned to [**Hospital1 346**] on [**2146-4-22**] for coronary artery
bypass grafting times three with left internal mammary artery
to left anterior descending, saphenous vein graft to obtuse
marginal, and saphenous vein graft to diagonal. Total
cardiopulmonary bypass time of 64 minutes and a cross-clamp
time of 49 minutes. Please see the Operative Note for full
details.
The patient was transferred to the Intensive Care Unit in
stable condition. The patient was weaned an extubated from
mechanical ventilation on his first postoperative day
DICTATION ENDED
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], MD 2229
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2146-4-26**] 11:18:51
T: [**2146-4-26**] 15:05:31
Job#: [**Job Number 55982**]
|
[
"41401",
"2720"
] |
Admission Date: [**2178-1-23**] Discharge Date: [**2178-1-29**]
Date of Birth: [**2119-1-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hepatocellular carcinoma and
hepatitis B virus infection.
Major Surgical or Invasive Procedure:
[**2178-1-29**] Ultrasound-guided placement of right pleural
pigtail catheter.
[**2178-1-23**] Right hepatic trisegmentectomy,
cholecystectomy, intraoperative ultrasound surgery. Resection
of segment III nodule.
History of Present Illness:
The patient is a 58-year-old Chinese male with a history of HBV
infection who
developed abdominal pain and an ultrasound that demonstrated a
10.5-cm mass in the right lobe of the liver. He subsequently
underwent a CT scan of the chest, abdomen and pelvis. The chest
CT demonstrated no evidence of pulmonary
metastases. The abdominal CT demonstrated a mass in segment A of
the liver that extends inferiorly into segment B measuring 10.6
x 9.3 cm. The mass appears to compress and possibly invade the
medial segment of the left lobe with the mass
being abutting the middle hepatic vein. There is also a
compression of the right main portal vein. There are satellite
nodules in the right lobe that measured 12 mm in diameter and
lie close to the surface. He does appear to have cirrhosis based
on the nodularity of the liver. He had no evidence of
portal hypertension. His HBV viral load preoperatively was
104,000 international units/milliliter. His alpha-fetoprotein
was 19.6. He underwent preoperative right portal vein
embolization with hypertrophy of the left lateral segment in
preparation for right trisegmentectomy.
Past Medical History:
HBV, HCC, Thrombosis of R Portal Vein
Social History:
Speaks Mandarin. Single, has 1 brother. Worked as a chef in
Chinese restraurant, but unable to work due to pain/nausea from
liver mass.
Habits: denies etoh, smoking, and recreational drugs
(cocaine/pot/heroin).
Family History:
Father colon ca
Brother died 60 unknown cancer
Physical Exam:
Pre operative
T 97.4 HR 94 Bp 125/84 Wght 50.2 KG
On physical exam he is an alert male in no acute distress.
HEENT: No scleral icterus.
His abdomen is benign. No
tenderness or abdominal distention.
Pertinent Results:
[**1-23**] Ct scan: Huge multilobulated right lobe hepatic mass as
described, status post right portal vein embolization. Small
similar-appearing segment III nodule was wedge resected after
ultrasound localization
[**2178-1-24**] Ct scan: 1. No intrahepatic biliary ductal dilation.
Normal flow within the left portal vein, left hepatic artery,
left hepatic vein, and IVC. 2. Moderate-sized right pleural
effusion. 3. Status post right hepatectomy.
[**1-29**] Ct Abd:1. No evidence of PE. 2. Bilateral moderate-to-large
pleural effusions with compressive atelectasis, right greater
than left.
3. Status post liver resection for HCC with low density fluid in
the surgical bed and percutaneous drain in place. 4. Two
subcentimeter liver hypodensities are too small to fully
characterize. 5. Anasarca.
1/28Echo:
PRE-CARDIAC ARREST: Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
severe global left ventricular hypokinesis (LVEF = [**10-21**] %).
Right ventricular chamber size is normal. with severe global
free wall hypokinesis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
POST RESUSCITATION FROM CARDIAC ARREST (on epinephrine
infusion): Left ventricular ejection fraction is now increased
to approximately 50 percent. Right ventricular contractile
function is also improved. Both ventricles are less dilated.
[**1-29**] CXR 10 am: interval increase in right pleural effusion and
potential
left pleural effusion with subsequent worsening of the right
lung aeration
[**1-29**] CXR: Improved aeration in right middle and right lower lobe
following reduction in size of pleural effusion. Post-operative
changes in the abdomen are again demonstrated as well as slight
worsening of gastric distention.
[**1-29**] CXR: IMPRESSION: Relatively rapidly reoccurring of pleural
effusion during last one hour examination interval. No
pneumothorax has developed. Findings explained by bilateral
pleural effusions rather than pulmonary edema.
Brief Hospital Course:
[**1-23**] PT admitted post operatively to the transplant service s/p
uncomplicated Right trisegmentectomy, CCY, excision of segment
III nodule with EBL of 700 CC. Post op patient's pain was
controlled with PCA. Patient was tachycardic in the PACU and
transfused 2 units PRBC.
[**1-24**] Lfts stable, post operative ultrasound without evidence of
biliary dilatations . 500 cc bolus x3 for low UOP.
[**1-25**] patient advanced to sips/ Epidural was capped. Vitamin K
given for INR 1.6.
[**1-26**] Diet was advanced to clears to regular diet with return of
bowel function. Epidural removed. Dilaudid for pain control.
[**1-27**] Low uop 18 cc/hr. Albumin replacement of increased JP
output and 1cc/cc replacement of UOP with resolve.
[**1-28**] Patient tachycardic to 160-170s. CTA to ro PE showed no
evidence of clot, but large right pleural effusion. Abdominal CT
showed ascites but no discrete fluid collections. CE negative.
Pain in RUQ requiring Dilaudid prn. ABG 7.32/37/70/20/-6. CXR
with increased RLL collapse. Patient remained persistently
tachycardic 120s with metoprolol and pain control but continued
to have oxygen saturations 96% on 4 L. [**1-29**] Morning pt became
increasingly tachycardic to 150s-170s w/o difficulty breathing
with decreased oxygen sats to the 80s on 6L. Pt was taken
urgently to the chest disease center for R thoracentesis. There
he desaturated w/ any movement and was started on a high flow
face mask. An 8fr pigtail was placed and drained 1L serous
fluid immediately when left to gravity. During the procedure
patient became hypotensive to 78 systolic. Blood pressure
increased to 80-90s with IVF. Upon completion of procedure
patient was brought urgently to the SICU. Arterial line placed
with ABG 7.21/32/63/ 13/-14. He was electively intubated by the
sicu staff. Despite IVF boluses he continued to be hypotensive
. A RIJ swan was placed with an initial [**Location (un) 1131**] 37/17 Co 4.31
CVP 8. VS at this time Temp 98.8 HR 129 BP 64/43 17 100Vent.
Vasopressin and Levophed started. IVF and albumin boluses.
IVF and albumin given. Neo added, all pressors maximal with
bradycardia to 50s then went PEA. CPR and ACLS initiated for 90
minutes. HR and pulse did return but patient continued to
require maximal doses of pressors. Pt also had massive
pulmonary edema with roughly 500 cc of serous fluid continuously
being suctioned from ETT. Epinephrine boluses started.
Persistent acidosis, hypoglycemia, hypotension, despite maximal
medication administration. Hypotensive again to the 50s with
loss of pulse, the decision was made that further efforts would
be futile. Pressors were stopped, morphine given to make
patient comfortable. Ventilator support stopped with all meds
withdrawn. Pt became asystolic at 16.25 and patient was
pronounced dead.
Medications on Admission:
Viread 300 [**Doctor Last Name **].o. daily.
percocet 1 prn q4h
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Hepatocellular carcinoma
Hepatitis B
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2178-1-30**]
|
[
"0389",
"5119"
] |
Admission Date: [**2166-8-24**] Discharge Date: [**2166-8-27**]
Date of Birth: [**2105-10-10**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Cough, Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 year old Male with PMHx of HIV on HAART (last CD4 of 175),
chronic Hepatits C, COPD, Benign Hypertension, CKD stage 4
recently weaned from HD who presents with acute on chronic
dyspnea and hemoptysis. Pt reported significant worsening in his
DOE over the 72 hours prior to admssion, much worsened over the
24hrs prior to admission, he began producing bloody sputum,
initially blood streaked and then fully bloody and that
continued intermittently throughout the day. He presented to the
ER today for further work up.
In the ED, initial vs were: T 98.6 P 110 BP 100/66 R 22 O2 sats
85% on 4L NC. The patient was placed on TB precautions as he has
AIDS and underwent CXR which revealed RML ground glass
opacities. Pt was given Ceftriaxone, Levofloxacin, Vancomycin,
Methylprednisolone 125mg IV, nebs and ordered for po Bactrim BS.
On arrival to the [**Name (NI) 153**], pt was comfortable and sating well on 4L
NC. He reports significant DOE but denies SOB at rest. He was
able to produce some bloody induced sputum but there was no
frank hemoptysis. He denied any fevers, chills, weight loss,
rash, travel exposures or diarrhea. Pt reports recent weight
gain and denies any changes in bowel or bladder habits. He was
stabilized and without massive hemoptysis was transferred to the
floor for further management.
Past Medical History:
1) HIV dx in [**2153**]. Most recent CL [**2166-2-6**] nondetectable, with
decreasing CD4 count since he was taken off ARV most recent
[**2166-4-1**] 132 (acute illness), [**2166-3-18**] 137 (acute illness), [**2166-2-6**]
261. Home ARV regimen was discontinued on [**2166-2-24**]: Atazanavir
300mg Qdaily, Ritonovir 100mg Qdaily, Truvada 1 tab qdaily, and
bactrim ppx. No hx of OI.
2) Hep C dx in [**2153**]. Most recent bx [**11-21**] with no cirrhosis,
grade 1. No hx of treatment.
3) COPD
4) GI bleed/ shock [**9-22**]
Workup notable for CMV esophogitis s/p valganciclovir, Cdiff
positive s/p po vancomycin.
5) Blindness R eye since [**2152**], unclear etiology
6) HTN
7) Polysubstance abuse
8) Diverticulitis s/p resection [**2150**]
9) Hypoplastic L kidney
10) CRF with concern for medication induced AIN/ATN as noted
above
11) Tobacco Abuse
Social History:
The patient is a widower, he currently lives in [**Hospital1 392**] with his
sister. [**Name (NI) **] reports he has a daughter and 2 cats The patient was
previously employed as a bricklayer, now unable to work. The
patient reports his Sister [**Name (NI) **] [**Name (NI) **] to be his HCP
[**Name (NI) 1139**]: 2 PPD
ETOH: Reports prior heavy use, none current
Illicits: History if IV Heroin and Cocaine, last documented use
[**2153**]
Family History:
Mother: [**Name (NI) **] CA
Father: CAD
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: + Dyspnea, + Cough, + Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 96.4, 130/76, 95, 20, 92%RA
GEN: NAD, cachectic
HEENT: R eye patch, MMM, - OP Lesions, bitemporal wasting
PUL: Wheezes have resolved, occaisional rhonchi clear with cough
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Pertinent Results:
[**2166-8-27**] 06:45AM BLOOD WBC-14.1* RBC-3.82* Hgb-12.0* Hct-38.9*
MCV-102* MCH-31.3 MCHC-30.8* RDW-14.0 Plt Ct-134*
[**2166-8-26**] 06:40AM BLOOD WBC-12.3* RBC-3.43* Hgb-10.9* Hct-33.8*
MCV-99* MCH-31.8 MCHC-32.3 RDW-14.1 Plt Ct-97*#
[**2166-8-25**] 10:33AM BLOOD WBC-18.0* RBC-3.62* Hgb-11.4* Hct-35.8*
MCV-99* MCH-31.5 MCHC-32.0 RDW-14.0 Plt Ct-64*
[**2166-8-24**] 11:07PM BLOOD WBC-21.7* RBC-3.78* Hgb-11.9* Hct-37.7*
MCV-100* MCH-31.5 MCHC-31.6 RDW-13.9 Plt Ct-52*
[**2166-8-24**] 07:20PM BLOOD WBC-24.9*# RBC-3.88* Hgb-12.4* Hct-38.6*
MCV-100* MCH-31.9 MCHC-32.1 RDW-13.4 Plt Ct-65*
[**2166-8-24**] 07:20PM BLOOD Neuts-85* Bands-2 Lymphs-8* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2166-8-26**] 06:40AM BLOOD PT-11.7 PTT-26.9 INR(PT)-1.0
[**2166-8-27**] 06:45AM BLOOD Glucose-88 UreaN-32* Creat-1.2 Na-139
K-4.6 Cl-104 HCO3-28 AnGap-12
[**2166-8-26**] 06:40AM BLOOD Glucose-202* UreaN-39* Creat-1.4* Na-134
K-4.2 Cl-99 HCO3-27 AnGap-12
[**2166-8-25**] 10:33AM BLOOD Glucose-218* UreaN-38* Creat-1.8* Na-135
K-4.6 Cl-98 HCO3-26 AnGap-16
[**2166-8-24**] 11:07PM BLOOD Glucose-174* UreaN-39* Creat-2.0* Na-135
K-4.9 Cl-100 HCO3-26 AnGap-14
[**2166-8-24**] 07:20PM BLOOD Glucose-103 UreaN-41* Creat-2.2* Na-134
K-4.5 Cl-99 HCO3-25 AnGap-15
[**2166-8-26**] 06:40AM BLOOD ALT-17 AST-21 LD(LDH)-199 AlkPhos-85
TotBili-1.4
[**2166-8-24**] 11:07PM BLOOD ALT-16 AST-21 LD(LDH)-137 CK(CPK)-97
AlkPhos-86 TotBili-1.6*
[**2166-8-24**] 11:07PM BLOOD CK-MB-7 cTropnT-0.02*
[**2166-8-24**] 07:20PM BLOOD cTropnT-0.02*
[**2166-8-24**] 07:20PM BLOOD CK-MB-7 proBNP-5308*
[**2166-8-27**] 06:45AM BLOOD Calcium-10.0 Phos-1.7* Mg-2.4
[**2166-8-26**] 06:40AM BLOOD Calcium-9.5 Phos-1.5*# Mg-2.6
[**2166-8-25**] 10:33AM BLOOD Calcium-9.8 Phos-3.4 Mg-2.3
[**2166-8-25**] 08:37AM BLOOD Type-ART Temp-36.7 pO2-68* pCO2-74*
pH-7.25* calTCO2-34* Base XS-1
[**2166-8-24**] 09:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.025
[**2166-8-24**] 09:15PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG
[**2166-8-24**] 09:15PM URINE RBC-0-2 WBC-[**3-20**] Bacteri-MOD Yeast-NONE
Epi-0-2
[**2166-8-24**] 09:15PM URINE CastGr-[**6-25**]* CastHy-[**12-5**]*
[**2166-8-24**] 11:07 pm MRSA SCREEN NASAL SWAB.
**FINAL REPORT [**2166-8-27**]**
MRSA SCREEN (Final [**2166-8-27**]): No MRSA isolated.
ACID FAST SMEAR (Final [**2166-8-25**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST SMEAR (Final [**2166-8-26**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST SMEAR (Final [**2166-8-27**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
CHEST (PA & LAT) Study Date of [**2166-8-24**] 7:40 PM
IMPRESSION: Extensive interstitial and airspace opacity in the
right mid and lower lung zone concerning for infection.
CHEST (PORTABLE AP) Study Date of [**2166-8-25**] 8:07 AM
FINDINGS: Worsening diffuse pneumonia in the right lung with
relative sparing of right lung apex, superimposed upon
underlying emphysema. There is some degree of volume loss, with
apparent slight shift of mediastinum towards the right. Small
pleural effusion on the right side has slightly worsened. Left
lung is hyperexpanded, but grossly clear.
Brief Hospital Course:
1. Bacterial Pneumonia, Hemoptysis
- Patient ruled out for TB with 3 concentrated sputums
- Improved with Levofloxacin, Ceftriaxone and Vancomycin
- Total of 10 day course
- Hemoptysis was never massive, but was more than simply rust
colored. It has started to resolve to rust-colored at time of
discharge.
2. COPD Exacerbation
- Steroid Taper was started in the [**Hospital Unit Name 153**] and was continued
through discharge
- Advair, Albuterol, Tioproprium
- Oxygen requirement had resolved by day of discharge.
3. Acute on Chronic Diastolic CHF
- This is the likely cause of the elevated BNP, as it was in the
setting of hypoxia and tachycardia. The symptoms resolved with
resolution of the pneumonia
4. HIV/AIDS
- His HAART was continued as was his bactrim
5. CKD Stage 4
- Renal Dosing
6. Chronic Hepatitis C
- Avoid Tylenol
7. Thrombocytopenia
- Continued improvement
8. Nicotine Dependence
- Smoking Counseling given
- Patient was maintained on nicotine patch, but proceeded to
smoke in respiratory isolation.
Medications on Admission:
Atazanavir 300mg daily
Diazepam (unclear dose)
[**Name (NI) 57593**] 200mg every other day
Advair diskus inhaled [**Hospital1 **]
Oxycodone SR 40mg TID
Ranitidine 150mg qhs
Ritonavir 100mg daily
Tenofovir 300mg daily
Spiriva daily
Bactrim SS daily (has not taken in 5 days)
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 6 days.
Disp:*9 Tablet(s)* Refills:*0*
2. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q72H
(every 72 hours).
3. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO Q72H (every 72 hours).
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Bacterial Pneumonia
Hemoptysis
COPD Exacerbation
HIV/AIDS
Chronic Kidney Disease Stage 4
Chronic Hepatitis C
Thrombocytopenia
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital with worsening of your cough, increased
coughing of blood, shortness of breath, fevers/chills or
diarhea.
You are being discharged on an antibiotic called Levofloxacin.
This
medication can weaken your tendons while taking it, so you
should avoid strenuous sports or activities. If you feel
palpitations in your heart, contact your doctor or go to the
Emergency Room. Finish all this medication even if you feel
better.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2166-9-25**] 3:00
Please contact your Infectious Disease Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2148**]
for follow up of this infection
|
[
"5849",
"2762",
"3051",
"4280"
] |
Admission Date: [**2126-3-20**] Discharge Date: [**2126-4-9**]
Date of Birth: [**2062-3-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Rollover motor vehicle crash
Major Surgical or Invasive Procedure:
s/p External fixation Left radial/Ulnar fracture, canthoplasty;
s/p ORIF L humerus [**3-25**];
s/p Trach/peg on [**3-28**]; s/p IVCF
History of Present Illness:
63 yo male s/p rollover motor vehicle crash, high speed with
ejection, unrestrained driver, +EtOH. Initial GCS 14. He was
taken to an area hospital and found to have bilateral
pneumothoraces with left hemothorax.
Past Medical History:
HTN
Social History:
+EtOH
Family History:
Noncontributory
Pertinent Results:
Upon admission:
[**2126-3-21**] 01:15AM BLOOD WBC-6.0 RBC-3.82* Hgb-11.3* Hct-32.7*
MCV-86 MCH-29.6 MCHC-34.6 RDW-14.9 Plt Ct-171
[**2126-3-20**] 05:55PM BLOOD PT-12.9 PTT-27.1 INR(PT)-1.1
[**2126-3-21**] 01:15AM BLOOD Glucose-178* UreaN-23* Creat-0.9 Na-137
K-4.7 Cl-109* HCO3-21* AnGap-12
[**2126-4-4**] 02:17AM BLOOD Glucose-61* UreaN-22* Creat-0.5 Na-143
K-4.6 Cl-104 HCO3-32 AnGap-12
[**2126-3-21**] 08:16AM BLOOD CK-MB-95* MB Indx-0.9 cTropnT-<0.01
[**2126-4-2**] 03:35AM BLOOD calTIBC-160* Ferritn-481* TRF-123*
[**2126-4-1**] 06:15AM BLOOD Lactate-0.9
[**2126-3-20**] 06:06PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2126-3-20**] 06:06PM URINE RBC-[**11-14**]* WBC-[**2-27**] Bacteri-RARE
Yeast-NONE Epi-0-2 TransE-[**2-27**]
[**2126-3-20**] 06:06PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.048*
CT HEAD W/O CONTRAST [**2126-3-22**] 10:19 AM
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Blood air level within the right maxillary sinus is
suspicious for fracture involving the right maxillary sinus and
facial CT can help for further assessment as described above.
CT C-SPINE W/O CONTRAST [**2126-3-22**] 10:19 AM
IMPRESSION:
1. No definite fracture or subluxation in the cervical region.
MRI can help to exclude ligamentous injury if clinically
indicated. There is no abnormal widening of the disc space or
widening of interspinous distances to indicate unstable injury.
2. Extensive subcutaneous emphysema in the neck. Correlation
with chest CT recommended.
3. Rib fractures as described above.
4. Degenerative changes.
CT CHEST W/O CONTRAST [**2126-3-22**] 10:20 AM
IMPRESSION:
1. Bilateral hemopneumothorax with bilateral chest tubes in
place.
2. Pneumomediastinum and extensive subcutaneous and chest wall
gas.
3. No definite evidence of mediastinal hematoma or of injury to
the great vessels. However, this examination is limited due to
lack of intravenous contrast.
4. Bilateral lower lobe and lingular pulmonary consolidation and
additional areas of patchy probable contusions in the upper
lobes.
5. Numerous and extensive fractures including left humerus,
bilateral scapula, multiple ribs, and thoracic spine. Dedicated
evaluation of the thoracic spine is recommended due to probable
but incompletely evaluated T8 burst fracture and inadequate
evaluation of the canal and its contents.
6. Limited evaluation of the upper abdomen without definite
evidence of hemoperitoneum.
CHEST (PORTABLE AP) [**2126-4-4**] 5:43 AM
COMPARISON: [**2126-4-2**].
As compared to the previous radiograph, there is no relevant
change. The PICC line and the tracheostomy tube are in unchanged
positions. There still is mild cardiomegaly with minimal signs
of overhydration. At the left lung base and in the retrocardiac
lung areas, older peribronchial opacities, potentially of
atelectatic nature, are identified. Otherwise, there are no
focal parenchymal lung opacities suggestive of pneumonia. No
pneumothorax.
Brief Hospital Course:
He was admitted to the Trauma Service. His hospital course by
systems as follows:
Neuro - He was vented and sedated prior to arrival to [**Hospital1 18**].
Because of his injuries he remained sedated in the Trauma ICU
for the majority of his stay there. There were no intracranial
processess identified on CT imaging of his head. He was placed
on Ativan per CIWA protocol given his history of EtOH. His
sedation was eventually weaned and he did awaken; he is awake,
alert, able to answer simple questions and follows commands. he
was started on Haldol prn for agitation; this has been used very
infrequently. For pain control he was evaluated by Acute Pain
Service for epidural catheter given his multiple rib fractures.
It was eventually decided that Methadone should be used for his
pain control.
HEENT - Plastic Surgery and Opthamology were consulted becasue
of an orbital wall fracture on the right and laceration to the
right lower lid. The laceration was repaired by Plastics injury;
a canthoplasty was performed by Opthamology [**3-23**] and he was
started on eye drops. He will require follow up in [**Hospital 8095**]
clinic in 2 weeks after discharge.
Cardiac - His initial Hematocrit was 41.4; prior to his arrival
to [**Hospital1 18**] he had received 4 units PRBC's at the referring
hospital due to profound hypotension. His most recent Hct is
32.7. Vascular surgery was immediately consulted given the open
left distal radius fracture and abscence of pulse; no operative
intervention was warranted by Vascular. Recommendations were
made for consultation by Plastc/Hand Surgery for definitive
care. He required beta blockade and Hydralazine to control his
HR and blood pressure during his ICU stay. He was transferred to
the regular nursing unit on Lopressor 37.5 mg tid; the dosage
and frequency were both decreased becasue of two noted episodes
of bradycardia on telemetry; in both instances the bradycardia
did resolve. An IVC filter was placed because of his multiple
bone fractures. His Lisinopril was restarted on [**4-9**].
Resp - Pt arrived to [**Hospital1 18**] intubated. His respiratory status
was originally tenuous due to his multiple rib fractures (see
below) and bilateral pneumothoraxes. He remained intubated on
the ventilator in the ICU and was later taken to the operating
room for an open tracheostomy and PEG on [**3-28**]. He was eventually
weaned from the ventilator and transferred to the floor on trach
mask. His chest tubes were pulled when the output had
sufficiently decreased. He had a consult placed for speech
therapy/passy muir valve on [**4-8**], and has been cleared to
continue sessions.
Musculoskeletal - Patient is cleared for activity as tolerated
w/ TLSO brace in place and LUE non-weightbearing. Injuries
include:
1) Open L radial ulnar fracture taken to the OR [**3-21**] by
plastics. An exfix was placed. Pt will be on augmentin x7d for
cellutic skin at exfix sites
2) L humerus fracture s/p ORIF [**3-25**] with orthopedics. staples
removed from incision, steri strips in place
3) L ribs [**1-5**], with 1-5 with multiple fracture locations.
4) R ribs multiple fx, w/ #7 fractured in >1 location
5) Comminuted R scapular fracture, non-operative
6) L scapular body fracture: non operative
7) Spine/Vertebral Injuries: non-operative, per Spine c/s, okay
for pt to sit, TLSO brace
--T5-T8, T10-T12 spinous process fractures
--Transverse process fractures R T2/4/5/7
--T8 body fracture
--T12 wedge fracture
--L5 compression fracture
8) R orbital wall fractures: non-operative
Pain Control: Pt originally required extremely a high dose
fentanyl drip for pain control given his multiple injuries.
Over the course of his ICU stay, the fentanyl was weaned and the
patient was transitioned to methadone (started [**3-30**]). He is now
in the process of being tapered off methadone (see methodone
taper in medication orders).
ID: From an ID standpoint the patient has been stable. He has
not had any major hospital aquired or other infections. His
MRSA screens were negative, blood cultures were negative, and
catheter tip was also negative. His ex fix pin sites developed
some erythema concerning for infection, and patient was started
on augmentin. Plastic Surgery would like this continued until
his follow up appointment in 2 weeks.
Heme: Pt is s/p IVC filter on [**4-1**], placed for concern over
DVT/PE given state of decreased activity.
Medications on Admission:
Lisinopril
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 176 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
6. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic [**Hospital1 **] (2
times a day).
7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. Pilocarpine HCl 2 % Drops Sig: One (1) Drop Ophthalmic Q6H
(every 6 hours).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
10. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
12. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1)
Appl Ophthalmic QHS (once a day (at bedtime)).
13. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D ().
14. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
15. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
17. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every Monday).
18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<110, HR<60 RN please check HR just
prior to giving Lopressor doses. .
19. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day): 6 doses via PEG, then d/c TID dosing, begin [**Hospital1 **] dosing
with plan to taper off methadone after [**Hospital1 **] dosing.
20. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: One (1) PO Q8H (every 8 hours).
21. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed for pain.
22. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
23. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 4 doses: 4 doses, START AFTER TID DOING FINISHED.
24. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN
10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
25. Haldol 5 mg/mL Solution Sig: 1-2 MG Injection every six (6)
hours as needed for agitation.
26. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
27. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]
Discharge Diagnosis:
s/p Rollover Motor vehicle crash
Injuries:
1. Left radio-ulnar Fx (open),
2. Left ribs [**1-5**] Fx, with 1-5 2 fx locations,
3. Multiple R rib fx with R7 with 2 fx,
4. Comminuted R scapula, L scapula body fx,
5. Left distal clavicle, comminuted L proximal humerus
(displaced),
6. Spinous processes of T5-8, [**10-6**], R transverse processes
T2,4,5, 7. T8 body fx, T12 wedge, L5 compression fx;
8. Right orbital wall fractures
Discharge Condition:
Good
Discharge Instructions:
The antibiotic will continue until ex-fix removed
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **], Trauma Surgery, in 2 weeks.
Call [**Telephone/Fax (1) 2537**] for an appointment.
Please follow up with Plastics Hand clinic in 2 weeks. Call [**Telephone/Fax (1) 40054**] for an appointment.
Please follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics in 2 weeks.
Call [**Telephone/Fax (1) 9769**] for an appointment.
Please follow up in [**Hospital 8095**] clinic in 2 weeks, call
[**Telephone/Fax (1) 253**] for an appointment.
|
[
"25000",
"4019",
"V5867"
] |
Admission Date: [**2183-7-3**] Discharge Date: [**2183-7-6**]
Date of Birth: [**2111-6-23**] Sex: M
Service: INT MED
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
African American male with multiple recent admissions for
urinary tract infection, a history of cerebrovascular
accident and an indwelling suprapubic catheter, who was
transferred from the [**Hospital3 6560**] Facility for shortness
of breath and decreased oxygen saturation to 76% on room air.
He had several days of congestion, with copious secretions on
the morning of admission. He was also found to be
tachycardic.
At the nursing home, the patient was suctioned and placed on
three liters by nasal cannula with oxygen saturations
increasing to 80%. The patient had a percutaneous endoscopic
gastrostomy tube in place and did not take anything by mouth.
He was nonverbal at baseline and recently moved to [**Location (un) 86**]
from [**State 19827**].
In the emergency room, the patient was found to be febrile to
101.9??????F with a pulse of 120 and sinus tachycardia. The
patient was found to have a urinalysis suggestive of a
urinary tract infection in addition to decreased oxygen
saturations and a streaky left lower lobe opacity suggestive
of an infiltrate. The patient was given levofloxacin and
ceftriaxone with intravenous fluids in the emergency room.
PAST MEDICAL HISTORY:
1. Benign prostatic hypertrophy.
2. Admission for urinary retention secondary to urethral
stricture.
3. Elevated PSA.
4. Cerebrovascular accidents, multiple, in the past.
5. Hypertension.
6. Suprapubic tube indwelling.
7. Gastrojejunostomy tube.
8. Methicillin resistant Staphylococcus aureus, Clostridium
difficile urosepsis.
MEDICATIONS ON ADMISSION:
Proscar 5 mg p.o. q.d.
Flomax 0.4 mg p.o. q.d.
Atenolol 25 mg p.o. q.d.
Ritalin 5 mg p.o. b.i.d.
Aspirin.
ALLERGIES: There were no known drug allergies.
SOCIAL HISTORY: The patient moved from [**State 19827**] to [**Location (un) 86**]
earlier this year. He lived at the Bostonian. He had two
daughters, [**Name (NI) 2048**] [**Name (NI) **] ([**Telephone/Fax (1) 34244**]) and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**]
([**Telephone/Fax (1) 34245**]), who were intimately involved in his care.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 101.9??????F with a pulse of 140, sinus
tachycardia and a blood pressure of 101/72. His oxygen
saturation was 96% on four liters and 87% on room air at the
time of admission; however, by the time we saw the patient,
he was 95% on room air. Generally, he was a nonverbal,
contracted, elderly male lying in bed in no acute distress.
On HEENT examination, the head was normocephalic and
atraumatic. The mucous membranes were mildly dry.
The lungs had coarse breath sounds at the left base by the
report of the emergency department. It was difficult to
interpret on my examination due to decreased effort. The
heart was tachycardic with no murmurs, rubs or gallops
appreciated. The abdomen had a gastrojejunostomy tube and a
suprapubic tube with thin, yellow liquid at the entry site.
He had a soft abdomen. On skin examination, the patient had
a decubitus ulcer that was 5 cm deep with granulation tissue
clear around the borders. The extremities were thin and
contracted.
LABORATORY DATA: At the time of admission, the patient had a
white blood cell count of 12,700 with a hematocrit of 39.
There was a sodium of 141, potassium of 4.1, chloride of 102,
bicarbonate of 26, BUN of 25, creatinine of 0.6 and glucose
of 131. Urinalysis showed large blood and was nitrite
positive with greater than 300 protein, 88 white blood cells
and occasional bacteria. The patient had cultures pending.
RADIOLOGY: The chest x-ray showed a left lower lobe
infiltrate.
ELECTROCARDIOGRAM: The electrocardiogram was terminis with a
poor baseline.
HOSPITAL COURSE BY ISSUE:
1. INFECTIOUS DISEASE: The patient was admitted with a
urinary tract infection and left lower lobe pneumonia. His
previous urinary tract infection had become systemic and the
patient had Escherichia coli resistant to ampicillin,
ciprofloxacin, gentamicin, levofloxacin and Bactrim on
[**2183-5-4**], in addition to Enterococcus sensitive to
ampicillin, penicillin and vancomycin. These were both found
in the blood and were thought to be spread from an initial
urinary tract infection.
Given the multiple resistant organisms, the patient was
started on Flagyl to cover possible anaerobes in the left
lower lobe infiltrate, ceftriaxone to cover the previously
resistant Escherichia coli and vancomycin to cover for a
history of Methicillin resistant Staphylococcus aureus in the
urine. At the time of this Discharge Summary, the patient is
growing Staphylococcus coagulase positive out of his urine;
however, the final sensitivities are still pending.
The patient did well throughout his hospitalization. He was
stable with a decreasing oxygen requirement. He was on two
liters of oxygen at the time of discharge with an oxygen
saturation of 99-100%. He was nonverbal, so it was difficult
to assess how he was feeling; however, he continued to have a
soft abdomen and a benign examination.
2. CARDIOVASCULAR: The patient had a history of
hypertension, however he was in sinus tachycardia in the
setting of being volume depleted at the time of admission.
We held his atenolol during this admission; this will be
started back up as the patient is discharged and gets back to
his baseline.
3. FLUID, ELECTROLYTES AND NUTRITION: The patient was
placed on high protein tube feedings at 75 cc/h with some
vitamin supplements. He was also placed on half normal
saline at 100 cc/h after completing three liters of normal
saline. The patient's heart rate came down after the volume
resuscitation. He was placed on all of his outpatient
medications in addition to subcutaneous heparin as deep vein
thrombosis prophylaxis.
4. CODE STATUS: The patient is a full code per a
conversation with his daughter on [**2183-7-3**].
DISCHARGE DIAGNOSES:
Urinary tract infection.
Pneumonia.
DISCHARGE MEDICATIONS:
1. Zantac 150 mg per gastrostomy tube q.d.
2. Tube feedings at 75 cc/h.
3. Flagyl 500 mg per gastrostomy tube t.i.d. for a total of
14 days with the last day on [**2183-7-16**]; further antibiotics
will be indicated in Page 1, given the sensitivities of the
final organisms.
4. Proscar 5 mg per gastrostomy tube q.d.
5. Aspirin 325 mg per gastrostomy tube q.d.
6. Colace 100 mg per gastrostomy tube b.i.d.
7. Dulcolax p.r.n.
8. Atenolol, which was on hold and was to be restarted as an
outpatient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8829**], M.D. [**MD Number(1) 8830**]
Dictated By:[**Last Name (NamePattern1) 16512**]
MEDQUIST36
D: [**2183-7-5**] 06:09
T: [**2183-7-5**] 07:20
JOB#: [**Job Number 34246**]
|
[
"486",
"5990",
"51881",
"4019"
] |
Admission Date: [**2193-11-3**] Discharge Date: [**2193-11-12**]
Date of Birth: [**2142-10-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Planned admission for aortic valve replacement
Major Surgical or Invasive Procedure:
[**2193-11-4**] - Aortic Valve Replacement (25mm St. [**Male First Name (un) 923**] Mechanical
valve) / Sternal plating with Talon System.
History of Present Illness:
51 year old male with no known hx of CAD, admitted to [**Hospital1 5979**] on [**10-26**] with increasing shortness of breath. Patient
reports that he has had worsening DOE for [**5-6**] wks. He states
that it is worse when walking up stairs or on an incline. Also
reports large wt gain but could not quantify an exact amount and
increase swelling of his LE b/l. At the OSH he was ruled out for
MI. An Echo was done which revealed an LVEF 30-35%. He underwent
diuresis with IV lasix and his resp status improved. An ETT was
done that showed inferolateral ischemia. He was transfered to
[**Hospital1 18**] for cath. Cath showed patent coronaries, but did show AS
w/ a peak to peak gradient of 80 mmHg and high filling
pressures. ECHO showed severe AS (valve area <0.8cm2), EF of 45%
by ECHO. He was seen by cardiothoracic surgery who recommended
valve replacement with mechanical valve, however recommend
plavix washout therefore surgery was scheduled for Mon [**11-4**]. Pt
requested discharge from the hospital while awaiting surgery and
is now being readmitted for the surgery. Since his discharge two
days ago, pt states that his SOB and LE edema have continued to
improve and he is feeling significantly better than he was on
admission to the OSH. He denies any new or worsening symptoms
including chest pain, fever, chills, or increased
errythema/edema of the lower extremities. He has been taking all
of his medications as prescribed on discharge.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, hemoptysis, black stools or red stools. He denies recent
fevers, chills or rigors. He denies exertional calf pain. All of
the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
Gastric banding procedure
Sleep apnea on CPAP
Prior staph infection of the spine
Cellulitis to right leg currently on keflex
1. CARDIAC RISK FACTORS: No lipid panel on file, sleep apnea
2. CARDIAC HISTORY: Pericarditis with pericardial effusion s/p
pericardial window
Social History:
Lobster distributer.
-Tobacco history: denies
-ETOH: 1-2 drinks/mo
-Illicit drugs: denies
Family History:
Dad with MI at age 75. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: T 96.6, BP 121/71, HR 75, RR 22, Sat 96% RA
GENERAL: Obese male, 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 with JVP of 8 cm.
CARDIAC:RR, normal S1, S2. III/VI rumbling SEM best heard at
RSB, radiates to carotids. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. BS distant but clear.
No crackles, rhonchi or wheezes.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. No abdominial
bruits.
EXTREMITIES: No c/c. 1+ edema b/l LE. No femoral bruits or
hematoma over inscision. Erythemathous, region of R leg appears
to have receeded from demarcation. No warmth, not painful to
palpation. No open ulcers.
SKIN: Chronic venous stasis changes in lower extremities.
PULSES: 2+ radial
NEURO: A+O x3, no focal deficits, 2+ biceps reflexes.
Pertinent Results:
[**2193-11-3**] 07:55PM PT-12.6 PTT-27.3 INR(PT)-1.1
[**2193-11-3**] 07:55PM PLT COUNT-261
[**2193-11-3**] 07:55PM WBC-9.5 RBC-5.38 HGB-13.5* HCT-42.8 MCV-80*
MCH-25.1* MCHC-31.5 RDW-15.5
[**2193-11-3**] 07:55PM TRIGLYCER-155* HDL CHOL-31 CHOL/HDL-5.5
LDL(CALC)-108
[**2193-11-3**] 07:55PM CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-1.9
CHOLEST-170
[**2193-11-3**] 07:55PM GLUCOSE-119* UREA N-29* CREAT-1.1 SODIUM-137
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
2D-ECHOCARDIOGRAM ([**2193-10-31**]):
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is regional left ventricular systolic
dysfunction with severe inferior, inferolateral hypokinesis and
mild anterolateral hypokinesis. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %). The right
ventricular cavity is mildly dilated. The ascending aorta is
mildly dilated. The aortic arch is mildly dilated. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. There is critical aortic
valve stenosis (valve area <0.8cm2). Mild to moderate ([**11-30**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
IMPRESSION: Regional left ventricular systolic dysfunction.
Severe aortic stenosis. Mild to moderate aortic regurgitation.
Mild mitral regurgitation. Moderate pulmonary artery systolic
hypertension.
.
ETT:
At OSH, Nuclear:
Anteroseptal ischemia, fixed inferolateral wall defect, dilated
LV w/ gen hypokinesis, EF 30%.
.
CARDIAC CATH:
1. Coronary arteries are normal.
2. Critical aortic stenosis.
3. Elevated right and left sided filling pressures
4. Moderate systolic ventricular dysfunction.
.
HEMODYNAMICS: AS w/a peak to peak gradient of 80 mmHg and high
filling pressures.
Brief Hospital Course:
Mr. [**Known lastname 349**] was admitted to the [**Hospital1 18**] on [**2193-11-3**] for surgical
management of his aortic valve stenosis. The next morning he was
taken to the operating room where he underwent and aortic valve
replacement using a 25mm St. [**Male First Name (un) 923**] Mechanical valve. Given his
large habitus, a Talon sternal plating system was used.
Postoperatively he was taken to the intensive care unit for
monitoring. The following morning he awoke neurologically intact
and was extubated. Coumadin was started for anticoagulation for
his mechanical valve with a goal INR of 2.5-3.0. He had acute
renal insufficiency post-operatively with a peak creatinine of
2.4 but was improved at the time of discharge. Heparin was
initiated until his INR was therapeutic. He was transferred to
the step down unit on post operative day # 3. On the floor he
had adequate urine output with IV lasix, was ambulating in the
halls with assistance and he was tolerating a full diet. He did
have sternal erythema (no drainage) and was started on kefzol
with a plan for 7 days of Keflex and a wound check in 1 week.
Beta blockers were titrated up and an ACE-I was added for blood
pressure control. He was receiving coumadin for the
mechanical valve and by post-operative day 8 he was ready for
discharge to home with a therapeutic INR. His INR will be
followed by his cardiologist [**Male First Name (un) **] Yeghazarians phone
[**Telephone/Fax (1) 12551**].
Medications on Admission:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Carvedilol 6.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
4. Zyrtec 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days.
Disp:*16 Capsule(s)* Refills:*0*
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 6 days.
Disp:*12 Capsule(s)* Refills:*0*
6. Outpatient Lab Work
INR draw on [**2193-11-13**] and fax results to Dr. [**Last Name (STitle) 84109**] office
[**Telephone/Fax (1) 84110**] for coumadin dosing.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: to be
evaluated when leg edema resolves.
Disp:*30 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: to be
discontinued when lasix stopped.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Coumadin 2 mg Tablet Sig: as directed Tablet PO once a day:
dose to be determined by Dr. [**Last Name (STitle) 32668**] for Mech AVR. Goal
INR 2.5-3.
Disp:*150 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic stenosis s/p AVR(25mm St. [**Male First Name (un) 923**] Mechanical)
Pericarditis with pericardial effusion s/p pericardial window
Gastric banding procedure
Sleep apnea on CPAP
Prior staph infection of the spine
Cellulitis to right leg currently on keflex
Pneumonia 6 month ago
Acute renal insufficiency, resolved
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming, and look at your incisions
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6)Please call with any questions or concerns [**Telephone/Fax (1) 170**]
7)Your INR and coumadin will be managed by Dr. [**Last Name (STitle) **]
office as confirmed with [**First Name8 (NamePattern2) 57342**] [**Last Name (NamePattern1) **] RN. Your next INR draw
will be [**2193-11-13**].
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) **] on [**12-5**] at 1:15 PM [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name (STitle) **] in [**11-30**] weeks [**Telephone/Fax (1) 6699**]
Cardiologist Dr [**Last Name (STitle) **] [**Name (STitle) **] in [**11-30**] weeks [**Telephone/Fax (1) 12551**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
The VNA will draw your INR on [**2193-11-13**] and fax results to Dr.
[**Last Name (STitle) 84109**] office fax [**Telephone/Fax (1) 84110**]
Completed by:[**2193-11-12**]
|
[
"4241",
"5849",
"4168",
"32723",
"4280"
] |
Admission Date: [**2128-8-21**] Discharge Date: [**2128-9-8**]
Date of Birth: [**2052-8-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Vomitting
Major Surgical or Invasive Procedure:
Exploratory Laparotomy with Adhesion Lysis
Open 26 Fr G-tube
History of Present Illness:
This is a 76 year old male from [**Hospital6 16166**] Home who has
had brown emesis and abdominal pain and for the last 2 days. He
reports + diarrhea.
Past Medical History:
PMHx: dementia, COPD, DM, EtOH, seizures, ^chol, aspiration PNA,
anxiety, GERD, GIB, BPH, DJD, gout
Social History:
Formerly in the Navy.
He has a past history of smoking for 2 years. He has not use
ETOH in years.
Per his records, he has no family
[**Hospital6 16166**] Facility [**Telephone/Fax (1) 56955**]
Physical Exam:
Vitals: T: 101.8, HR 119, BP 131/57, 100% on 2L NC
HEENT: PERRL, EOMI, anicteric sclera, eyes weeping, MMM,
adentulous, OP clear
Neck: supple, no LAD, no thyromegaly
Cardiac: tachycardic, regular rhythm, NL S1 and S2, no MRGs, no
JVD
Lungs: rales at left base, no wheezes
Abd: mildly distended, soft, periumbilical tenderness, worse in
LLQ, no epigastric tenderness, no rebound, +voluntary guarding,
+ BS, dullness to percussion in flanks
Ext: warm, 2+ DP pulses, no C/C/E
Neuro: alert to person and time, not place, easily distracted,
MAE
Pertinent Results:
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2128-9-1**] 2:09 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: FEVERS, ABDOMINAL DISTENTION,N/V,ABD PAIN;
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with fevers, abdominal distention, n/v,
abdominal pain, lactate of 4.
REASON FOR THIS EXAMINATION:
Please r/o acute process.
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: CT of the abdomen and pelvis.
CLINICAL HISTORY: 76-year-old man with fevers, abdominal
distention, nausea and vomiting, abdominal pain. Rule out acute
process. The patient is status post laparotomy on [**2128-8-22**].
CT OF THE ABDOMEN: There are small bilateral pleural effusions,
right greater than left. The liver is normal, without focal
lesions. No intra - or extra- hepatic ductal dilatation. There
are multiple gallstones. Otherwise, the gallbladder is
unremarkable. There has been interval placement of a gastrostomy
tube. The pancreas, spleen, adrenal glands, and kidneys are
unremarkable.
There is dilatation of several loops of small-bowel that has
decreased in caliber in the interval. Contrast is seen through
to the colon. There is a small amount of intra-abdominal free
fluid abutting the anterior abdominal wall in the region of
prior surgery. There is induration of the mesenteric fat.
The celiac and SMA are widely patent.
CT OF THE PELVIS: There is a Foley catheter within the urinary
bladder. The rectum and sigmoid colon are unremarkable. No
pelvic free fluid or lymphadenopathy.
No suspicious osseous lesions.
IMPRESSION:
1. Interval decrease in degree of small-bowel dilatation
post-surgery. No evidence of mechanical obstruction.
2. Gallstones.
3. Small bilateral pleural effusions.
VIDEO OROPHARYNGEAL SWALLOW [**2128-9-1**] 2:47 PM
VIDEO OROPHARYNGEAL SWALLOW
Reason: sp and sw
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with
REASON FOR THIS EXAMINATION:
sp and sw
STUDY: Video oropharyngeal swallow.
INDICATION: 76-year-old male with difficulty swallowing. Please
evaluate.
VIDEO OROPHARYNGEAL SWALLOW EXAMINATION: An oral and pharyngeal
swallowing video fluoroscopy was performed today in
collaboration with the speech and language pathology division.
Various consistencies of barium including thin liquid and
pudding were administered.
FINDINGS: There was severe oral phase deficiency. Initiation of
swallowing was significantly delayed. Premature spillover of the
oral contents is identified. There is an inconsistent mild
swallow delay. Penetration was observed with thin liquids but no
aspiration was identified.
RADIOLOGY Final Report
ABDOMEN (SUPINE & ERECT) [**2128-8-30**] 2:29 AM
ABDOMEN (SUPINE & ERECT)
Reason: Please r/o acute process.
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with distended abdomen and no bowel sounds.
REASON FOR THIS EXAMINATION:
Please r/o acute process.
INDICATION: Distended abdomen with no bowel sounds. Rule out
acute process.
COMPARISON: [**2128-8-29**].
FINDINGS: There has been no marked interval change. A single
dilated small bowel loops is present in the right upper quadrant
measuring 3.5 cm, nonspecific. A few air-fluid levels are
present on the lateral decubitus image. The colon is normal
caliber and contains stool and contrast from previous study.
Skin staples left of midline and drainage catheter is present.
No free air is present under the diaphragms on upright.
ABDOMEN (SUPINE ONLY) [**2128-8-29**] 10:42 AM
ABDOMEN (SUPINE ONLY)
Reason: abd pain
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with abdominal pain
REASON FOR THIS EXAMINATION:
abd pain
STUDY: SUPINE ABDOMEN [**2128-8-29**].
HISTORY: 76-year-old man with abdominal pain.
FINDINGS: There are skin staples seen along the left abdomen.
There is a gastrostomy tube identified. There is air and stool
seen throughout the colon and rectum. There are few air-filled
loops of small bowel within the mid abdomen which is
nonspecific. This is not significantly changed since previous.
There is no definitive evidence for free air on this limited
supine radiograph. Bony structures are grossly intact.
ABDOMEN (SUPINE ONLY) [**2128-8-29**] 10:42 AM
ABDOMEN (SUPINE ONLY)
Reason: abd pain
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with abdominal pain
REASON FOR THIS EXAMINATION:
abd pain
STUDY: SUPINE ABDOMEN [**2128-8-29**].
HISTORY: 76-year-old man with abdominal pain.
FINDINGS: There are skin staples seen along the left abdomen.
There is a gastrostomy tube identified. There is air and stool
seen throughout the colon and rectum. There are few air-filled
loops of small bowel within the mid abdomen which is
nonspecific. This is not significantly changed since previous.
There is no definitive evidence for free air on this limited
supine radiograph. Bony structures are grossly intact.
CHEST (PORTABLE AP)
Reason: Eval for effusion
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with abd distention, fevers, N/V, code sepsis,
possible aspiration. s/p ex lap
REASON FOR THIS EXAMINATION:
Eval for effusion
EXAMINATION: AP chest.
INDICATION: Fevers, sepsis.
A single AP view of the chest is obtained [**2128-8-23**] at 0810 hours
and is compared with the prior mornings radiograph. The patient
has been extubated. Allowing for the change in technique and
penetration, there likely has been little significant change in
the appearance of patchy airspace disease in the right lung and
left lower lobe. Findings would be consistent with focal
pneumonia possibly secondary to aspiration. A right-sided
subclavian line has its tip projecting over the SVC.
IMPRESSION:
Evidence of airspace disease in the right lung and to a lesser
extent the left lower lobe with frank consolidation in the right
lower lung field. Findings would be consistent with multifocal
pneumonia or aspiration which is not significantly changed since
the prior examination.
PORTABLE ABDOMEN [**2128-8-21**] 2:30 PM
PORTABLE ABDOMEN; ABDOMEN (LAT DECUB ONLY) LEFT
Reason: free air?
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with mildly distended abd w/o ttp on exam.
REASON FOR THIS EXAMINATION:
free air?
HISTORY: Mildly distended abdomen with tender to palpation on
exam, question free air.
Abdomen, two views including portable supine and left lateral
decubitus portable. The technologist notes that the patient was
unable to position her whole breast for the exam and was not
able to leave the EU. A wet [**Location (un) 1131**] was provided by the
resident, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 63915**] at 2:47 p.m. on the day
of the exam as follows, "I don't see evidence of free air."
Films are degraded by motion artifact. The bowel gas pattern is
nonspecific. Gas is seen in the rectum. The decubitus view is
suboptimal due to positioning. Allowing for marked limitations,
no free air is identified.
CT ABDOMEN W/CONTRAST [**2128-8-21**] 10:54 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: Evidence of ischemic bowel, inflammation, obstruction,
diver
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with fevers, abdominal distention, n/v,
abdominal pain, lactate of 4.
REASON FOR THIS EXAMINATION:
Evidence of ischemic bowel, inflammation, obstruction,
diverticulitis, etc.
CONTRAINDICATIONS for IV CONTRAST: elevated cr
INDICATION: Fever, abdominal distention, nausea, vomiting and
abdominal pain. Lactate of 4. Evaluate for ischemic bowel,
inflammation, obstruction or diverticulitis.
There are no prior cross-sectional abdominal studies for
comparison.
TECHNIQUE: Contiguous axial images through the abdomen and
pelvis were obtained following the administration of oral and
130 cc of Optiray contrast. Coronal and sagittal reformatted
images were generated.
CT OF THE ABDOMEN WITH CONTRAST: There are patchy bibasilar
opacities within the lungs. The liver, spleen, pancreas, and
adrenal glands are normal. There are numerous gallstones within
the gallbladder, which is otherwise unremarkable in appearance.
Kidneys enhance symmetrically and excrete normally.
There is a nasogastric tube in place. The distal esophagus is
distended with oral contrast, and the stomach is quite distended
with contrast, with a long air-fluid level within the stomach.
The duodenum takes a slightly unusual course, with the
third/fourth portion of the duodenum coming to the abdominal
midline (anterior to the aorta), and then coursing immediately
back into the right upper quadrant. The relationship of the
superior mesenteric artery and vein is normal. There are
multiple dilated loops of small bowel with air- fluid levels
consistent with obstruction. Dilated small bowel loops are
located in the right and left upper quadrants. There is a
possible transition point identified within the left anterior
mid abdomen (series 2A, image 50) and in the coronal plane
(series 424B, image 13). Small bowel loops within the lower
abdomen and within the pelvis are completely decompressed. There
is a small amount of stool material and air within the colon. It
is also noted that the transverse colon courses posterior to
several of the dilated small bowel loops. There are small
triangles of fluid surrounding the dilated small bowel loops,
raising the possibility of ischemia of these loops. There is no
free air in the abdomen.
The aorta is of normal caliber, and the proximal celiac, SMA,
and [**Female First Name (un) 899**] are patent.
CT OF THE PELVIS WITH CONTRAST: There is a small amount of air
within the rectum. The colon is largely decompressed, containing
small amounts of stool and air material. There is a Foley
catheter within the bladder, and air within the bladder likely
related to instrumentation. The distal ureters are unremarkable.
There are traces of free fluid within the pelvis. No
pathologically enlarged pelvic or inguinal lymph nodes.
BONE WINDOWS: There are no suspicious osteolytic or sclerotic
lesions. There are degenerative changes of the spine.
Multiplanar reformatted images were essential in delineating the
anatomy and pathology in this case.
IMPRESSION:
1. Evidence of small bowel obstruction, with dilated loops of
small bowel and air-fluid levels present. Small triangles of
fluid adjacent to the dilated small bowel loops raise the
possibility of ischemia of these loops.
2. There is a possible transition point within the anterior left
mid abdomen. The possibility of a [**Doctor Last Name 6261**] hernia is raised at
this locale.
3. Unusual configuration of the third and fourth portion of the
duodenum, with this portion of the duodenum crossing just
anterior to the aorta, and then immediately coursing into the
right upper quadrant. The SMV and SMA relationship remains
normal.
4. Small bowel loops are located anterior to the transverse
colon, of undetermined significance. Given that the transition
point appears to be located at the anterior abdominal wall,
internal herniation of significance is thought to be less
likely.
The findings of small bowel obstruction and concern for ischemia
were discussed with Dr. [**First Name (STitle) 3037**] at approximately 11:50 p.m. on
[**2128-8-21**]. Surgical consultation was advised.
Brief Hospital Course:
He is an elderly, debilitated gentleman with dementia, who
presented with peritonitis. An NGT was placed and coffee ground
fluid was extracted.
# Abdominal Pain/Nausea - [**Month (only) 116**] be related to upper GI etiology.
However, elevated lactate also concerning for ischemia, but
guaiac negative. Diarrhea does not appear to be acute so
unlikely acute infectious etiology. LFT's not elevated (amylase
elevation d/t vomiting).
- A CT on [**2128-8-21**] showed evidence of small bowel obstruction,
with dilated loops of small bowel and air-fluid levels present.
The decision for exploratory laparotomy was made and he had a
gastrostomy tube placement.
-Post-operatively he was NPO. POD 3 he was started on tube
feedings at a slow rate and his rate was slowly advanced while
watching his residuals. He was noted to have a residual of >120
cc. His tube feedings were held on POD 5 and POD 6. After a
bowel movement with aid of a Fleet enema, tube feedings were
started back at 20cc/hr. We were able to increase his tube
feedings and reach his goal of 70cc/hr.
.
A Speech and Swallow Video Oropharyngeal evaluation revealed
that he could tolerate thin liquids and pureed solids. Yet, he
had minimal PO intake and will need to continue on the
tubefeedings.
.
# GIB - He had coffee ground emesis that was guaiac positive. No
evidence of obstruction on KUB. Hct was 40 on admission, but
likely hemoconcentrated as not eating or drinking for multiple
days. It was lavaged until clear, then close off NGT (not to
suction). He also was started on Reglan IV to help with motility
and we held his ASA.
.
#ID - He had a spike in temperature to 101.7 on the morning of
POD 9. Blood, urine and central line catheter tip was cultured
and were all negative.
MICRO: [**8-23**] VRE:+entercoccus sensitivity P, cath Cx: neg; [**8-22**]
BCx p, [**8-21**] Bcx: coag neg staph [**1-6**], [**2-6**] P, Ucx: neg.
.
#Radiology - [**9-1**] Abd CT: no obstruction. [**8-29**] Abd-XR: no free
air. [**8-28**] CXR: pulmonary edema [**8-27**] CXR - LLL atelectasis is
improving. [**8-25**] CXR increased moderate-sized right pleural
effusion, and atelectasis at the left lung base has worsened.
Mediastinal vascular engorgement has worsened. No pneumothorax.
[**8-24**] CTA- no PE, RUL interstitial infiltrates (edema vs
aspiration vs pneumonia), [**8-23**] CXR: R lung and LLL opacities c/w
multifoc PNA vs asp; [**8-22**] CXR Rt patchy opacity/retrocardiac;
[**8-21**] CXR: L retrocardiac consolidation, [**8-21**] CT AP: Proximal
SBO.
.
# Sepsis - Qualifies as severe sepsis with leukocytosis, fever,
suspected infection, elevated lactate. Unclear source, although
may have PNA based on repeat CXR.
- Continue broad spectrum antibiotics. After the OR he was
initially on Vancomycin and then this was D/C'd as his cultures
were negative except for Staphylococcus, Coagulase Negative,
isolated from one set only. He had a WBC of 13.7 on POD 6.
.
# Elevated Cr - Cr 1.3 on admission, down to 1.2. Unclear
baseline.
- Hold metformin and lisinopril
- Hydration prior to CT with contrast, as well as mucomyst
.
# HTN - He was normotensive to hypotensive on admission
- His lisinopril and atenolol were held until GIB stable and
the was managed on IV Lopressor as needed, until he was able to
receive his pills thru the G-tube.
.
# DM - On metformin as outpatient
- Hold metformin in setting of mildly elevated Cr and contrast
from CT
- ISS
.
# GERD -
- [**Hospital1 **] IV PPI
.
# Seizures - On POD 6, he was noted to have some seizure
activity in the AM lasting several minutes. A phenobarbital
level was 23 at the time. We continued with phenobarbital IV.
.
# Resp - The was transferred to [**Hospital Ward Name 121**] 2 for ?Tb precaution. It
was later determined that that the patient had Tb 10 years ago,
was treated and no longer needs to be on precautions.
.
# Psych - Dementia based on outpt meds
- Restart Aricept once taking PO
- Ativan HS
.
# PPX -
- Hep SQ
- Bowel regimen
- PPI
.
# Access - R subclavian D/C'd POD 8. Peripheral access was
obtained.
.
# Code - Do not resuscitate (DNR/DNI)
Comments: pt demented, no health care proxy. DNR/[**Name2 (NI) 835**] per nursing
home records. order reinstated as now 7 days post-op from
operation.
Corroborated with: [**Last Name (LF) **],[**First Name3 (LF) 251**] on [**2128-8-30**] at 1800
Medications on Admission:
Nabumetone 500 [**Hospital1 **] w/ meals, Metformin 500 PO BID,Lisinopril 20
PO QAM,Tylenol 325-650 prn, ASA 81mg QD, Phenobarbitol 60 PO BID
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): See sliding scale.
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for HR<60, BP<100.
11. Phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
13. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 16166**] Facility - [**Location (un) 538**]
Discharge Diagnosis:
Multifocal Adhesive Peritonitis with Small Bowel Obstruction
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all medications as ordered.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in [**2-6**] weeks. Call ([**Telephone/Fax (1) 27730**] to schedule an appointment.
Completed by:[**2128-9-8**]
|
[
"5849",
"486",
"4280",
"25000",
"4019",
"2720"
] |
Admission Date: [**2125-8-16**] Discharge Date: [**2125-8-24**]
Date of Birth: [**2061-8-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest burning
Major Surgical or Invasive Procedure:
[**2125-8-20**] CABG x 5 (LIMA to LAD, SVG to Ramus, SVG to OM1 and OM2
sequentially, SVG to PDA)
History of Present Illness:
63 year old white male with no previous cardiac history who
developed chest burning on exertion while on vacation.
Cardiology workup revealed non-ST elevation MI. Cardiac
catheterization and coronary angiography reveals severe 3VD.
Past Medical History:
Coronary artery disease
NSTEMI [**2125-8-1**]
infrarenal AAA
prostate cancer s/p seed implants [**2121**]
melanoma- anterior abd wall- awaiting excision
Social History:
Manufacturer of stair cases. Lives with wife. Quit smoking 40
years ago with 12 pyh
Family History:
No family history of coronary disease.
Physical Exam:
Pulse: 73 Resp: 14 O2 sat: 95%RA
B/P Right: 149/100 Left:
Height: 68" Weight: 71.9 KG
General: WG, WN, WD [**Male First Name (un) 4746**] in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur no 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 x
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Pertinent Results:
Conclusions
PRE BYPASS The left atrium is elongated. 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. The interatrial septum is aneurysmal. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild global left ventricular hypokinesis (LVEF = 40-45
%). The right ventricle displays borderline normal free wall
function. 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. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**2-2**]+)
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 The patient is being AV paced. Suboptimal imaging is
worsened and the study is limited for that reason. The left
ventricular systolic function is about the same as pre-bypass
with an EF of about 40-45%. A focal wall motion abnormality is
not seen but can not be fully excluded. Initially after
separation from bypass, the basal right free wall of the right
ventricule, which is the only portion that is well seen,
displayed moderate to severe hypokinesis. Ten minutes after
separation, the function was improved to the pre-bypass state.
The tricuspid regurgitation was slightly worsened and bordered
on moderate but improved to pre-bypass level as well. The mitral
valve is not seen and the extent of mitral regurgitation could
not be adequately assessed. In limited views, the thoracic aorta
appears intact
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2125-8-20**] 17:52
?????? [**2119**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted from OSH on [**8-16**]. Preop w/u completed and went to
surgery with Dr. [**First Name (STitle) **] on [**8-20**]. Transferred to the CVICU in
stable condition on titrated phenylephrine and propofol drips.
Extubated later that evening and awoke neurologically intact.
Transferred to the floor on POD #1. In the operating room the
patient was found to have costochondral dissociation at the
sternum. This has been followed on CXR as well as physical exam
and has remained stable post-operatively. Chest tubes and
pacing wires were discontinued without complication. Physical
therapy was consulted for assistance with post-operative
strength and mobility. The patient progressed as planned
through the cardiac surgery pathway without complication. He
was discharged in good condition to home on POD 4. He was found
to have an abdominal aortic aneurysm preoperatively and has been
arranged to follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) 4902**].
Medications on Admission:
[**Doctor First Name 130**]
flonase
optivar eye gtt
prozac 2mg elixir daily
viagra prn
Plavix 300 MG at outside hospital
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
4. Fluoxetine 20 mg/5 mL Solution Sig: Two (2) mg PO DAILY
(Daily).
5. Fexofenadine 60 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]/[**Hospital1 8**] VNA
Discharge Diagnosis:
CAD s/p CABG x 5
NSTEMI [**8-9**]
infrarenal AAA
prostate CA s/p seed implants [**2121**]
melanoma of anterior abdominal wall- awaiting excision
Discharge Condition:
Good
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. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr. [**Last Name (STitle) 171**] [**Telephone/Fax (1) 62**] in 1 week please call for appointment
Dr. [**Last Name (STitle) **] in [**3-6**] weeks () please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2125-8-24**]
|
[
"41071",
"2761",
"41401"
] |
Admission Date: [**2112-10-31**] Discharge Date: [**2112-11-13**]
Service: NEUROSURGERY
Allergies:
Novocain / Fentanyl
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Thoracic mass
Major Surgical or Invasive Procedure:
Thoracic spinal mass resection
History of Present Illness:
83y/o male with hx of recal cell carcinoma presented with
abdominal pain over the past one month. The pain located at the
left side of umbilicus, almost as band like distribution. The
pain was also sensed as dull, uncomfortable feeling.
Besides this pain, he did not have any other symptoms such as
weakness, numbness, difficulty in ambulation, urination,
stooling.
Last weekend, he felt the symptom did not imporved and visited
OSH ED. There he was obtained CT scan and eventually follow up
MRI, and found to have T9 mass lesion. He was referred to [**Hospital1 18**]
for further evaluation.
ROS: No headache, fever, trauma hx, urinary/bowel incontinence.
Past Medical History:
Renal cell carcinoma: s/p L nephrectomy in [**2104**]. Pathology was
renal cell ca, clear cell type, grade III, size 8.5 cm, invasion
into renal vein was present. Has had surveillance CT scans
yearly
at OSH - all negative.
Atrial fibrillation - has been in sinus, anti-coagulated
TURP for BPH
hyperlipidemia
Social History:
Married, 6 children. Retired from the air force, was a fighter
pilot. Drinks 3-4 drinks/week. Tobacco - smoked 40 yrs, ~1
pack/wk - quit in [**2089**]. No illicits.
Family History:
father - MI, mother - AD, brother - colon ca at age 73.
Physical Exam:
Vitals: 97.8 HR 64, reg BP 105/64 RR 16 SO2 100% r/a
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear. Extra ear canals, ear drums
clear.
Neck: No Carotid bruits
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Tenderness at the left side of umbilicus. No defenese,
rebound.
Ext: No arthralgia, no cyanosis/edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect
Orientation: Oriented to person, place, and date
Language: Fluent with good comprehension and repetition. Naming
intact. No dysarthria or paraphasic errors
No apraxia, no neglect
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Visual fields are full to finger movement. Fundi
normal bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to tuning fork bilaterally. No tinnitus. No
nystagmus.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk and tone bilaterally
No tremor, no asterixis
Full strength throughout
MMT [**Doctor First Name **] Tri [**Hospital1 **] WExt WFlx IO IP Quad HS TA GC [**Last Name (un) 938**] ToeExt ToeFlx
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
Slightly unstable one foot standing at the left.
No pronator drift
Sensation: Hyperestesia at the left T9-T10 both
anterior/posterior trunk. Intact to light touch, pinprick,
temperature (cold), vibration, and propioception throughout all
extremities.
Position sense slightly decreased at the left toe.
Reflexes: B T Br Pa Ankle
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes were downgoing bilaterally
Coordination: Normal on finger-nose-finger, rapid alternating
movements normal, FFM normal.
Gait: stance is narrow based, with stable gait. Stable tandem
gait
Meningeal sign: Negative Brudzinski sign. No nucal rigidity.
Pertinent Results:
6.1>13.4/37.7<202
SED-Rate: 17
PT: 37.5 PTT: 37.7 INR: 4.2
139 107 29 99 AGap=14
------------------
4.3 22 1.6
Ca: 9.4 Mg: 2.4 P: 3.1
T-spine CT ([**11-1**]):
1. Large mass involving the posterior elements at the level of
T9 on the left which is invading the central canal and causing
thecal sac compression.
2. Multiple masses in the lung consistent with metastases.
Findings were discussed with you the day of the study.
L-spine CT ([**11-1**]):
1. Congenitally narrowed central spinal canal as described
above. Mild degenerative changes at L4-5 with a diffuse
broad-based disc bulge. There is no evidence for neural
foraminal narrowing.
2. No bony lesions are identified to indicate metastatic isease
in the lumbar spine. Please see thoracic spine report of the
same date for significant findings regarding likely metastatic
disease.
Chest CT ([**11-1**]):
1. Numerous bilateral soft tissue density pulmonary nodules
consistentwith pulmonary metastases. Given the history of prior
nephrectomy, metastatic renal cell carcinoma is likely.
2. Destructive osseous lesion in the T9 vertebral body with
encroachment upon the spinal canal. Urgent Neurosurgery consult
and further characterization with dedicated MRI is required.
3. Coronary artery calcifications.
Brief Hospital Course:
Patient was admitted to Medicine service for initial work up. CT
guided biospy was performed on [**2112-11-3**], pathology result was
renal cell carcinoma and the T9 lesion was considered
metastasis.
Right after receiving this result, patient was scheduled for (1)
tumor embolization by interventional radiology and (2)t7-11
laminectomies/mass resection and fusion on [**2112-11-8**] by Dr.
[**Last Name (STitle) 548**].
Post operatively he was moving all extremities with full
strength he had a drain placed interoperatively.
On POD#2 his hematocrit was 22.8 he received 2 units of PRBCs,
follow up crit was:
Physical therapy was consulted and cleared patient for discharge
to home.
Medications on Admission:
Coumadin
Tricor
Zocor
Discharge Medications:
1. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
2. Simvastatin 40 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. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Metastic Renal Cell Carcinoma
Discharge Condition:
Neurologically stable.
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
?????? If you have steri-strips in place ?????? keep dry x 72 hours. Do
not pull them off. They will fall off on their own or be taken
off in the office
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for signs of
infection
?????? If you are required to wear one, wear cervical collar or back
brace as instructed
?????? You may shower briefly without the collar / back brace unless
instructed otherwise
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? 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:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Restart Coumadin in a month
Followup Instructions:
Have staples removed in 10 days.
Follow up in 6 weeks with Dr. [**Last Name (STitle) 548**], [**Hospital 18**] [**Hospital 4695**] Clinic,
[**Telephone/Fax (1) 1669**].
Follow up with Renal Oncology Clnic at 4pm on [**2112-12-5**] with Dr.
[**Last Name (STitle) 1729**]/Dr. [**Last Name (STitle) **], [**0-0-**].
Completed by:[**2112-11-12**]
|
[
"42731",
"5849",
"4019",
"2724",
"V1582"
] |
Admission Date: [**2151-2-12**] Discharge Date: [**2151-2-25**]
Service:
ADMISSION DIAGNOSIS:
Unresponsive episode.
DISCHARGE DIAGNOSES:
1. Coronary artery disease
2. Status post coronary artery bypass grafting x 4.
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
man who was brought to an outside hospital Emergency
Department after he had an unresponsive episode of [**2-1**]
minutes in duration. The patient remained continent of both
bladder and bowel, no chest pain, significant for shortness
of breath. EKG showed inferior changes and evidence of old
myocardial infarction. The patient was started on
nitroglycerin, heparin drips and transferred for cardiac
catheterization.
PAST MEDICAL HISTORY: 1. Essential tremor. 2. Hard of
hearing.
MEDICATIONS: 1. Inderal 80 mg q.d. 2. Primidone.
PHYSICAL EXAMINATION: The patient was an elderly man in no
acute distress. Vital signs were stable, afebrile. HEENT:
Atraumatic, normocephalic, extraocular movements intact,
pupils were equal, round, and reactive to light, anicteric,
throat was clear. Neck: Supple, midline without masses or
lymphadenopathy. Chest: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm without murmur, rub
or gallop. Abdomen: Soft, nontender, nondistended without
masses or organomegaly, obese. Extremities: Warm,
nontender, nonedematous x 4. Neurologic: Grossly intact.
LABORATORY DATA: On admission complete blood count was
4.6/12/35/144. Chemistries were 136/3.5/102/20/24/0.8/108.
CK was 284, CK MB 42.5, troponin 0.24.
HOSPITAL COURSE: The patient was admitted for cardiac
catheterization, given outside hospital findings on the EKG
consistent with a cardiac event. Cardiac catheterization
revealed an ejection fraction of 35-40%, right dominant
coronary artery system with severe left main and three-vessel
disease. There were also findings consistent with an acute
inferolateral myocardial infarction and the patient was
placed on an intra-aortic balloon pump. Subsequent to the
cardiac catheterization, the patient was transferred to the
coronary care unit for close monitoring. In the coronary
care unit he was maintained on his balloon pump.
Cardiovascular surgery was consulted and it was felt that the
patient would benefit from revascularization surgery.
On [**2151-2-15**], the patient was taken to the operating room for
coronary artery bypass grafting x 4 with intra-aortic balloon
pump placed preoperatively. The anastomoses were as follows:
Left internal mammary artery to the diagonal artery,
saphenous vein graft to the left anterior descending coronary
artery, PL and OM. Overall the patient tolerated the
procedure well without significant complication.
Postoperatively he was taken to the CSRU for closer
monitoring. The intra-aortic balloon pump was weaned from a
1:1 rate to a 1:2 rate. The patient was ultimately extubated
on postoperative day number one and the intra-aortic balloon
pump was discontinued at that time as well. The patient did
require some Neo-Synephrine blood pressure support. On
postoperative day two in the early morning, the patient went
into atrial fibrillation with a rapid response. He received
an amiodarone bolus intravenously followed by an amiodarone
drip as well as Lopressor intravenous. The patient converted
back to normal sinus rhythm after approximately three hours
of rate-controlled atrial fibrillation.
The remainder of his postoperative course was largely
unremarkable. He did have a mild episode of confusion on
postoperative day four before he was transferred out of the
unit. This resolved quickly without any intervention.
The patient was ultimately transferred to the floor on
postoperative day four and had no significant events after
that. He was noted to have some serosanguinous drainage
coming from his sternal wound, but this was assessed by both
the fellow and the attending physician and felt to be
relatively stable. Dr. [**Last Name (STitle) **] also made the decision that he
would not need any further operative management. The
remainder of his postoperative course was concerned largely
with physical therapy and diuresis. The patient was
ambulating well although he was noted to have saturations
dropping down into the mid-80s on room air while ambulating.
Ultimately, the patient was discharged on postoperative day
10 tolerating a regular diet and with adequate pain control,
and having only minimal drainage from his sternal wound. He
was cleared for home by physical therapy.
Physical examination on discharge, in general the patient was
in no acute distress. Vital signs were 98.1, heart rate 77,
blood pressure 128/63, respiratory rate 18, 100% on two
liters nasal cannula. Chest: Fine crackles at the bases.
There was some minimal serosanguinous drainage coming from
his sternal wound, although his sternum was stable.
Cardiovascular: Regular rate and rhythm without murmurs,
gallops, or rubs. The patient does have [**12-31**]+ edema improved
slightly over his floor stay. Neurologic: Grossly intact.
Laboratory studies on discharge were hematocrit 32.4,
chemistries 138/4.5/103/25/25/1.1/113. Magnesium 2.5.
DISCHARGE CONDITION: Stable.
DISPOSITION: To home with services.
DIET: Cardiac.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Amiodarone 400 mg q.d.
3. Lasix 40 mg b.i.d. x 7 days.
4. Potassium chloride 20 mEq b.i.d. x 7 days.
5. Lopressor 12.5 mg b.i.d.
6. Clindamycin 300 mg q.i.d. x 7 days.
7. Percocet 5/325, 1-2 tablets p.o. q. 4 hours p.r.n.
8. Colace 100 mg b.i.d.
9. Primidone 50 mg b.i.d.
DISCHARGE INSTRUCTIONS:
1. The patient is to continue incentive spirometry,
ambulation and physical therapy at home.
2. He is to have VNA for cardiopulmonary checks as well as
dry sterile dressing to the sternum b.i.d. Frequency may
decrease to q.d. if drainage decreases appropriately.
3. The patient should follow up with cardiology in [**12-31**] weeks'
time and address the need for continuing diuresis as well as
adjustment of cardiac medications at that time.
4. The patient should follow up with Dr. [**Last Name (STitle) **] in four
weeks' time.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2151-2-25**] 13:17
T: [**2151-2-25**] 13:31
JOB#: [**Job Number 45811**]
|
[
"41401",
"9971",
"42731",
"4241",
"4280"
] |
Admission Date: [**2137-1-18**] Discharge Date: [**2137-2-4**]
Service: VSU
HISTORY OF PRESENT ILLNESS: Patient is an 83-year-old,
Russian only speaking female admitted due to likely
cellulitis of her right above the knee amputation stump. Her
history was limited by absence of a family member or
translator at the time of interview, and the remainder of her
history was obtained from her medical record.
Past medical history includes coronary artery disease, status
post percutaneous transluminal coronary angioplasty and stent
in [**2131**], coronary artery bypass graft in [**2132-7-29**],
cerebrovascular accident in [**2128**], right medullary
cardiovascular accident in [**2135-3-29**], seizure disorder,
diabetes, hypertension, hypercholesterolemia, carotid artery
stenosis, renal artery stenosis status post stent placement
in the left renal artery, recurrent urinary tract infection,
severe depression status post ECT therapy, left femoral neck
fracture, right groin hematoma, recurrent urinary tract
infections, peripheral vascular disease.
Past surgical history includes repair of a ruptured infected
right femoral pseudo aneurysm, coronary artery bypass graft,
right common femoral to anterior tibial artery bypass graft
with a PTFE and distal talar vein patch in [**2131**] by Dr.
[**Last Name (STitle) **], left closed reduction internal fixation of the left
hip fracture, and evacuation of right groin hematoma.
SOCIAL HISTORY: Patient does not drink alcohol. She does
not smoke cigarettes. She has a son and daughter-in-law and
daughter who are involved in her care.
PHYSICAL EXAMINATION: Temperature 98.8, heart rate 70, blood
pressure 118/74, sating 96 percent on room air. In general,
the patient was alert, in no acute distress. She has slight
scleral icterus and some sublingual icterus. Heart is
regular rate and rhythm. Lungs are clear to auscultation
bilaterally. Abdomen is soft, nontender, obese; positive
bowel sounds. She has a bluish tinge periumbilically.
Extremities, particularly the left lower extremity, show 2 to
3 plus pitting edema. Pulses right femoral is 2 plus, left
femoral 2 plus, popliteal 1 plus, DP triphasic, PT triphasic.
PERTINENT RESULTS AT THE TIME OF ADMISSION: White blood cell
count 9.3 with 73 percent neutrophils. Creatinine of 1.5.
CT of the legs showed skin thickening and subcutaneous
stranding in the medial thigh corresponding to physical exam
without underlying abscess, similar skin thickening and
pronounced subcutaneous stranding and extensive soft tissue
attenuation surrounding the prosthetic graft in the anterior
lateral thigh also suspicious for infection, mottled and
demineralized appearance of the femur likely related to
disease.
Medications on admission include nifedipine 30 mg p.o. once
daily, metoprolol 50 mg p.o. b.i.d., atorvastatin 20 mg p.o.
once daily, glyburide 5 mg p.o. b.i.d., aspirin 325 mg p.o.
once daily, valsartan 80 mg p.o. once daily, levofloxacin 250
mg p.o. once daily, buspirone 10 mg p.o. b.i.d., bupropion
150 mg p.o. b.i.d., multivitamin 1 cap p.o. once daily,
acetaminophen 325 to 650 mg p.o. q. [**4-3**] p.r.n., lorazepam at
1.5 mg p.o. at bedtime, vancomycin 1 gm IV q. 48h., Flagyl
500 mg p.o. t.i.d., heparin 5000 units subcutaneously b.i.d.
Patient was admitted on [**2137-1-18**] and was continued on IV
vancomycin and levofloxacin for presumed right above the knee
amputation stump infection. She was also evaluated for heart
failure causing the peripheral edema. During the patient's
stay she had considerable difficulty receiving blood pressure
control. This required multiple medication maneuvers.
She was taken on [**2137-1-21**] to the Operating Room for an I
and D of the infected leg and removal of her right thigh
graft, which she tolerated well. Renal function was a
concern, however, afterwards and her chronic renal
insufficiency with acute exacerbation required monitoring.
Postoperatively, she continued to receive her IV antibiotics
and did receive a PICC line for easier administration. Also
postoperatively, the patient was seen by Psychiatry both for
treatment of her severe depression as well as acute mental
status exacerbations and need for a one-to-one sitter.
After a couple days of dressing changes soaked in acetic
acid, the patient's leg wound had a VAC dressing placed,
which worked well for healing purposes.
On postoperative day 3 the patient did experience a fever and
received a fever workup. Her chest x-ray did not have any
CHF or pneumonia. She also had blood and urine cultures
performed. During her stay the patient did require blood
transfusion which did cause a degree of heart failure and the
need for Lasix. Cardiac service was made involved at that
time because during her blood transfusion her systolic blood
pressure decreased and the patient went into a junctional
escape rhythm requiring telemetry and close observation.
However, the patient did spontaneously convert back to sinus
rhythm. The cardiac service made recommendations to hold
beta blockers as well as began to make plans for possible
pacer placement.
On the morning of [**2137-1-30**] the patient was noted on
telemetry to acutely brady down to asystole. She was
emergently coded, requiring artificial respiration and chest
compressions. She was shocked a number of times as well as
received a number of cardiac inotropic medications. Patient
was successfully revived and was transferred to the Intensive
Care Unit for further care. She was, at that time, seen by
the Electrophysiology Department, who then placed a cardiac
pacemaker. While in the ICU the patient never truly woke up
from a neurological standpoint, although she would turn her
head to the left and withdraw her left leg to pain. She
never truly regained consciousness. She was started on tube
feeds. She did require IV blood pressure management and
drips for severe hypertension. She did remain vent dependent
after resuscitation in the ICU, and finally on [**2137-2-4**] the
patient was made comfort measures only by the family.
Patient's ventilatory support was removed and by the evening
of [**2137-2-4**] at 9:55 p.m. the patient expired with no blood
pressure and no respiratory effort. Patient's family has
been contact[**Name (NI) **] to alert them of the passing, and they do not
wish an autopsy to be performed. She will be discharged to
the funeral home.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3186**]
Dictated By:[**Last Name (NamePattern1) 3956**]
MEDQUIST36
D: [**2137-2-4**] 22:51:38
T: [**2137-2-5**] 10:33:29
Job#: [**Job Number 3957**]
|
[
"25000",
"42789",
"41401",
"V4581"
] |
Admission Date: [**2163-10-2**] Discharge Date: [**2163-10-4**]
Date of Birth: [**2085-3-26**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
CARDIAC CATHETERIZATION with stent placement [**2163-10-2**]
History of Present Illness:
Mr. [**Known lastname 1313**] is a 78 year-old male with PMHx of DM who presented
to the [**Hospital1 18**] ED with bilateral arm pain as well as anterior neck
pain on activity. He initially noticed while walking on the
treadmill. Today, pain was severe [**11-16**]. He stopped walking,
went home and took a nap. He then went to visit his sister in
the hospital and had recurrent symptoms prompting ED evaluation.
He reports that the pain is exertional in nature, radiates to
the neck and shoulders bilaterally, and ussually resolves with
rest. He denies any shortness of breath nausea or diaphoresis
associated with the chest pain. He reports that he has never had
this pain before. He also denies any cough, fever or chills.
.
In the ED, initial vitals were 96.6 58 122/76 18 100% on RA.
Labs and imaging significant for Troponin of 0.03, and an EKG
with ST depressions in V1-3 and sub-millimeter elevation in lead
III.
.
Patient given heparin, ASA, plavix 600 and taken to the cath
lab. There he was found to have a large thrombus occulsion of
the LCx that was treated and stented with resumption of normal
flow. During the procedure he experienced flushing and itching
and was thought to be having an allergic reaction, potentially
to the contrast and was given solumedrol and benadryl. He was
transfered to the CCU for monitoring following the procedure.
Vitals on transfer were 97.8, 61, 141/61, 17, 99% on RA.
.
On arrival to the floor, patient was stable and resting
comfortable. He denied and difficulty breathing and was chest
pain free.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
bilateral cataracts s/p surgery
history of prostate CA
Social History:
-Tobacco history: Never
-ETOH: Never
-Illicit drugs: Never
# Accountant, still working. He lost his wife 9 months ago to
prolonged illiness. He has 2 children. Both live in the area
Family History:
Non-contributory
Physical Exam:
VS: T=97.8 BP=141/61 HR=61 RR=17 O2 sat= 99% RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP unable to determine as pt laying flat as
per cath closure.
CARDIAC: RR, normal S1, S2. Soft 2/6 systolic ejection murmer.
No r/g. No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Right groin site
c/d/i, soft, no hematoma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2163-10-2**] 05:07PM BLOOD WBC-6.0 RBC-4.64 Hgb-14.5 Hct-41.3 MCV-89
MCH-31.3 MCHC-35.2* RDW-13.6 Plt Ct-178
[**2163-10-2**] 05:07PM BLOOD Glucose-134* UreaN-24* Creat-1.3* Na-141
K-4.5 Cl-107 HCO3-23 AnGap-16
[**2163-10-3**] 12:51AM BLOOD CK-MB-5 cTropnT-0.08*
.
[**2163-10-2**]:
Cardiac Cath:
1. Selective coronary angiography of this co-dominant system
demonstrated single vessel coronary artery disease. The LMCA was
without angiographically apparent flow-limiting stenosis. The
LAD had mild diffuse plaquing proximally and a 50% smooth
tubular stenosis at the mid-vessel. The LCx was a large vessel
with a 90% thrombotic lesion in the mid-segment prior to take
off of OM2. The LCx gives a reasonable sized L-PDA, small OM1
(takes off at the lesion), long 2.5mm OM2 that reaches the apex
and large bifurcating OM3. The AV groove LCs is a 2mm vessel.
OM2 has a 30% stenosis and OM3 has a 40% lesion proximal to
bifurcation. TIMI 2 flow noted distally. The RCA was a smaller
vessel that gives a small RPDA with mild luminal irregularities
throughout. There was a 20% proximal stenosis and diffusely
diseased distal segment that tapers to 80% at the bifurcation.
The RPDA takes off at a ("mild z") angle. TIMI 2 flow noted
distally.
2. Limited resting hemodynamics revealed systemic arterial
normotension.
3. Notably, while taking initial images, patient complained of
diffuse itching with an erythematous rash on his face. This was
contributed to contrast allergy and he was given Pepcid 20mg,
solumedrol 125mg, and benadryl 50mg promptly with gradual
symptom relief.
4. Successful aspiration thrombectomy, PTCA and stenting of the
mid LCx
with 3.0x18mm Promus Element drug-eluting stent post-dilated to
3.25mm
(see PTCA comments).
5. Successful right femoral arteriotomy closure with 6F
AngioSeal
device.
.
Echo [**2163-10-3**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). The right
ventricular cavity is dilated The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild aortic
regurgitation with normal valve morphology.
Brief Hospital Course:
78 yo male with PMHx of DM who presented with 2 days of
intermittent chest pain who on presentation was found to have a
posterior STEMI. He had PCI with placement of a DES to the LCx
with restoration of flow. The procedure was complicated by
itching during the procedure for which he received Solu-Medrol
and Benadryl.
.
Active Issues:
# Posterior STEMI: He presented with 2 days of intermittent
chest pain who on presentation to the [**Hospital1 18**] ED was found to have
a posterior STEMI. He had PCI with placement of a DES to the LCx
with restoration of flow. His course was complicated by the
below mentioned contrast allergy. He was initially maintained on
Integrilin and subsequently started on Plavix and aspirin. He
did well post procedure. He had a cardiac echo that showed an EF
of 55% and no wall motion abnormalities. Low-dose metoprolol
succinate was started on the day of discharge at 12.5mg daily
and can be uptitrated as tolertaed. His blood pressures were
100s-120s systolic and so given normal EF, ACEi was not started.
.
# Allergic Reaction: During the procedure the patient
experienced flushing and itching over his body. Never any airway
compromise. He received 125mg Solu-Medrol, Benadryl and Pepcid
in the cath lab. On presentation to the floor he denied any
difficulty breathing. He did well overnight with complete
resolution of the symptoms without breathing issues.
.
Chronic Issues:
# Diabetes: He is a diabetic on only metformin at home. He
reports that his diabetes is under good control having recent
lost 14 lbs. His home metformin was held during the
hospitalization and was placed on a low dose insulin sliding
scale and his blood sugars were well controlled. At time of
discharge he was placed back on his home dose metformin.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Sertraline 50 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO DAILY Hold for SBP<100,
HR<60
6. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevated Myocardial Infarction (heart attack) with thrombus
in left circumflex artery.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 6457**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for arm pain and found to have
a heart attack. You had a cardiac catheterization, and one of
your coronary arteries was stented open. The ultrasound of your
heart afterwards showed no obvious damage; you heart is still
pumping very well!
We started new medicines to prevent future heart attacks and a
very important medicine called Plavix (clopidogrel). Do NOT stop
taking Plavix without talking to your Cardiologist! We
electronically sent prescriptions to your pharmacy ([**Company 25282**])
at your request.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Address: [**Apartment Address(1) 26992**], [**Hospital1 **],[**Numeric Identifier 26419**]
Phone: [**Telephone/Fax (1) 16335**]
Appt: [**10-12**] at 1pm
Department: CARDIAC SERVICES
When: WEDNESDAY [**2163-11-2**] at 10:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You are seeing Dr. [**First Name (STitle) **] who did your cardiac cath
procedure. If you would like, you can see Dr. [**Last Name (STitle) **] in the
future. Dr. [**Last Name (STitle) **] does not have appointments for several weeks
and we did not want you to wait that long to see a cardiologist.
|
[
"41401",
"25000"
] |
Admission Date: [**2108-10-11**] Discharge Date: [**2108-10-17**]
Date of Birth: [**2065-7-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
- Mitral valve replacement with an On-X 25/33 mechanical mitral
valve prosthesis
- Patent foramen ovale closure.
- Resection of left atrial appendage.
- Talon sternal plating closure of sternum.
History of Present Illness:
This is a 43 year old female with progressive dyspnea on
exertion and lower extremity edema which required
hosptitalization in [**2108-4-20**]. During that
hospitalization, she was found to have severe pulmonary
hypertension and mild mitral stenosis. Despite medical therapy,
she has continued to experience dyspnea even at rest and
especially with minimal exertion such as walking up one flight
of stairs. Recent echocardiogram in [**2108-7-21**] revealed 3+MR
and a
PFO. Dr.[**Last Name (STitle) 914**] was consulted for surgical intervention.
Past Medical History:
Hypertension
Pulmonary Hypertension
Possible Rheumatic heart disease - MR/MS
[**First Name (Titles) 70393**] [**Last Name (Titles) **]
Asthma/COPD
Marked lower extremity edema/Lymph Edema
Migraines
Obstructive sleep apnea (CPAP- uses periodically)
Depression/Bipolar disorder
Possible Fibromyalgia on Percocet
Osteoarthritis
History of Bells Palsy, 10 years ago
Past Surgical History:
s/p cervical spine surgery in [**2103**] at [**Hospital1 1774**]
s/p TAH for excessive bleeding in [**2105**]
s/p C-section x 2
Social History:
She currently lives in [**Location 8985**], [**State 350**]. She is
married with two daughters who are healthy. She smokes one to
two packs per day for the past 21 years. Social alcohol use.
No drug use. She is currently unemployed and not on disability
Family History:
Significant for fibromyalgia in her brother, mother and maternal
aunt. History of ovarian, breast, and colon cancer in maternal
side. Congenital heart dz in niece. Mother with RHD and MVR as
well as MI in her 40s. MGF with stroke in 80s.
Physical Exam:
Pulse: 79 Resp: 22 O2 sat:94% RA
B/P Right: 119/75 Left: 114/70
Height:5'6" Weight:360 lbs
General: Obese female, very short of breath, appears older than
stated age of 43,
Skin: erythema/cellulitic changes noted on lower extremities.
was
non-tender to touch and did not feel warm to touch
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] - heart sounds very distant
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x]
Edema: 2+ pitting edema
Neuro: Grossly intact
Pulses:
DP Right: NP Left: NP
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 1+ Left: 1+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2108-10-15**] 03:39AM BLOOD WBC-10.7 RBC-3.22* Hgb-9.2* Hct-27.0*
MCV-84 MCH-28.5 MCHC-33.9 RDW-17.8* Plt Ct-351
[**2108-10-11**] 11:20AM BLOOD WBC-20.9*# RBC-4.03* Hgb-11.2* Hct-34.2*
MCV-85 MCH-27.7 MCHC-32.6 RDW-17.7* Plt Ct-407
[**2108-10-15**] 03:39AM BLOOD PT-15.6* PTT-27.4 INR(PT)-1.4*
[**2108-10-11**] 11:20AM BLOOD PT-14.2* PTT-25.3 INR(PT)-1.2*
[**2108-10-15**] 03:39AM BLOOD Glucose-106* UreaN-13 Creat-0.4 Na-137
K-4.0 Cl-96 HCO3-32 AnGap-13
[**2108-10-12**] 02:22AM BLOOD Glucose-123* UreaN-6 Creat-0.6 Na-135
K-4.2 Cl-101 HCO3-26 AnGap-12
[**2108-10-17**] 03:56AM BLOOD WBC-13.5* RBC-3.61* Hgb-9.7* Hct-30.7*
MCV-85 MCH-27.0 MCHC-31.7 RDW-16.9* Plt Ct-445*
[**2108-10-17**] 03:56AM BLOOD Plt Ct-445*
[**2108-10-17**] 03:56AM BLOOD PT-24.7* PTT-87.6* INR(PT)-2.4*
[**2108-10-15**] 03:39AM BLOOD WBC-10.7 RBC-3.22* Hgb-9.2* Hct-27.0*
MCV-84 MCH-28.5 MCHC-33.9 RDW-17.8* Plt Ct-351
[**2108-10-17**] 03:56AM BLOOD Glucose-123* UreaN-15 Creat-0.7 Na-137
K-3.9 Cl-100 HCO3-27 AnGap-14
[**2108-10-17**] 03:56AM BLOOD Calcium-10.0 Mg-2.7*
Radiology Report CHEST (PA & LAT) Study Date of [**2108-10-15**] 8:08 AM
[**Last Name (LF) **],[**First Name3 (LF) 177**] C. CSURG FA6A [**2108-10-15**] 8:08 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 70394**]
Reason: eval for effusion
[**Hospital 93**] MEDICAL CONDITION:
43 year old woman s/p MVR
REASON FOR THIS EXAMINATION:
eval for effusion
Provisional Findings Impression: YMf MON [**2108-10-15**] 2:08 PM
Interval increase in bilateral pleural effusions. No pulmonary
edema. Right
internal jugular line appears to be kinked at the site of
insertion, direct
examination is recommended.
Final Report
PA AND LATERAL CHEST RADIOGRAPH
INDICATION: 43-year-old woman post-MVR.
COMPARISON: [**2108-10-12**].
FINDINGS: The cardiomediastinal silhouette is stable. Bilateral
pleural
effusions have decreased. The aeration of the left lower lobe
has slightly
improved. There is no pulmonary edema, pneumothorax, or new
consolidation.
The appearance of the sternal wires and plates is stable. The
right internal
jugular central venous catheter ends in the mid-to-lower
superior vena cava,
catheter appears kinked at the site of the entrance in the skin,
clinical
correlation suggested.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Admitted same day surgery and underwent Mitral Valve Replacement
(#25/33mm On-X Mechanical Valve)/Patent foramen ovale
closure/Left atrial appendage ligation) with Dr.[**Last Name (STitle) 914**]. Cross
clamp time=72 minutes. Cardiopulmonary bypass time= 89 minutes.
She tolerated the procedure well and was transferred intubated
and sedated to the CVICU. See operative report for further
surgical details. She awoke neurologically intact and was
extubated without incident on POD#1. CPAP for obstructive sleep
apnea was initiated which she wears at home, along with
aggressive pulmonary hygiene. Anticoagulation with Coumadin was
initiated. INR goal for mechanical valve 3.0-3.5. All lines and
drains were discontinued in a timely fashion with criteria met.
Aspirin/Beta-blocker/statin started. POD#3 Heparin bridge to
therapeutic INR was begun. She continued to progress and was
transferred to the step down unit. Physical therapy was
consulted for evaluation of increased mobility and strength. The
remainder of her postoperative course was essentially
uneventful. She continued to progress and was cleared by
Dr.[**Last Name (STitle) 914**] for discharge to home, on post operative day six.
Medications on Admission:
Lasix 120mg po BID
KCl 20mEq po daily
Lisinopril 20mg po daily
Metolazone 5 mg po daily
Metoprolol Tartrate 100mg po BID
Alprazolam PRN
Albuterol Sulfate Inhaler 4 times a day PRN
Advair Diskus [**Hospital1 **]
Ipratropium PRN
Combivent Inhaler 4 times a day PRN
Nortriptyline 40mg po QHS
Abilify 15mg po qHS
Effexor XR 225mg po QHS
Percocet PRN back pain
Ibuprofen PRN
Fioricet PRN
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: INR goal 3.0-3.5 Tablets PO daily
dose varies: dose to be adjusted
Plan for 10mg on [**10-18**] with dose and then lab draw [**10-19**] for
further dosing .
Disp:*90 Tablet(s)* Refills:*2*
2. Warfarin 5 mg Tablet Sig: INR goal 3.0-3.5 Tablets PO dose
varies based on INR : Plan for 10mg on [**10-18**] and then lab draw
[**10-19**] for further dosing .
Disp:*90 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-23**]
Puffs Inhalation Q4H (every 4 hours).
Disp:*qs qs* Refills:*0*
7. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
8. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three
(3) Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*90 Capsule, Sust. Release 24 hr(s)* Refills:*0*
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
12. Nortriptyline 10 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
Disp:*120 Capsule(s)* Refills:*0*
13. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain.
Disp:*180 Tablet Sustained Release 12 hr(s)* Refills:*0*
14. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks: please follow up with PCP before complete .
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks: please follow up with PCP before complete .
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Mitral valve replacement with an On-X 25/33 mechanical mitral
valve prosthesis
Patent foramen ovale s/p closure
Hypertension
Pulmonary Hypertension
Rheumatic heart disease
[**Location (un) 34649**]
Asthma/COPD
Marked lower extremity edema/Lymph Edema
Migraines
Obstructive sleep apnea (CPAP- uses periodically)
Depression/Bipolar disorder
Possible Fibromyalgia on Percocet
Osteoarthritis
History of Bells Palsy, 10 years ago
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 100.5
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, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr.[**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (cardiologist) 2-3 weeks
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**] (PCP):in 1 week
Coumadin for mechanical MVR - plan for Dr [**Last Name (STitle) 3649**] to follow
coumadin and then she will refer to [**Location (un) **] coumadin clinic in
future spoke with office after patient discharged
PT/INR with goal INR 3.0-3.5 for mechanical MVR
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2108-10-18**]
|
[
"32723",
"3051",
"4168",
"311"
] |
Admission Date: [**2198-1-22**] Discharge Date: [**2198-2-14**]
Date of Birth: [**2116-6-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Attending Info 8238**]
Chief Complaint:
R knee pain
Major Surgical or Invasive Procedure:
Right knee debridement x2 and washout
Trans-esophageal echo and cardioversion
Electrophysiology ablation
History of Present Illness:
81 M history of AAA repair, COPD, CAD (pt denies any stents of
MIs), chronic pedal edema, right knee replacement 10 yrs ago
complicated with infection with removal of hardwear and
replacement, who is an OSH transfer for septic right knee.
Pt states that he had R knee replacement 10 yrs ago. 6 mo later
he had infected right knee. Hardware was removed,had spaced x 10
weeks. He was given IV antibiotics and had new implant later
that year and has no complicated since then.
Pt reports he was in his usual state of health until about a
week ago when started having chills. Few days later, noted right
knee pain when he stood up and "twisted" his knee. Then noted
some swelling. He came to the OSH ED where he was febrile and
found to have right septic knee. He met sepsis criteria with
fever, tachycardia, leukocytosis and was started on ceftriaxone
(day 1/1/8 in evening) and vanco (day 1=[**1-20**]). Flu swab negative,
blood cx neg thus far, UA neg. Pt had arthrocentesis on [**1-22**]
which showed frank pus. He was transfered to [**Hospital1 18**] for further
care.
Of note, throughout his hospitalization, he has been tachycardic
in the high 130s, febrile up to 103, RR 18, satting 95% on 2L.
.
On arrival to floor, pt triggered for tachycardia, Hr in the
high 140s. Sinus tach on EKG. no ST or TWI changes. Pt also
reported indigestion pain. Ambulance had given him SL nitro
which improved his heartburn pain. Pt currently feels okay, says
he has indigestion pain. No chest pain. he reports mild SOB,
currently breathing in mid 90s on 2L NC. he says his abd feels
distended, had very small bm this AM but otherwise is not having
regular bms.
.
On arrival to the MICU, patient was in moderate distress with
venturi mask in place. Satting 94% on venturi mask with RR of
35. He is c/o dyspnea and mild Gerd-like symptoms.
Past Medical History:
COPD
AAA [**11/2196**] repair
CAD
chronic pedal edema
bilateral knee replacement
melanoma of nose
colon polyps
Social History:
Active smoker most of his life 70+ years. No EOTH, no drugs.
Quit ETOH at age 50. used to be a big drinker. last drink 1 yr
ago.
Family History:
father - died 86
mother - died 89
GM - Dm2
Physical Exam:
ADMISSION EXAM
VS - T 99.5, HR 140, BP 122/80, RR 24,94%2L
GENERAL - ill appearing M in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - poor breath sounds bilaterally, crackles in the bases
bilaterally
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - distended, soft, non tender
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3,
right knee: effusion, warm
DISCHARGE EXAM:
VS: 98.1 119/64 78 20 93% RA 1560/2250
Gen: NAD, AAOx3, breathing comfortably
HEENT: MMM, OP clear, neck supple, no JVP
Chest: CTA b/l
CV: RRR, s1/s2 -m/r/g
ABD: soft, slightly distended
EXT: R knee in brace, non-erythematous, 1+ LE edema to knees
bilaterally, 2+ peripheral pulses
Pertinent Results:
ADMISSION LABS
[**2198-1-22**] 11:34PM BLOOD WBC-14.2* RBC-3.84* Hgb-12.0* Hct-34.3*
MCV-89 MCH-31.4 MCHC-35.1* RDW-12.8 Plt Ct-175
[**2198-1-22**] 11:34PM BLOOD Neuts-90.1* Lymphs-5.8* Monos-3.9 Eos-0.1
Baso-0.1
[**2198-1-22**] 11:34PM BLOOD Glucose-151* UreaN-14 Creat-0.8 Na-133
K-4.0 Cl-100 HCO3-23 AnGap-14
[**2198-1-23**] 09:58AM BLOOD Type-ART O2 Flow-2 pO2-72* pCO2-37
pH-7.45 calTCO2-27 Base XS-1 Intubat-NOT INTUBA
CTA CHEST [**2198-1-23**]
1. No evidence of central pulmonary embolism. However, due to
suboptimal
bolus timing, evaluation of subsegmental arteries is limited.
2. Ground-glass opacities at the right lung base, likely a
combination of
atelectasis and aspiration. Secretions in the trachea.
3. Small bilateral pleural effusions, right greater than left.
Bibasilar
atelectasis, right greater than left.
4. Left lower lobe pulmonary nodule measuring 5 mm. Followup
chest CT in 6
to 12 months is recommended.
5. Coronary artery and aortic valve calcifications.
6. Prominent right and left pulmonary arteries, suggestive of
pulmonary
hypertension.
7. Left adrenal adenoma.
8. Diffuse thickening of the esophagus, likely due to diffuse
esophagitis,
with a small hiatal hernia.
TTE [**2198-1-24**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. 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 normal (LVEF>55%). The aortic valve
leaflets are mildly thickened.The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.
Tricuspid regurgitation is present but cannot be quantified.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Preserved left ventricular systolic function. The TR
jet velocity suggests mild pulmonary hypertension, though the
right ventricle is not well seen to evaluate for RV
pressure/volume overload.
TEE [**2198-1-25**]
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 mass/thrombus is seen in the
left atrium or left atrial appendage. Right atrial appendage
ejection velocity is good (>20 cm/s). No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta to 40
centimeters from the incisors. The aortic valve leaflets (3) are
mildly thickened. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation
is present but cannot be quantified. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No evidence of intracardiac mass/thrombus. Mildly
dilated aortic root and ascending aorta. Simple atheroma aortic
arch. Complex atheroma in the descending thoracic aorta. Mild
mitral regurgitation. Significant tricuspid regurgitation.
CTA [**2-5**]:
IMPRESSION:
1. Retroperitoneal bleed into the left posterior pararenal space
and into the left psoas region.
2. A rounded cystic lesion measuring 18 x 19 mm is seen,located
in proximity to the left adrenal and the gastroesophageal
junction. This might represent an adrenal adenoma or an enteric
diverticulum.
CTA [**2-6**]:
IMPRESSION:
1. No acute pulmonary embolism or thoracic aortic pathology.
2. Large left retroperitoneal hematoma extending into the
pelvis, stable in extent and size since the prior study.
3. Stable left adrenal adenoma.
[**2198-1-22**] 11:34PM BLOOD WBC-14.2* RBC-3.84* Hgb-12.0* Hct-34.3*
MCV-89 MCH-31.4 MCHC-35.1* RDW-12.8 Plt Ct-175
[**2198-1-23**] 12:05AM BLOOD WBC-14.4* RBC-3.87* Hgb-12.5* Hct-34.6*
MCV-89 MCH-32.3* MCHC-36.2* RDW-12.8 Plt Ct-163
[**2198-1-23**] 05:45AM BLOOD WBC-15.2* RBC-3.64* Hgb-11.5* Hct-33.0*
MCV-91 MCH-31.8 MCHC-35.0 RDW-13.0 Plt Ct-194
[**2198-1-23**] 01:30PM BLOOD WBC-14.7* RBC-3.58* Hgb-11.3* Hct-32.5*
MCV-91 MCH-31.4 MCHC-34.6 RDW-12.9 Plt Ct-250
[**2198-1-24**] 01:41AM BLOOD WBC-10.4 RBC-3.23* Hgb-10.1* Hct-29.1*
MCV-90 MCH-31.5 MCHC-34.9 RDW-12.9 Plt Ct-192
[**2198-1-25**] 02:24AM BLOOD WBC-9.0 RBC-3.14* Hgb-9.7* Hct-28.4*
MCV-91 MCH-31.0 MCHC-34.3 RDW-13.1 Plt Ct-221
[**2198-1-26**] 04:44AM BLOOD WBC-10.4 RBC-3.21* Hgb-9.8* Hct-29.3*
MCV-91 MCH-30.4 MCHC-33.3 RDW-12.8 Plt Ct-343#
[**2198-1-27**] 12:40AM BLOOD WBC-7.8 RBC-3.00* Hgb-9.5* Hct-27.3*
MCV-91 MCH-31.6 MCHC-34.7 RDW-12.6 Plt Ct-323
[**2198-1-28**] 12:01AM BLOOD WBC-7.0 RBC-3.20* Hgb-9.8* Hct-28.8*
MCV-90 MCH-30.6 MCHC-34.0 RDW-12.8 Plt Ct-403
[**2198-1-29**] 06:00AM BLOOD WBC-8.5 RBC-3.36* Hgb-10.5* Hct-30.6*
MCV-91 MCH-31.1 MCHC-34.2 RDW-12.6 Plt Ct-484*
[**2198-1-29**] 03:55PM BLOOD WBC-7.8 RBC-3.10* Hgb-9.4* Hct-28.4*
MCV-91 MCH-30.2 MCHC-33.0 RDW-12.8 Plt Ct-476*
[**2198-1-30**] 05:58AM BLOOD WBC-7.2 RBC-3.14* Hgb-9.7* Hct-28.4*
MCV-91 MCH-30.8 MCHC-34.0 RDW-13.1 Plt Ct-510*
[**2198-1-31**] 05:59AM BLOOD WBC-6.9 RBC-2.88* Hgb-8.6* Hct-26.4*
MCV-92 MCH-29.9 MCHC-32.6 RDW-12.9 Plt Ct-481*
[**2198-2-1**] 05:45AM BLOOD WBC-6.5 RBC-3.07* Hgb-9.2* Hct-27.8*
MCV-91 MCH-29.9 MCHC-32.9 RDW-12.9 Plt Ct-493*
[**2198-2-2**] 05:35AM BLOOD WBC-9.2 RBC-2.99* Hgb-9.3* Hct-27.5*
MCV-92 MCH-31.1 MCHC-33.8 RDW-13.0 Plt Ct-527*
[**2198-2-3**] 06:35AM BLOOD WBC-9.2 RBC-2.72* Hgb-8.3* Hct-24.7*
MCV-91 MCH-30.4 MCHC-33.4 RDW-13.5 Plt Ct-520*
[**2198-2-4**] 11:55AM BLOOD Hct-21.6*
[**2198-2-4**] 07:51PM BLOOD Hct-24.2*
[**2198-2-4**] 11:58PM BLOOD Hct-22.8*
[**2198-2-5**] 02:01AM BLOOD Hct-23.4*
[**2198-2-5**] 06:42AM BLOOD WBC-9.9 RBC-2.58* Hgb-7.7* Hct-22.6*
MCV-88 MCH-29.9 MCHC-34.0 RDW-15.1 Plt Ct-578*
[**2198-2-5**] 10:11AM BLOOD Hct-37.1*#
[**2198-2-5**] 12:31PM BLOOD WBC-11.3* RBC-2.84* Hgb-8.4* Hct-24.8*#
MCV-87 MCH-29.6 MCHC-33.8 RDW-14.4 Plt Ct-563*
[**2198-2-5**] 11:57PM BLOOD Hct-26.2*
[**2198-2-6**] 05:18AM BLOOD WBC-11.6* RBC-2.89* Hgb-8.6* Hct-25.0*
MCV-87 MCH-29.9 MCHC-34.5 RDW-14.9 Plt Ct-472*
[**2198-2-6**] 05:03PM BLOOD Hct-22.2*
[**2198-2-6**] 09:55PM BLOOD Hct-22.5*
[**2198-2-7**] 03:44AM BLOOD WBC-11.4* RBC-2.51* Hgb-7.4* Hct-21.8*
MCV-87 MCH-29.5 MCHC-33.9 RDW-15.4 Plt Ct-437
[**2198-2-7**] 04:00PM BLOOD Hct-24.3*
[**2198-2-8**] 02:43AM BLOOD WBC-6.5 RBC-2.72* Hgb-8.2* Hct-24.3*
MCV-89 MCH-30.1 MCHC-33.7 RDW-14.7 Plt Ct-417
[**2198-2-8**] 09:07AM BLOOD Hct-23.9*
[**2198-2-8**] 02:42PM BLOOD Hct-24.6*
[**2198-2-9**] 06:33AM BLOOD WBC-5.7 RBC-3.07* Hgb-9.1* Hct-26.9*
MCV-88 MCH-29.8 MCHC-33.9 RDW-14.9 Plt Ct-395
[**2198-2-10**] 04:40AM BLOOD WBC-6.1 RBC-2.95* Hgb-8.9* Hct-26.2*
MCV-89 MCH-30.1 MCHC-34.0 RDW-15.1 Plt Ct-406
[**2198-2-10**] 04:40PM BLOOD Hct-28.8*
[**2198-2-11**] 05:32AM BLOOD WBC-7.2 RBC-3.06* Hgb-9.3* Hct-27.3*
MCV-89 MCH-30.3 MCHC-33.9 RDW-14.7 Plt Ct-394
[**2198-2-12**] 04:45AM BLOOD WBC-9.0 RBC-3.19* Hgb-9.6* Hct-28.4*
MCV-89 MCH-30.0 MCHC-33.7 RDW-14.9 Plt Ct-409
[**2198-2-14**] 06:20AM BLOOD WBC-8.4 RBC-3.11* Hgb-9.4* Hct-27.6*
MCV-89 MCH-30.2 MCHC-34.0 RDW-14.9 Plt Ct-430
[**2198-2-9**] 06:33AM BLOOD PT-13.5* PTT-28.1 INR(PT)-1.3*
[**2198-2-10**] 04:40AM BLOOD PT-13.8* PTT-30.3 INR(PT)-1.3*
[**2198-1-23**] 05:45AM BLOOD ESR-112*
[**2198-2-9**] 06:33AM BLOOD Glucose-108* UreaN-20 Creat-1.3* Na-138
K-3.6 Cl-102 HCO3-31 AnGap-9
[**2198-2-9**] 03:39PM BLOOD Glucose-117* UreaN-19 Creat-1.3* Na-136
K-3.2* Cl-99 HCO3-32 AnGap-8
[**2198-2-10**] 04:40AM BLOOD Glucose-105* UreaN-18 Creat-1.2 Na-136
K-3.3 Cl-100 HCO3-31 AnGap-8
[**2198-2-10**] 04:40PM BLOOD Glucose-173* UreaN-17 Creat-1.1 Na-136
K-3.5 Cl-99 HCO3-30 AnGap-11
[**2198-2-11**] 05:32AM BLOOD Glucose-121* UreaN-16 Creat-1.1 Na-137
K-4.7 Cl-99 HCO3-31 AnGap-12
[**2198-2-12**] 04:45AM BLOOD Glucose-99 UreaN-15 Creat-1.1 Na-137
K-3.2* Cl-97 HCO3-33* AnGap-10
[**2198-2-12**] 03:26PM BLOOD UreaN-17 Creat-1.1 Na-135 K-3.9 Cl-97
HCO3-32 AnGap-10
[**2198-2-13**] 06:15AM BLOOD Glucose-97 UreaN-16 Creat-1.1 Na-136
K-3.3 Cl-97 HCO3-36* AnGap-6*
[**2198-2-13**] 04:52PM BLOOD Na-137 K-3.7 Cl-97
[**2198-2-14**] 06:20AM BLOOD Glucose-99 UreaN-18 Creat-1.0 Na-136
K-3.6 Cl-99 HCO3-32 AnGap-9
[**2198-2-12**] 09:00PM BLOOD CK(CPK)-55
[**2198-2-5**] 11:57PM BLOOD CK-MB-2 cTropnT-0.08*
[**2198-2-12**] 09:24AM BLOOD CK-MB-3 cTropnT-0.04*
[**2198-2-12**] 09:00PM BLOOD CK-MB-2 cTropnT-0.03*
[**2198-2-14**] 06:20AM BLOOD Calcium-8.7 Phos-2.1* Mg-2.0
[**2198-2-13**] 04:52PM BLOOD Mg-2.0
[**2198-2-6**] 05:03PM BLOOD Hapto-173
[**2198-1-29**] 06:00AM BLOOD TSH-0.20*
[**2198-1-29**] 03:55PM BLOOD T4-5.0 T3-49* Free T4-1.2
[**2198-1-23**] 05:45AM BLOOD CRP-263.1*
[**2198-2-9**] CXR:
Mild pulmonary edema and moderate bilateral pleural effusions
have both
improved since [**2-8**]. The heart remains moderately
enlarged, and
mediastinal and pulmonary vasculature are engorged. Substantial
bibasilar
consolidation also persists. Whether this is pneumonia or more
likely a
combination of atelectasis and residual dependent edema is
really
indeterminate. Right PIC line ends in the mid SVC. No
pneumothorax.
[**2198-2-6**] CT Abdomen:
IMPRESSION:
1. No acute pulmonary embolism or thoracic aortic pathology.
2. Large left retroperitoneal hematoma extending into the
pelvis, stable in extent and size since the prior study.
3. Stable left adrenal adenoma.
[**2198-1-25**] TTE:
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 mass/thrombus is seen in the
left atrium or left atrial appendage. Right atrial appendage
ejection velocity is good (>20 cm/s). No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta to 40
centimeters from the incisors. The aortic valve leaflets (3) are
mildly thickened. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation
is present but cannot be quantified. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No evidence of intracardiac mass/thrombus. Mildly
dilated aortic root and ascending aorta. Simple atheroma aortic
arch. Complex atheroma in the descending thoracic aorta. Mild
mitral regurgitation. Significant tricuspid regurgitation.
Brief Hospital Course:
81 yo M with COPD, CAD and b/l knee replacements, transferred
from OSH on [**2198-1-22**] with a septic right knee, underwent
debridement with hardware repair by ortho surgery. Hospital
course complicated by aflutter with RVR and hypotension, fluid
overload with pulmonary edema, knee hematoma s/p repeat washout,
postop ileus, retroperitoneal bleed, UGIB from esophagitis,
delerium and [**Last Name (un) **].
# Septic R knee - Initially admitted to the medicine service for
a septic R knee, then sent to ortho for debridement. Outside
hospital cultures showed MSSA and he was started on nafcillin.
Post-debridement he required transfer to the SICU for pressors
and continued intubation. He was then transferred to medicine
where nafcillin was continued. He required a second debridement
of hematoma a few days later, and was then treated with a wound
vac until wound could be closed. ID was consulted and
recommended treatment with IV nafcillin for 6 weeks, then 6
months of oral suppressive thearpy afterwards with oral rifampin
indefinitely. He will need weekly labwork and follow-up as
instructed below.
.
# Atrial flutter - Found to be in aflutter on admission. This
was a new rhythm for him. Thought to be related to his septic
knee. He required SICU admission post-op for pressors and rate
control. He underwent TEE/cardioversion successfully, but then
returned to aflutter. He went on an amiodarone drip which
converted to sinus. On transfer back to medicine he returned to
aflutter with RVR. EP was called and he had an EP study with
ablation. Post-ablation he had atrial fib/aberrancy requiring
diltiazem for rate control eventually requiring maximum dose
diltiazem as well as increasing doses of metoprolol. He was
initially started on heparin, then transtioned to lovenox, with
plan to bridge to coumadin for 3 months of anticoagulation
post-ablation. However, anticoagulation was held due to
multiple bleeding risks, including active UGIB, a large RP bleed
and hematoma s/p washout of the right knee. He has a CHADS2
score of 2 and so would indicate anticoagulation with coumadin
if safe after his repeat EGD in mid-[**Month (only) 958**].
.
# Retroperitoneal bleed - On [**2-4**], his Hct began to trend down
to around 22. He received 2 units without a significant bump in
Hct. He then complained of L back pain and was found to have an
RP bleed. His Hct remained somewhat stable and he received
another 2 units on [**2-5**]. His lovenox and aspirin were held. His
Hct continued to trend down, yet repeat imaging showed a stable
RP bleed. At the time of discharge, his hematocrit stabilized.
# Suspicion for coronary disease- on [**2-12**] he had some episodes
of tachycardia, during which time an EKG showed anterior ST
depressions. These resolved with decreased heart rate. This
implies he may have some coronary plaque burden.
# Melena: The patient's Hct continued to trend down in the
setting of a stable RP bleed. During his MICU stay, the patient
had 2-3 episodes of black tarry stool. The patient was started
on a PPI IV and transfused 2 units PRBCs. The patient underwent
an EGD that showed esophagitis, gastritis, and duodenitis, but
no active bleeding and no intervention was undertaken. The
patient's Hct was trended and stabilized. He will require a
repeat EGD in 8 weeks (mid-[**Month (only) 958**]) and GI follow-up.
.
# Hypoxia/hypercapnia/delirium - His ventilation and oxygenation
status varied throughout his hospitalization. He was very
tachypneic due to infection on admission, and then intubated in
the SICU. After extubation his delirium slowly resolved. His
hypoxia improved with some diuresis. On [**2-5**], he required MICU
transfer for hypoxic respiratory failure. A CTA ruled out PE.
Chest imaging showed slight pulmonary edema, but no
consolidations. The patient was further diuresed and weaned down
on his O2. His hypoxia resolved by the time of discharge with
daily lasix doses. He will be continued on lasix 40mg PO and
will require twice weekly Chem 7 testing to assess for renal
function, to hold lasix if his renal function increases by more
than 50%.
.
# Acute kidney injury - His basline creatinine was around 0.8.
He had intermittent kidney injury with cr up to 1.4 during the
hospitalization. Likely ATN in the setting of hypotension vs.
contrast. Resolved with time.
CHRONIC
# COPD - does not use O2 at home. Required O2 while in hospital
likely due to pulmonary edema. Continued advair, continued nebs.
At discharge, was stably saturating 90-93% on room air
(acceptable due to his history of COPD).
TRANSITIONAL
-- needs 6 weeks of IV nafcillin (start date [**2-8**], last day [**3-22**])
as well as indefinite PO rifampin (300mg TID). After his
nafcillin course is complete, he will require PO antibiotics for
6 months which will be determined by infectious disease.
-- Recommend repeat EGD in 8 weeks to evaluate the GE junction
for Barrett's. the area could not be evaluated at this time
because of esophagitis.
-- consider resuming coumadin after his repeat EGD in mid-[**Month (only) 958**]
-- PFTs should be repeated, with possible sleep study to
evaluate for OSA
-- Lung nodule seen on imaging that needs to be followed up with
repeat CT scan in [**6-26**] months.
.
Laboratory monitoring required: CBC c diff, chem-7, LFTs
Frequency: Weekly
Opat attending visit: [**2198-2-16**] 2PM
Fellow visit: [**2198-3-12**] 10AM
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to
on [**Name8 (MD) 138**] MD in when clinic is closed
Medications on Admission:
Advair
Atrovent
MVI
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO once a day.
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime): hold for loose stools.
5. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily): hold for loose stools.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas/bloating.
10. ipratropium bromide 0.02 % Solution Sig: One (1) solution
Inhalation Q6H (every 6 hours).
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
16. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath.
17. diltiazem HCl 360 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day: In AM.
18. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: In PM.
19. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for sbp<100.
20. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day: discontinue if lasix is discontinued.
21. rifampin 300 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours.
22. Nafcillin 2 g IV Q4H
23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) **]
Discharge Diagnosis:
PRIMARY
Right knee MSSA infection
Atrial flutter
SECONDARY
COPD
Gastritis
Retroperitoneal hematoma
Hemarthrosis
Congestive heart failure, diastolic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 91975**],
It was a pleasure caring for you at [**Hospital1 18**]. You were initially
admitted to the hospital for an infection in your knee. You
required surgery twice and will need IV antibiotics for 6 weeks
and oral antibiotics for 6 months afterwards. You also had an
arrythmia in your heart that required an ablation procedure and
other medictions. Given your long hospital stay, you will be
discharged to a rehab facility.
Medication changes:
START nafcillin 2g every 4 hours for 6 weeks for infection
START rifampin 300mg by mouth three times per day
START aspirin 325mg daily
START docusate sodium 100mg twice daily for stool softener
START senna 8.6mg daily as needed for constipation
START diltiazem 360mg ER once daily for heart rate control
START metoprolol XL 100mg by mouth at night for heart rate
control
START lasix 40mg by mouth once per day for fluid retention
START potassium 20meq by mouth daily while on lasix
START colace 100mg by mouth twice per day
START senna 1 tab by mouth twice per day
START bisacodyl 5 mg by mouth once per day (hold for loose
stools)
Followup Instructions:
Department: INFECTIOUS DISEASE
When: FRIDAY [**2198-2-16**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: HEART ASSOCIATIONS OF [**Location (un) **] AT [**Hospital3 **]
Address: 131 [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Building, [**Location (un) 1514**], MA
Phone: [**Telephone/Fax (1) 71179**]
When: Thursday, [**3-1**], 4:30 PM
Department: INFECTIOUS DISEASE
When: MONDAY [**2198-3-12**] at 10:00 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Orthopaedics:
Follow up in 1 week with Dr. [**First Name (STitle) **]. Please call [**Telephone/Fax (1) 1228**] to
make an appointment.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: HEART ASSOCIATIONS OF [**Location (un) **] AT [**Hospital3 **]
Address: 131 [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Building, [**Location (un) 1514**], MA
Phone: [**Telephone/Fax (1) 71179**]
When: Thursday, [**3-1**], 4:30 PM
Department: ORTHOPEDICS
When: WEDNESDAY [**2198-2-21**] at 11:05 AM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
***It is recommended you obtain a repeat EGD in 8 weeks. Please
call the GI office at [**Telephone/Fax (1) 463**] to arrange one.***
|
[
"51881",
"5849",
"2851",
"41401",
"496",
"4280",
"25000",
"V4582"
] |
Admission Date: [**2152-7-6**] Discharge Date: [**2152-7-18**]
Date of Birth: [**2086-6-26**] 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:
[**2152-7-7**] - Cardiac Catheterization
[**2152-7-11**] - Urgent coronary artery bypass graft x4, left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to diagonal obtuse marginal and posterior descending
arteries.
History of Present Illness:
Pleasant 66 yo gentleman with history of hypertension, reflux,
hyperlipidemia who presents from stress lab after having ST
depressions and evidence of myocardial stunning on imaging.
Patient states that he consistently has substernal, left sided
non-radiating chest pain with exertion, which is predicable,
relieved with rest, not associated with Nausea, vomiting or
diaphoresis and at worst is [**2152-7-17**]. He would occasionally have
episodes of heavy breathing when this occurred. He states this
has been going on for several months, however last weekend he
was awakened by the pain at night. At that time, it took several
hours for the pain to go away, however pt thought it may just be
indigestion and waited for it to resolve. He later presented to
his PCP who referred him for stress testing. Cardiac surgery
was consulted for revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes Mellitus
Gastroesophageal reflux disease
Tenosynovitis
Obstructive uropathy, urge incontinence
GI Bleed [**2149**] d/t gastric ulcer
Colonic adenoma s/p polypectomy
ADHD
Psoriasis
Hearing loss
Depression with h/o lithium toxicity-- misses work weekly [**3-14**]
Chronic low back pain/sciatica
Muscle cramps
Social History:
Denies ETOH, tobacco, illicits. Lives alone in [**Location (un) 86**], has a
friend that lives upstairs from him. He works as a health
inspector.
Family History:
Mother with hx of stroke, died of "old age". Father died in his
40s of unknown causes.
Physical Exam:
On Admission:
VS - 140/75 97.4 63 14 97% RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 5 cm.
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, scars, or xanthomas. Small
errythematous plaques on forehead, scalp
.
Pulses:
Right: DP 2+ PT 2+
Left: 2+ DP 2+ PT 2+
Pertinent Results:
Cardiac Cath [**2152-7-7**]: LM:30% prox LAD:70% tubular prox 99%, mod
sized D1 with total occlusion of lower pole branch LCx:50% prox,
60% mid, and 50% diffuse OM1 RCA:100% mid, distal vessel fills
via L-R collaterals
.
Carotid US [**2152-7-7**]: Right ICA stenosis 60-69% Left ICA stenosis
<40%.
.
Echo [**2152-7-11**]: Prebypass: No atrial septal defect is seen by 2D or
color Doppler. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person
of the results on [**2152-7-11**] at 1330pm.
Post bypass: Patient is AV paced and receiving an infusion of
phenylephrine. Biventricular systolic function is unchanged.
Aorta is intact post decannulation. Mild mitral regurgitation
present.
[**2152-7-17**] 09:40AM BLOOD WBC-5.4 RBC-2.71* Hgb-8.6* Hct-24.4*
MCV-90 MCH-31.6 MCHC-35.0 RDW-13.7 Plt Ct-143*
[**2152-7-6**] 07:10PM BLOOD WBC-5.7 RBC-4.47* Hgb-14.1 Hct-41.5
MCV-93 MCH-31.5 MCHC-33.9 RDW-14.1 Plt Ct-178
[**2152-7-13**] 04:50AM BLOOD PT-13.8* PTT-31.0 INR(PT)-1.2*
[**2152-7-7**] 11:30AM BLOOD PT-13.3 PTT-30.1 INR(PT)-1.1
[**2152-7-17**] 09:40AM BLOOD Glucose-234* UreaN-31* Creat-1.5* Na-132*
K-4.2 Cl-97 HCO3-30 AnGap-9
[**2152-7-6**] 07:10PM BLOOD Glucose-140* UreaN-35* Creat-1.4* Na-139
K-4.8 Cl-102 HCO3-29 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2152-7-6**] for further
management of his chest pain. He underwent a cardiac
catheterization which revealed severe three vessel disease.
Given the severity of his disease, the cardiac surgery service
was consulted. Mr. [**Known lastname **] was worked-up in the usual preoperative
manner including a carotid ultrasound which showed moderate
right internal carotid artery stenosis. As he had a mild
elevation in his creatinine following the cardiac
catheterization, his renal function was allowed to normalize
prior to surgery. On [**2152-7-11**], Mr. [**Known lastname **] was taken to the operating
room where he underwent coronary artery bypass grafting to four
vessels. Please see operative note for details. Postoperatively
he was taken to the intensive care unit for monitoring. Over the
next 24 hours, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. Beta blockade, statin and aspirin were resumed. Later
on postoperative day one, he was transferred to the step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. Chest tubes and epicardial pacing wires
were removed per protocol. Mr. [**Known lastname **] had a brief bout of afib
lasting less than 24hrs and was placed on amiodarone. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility.
Mr. [**Known lastname **] continued to make steady progress and was discharged to
[**Hospital3 2558**] on postoperative day #6. He will follow-up with
Dr. [**First Name (STitle) **] and his primary care physician as an outpatient. His
primary care physician will refer him to a local cardiologist
for continued care. His anticipated length of stay at rehab will
be less than 30days.
Medications on Admission:
flomax 0.4 ER q day
metoprolol SR 100 q 24
ketoconazole topical
metformin 1000
vesicare 5 mg
lantus 50 u q day
lisinopril 40 mg q day
omeprazole 20 mg
amlodipine 5 mg q day
lorazepam 2 mg [**Hospital1 **]
crestor 5 mg q HS
aspirin 81 mg
concerta 10 mg daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Concerta 54 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO daily ().
10. Vesicare 5 mg Tablet Sig: One (1) Tablet PO daily ().
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous QAM.
14. humalog
sliding scale humalog based on fingertsick qid
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
16. Lantus 100 unit/mL Cartridge Sig: 50 units Subcutaneous
QPM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p CABGx4
Past medical history:
Hypertension
Hyperlipidemia
Diabetes Mellitus
Gastroesophageal reflux disease
Tenosynovitis
Obstructive uropathy, urge incontinence
GI Bleed [**2149**] d/t gastric ulcer
Colonic adenoma s/p polypectomy
ADHD
Psoriasis
Hearing loss
Depression with h/o lithium toxicity-- misses work weekly [**3-14**]
Chronic low back pain/sciatica
Muscle cramps
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesic
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema -trace pedal edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] Wednesday [**2152-8-7**] 1:45PM ([**Telephone/Fax (1) 4044**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 30186**] in [**2-12**] weeks [**Telephone/Fax (1) 3530**]
Cardiologist in [**2-12**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2152-7-17**]
|
[
"41071",
"5849",
"9971",
"2859",
"41401",
"42731",
"4019",
"53081",
"2724",
"311",
"V5867"
] |
Admission Date: [**2112-10-21**] Discharge Date: [**2112-10-27**]
Date of Birth: [**2045-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
adhesive tape / Latex
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2112-10-21**] Coronary artery bypass graft x 4 (Left internal mammary
artery to left anterior descending, saphenous vein graft to
ramus, saphenous vein graft to obtuse marginal, saphenous vein
graft to posterior descending artery)
History of Present Illness:
66 year old male with PCIx3 (RCA, LAD, OM2) in [**2103**] who states
that he has been experiencing intermittent exertional chest pain
relieved with rest or NTG (NTG use is 2-3 times per week). He
states that the chest pain may have been more progressive over
the past few weeks. Stress test today at [**Hospital3 4107**] showed
ST depressions along with prolonged chest pain. Transferred for
cardiac catheterization. He was found to have three vessel
disease that was poorly suitable for stenting and is now being
referred to cardiac surgery for revascularization.
Past Medical History:
Hypertension
Dyslipidemia
Borderline diabetes
Coronary artery disease s/p PCI in [**2103**]
Pacreatitis (gallstone)
tremor hands (neurology appt. [**2112-10-13**])
s/p appendectomy
s/p partial colectomy
Social History:
Race:Caucasian
Last Dental Exam:many years ago
Lives with:wife
Occupation:accountant
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-11**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Mother passed away MI age 54,
Father dies age 77 from diabetes/CAD, 2 children A&W
Father MI < 55 [] Mother < 65 [x]
Physical Exam:
Pulse:66 Resp:16 O2 sat:98/2L
B/P Right:180/82 Left:162/88
Height:5'6" Weight:190 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses: all palpable
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2112-10-21**] Echo: PRE-BYPASS: The left atrium is elongated. No
spontaneous echo contrast is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. Physiologic mitral
regurgitation is seen (within normal limits). There is no
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results prior to incision.
POST-BYPASS: The patient is in sinus rhythm. The patient is on
no inotropes. Biventricular function is unchanged. Mitral
regurgitation is unchanged. Aortic regurgitation is unchanged.
Tricuspid regurgitation is mild (1+). The aorta is intact
post-decannulation.
[**2112-10-27**] 08:50AM BLOOD Hct-35.4*
[**2112-10-26**] 07:13AM BLOOD WBC-9.5 RBC-3.78* Hgb-11.6* Hct-33.8*
MCV-89 MCH-30.8 MCHC-34.5 RDW-14.1 Plt Ct-272
[**2112-10-25**] 08:44AM BLOOD WBC-11.2* RBC-4.02* Hgb-12.5* Hct-36.1*
MCV-90 MCH-31.1 MCHC-34.6 RDW-14.5 Plt Ct-246#
[**2112-10-27**] 08:50AM BLOOD UreaN-29* Creat-1.4* Na-143 K-4.6 Cl-106
[**2112-10-26**] 07:13AM BLOOD Glucose-107* UreaN-30* Creat-1.2 Na-139
K-4.2 Cl-102 HCO3-28 AnGap-13
[**2112-10-25**] 08:44AM BLOOD Glucose-135* UreaN-28* Creat-1.3* Na-142
K-4.4 Cl-105 HCO3-30 AnGap-11
[**2112-10-24**] 05:50AM BLOOD Glucose-157* UreaN-28* Creat-1.4* Na-139
K-4.3 Cl-105 HCO3-26 AnGap-12
[**2112-10-23**] 02:53AM BLOOD Glucose-186* UreaN-21* Creat-1.1 Na-135
K-4.0 Cl-106 HCO3-22 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 656**] was a same day admit and on [**10-21**] was brought to the
operating room where he underwent a coronary artery bypass graft
x 4 with left internal mammary artery to left anterior
descending coronary; reverse saphenous vein single graft from
the aorta to first obtuse marginal coronary artery; reverse
saphenous vein single graft from the aorta to the second obtuse
marginal coronary artery; as well as reverse saphenous vein
single graft from the aorta to posterior descending coronary
artery.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. On
postoperative day one, he developed atrial fibrillation which
was treated with amiodarone. On postoperative day two, he was
transferred to the step down unit for further recovery. He was
gently diuresed towards his preoperative weight. Chest tubes and
epicardial pacing wires were removed per protocol. Coumadin was
started with 3 doeses given but then stopped with INR 3.9 at
discharge and patient in sinus rhythm for greater than 48 hours.
[**Last Name (un) **] was consulted due to a preop HBA1C 9.0% preop. They
added Lispro sliding scale and Lantus pen to his regimen. He
underwent diabetes/insulin teaching and was discharged home with
instructions. His Lasix was decreased on the day of discharge
with creatinine increased to 1.4 (baseline 0.8). The physical
therapy service was consulted for assistance with his
postoperative strength and recovery. Mr. [**Known lastname 656**] continued to
make steady progress and was discharged home on postoperative
day 6 with VNA and home PT services. VNA instructed to check
INR, BUN, Creatinine and K on [**10-28**] and call CT surgery office
with results. All follow-up appointments were instructed.
Medications on Admission:
CLOPIDOGREL 75 mg Daily (last dose 11/9)
LISINOPRIL 2.5 mg Daily
METOPROLOL TARTRATE 50 mg Daily
ROSUVASTATIN [CRESTOR] 40 mg Daily
ASPIRIN 81 mg DAily
NIACIN 500 mg Daily
OMEGA-3 FATTY ACIDS [FISH OIL] 500 mg Daily
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO DAILY (Daily).
4. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or temp >38.4.
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 2 weeks then 200 mg [**Hospital1 **] x 2 weeks then 200 mg daily x
1 month.
Disp:*100 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Humalog KwikPen 100 unit/mL Insulin Pen Sig: Six (6) units
Subcutaneous before meals: follow sliding scale .
Disp:*QS 1 month 1* Refills:*0*
14. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Thirty
(30) units Subcutaneous once a day: 30 Subcutaneous q hs glc
control
.
Disp:*QS 1 month 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 4
Past medical history:
Hypertension
Dyslipidemia
Borderline diabetes
s/p PCI in [**2103**]
Pacreatitis (gallstone)
tremor hands (neurology appt. [**2112-10-13**])
s/p appendectomy
s/p partial colectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with: Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage.
Edema- 1+ bilat edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2112-12-12**] at 1:00PM
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] on [**11-23**] at 3:00pm
Wound check on [**11-3**] at 11:15am in [**Hospital Unit Name **], [**Hospital Unit Name **]
Please call [**Hospital **] [**Hospital 982**] Clinic [**Telephone/Fax (1) 3402**] at for follow up
appointment within 1 week
***VNA to draw INR, BUN/Crea/K on [**10-28**] and call results to
[**Telephone/Fax (1) 170**]***
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2112-10-27**]
|
[
"41401",
"9971",
"42731",
"25000",
"4019",
"2724",
"V4582"
] |
Admission Date: [**2133-5-29**] Discharge Date: [**2133-6-3**]
Date of Birth: [**2067-7-20**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Iodine; Iodine Containing / Tetracyclines /
Macrodantin / Flexeril / Keflex
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
fatigue and bradycardia
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
The patient is a 65 year old woman with multiple medical
problems most notably CHF (EF 40-45%), DM2, seizure disorder,
multiple admissions for bradycardia presenting with bradycardia.
She was just discharged from [**Hospital1 18**] on [**2133-5-4**] at which time she
presented with bradycardia and weakness. At that time the
bradycardia was junctional escape and self resolved during the
hospital stay. Per discharge notes, the bradycardia was
attributed to Zoloft which was held on admission and removed
from her medication list. The patient states that she has not
taken any of the Zoloft or her prior metoprolol which had been
discontinued in [**1-24**] after being admitted with bradycardia.
When returning home from breakfast she noted progressive
weakness. She also had sudde onset of shortness of breath and
right sided chest pain. The pain happened both at rest and with
exertion. The pain was worse with deep breathing. The pain
radiated to her neck and both shoulders. The pain was a
tightness. She noted that she was so weak that she could only
take a nap. When her boyfriend found her she was too weak to
transfer to her wheelchair, so EMS was called. She states that
she takes all of her medications daily with the help of a nurse
who lays them out for her in medication boxes. She denies
getting confused and taking extra doses of medication. She
states that she took her blood sugar this morning but does not
remember the value.
.
Initial vital signs in the ED were [**Age over 90 **]F 36 117/61 12 99%RA. An
EKG showed junctional bradycardia @30-40 with no ischemic
changes seen.
A head CT was unremarkable.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, black stools or red stools. She denies recent
fevers, chills or rigors. She has no dysuria or abdominal pain.
She denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, syncope or presyncope.
Past Medical History:
# skin cancer s/p resection to right temple ([**5-26**])
# bradycardia
# CHF ([**2129**]: EF 40-50%)
# HTN
# Asthma
# DM2 with peripheral neuropathy
# Grand mal seizures [**12-20**] MVA [**2103**]
# Depression
# B total knee replacement ([**2120**])
# L4-L5 lumbar laminectomy, L4-L5 diskectomy, and foraminotomy
(L5-S1) [**12-20**] lumbar spinal stenosis
# Hip pinning
# L2 compression fracture [**12-20**] fall from height ([**10/2131**])
# LBKA [**12-20**] train accident ([**1-/2132**])
# Barrett's esophagus
# Diverticulosis, diverticulitis
# Lower GI bleed ([**2130**])
# Appendectomy (remote)
# Laparascopic cholecystectomy (remote)
# Peptic ulcer disease
# Kidney trauma [**12-20**] MVA requiring surgeries, unclear procedures
# Bladder reconstruction (remote)
# Total abdominal hysterectomy, unilateral oophorectomy (remote)
.
Cardiac Risk Factors: +Diabetes, Dyslipidemia, +Hypertension
Social History:
Lives alone in apartment. Receives VNA services and home visits
from [**Hospital3 **]. Per previous d/c summary--She has never been
employed and has received welfare. The patient denies EtOH or
smoking history but per past d/c summary has a history of [**11-19**]
ppd x 20y, quit [**2094**] and alcohol abuse x 20y, quit [**2104**],
recreational drugs (multisubstance and IVDU in [**2094**]). patient
had 5 children all died by age 13.
Family History:
N/C
Physical Exam:
VS: T 98.4 , BP 121/49, HR 33, RR 21, O2 97-100% on RA
Gen: obese middle aged female in NAD, resp or otherwise.
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: well healing surgical scar on right forehead. Sclera
anicteric. left anisocoria, bilateral reactive pupils, left
cataract, EOMI. lid droop on right. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. edentulous
Neck: Supple with JVP flat
CV: PMI located in 5th intercostal space, midclavicular line.
bradycardic, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: well healed surgical scars. Obese, soft, NTND, No HSM or
tenderness. No abdominal bruits.
Ext: No c/c/e. No femoral bruits. s/p left BKA w/o stump
erythema
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit
Neuro:
MS - alert and oriented x3, coherent response to interview
CN: II-XII intact except for anisocoria
Motor: normal tone and bulk. [**3-23**] bicep/tricep/hip flex bilat
[**Last Name (un) **]: light touch intact to face/hands/right foot w/o extinction
Coord: FTN intact and rapid
Brief Hospital Course:
65 year old woman with MMP and prior hx of bradycardia
previously attributed to medications who presented with
symptomatic junctional bradycardia (HR 35 bpm) on no AV nodal
agents.
.
# Rhythm:
Pt was admitted with a junctional bradycardia that spontaneously
converted to sinus bradycardia. After multiple admissions for
symptomatic bradycardia attributed to medications (Zoloft,
metoprolol), on this admission it was determined that pt likely
had sick sinus syndrome due tointrinsic SA nodal failure. An
ischemic trigger was ruled out by negative cardiac enzymes and a
recent TSH was normal. The patient was monitored on telemetry
and received a dual-chamber pacemaker on [**6-2**]. The patient did
not experience any episodes of bradycardia or arrhythmia
following pacemaker placement. The patient was discharged with a
short course of clindamycin following pacemaker placement.
.
# UTI:
Pt developed urinary retention on day 1 of admission and the
urine culture grew gram negative rods. The patient was treated
with aztreonam empirically due to multiple drug allergies, and
when sensitivities were available it was confirmed by telephone
with the clinical lab that the pt's E. coli UTI was sensitive to
aztreonam. The patient completed a 3-day course of aztreonam.
.
# CHF/Pump:
2D-ECHOCARDIOGRAM performed on [**2130-9-8**] calculated LVEF 35%. The
patient remained euvolemic during admission.
.
# CAD:
EKG from admission demonstrated no significant ST changes
compared with prior dated [**2133-5-1**]. Cardiac enzymes were
negative. The patient was continued on aspirin.
.
# Hypertension:
HCTZ and lisinopril were started and the patient's blood
pressure tolerated the medications.
.
# DM2:
The patient was continued on her home dose of insulin.
.
# Seizure Disorder:
The patient was continued on her home Tegretol for her history
of seizure disorder. The patient did not experience any seizure
activity during the hospitalization.
.
# FEN:
The patient followed a diabetic, heart-healthy diet.
.
# Code: full
Medications on Admission:
1. Insulin NPH 30 units in the morning and 12 units at night.
2. Gabapentin 300 mg QAM
3. Trazodone 100 mg HS prn
4. Hydrochlorothiazide 25 mg daily
5. Mirtazapine 30 mg qhs
6. Gabapentin 1200 mg qhs.
7. Carbamazepine 200 mg HS
8. Albuterol 90 mcg INH q6prn
9. Lisinopril 20 mg daily
10. Aspirin 81 mg daily
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
7. Gabapentin 600 mg Tablet Sig: Two (2) Tablet PO at bedtime.
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
10. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous once a day.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) units Subcutaneous at bedtime.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
14. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO
three times a day for 2 days.
Disp:*18 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Bradycardia s/p pacemaker
Urinary Tract Infection
.
Secondary:
seizure disorder
hypertension
Discharge Condition:
Stable. Transfers from bed to wheelchair without assist.
Discharge Instructions:
You were admitted with generalized weakness and a slow heart
rate. You were also found to have a urinary tract infection.
You had a pacemaker placed on [**2133-6-2**]. You will need to follow
up with device clinic as shown below. You also had a urinary
tract infection that was treated with antibiotics.
.
We have started you on an antibiotic called Clindamycin 450mg
three times a day for the next 2 days to prevent infection
around the new pacemaker. Otherwise, we have not made any
changes to your medications.
.
If you develop any chest pain, shortness of breath, weakness,
loss of consciousness or any other general worsening of
condition, please call your PCP or come directly to the ED.
Followup Instructions:
Primary Care Doctor: Dr. [**Last Name (STitle) 1266**] knows that you are home and
will make sure your home visits resume. Please call [**Telephone/Fax (1) 608**]
with questions.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2133-6-10**]
1:30
Neurology:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2133-6-9**] 6:00
|
[
"5990",
"4280",
"4019",
"49390",
"V5867"
] |
Admission Date: [**2164-4-16**] Discharge Date: [**2164-4-20**]
Date of Birth: [**2119-11-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
hypotension, AMS
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
44M w/ hx EtOH cirrhosis transferred from [**Hospital 5871**] hospital for
re-admission to liver service. Eloped from [**Hospital1 18**] yesterday,
patient will not disclose why he did this stating "I had
business to take care of". He slept in the [**Doctor Last Name 6641**] overnight after
arguement with his family, re-presented to his parents house
today where police were called. Patient admits to having 1 beer
while in the [**Doctor Last Name 6641**]. He was taken to [**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **] where liver
service was contact[**Name (NI) **] for transfer back to [**Hospital1 18**]. Per records
from [**Location (un) 5871**], patient was section 12 as he had a note mentioning
his obituary and trust fund and told his brother that he was
suicidal. Patient has multiple scratches throughout body which
he received when walking through [**Doctor Last Name 6641**] overnight, Td updated by
[**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **].
.
In the ED, vitals were 97.8 122 106/52 16 99%. Labs were
significant for 2:1 AST:ALT ratio with elevated total bilirubin
to 13.4, normal alk phos. Lactate was 1.7. INR was elevated to
2.4. Lipase was normal. Hematocrit was 28 from baseline of
around 30-32. Patient was referred originally for ? SI, which
he currently denies, but was somnolent on presentation,
reportedly unarousable to sternal rub initially, with concern
for hepatic encephalopathy. He woke up soon afterwards with no
intervention. Patient became hypotensive to SBP 80s, HR 120s,
received 1 liter NS IVF with response to SBP 95, HR 110s.
Diagnostic paracentesis was peformed in ED with cell counts
pending. Blood cultures were drawn prior to this, and patient
was placed on vancomycin/zosyn empirically. Chest X-ray and
head CT were performed, with reports pending. Vitals upon
transfer were 98.0 hr 119 rr 20 b/p 110/50 02 sat 96 % ra.
.
On arrival to the MICU, patient reports pain from neck to toes
that is rated 15/10 in severity.
Past Medical History:
Alcoholic cirrhosis and hepatitis (per report EGD [**2163-12-28**] which
noted portal hypertensive gastropathy without ulcers or
esophageal varices)
Social History:
Works as a corrections officer. Lived alone, but moved in with
his brother after his cirrhosis diagnosis. Never smoker. Last
drink 40 days ago per patient report. Prior to diagnosis of
cirrhosis drank >8 "mixed drinks" per day. Started drinking at
age 18. Denies any current or prior IVDU or other street drugs,
although does have h/o marijuana use many years ago. Is
concerned about work and disability benefits, as supposedly his
disability and life insurance policies do not cover alcoholic
cirrhosis. Never married, has 21 year old daughter who is a part
of his life. Denies any h/o alcohol withdrawal symptoms or
seizures
Family History:
Maternal grandfather with a history of alcohol abuse. Parents
are alive and well (father has HTN). No family history of liver
disease.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.1 BP:111/56 P: 112 R: 18 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: distended. diffusely tender to palpation. bowel sounds
present.
GU: no foley
Ext: 2+ LE edema bilaterally. warm, well perfused, 2+ pulses, no
clubbing, cyanosis. excoiations/abrasions over both upper and
lower extremities.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
T:98.3 BP:127/63 P108 R:20 O2:100% RA
General: Alert, oriented to person, place, date. follows
commands, responds to questions appropriately
HEENT: Sclera icteric, MMM
Neck: supple, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender to palpation. dull to percussion at
the flanks. unable to palpate liver/spleen.
Ext: 1+ LE edema bilaterally. warm, well perfused, 2+ pulses,
abrasions over both upper and lower extremities and left side of
head.
Neuro: CNII-XII intact, moving all extremities, no asterixis, no
tremor
Pertinent Results:
ADMISSION LABS:
[**2164-4-16**] 12:34PM PT-24.9* PTT-36.3 INR(PT)-2.4*
[**2164-4-16**] 12:34PM PLT COUNT-167
[**2164-4-16**] 12:34PM NEUTS-77.7* LYMPHS-16.0* MONOS-6.0 EOS-0.1
BASOS-0.2
[**2164-4-16**] 12:34PM WBC-10.9 RBC-2.76* HGB-9.7* HCT-28.0*
MCV-101* MCH-35.1* MCHC-34.7 RDW-13.7
[**2164-4-16**] 12:34PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2164-4-16**] 12:34PM ALBUMIN-3.5 CALCIUM-9.2 PHOSPHATE-3.0
MAGNESIUM-1.7
[**2164-4-16**] 12:34PM LIPASE-25
[**2164-4-16**] 12:34PM ALT(SGPT)-43* AST(SGOT)-104* ALK PHOS-107 TOT
BILI-13.4*
[**2164-4-16**] 12:34PM GLUCOSE-137* UREA N-21* CREAT-1.2 SODIUM-133
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-22 ANION GAP-15
[**2164-4-16**] 06:21PM ASCITES WBC-195* RBC-585* POLYS-2* LYMPHS-30*
MONOS-0 MESOTHELI-4* MACROPHAG-64*
[**2164-4-16**] 06:21PM ASCITES WBC-195* RBC-585* POLYS-2* LYMPHS-30*
MONOS-0 MESOTHELI-4* MACROPHAG-64*
[**2164-4-16**] 06:21PM ASCITES TOT PROT-1.9 GLUCOSE-138 CREAT-1.1
ALBUMIN-1.4
[**2164-4-15**] 12:37PM BLOOD D-Dimer-6213*
[**2164-4-16**] 12:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-4-17**] 12:00AM URINE Color-AMBER Appear-Hazy Sp [**Last Name (un) **]-1.027
[**2164-4-17**] 12:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-8* pH-6.0 Leuks-NEG
[**2164-4-17**] 12:00AM URINE RBC-<1 WBC-7* Bacteri-MOD Yeast-NONE
Epi-1 TransE-1
[**2164-4-17**] 12:00AM URINE CastHy-5*
[**2164-4-17**] 12:00AM URINE Mucous-MOD
DISCHARGE LABS:
[**2164-4-20**] 06:20AM BLOOD WBC-10.0 RBC-2.94* Hgb-10.5* Hct-30.9*
MCV-105* MCH-35.7* MCHC-33.9 RDW-14.1 Plt Ct-137*
[**2164-4-20**] 06:20AM BLOOD PT-26.3* INR(PT)-2.5*
[**2164-4-20**] 06:20AM BLOOD Glucose-124* UreaN-21* Creat-1.2 Na-135
K-3.7 Cl-103 HCO3-20* AnGap-16
[**2164-4-20**] 06:20AM BLOOD ALT-39 AST-74* AlkPhos-128 TotBili-13.6*
[**2164-4-20**] 06:20AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.6
URINE CULTURE (Final [**2164-4-19**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
IMAGING:
CT HEAD W/O CONTRAST Study Date of [**2164-4-16**] 5:00 PM
FINDINGS: There is no evidence of acute hemorrhage, edema,
large vessel
territorial infarction, or shift of normally midline structures.
The
ventricles and sulci are slightly prominent for the patient's
age, however
this finding is nonspecific. Mild periventricular white matter
hypodensities likely sequela of chronic small vessel ischemic
disease. A tiny hypodensity is noted in the anterior limb of
the left internal capsule may represent an old lacunar infarct.
No acute fractures are identified. The visualized mastoid air
cells and paranasal sinuses are clear.
IMPRESSION: No acute intracranial process. Slightly prominent
ventricles and sulci are for the patient's age, however this
finding is nonspecific.
CHEST (PORTABLE AP) Study Date of [**2164-4-16**] 5:46 PM
Heart size and mediastinum are grossly unremarkable. Lungs are
essentially clear within the limitations of this extremely
lordotic radiograph. No appreciable pleural effusion or
pneumothorax is seen.
Brief Hospital Course:
44 yo M with hx of cirrhosis [**1-5**] ETOH and alcoholic hepatitis
who presents from [**Hospital 5871**] hospital after spending an evening in
the [**Doctor Last Name 6641**] found to be hypotensive with SBPs in the 80s and
initially unarousable to sternal rub, subsequently found to have
a UTI as well as labile psychiatric state.
ACUTE ISSUES
.
# Hypotension -> Initially presented with SBPs in the 80s and
was unresponsive to sternal rub. He had spent the prior evening
in the [**Doctor Last Name 6641**] and had drank one beer. He was given 1L NS in the
ED and another 1L in the MICU with some improvement of his blood
pressure to the SBP 100s. SBP was considered, but ascitic fluid
had a WBC count of 195. Blood and urine cultures were sent.
Patient remained afebrile. PE was considered but he had just
had a PE-CT on [**4-14**] that was negative. He was transfered out to
the floor once his BP was stable in the low 100s a few hours
later. SBPs remained stable subsquently. He underwent
therapeutic paracentesis of 5L and infusion of 25g albumin on
second day of hospital admission with further improvement of BPs
into the 120s/80s. Most likely, hypotension was related to
intravascular volume depletion and systemic vasodilation in the
setting of cirrhosis or possible initial volume depletion. He
was also subsequently found to have an enterococcal UTI,
although blood cx remained negative, so this was unlikely to
have resulted in hypotension. Remained stable throughout
hospitalization.
# Tachycardia -> Has history of sinus tachycardia. Remained in
sinus tachycardia throughout most of this hospitalization. He
did have a D dimer checked on admission, which was elevated, but
without other signs or symptoms of thrombo-embolic disease. EKG
without signs of ischemia. Most likely related to systemic
vasodilation and high output cardiac failure. On day two of
admission, he developed chest pain over the left chest. EKG was
done and was stable from prior. Patient had stable sinus
tachycardia throughout the admission.
# Hepatic encephalopathy and concern for suicidal ideation ->
Initially presented with altered mental status, likely due to
hepatic encephalopathy. Patient's family was very concerned that
he was going to hurt hiimself, as he had left notes discussing
his funeral, obituary and talking to his daughter about getting
his affairs in order. Per his family, his behaviour had not
been at his baseline. He was brought to [**Hospital 5871**] Hospital on a
section 12, but was not placed on a section 12 at [**Hospital1 18**]. At
[**Hospital1 18**], he was started on lactulose for presumed hepatic
encephalopathy with subsequent improvement of symptoms. He
remained oriented throughout the hospitalization, without
asterixis or signs of confusion. Psychiatry saw him initially
and felt his bizarre behavior was related to chronic hepatic
encephalopathy and did not require section 12 or inpatient
admission. His mental status cleared during his admission. As
he was prepared for discharge, his family became very concerned
again amd did not want him to be discharged because they thought
he would hurt himself. Psychiatry was reconcsulted, at on
evaluation, found that he was not at acute risk to himself and
thus there was no legal basis to hold him against his will or
pursue psychiatric hospitalization. Psychiatry communicated
this to his family, who were ultimately in agreement.
Psychiatry referred Mr. [**Known lastname 1356**] to [**Hospital1 **] in [**Hospital1 6930**] for ETOH
abuse treatment. Mr. [**Known lastname 1356**] then decided that we were no longer
allowed to speak with him family and that he would be taking a
cab home and did not want his family to come pick him up.
# UTI -> He did not have any urinary symptoms but urine culture
was positive for enterococcus sensitive to ampicillin. He was
started on amoxicillin 875 mg [**Hospital1 **] for 7 days.
# Alcoholic Hepatitis -> He has had several episodes of
alcoholic hepatitis this year. He was previously treated with
prednisone without much improvement in his LFTs. On admission,
he had elevation of AST>ALT, elevated bilirubin to 13, and
DF=60. As he had not responded well to prior course of
prednisone, he was started on a nutritional therapy for
alcoholic hepatitis of 200kcal/day with nutrition consult and
calorie count while in house. He did not want a feeding tube.
The important of this therapy was fully explained to the patient
on several occasions, and he appeared to understand. His LFTs
downtrended slightly while in house. Discussed several times the
importance of abstaining from ETOH.
# Cirrhosis [**1-5**] ETOH -> He was notably volume overloaded on
admission with large volume ascites and LE edema. Two
therapeutic taps of 5L followed by albumin were performed with
good results. SAAG 2.5 (serum albumin 3.5, ascites albumin 1.4),
so ascites is likely due to portal hypertension. Started on
fluid restriction and low Na diet. His home diuretics were
restarted once his Na corrected back to mid 130s. He had a
recent history of BRBPR and will likely require EGD as
outpatient. No known varices; not currently on nadolol. No
evidence of SBP on this admission. On lactulose for prevention
of encephalopathy. Will need close follow-up with hematology as
outpatient.
# Hyponatremia -> Initially low 130s, likely [**1-5**] to cirrhosis,
hypervolemic hyponatemia. Improved to 136 after large volume
paracentesis.
# Coagulopathy -> Elevated INR likely [**1-5**] to liver synthetic
dysfunction. Received vitamin K 10 mg PO for three days with
little improvement.
CHRONIC ISSUES:
# Anemia -> HCT 27.5, MCV 100. Hct is currently stable with no
evidence of bleeding. Recent iron studies show a low TIBC, high
ferritin, normal iron. Folate and B12 normal. Likely
representative of anemia of chronic disease.
# ETOH abuse -> History of ETOH abuse with ETOH use while in the
[**Doctor Last Name 6641**]. Started on CIWA scare but did not score. Patient is
taking baclofen for ETOH abstinence. Continued on baclofen.
Social work was consulted. He was not interested in AA.
TRANSITIONAL ISSUES:
1. Follow-up suicidal ideation/ [**Hospital 1680**] Hospital referral
2. Follow-up dietary recommendations ([**2151**] kcal diet, 2gm salt,
2L fluids)
Medications on Admission:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to [**2-5**] bowel movements daily.
2. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
8. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. amoxicillin 875 mg Tablet Sig: One (1) Tablet PO twice a day
for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cirrhosis secondary to alcohol abuse
Alcoholic hepatitis
Hepatic Encephalopathy
Hypotension
Tachycardia
Hyponatremia
Alcohol Abuse
Suicidal Ideation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1356**],
You were admitted to the hospital because you had a low blood
pressure and had fluid in your belly. We gave you fluid to
treat your low blood pressure, and it improved. We removed 10
liters of fluid from your abdomen. You were started on a new
diet of [**2151**] calories per day to help treat your liver
inflammation. We restarted you on all of your home medications.
You had a urinary tract infection. We started you on
antibiotics.
Please continue your home medications as previously prescribed.
Please change the following:
START taking Amoxicillin 875 mg every 12 hours for 6 days
START eating [**2151**] calories per day
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 **] PRIMARY CARE
Address: [**Street Address(2) 20897**], [**Hospital1 **],[**Numeric Identifier 20898**]
Phone: [**Telephone/Fax (1) 20894**]
When: [**Last Name (LF) 766**], [**2162-4-23**]:30 AM
Department: LIVER CENTER
When: TUESDAY [**2164-5-1**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"2761",
"5990",
"2859",
"42789"
] |
Admission Date: [**2111-4-18**] Discharge Date: [**2111-4-28**]
Date of Birth: [**2050-5-13**] Sex: F
Service: SURGERY
Allergies:
Macrolide Antibiotics / Percocet
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p bicycle crash
Major Surgical or Invasive Procedure:
[**2111-4-20**] - ORIF right radius/olecranon
[**2111-4-21**] - closed reduction & wiring mandible
History of Present Illness:
60 yo female with bicycle crash, +LOC at the scene. Patient had
AMS on scene and GCS 8 in ED, where she was intubated
fiberoptically after sedation with 60mcg of dexmetetomidine.
Prior to the intubation there was some abnormal tracheal
mobility but bronchoscopy after intubation revealed no tracheal
trauma. The patient also received 50g of mannitol in the ED
before getting pan scanned and sent to the TICU. Upon arrival in
TICU patient was still GCS of 8, with eye opening to voice and
localizing of pain with her left upper extremity.
Past Medical History:
CAD s/p LAD stent
PSH: none
Social History:
Married. Denies no tobacco, minimal alcohol
Family History:
Noncontributory
Physical Exam:
Admission Exam
O: BP: 89/54 HR:80 R 20 O2Sats 100%
Gen: intubated and sedated (Versed and Fentanyl)
HEENT: Pupils: PERRL 3-2mm EO to voice when sedation held, +
corneals + gag
Neck: Hard Collar in place
Extrem: multiple hematomas, abrasions and fractures
Orientation: unable to assess
Motor: no mvmt to noxious stimuli x4. Slight mvmt spont x4.
Reflexes: B R Pa Ac
Right 2 2 2 2
Left 2 2 2 2
no clonus or hoffmans
Toes downgoing bilaterally
Pertinent Results:
[**2111-4-18**] 12:11PM WBC-15.6* RBC-3.93* HGB-12.4 HCT-38.8 MCV-99*
MCH-31.5 MCHC-31.9 RDW-13.1
[**2111-4-18**] 05:45PM GLUCOSE-123* UREA N-16 CREAT-0.6 SODIUM-141
POTASSIUM-3.1* CHLORIDE-110* TOTAL CO2-21* ANION GAP-13
[**2111-4-18**] 12:11PM LIPASE-39
[**2111-4-18**] 05:56PM LACTATE-1.4
Imaging studies:
[**4-18**] CT neck: CT C-spine: 1. No C-spine fracture.
2. In the proximal right ICA, just distal to the origin there is
a small segment of mural irregularity (2:117), which may
represent an ulcerated plaque vs focal traumatic injury. The
distal vessel is patent. No other vascular abnormality.
[**4-18**] ct torso: Unstable burst fracture of T6 vertebral body,
with 2 mm retropulsion of fracture fragments. Recommended
T-spine MRI for assessment of cord. A 2.0 cm hypodense lesion in
the segment VI of the liver, may represent a hemangioma or
laceration. No perihepatic hematoma. No abdmominal free fluid.
Recommend correlation with prior imaging if available or a
follow-up US to assess the same.
[**4-18**] CT max/face: CT max/face:
1. Left mandibular neck with medial displacement of the
mandibular head. left TMJ dislocation. Small chip fracture off
the left temporal articular surface at the TMJ.
2. R maxillary sinus anterior wall fracture with hemosinus.
[**4-18**] CT head: 1. Extensive subarachnoid hemorrhage in the left
frontoparietal and temporal lobes and a small amount of SAH in
the right frontoparietal region. 2. Multiple hemorrhagic
parenchymal contusions in the left inferior frontal and temporal
lobes. 4. Intraventricular extension of hemorrhage into the
occipital horns of both lateral ventricles.
[**4-18**] 2nd CT head: 1. Similar appearance of extensive left
subarachnoid hemorrhage 2. Increased number and conspicuity of
round hyperdense foci bilaterally, some of which are located
along the junction of [**Doctor Last Name 352**] and white matter, likely representing
diffuse axonal injury, possibly parenchymal contusions.
[**4-18**] CXR: 1) Right subclavian central line present, tip over
distal SVC. No ptx detected. 2) T6 fracture with significant
loss of height. Torso CT report describes burst fracture with
retropulsion, raising concern for unstable fracture. Appropriate
treatment and, if clinically indicated, further assessment with
t-spine MRI is recommended.
[**4-19**] Elbow- Fracture of the R olecranon, with approximately 11.8
mm distraction.
[**4-19**] Head CT: 1. Unchanged appearance of extensive subarachnoid
blood products and [**Doctor Last Name 352**]-white matter junction hematomas, the
latter compatible with traumatic diffuse axonal injury.
2.Unchanged dislocation of the left TMJ joint with associated
left
mandibular fracture, better seen on prior studies.
3. Increased fluid within the sphenoid and ethmoid sinuses.
Persistent aerosolization and a large amount of fluid within the
right maxillary sinus.
[**4-19**]: MRA neck- Concerning for traumatic pseudoaneurysms.
[**4-19**]: MR [**Last Name (Titles) **]/t-spine: Unstable T6 Burst fracture with approx 5
mm retropulsion of fracture fragments. Moderate spinal canal
stenosis at this level. The thoracic cord is not compressed. No
cord signal abnormality. Disruption of the PLL at this level. T2
hyperintensity in the interspinous ligaments at this level
concerning for ligamentous injury. No acute C-spine trauma. Mild
C-spine DJD,
without significant spinal canal stenosis
[**4-21**]: Carotid study: No evidence of stenosis, dissection, or
pseudoaneurysm .
Brief Hospital Course:
Ms [**Known lastname 24642**] was admitted to the trauma ICU [**4-18**] after being
intubated in the ED.
In brief, she was intubated HD1 through HD6, she went to the OR
HD 3 & 4 for fracture repair, and displayed slowly improving
mental status.
Her course in the ICU is summarized below:
[**4-18**]: She was weaned off pressors using fluid resuscitation. On
arrival to the ICU, a CVL was inserted. Her neuro exam was
stable, following no commands but spontaneously moving all four
extremities and opening eyes intermittently. She was placed on
logroll precautions given her T6 fracture.
[**4-19**]: She received 1 unit pRBC for hematocrit of 23. To
facilitate frequent neurologic exams, she was frequently weaned
from sedation. During one of these weans, she self-extubated and
was subsequently re-intubated. Her neurologic exam was slowly
improving in that she was squeezing hand intermittently on
command and spontaneously moving all extremities.
[**4-20**]: She was taken to the operating room by orthopedics for
ORIF of radius and olecranon and placed in a R arm cast. Also on
this day her ETT was converted to a nasotracheal tube to
facilitate OMFS operating on her mandible the following day.
Given the operative procedure, frequent neuro exams were
deferred.
[**4-21**]: She was taken to the operating room by OMFS for closed
reduction mandible fracture and jaw wiring. Her neuro exam had
not progressed, still intermittently following commands, but
typically not interactive. She had a carotid series performed
which confirmed there was no injury to her vessels. She was
fitted with a TLSO brace as neurosurgery felt her T6 fracture
was best treated in this manner. A family meeting was held to
discuss her lack of neurologic progression. The prospect of a
tracheostomy was discussed and it was decided if she had not
progressed by HD 7 a tracheostomy would be performed.
[**4-22**]: Her neuro exam showed some improvement, following commands
more often.
[**4-23**]: Her neuro exam showed significant improvement. She was
much more alert and interactive so was deemed safe for
extubation. The nasotracheal and nasogastric tubes were removed
simultaneously which she tolerated well. She worked with phyical
therapy who had her sitting on the side of the bed in her TLSO
brace. She remained significantly delerious but was regularly
directable and not agitated. She was kept NPO as her NGT had
been removed and her mandible was wired.
[**4-24**]: A speech and swallow evaluation showed inability to
swallow apropriately. A DHT was placed and tube feeds were
started. They were advanced to goal.
[**4-25**]: She was screened for rehab and is awaiting aproval. She
was transferred to a regular hospital floor.
Her remaining hospital course after transfer from the ICU to the
floor as follows by systems:
Neuro: Her mental status has overall showed much improvment. She
is ableto recognize her family by face and name, is able to
recall some events that occurred prior to her trauma. She was
started on low dose Zyprexa at hs to help regulate her sleep
wake cycle becasue of her head injury. She move all extremities.
HEENT: Her jaw remains wired from her mandible repair surgery -
wire cutters will need to remain at bedside at all times in the
event of a respiratory emergecny and/ or vomiting the wires will
need to be cut. She will have follow up with OMFS in about 1
week after discharge. The tentative plan at this time is that
her jaw will remain wired for approx 2 weeks. She is on mouth
rinses tid.
CV: There are currently no active issues. Her home Amlodipine
and HCTZ were restarted.
GI: Currently she is being fed through a Dobhoff and is
receiving tube feedings at goal rate. She was evaluated again by
Speech and Swallow and is recommended for nectar thickened
liquids. Once her jaw wires are removed she should be
re-evaluated for swallowing and it is expected that she will be
able to tolerate a regular diet.
GU: She was noted with a slight elevation in her WBC - u/a was
positive and she is being treated for a UTI with Ciprofloxacin.
Her Foley catheter has been removed and she is voiding.
MSK: Her right wrist has a splint and she is non weight bearing
on this extremeity. She will follow up in [**Hospital 5498**] clinic in
about 2 weeks. She was evlauted by Physical and Occupational
therapy and is recommended for rehab after her hospital stay.
Prophlaxis: She is receiving Heparin subcutaneously tid for DVT
ppx.
Dispo: She is being discharged to [**Hospital 110269**] rehab in [**Location (un) 86**].
Medications on Admission:
toprol XL 25mg PO qday
ASA 325 PO Qday
lipitor 20mg PO Qday
norvasc 5mg PO Qday
HCTZ 25mg PO Qday
levothyroxine 50mcg PO Qday
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
HOLD if SBP <110, HR <60.
3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for sbp < 110 HR <60
.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
7. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG
PO BID (2 times a day) as needed for constipation: HOLD if loose
stools
.
8. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
10. Milk of Magnesia 400 mg/5 mL Suspension Sig: [**5-7**] ML's PO
once a day as needed for constipation.
11. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane TID (3 times a day).
12. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Bicyclist struck by auto
Injuries:
Left subarachnoid hemorrhage
Right parafalcine subdural hemorrhage
Right maxillary fracture
Left mandible fracture with TMJ out
T6 unstable burst fracture
Right radius/ulna fracture
Grade I liver laceration
Urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after being struck by an auto
causing multiple injuries including bleeding brain injury,
facial and jaw fractures, spine bone ftacture in your mid back
region, a liver laceration and broken wrist bones. You required
several operations to repair your broken face/jaw bones where
your jaw was wired. Your wrist fracture was also repaired and
you should avoid putting weight on your right wrist until you
have follow up with the Orthoepdic specialist who will upgrade
your weight bearing status.
*The wire cutters will need to stay at the bedside at all times
in the event of a respiratory emergency and/or if vomiting
occursthe wires should be cut.
Postoperative instructions following jaw surgery
Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the type
that self dissolve. If you have any sutures on the skin of your
face or neck, your surgeon will remove them on the day of your
first follow up appointment. SMOKING is detrimental to healing
and will cause complications.
Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
30-45 minutes at a time may control the bleeding. If you had
nasal surgery, you may have occasional slow oozing from your
nostril for the first 2-3 days. Bleeding should never be severe.
If bleeding persists or is severe or uncontrollable, please call
our office immediately. If it is after normal business hours,
please come to the emergency room and request that the oral
surgery resident on call be paged.
Healing: Normal healing after oral surgery should be as follows:
the first 2-3 days after surgery, are generally the most
uncomfortable and there is usually significant swelling. After
the first week, you should be more comfortable. The remainder of
your postoperative course should be gradual, steady improvement.
If you do not see continued improvement, please call our office.
Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless you
obtain permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice bag
or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first 2-3 days after
surgery. If you have been given medicine to control the
swelling, be sure to take it as directed.
Hot applications: Starting on the 3rd or 4th day after surgery,
you may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to decrease swelling and stiffness. Please use caution when
applying ice or heat to your face as certain areas may feel numb
after surgery and extremes of temperature may cause serious
damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous brushing,
but please make every effort to clean your teeth with the bounds
of comfort. Any toothpaste is acceptable. Please remember that
your gums may be numb after surgery. To avoid injury to the gums
during brushing, use a child size toothbrush and brush in front
of a mirror staying only on teeth.
Mouth rinses: Keeping your mouth clean after surgery is
essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass
of warm water and gently rinse with portions of the solution,
taking 5 min to use the entire glassful. Repeat as often as you
like, but you should do this at least 4 times each day. If your
surgeon has prescribed a specific rinse, use as directed.
Showering: You may shower 1-2 days after surgery, but please ask
your surgeon about this. If you have any incisions on the skin
of your face or body, you should cover them with a water
resistant dressing while showering. DO NOT SOAK SURGICAL SITES.
This will avoid getting the area excessively wet. As you may
physically feel weak after surgery, initially avoid extreme hot
or cold showers, as these may cause some patients to pass out.
Also it is a good idea to make sure someone is available to
assist you in case if you may need help.
Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing you to breathe more easily. One or two pillows may be
placed beneath your mattress at the head of the bed to prop the
bed into a more vertical position.
Pain: Most facial and jaw reconstructive surgery is accompanied
by some degree of discomfort. You will usually have a
prescription for pain medication. Some patients find that
stronger pain medications cause nausea, but if you precede each
pain pill with a small amount of food, chances of nausea will be
reduced. The effects of pain medications vary widely among
individuals. If you do not achieve adequate pain relief at first
you may supplement each pain pill with an analgesic such as
Tylenol or Motrin. If you find that you are taking large amounts
of pain medications at frequent intervals, please call our
office.
If your jaws are wired shut with elastics, you may have been
prescribed liquid pain medications. Please remember to rinse
your mouth after taking liquid pain medications as they can
stick to the braces and can cause gum disease and damage teeth.
Diet: Unless otherwise instructed, only a cool, clear liquid
diet is allowed for the first 24 hours after surgery. After 48
hours, you can increase to a full liquid diet, but please check
with your doctor before doing this. Avoid extreme hot and cold.
If your jaws are not wired shut, then after one week, you may be
able to gradually progress to a soft diet, but ONLY if your
surgeon instructs you to do so. It is important not to skip any
meals. If you take nourishment regularly you will feel better,
gain strength, have less discomfort and heal faster. Over the
counter meal supplements are helpful to support nutritional
needs in the first few days after surgery. A nutrition guidebook
will be given to you before you are discharged from the
hospital. Remember to rinse your mouth after any food intake,
failure to do this may cause infections and gum disease and
possible loss of teeth.
Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes
pain medications are the cause. Precede each pill with a small
amount of soft food. Taking pain pills with a large glass of
water can also reduce nausea. Try taking clear fluids and
minimizing taking pain medications, but call us if you do not
feel better. If your jaws are wired shut with elastics and you
experience nausea/vomiting, try tilting your head and neck to
one side. This will allow the vomitus to drain out of your
mouth. If you feel that you cannot safely expel the vomitus in
this manner, you can cut elastics/wires and open your mouth.
Inform our office immediately if you elect to do this. If it is
after normal business hours, please come to the emergency room
at once, and have the oral surgery on call resident paged.
Graft Instructions: If you have had a bone graft or soft tissue
graft procedure, the site where the graft was taken from (rib,
head, mouth, skin, clavicle, hip etc) may require additional
precautions. Depending on the site of the graft harvest, your
surgeon will [**Location (un) 8146**] you regarding specific instructions for
the care of that area. If you had a bone graft taken from your
hip, we encourage you to ambulate on the day of surgery with
assistance. It is important to start slowly and hold onto stable
structures while walking. As you progressively increase your
ambulation, the discomfort will gradually diminish. If you have
any problems with urination or with bowel movements, call our
office immediately.
Elastics: Depending on the type of surgery, you may have
elastics and/or wires placed on your braces. Before discharge
from the hospital, the doctor [**First Name (Titles) **] [**Last Name (Titles) 8146**] you regarding these
wires/elastics. If for any reason, the elastics or wires break,
or if you feel your bite is shifting, please call our office.
Followup Instructions:
**You will be contact[**Name (NI) **] for an appointment with the Oral
[**Hospital 110270**] Clinic. If you do not receive a call by the end of
week please contact their office at [**Telephone/Fax (1) 110271**]
Department: ORTHOPEDICS
When: TUESDAY [**2111-5-12**] at 9:20 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2111-5-12**] at 9:40 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2111-5-27**] at 9:00 AM & 9:15 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: WEDNESDAY [**2111-5-27**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2111-4-28**]
|
[
"5990",
"2760",
"2449",
"41401",
"V4582"
] |
Admission Date: [**2190-9-24**] Discharge Date: [**2190-9-24**]
Date of Birth: [**2125-6-1**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
aspirin allergy, needs pentasa desensitization
.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yo female with history of asthma, UC, Crohn's, and atrial
tachycardia who presents to CCU for monitoring and observation
during Pentasa desensitization. The patient states she was
found to have an allergy to aspirin, develops hives and rash.
Attempted to undergo desensitization of aspirin but unable to
tolerate secondary to hives on her back. The Pentasa
desensitization needs to be done so that she can be treated with
this for her Crohn's disease.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. She denies
recent fevers, chills or rigors. Weight, appetite and energy
level have all been stable. No recent rash. All other ROS
negative.
.
*** Cardiac review of systems is notable for absence of chest
pain, dyspnea on exertion, orthopnea, ankle edema, palpitations,
syncope or presyncope.
Past Medical History:
asthma
Crohn's
UC s/p colectomy and ileostomy
kidney stones
HTN
atrial tachycardia
GERD
Social History:
Social history is significant for the absence of current or
previous tobacco use. There is no history of alcohol abuse.
There is no family history of premature coronary artery disease
or sudden death, father died of heart disease at age 74, mother
with lung cancer.
Physical Exam:
Gen: appears well, stated age, NAD, mood, affect appropriate.
Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, no JVD.
CV: Normal s1/s2, no murmurs, rubs or gallops. No carotid
bruits
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: soft, NT, ND, NABS. Ostomy bag in place with normal
output.
Ext: No c/c/e. Multiple varicosities on LE. No femoral bruits.
Skin: warm, dry, no rashes
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Brief Hospital Course:
ASSESSMENT AND PLAN: 65 yo female with Crohn's disease needing
pentasa treatment, complicated by severe aspirin allergy
requiring Pentasa desensitization.
.
# Allergy- Patient underwent Pentasa desensitization per
protocol. Developed slight itchyness after third dose, without
any other associated symptoms. Was given benedryl, and
itchyness resovled. Patient completed protocol, and was
monitered for 2 hours without complication.
Medications on Admission:
singulair 10 mg
flovent 2 puffs qhs
metoprolol 25 mg daily
cardia 120 mg daily
dig .125 mg daily
protonix 40 mg daily
allopurinol 300 mg daily
Discharge Medications:
singulair 10 mg
flovent 2 puffs qhs
metoprolol 25 mg daily
cardia 120 mg daily
dig .125 mg daily
protonix 40 mg daily
allopurinol 300 mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
ASA allergy here for desensitazation
Chron's disease
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after scheduled
admission for desisitization to Pentasa desensitization. You
have now completed the desensitization protocol. You should
take your medications as prescribed. If you develop any
concerning symptoms, including lightheadedness, shortness of
breath, confusion, or chest pain, take 50mg of Benadryl and call
the allergist on call or 911.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 8122**] [**Last Name (NamePattern4) 8123**], M.D. Phone:[**Telephone/Fax (1) 2977**]
Date/Time:[**2190-9-27**] 9:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Date/Time:[**2190-11-22**] 9:00
Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2190-12-20**] 10:00
|
[
"4240",
"42789",
"49390",
"53081"
] |
Admission Date: [**2178-9-29**] Discharge Date: [**2178-10-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
JP drain placement
History of Present Illness:
HPI: 81 year old male, CP, A fib hx,L DVT in femoral vein,
started to develop GIB, , s/p IVC filter RA on MTX and
prednisone, recently admitted for worsening hip pain and
inability to walk, and recent CT of abd/hip that revealed
diverticular abscess [**3-4**] to perforated diverticulum and s/p
drainage and drain removed on [**9-28**]. CT scan noted abscess well
drained. He was d/c back to rehab Vanc/Levo/Flagyl. levaquin 500
qd x 3, ticarcillin 3.1 gm IV
He is was noted to have spiking over past 24-48 hrs
(101.8-103.8) with highest 103. 8 at 10pm on [**9-28**]. CXR -> LLL
infiltrate . He was examed by HO at 9pm on [**9-28**] He did not have
any complaints to HO at rehab. He denies any abd pain, SOB or
SOB, no diarrhea. No cough or sputum. He was given vanco X 1. On
exam, CV: tachy, abd: no pain on deep palp, no rebound, Resp:
scattered rales, Ext: + pain w/ flexor of L hip
He c/o [**9-9**] CP this AM at 9am. He was given asa, sub lingual
nitro, BP 100/60, P 132-> 5 mins post 162/88 P 192 A fib and 2nd
sublingual nitro given-> 10 mins post, BP 172/88 P 192, 2nd
nitro sl given-> 9am 5 mg lopressor, HR down to 130s.CP
disspiated at 945am. BP normalized in 100/60 at 10am. He was
admitted to [**Hospital1 18**] where sepsis protocal was initiated in the ED
after CT abd showed marked increase in the size of the LLQ
abscess associated with ileopsoas muscle and extending into the
thigh. Bilateral residual pulmonary emboli were also noted
Pt had fevers/sepsis on admission which was from diverticular
abscess but also concern for about PICC line infection. PICC
line was d/c on [**9-29**] - no growth from tip. Blood culture from
[**9-29**] grew [**Female First Name (un) **] parapsilosis ([**2-3**]). Blood cultures are
negative to date subsequent. A drain was placed by IR on [**10-1**] by
CT guidance. Colorectal surgery has been following. Abscess
culture from [**10-1**] grew entrococcus (vanc/amp/levo/pcn resistant)
and yeast (likely c. albicans). Pt covered linezolid (hx VRE),
meropenem (for GNR and anaerobes) and caspofungin (fungemia) .
Infectious disease team has been following. Right IJ line was
d/c and tip showed no growth. Pt has been afebrile for past 48
hours. His WBC count has improved from 14K to 6k since
admission.
Pt blood pressure runs in SBP 90-100. HR is controlled with QID
metoprolol. Today the MICU team is attempting gentle diuresis
for volume overload
Past Medical History:
1) Perforated diverticulum with pelvic abscess
[**Hospital1 18**] admission, his CT pelvis which revealed a large left
pelvic abscess (7.3 x 11.1 x 14.4 cm), felt likely secondary to
perforated diverticulum. He underwent CT-guided drainage of his
abscess on [**9-3**] in IR, and was started on emipiric abx with
Levo/Flagyl. Vanco added following an episode of hypotension
responsive to IVF, D/C'd [**9-7**]. He was also started on Heparin
on [**9-3**] with initial bolus for PE, and Coumadin started on
[**9-4**].
On [**2178-9-7**], Mr. [**Known lastname 50388**] had an episode of BRBPR, initially with
BM described as 3 "coinsized clots", then 2 further episodes
with clots without stools. Hct drop 34 last night-->27 this AM,
transfused an additional unit of PRBCs. Hemodynamically stable
overnight, but this AM BP drop to 84/60, with spontaneous
recovery. PTT intermittently supratherapeutic (101, 108, 143) in
past days, INR 2.5 this AM. Still on heparin, last Coumadin on
[**9-6**]. Last C-scope in [**2172**] with diverticulosis. Only prior
history of occasional blood on toilet paper after straining.
2) CAD since [**2138**], s/p IMI in [**2145**]. Stress thallium in [**2163**] with
redistributing posterolateral and inferior defect.
3) Hypertension
4) Hyperlipidemia
5) Rheumatoid arthritis, recently diagnosed, on Prednisone 5 mg
PO BID and Methotrexate 10 mg Qwk
6) Diverticulosis, last colonoscopy in [**2172**]
7)VRE but unclear sources
8)RLL PE ([**2178-9-28**]), bilat DVT
9) GI bleed on last admission, coumadin and hep held -> filter
placed by IR s/p IVC filter (removable)
Social History:
No etoh, no tob, was at [**Hospital **] rehab since d/c from [**9-25**],
previously lived w/ wife ( who is unofficial HCP)
Family History:
Noncontributory
Physical Exam:
VS: T98.9 BP110-138/60-90 HR84-90 RR20-22 o2sat: 94-98%RA
Is/Os 1750/4200cc over 24 hrs FS99-247
HEENT: O/P clear. Anicteric sclera.
Neck: Supple.
CV: Regular, occasional irreg beats. Nml s1,s2. No s3 or
murmur
Resp: CTAB with occasional crackles at the bases.
Abd: Soft. NTND. +BS. No TTP over LLQ. No HSM. No rebound or
gurading. No erythema or TTP over JP drain site.
Ext: [**2-1**]+ edema to mid-shins bilat.
GU: no CVA tenderness
Neuro: AAOx3, moves all extremities
Pertinent Results:
[**2178-10-9**] 05:40AM BLOOD WBC-8.8 RBC-3.59* Hgb-10.7* Hct-32.2*
MCV-90 MCH-29.8 MCHC-33.2 RDW-16.7* Plt Ct-210
[**2178-10-9**] 05:40AM BLOOD Plt Ct-210
[**2178-10-9**] 05:40AM BLOOD Glucose-78 UreaN-22* Creat-1.0 Na-139
K-3.8 Cl-102 HCO3-27 AnGap-14
[**2178-10-8**] 05:35AM BLOOD ALT-30 AST-27 LD(LDH)-173 AlkPhos-66
TotBili-0.2
[**2178-10-9**] 05:40AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.5*
[**2178-9-21**] 1:30 pm ABSCESS Source: LLQ drain.
**FINAL REPORT [**2178-9-27**]**
GRAM STAIN (Final [**2178-9-21**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final [**2178-9-25**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
CITROBACTER FREUNDII COMPLEX. MODERATE GROWTH.
Trimethoprim/Sulfa sensitivity available on request.
ENTEROCOCCUS SP.. SPARSE GROWTH.
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CHLORAMPHENICOL------- 8 S
GENTAMICIN------------ 4 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 0.5 S =>8 R
MEROPENEM-------------<=0.25 S
PENICILLIN------------ =>64 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 4 S
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2178-9-27**]):
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
**FINAL REPORT [**2178-10-5**]**
AEROBIC BOTTLE (Final [**2178-10-3**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name 17975**] ON [**2178-10-1**] @ 10:10AM.
[**Female First Name (un) **] PARAPSILOSIS.
ANAEROBIC BOTTLE (Final [**2178-10-5**]): NO GROWTH.
Brief Hospital Course:
A/P: 81 year old, CAD, HTN, recent admission w/ diverticular
abscess, s/p drainage, hosp course c/b PE/DVT and GIB likely [**3-4**]
anticoagulation, d/c to [**Hospital1 **] for rehab, re-presented with hx
of 24-48 hx of fever and CP, with a 5 day stay in the MICU s/p
IVF, [**Last Name (un) **]/Caspo/Linezolid, pRBC, never required pressors or
intubation.
*
1. Fever
Patient with recurrant LLQ intraabdominal abscess as seen on abd
CT, s/p drainage. Cx's have grown VRE, C.parapsilosis,
Citrobacter, Bacteroides at various times of drainage.
-Pt afebrile, without leukocytosis, appears resolving today.
Continues to have minor pus drainage from JP drain, <50cc/day.
Cont to flush drain with 10cc twice daily, and monitor for
patency.
-ID following, appreciate recs
-Cont Levaquin 500mg po qD, Flagyl 500mg po q8, Diflucan 400 mg
po qD, Linezolid 600 PO qD.
- Will check repeat CT abd in 2 weeks to look for resolution of
abscess.
-Surgery following, who believes that surgical intervention is
not required at the present time. Pt to continue to have drain
in place, to follow up with Dr. [**Last Name (STitle) **] in 2 weeks to
reevaluate surgical candidacy.
-PICC line pulled on [**9-29**]
-R IJ pulled on [**10-1**] -> tip sent for cx, (-) on cx.
-Pt with hx of onchomycosis predating diverticular abscess,
candidemia. No need for ECHO, r/o endocarditis at this time.
Cont diflucan.
*
2. CP - now resolved.
-unclear etiology, resolved since admission
-No new PE per reread of CTA
-admission EKG notable for a fib but resolved to sinus on
admission s/p fluid boluses
-3 sets of CKs flat, trop peaked 0.44 on [**9-30**]
-monitor clinically for now
*
3. A fib - now resolved
-initial a fib likely in setting of sepsis but resolved to sinus
on admission
-no anticoag per hx of GIB, IVC filter in place.
-returned to a fib on [**9-30**], lopressor IV given x 3 this AM
-continue on lopressor 25mg [**Hospital1 **]
*
4. CAD
-Cont ASA, Lopressor increased to 25mg [**Hospital1 **] (originally held with
GIB, sepsis)
-d/c'ed Zetia, Atorvastatin due to risk of LFT abnormalities.
Restart under direction of Dr. [**Last Name (STitle) **], PCP.
*
5. CHF
Patient currently volume overloaded, with 2+ pitting edema, but
improving on Lasix and increased mobilization with PT.
-Cont Lasix 20mg PO qD, putting out good UOP to this dose
-Goal -1L per day.
*
5. PE/DVT
- No new PE on reread of CTA on [**9-29**]; residual PE remains from
before, femoral DVTs bilaterally remain. Pt not a candidate for
coumadin d/t GI bleed hx.
-IVC filter in place. Cont to hold anticoagulation.
*
6. Anemia
-baseline 31-32, currently at baseline.
-goal hct>27
-daily hct, transfuse as needed.
*
7. ARF - now resolved
-initially 1.3 up from 0.9-1.0 but resolved to baseline 0.9 s/p
fluid boluses
-likely [**3-4**] to shock/ATN, now resolved.
*
8. Adenopathy on abd CT
- f/u abd CT as outpt
*
9. RA
Pt complaining of worsening R shoulder and R elbow pain.
Patient in past had RA mostly in bilat knee, but has had
shoulder pain in past. Patient has been off MTX x4 weeks, and
at a lower dose of prednisone due to infection/sepsis.
-Consulted rheum , will cont pred at dose of 5mg po qd today -
pt more comfortable. If continues to have escalating pain, will
consider increasing to [**Hospital1 **], although in lieu of systemic
infection, will not increase steroid dose unless absolutely
necessary. No joints appear septic at this time - will continue
to closely monitor.
-Hold off MTX for now due to infection risk. No NSAIDs due to
GI bleed.
-Cont pain medicine as tolerated.
*
10. FEN:
-continue cardiac/low residue diet
*
11. PPX: IVC filter, hep sc, holding coumadin d/t GIB hx. C.dif
(-) x2.
*
12. Hyperglycemia
No hx of DM. In light of infection, will attempt to control
sugars while currently infected.
- Cont NPH 4mg SQ qAM with breakfast, and Insulin SS with
regular insulin throughout day to prevent high sugars leading to
worsening infection.
*
13. Code: full
*
14. Drain: JP drain in place. Please flush with 10cc NS [**Hospital1 **] -
tid and ensure that are removing amount flushed to ensure
patency. Drain was noted to be out of place on [**10-9**], and patient
was taken down to CT to have his drain re-placed in the abscess.
*
15. DISPO: Pt is being discharged to Rehab today. Pt
continues to have drain in place, which will remain in place for
a minimum of 2 weeks, until has a repeat CT scan of abdomen in 2
weeks to evaluate for resolution of his abscess. Continue pt on
4 ABx regimen (Linezolid, Levaquin, Flagyl, Diflucan PO) for a
minimum of 2 weeks, and do not stop unless instructed by ID
fellow, Dr. [**Last Name (STitle) 4334**]. Pt is tolerating PO diet, and ambulating
with assistance of walker. Please continue to improve his
functional status with rehab, along with proper drain
maintainence. Please refer to the numbers below for his
continued follow up.
*
*
Consults
PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 16148**]
ID- Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4334**] ([**Telephone/Fax (1) 457**]
Gen Surgery - Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1483**]
Medications on Admission:
Insulin SS
Linezolid 600 mg IV Q12H
Aspirin 325 mg PO DAILY
Atorvastatin 20 mg PO DAILY
Meropenem 1000 mg IV Q8H
Metoprolol 12.5 mg PO QID
Caspofungin 50 mg IV Q24H
Ezetimibe 10 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Folic Acid 1 mg PO DAILY
Furosemide 20 mg IV
Prednisone 5 mg PO DAILY
Heparin 5000 UNIT SC TID
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
14. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) Unit Injection TID (3 times a day).
[**Telephone/Fax (1) **]:*[**Numeric Identifier 31034**] Unit* Refills:*2*
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Scale
as below Insulin Scale Subcutaneous four times a day: FS 150-200
Give 2 Units
FS 200-250 Give 4 Units
FS 250-300 Give 6 units
FS 300-350 Give 8 Units
FS 350-400 Give 10 Units
FS >400 Call physician.
[**Name Initial (NameIs) **]:*300 Insulin Scale* Refills:*2*
19. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Four (4)
Units Subcutaneous qBreakfast.
[**Name Initial (NameIs) **]:*10 mL* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Diverticular Abscess
2. Hypertension
3. Coronary Artery Disease.
Discharge Condition:
Stable to be discharged to rehab.
Discharge Instructions:
1. Please continue all medications as prescribed. Please
continue all antibiotics until your next ID appointment. Please
schedule a follow up appointment with Dr. [**Last Name (STitle) **] in 2 weeks
after discharge. Please call ([**Telephone/Fax (1) 1483**] to schedule that
appointment.
.
2. Please have abdominal CT scan on [**2178-10-15**].
.
3. The JP drain should remain in place until follow up with ID
(Dr. [**Last Name (STitle) 4334**], and Dr. [**Last Name (STitle) **].
Followup Instructions:
CT Scan of abdomen. Where: [**Hospital Ward Name 452**] 3 ([**Hospital Ward Name 516**]). When:
[**2178-10-15**] at 8:45 am. You must not eat or drink anything after
4am on [**2178-10-15**].
.
Provider: [**Name10 (NameIs) 12082**] CARE ID Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2178-10-22**] 2:00
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2178-11-5**] 11:30
.
Provider: [**Name10 (NameIs) **] WEST,ROOM FOUR GI ROOMS Where: GI ROOMS
Date/Time:[**2178-10-28**] 10:00
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX)
Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2178-10-28**] 10:00
.
|
[
"0389",
"78552",
"42731",
"5845",
"4280",
"99592"
] |
Admission Date: [**2156-11-17**] Discharge Date: [**2156-11-20**]
Date of Birth: [**2108-7-29**] Sex: F
Service: MEDICINE
Allergies:
acetaminophen-codeine
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48 yo female history poorly controlled DM1 (last A1C [**10-2**]) and
med noncompliance presented to her PCP's office with 1 day N/V
and mild crampy abdominal discomfort found to have critically
high BS. She denies any hematemesis. She reports that she has
been taking her insulin as scheduled, and last took it twice
this morning with BS in the 100's. She checks her FS QID at
home. However, in the past she has noted that she often misses
not infrequently. She denies chest pain and denies urinary
symptoms beyond polyuria. Notes initial SOB upon arrival to her
clinic appointment. Notes increaseing fatigue and decreased
exercise tolerance recently. She notes subjective F/C, but was
afebrile in clinic and in the ED. Also notes diffuse abdominal
pain which is worse with vomiting, but is improving. At clinic
her VS were T 98.1 BP 138/70 P 120, critically high BS. She
received 14 units of humalog in clinic, but her repeat BS was
still critically high. Her clinic urine dip showed glucose >160
mg/dL, neg nitrites and neg leuk est. Urine HCG was also
negative.
.
In the ED, initial Vitals were 97.9,126,127/57,16,100/ra. Labs
revealed an wbc 19.5 left shift, Na 135, Cl 99, HCO3 8, AG 28.
UA was within normal limits. CXR done. She was given 1L NS, 1L
LR, and 10U regular insulin SQ. She was started on an insulin
drip at 10U/hr. One PIV placed.
.
In the [**Hospital Unit Name 153**], she is feeling better with no further nausea or
vomiting. She notes improved abdominal pain from prior.
Past Medical History:
DM1, dx [**2144**], poorly controlled with last A1C [**10-2**]
HTN
HL
anemia, baseline hct 30
cardiomyopathy, nonischemic mild [**Last Name (LF) 19874**], [**First Name3 (LF) **] 40-45%,(-) cath in
[**2149**]
hx Pancreatitis
GERD
Social History:
Lives with fiance and three children in [**Location (un) 686**]. Works as a
legal secretary. Denies tobacco, EtOH, drug use.
Family History:
Mother had DM.
Physical Exam:
Admission Physical Exam:
VS: Temp: 98.9 BP: 129/68 HR: 115 RR: 24 O2sat 99% on RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, [**Location (un) 3899**], anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: tachycardic, S1 and S2 wnl, no m/r/g
ABD: nd, +bs, soft, nt, nd, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
Labs on Admission:
[**2156-11-17**] 08:45PM GLUCOSE-556* UREA N-15 CREAT-1.1 SODIUM-135
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-8* ANION GAP-33*
[**2156-11-17**] 08:45PM estGFR-Using this
[**2156-11-17**] 08:45PM ALT(SGPT)-16 AST(SGOT)-18 CK(CPK)-72 ALK
PHOS-113* TOT BILI-0.2
[**2156-11-17**] 08:45PM LIPASE-15
[**2156-11-17**] 08:45PM CK-MB-2 cTropnT-<0.01
[**2156-11-17**] 08:45PM ALBUMIN-4.6
[**2156-11-17**] 08:45PM %HbA1c-11.3* eAG-278*
[**2156-11-17**] 08:45PM ACETONE-MODERATE OSMOLAL-320*
[**2156-11-17**] 08:45PM URINE HOURS-RANDOM
[**2156-11-17**] 08:45PM URINE GR HOLD-HOLD
[**2156-11-17**] 08:45PM WBC-19.3*# RBC-4.46 HGB-12.8 HCT-39.3 MCV-88
MCH-28.8 MCHC-32.7 RDW-13.0
[**2156-11-17**] 08:45PM NEUTS-92.9* LYMPHS-5.4* MONOS-1.1* EOS-0.5
BASOS-0.1
[**2156-11-17**] 08:45PM PLT COUNT-348
[**2156-11-17**] 08:45PM PT-13.3 PTT-17.6* INR(PT)-1.1
[**2156-11-17**] 08:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2156-11-17**] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2156-11-17**] 08:45PM URINE RBC-0-2 WBC-0 BACTERIA-OCC YEAST-NONE
EPI-[**1-22**]
Labs on Discharge:
[**2156-11-20**] 07:15AM BLOOD WBC-7.6 RBC-4.14* Hgb-11.6* Hct-34.4*
MCV-83 MCH-28.0 MCHC-33.7 RDW-13.1 Plt Ct-289
[**2156-11-20**] 07:15AM BLOOD Glucose-77 UreaN-6 Creat-0.5 Na-142 K-3.5
Cl-106 HCO3-26 AnGap-14
[**2156-11-20**] 07:15AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.7
Imaging:
CHEST (PA & LAT) Study Date of [**2156-11-17**] 10:21 PM
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
48 yo female history poorly controlled DM1, HTN, HL, and
cardiomyopathy presents with N/V/D in DKA.
.
#DKA: The patient presented with hyperglycemia and DKA with an
anion gap of 28. The patient was started on IVF with potassium,
as well as an insulin gtt. We awaited closure of the patient's
AG, after which point SC insulin was started (home regimen of
lantus 60 plus humalog sliding scale). [**Last Name (un) **] was consulted.
The patient's DKA was felt likely secondary to insulin
non-compliance, as she did not have any active signs or cultures
indicative of infection, though it is possible that she had a
mild viral gastroenteritis as a trigger. A normal EKG made ACS
unlikely. We aggressively repleted her potassium. Extensive
diabetes education was done by MDs and RNs. She will follow up
closely with her PCP, [**Name10 (NameIs) **] [**First Name (STitle) 31365**].
.
#leukocytosis: Pt WBC count was initally 20 on arrival to the
ED, which trended down to 12 the next day in the ICU, then
normalized. Urine cx and CXR were unremarkable, and did not
reveal any source of infection; this was likely a stress
response from DKA.
.
#tachycardia: likely [**12-22**] to dehydration in the setting of DKA.
Abdominal pain improving. The patient's tachycardia resolved
after administration of IV fluids.
.
# she was continued on her home medications for hypertension and
hyperlipidemia.
Medications on Admission:
insulin glargine [Lantus] 60 UNITS SC qpm
insulin lispro [Humalog] 14 units tid with meals
lisinopril-hydrochlorothiazide 40 mg-25 mg daily
simvastatin 80 mg Tablet by mouth qhs
aspirin 81 mg Tablet daily
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Insulin
Glargine: 60 units at bedtime
Humalog: Per sliding scale (attached)
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Type 1 Diabetes, uncontrolled with complications
Hypertension
gerd
cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with diabetic ketoacidosis. This is a life
threatening complication of your diabetes. You were treated in
the intensive care unit and improved.
It is critically important for you to follow a diabetic diet, to
to take your insulin as scheduled, to check your fingersticks 4x
/ daily, and to contact your PCP with any worrisome glucose
readings.
Followup Instructions:
Follow up with your PCP, [**Name10 (NameIs) **] [**First Name (STitle) 31365**], this week. Please call her
office to schedule an apppointment: [**Telephone/Fax (1) 7976**]
|
[
"4280",
"4019",
"53081"
] |
Admission Date: [**2145-1-4**] Discharge Date: [**2145-1-27**]
Service: MEDICINE
Allergies:
Fosamax
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
left leg ischemic ulcer
Major Surgical or Invasive Procedure:
angiogram with left lower extremity runoff [**2145-1-12**]
History of Present Illness:
89y/o white male with known COPD hospitalized at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
for UTI with sepsis ( entercoccal) and associated renal failure
[**Date range (1) 60131**] which was treated with marked improvement of
respiratory status and uti. Plastics was consulted during that
admission for a chronic venous stasis ulceration for three
months. secondary to trama induced wound. He was treated with
Vancomycin 1 gm q24h, aztreonam 1 gm IV q8h and bactrium 160mgm
[**Hospital1 **]. Wound cultrues grew MRSA,pseudomonas and xanthomonas
maltophila.He was initally refered to DR. [**First Name (STitle) 7749**] @ [**Hospital3 2358**].
He felt patient was to ill for consideration for vascular
surgery. PVR's were done significant for severe intrapopliteal
disease. Dr. [**Last Name (STitle) 1391**] was consulted for a second opnion .
Patient transfered to [**Hospital1 18**] Vascular Surgery Service [**2145-1-4**]
Past Medical History:
rt. olecranon infected bursitis s/p I&D [**12-3**]
?COPD/Asthma, steroid dependent (minimal smoking hx, see below)
chronic renal failure with excerbation secondary to UTI and
sepsis [**12-3**]
MRSA
PVD
hypertension
BPH
Social History:
resident of an [**Hospital3 **] complex
Smoked 1PP for 5 years, quit >50 years ago.
Son & daughter active in his care.
Family History:
unknown
Physical Exam:
Vital signs: 98.2-80-20 140/71 o2 saturation 97%
HEENT: no JVD
Lungs: with course bronchial sounds and expiratory wheezing
Heart: irregular 1-2/6 SEM at base
ABD: soft nontened nondistended no AAA, no bruits, periumbilical
hernia
PV: chronic venous stasis skin changes bilaterally .anterior
tibial ulceration with fibrious base and excudate with
surrounding erythema. Edema 1+
Pulse exam: palpable radial pulses bilaterally,femoral pulses 1+
bilaterally, absent popliteal pulses and monophasic dopper
signal dp and Pt bilaterally.
Neuro oriented person/place.
Pertinent Results:
[**2145-1-5**] 12:02AM BLOOD WBC-8.3 RBC-3.39* Hgb-10.1* Hct-30.4*
MCV-90 MCH-29.8 MCHC-33.3 RDW-16.2* Plt Ct-371
[**2145-1-5**] 12:02AM BLOOD PT-13.5 PTT-29.2 INR(PT)-1.2
[**2145-1-5**] 12:02AM BLOOD Glucose-78 UreaN-21* Creat-1.5* Na-136
K-4.6 Cl-100 HCO3-28 AnGap-13
[**2145-1-18**] 09:15PM BLOOD CK-MB-2 cTropnT-0.06*
[**2145-1-5**] 12:02AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.6
[**2145-1-14**] 04:49AM BLOOD calTIBC-111* Ferritn-775* TRF-85*
[**2145-1-7**] 05:28AM BLOOD Triglyc-135 HDL-36 CHOL/HD-4.0 LDLcalc-82
[**2145-1-14**] 04:49AM BLOOD TSH-2.6
Brief Hospital Course:
1. Ischemic Leg Ulcer: Pt was admitted from OSH for
intervention for non-healing LLE ischemic-limb-threatening
ulcer. LE angiogram which revealed distal above-knee 85%
stenosis of the popliteal artery, TO tibial artery an peroneal
artery with patent but diffusely diseased posterior tibial.
Initially the wound appeared frankly purulent and grew
Pseudomonas (treated with Zosyn and emperic vancomycin). Given
the pt's comorbidities (see below) and his high-risk for
perioperative mortality, the decision was made to forgo
definitive surgery at this time. The wound was debrided daily
at bedside and Mr.[**Known lastname 60132**] was taken to the OR [**1-18**] for
debridement under anesthesia and went into hypovolemic
shock/adrenal insufficiency/septic shock subsequently (see
below). Taken to the MICU and treated with stress steroids and
fluid boluses. Pt will have skin graft in future by Dr.
[**Last Name (STitle) 60133**] in plastic surgery clinic, since Mr.[**Known lastname 60132**] has too
many medical comorbidities to undergo a vascular surgery safely.
Pt will need VAC dressing changes every 3-4 days. We will
continue vancomycin and zosyn as long as the pt has an open
wound. He has PICC access for IV antibiotics.
2. CAD: Pt had stress MIBI during pre-op risk stratification.
Had a small reversible inferior defect. He was continued on
asprin, beta blocker, statin and ACE. No chest pain or EKG
changes during his hospitalization.
3. CHF: Pt with diastolic heart failure with preserved EF of
>65%. Mr.[**Known lastname 60132**] went into acute volume overload with the dye
load from his lower extremity angiogram. When he was
transferred to the medicine service he was diuresed with IV
lasix and his beta-blocker was titrated up to decrease
chronotropy. Mr.[**Known lastname 60132**] is quite volume sensitive. Currently
he is on PO lasix at a dose of 40mg per day, which should be
continued. He is on maximal beta-blocker therapy of lopressor
100 mg [**Hospital1 **] for the above reasons.
4. Shock: Pt went into combined hypovolemic/septic shock with
adrenal insufficiency at the time of open debridement [**1-18**]. He
required numerous fluid boluses and neosynephrine gtt overnight.
He was transferred to the MICU where he was started on
gentamycin for Pseudomonal coverage and stress dose steroids
(for 7 days, no longer on gentamycin). He takes 5 mg po qD
prednsione for "COPD," and now likely has a primary adrenal
insufficiency due to this. He will be discharged on prednisone
20mg po qD for life. He should wear a adrenal insufficiency
med-alert bracelet. Currently, the pt's blood pressure is
stable ~130's/70's.
5. R-sided Pleural Effusion: Pt had a R-sided pleural effusion
associated with his possible aspiration pneumonia. Since the
effusion cleared with diuresis, it was attributed to CHF and not
empyema/parapneumonic. No tap was done.
6. Aspiration PNA: Mr.[**Known lastname 60132**] was noted to have bibasilar
opacities worrisome for aspiration pneumonia. He was already
being treated with vanc/zosyn so no new antibiotics were added.
Sputum culture only showed oropharyngeal flora. The opacities
resolved by time of discharge.
7. COPD: Pt required nebulized albuterol and atrovent
throughout his hospitalization. He had audible wheezing and
decreased air movement on physical. He will require nebs and
continued steroids as an outpt. Diagnosis needs to be clarified;
recommend outpt PFTs if hasn't had recently. Pt will f/u with
PCP for this.
8. Refeeding Syndrome: Mr.[**Known lastname 60132**] developed refractory
hypokalemia, hypomagnesiumeima and hypophosphatemia when he
began to take PO after his ICU stay (where he was NPO). These
electrolyte abnormalities were repleted vigilantly. Other
potential contributors to Mr.[**Known lastname 60134**] electrolyte problems
include albuterol toxicity (cellular redistribution of
potassium) and zosyn (acting as a non-reabsorbable anion,
increasing distal delivery of sodium, and coupled with [**Male First Name (un) 2083**],
causing potassium wasting at principal cell). At time of
discharge, his electrolytes will need to be checked 3 times per
week.
Medications on Admission:
adivir 250/50 puff 1 [**Hospital1 **]
singular 10mgm qd
Vitamin C 500mgm qd
EC asa 81 mgm qd
zestril 10mgm qd
zinc 220mgm daily
colace 100mgm [**Hospital1 **]
Vancomycin 500mgm qd
bactrium 160mgm [**Hospital1 **]
aztreonam 1gm IV q8h
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-31**]
Puffs Inhalation Q4H (every 4 hours).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
15. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
20. Vancomycin HCl 1000 mg IV Q24H
21. Piperacillin-Tazobactam Na 4.5 gm IV Q8H
22. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale insulin Injection ASDIR (AS DIRECTED): for FS 150-200,
give 2u, for FS 201-250 give 4u, for FS 251-300 give 6u, for FS
301-350 give 8u, for FS 351-400 give 8u.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
PVD
infected venous stasis ulcer
diastolic CHF
LLL pneumonia
CAD with EF 50%
Pmibi : small reversible perfusion defect of inferior wall
?COPD, steroid-dependent
adrenal insufficiency
Discharge Condition:
Stable
Discharge Instructions:
Return to Emergency room for shortness of breath, chest pain,
worsening of your ulcer.
Followup Instructions:
1. Dr. [**Last Name (STitle) 1391**] [**Telephone/Fax (1) **]
2. Dr. [**Last Name (STitle) 60133**] [**Telephone/Fax (1) 60135**] Plastic surgery for a skin graft.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"5070",
"41071",
"42789"
] |
Admission Date: [**2132-1-2**] Discharge Date: [**2132-1-10**]
Date of Birth: [**2063-9-16**] Sex: M
Service:
ADMITTING DIAGNOSIS: Coronary artery disease, status post MI
in [**2119**], status post cath and PTCA at that time.
HISTORY OF PRESENT ILLNESS: This is a 68-year-old man with
coronary artery disease, status post MI in [**2119**], status post
cath and PTCA at that time with a negative stress test two
years ago. He complained of chest pain that began three days
before he came in while he was shovelling snow and was
relieved by rest. He does not take Nitroglycerin. He
characterized the chest pain as band-like pain around his
chest. He had no shortness of breath or nausea or vomiting
associated with that, no radiation of the chest pain.
Characterizes the pain as a [**2140-5-24**]. He then was relieved by
rest. He then woke up with chest pain that night. He came
to the Emergency Room on the 16th with chest pain and was
given Nitroglycerin and it was relieved. He then proceeded
to go to the cath lab. Please see full report for all the
details. Briefly, he had a normal left main coronary artery,
the LAD was calcified with minimal luminal irregularities,
80% mid lesions and 80% diagonal II. The left circumflex had
80% of the OM1 and right coronary artery was totally occluded
and he had 80% proximal, 90% mid with thrombus and sequential
80% PDA lesions. In the cath lab he had three right coronary
lesions stented and he tolerated that procedure well. He
also had an echocardiogram on the 17th. Please see report
for full details. Briefly, he had overall severely depressed
left ventricular systolic function, ejection fraction of 30%,
severe hypokinesis, akinesis of the apex, hypokinesis of the
inferior wall, mid apical segments of the anterolateral,
anterior septal walls, dyskinesis of the basal segments of
the inferior septal and inferior walls.
PAST MEDICAL HISTORY: Includes MI in [**2119**]. At that time he
had a catheterization. Also has prostate cancer,
hypertension, hypercholesterolemia.
MEDICATIONS: On admission included Atenolol, Vasotec and
Aspirin.
LABORATORY DATA: White blood cell count 5.3, hemoglobin
10.9, hematocrit 31.5 and platelet count 176,000. Sodium
140, potassium 3.9, CO2 29, chloride 102, BUN 15, creatinine
1.1 and glucose 99.
PHYSICAL EXAMINATION: On exam his sternum was stable, no
drainage coming from the sternum or from his leg incision.
He had a slight erythematous rash on his back. He was alert
and oriented, carotids with good upstroke, no bruits, no JVD.
His cardiovascular, he had a regular rate and rhythm, regular
S1 and S2, no murmurs, rubs or gallops. His abdomen was
soft, positive bowel sounds, his lungs were clear, no
crackles. Extremities with no edema. He had palpable pedal
pulses, warm extremities.
HOSPITAL COURSE: On [**1-4**] the patient went to the OR and had
a CABG times four, LIMA to the diagonal, SVG to the LAD, PL
in the OM1. He tolerated that procedure well. He came out
of the OR on an epi drip .04 and Propofol and the epi drip
and Propofol were weaned off that night and he was also
extubated that night. On postoperative day #1 the patient
went into a rapid atrial fibrillation with subsequent
decrease in blood pressure, systolic blood pressure of 80-90.
He received Lopressor at that time and was started on
Amiodarone. He also had complained of some left chest pain
and there were some ischemic changes on his EKG which later
was thought to be musculoskeletal pain because it was
relieved with Toradol. It was thought that the ST changes in
the lateral leads were due to pericarditis. After receiving
the Lopressor and the Amiodarone, the patient converted to
normal sinus rhythm. The patient was also started on
Neo-Synephrine at that time for a low blood pressure. On
postoperative day #2 the patient had a drop in hematocrit to
20 and he received two units of packed red blood cells for
that. He was weaned off the Neo on that day. He had a brief
episode of atrial fibrillation which was converted with 2.5
mg of Lopressor and on postoperative day #3 the patient was
transferred to Far 6. Upon transfer the patient went into
rapid atrial fibrillation again at a rate of around 150. He
received Lopressor 10 mg IV at that time and some magnesium.
He was continued on his Amiodarone and he converted to normal
sinus rhythm in the 70's and his Lopressor dose was
increased. Over the next several days the patient remained
hemodynamically stable, his activity level increased with the
help of physical therapy. He was able to ambulate around the
unit. His O2 sats on room air were 94% and he was ready for
discharge. On postoperative day #6 the patient was
discharged from the hospital. Vital signs at time of
discharge were 97.8, heart rate 81 and normal sinus rhythm,
respiratory rate 16, blood pressure 115/76, O2 saturation 95%
on room air. His weight was 80.2 kg, up from his
preoperative weight of 77 kg.
DISCHARGE MEDICATIONS: Lasix 20 mg po q d times one week,
Calcium Chloride 20 mcg po q d times one week, Plavix 75 mg
po q d, Amiodarone 400 mg po tid times two days, then [**Hospital1 **]
times one week and then q d, Lopressor 25 mg po bid,
Ciprofloxacin 500 mg [**Hospital1 **] times three days, Aspirin 325 mg po
q d, Lipitor 10 mg po q d, Percocet 1-2 tabs po q 4 hours prn
pain, Ibuprofen 400 mg po q 6 hours prn for pain, Colace 100
mg po bid. The patient is to follow-up with his primary care
provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in one month. He is to
follow-up with Dr. [**Last Name (STitle) **] in one month.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post MI.
3. Status post angioplasty times three and CABG times four.
4. Hypertension.
5. Hypercholesterolemia.
6. Prostate cancer.
The patient was discharged to home.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 4060**]
MEDQUIST36
D: [**2132-1-10**] 11:47
T: [**2132-1-10**] 12:16
JOB#: [**Job Number 27062**]
|
[
"41401",
"9971",
"42731",
"4019",
"2720",
"412"
] |
Admission Date: [**2129-8-10**] Discharge Date: [**2129-8-17**]
Date of Birth: [**2080-9-30**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Codeine / Adhesive Tape
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
s/p revision L hip hemiarthroplasty
History of Present Illness:
[**Known firstname 13291**] is a very nice 48 y/o man with Charcot arthropathy of the
left hip. He is well known to the arthroplasty service at [**Hospital1 18**].
He previously had undergone Girdlestone resection arthroplasty,
then a reconstruction with hemiarthroplasty was attempted in
[**3-31**]. This attempt had to be aborted due to poor bone stock, and
instead a femoral autograft was used to reconstruct part of his
acetabulum. He presented again electively for attempted
arthroplasty of his left hip.
Past Medical History:
1. Hypertension
2. Chronic atrial fibrillation
3. Gout
4. Degenerative joint disease
Social History:
1. On disability since [**2128-6-16**]
2. Nonsmoker, social alcohol
3. Denies drug use.
Family History:
1. Mom died from lung cancer at the age of 79
2. Father died of congestive heart failure
3. Two siblings alive and well
4. One brother who died from gunshot wound
Physical Exam:
In pre-op:
NAD, A+O x3
Breathing comfortable, Cor reg.
Left LE:
+ [**Last Name (un) 938**], TA, G-S
SILT at S/S/T/DP/SP
Warm toes, 2+ DP pulses bilaterally.
Brief Hospital Course:
On [**2129-8-10**] the patient was brought to the operating room and
underwent revision right hip hemiarthroplasty. A total
arthroplasty could not be performed secondary to poor bone stock
of his acetabulum. The case was uncomplicated but did involve a
significant blood loss. Please see Dr. [**Last Name (STitle) **] operative note for
details. Post-operatively extubation was delayed due to the
length of the case and the late hour of its completion, so the
pt was managed in the ICU for close monitoring overnight. The
patient was treated with IV then PO antibiotics for ten days for
prophylaxis of infection. Lovenox was given for DVT prophylaxis
and TEDS and pneumoboots were used. The patients home dose of
coumadin was restarted and the lovenox was stopped when his INR
became therapeutic (> 2.0). The patient was made WBAT on the
operative extremity with posterior hip precautions and physical
therapy assisted with mobilization. His other home medications
were restarted.
As the patient had no well formed acetabulum, the
hemiarthroplasty came to form an articulation with his pelvis
just superior to the original acetabulum. This was noted both
intraoperatively and on post-operative plain films. As such, the
patient was left with a known leg length discrepency, and he
will be fitted with a shoe lift prosthesis near his home. The
joint remained stable to WBAT with crutch ambulation while the
patient was in house.
The acute pain service followed the patient while in-house a PO
regimen was found that kept him comfortable before discharge.
Prior to discharge the patient was afebrile with stable vital
signs. Hematocrit was stable and pain was adequately
controlled on a PO regimen. The operative extremity was
neurovascularly intact and the wound was benign. Patient was
discharged in stable condition.
Medications on Admission:
Coumadin, Diltiazem, Metoprolol, Lisinopril, Allopurinol,
Clonazepam, Baclofen, Oxycontin, Dilaudid, Lasix
Discharge Medications:
1. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO Q8H (every 8 hours).
Disp:*180 Tablet Sustained Release 12HR(s)* Refills:*0*
2. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Goal INR 2.0-2.5-- Take daily- alternate 7.5 mg and 10.0 mg .
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID PRN () as
needed for spasms.
7. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
9. Hydromorphone 4 mg Tablet Sig: 3-4 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*300 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 11485**] VNA
Discharge Diagnosis:
left hip osteoarthritis/neuropathic joint
Discharge Condition:
Good.
Discharge Instructions:
Wound: keep wound clean and dry. cover with dry sterile
dressing until dry x 72 hours and then open to air. [**Month (only) 116**] shower,
but keep all water off of wound until 1 week post-op.
Medications: take all medications as prescribed.
Call Dr. [**Last Name (STitle) **] for fevers >101, chills, sweats, redness or
discharge around your wound or any other changes that are
concerning to you.
Physical Therapy:
Activity:
Left lower extremity: Full weight bearing
Assist in ambulation w/ crutches
** pt is chronically dislocated and is forming an articulation
between his hemiarthroplasty and the side of his pelvis--
consequently his left leg is shorter than the right, and he will
be fitted for a corrective shoe prosthesis
See attached PT note for further details
Treatments Frequency:
-dry dressings prn to incision
-staples and stitches will be removed at f/u visit
-INR to be followed by PCP as was prior routine
Followup Instructions:
2 weeks with Dr. [**Last Name (STitle) 62823**] please call [**Telephone/Fax (1) 1228**] ASAP to
schedule an appointment as close to [**2129-8-31**] as possible. Your
stitches and staples will be removed then.
Completed by:[**2129-10-18**]
|
[
"2851",
"42731",
"4019",
"V5861"
] |
Admission Date: [**2101-5-27**] Discharge Date: [**2101-5-31**]
Date of Birth: [**2039-3-10**] Sex: M
Service: ACOVE
HISTORY OF PRESENT ILLNESS: This is a 62 year-old man with
multiple chronic obstructive pulmonary disease exacerbations in
the past last admitted in [**Month (only) 547**]. According to the family the
patient had sudden onset of shortness of breath. EMS was called.
Initial pulse was 124, oxygen saturation is 83% requiring rapid
sequence intubation in the field. He was admitted three times
for chronic obstructive pulmonary disease flare in the past five
months, the last one being in [**Month (only) 547**] with a tracheostomy. He had
a G tube placed as well, which was discontinued after successful
wean in [**Month (only) 547**]. The patient is still on a Prednisone taper for
outpatient shortness of breath episodes. No further history was
elicited at the time of admission.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Asthma.
3. Hypertension.
4. Coronary artery disease status post myocardial infarction
[**2101-1-5**].
5. Low back pain status post L1-L2 disc fusion.
6. Hypercholesterolemia.
7. Depression.
SOCIAL HISTORY: Quit smoking 28 years ago. The patient has
two daughters and lives with wife.
MEDICATIONS:
1. Lisinopril 2.5 mg po q.d.
2. Lopressor 25 mg po b.i.d.
3. Ativan 0.5 mg po q.h.s.
4. Lipitor 10 mg po q.d.
5. ASA 325 mg po q.d.
6. Colace.
7. Zoloft 50 mg po q.d.
8. Prednisone taper.
9. Ciprofloxacin 250 mg po b.i.d.
10. Albuterol two puffs q 6.
11. Atrovent two puffs q 4 to 6.
12. Flovent 220 two puffs b.i.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs 97.6, 120, 160/50 down to
85/50. Initial vent settings tidal volume 600, rate 12,
pressure support of 5, PEEP of 5, 100% FIO2 changed to volume
of 600, rate 15, pressure support of 5, PEEP of 5, 40% FIO2.
in general, he is intubated and sedated. HEENT pupils are
equal, round and reactive to light. Extraocular movements
intact. Neck no JVD. Lungs distant breath sounds,
occasional wheezing bilaterally. Heart regular rate and
rhythm. S1 and S2. Normal 1 out of 6 systolic murmur.
Abdomen soft, nontender, nondistended. Positive bowel
sounds. Extremities no edema, thin. Neurological withdraws
to noxious stimuli, sedated.
PERTINENT LABORATORIES ON ADMISSION: The patient's CBC
revealed a white count of 15.5, hematocrit 38, platelet count
333, PT 13.1, PTT 27.2, INR 1.1. Chemistries revealed a
sodium of 140, potassium 4.5, chloride 102, bicarbonate 26,
BUN 21, creatinine 1.0, glucose 149, CK 51, troponin less
then 0.3. Electrocardiogram revealed sinus tachycardia at
115, normal axis and intervals, [**Street Address(2) 4793**] depressions in V3
through V6, 2, 3 and F compared with [**2101-5-6**]. First
blood gas revealed pH of 7.27, PCO2 59, PO2 489, bicarbonate
of 28, oxygen saturation 99% on SIMV 600 times 12, pressure
support of 5 and PEEP of 5, 100% FIO2. Chest x-ray revealed
hyperinflated lungs, no pneumothorax. No infiltrate.
ASSESSMENT: The patient is a 62 year-old man with severe chronic
obstructive pulmonary disease, asthma with respiratory failure
and hypotension.
HOSPITAL COURSE: The patient ruled out for myocardial infarction
by CPK times two. The patient was placed on intravenous Solu-
Medrol in addition to Prednisone 50 mg po q.d. on [**5-30**]. By
then the patient had been extubated and weaned to BiPAP for 24
hours and finally back to oxygen by nasal cannula first 4 liters
and then finally down to his baseline of 2 to 3 liters. The
patient's shortness of breath improved significantly while in the
hospital. He had no chest pain, pleuritic pain, cough, fevers or
chills. He did continue to have low blood pressures while in
house and his ace inhibitor was held, although he was continued
on Metoprolol. He was continued on his inhalers as well as his
steroid taper.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease with acute
exacerbation.
2. Coronary artery disease.
3. Hypertension.
DISCHARGE STATUS: To home with services.
DISCHARGE CONDITION: Good.
RECOMMENDED FOLLOW UP: The patient was told to follow up with
his primary care physician in one week to assess respiratory
function and to check his blood pressure in order to determine
whether or not he can restart his Lisinopril.
DISCHARGE MEDICATIONS: The patient was told to restart all
of his outpatient medications and to start a new Prednisone
taper 60 mg po q.d. for four days and then 40 mg po q.d. for
four days and then 20 mg po q.d. for four days and 10 mg po
q.d. for four days and then 5 mg po q.d. for four days.
The patient was to have Care Group VNA to resume visits as
before. He was written for home oxygen as well. He was
encouraged to take in a cardiac heart healthy diet.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 1595**]
MEDQUIST36
D: [**2101-6-26**] 07:55
T: [**2101-7-4**] 09:02
JOB#: [**Job Number 20164**]
|
[
"51881",
"41401",
"4019"
] |
Admission Date: [**2201-5-31**] Discharge Date: [**2201-6-4**]
Service: Medicine
CHIEF COMPLAINT: Black stools.
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female
with a history of gastroesophageal reflux disease and peptic
ulcer disease, now with black stools times two days. She has
had nauseousness but denies vomiting. She has had
epigastric/sternal pain for a few days, but currently she
denies any chest pain or shortness of breath. She also
denies lightheadedness or dizziness. The patient is a poor
historian and has been transferred from [**Hospital3 **]
Center.
PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease;
2. Hypertension; 3. Left lazy eye; 4. History of multiple
falls; 5. Benign positional vertigo; 6. History of pelvic
ulcer disease; 7. Dementia; 8. Depression; 9. NPH.
MEDICATIONS ON ADMISSION: 1. Norvasc 2.5 mg q. day; 2.
Zoloft 50 mg q. day; 3. Aspirin 81 mg q. day; 4. Os-Cal 500
mg q. day; 5. Pepcid 20 mg b.i.d.; 6. Vioxx 25 mg q. day;
7. Miacalcin 2 tablets per day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives at [**Hospital3 **] Center.
There is a remote history of tobacco smoking but is not
currently a smoker.
PHYSICAL EXAMINATION: Vital signs, temperature 98.4,
heartrate 77, blood pressure 135/79, respirations 24, oxygen
saturation 94% on room air. In general, elderly female in no
apparent distress. Head, eyes, ears, nose and throat
examination, anicteric sclera, moist mucous membranes. Neck
examination, no jugulovenous distension. Cardiovascular
examination, regular rate, normal rhythm with a II/VI
systolic ejection murmur best heard at the left lower sternal
border. Pulmonary examination was clear to auscultation
bilaterally. Abdominal examination, positive bowel sounds,
soft, nontender, nondistended. Extremities examination was
warm, no edema. Neurological examination, alert and
appropriately responsive.
LABORATORY DATA: Electrocardiogram showed normal sinus
rhythm at 69 beats/minute, no ST changes when compared to an
electrocardiogram done on [**2201-1-22**]. Complete blood
count, white count 7.7, hematocrit 32.1, platelets 250,
neutrophils 84% lymphocytes 10%, INR 1.1. Chem-7 145, 3.8,
109, 25, 28, 0.5 and 96. Creatinine kinase was 29.
HOSPITAL COURSE: 1. Gastrointestinal bleed - This was
likely to be an upper gastrointestinal bleed. She was typed
and crossed for 4 units. She had her hematocrit checked
every eight hours initially. The patient was initially
started on Protonix 40 mg intravenously b.i.d. and was kept
NPO and her Aspirin and Vioxx was held. Upon admission her
hematocrit was 32.1%. She appeared stable and alert and
oriented appropriately. She had a negative nasogastric
lavage in the Emergency Department. Two large intravenous
needles were placed. However, later that afternoon the
patient's hematocrit was rechecked. It was 27.4%. Again,
the patient seemed to remain hemodynamically stable, but she
was transfused 2 units of blood. The patient's hematocrit
rose appropriately by hospital day #2 to 39.4%. However, the
patient did have one episode of hematest with about 100 to
150 cc of bright red blood that did not clear this time with
nasogastric lavage. The patient was found to be
tachycardiac, however, her blood pressure remained stable.
The patient was at this time transferred to the Medicine
Intensive Care Unit for further treatments. The patient was
transfused another 2 units of packed red blood cells. She
remained stable over night. Her hematocrit on hospital day
#3 rose appropriately to 41.4% and upon dictation of this
discharge summary her hematocrit remained stable at 41.8%.
She did not have any other episodes of hematemesis. An
nasogastric tube was initially placed and approximately 400
cc of dark red blood was suctioned out of her stomach. Her
nasogastric tube was discontinued on hospital day #3.
Gastroenterology was consulted for this gastrointestinal
bleed, but after extensive discussions with family members,
given the patient's elderly status and her Do-Not-Intubate
Do-Not-Resuscitate code status, it was thought in the best
interest that they did not do an endoscopy to see the source
of her bleeding because this would require further sedation
and anesthesia with risks that would accompany the procedure.
The patient remained hemodynamically stable throughout the
rest of her hospital stay.
2. Chest pain - The patient was ruled out for a heart attack
with three negative sets of cardiac enzymes. Her chest pain
was attributed likely to gastroesophageal reflux disease.
The patient was started on Protonix 40 mg intravenously
b.i.d. initially and did not complaint of any chest pain or
shortness of breath past this point. An electrocardiogram
was initially done in the Emergency Room which was normal. A
chest x-ray was obtained which was unchanged from previous
chest x-ray.
3. Fluids, electrolytes and nutrition - The patient's
electrolytes remained stable throughout the hospital course.
She was initially kept NPO until hospital day #4 which time
her diet was advanced to a thick liquid diet and then to a
full pureed diet. The patient tolerated this without
difficulties. Nutrition consult was obtained, and their
recommendations were followed.
4. Cardiovascular status - The patient's blood pressure
remained stable throughout the hospital course. She was
initially started on Amlodipine 2.5 mg q. day. This was
discontinued on hospital day #4 per Gerontology's request.
The patient was also continued on Telemetry throughout this
hospital course. There were no arrhythmias and no further
issues.
5. Infectious disease - The patient complained of some
dysuria on hospital day #3 at which time a urinalysis was
obtained. She had large blood, small leukocyte esterase,
white blood cells 21 through 50 and many bacteria and no
epithelial cells. It was thought that the patient had a
urinary tract infection. She was started and will continue a
three day course of Ciprofloxacin 250 mg b.i.d.
CODE STATUS: The patient remained Do-Not-Intubate,
Do-Not-Resuscitate throughout her hospital stay.
DISCHARGE DISPOSITION: The patient will be discharged back
to [**Hospital3 **].
DISCHARGE DIAGNOSIS:
1. Upper gastrointestinal bleed
2. Gastroesophageal reflux disease
3. Hypertension
4. History of multiple falls
5. Left lazy eye
6. Benign positional vertigo
7. History of peptic ulcer disease
8. Dementia
9. Depression
DISCHARGE MEDICATIONS:
1. Norvasc 2.5 mg q. day
2. Zoloft 50 mg
3. Aspirin 81 mg q. day
4. OsCal 500 mg q. day
5. Pepcid 20 mg b.i.d.
6. Vioxx 25 mg q. day
7. Miacalcin two tablets q. day
DISCHARGE FOLLOW UP PLANS:
1. Follow up by Gerontology on an outpatient basis at the
[**Hospital3 **] Center.
2. Will need follow up with primary care provider within one
week of discharge status.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1604**], M.D.
[**MD Number(1) 1605**]
Dictated By:[**Last Name (NamePattern1) 1892**]
MEDQUIST36
D: [**2201-6-3**] 18:03
T: [**2201-6-3**] 18:11
JOB#: [**Job Number 20984**]
|
[
"5990",
"53081",
"4019"
] |
Admission Date: [**2126-10-7**] Discharge Date: [**2126-10-21**]
Date of Birth: [**2056-10-23**] Sex: F
Service: CARDIAC S.
CHIEF COMPLAINT: Shortness of breath, lower extremity edema.
HISTORY OF THE PRESENT ILLNESS: The patient is a 69-year-old
woman with history significant for moderate-to-severe aortic
insufficiency and moderate mitral regurgitation, in addition
to history of atrial fibrillation. She has been admitted
previously for congestive heart failure, and she was managed
medically. The patient's most recent cardiac catheterization
performed in [**2126-4-8**] for symptoms of shortness of breath,
showed normal coronary arteries, but moderate mitral
regurgitation and moderate-to-severe aortic regurgitation, in
addition to left ventricular ejection fraction of 51%,
elevated filling pressures, 2+ tricuspid regurgitation,
moderate [**Last Name (un) 6879**] and small pericardial effusion. She also had
an echocardiogram performed at the time, which showed mild
global left ventricular hypokinesis. The patient recently
has had progressive shortness of breath and lower extremity
edema. She, however, denies any claudication, orthopnea,
paroxysmal nocturnal dyspnea, or lightheadedness.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Atrial fibrillation since the age of 30s.
3. Parkinson disease.
4. Congestive heart failure with ejection fraction of 51%.
5. Aortic insufficiency/mitral regurgitation.
6. Back pain.
7. Osteoporosis.
PAST SURGICAL HISTORY:
1. Status post pilonidal cyst repair.
2. Status post pacemaker placement 1?????? years ago.
ALLERGIES: The patient is allergic to NORVASC.
SOCIAL HISTORY: The patient is single and lives in a
retirement community with nursing supervision.
MEDICATIONS ON ADMISSION:
1. Coumadin 5 mg q.d.
2. Lasix 20 mg q.d.p.r.n.
3. Zestril 10 mg q.d.
4. Mirapex 0.25 mg PO t.i.d.
5. Sinemet 2 pills at 7 Am, 12 noon, at night and one pill
at 7 Am, 11 AM, 3 PM, and 5:30 PM.
6. Paxil 10 mg PO q.d.
LABORATORY DATA: Laboratory values on admission revealed the
following: White blood cell count 5.6, hematocrit 35,
platelet count 222,000, PTT 35.1, INR 2.6, glucose 78, BUN
25, creatinine 0.9, sodium 141, potassium 4.1, ALT 7, AST 17,
LD 296, alkaline phosphatase 81, total bilirubin 1.4.
PHYSICAL EXAMINATION: Examination revealed the following:
VITAL SIGNS: Afebrile. Blood pressure 105/57. Heart rate
81. 97% on room air. GENERAL: The patient was alert and
oriented in no apparent distress. SKIN: Within normal
limits. HEENT: Teeth with no caries, within normal limits.
CARDIAC: Examination revealed regular rate and rhythm, 3/6
systolic ejection murmur, diastolic rumble. LUNGS: Lungs
were clear to auscultation bilaterally. ABDOMEN: Soft,
nontender, nondistended. EXTREMITIES: 1+ lower extremity
edema, warm, and well perfused. Pulses present bilaterally.
NEUROLOGICAL: Shuffled gait, no cogwheel rigidity. Tremor
in the upper extremities.
HOSPITAL COURSE: Given the patient's symptoms of shortness
of breath and edema, a surgical intervention was thought to
be the best solution. The patient was admitted to the
Cardiac Surgery Service. On [**2126-10-16**], the patient
underwent aortic valve replacement (23 mm CE), and mitral
valve replacement (26 mm [**Doctor Last Name 405**]) for the diagnosis of
symptomatic aortic insufficiency, mitral regurgitation. The
patient tolerated the procedure well. There were no
complications. Please see the full operative note for
details.
The patient was transferred to the Intensive Care Unit in
stable condition. She was intubated. However, on the same
day she was slowly weaned off the ventilator support and
successfully extubated. Pain was well controlled, and she
showed good hemodynamics. She was V-paced in the beginning.
She was noted to be occasionally confused. It was thought to
be not much different from her baseline. The rhythm
overnight showed occasional atrial fibrillation. She was
oxygenating well. Chest tubes were producing rather small
amounts of serosanguinous drainage. She had one episode of
hyperkalemia that was treated. The patient was making good
urine. She was taking her anti-Parkinsonian medication as
prescribed. The hematocrit remained stable in the beginning.
Blood pressures and heart rate remained stable.
On postoperative day #1, the patient was transfused with two
units of packed red blood cells for hematocrit of 26.
On postoperative day #2, the Foley catheter, chest tubes, and
pacing wires were removed. The Swan-Ganz catheter was
removed as well. The patient was transferred to the regular
floor in stable condition.
On postoperative day #3, the patient remained afebrile in
sinus rhythm. She was tolerating an oral diet. Incision was
clean, dry, and intact. She was ambulating with assistance.
She was followed by the Department of Physical Therapy. The
patient was started on Coumadin with goal INR of 2 to 2.5 for
atrial fibrillation prophylaxis. The patient continued to do
well. She was discharged on [**2126-10-21**] to the skilled
nursing facility.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Skilled nursing facility.
DISCHARGE DIAGNOSES:
1. Aortic insufficiency.
2. Mitral regurgitation, status post aortic valve
replacement (23 mm CE).
3. Mitral valve repair (26 mm [**Doctor Last Name 405**]).
4. Congestive heart failure.
5. Parkinson's disease.
6. Atrial fibrillation.
7. Hypertension.
8. Osteoporosis.
9. Back pain.
DISCHARGE MEDICATIONS:
1. Sinemet 2 tablets at 7 AM, 12 noon, in the evening; one
tablet at 7 AM, 11 AM, 3 PM, and 5:30 PM.
2. Sinemet p.r.n. at night.
3. Coumadin 5 mg h.s. adjust for INR of 2 mg to 2.5 mg.
4. Zestril 10 mg q.d.
5. Lasix 40 mg PO q.d.
6. Paxil 10 mg PO q.d.
7. Mirapex 0.25 mg PO t.i.d.
8. Amoxicillin p.r.n. prior to dental work.
9. Brimonidine tartrate 0.1% ophthalmic solution, one drop
b.i.d.
10. Milk of Magnesia p.r.n.
11. Percocet one to two tablets PO q.4h. to 6h.p.r.n. pain.
12. Aspirin 81 mg PO q.d.
13. Ranitidine 150 mg PO b.i.d.
14. Colace 100 mg PO b.i.d.p.r.n. constipation.
DISCHARGE INSTRUCTIONS:
1. The patient is to schedule a follow up appointment with
Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in approximately four weeks.
2. The patient is to schedule an appointment with the
cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in approximately 3 weeks.
3. The patient is to see her primary care physician,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in approximately one to two weeks.
4. The patient's Coumadin dose is to be closely followed
with labs and to be adjusted to the INR goal of
2 mg to 2.5 mg.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2126-10-21**] 10:48
T: [**2126-10-21**] 11:02
JOB#: [**Job Number 16295**]
|
[
"9971",
"4019"
] |
Admission Date: [**2178-8-22**] Discharge Date: [**2178-9-19**]
Date of Birth: [**2130-2-8**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Left leg pain.
HISTORY OF PRESENT ILLNESS: This is a 48 year-old male well
known to our service with a history of hypertension,
gastroesophageal reflux disease, severe peripheral vascular
foot pain times duration of four days. The patient
reportedly noticed this a.m. his pain has gotten much worse
then previously and his left leg and foot has gotten cold.
He also noted that he had no longer can feel his left femoral
pulse, which is a change. The patient was originally
scheduled for surgery electively next Tuesday with Dr.
[**Last Name (STitle) 1391**], but now is admitted urgently for ischemic
Room. He was begun on intravenous heparin.
PAST MEDICAL HISTORY: Hypertension, gastroesophageal reflux
disease, peripheral vascular disease.
PAST SURGICAL HISTORY: Aortobifemoral in [**2174**], left femoral
AK [**Doctor Last Name **] in [**2174**], left fem AK [**Doctor Last Name **] with Dacron in [**2176**], right
femoral popliteal with PTFE and a right femoral popliteal
with arm vein in [**2175**]. Revision of the aortobifemoral and
left femoral AK [**Doctor Last Name **]. In [**Month (only) 404**] of this year left common
femoral artery to profunda with Dacron bypass in [**2178-3-2**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Lopresor 12.5 mg b.i.d., Prilosec
20 mg b.i.d., Procardia XL 30 mg q.d., Zestril 10 mg q.d.,
Coumadin 7.5 mg q.d., Amitriptyline 25 mg at h.s.
SOCIAL HISTORY: The patient has a fifty pack year history of
smoking. He was previously a three pack per day and he has
now decreased his smoking to one pack per day.
PHYSICAL EXAMINATION: Vital signs 99.4. Pulse 114. Blood
pressure 145/67. Respiratory rate 18. O2 sat 96% on room
air. General appearance, the patient is in mild distress
secondary to pain. HEENT examination is unremarkable except
for bilateral carotid bruits. Chest is clear to auscultation
bilaterally. Heart is a regular rate and rhythm without
murmurs, rubs or gallops. Abdominal examination is
unremarkable. There is no problems with the abdominal aorta.
Extremity examination left foot is modeled, cold with delayed
capillary refill. He has absent femoral, popliteal, dorsalis
pedis pulse and posterior tibial pulses on the left. On the
right he has a palpable femoral popliteal triphasic dorsalis
pedis and posterior tibial signal on the right.
LABORATORY: Laboratories included a CBC with a white blood
cell count of 12.7, hematocrit 32.9, platelets 302K, BUN 6,
creatinine .8, K 4.5. PT, INR, PTT were normal. Vascular
surgery was consulted.
HOSPITAL COURSE: The patient was taken to angiography.
Angiography noted prior aortobifemoral bypass with occluded
left limb of the aortobifemoral. An attempt was to cross
lesion from the right groin, successful with wire,
unsuccessful with a gldewire and catheter as well as a 6 French
sheath. The
left groin was entered in a retrograde fashion. The left
femoral was accessed. The infusion catheter was placed at
the limb of the ABF graft. Tissue plasminogen activator was
begun at 1 mg per hour. The following day repeat arteriogram
was done. The patient's left limb of the aortobifemoral was
patent. The left common femoral to profunda graft was
occluded. The left femoral to AK [**Doctor Last Name **] bypass with dacron
was patent with distal stenosis and no run off. The patient
was taken to surgery and underwent at that time a left
femoral popliteal revision with a femoral popliteal to bypass
jump graft to BK [**Doctor Last Name **] of PTFE and left leg 4 compartment
fasciotomies.
Intravenous heparinization was begun. The patient was
transferred to the CICU for continued monitoring and care.
Postoperative day one the patient's foot remained good. He
had a palpable graft pulse. He required intravenous
nitroglycerin for his hypertension. Morphine PCA was
converted to oral analgesic agents and his diet was advanced
as tolerated. On postop day number two the patient was
transferred to the VICU for continued monitoring and care.
Postop day number three the patient had a T max of 101.5.
Vancomycin was begun empirically. Heparin was continued and
Coumadization was begun. Cultures were sent. Blood cultures
were obtained, which finalized as no growth. Chest x-ray was
also obtained at that time, which demonstrated a mild
congestive heart failure with volume overload. There was a
more focal opacity within the right middle lobe for which
focal pneumonia could not be excluded. Venous duplex were
done, which were negative for deep venous thrombosis.
Ambulation was begun and on [**8-31**] he underwent closure of his
fasciotomy sites without complications. Duplex of the graft
was done, which showed a patent graft without stenosis.
Duplex of the veins were negative for deep venous thrombosis,
but did show a left calf hematoma. His hematocrit dropped
and he required transfusions for a hematocrit of 26.
He was continued on heparin and Coumadin anticoagulation and
on [**2178-9-4**] he underwent an incision and drainage of the left
graft hematoma without problems. [**Name (NI) **] required two packed red
blood cells for a hematocrit of 28.2. The patient was
followed by physical therapy and they felt he would be safe
to be discharged to home. The patient would be discharged to
home in stable condition once INR remained at a steady
therapeutic state of 1.9 or greater. Heparin would be
discontinued at that time. Wounds at the time of discharge
were clean, dry and intact. He had a palpable graft pulse.
At the time of discharge the patient's hematocrit was 30.8
with a white count of 10.3. His INR on [**2178-9-8**] was 1.7 with
a PTT of 60.6.
DISCHARGE MEDICATIONS: Coumadin 10 to 15 mg q.d. maintain an
INR between 2.0 and 3.0. Gabapentin 400 mg t.i.d.,
Pantoprazole 40 mg b.i.d., amitriptyline 25 mg at h.s.,
Ambien 5 mg at h.s. prn, Nifedipine CR 30 mg q.d., Lisinopril
10 mg q.d., Percocet tablets one to two q 4 to 6 hours prn
for pain, Colace 100 mg b.i.d., Nicotine patch 21 mg q.d.
this should be for a total of twenty one days and this should
be reassessed to determine whether he can go to a lower
dosing. Bupropion SR 150 mg b.i.d., Metoprolol 100 mg b.i.d.
Care to left calf dry sterile dressing q.d. The patient
should follow up with Dr. [**Last Name (STitle) **] in two to three weeks.
DISCHARGE DIAGNOSIS:
1. Ischemic left leg status post arteriogram and tissue
plasminogen activator.
2. Status post revision of femoral popliteal with a jump
graft from femoral popliteal graft to BK popliteal with PTFE.
3. Left leg fasciotomies. Fasciotomy sites closed [**8-31**].
4. Blood loss anemia corrected.
5. Left calf hematoma status post incision and drainage.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2178-9-8**] 16:27
T: [**2178-9-9**] 08:14
JOB#: [**Job Number 23821**]
|
[
"4280",
"4019",
"53081",
"3051"
] |
Admission Date: [**2163-1-23**] Discharge Date: [**2163-1-26**]
Date of Birth: [**2111-11-5**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Tape / Ativan / Aloe / Dilantin
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
Rash/Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51 year old female h/o metastatic melanoma s/p ICH and placement
of VP shunt presented [**1-24**] with fever and rash. On [**1-2**]
patient had left hemiplegia and HA, was diagnosed with ICH from
metastatic melanoma. Underwent emergent craniotomy for
evacuation of bleed and tumor rescetion, she was also started on
dilantin for seizure prophylaxis. She then developed
hydrocephalus and had VP shunt placed on [**1-6**] and repeat VP
shunt operation on [**1-14**] secondary to her failure at clamping
trials. Prior to discharge she was noted to be febrile to 103 on
[**11-13**] temp spiked to 101.5 with a productive cough,
influenza was negative so she was discharged on levofloxacin,
completed course [**1-21**]. Three sets of blood cultures and urine
culture negative. She also developed a diffuse morbiliform
eruption rash after dilantin was started. However, Dilantin was
continued since the benefits of sizure prophylaxis outweighed
risks of continuing medicaitons. After discharge her fever
resolved but the rash did not. She used Sarna lotion and
benadryl at home, but noted spread of the rash from truck
outwards to extremities, sparing face palms and soles.
.
On day of admission ([**1-23**]) she developed a high fever with
chills and was brought to [**Hospital3 3583**], and was then
transfered here for further care. Upon arrival to the ED the
patient recieved 125 mg
Solumedrol, 50 mg IV Benadryl, 1 gram tylenol, Motrin 800 mg and
4 liters of normal saline. Her fever initially was >104.8
rectally (107 temporal) but trended down to 99.1. Got CXR,
cultures, urine and shunt tapped. ID was consulted who
recommended holding on Abx given lack of source, did not feel
that VP fluid cell count was indicative of shunt infection, more
likely blood. Dermatology was also consulted.
Past Medical History:
- Malignant melanoma w/ metastases to brain s/p ICH evacuation
and IP shunt placement for hydrocephalus
- Graves' disease s/p Tapazole treatment 13yrs ago
- cervical dysplasia s/p LEEP
- s/p resection of melanoma from left lower back
- s/p resection of intradermal melanocytic nevus from left
lateral chest wall
Social History:
Previous smoker 28 pack years, recently quit. Social alcohol.
Denies illicit drug use. No pets, currently living with her
mother and working as a buyer for [**Name (NI) 9400**] NY. Never married.
Family History:
Father with carotid stenosis and history of CVA
x2, age 78. Mother age 68 and healthy. Brother, age 50,
healthy. No known early CAD or cancer history.
Physical Exam:
On Admission
Vitals: T: 99.6 BP: 110/58 HR: 117 RR: 18 02 sat: 97%
GENERAL: awake, conversant
HEENT: Large craniotomy wound w/o erythema or purulence on R
skull. Smaller shunt wound w/ shunt present on L skull, no
erythema, tenderness or purulence, no fluctuence. MMM, OP clear,
slight exophthalmos
CARDIAC: RRR, No MRG
LUNG: CTAB
ABDOMEN: Soft, NT, ND, BS+, 6cm well healing surgical wound in
RUQ, no erythema or purulence, nontender.
EXT: No edema, 2+ DP/PT pulses.
NEURO: A&Ox3, Slight facial droop on left o/w CNII-XII intact,
5/5 strength, no gross sensory deficits
SKIN: Diffuse, highly confluent, deeply erythematous
maculopapular blanching rash, no bullae, no bleeding. Mucous
membranes and palms/soles unaffected.
On Discharge:
GENERAL: NAD
HEENT: Large craniotomy wound w/o erythema or purulence on R
skull. Smaller shunt wound w/ shunt present on L skull, no
erythema, tenderness or purulence, no fluctuence. MMM, OP clear
without evidence of oral lesions
CARDIAC: RRR, No MRG
LUNG: CTAB
ABDOMEN: Soft, NT, ND, BS+, 6cm well healing surgical wound in
RUQ, no erythema or purulence, nontender.
EXT: No edema, 2+ DP/PT pulses.
NEURO: A&Ox3, Slight facial droop on left o/w CNII-XII intact,
5/5 strength, no gross sensory deficits
SKIN: Diffuse, highly confluent, erythematous maculopapular
blanching rash, no bullae, no bleeding over truck and
extremities. Mucous membranes and palms/soles unaffected.
Pertinent Results:
Labs on admission:
WBC-7.3# Hgb-10.9* Hct-31.4* MCV-88 MCH-30.7 MCHC-34.8 RDW-13.7
Plt Ct-518*#
diff: Neuts-74.8* Lymphs-11.0* Monos-2.8 Eos-11.0* Baso-0.5
PT-11.6 PTT-26.7 INR(PT)-1.0
Ret Aut-2.8 calTIBC-173* Ferritn-769* TRF-133*
Glucose-124* UreaN-12 Creat-0.8 Na-131* K-6.7* Cl-95* HCO3-26
AnGap-17
ALT-78* AST-111* AlkPhos-107 TotBili-0.3
Lipase-39
HBsAg-NEGATIVE HBsAb-PND HBcAb-PND IgM HBc-NEGATIVE IgM
HAV-NEGATIVE
HCV Ab-NEGATIVE
Labs on discharge:
WBC-8.7 Hgb-9.6* Hct-29.1* MCV-92 MCH-30.3 MCHC-33.0 RDW-14.9
Plt Ct-525*
diff: Neuts-48* Bands-1 Lymphs-21 Monos-7 Eos-23* Baso-0 Atyps-0
Metas-0 Myelos-0
Glucose-117* UreaN-4* Creat-0.5 Na-140 K-3.7 Cl-106 HCO3-27
AnGap-11
ALT-78* AST-62* AlkPhos-116 TotBili-0.1
Albumin-3.0* Calcium-7.9* Phos-3.4 Mg-1.8
[**2163-1-23**] 11:57PM CEREBROSPINAL FLUID (CSF) WBC-13 RBC-1075*
Polys-10 Lymphs-18 Monos-0 Eos-57 Macroph-15
[**2163-1-23**] 11:57PM CEREBROSPINAL FLUID (CSF) TotProt-33 Glucose-95
Imaging:
CXR: No acute cardiopulmonary process.
CT head:
1. Interval evolution of encephalomalacia and decrease of blood
products at prior sites of hemorrhage.
2. Slight increase in right frontal subdural low density
collection.
3. Stable ventriculostomy catheter location with no interval
development of hydrocephalus.
4. No new site of hemorrhage.
5. 4-mm leftward midline shift.
CT abd/pelv:
1. Interval VP shunt placement, with no adjacent fluid
collection. No
evidence of acute intra-abdominal process.
2. Left adrenal adenoma, unchanged.
3. Small amount of pelvic free fluid, fluid in the endometrial
cavity, and a small amount of air in the bladder may relate to
recent LEEP procedure.
4. Increase in size of left buttock subcutaneous nodule, highly
concerning for metastatic disease in this patient with known
melanoma.
5. Right paramedian Bartholin gland cyst with tiny dependent
stone; less likely urethral diverticulum.
EKG: Sinus tach
Brief Hospital Course:
Initially transferred to MICU for closer monitoring for
development vessicles/bullae or mucosal involvment. Stable
overnight. Developed fever to 104 following morning with HR in
the 130s, which improved with fluids, acetaminophen and motrin.
Dilantin held and Keppra started for seizure [**Last Name (LF) 9401**], [**First Name3 (LF) **] Dr.
[**Last Name (STitle) 724**].
#Rash: Most likely hypersensitivity reaction (DRESS) from
dilantin vs famotidine. Both were held. Concerned for SJS
initially, however rash did not appear to involve mucosa or
palms/soles, and no bullae. Also considered toxic shock
syndrome initially w/ fever and rash, but no tampon use. No
evidence of meningitis given neck supple, no headache, CSF fluid
does not appear infected, no fluid around abdominal portion of
VP shunt. Seen by dermatology who recommended clobetasol,
hydrocortisone cream, steroids as well as benadryl, Sarna and
atarax. Rash remained stable, not spreading and perhaps slighty
improving. Her fever decreased and she was able to tolerate PO.
LFTs trending down, Cr stable, but she had a persistant
eosinophilia. Per derm, rash likely to last for several weeks
prior to resolution. Will follow up with dermatology as an
outpatient.
.
#Fever: Most likely drug reaction. Infection considered,
however no localizing signs of infection and no sick contacts.
Cultures negative. No Abx given. Flu negative. Given
acetaminophen and motrin as well as IVF. Temperature trended
down and had normalized at time of discharge.
.
# Tachycardia: Persistant in 90-100s, fluid responsive,
improving when afebrile. Likely [**3-15**] insensible losses from
fever and rash. Encouaged PO fluids on discharge, fever control
and close followup.
.
#Malignant melanoma: s/p ICH w/ multiple mets to brain. No
current e/o neurologic defict other than left facial droop
likely residual from previous ICH. Will follow up as
outpatient.
.
Medications on Admission:
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H
Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
prn
Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY finished
2 days ago.
Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day)
Benadryl
Discharge Medications:
1. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 2 weeks.
Disp:*1 tube* Refills:*0*
2. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day) for 2 weeks: Do not use for greater than 2 weeks.
Disp:*1 tube* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for fever.
4. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO
every 6-8 hours as needed for itching.
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pruritis.
Disp:*30 Tablet(s)* Refills:*0*
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 7 days.
Disp:*140 ML(s)* Refills:*0*
8. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day
for 10 days: Take 5 tabs daily for two days, take 4 tab daily
for two days, take 3 tabs daily for two days, take 2 tabs daily
for two days and then take 1 tab daily for two days. 10 days
total.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Drug Related Esosinophilia and Systemic Symptoms
Secondary Diagnosis:
Metastatic Melanoma
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were seen in the hospital for a fever and rash that is
likely due to the dilantin you were prescribed for seizure
propalaxis. You were evaluated by the dermatology team and
given steroids and medication to decrease itching. It is
important to drink lots of fluids to avoid dehydration with your
fever. The rash might worsene before it gets better and it is
possible your skin will slough off as it heals.
You should STOP your dilantin. Instead take Keppra as
prescribed for seizure prophalaxis. You were given
prescriptions for steroids and anti-itch cream that you should
take as directed.
Followup Instructions:
[**Company 191**] POST [**Hospital 894**] CLINIC
Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2163-1-31**] 1:50
Dermatology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2163-2-2**] 2:30
|
[
"2859"
] |
Admission Date: [**2191-2-11**] Discharge Date:[**2191-2-17**]
Date of Birth: [**2116-9-11**] Sex: M
Service: GENERAL SURGERY- BLUE SERVICE
Admitting Diagnois: Klatskin's tumor
HISTORY OF PRESENT ILLNESS: Patient is a 74-year-old white
male with a recent history of painless jaundice who had
undergone endoscopic retrograde cholangiopancreatography in
bifurcation consistent with cholangiocarcinoma. He underwent
duct dilatation but no evidence of a portal mass and no
evidence of a pancreatic mass. He had replacement of biliary
stents and did well. He was admitted on [**Hospital1 **] [**First Name (Titles) **] [**2191-2-1**] for percutaneous transhepatic
cholangiography. Prior to the percutaneous transhepatic
cholangiography, the endoscopic stents were removed. He
duct to the bifurcation and a stricture to the left hepatic
duct right at the bifurcation consistent with
cholangiocarcinoma. Both catheters were passed into the
duodenum. On the day after his percutaneous transhepatic
cholangiography, he developed a transient rise in his amylase
to a peak of 1800 which rapidly returned toward normal. He
had no clinical evidence of pancreatitis. His diet was
restarted, advanced and he was discharged on [**2191-2-3**]. Patient has done well at home and now returns for
elective resection of cholangiocarcinoma.
PAST MEDICAL HISTORY: Significant for coronary artery
disease in which he had a coronary artery bypass graft in
[**2178**], noninsulin dependent diabetes mellitus, which was
controlled with Starlix, hypertension and benign prostatic
hypertrophy. He also had an appendectomy in the past.
ALLERGIES: He is allergic to Indocin which put him
into anaphylactic shock.
PREOPERATIVE PHYSICAL EXAMINATION: He was in no apparent
distress. He had a pulse of 58. Blood pressure of 185/100.
He was pleasant, alert and oriented. He had no cervical
lymphadenopathy. His lungs were clear to auscultation
bilaterally. He had a regular rate and rhythm, normal S1,
S2. He has somewhat two soft nontender abdomen, no
hepatosplenomegaly. No edema of his extremities.
Prior to the surgery, he was cleared by Cardiology by Dr.
[**Last Name (STitle) 13179**]. He came in on [**2191-2-11**] for a removal
of a Klatskin tumor, cholecystectomy, and bile duct excision,
Roux-en-Y hepaticojejunostomy.
Postoperatively, the patient was transferred to the Surgical
Intensive Care Unit for hemodynamic monitoring. Patient did
well overnight and remained hemodynamically stable. He was
extubated and given a unit of packed red blood cells to
maintain his hematocrit above 30. Patient was transferred
out of the unit, continued to do well. He remained afebrile.
His vital signs remained stable and his pain was controlled.
The remainder of the [**Hospital 228**] hospital course was
uneventful. His vital signs continued to remain stable. He
continued to be afebrile and his laboratory values of which
his liver LFTs were slightly elevated postoperatively
continued to trend downward. Patient began to tolerate a
regular diet, was ambulating. He had a cholangiogram on
postoperative day number five which showed a patent
anastomosis and no evidence of a leak. His pathology results
came back on the 24th which showed evidence of
adenocarcinoma, poorly differentiated involving the common
bile duct, the gallbladder. There was a positive node and
the distal margin was also positive. He had a transient period of
oliguria related to IV Toradol that resolved with
discontinuation of the Toradol. There was no significant
change in serum CR. Patient was discharged
home in stable condition.
DISCHARGE DIAGNOSIS: Advanced most likely cholangiocarcinoma
versus gallbladder carcinoma.
FOLLOW-UP: Patient will follow-up with Dr. [**Last Name (STitle) **] for further
management of his tumor.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D., Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 2649**]
MEDQUIST36
D: [**2191-2-17**] 12:07
T: [**2191-2-17**] 12:07
JOB#: [**Job Number 37207**]
|
[
"25000",
"V4581",
"4019",
"2720"
] |
Admission Date: [**2175-5-12**] Discharge Date: [**2175-5-15**]
Date of Birth: [**2138-12-6**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
36 yo male with a history of hypertension and hepatitis C (on
ribavirin and PEG-interferon) presenting with weight loss,
polyuria, tingling in leg, found to have hyperglycemia. The
patient states that he began having polyuria about three weeks
ago. He started to feel SOB with exertion about 2 weeks ago. He
notes starting to feel increasingly weak about 1.5 weeks ago. He
presented to his doctor today with the above complaints which
were concerning for hyperglycemia. He also complained of a 30
pound weight loss since [**11/2174**], dry mouth, polydipsia, and
blurry vision. He complained of mild abdominal and urethral pain
with urination. His fasting blood glucose at the outpatient
office was 570 and after obtaining laboratories, he was sent to
the ED for further evaluation.
.
In the ED, initial vs were: T: 99.4 P: 116 BP: 137/93 RR: 16 O2
sat: 100% RA. Laboratories revealed a glucose of 908 with an
anion gap of 16 and no respiratory distress. An EKG showed ST
segment elevations in II, V4-V6. The patient was started on
regular insulin with a 7 unit bolus and then 7units/hr, aspirin
325 mg, and 1 liter NS per hour for 3 liters.
.
On the floor, the patient does not have any further complaints
than those mentioned above. He complains of thirst. No sick
contacts or infectious symptoms besides dysuria. Says
constipated.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
abdominal pain. Denies myalgias. Denies rashes or skin changes.
Past Medical History:
-hepatitis C genotype 1: Mr. [**Known lastname **] has chronic hepatitis C
genotype treatment with pegylated interferon and ribavirin
-hypertension
-?hereditary and possibly demyelinating peripheral neuropathy
-?migratory arthritis
Social History:
occupation: works for [**Company **]
- Tobacco: quit greater than a year ago
- Alcohol: quit with HCV diagnosis, socially in the past
- Illicits: None
- lives with wife, daughter, step-son
Family History:
Mother had "thyroid problems" s/p thyroid surgery. Brother and
child healthy. does not know about father's side
Physical Exam:
Vitals: BP: 140/92 P: 101 R: 18 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardia, normal rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2175-5-12**] 07:50PM BLOOD WBC-3.3* RBC-5.10 Hgb-11.2* Hct-39.0*
MCV-76* MCH-22.0* MCHC-28.8* RDW-18.9* Plt Ct-163
[**2175-5-12**] 07:50PM BLOOD PT-11.0 PTT-28.1 INR(PT)-0.9
[**2175-5-12**] 12:10PM BLOOD UreaN-17 Creat-1.0 Na-133 K-4.8 Cl-93*
HCO3-21* AnGap-24*
[**2175-5-12**] 12:10PM BLOOD ALT-46* AST-24 Amylase-26
[**2175-5-12**] 12:10PM BLOOD %HbA1c-10.0* eAG-240*
[**2175-5-12**] 07:50PM BLOOD Acetone-NEG
[**2175-5-12**] 12:10PM BLOOD Osmolal-308
Cardiac enzymes:
[**2175-5-12**] 07:50PM BLOOD CK-MB-10 MB Indx-10.0* cTropnT-<0.01
[**2175-5-12**] 07:50PM BLOOD CK(CPK)-100
[**2175-5-13**] 03:56AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2175-5-13**] 03:56AM BLOOD CK(CPK)-94
[**2175-5-13**] 11:56AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2175-5-13**] 11:56AM BLOOD CK(CPK)-76
.
Diabetes:
[**2175-5-12**] 12:10PM BLOOD %HbA1c-10.0* eAG-240*
.
Thyroid:
[**2175-5-12**] 12:10PM BLOOD TSH-1.0
[**2175-5-12**] 12:10PM BLOOD T4-8.5 T3-79* calcTBG-1.04 TUptake-0.96
T4Index-8.2 Free T4-1.4
.
LFT's:
[**2175-5-12**] 12:10PM BLOOD ALT-46* AST-24 Amylase-26
.
Discharge labs:
[**2175-5-15**] 05:55AM BLOOD WBC-2.5* RBC-4.25* Hgb-9.7* Hct-31.1*
MCV-73* MCH-22.8* MCHC-31.1 RDW-18.5* Plt Ct-143*
[**2175-5-15**] 05:55AM BLOOD Glucose-199* UreaN-8 Creat-0.6 Na-135
K-3.7 Cl-104 HCO3-24 AnGap-11
[**2175-5-15**] 05:55AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.0
.
[**5-12**] Blood cultures & urine culture negative. U/A negative.
.
EMG:
Abnormal study. There is electrophysiologic evidence for a
severe, chronic, sensorimotor, generalized polyneuropathy,
predominantly demyelinating with axonal features. The lack of
conduction block or temporal dispersion is suggestive of
hereditary rather than acquired etiology. No clear evidence of
focal compressive neuropathies is evident- a median neuropathy
at the right wrist cannot be excluded. The findings are most
consistent with a hereditary motor-sensory neuropathy (Charcot
[**Doctor Last Name **] Tooth Disease, demyelinating).
.
ECG [**5-12**]:
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
.
[**5-13**] ECG:
Early repolarization pattern is more prominent. Compared to the
previous
tracing, probably normal variant.
.
[**5-15**] ECG:
Sinus rhythm. ST-T wave configuration consistent with early
repolarization
pattern. Unstable baseline makes assessment difficult.
.
CXR [**5-12**]:
Normal chest radiograph.
Brief Hospital Course:
Assessment and Plan: 36 yo male with a history of hypertension
and hepatitis C (on ribavirin and PEG-interferon) presenting
with weight loss, polyuria, polydipsia, found to have
hyperglycemia.
.
# Hyperglycemia: The patient presented with a glucose around
900, glucosuria, anion gap=16 and ketonuria. Hgb A1C=10.0. The
patient had no history of diabetes and his problems have
progressed over the past couple of months (weight loss, thirst,
urinary frequency). New medications include ribavirin and PEG
interferon which could potentially cause diabetes (ie: unmask an
autoimmune process). Theory was that the diabetes was either
latent adult-onset diabetes versus unmasking of an autoimmune
process due to interferon treatment. In the ICU, the patient was
started on an insulin gtt (bolused with 7 units and then 7
u/hour) in the ER and started on 1 liter of NS/hr. On
presentation to the floor, the patient had a glucose of 307. His
insulin gtt was decreased to 2 units/hr. The patient was able to
tolerate POs and was started on a diet. His insulin drip was
discontinued and the patient received 10 units of SC Humalog.
With fluid resusitation and glucose control, the patient felt
better and has no polyuria. Infectious work-up for cause for DKA
was negative. [**Last Name (un) **] was consulted and suggested lantus &
humalog sliding scale. Upon transfer to the floor, gap had
closed. On the floor, patient's blood sugars improved, as did
his polyuria/polydipsia. Started on ASA 81mg. Patient had
diabetic teaching regarding blood sugar checks and insulin
administration and his new diagnosis, and he was sent home with
visiting nurses (for further insulin and diabetic diet teaching)
and [**Last Name (un) **] diabetes center follow-up.
.
# Hepatitis C: Has been on PEG interferon and ribavirin since
[**12/2174**] with good effect (viral load undectable). Slightly
elevated ALT=46, but rest of LFTs normal. Per his outpatient GI
doctor, he should hold PEG interferon and ribavirin. Discharged
with hepatology follow-up.
.
# Chest tightness: The patient gave a history of chest tightness
while ambulating for 1 minute prior to presentation to the
hospital. EKG showed likely J point elevateions in II, V4-V6.
EKG faxed to cardiology and felt not concerning for pericarditis
or ischemia. Three sets of cardiac enzymes were negative, there
were no telemetry changes. Repeat EKG was similar. Patient
thereafter asymptomatic at rest and on ambulation.
.
# Motor sensory neuropathy: Patient diagnosed with motor sensory
neuropathy on EMG on day of admission. Patient with distal
muscle weakness, and occasional abnormal extremity sensations,
and with migratory polyarthralgias/edema. No family history of
disease, though EMG thought most likely hereditary. This was not
an active issue during this hospitalization; patient already
with neurology follow-up set-up.
Medications on Admission:
-Pegasus
-ribavirin
-tylenol PRN
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. One Touch Ultra Test Strip Sig: One (1) strip In [**Last Name (un) 5153**]
per blood sugar check.
Disp:*120 strips* Refills:*2*
3. One Touch UltraSoft Lancets Misc Sig: One (1) lancet
Miscellaneous per blood sugar check.
Disp:*120 lancets* Refills:*2*
4. Insulin Syringe Ultrafine [**1-7**] mL 29 x [**1-7**] Syringe Sig: One
(1) syringe use with appropriate amount of insulin drawn up in
it Miscellaneous per each insulin administration.
Disp:*120 syringes* Refills:*2*
5. Glucometer
6. Lantus 100 unit/mL Solution Sig: Thirty (30) units
administered Subcutaneous once a day in the morning.
Disp:*1 vial* Refills:*2*
7. Humalog 100 unit/mL Solution Sig: # of units given per
sliding scale units per sliding scale Subcutaneous Every day
before breakfast, lunch, dinner, bedtime.
Disp:*1 vial* Refills:*2*
8. Please follow the attached insulin regimen.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hepatitis C
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with extremely high blood
sugar and were found to have a new diagnosis of diabetes. This
illness requires close blood sugar monitoring and insulin
administration, to keep your blood sugar controlled and to
prevent complications from diabetes.
.
Your medications have changed:
- STOP ribavirin
- STOP pegasus (interferon)
- START insulin, both a long-acting insulin (glargine also known
as lantus) to be taken each morning, and a short-acting insulin
(humalog) to be taking as a sliding scale with the dose based on
what your fingersticks show your blood sugar to be
- START aspirin 81mg daily
.
If you have questions about your new diabetes regimen, because
it can seem complicated when diabetes is a new diagnosis, do not
hesitate to call Dr. [**Last Name (STitle) 978**] the diabetes doctor you met in the
hospital, of your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 31365**] [**Telephone/Fax (1) 7976**],
or Dr. [**Last Name (STitle) **] your liver doctor, or the doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] who will
be monitoring your diabetes. In particular, if your blood sugar
is less than 80 or over 250, you must call one of these
physicians.
Followup Instructions:
Please attend the following important appointments:
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**First Name8 (NamePattern2) **] [**Last Name (Titles) **], [**Name8 (MD) **] MD = Diabetes
doctors
[**Name5 (PTitle) **]: Thursday, [**5-18**], 8:00AM
Location: [**Last Name (un) **] Diabetes Center
Address: [**Last Name (un) 3911**], [**Location (un) **], [**Location (un) 86**] MA
Phone: [**Telephone/Fax (1) 2384**]
.
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: SATURDAY [**2175-5-20**] at 10:45 AM
With: [**First Name11 (Name Pattern1) 2801**] [**Last Name (NamePattern4) 14773**], NP [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
.
Department: NEUROLOGY
When: WEDNESDAY [**2175-5-24**] at 4:00 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: INTERNAL MEDICINE/ LIVER
When: FRIDAY [**2175-6-2**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2175-5-18**]
|
[
"4019"
] |
Admission Date: [**2141-11-20**] Discharge Date: [**2141-11-27**]
Date of Birth: [**2092-4-6**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Bactrim
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49yM s/p recent Kidney transplant [**10-6**] c/b drug induced
interstitial nephritis likely secondary to bactrim and/or PPI,
also c/b upper GI bleed managed medically, and Renal AV fistula
likely secondary to kidney biopsy. Now presents with three days
of increasing lethargy, dizziness, and suprapubic pain. Pt says
he lost his blood sugar monitor under the bed and has not been
checking his sugars for days. Because of that he is only taking
small doses of insulin because he was afraid of becoming
hypoglycemic.
He admits to some mild tenderness that is suprapubic. No
dysuria
or hematuria. Denies any bleeding per rectum, melena, or
hemeatemesis. He has had some N/V for past few days. No
diarrhea, fevers, or chills.
Past Medical History:
1. CAD s/p [**Month/Year (2) **] to OM1 in [**9-2**] and [**Month/Day (1) **] to RCA in [**5-5**]
2. End-stage renal disease, on HD since [**6-3**] (MWF)
3. Diabetes mellitus, type I: Diagnosed at age 20, on insulin,
c/b nephropathy, neuropathy, and retinopathy status post
multiple laser surgeries. Right upper extremity fistula. Chronic
ulcers on left foot.
4. Hypertension
5. Hyperlipidemia
6. Obstructive sleep apnea
7. G6PD deficiency
8. Right fifth toe amputation, [**2137-3-29**].
9. History of hepatitis B infection
10. Sexual dysfunction s/p penile prosthesis implantation
11. Kidney transplant, right iliac fossa [**2141-10-14**].
Social History:
The patient lives with his wife and 2 sons in [**Name (NI) 669**].
Previously worked at NSTAR as a janitor, and is currently on
diability. No tobacco or EtOH use.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother has diabetes mellitus. Father is healthy
and multiple half brothers and sisters. Two children, both boys,
are healthy. Multiple aunts and uncles decreased from
complications of diabetes. No family hx of Wegener's or
[**Last Name (un) 95749**]-[**Doctor Last Name 3532**] disease.
Physical Exam:
T 97.7 HR 74 BP 146/65 RR 20 O2 sat 100
Gen-mild distress, diaphoretic
Heent-anicteric, no jaundice
CV-RRR
Pulm-CTA b/l
Abd-soft, non-distended, graft palp RLQ, no tenderness. Some
suprapubic TTP
Ext-no edema or cyanosis, palp pulses
Pertinent Results:
On Admission: [**2141-11-20**]
WBC-12.7*# RBC-4.98 Hgb-13.9* Hct-44.3 MCV-89 MCH-27.8 MCHC-31.3
RDW-15.8* Plt Ct-285
PT-11.2 PTT-27.4 INR(PT)-0.9
Glucose-720* UreaN-54* Creat-2.1* Na-129* K-6.6* Cl-96 HCO3-12*
AnGap-28*
Calcium-10.0 Phos-2.0* Mg-2.0
[**2141-11-23**] VitB12-424 Folate-8.8
On Discharge: [**2141-11-27**]
WBC-5.7 RBC-3.27* Hgb-9.3* Hct-28.5* MCV-87 MCH-28.4 MCHC-32.7
RDW-16.7* Plt Ct-182
Glucose-161* UreaN-26* Creat-1.3* Na-138 K-4.8 Cl-112* HCO3-21*
AnGap-10
Calcium-9.5 Phos-1.9* Mg-1.5*
tacroFK-7.3
Brief Hospital Course:
49 y/o male s/p kidney transplant [**2141-10-14**] who returns with
complaint of dizziness at home and found to be in DKA when
admitted.
He was started on an insulin drip and sugars very slowly
improved but have not yet normalized. He was found in interview
to have been unable to manage blood sugars at home.
Blood pressure medications were adjusted and he was found to be
orthostatic and having some dizziness. With decreased blood
pressure meds the dizziness seems to be improved but needs
orthostatic signs daily until meds have been adjusted
appropriately.
A neuro consult was obtained for patient complaint of hand
numbness, and they recommended outpatient [**Month/Day/Year 2841**] as previously
scheduled.
Also, the patient may be switched to Rapamycin as an outpatient
due to Prograf neurotoxic effects.
Medications on Admission:
Valcyte 450', insulin, cellcept [**Pager number **]'''', hydral prn, Isosorbide
mononitrate ER 60', nifedipine 180', percocet prn, trazadone 50
prn, ranitidine 150', metoprolol succ ER 200'', Tacro [**10-7**]
.
Discharge Medications:
1. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
3. Nifedical XL 60 mg Tablet Extended Rel 24 hr Sig: Two (2)
Tablet Extended Rel 24 hr PO once a day.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a
day): Hold for SBP < 110 or HR < 60.
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty
Two (32) units Subcutaneous twice a day: AM and PM doses and
continue humalog sliding scale.
10. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
11. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
Hyperglycemia
Hypertension
S/p renal transplant [**2141-10-14**]
LV diastolic dysfunction per [**10-6**] Echo
Discharge Condition:
Stable/good
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, increased dizziness/lightheadedness,
drops in orthostatic blood pressure inability to take food,
fluids or medications
Labs q Monday and Thursday with results faxed to transplant
clinic at [**Telephone/Fax (1) 697**]: CBC, Chem 7, Ca, Mg Phos, Trough Prograf
Monitor Blood sugars and give insulin accordingly
Orthostatic BP checks daily. Please call if consistently drops
to the [**Hospital 95754**] clinic at [**Telephone/Fax (1) 673**]
[**Telephone/Fax (1) 2841**] as outypatient, previously scheduled
Followup Instructions:
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2141-12-1**] 9:10
BONE DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2141-12-1**] 10:40
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7167**], RD Phone:[**Telephone/Fax (1) 3681**] Date/Time:[**2141-12-5**] 10:30
Completed by:[**2141-11-27**]
|
[
"V5867",
"41401",
"32723",
"2724",
"4019"
] |
Admission Date: [**2116-7-16**] Discharge Date: [**2116-7-20**]
Date of Birth: [**2054-7-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Syncope, Hypotension
Major Surgical or Invasive Procedure:
Central Line Placement, Arterial Line Placement
History of Present Illness:
Mrs. [**Known lastname **] is a 62 yo F with DM2, HTN, schizophrenia,
syncope, and history of breast and renal cell carcinoma who
presents with unresponsiveness. She states she was sitting in a
chair with her daughter combing her hair when she suddenly
passed out. Denied any heralding symptoms (chest pain,
palpitations, nausea, diaphoresis). Woke up with some suprapubic
abdominal pain this AM and complaining of bilateral shoulder
pain that was bothering her more than usual this morning. Her
dtr witness the event and called 911, and she was found
unresponsive at home by EMS with an SBP of 60. Patient aroused
without any confusion in the ambulance, not post-ictal, no
tongue biting, bowel or bladder incontinence. No head strike.
She endorses good oral intake. Dtr and grandchildren were ill
with nausea/vomiting recently but have been doing well recently.
She reports her FS was 103 that morning (normal range 120-140s),
and she takes her piaglitazone and her anti-hypertensives all in
the morning with breakfast. She was also recently seen in [**Company 191**]
from [**Month (only) **] to [**2116-6-4**] for episodes of hypotension assoicated
with LH/dizziness, and her BP meds were down-titrated to
Lisinopril 40 mg PO daily and metoprolol 25 XL PO daily. Of
note, patient was also admitted to [**Hospital1 18**] ED multiple times from
[**2110**]-[**2112**] with syncope and had a negative syncope work-up from
[**2111**]-[**2112**] including outpatient cardiology evaluation, TTE,
Holter monitor, and autonomic testing.
.
In the ED, initial vs were: 95 84/60 88 17 100% on RA. In the
ED, patient triggered for hypotension on arrival. Her blood
pressures came up to SBP of 80 with 3 L NS (baseline SBP as
outpatient is 120s-140s). Labs significant for Na of 130, K of
6.3 (hemolyzed 4.9 on repeat), Cre of 1.9 (baseline 1.5-1.9),
WBC of 3.7 with 3% bands, CK 206 and Troponin-T 0.01, Lactate
1.7. U/A with positive leuks, WBCs. Patient was given Vancomycin
and Zosyn IV x1 in the ED. ABD U/S done at bedside in ED showed
no AAA. Noted to be guiac negative. CT abdomen showed no obvious
source of infection. Patient was transferred to MICU for
persistent hypotension. FS of 50 around 4 pm, required [**12-7**] amp
of D50.
.
On the floor, patient is alert and oriented x 3 and conversant.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, or changes in
bowel habits. Denies rashes or skin changes.
Past Medical History:
1. HTN
2. DM2
3. Breast CA [**2106**] s/p chemo and xrt
4. Schizophrenia
5. Bipolar disorder
6. Glaucoma
7. OA
8. Recurrent left knee effusion
9. S/P TAH (fibroids)
10. S/P partial R nephrectomy (R leiomyoma)
11. frequent falls (negative w/u)
Social History:
Lives with daughter and son in [**Name (NI) 669**] in a rented duplex;
currently unemployed. unmarried with 2 children. Has 80pack yr
hx, quit [**2106**]; no etoh. no illicits.
Family History:
Daughter has asthma, sister and brother with DM, mother died of
CVA
Physical Exam:
Admission Exam:
Vitals: T: 97.5 BP: 134/76 P: 114 R: 18 O2: 99% on RA
General: AA F lying in bed 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; no
suprapubic tenderness
Ext: warm, well perfused, cold feet below ankles, 1+ pulses, no
clubbing, cyanosis or edema
Neuro: CNs [**1-17**] intact; 5/5 strength in UE/LEs; sensation
grossly intact. reflexes 1+ and symmetric bilaterally,
cerebellar function intact. good passive and active ROM in both
shoulders BL.
Pertinent Results:
On Admission:
[**2116-7-16**] 09:30AM BLOOD WBC-3.7* RBC-3.33* Hgb-10.6* Hct-33.2*
MCV-100* MCH-31.7 MCHC-31.8 RDW-13.4 Plt Ct-190
[**2116-7-16**] 09:30AM BLOOD Neuts-78* Bands-3 Lymphs-11* Monos-6
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2116-7-16**] 09:30AM BLOOD PT-12.6 PTT-22.4 INR(PT)-1.1
[**2116-7-16**] 09:30AM BLOOD Glucose-162* UreaN-41* Creat-1.9* Na-130*
K-6.3* Cl-96 HCO3-28 AnGap-12
[**2116-7-16**] 09:30AM BLOOD ALT-18 AST-51* CK(CPK)-206* AlkPhos-32*
TotBili-0.2
[**2116-7-16**] 10:21PM BLOOD Calcium-9.2 Phos-2.0*# Mg-1.7
[**2116-7-19**] 06:45AM BLOOD calTIBC-222* Ferritn-201* TRF-171*
[**2116-7-16**] 09:59AM BLOOD Glucose-153* Lactate-1.7 Na-134* K-4.9
Cl-95* calHCO3-29
On Discharge:
[**2116-7-20**] 06:10AM BLOOD WBC-3.8* RBC-2.50* Hgb-7.8* Hct-25.1*
MCV-100* MCH-31.3 MCHC-31.2 RDW-13.8 Plt Ct-159
[**2116-7-17**] 04:00AM BLOOD Neuts-64.7 Lymphs-22.5 Monos-10.9 Eos-1.2
Baso-0.6
[**2116-7-20**] 06:10AM BLOOD PT-13.2 PTT-29.2 INR(PT)-1.1
[**2116-7-20**] 06:10AM BLOOD Glucose-102* UreaN-10 Creat-1.0 Na-140
K-3.7 Cl-108 HCO3-26 AnGap-10
[**2116-7-17**] 04:00AM BLOOD ALT-16 AST-21 LD(LDH)-145 CK(CPK)-95
AlkPhos-30* TotBili-0.2
[**2116-7-20**] 06:10AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9
Microbiology:
Blood culture negative x4
Urine culture negative x2
Negative C. diff
Stool Culture: no enteric gram negative rods found, no
salmonella or shigella found
Imaging:
Chest XRay:
Lung volumes are low as before with elevated left hemidiaphragm.
A prominent gastric bubble is stable. Cardiac, mediastinal and
hilar contours are stable, re-demonstrating a calcified node in
the right paratracheal station. There is a small amount of
bibasilar subsegmental atelectasis and otherwise the lungs are
clear. There is no
pleural effusion or pneumothorax.
CT Abdomen/Pelvis:
IMPRESSION:
1. Focal area of mesenteric stranding in the upper abdomen with
prominent adjacent mesenteric lymph nodes. Overall, this is
nonspecific, with considerations including mesenteric
panniculitis, neoplasm. These findings are new from the study
done in [**2108**]. Repeat CT is recommended in [**2-8**] months.
2. Cholelithiasis.
3. Left lower lobe 5-mm pulmonary nodule. In this patient with
history of
previous malignancy, followup with a dedicated CT of the chest
is recommended in six months.
4. Hyperdense right renal lesion which is otherwise not
completely characterized. This may be a hyperdense cyst, though
this could be
corroborated with ultrasound or MRI.
ECHO:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild (non-obstructive)
focal hypertrophy of the basal septum. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is a septal
attachment of the papillary muscle (normal variant) wihtout
clear LVOT obstruction. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
62 yo F with HTN, DM2, schizophrenia, h/o breast cancer
presenting with altered mental status and hypotension.
.
1. Syncope/Hypotension: Patient initally admitted to MICU from
ED with persistent hypotension. Upon arrival to the MICU,
patient's blood pressure was 138/76 with a baseline tachycardia
which is present as an outpatient. DDx included hypoglycemia,
medication effect (recent history of hypotension as an
outpatient with decrease in blood pressure medications). Patient
also with history of syncope in the past with negative
outpatient work-up in the past including TTE, autonomic testing,
stress test, and EEG. DDx also includes possible vagal episode
from pain, infection was also on the differential so she was
initially broadly covered with vancomycin and zosyn, especially
in the setting of fat stranding and mesesnteric LAD seen on CT
A/P. Overnight she again became hypotensive, requiring
placement of a CVL and arterial line. Her blood pressure
improved with IV fluids, never requiring pressors. She remained
on antibiotics until her cultures were negative for 48 hours,
and then remained afebrile off antibiotics. Her
anti-hypertensives were held and her tricyclic (desipramine) was
weaned, given that it can cause orthostatic hypotension. After
her first night in the ICU her blood pressures remained stable
and she was stable to be called out to the medical floor.
On the medical floor, the patient remained stable with no
further episodes of hypotension or syncope. She became
hypertensive and her anti-hypertensive medications were slowly
added back to her medication regimen. We continued to wean her
desipramine slowly.
.
2. Leukopenia: Pt with WBC of 3.7 (baseline [**4-9**]), was considered
to be possibly in the setting of infection. However, the
patient's blood cultures, urine cultures, and chest x-ray did
not show evidence of infection. She did have diarrhea on the
floor. Her WBC count remained stable throughout the
hospitalization and was 3.8 at discharge.
.
3. Shoulder discomfort: Patient c/o bilateral shoulder
discomfort over past two months. Joint exam/ROM was without
focal findings. DDx includes osteoarthritis, polymyalgia
rheumatica. We gave the patient tylenol PRN for the pain. She
may benefit from physical therapy as an outpatient.
.
4. Hypertension: In the MICU the patient's lasix, lisinopril,
metoprolol were held. On the floor, she was hypertensive and
her blood pressure medications were slowly re-introduced. At
the time of discharge her lisinopril had not yet been added back
to her regimen. The patient will follow-up with her primary
doctor in terms of when to re-start her lisinopril.
.
5. Diabetes Mellitus: HgA1c 6.5 in 6/[**2115**]. Patient possibly
hypoglycemic, but actos does not usually cause hypoglycemia
unless combined with insulin or sulfonylureas. Her oral
hypoglycemics were held while in house and she was kept on an
insulin sliding scale.
.
6. Schizophrenia: We continued risperdone and benztropine.
.
7. Bipolar d/o: We continue depakote and desipramine. However,
the dose of desipramine was weaned throughout the
hospitalization.
.
8. A Right Lower Lobe pulmonary nodule should get follow-up with
a chest CT in 6 months.
Medications on Admission:
BENZTROPINE 0.5 mg Tablet PO qAM and PRN
BIMATOPROST [LUMIGAN] - 0.03 % Drops - 1 drop both eyes at
bedtime
DESIPRAMINE 100 mg PO daily
DIVALPROEX 250 mg Tablet, Delayed Release (E.C.) - 2 (Two)
Tablet(s) by mouth every morning and 7 (seven) at bedtime
DORZOLAMIDE-TIMOLOL [COSOPT] - 0.5 %-2 % Drops - 1 drop both
eyes twice a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 (Two) sprays NU daily
FUROSEMIDE 40 mg PO daily
LISINOPRIL 40 mg PO daily
METOPROLOL SUCCINATE (XL) 25 mg PO daily
PIOGLITAZONE [ACTOS] 30 mg PO daily
RISPERIDONE 2 mg PO BID
Tylenol PRN pain
ASA 81 mg PO daily
Ferrous Sulfate 325 mg PO daily
Discharge Medications:
1. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Risperidone 0.5 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Desipramine 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
9. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Nine
(9) Tablet, Delayed Release (E.C.) PO QHS (once a day (at
bedtime)): Take 500mg (2 tablets) every morning and 1750mg (7
tablets) every evening.
10. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. Bimatoprost 0.03 % Drops with Applicator Sig: One (1)
Topical at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY:
Hypotension, NOS
SECONDARY:
Diabetes Type 2
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure participating in your care during your
admission at [**Hospital1 69**].
You were admitted to the hospital after you lost consciousness
at home. You were found to have a very low blood pressure in the
emergency room and were given fluids to increase your blood
pressure. Your lab tests did not show any signs of an infection
that may have caused the low blood pressure. We did x-rays and a
CT, which did not show infections. We did an ECHO of your heart,
which was within normal limits. Your low blood pressure and loss
of consciousness may be due to some of the medications you take
that can cause low blood pressure. Please adjust your
medications with your primary doctor.
We have made some changes to your medications. Please decrease
your dose of desipramine from 100 mg daily to 50 mg daily.
Please hold off on taking your lisinopril until you see your
primary care physician. [**Name10 (NameIs) **] is to make sure you are having
normal blood pressures before restarting this medication. It is
important in the long run that you be on this drug, however, so
please be sure to discuss this with your primary care physician.
Finally, we have scheduled follow up appointments for you as
listed below. We were not able to get you an appointment with
your regular primary care physician until [**Name9 (PRE) 2974**], [**8-14**]. We would like you to be seen by one of the covering
providers at [**Hospital6 733**] later this week or early
next week as well. Please contact the [**Name (NI) 191**] clinic at [**Telephone/Fax (1) 250**]
to schedule this follow up appointment. You should have your
blood pressure checked at this appointment and discuss whether
or not to restart your lisinopril.
Followup Instructions:
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2116-8-14**] at 10:50 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PODIATRY
When: [**Hospital Ward Name **] [**2116-8-28**] at 9:30 AM
With: [**Hospital 1947**] CLINIC (SB) [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: [**Street Address(1) **] [**2116-8-28**] at 11:00 AM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: [**Hospital Ward Name **] CLINICAL CENTER [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"25000",
"4019",
"2859"
] |
Unit No: [**Numeric Identifier 62809**]
Admission Date: [**2155-7-20**]
Discharge Date: [**2155-10-15**]
Date of Birth: [**2155-7-20**]
Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname 62810**] is a former 28-5/7 weeks
gestational age premature male infant currently 87 days old
with corrected gestational age 41-1/7 weeks. He was born
prematurely at 28-5/7 weeks to 33-year-old G1, P0 now 1
mother. Maternal prenatal screens were blood group O-
positive, antibody negative, hepatitis B negative, RPR
nonreactive, rubella immune, GBS unknown. Pregnancy was
complicated by spotting at 18 weeks and 26 weeks. Also was
complicated by cervical shortening and preterm labor. Mother
was admitted to [**Hospital1 69**] on
[**2155-7-9**] for tocolysis. She was betamethasone
complete on [**2155-7-9**].
Pregnancy was remarkable for history of GBS UTI
during this pregnancy. Infant was delivered vaginally on
[**2155-7-20**] due to progressive preterm labor and cervical
dilatation. Infant emerged with good tone. Blow-by oxygen was
provided initially and then facial CPAP was initiated in the
delivery room due to retractions. Apgars were 7 at 1 minute
and 8 at 5 minutes. Infant was transported to neonatal
intensive care unit on facial CPAP without complications.
PHYSICAL EXAM ON ADMISSION TO THE NICU: Weight 1,215 grams,
length 40 cm, head circumference 26.5 cm. Nondysmorphic,
pink, premature infant in moderate respiratory distress with
facial CPAP. Retractions and delayed capillary refill was
noticed. Exam: Otherwise was unremarkable.
HOSPITAL COURSE BY SYSTEMS: Respiratory. Baby [**Name (NI) **] [**Known lastname 62810**] was
intubated shortly after admission to the neonatal intensive
care unit due to worsening respiratory distress. His chest x-
ray was consistent with hyaline membrane disease. He was
treated with 2 doses of surfactant over the 1st 24 hours. He
remained intubated for 1st week of life and was extubated to
nasal CPAP on [**2155-7-27**], day of life 7. He remained
on nasal CPAP til day of life 11 when he was transitioned to
nasal cannula.
He remained on nasal cannula oxygen til [**2155-9-2**], day
of life 44 when he was transitioned to room air. He was
started on Diuril for persistent oxygen requirement on
[**2155-8-30**], day of life 41 and was weaned off diuretics
on [**2155-9-18**], day of life 60. He remained on room air
since day of life 44 and had no significant respiratory
issues. He was treated with caffeine for apnea of
prematurity. Caffeine was discontinued on [**2155-8-15**],
day of life 25.
His last spell not associated with feeds was on [**2155-9-17**], day of life 59. Through his hospital course, he had
intermittent desaturation episodes associated with p.o.
feeds. He slowly improved over the last 3 weeks of his
hospital course and at the moment of discharge, can be fed
without any difficulties.
Cardiovascularly. Umbilical vein catheter and umbilical
artery catheter were placed on admission. They were both
discontinued on day of life 7. Due to need for vascular
access, peripherally inserted central catheter was placed on
[**7-25**] and was discontinued on [**8-4**].
On admission, Baby [**Name (NI) **] [**Known lastname 62810**] was hypotensive. Normal saline
boluses were given with good response. Dopamine was started on
the 1st day of life for persistent hypotension, and dopamine
was discontinued on day of life 3. He was noticed to have a
loud murmur on day of life 2, and an echocardiogram confirmed
diagnosis of patent ductus arteriosus. He was treated with 1
course of indomethacin and follow-up echocardiogram showed
persistent PDA. He was treated with a 2nd course of
indomethacin with clinical resolution of symptoms of PDA.
Follow-up echocardiogram was done on [**8-13**] due to
persistent murmur which showed small-to-moderate PDA with
mildly dilated left ventricles. He was followed through his
hospital course with series of echocardiogram. The last was
echocardiogram was done on [**2155-9-8**] which showed
small PDA with continuous left-to-right shunt. Cardiology is
planning to follow Baby [**Name (NI) **] [**Known lastname 62810**] as an outpatient, and
echocardiogram is planned to repeat in the 1st 2 months after
discharge from the neonatal intensive care unit.
FEN and GI. Baby [**Name (NI) **] [**Known lastname 62810**] remained NPO for the 1st 7 days
of life. PN was started on day of life 1. Enteral feeds were
introduced on day of life 7. Enteral feeds were slowly
advanced, and he was on full feeds on day of life 14. Due to
poor weight gain, his calories were increased and he was at
32 calories breast milk with ProMod. He demonstrated
excellent weight gain with this caloric intake, and he was
weaned back to breast milk 24 with Enfamil powder.
He is on breast milk with Enfamil powder 24 calories per
ounce since [**2155-9-18**], day of life 57. He continued to
have appropriate weight gain. At discharge, his weight is
3,6205 grams. He was started on phototherapy on admission due
to significant bruising. His bilirubin level peaked on day of
life 7 and was 8.2. His phototherapy was discontinued on day
of life 10.
Hematology. His initial CBC was reassuring with white blood
cell count 8.2, 16 polys, 0 bands, 72 lymphocytes, hematocrit
45.9, and platelets 226. He was transfused with 15 cc per
kilograms of pack red blood cells on day of life 4 for
hematocrit of 35. He requires no additional transfusion
through his hospital stay. His last hematocrit was done on
[**8-31**], day of life 73, and was 26.8 with reticulocyte
count 3.2.
He was started on iron supplementation on day of life 16 and
remained on ferrous sulfate through his hospital course.
Infectious disease. On admission, Baby [**Name (NI) **] [**Known lastname 62810**] was started
on ampicillin and gentamicin. Antibiotics were discontinued
on day of life 2 when blood cultures were negative at 48
hours. He remained free of signs of infection through his
hospital course.
Neurology. Baby [**Name (NI) **] [**Known lastname 62811**] clinical exam remained within
normal limits through his hospital stay. He was followed with
a series of head ultrasounds. Head ultrasounds were done on
[**7-31**] and [**8-19**] and all of them were within
normal limits without any signs of interventricular
hemorrhages.
Audiology. He passed both ears on hearing screen on [**2155-10-3**].
Ophthalmology. Eyes were examined most recently on [**2155-9-29**] revealing immature retinal vessels. A follow-up exam
is recommended in 9 months.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY PEDIATRICIAN: Is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 43579**], [**First Name3 (LF) **]
Pediatrics, phone #[**Telephone/Fax (1) 37875**].
CAR SEAT TEST: Baby [**Name (NI) **] [**Known lastname 62810**] passed car seat position test on
[**2155-10-9**].
STATE NEWBORN SCREEN: The last newborn screen was done on
[**2155-9-1**] and was within normal limits.
VACCINATIONS: Hepatitis B vaccine given on [**2155-8-24**].
Pediarix given on [**2155-9-24**], Prevnar given [**2155-9-24**]. HIB given [**2155-9-24**]. Synagis given [**2155-10-12**].
CURRENT MEDICATIONS: Neonatal multivitamins 1 cc p.o. once a
day, ferrous sulfate 0.6 cc p.o. once a day.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1. Born at less than 32
weeks; 2. Born between 32 and 35 weeks with 2 of the
following: Daycare during the 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 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS: Recommended with cardiology in 2
months after discharge. Parents to make the appointment. With
ophthalmology 9 months after discharge. Parents to make an
appointment. With primary care pediatrician in 1st week after
discharge. Parents to make an appointment.
DISCHARGE DIAGNOSIS LIST:
1. Prematurity.
2. Respiratory distress, hyaline membrane disease.
3. Rule out sepsis.
4. Patent ductus arteriosus.
5. Apnea of prematurity.
6. Retinopathy of prematurity.
7. Hypotension
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name8 (MD) 62812**]
MEDQUIST36
D: [**2155-10-15**] 09:27:01
T: [**2155-10-15**] 10:02:08
Job#: [**Job Number 62813**]
|
[
"7742",
"V053"
] |
Admission Date: [**2191-4-22**] Discharge Date: [**2191-5-29**]
Service: MEDICINE
Allergies:
Sulfonamides / Olanzapine / Risperidone / Propranolol /
Haloperidol
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Dyspnea, cough
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Ms. [**Known lastname 103426**] is a 76 yo F with PMH schizophrenia, HTN, h/o colon
cancer transferred from NH were she was found to be shivering
with BP 120/80 HR 136-140, RR 22 and room air oxygen saturation
of 88-89% up to 93% on 2L face mask. Patient reports that she
has not been feeling well for the past two days primarily due to
cough. She denies any chest pain, abdominal pain, nasuea,
vomiting, diarrhea, rash or other symptoms.
VS on arrival in the ED T98.5 BP 79/51 HR 78 RR 26 98% on NRB.
On the monitor she was noted to have HR 140-150 in atrial
fibrillation. She was given 5mg IV lopressor with HR to the
130's. A second dose of 5mg IV lopressor was given whith
improvement in HR to 90's to 120's however BP decreased to 74/54
transiently. She was given 1 L NS wit BP 91/58 on transfer to
the ICU. She had a CXR which showed LLL infiltrate. She was
given ceftriaxone 1g IV, vancomycin 1gm IV and levoquin 750mg
IV. She had a rectal temp of 103.8 and was given 1g tylenol pr.
On arrival to the floor HR 70's, SBP 91/43 93% 3L NC. She is
resting comfortably in no respiratory distress. She denies pain.
Past Medical History:
Schizophrenia
Cellulitis
HTN
h/o colon cancer - T3N0M0, s/p resection in 1/98, local
recurrence at site of anastomosis in 8/99 and in 9/00 requiring
repeat resections. In 12/00 had transverse colon resected.
latest colonoscopy in [**6-16**] nml.
B12 deficiency
Peripheral neuropathy
Social History:
lives in [**Hospital3 **] and rehab center, eats regular low
salt diet, ambulates with a walker. She stopped drinking alcohol
since she moved into a nursing home. She does not smoke.
Family History:
Father with bipolar d/o
Physical Exam:
VS: T 99.6 92/48 HR 72 RR 18 93% on 3L NC
Gen: A&O x3, resting comfortably, no distress
HEENT: NC AT EOMI PERRLA
Neck: supple, JVP flat
CV: RRR, s1 s2, frequent premature beats
Lungs: bronchial breath sounds at the left base, no wheezing
Abd: well healed midline surgical scar, ventral hernia,
distended, nontender, bowel sounds positive
Ext: warm, palpable DP's, trace edema
Pertinent Results:
Na 138 K 4.5 Cl 104 HCO 24 BUN 38 creat 1 gluc 102
CK 602 MB 4 Trop 0.03
BNP [**Numeric Identifier 103427**]
WBC 9.7 (N71 B4 L13) HCT 36.3 PLT 121
Venous lactate 2
UA: small leuk, nitr positive, 0-2 RBC, >50 WBC, moderate
bacteria, 0-2 epi, rare yeast.
[**2191-4-22**] EKG: Afib with RVR at a rate of 153 bpm, left axis
deviation, poor baseline, no apparent ischemic changes. No prior
for comparision.
Imaging:
[**2191-4-24**] CXR: Right PICC tip can be followed only to the upper
SVC. No other interval change from prior study performed the
same day earlier in the morning.
[**2191-4-22**] CXR:
Limited study as above. There are patchy opacities in the mid
and lower left lung highly consistent with pneumonia. Correlate
clinically. If clinically feasible and useful for management,
consider PA and lateral views in the radiology suite for further
evaluation.
[**2191-3-21**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is small.
Overall left ventricular systolic function is low normal (LVEF
50%). There is no ventricular septal defect. The right
ventricular cavity is dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace 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.
Brief Hospital Course:
Health Care Associated pneumonia - She presented with a large
left lower lobe infiltrate on CXR. Respiratory function stable
on admission, requiring 3L NC only. Borderline hypotension,
fever of 103 and tachycardia c/w SIRS/sepsis. She was treated
with broad coverage with vancomycin, cefepime, levofloxacin
given h/o resistant gram negative organisms and that she lives
in a health care facility. Urine was negative for legionella.
Over her prolonged hospital course, she continued to have
worsening hypoxia and consolidation of her LLL and ultimately
required MICU transfer. In the MICU, she developed large pleural
effusions and a trapped lung on the left. Resp status
deteriorated to requiring bipap at night and high flow mask
constantly. Chest CT revealed evidence of numerous distal mucous
plugs. However, Bronchoscopy on [**5-7**] did not reveal large mucous
plugs. She then underwent thoracentesis and drainage of
transudative fluid X 1, however, it quickly reaccumulated and
she received an IP placed pigtail catheter on [**5-10**] with
immediate drainage of large clear transudative fluid and
improvement of her resp status back down to nasal cannula. She
developed a small pneumothorax which was not symptomatic.
After a prolonged hospital course ethics was consulted and she
was made DNR/DNI with no escalation of care after speaking with
her guardian. She expired on [**2191-5-29**].
Communication: [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 656**] Guardian [**Telephone/Fax (1) **] or
[**Telephone/Fax (1) 103428**]
Medications on Admission:
Meds: from NH med list
depakote ER 1500mg daily
perphenazine 6mg po daily
perphenazine 2mg po q4 hours prn agitation
EC ASA 325mg daily
Tums 2 tabs po prn
loratadine 10mg po daily for 5 months
vitamin c 500mg po BID
aldactone 25mg po daily
colace 100mg po bid prn
ibuprofen 600mg po q8 hours prn
atenolol 25mg po daily
mtv one daily
B12 100 mcg daily
amlodipine 5mg po daily
vitamin D 400 units po daily
Eucerin cream to lower extremities
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Hospital acquired pnemonia
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"5070",
"51881",
"5990",
"40391",
"5119",
"2762",
"2761",
"42731",
"2859"
] |
Admission Date: [**2110-12-16**] Discharge Date: [**2110-12-21**]
Date of Birth: [**2038-3-31**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 72 year old male with
known aortic stenosis. He is a patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57621**]
who reports a one month history of increasing dyspnea and
dizziness with testing showing severe aortic stenosis with an
aortic valve area of 0.63 cm2 and a mean gradient of 40 mmHg.
He was then referred for an aortic valve replacement.
PAST MEDICAL HISTORY: Past medical history includes aortic
stenosis, severe emphysema, arthritis, osteoporosis, peptic
ulcer disease with a GI bleed four years ago.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Atenolol 25 mg daily, Accupril 40
mg daily, Protonix 40 mg daily, Lipitor 10 mg daily,
prednisone 5 mg daily, Fosamax 70 mg q week and aspirin 81 mg
daily.
PHYSICAL EXAMINATION: Neurologic - alert and oriented times
three. Neck - no carotid bruits. Chest - clear to
auscultation bilaterally with right pectoral muscle absence
since birth. Cardiac - regular rate and rhythm, 1/6 systolic
ejection murmur. Abdomen is soft, nontender and nondistended.
Extremities - significant for right arm varicosity known to
patient.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
on [**2110-12-16**] and proceeded to the Operating Room for an
aortic valve replacement with a 25 mm CE pericardial valve by
Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. His total cardiopulmonary bypass time
was 116 minutes and a cross-clamp time of 146 minutes. He
proceeded to the Cardiac Surgery Recovery Room with mean
arterial pressure of 67, CVP of 4 and a normal sinus rhythm
at a rate of 71. He was on nitroglycerin and propofol drip
for support. On postoperative day 1, the patient was woken
up, weaned from his ventilator and extubated. He continued to
receive intravenous nitroglycerin for support and also
received 1 unit of packed red blood cells. Over the first
three postoperative days, the patient had some trouble with
his mean arterial pressure with nitroglycerin and labetalol
drips titrated along with po Lopressor started to keep his
mean arterial pressure greater than 55. On postoperative day
3, his chest tubes were discontinued and he was transferred
to the Inpatient Floor for continued recovery. On
postoperative day 3, he also experienced some intermittent
atrial fibrillation treated with IV push Lopressor. He
continued to have bursts of intermittent atrial fibrillation
through postoperative day 5 and was treated with Lopressor as
well as an increase in his po Lopressor and po Captopril.
Anticoagulation was considered and decided against. At the
time of discharge, he had been without any atrial
fibrillation for over 24 hours. The patient was also followed
by Physical Therapy throughout his hospital course, the last
visit on [**12-21**] when the patient was found to be safe for
discharge home when medically stable. On [**2110-12-21**], the
patient was discharged home with [**Hospital1 1474**] Visiting Nurses to
follow up with patient.
CONDITION ON DISCHARGE: Vital signs - temperature 98.8,
blood pressure 154/74, heart rate 77 and sinus rhythm,
respiratory rate 20, O2 sat 93 percent on room air.
Cardiovascular - regular rate and rhythm. Respiratory -
crackles in the left base and clear on the right. Abdomen is
soft, nontender and nondistended. Sternal incision is clean
and dry with Steri-Strips intact and sternum stable.
DISCHARGE DIAGNOSES: Aortic stenosis, osteoarthritis and
postoperative atrial fibrillation.
DISCHARGE MEDICATIONS: Lasix 20 mg po bid for seven days,
potassium chloride 20 mEq po bid for seven days, Colace 100
mg po bid, aspirin 81 mg po bid, Tylenol 325-650 mg po q4h
prn, Percocet 5/325 one to two tablets po q4h, prn - do not
take in addition to Tylenol, folic acid 1 mg po daily,
thiamine 100 mg po daily, Protonix 40 mg po daily, Lipitor 10
mg po daily, Captopril 37.5 mg po tid and Lopressor 100 mg
[**Hospital1 **] and prednisone 10 mg po daily.
FO[**Last Name (STitle) 996**]P PLANS: The patient is to see Dr. [**Last Name (Prefixes) **] in
one month and to see cardiologist in one to two weeks. He
will also be followed by the visiting nurses at home and will
be seen in the Outpatient [**Hospital 409**] Clinic in approximately two
weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 5898**]
MEDQUIST36
D: [**2110-12-22**] 13:34:38
T: [**2110-12-22**] 14:23:49
Job#: [**Job Number 57622**]
|
[
"4241",
"9971",
"42731",
"4019",
"53081"
] |
Admission Date: [**2122-7-10**] Discharge Date: [**2122-7-16**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
Struck by auto
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 s/p falling over next to car when open car door struck
her, uncertain if car ran over foot, and not sure of exact
mechanics of fall, but fell to ground on left side, evaluated at
OSH and found pelvic fractures and foot fracture. She was then
transferred to [**Hospital1 18**] for further care.
Past Medical History:
ventricular arrhythmia, HLD, osteoporosis
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Temp: Afebrile HR: 60 BP: 139/76 Resp: 12 O(2)Sat: 99% room
air Normal
Constitutional: General appearance: The patient arrives
boarded and collared and is in no acute distress. The GCS is
15.
Head: The scalp is nontender and shows no trauma.
HEENT: The extraocular muscles are intact and the pupils
both constrict to light from 3 mm to 2 mm.
Neck: There is no C-spine tenderness or step off.
Upper extremities: The upper extremities show no trauma.
Thorax: The chest wall is nontender.
Lungs: The lungs are clear and symmetrical.
Heart: The heart sounds are crisp.
Abdomen: soft, scaphoid, and nontender.
Spine: There is no thoracic or lumbar spine tenderness.
Hips and pelvis: The pelvis is tender and it is wrapped in a
pelvic binder.
Lower extremities: she has tenderness over her right foot
dorsum.
Dorsalis pedis pulses are intact in both feet.
Neurological: The patient moves all 4 extremities equally.
Pertinent Results:
IMAGING:
CT TORSO:
1. Fractures of the left superior and inferior pubic rami, left
iliac crest extending into the sacroiliac joint, and left sacrum
with associated hematoma but no arterial extravasation.
Diastasis of the left sacroiliac joint. 2. Fractures of the
right L2-L4 transverse processes. 3. 2 mm right upper lobe
pulmonary nodule. No follow-up is needed if the patient is low
risk for malignancy. A 12 month follow-up is recommended for
further evaluation if the patient is high risk for malignancy.
L HIP: 1. Comminuted fracture of the left superior pubic ramus
involving the parasymphyseal region as well as a nondisplaced
fracture of the left inferior pubic ramus. 2. Comminuted
fracture of the left iliac [**Doctor First Name 362**] extending into the left
sacroiliac joint with diastasis.
R FOOT: Mildly displaced oblique fracture involving the distal
diaphysis of the 3rd metatarsal of the right foot. Possible
fracture involving the base of the 3rd metatarsal.
XRAY pelvis:
FINDINGS: Fractures through the superior and inferior left pubic
rami are
perhaps slightly more displaced superiorly and medially,
allowing for
differences in technique from the prior CT. Posterior left
iliac fracture is not well assessed. Enthesopathic changes are
seen at the ischial tuberosities and superior iliac spines
bilaterally. Multilevel degenerative changes seen in the spine.
Transverse process fractures are not well assessed.
[**2122-7-10**] 09:08PM GLUCOSE-109* NA+-142 K+-4.1 CL--106 TCO2-25
[**2122-7-10**] 08:50PM PT-11.5 PTT-25.2 INR(PT)-1.1
[**2122-7-10**] 08:50PM FIBRINOGE-288
[**2122-7-10**] 08:50PM URINE RBC-11* WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2122-7-10**] 08:49PM UREA N-23* CREAT-0.9
[**2122-7-10**] 08:49PM LIPASE-28
[**2122-7-10**] 08:49PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2122-7-10**] 08:49PM WBC-13.5* RBC-3.76* HGB-12.5 HCT-37.8
MCV-101* MCH-33.3* MCHC-33.1 RDW-13.0
[**2122-7-10**] 08:49PM PLT COUNT-144*
Brief Hospital Course:
She was admitted to the Acute Care Surgery team and evaluated by
Orthopedics for her multiple fractures. Her injuries were
treated non operatively. For her pubic rami fractures she may
weight bear as tolerated on her left leg and touch down weight
bear on her right leg with a hard sole shoe due to the 3rd
metatarsal fracture.
Her hematocrits were followed closely as she was noted with a
decline in her values during her hospital stay. Hemodynamically
she remained stable with the decreased hematocrits. On day of
discharge her hematocrit was 28.4 which is up from 26.7 on the
day prior.
Her home medications were restarted and she was given a regular
diet for which she was able to tolerate. Her pain is well
controlled with oral narcotics and she is on a bowel regimen.
She was also evaluated by Physical and Occupational therapy and
being recommended for rehab after her acute hospital stay.
She was discharged to rehab on hospital day 5 and will follow up
in [**Hospital 5498**] clinic in the next several weeks for repeat
xrays. She will require PCP follow up after discharge from
rehab.
Medications on Admission:
flecainide 40 [**Hospital1 **], simvastatin 40 mg qd Acyclovir 400 mg PO
Q12H; Alendronate Sodium 70 mg PO QTUES
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Acyclovir 400 mg PO Q12H
3. Alendronate Sodium 70 mg PO QTUES
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Cyclobenzaprine 10 mg PO TID:PRN spasms
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC DAILY
8. Flecainide Acetate 50 mg PO Q12H
9. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5-1 tablet(s) by mouth every 4-6 hours as
needed Disp #*40 Tablet Refills:*0
10. Senna 2 TAB PO HS
11. Simvastatin 40 mg PO DAILY
12. Calcium Carbonate 500 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital
Discharge Diagnosis:
s/p Pedestrian struck by auto
Injuries:
Left superior/inferior pubic rami fractures
Small pelvic hematoma
Right L2-4 transverse process fractures
Left 3rd Metatarsal fracture
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 after being struck by an auto
causing mulitple fractures of your pelvis, lower spine bones and
left 3rd toe. Your injuries did not require any operations at
this time. You should avoid putting full weight on your right
leg but may put full weight on your left leg.
You were evaluated by the Physcial therapists and being
recommended for rehab after your acute hospital stay.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2122-7-28**] at 11:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2122-7-28**] at 11:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"42789",
"4019"
] |
Admission Date: [**2173-10-22**] Discharge Date:
Date of Birth: [**2115-1-19**] Sex: M
Service: Cardiothoracic Surgery
HISTORY: The patient is a 50-year-old male with a silent MI
at age of 32 and patient experienced shortness of breath with
exertion and substernal chest pain. The patient had a
positive ETT on [**10-21**] depression inferiorly and
laterally. Cath at the time showed a 70% left circumflex
lesion and 80% proximal and mid RCA lesion and 50% mid LAD
lesion. Also aneurysm in LAD and 60% diagonal lesion.
Ejection fraction at the time was 60%.
PAST MEDICAL HISTORY: Included hypertension, diabetes,
hypercholesterolemia, GERD, hemorrhoids status post hernia
repair.
MEDICATIONS: Home medications include Aspirin 325 mg po q d,
Lopressor 50 mg po bid, Avandia 2 mg po q a.m., Glucotrol 5
mg po bid, Glucophage 1 gm q a.m. and q h.s. and 500 mg q
p.m.
HOSPITAL COURSE: The patient was taken by Dr. [**First Name (STitle) 10102**] to
the OR and underwent CABG times five on [**2173-10-26**], LIMA to LAD
and right saphenous vein to RCA and PD and RCA and PL, OM and
DX. Post-operatively the patient did well. The patient was
extubated and weaned off all drips in the Intensive Care Unit
without any incidents. On postoperative day #1 the patient
was transferred to the floor. Prior to discharge the patient
was able to work with physical therapist, ambulating at level
V and demonstrated the ability to climb stairs and walk more
than 500 feet. Upon discharge the patient's condition was
stable and afebrile. Physical exam at the time was chest
clear, heart regular rate and rhythm, normal sinus, sternum
as stable, incision was clean, dry and intact, no drainage,
no pus.
DISCHARGE MEDICATIONS: Glucotrol 5 mg po bid, Glucophage 1
gm po q a.m. and q h.s. and 500 mg q p.m., Avandia 2 mg po q
a.m., Lipitor 10 mg po q h.s., Aspirin 81 mg po q d, Lasix 20
mg po bid times five days and potassium chloride 20 mEq po
bid times five days. Percocet 1-2 tablets po q 4-6 hours
prn, Colace 200 mg po q d.
The patient is to be discharged home with Home [**Hospital **]
Nursing care and told to follow with Dr. [**First Name (STitle) 10102**] in [**3-7**]
weeks.
[**Hospital **] hospital course was unremarkable with no
complications.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13625**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2173-10-29**] 17:55
T: [**2173-10-29**] 19:28
JOB#: [**Job Number 36232**]
|
[
"41401",
"42731",
"2859",
"53081",
"4019",
"2720",
"25000",
"412"
] |
Admission Date: [**2154-7-10**] Discharge Date: [**2154-7-15**]
Date of Birth: [**2098-10-4**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 54-year-old male is status
post LAD and left circumflex stenting with subsequent LAD
instant restenosis and was referred by Dr. [**Last Name (STitle) 1295**] for an
outpatient cardiac catheterization. Approximately six weeks
prior to admission he started experiencing recurrent chest
tightness and dyspnea associated with exertion that occurs
with minimal activity such as walking for two minutes. The
patient also reports that for the past few days he has had
mild chest discomfort on an almost constant basis. He was
advised to take Nitroglycerin but had refused. The patient
was also advised to go to the hospital but refused. He
denies claudication, orthopnea, edema, paroxysmal nocturnal
dyspnea or lightheadedness. He is now admitted for cardiac
catheterization.
PAST MEDICAL HISTORY: Significant for history of
hypertension, history of hypercholesterolemia, history of
coronary artery disease and is status post a rotational
atherectomy and percutaneous transluminal coronary
angioplasty stenting to the LAD in [**3-/2153**] and stenting of
the mid circumflex and OM at the same time. He also had a
LAD instant restenosis with a percutaneous transluminal
coronary angioplasty and brachytherapy in 06/[**2153**].
FAMILY HISTORY: Significant for coronary artery disease.
ALLERGIES: He has no known allergies.
MEDICATIONS: His medications on admission were Lipitor 40 mg
p.o. once a day, atenolol 50 mg p.o. once a day, lisinopril
10 mg p.o. once a day, Aspirin 325 mg p.o. once a day, Plavix
75 mg p.o. once a day, folic acid 800 mg p.o. once a day,
Tylenol PM q.h.s.
SOCIAL HISTORY: He does not smoke cigarettes. He does not
drink alcohol. He lives at home with his wife.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION: He is a well-developed, well-nourished
white male in no apparent distress. Vital signs stable,
afebrile. HEENT examination: Normocephalic, atraumatic.
Extraocular movements intact Oropharynx benign. Neck was
supple. Full range of motion. No lymphadenopathy,
thyromegaly. Carotids 2 plus and equal bilaterally without
bruits. Lungs were clear to auscultation and percussion.
Cardiovascular examination: Regular rate and rhythm, normal
S1, S2 with no rubs, murmurs or gallops. Abdomen was soft,
nontender, with positive bowel sounds. No masses or
hepatosplenomegaly. Extremities were without clubbing,
cyanosis or edema. Neurological examination was nonfocal.
On [**2154-7-10**] he underwent a cardiac catheterization which
revealed the left main coronary artery was normal. The LAD
had diffuse moderate disease. The osteal stent had a 40
percent recurrent instant stenosis, three sequential 60 to 70
percent stenosis in the mid vessel. The left circumflex had
a 90 percent osteal stenosis and the RCA had diffuse mild
disease with an 80 percent stenosis in the proximal portion
of the posterolateral system. Ejection fraction was
approximately 65 percent with no mitral regurgitation. Dr.
[**Last Name (STitle) 70**] was consulted and on [**2154-7-11**], the patient
underwent a coronary artery bypass graft times two with a
LIMA to the LAD, reverse saphenous vein graft to the diagonal
and OM. Cross clamp time was 41 minutes. Total bypass time
64 minutes. He was transferred to the CSRU in stable
condition on Propofol. He was extubated on his postoperative
night and was on Neo postoperative day no. 1. He has his
chest tube discontinued on postoperative day no. 2. He was
off his Neo started on Lopressor and transferred to the
floor. He had his epicardial pacing wires discontinued on
postoperative day no. 3 and on postoperative day no. 4 he was
discharged to home in stable condition.
LABORATORY DATA ON DISCHARGE: Hematocrit 26.6, white count
6,100, platelets 195,000, sodium 135, potassium 4.6, chloride
98, CO2 29, BUN 17, creatinine 1.1, blood sugar 106.
DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. once a day,
Plavix 75 mg p.o. once a day, atenolol 50 mg p.o. once a day,
vitamin C 500 mg p.o. twice a day, Lasix 20 mg p.o. once a
day for seven days, KCL 10 mEq p.o. once a day for seven
days, Percocet [**1-4**] p.o. q.4-6h. p.r.n. pain, Lipitor 40 mg
p.o. once a day, Zantac 150 mg p.o. twice a day, Niferex 150
mg p.o. once a day.
He will be seen by Dr. [**Last Name (STitle) 1295**] in one to two weeks and by
Dr. [**Last Name (STitle) 70**] in 5 to 6 weeks, and by Dr. [**Last Name (STitle) 4427**] in one to
two weeks.
DISCHARGE DIAGNOSES: Hypertension, hypercholesterolemia,
coronary artery disease.
[**Known firstname **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2154-7-15**] 12:26:35
T: [**2154-7-15**] 13:24:22
Job#: [**Job Number 48173**]
|
[
"41401",
"4019",
"2720"
] |
Admission Date: [**2101-4-19**] Discharge Date: [**2101-5-10**]
Date of Birth: [**2048-2-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
umbilical hernia
Major Surgical or Invasive Procedure:
[**2101-4-19**]: umbilical hernia repair
[**2101-4-21**], [**5-6**], [**5-9**]: paracentesis
[**2101-4-22**]: ex-lap with hematoma evacuation
[**2101-4-23**]: PICC insertion.
[**2101-5-2**]: Abdominal wound closure
[**2101-5-10**]: picc removal
History of Present Illness:
53 y/o male with cirrhosis secondary to hepatitis C and alcohol
with several months of increasing discomfort over the umbilica
hernia. The hernia reduces while supine and he does not note any
obstructive symptoms. He is currently listed for liver
transplant with a MELD of 22. He has been undergoing frequent
paracentesis for diuretic resistant ascites.
Past Medical History:
PMH: HCV and EtOH cirrhosis, HTN, depression, esophageal varices
PSH: R inguinal hernia repair ([**5-16**])
[**2101-4-19**]: umbilical hernia repair
[**2101-4-21**], [**5-6**], [**5-9**]: paracentesis
[**2101-4-22**]: ex-lap with hematoma evacuation
[**2101-5-2**]: Abdominal wound closure
Social History:
He was a heavy drinker for 30 years, but quit one year ago. He
smoked one pack of cigarettes per day for 30 years, but has
quit. He has had no IV drug use; however, he does smoke
marijuana daily. He is married and has three children. He is
currently unemployed but used to work for [**Company 14672**].
Family History:
Mother and brother have [**Name (NI) 2320**].
Physical Exam:
VS: afebrile, Tmax 98.3, HR 76, BP 120/67
Gen: Chronically ill, jaundice
HEENT: + sclarae icterus, NG tube in place draining large
amounts
of dark brown fluid
Neck: No JVP
CV: no m/g/r
Lungs: decrease BS in the right base
Ab: distended, diffusely tender, NO BS
Ext: 2+ pulses, 1+ edema b
Pertinent Results:
[**2101-4-20**] 06:58PM BLOOD WBC-8.6# RBC-2.44* Hgb-8.2* Hct-26.4*
MCV-108* MCH-33.7* MCHC-31.1 RDW-14.6 Plt Ct-87*
[**2101-4-21**] 10:20PM BLOOD Hct-20.8*
[**2101-4-22**] 02:39PM BLOOD WBC-5.4 RBC-2.96* Hgb-9.6* Hct-29.0*
MCV-98 MCH-32.3* MCHC-33.1 RDW-18.1* Plt Ct-68*
[**2101-5-9**] 04:30AM BLOOD WBC-8.3 RBC-2.57* Hgb-8.8* Hct-26.5*
MCV-103* MCH-34.1* MCHC-33.1 RDW-18.0* Plt Ct-114*
[**2101-5-10**] 05:26AM BLOOD WBC-7.6 RBC-2.92* Hgb-9.7* Hct-29.6*
MCV-102* MCH-33.2* MCHC-32.7 RDW-19.0* Plt Ct-108*
[**2101-5-10**] 05:26AM BLOOD PT-21.3* PTT-39.0* INR(PT)-2.0*
[**2101-5-10**] 05:26AM BLOOD Glucose-83 UreaN-20 Creat-1.2 Na-137
K-4.5 Cl-105 HCO3-25 AnGap-12
[**2101-5-9**] 04:30AM BLOOD ALT-21 AST-56* AlkPhos-89 TotBili-3.1*
[**2101-5-10**] 05:26AM BLOOD Albumin-2.9*
Brief Hospital Course:
On [**2101-4-19**], he underwent elective umbilical hernia repair
without mesh and ascites drainage (see op note for further
details). Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Postop, clear liquid
were started. He was noted to become increasingly confused with
asterixis. Lactulose was increased to every 2 hours. Urine
output was low which was treated with IV fluid boluses and
albumin.
Overnight, on POD 1, he had 900 cc of non-bilious emesis
requiring NG tube placement with over 1 liter output. Due to
confusion, he self-removed the tube. Nausea improved, but
abdomen remained distended. On POD 2, he was encephalopathic and
lactulose enemas were started. Portable KUB was obtained which
was concerning for ileus. Creatinine increased to 2.5 from
baseline of 1.4. Repeat doses of Albumin were administered with
adequate urine output. Urine lytes demonstrated pre-renal
azotemia. Hepatology was consulted to assist with management.
Serial Albumins were checked and Albumin was given. Lactulose
enemas and diuretics were held. Abdomen remained distended and
diffusely tender with concern for re-accumulation of ascites.
Ultrasound demonstrated multiple small pockets of ascites. The
left upper quadrant ascites was tapped and 10 mL of grossly
bloody ascites was sent for analysis and culture.
Post-paracentesis hematocrit dropped to 19.2 with INR of 2.3. 4
units of PRBC, 4 units of FFP, and 1 unit of platelets were
transfused. CT scan was obtained and demonstrated multiple
distended loops of small bowel proximal to an umbilical hernia
with decompressed distal small bowel and fluid filled colon
concerning for an early or partial small bowel obstruction was
noted.
Due to concern for bowel obstruction and intra-abdominal
bleeding, he was taken to the OR overnight POD [**1-7**] for ex lap
and evacuation of 1 litre of hemoperitoneum with no source of
bleeding noted. No obstruction was noted, and there was no
hernia recurrence. Post-op hematocrit was 28.4 and INR was 1.7.
Repeat labs in the morning demonstrated hematocrit of 24.2, INR
1.9, Fibrinogen 113. Additional PRBC (2), 1 unit FFP, and 1 unit
of Cryo were given. A right PICC line was placed for IV access
and he was transferred to the SICU for monitoring.
He remained hemodynamically stable and hematocrits improved and
he was transferred to the floor the following day. On POD [**6-8**]. A
wound VAC was placed for ascites leak after several staples were
removed. On POD [**7-10**] he began passing flatus and having bowel
movements and was started on clear liquid diet and was advanced
to regular diet. Wound VAC output was as high as 4 liters per
day. This fluid was replaced cc/cc. Scheduled albumin was
administered. Creatinine increased to 2.3. Diuretics were again
held.
On [**2101-5-2**], he was taken back to the OR for wound closure.
Surgeon was Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. JP drain was placed. This output
averaged 100-60 cc of sanguinous fluid. Pain was initially
managed with Morphine IV. Diet was slowly advanced and
tolerated.
Abdomen was distended and paracentesis was performed for 1 liter
of ascites on [**5-4**]. Culture of this fluid was negative. He was
started on Ceftriaxone for cell count that was elevated. He
remained afebrile with stable vital signs.
Paracentesis was repeated after FFP on [**5-6**] for 2 liters. Ascites
ANC was 300. Culture was negative. Ceftriaxone was continued.
Paracentesis was repeated after Vit K iv, FFP and cryo on [**5-9**]
for 1.7 liters. Cell count was 64 with culture negative to date.
Incision with staples remained intact. JP output was 65 cc of
serosanguinous fluid.
Diet was well tolerated. Morphine was switched to intermittent
oxycodone prn. He was ambulating independently. Diuretics were
resumed at 40mg Lasix daily. Lactulose was held and Rifaximin
was continued tid. Lactulose was held to avoid over distension.
He was alert and felt well enough to go home on [**5-9**].
The plan was to continue just Lasix 40mg daily. Eplerenone was
held. Patient was instructed to have labs drawn on [**5-13**]. VNA
services were arranged to assist with JP drain care and
assessment of incision/ascited. Ceftriaxone was switched to po
Cipro 500 mg [**Hospital1 **] for 1 week then decrease to 500 mg daily. R arm
PICC was removed just prior to discharge to home.
Medications on Admission:
Eplerenone 50', Lasix 40', Lactulose 30''', Nadolol 40',
Omeprazole 20', Calcium', Vitamin D ', Clotrimazole 10 lozenge
5x/day, Rifaximin 550''
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
2. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
five times a day.
3. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day: for 1
week then decrease to one tablet (500mg)daily.
Disp:*35 Tablet(s)* Refills:*2*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
Disp:*20 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Friday [**5-13**] at [**Last Name (NamePattern1) 439**] Lab, [**Location (un) 453**]
11. Medications on HOLD
Lactulose
Eplereenone
Meds to be reviewed in follow up with Dr. [**Last Name (STitle) **]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
umbilical hernia
hepatic encephalopathy
hemoperitneum
post operative ileus
Acute kidney injury
peritonitis
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, confusion, excessive sleepiness, nausea, vomiting,
diarrhea, constipation, inability to tolerate food, fluids or
medications, increased abdominal pain, increased yellowing of
eyes or skin, drainage or redness at the incision site or other
concerning symptoms.
-Please empty and record JP drain output.
-Bring the record of drain outputs with you to your next clinic
visit.
-Please monitor the drainage and call if the drainage turns
green in color, develops a foul odor, increases significantly or
stops completely.
- Keep a drain sponge around the drain insertion site, which
should be changed daily, monitor the insertion site for redness,
drainage or bleeding.
-Please weigh yourself daily and call if your weight increases
by 3 pounds in a day or 5 pounds in a week. Call if your abdomen
feels tense or uncomforatable, if the incision or drain site
starts to leak or if you are generally uncomfortable in the
abdomen because of fluid. You will be restarting your diuretic.
-Please do not take the epleronone until notified you may do so
-Plan is to have evaluation with Dr [**Last Name (STitle) **] next week, and have
abdomen tapped as needed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2101-5-18**] 2:40
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2101-5-19**]
9:10
[**Doctor Last Name 1022**] or [**Doctor First Name **] will call you with a scheduled paracentesis time for
[**5-19**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2101-5-10**]
|
[
"5849",
"V1582"
] |
Admission Date: [**2130-2-12**] Discharge Date: [**2130-2-15**]
Date of Birth: Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old
male with moderate dementia, 3-vessel coronary artery disease
(under medical management), and a recent admission to [**Hospital1 1444**] on [**2130-2-5**] (status
post a motor vehicle accident complicated with a myocardial
contusion with stunned right ventricle, pelvic fracture) who
was managed medically with ACE inhibitor and aspirin therapy
and discharged to rehabilitation.
The patient was involved in a motor vehicle accident on
[**2-5**] and transferred from an outside hospital for
hypotension secondary to a myocardial contusion. Some
concern for acute inferior myocardial infarction was raised,
and the patient was taken to emergent cardiac catheterization
after having an evaluated creatine kinase of 600 and a
troponin of 47.
Cardiac catheterization revealed severe 3-vessel disease and
severe aortic stenosis. It was determined to continue the
patient on medical management without intervention secondary
to his baseline dementia and baseline poor functional status.
The patient was continued on aspirin therapy, and started on
an ACE inhibitor. However, he was not placed on a beta
blocker secondary to occasional sinus pauses.
Once the patient was hemodynamically stable, he was
discharged to rehabilitation on [**2130-2-11**].
In the evening of [**2130-2-11**], the patient was found to
be in acute respiratory distress. He was brought emergently
to an outside hospital and was admitted to the Intensive Care
Unit with a questionable diagnosis of pneumonia and/or
congestive heart failure. The patient was started on CPAP
for hypoxia. Dopamine was initiated but later discontinued
secondary to atrial fibrillation with a rapid ventricular
response. He underwent resuscitation with intravenous
fluids, and a Neo-Synephrine drip was begun.
A Cardiology consultation was obtained, who placed a
pulmonary artery catheter; the initial recordings of which
demonstrated a right atrial pressure of 15, right ventricular
pressure of 60/15, pulmonary artery pressure of 60/28 with a
mean of 38, pulmonary capillary wedge pressure of 30,
pulmonary artery saturation was 45, cardiac index of 1.
Inotropic support was considered with dobutamine. Lasix was
also attempted with minimal urine output as a result. After
further discussion between the family, Cardiology, and the
patient's primary care physician, [**Name10 (NameIs) **] decision was made to
send the patient back to the [**Hospital1 188**] for further management and evaluation.
At that point, the patient demonstrated an elevated creatine
kinase to 1347 with a troponin of 79. The initial plan was
for aggressive therapy with a re-look cardiac catheterization
and consideration of intra-aortic balloon pump. At the time
of presentation, the patient was do not resuscitate; however
not do not intubate.
On initial presentation to [**Hospital1 188**], the patient complained of bilateral knee pain as well
as pelvic pain. The patient denied any chest pain or
shortness of breath. He was able to state that he was at
[**Hospital1 **]. He complained of a cough that was
dry and nonproductive and had no further complaints.
PAST MEDICAL HISTORY:
1. History of angina.
2. History of dementia.
3. Cardiac catheterization on [**2130-2-6**]
demonstrating 3-vessel coronary artery disease and severe
aortic stenosis.
4. Status post motor vehicle accident on [**2-5**]
complicated with myocardial contusion and pelvic fracture.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Levofloxacin 500 mg p.o. q.d.
3. Flagyl 500 mg p.o. q.8h.
4. Heparin drip.
5. Neo-Synephrine drip.
ALLERGIES: The patient reported that DEMEROL and CODEINE
cause nausea and vomiting.
SOCIAL HISTORY: The patient currently lives with his wife in
the [**Location (un) **] Retirement Center.
PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure
was 103/62, heart rate was 87, respiratory rate was 16,
oxygen saturation of 93% on a 50% face mask. Pulmonary
artery pressure was 61/31, cardiac output was 2.6, cardiac
index was 1.29, systemic vascular resistance was 1323. In
general, the patient was lying flat in bed, face mask was in
place. In no acute distress. Head, eyes, ears, nose, and
throat revealed eyes were open, mouth was dry. Neck revealed
right cordis/Swan in place. Cardiovascular revealed a
regular rate and rhythm. Normal first heart sound and second
heart sound. A 3/6 systolic ejection murmur at the right
upper sternal border. Chest revealed decreased breath sounds
at the bilateral bases. The abdomen had positive bowel
sounds, soft, nontender, and nondistended. Extremities
revealed 2+ edema to the thighs bilaterally. Positive
ecchymoses on the bilateral knees and left ankle.
Neurologically, answered questions fully. Alert and oriented
times two. Moved all extremities.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories at
the time of admission revealed creatine kinase from the
outside hospital was 1347, troponin from the outside hospital
was 67. White blood cell count was 9.3, hematocrit was 31.6,
platelets were 233 (with a differential of 76 neutrophils,
11 lymphocytes, and 5 monocytes). PT was 17.6, PTT was 150,
INR was 2.1.
RADIOLOGY/IMAGING: Electrocardiogram revealed a normal
sinus rhythm at 88 beats per minute, leftward axis, biphasic
T waves, Q waves present in V1 through V4, and T wave
inversions in leads II, aVF, V3 through V6, with poor R wave
progression.
A chest x-ray from the outside hospital revealed decreased
lung volumes, right middle lobe and right lower lobe
infiltrates, with small bilateral pleural effusions.
HOSPITAL COURSE: The patient is an 80-year-old gentleman
with a history of coronary artery disease, status post
myocardial infarction, status post motor vehicle accident on
[**2-5**], who was initially treated for right ventricular
failure in the setting of myocardial contusion and discharged
to rehabilitation two days prior to presentation.
The patient returned to [**Hospital1 69**]
after suffering an acute episode of respiratory distress;
currently maintained on CPAP as well as a Neo-Synephrine
drip, and a pulmonary artery catheter [**Location (un) 1131**] suggested
cardiac shock.
CARDIOVASCULAR: Pump: The patient's initial low values of
cardiac output and cardiac index were consistent with
cardiogenic shock. Given the patient's elevated creatine
kinases and troponins, it was felt likely secondary to an
acute myocardial infarction.
Therefore, the patient was sent emergently to cardiac
catheterization for attempt at revascularization and
consideration of placement of an intra-aortic balloon pump.
In the meantime, the patient was continued on inotropic
support.
Cardiac catheterization revealed a 40% stenosis in the left
main, an 80% proximal stenosis of the left anterior
descending artery with diffuse mild-to-moderate disease in
the remainder of the vessel, and poor visualization of the
left circumflex which was known to have an 80% distal
stenosis, as well as a totally occluded right coronary artery
which was filled with collaterals. The proximal left
anterior descending artery lesion was treated with
percutaneous transluminal coronary angioplasty and an
intra-aortic balloon pump was successfully inserted in place.
During this time, the patient was weaned off of
Neo-Synephrine and started on a Milrinone drip. However,
still required a certain amount of Neo-Synephrine for blood
pressure maintenance. In addition, the patient was started
on amiodarone with a bolus in an effort to keep the patient
in a normal sinus rhythm. The patient was also continued on
heparin as well as [**Last Name (LF) 13860**], [**First Name3 (LF) **] post cardiac
catheterization procedure protocol.
The patient's elevated cardiac enzymes peaked on the
following day with a high of 1491 with a troponin of greater
than 50. Cardiac catheterization had revealed 3-vessel
disease too diffuse for intervention, more than a
percutaneous transluminal coronary angioplasty to the left
anterior descending artery. The patient was continued on
aspirin, heparin, and [**First Name3 (LF) 13860**] for 18 hours post procedure
and was started on Plavix on the following day.
Further cardiac evaluation suggested the patient was likely
volume overloaded, as his chest x-ray showed significant
evidence of congestive heart failure. After initiation of
the Milrinone drip, the patient's cardiac output and cardiac
index improved; likely also due in part to the placement of
the intra-aortic balloon pump. The patient continued to
weaned down on the Neo-Synephrine drip with a goal of
maintenance mean arterial pressures of greater than 55. In
addition, the patient continued to be in and out of atrial
fibrillation/atrial flutter, and it was known that the
patient was able to maintain much better blood pressures when
in sinus rhythm.
Over the next hospital day, the patient continued to
demonstrate labile blood pressures and required more
Neo-Synephrine as well as the addition of Levophed for
adequate blood pressure control. Eventually, Milrinone was
discontinued. However, the intra-aortic balloon pump was
continued at 1:1.
Over the next hospital day, the patient continued to require
inotropic support to maintain adequate blood pressures. He
continued to demonstrate a positive fluid balance, however,
with poor results to Lasix. The patient was continued on an
amiodarone drip and was able to maintain sinus rhythm with
occasional premature atrial contractions. However, the
patient continued to require the use of the intra-aortic
balloon pump to maintain his cardiac output as well as to
maintain adequate blood pressures.
After further discussions with his wife and the remainder of
the family, it was elected to discontinue the intra-aortic
balloon pump and make the patient do not resuscitate/do not
intubate, however, to continue other medical treatments.
Following discontinuation of the intra-aortic balloon pump,
the patient's blood pressure slowly dropped, and he was
switched to comfort measures only. The patient subsequently
expired at 5 p.m. on [**2130-2-15**].
2. PULMONARY: A chest x-ray obtained from the outside
hospital upon initial presentation demonstrated worsening
right lower lobe infiltrate suggestive of a pneumonia as well
as some component of congestive heart failure. The patient
was continued on Levaquin and Flagyl for a community-acquired
pneumonia and was treated with Lasix in an attempt to
initiate aggressive diuresis.
In addition, the patient was started on ceftazidime and
vancomycin out of concern for a possible hospital-acquired
pneumonia during his prior hospitalization.
Over the next two hospital days, the patient continued to
have an increasing oxygen requirement and demonstrated poor
urine output in response to Lasix therapy. The patient
continued to require increasing amounts of supplemental
oxygen, however, had been do not resuscitate/do not intubate
by his family.
After further discussion with the patient's wife and
discontinuation of the intra-aortic balloon pump, the patient
expired on [**2130-2-15**].
3. HEMATOLOGY: The patient was noted to have a low
hematocrit at the time of admission and was transfused one
unit of packed red blood cells, and serial hematocrits were
followed on a b.i.d. basis. The patient continued to require
transfusion support packed red blood cells over the remainder
of the hospital stay.
4. RENAL: The patient was noted to have an elevated blood
urea nitrogen and creatinine of 47 and 1.5 at the time of
admission which continued to rise over the remainder of his
hospital stay despite hopes of increasing urine output with
increasing cardiac output. Despite aggressive Lasix therapy,
the patient had poor diuresis and continued to maintain low
urine output.
5. CODE STATUS: The patient was initially do not
resuscitate, however, was not do not intubate at the time of
admission from the outside hospital. After a repeat cardiac
catheterization and further discussions with the patient's
family with regard to the patient's wishes, it was determined
to make the patient do not resuscitate/do not intubate.
As the patient maintained in severely critical condition
despite optimal therapy over the next few hospital days,
further discussions were had with the patient's wife who
decided to discontinue the intra-aortic balloon pump as well
as any further invasive measurements. As further medical
therapies were insufficiency to be able to reverse the
patient's condition, the patient expired at 5 p.m. on
[**2130-2-15**].
The patient's family was notified, and an autopsy was
refused.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2130-9-14**] 14:07
T: [**2130-9-21**] 08:26
JOB#: [**Job Number 40184**]
|
[
"41401",
"42731",
"5070",
"4280"
] |
Admission Date: [**2109-11-24**] Discharge Date: [**2109-12-1**]
Date of Birth: [**2079-2-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catherization
central line (Cordis) placement with Swan-Ganz
History of Present Illness:
30 YOM with no pmh, p/w to OSH on [**11-23**] with mid-sternal CP,
[**10-12**] in severity in the setting of cocaine and alcohol use. He
also was taking Klonopin (not prescribed to him, obtained from
friends) the days prior to presentation. In OSH ED, his initial
vitals were 38 128 120/67 24 98% on 15L NRB 97.5kg. He was
noted to have STE in the anterior leads on the ECG. He had an
episode of seizure like activity and went into PEA which after
CPR converted to torsade/VF. He was given 4g of Magnesium and
was shocked back to normal rhythm. Total time was approx. 15
minutes. He also recieved 6mg Ativan, 324 ASA, lidocaine bolus,
integrillin load and gtt, heparin load and gtt, and was placed
on nitro gtt. He has a L tibial osteo-line. FSG was 210.
Other pertinent labs were: Na of 145, K 3.5, HCO3 18, Ca 9.8,
creatinine 1.5, Glucose 176, WBC 21.6, Hct 47.8, CK 382, MB 3.7,
trop 0.01, toxic screen was negative.
.
On transfer to [**Hospital1 18**] ED, he was noted to: 103 99/73 16 100% NRB.
He was given phentolamine x1, sent to cath lab. He was noted
to have a a prox. LAD thrombus with complete occlusion that
resolved with suction.
.
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:
1. CARDIAC RISK FACTORS: Diabetes (-), Dyslipidemia (-),
Hypertension (-)
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY: none.
Social History:
-Tobacco history: yes
-ETOH: yes
-Illicit drugs: yes
Family History:
+ father and sister - protein S deficiency, father had early
strokes in his 40's, HTN.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: WDWN, in NAD. disoriented.
HEENT: NCAT, bloody sclera. PERRL, EOMI. Conjunctiva were pink,
no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Pertinent Results:
[**2109-11-29**] 06:04AM BLOOD WBC-10.0 RBC-3.91* Hgb-11.9* Hct-34.4*
MCV-88 MCH-30.4 MCHC-34.6 RDW-14.2 Plt Ct-250
[**2109-11-24**] 04:29AM BLOOD Neuts-90.0* Lymphs-7.2* Monos-2.5 Eos-0
Baso-0.3
[**2109-11-29**] 06:04AM BLOOD PT-18.2* PTT-52.4* INR(PT)-1.6*
[**2109-11-29**] 06:04AM BLOOD Glucose-98 UreaN-19 Creat-1.0 Na-137
K-4.1 Cl-102 HCO3-22 AnGap-17
[**2109-11-29**] 06:04AM BLOOD CK(CPK)-5435*
[**2109-11-28**] 06:29AM BLOOD ALT-48* AST-133* LD(LDH)-1103*
CK(CPK)-9112* AlkPhos-37* TotBili-0.8
[**2109-11-26**] 03:02PM BLOOD CK(CPK)-8561*
[**2109-11-25**] 08:26PM BLOOD CK(CPK)-4287*
[**2109-11-24**] 08:11AM BLOOD ALT-128* AST-811* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-46 TotBili-1.4
[**2109-11-24**] 04:29AM BLOOD CK(CPK)-7946*
[**2109-11-29**] 06:04AM BLOOD CK-MB-5
[**2109-11-26**] 01:54AM BLOOD CK-MB-11* MB Indx-0.2
[**2109-11-25**] 06:43AM BLOOD CK-MB-58* MB Indx-1.3 cTropnT-12.07*
[**2109-11-24**] 03:59PM BLOOD CK-MB-315* MB Indx-3.6
[**2109-11-24**] 04:29AM BLOOD CK-MB-493* MB Indx-6.2* cTropnT-22.18*
[**2109-11-29**] 06:04AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.2
[**2109-11-24**] 08:11AM BLOOD Triglyc-61 HDL-31 CHOL/HD-4.9 LDLcalc-110
LDLmeas-109
.
c cath
COMMENTS:
1- Selective coronary angiography of this right-dominant system
demonstrated acute thrombotic occlusion of the proximal LAD and
TIMI 0
flow throuhghout the LAD system beyong the occlusion. The LCX
and RCA
were free from angiographic disease.
2- Limited resting hemodynamic assessment showed markedly
elevated
left-sided filling pressures (mPCWP 25 mmHg), normal right-sided
filling
pressures (RVEDP 5 mmHG), mild pulmonary HTN (36/26 mmHg) and
preserved
cardiac output (5.3 L/min) and cardiac index (2.5 L/min/m2).
3- Successful percutaneous thrombectomy of the LAD and diagonal
with
restoration of TIMI 3 flow. Final angiography showed no stenotic
lesions
at the thrombus site. No dissection or distal emboli.
4- Successful deployment of a 6 French Angioseal to the RCFA.
.
FINAL DIAGNOSIS:
1. Complete thrombotic occlusion of the proximal LAD.
2. Successful percutaneous thrombectomy of the LAD and diagonal
branch
3. Successful deployment of a 6 French Angioseal closure device
.
TTE
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction with akinesis of the mid
to distal anterior wall, anterior septum and lateral wall. The
basal anterior and anteroseptal, distal inferior and
inferolateral segments are hypokinetic. A left ventricular
thrombus cannot be excluded. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
.
IMPRESSION: Severe focal LV systolic dysfunction consistent with
large LAD territory infarction. No significant valvular
abnormality seen. EF 20%
Brief Hospital Course:
In brief, this is a 30 year old man with history of cocaine
abuse who presented with STEMI and found to have a LAD thrombus.
His STEMI was associated with cocaine and ETOH use. He is
currently s/p thrombectomy. His post cath course was
complicated by cardiogenic shock and a Swan-Ganz was placed for
monitoring. His shock improved with furosemide diuresis and
afterload reduction with ACEI. He was also noted to have mild
respiratory distress that was atributed to a combination of
pulmonary edema and atelectasis. Also, the patient experienced
two episodes of emesis while hospitalized and there was concern
for aspiration pneumonia. He was empirically treated with
levofloxacin and metronidazole. His respiratory status improved
with these interventions. Post catheterization the patient was
mantained on therapeutic anticoagulation with heparin gtt and
bridged to warfarin. The reason for this intervention was his
low EF of 20% with anterior/apical akinesis and subsequent
concern for LV thrombosis. Of note, upon initial presentation
to OSH ED, he experienced a cardiac arrest with torsades de
pointes/VF, which was treated with defibrillation and magnesium.
He remained in sinus rhythm during this hospitalization. Given
his ETOH abuse he was maintained on a diazepam scale for
withdrawl symptoms. The medical regimen on discharge includes
ASA, metoprolol, lisinopril, clopidogrel, atorvastatin,
epleronone, furosemide and warfarin. He was strongly advised to
abstain from cocaine and alcohol abuse in order to prevent
further morbitity. Dr. [**Last Name (STitle) **], the patient's PCP, [**Name10 (NameIs) **] notified
via email of this hospitalization.
Medications on Admission:
N/A
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): for one month.
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Eplerenone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO QAM (once a day (in
the morning)).
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*90 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- ST-elevation myocardial infarction
- acute systolic heart failure
- cardiogenic shock
Secondary Diagnoses:
- substance abuse
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were seen at [**Hospital1 18**] for heart attack complicated by shock and
fluid in the lungs. You were hospitalized in the intensive care
unit for several days, during which time we were able to improve
your breathing and heart function.
At discharge, your heart function is at approximately one-third
of normal from your heart attack. We believe your heart attack
was likely due to your substance abuse. In the future, it is
vitally important that you abstain completely from all illicit
drugs as well as smoking. You will need to continue to follow
up with a cardiologist regularly as well as your primary
physician in order to adjust your medications. These
medications are very important in order to preserve your
remaining heart function.
You will need to weigh yourself daily in order to assess for
fluid retention. If you gain greater than [**2-5**] lbs. suddenly,
notify your PCP as this could indicate your heart failure is
worsening.
The following medications have been changed:
ADDED aspirin for your heart
ADDED atorvastatin for your heart
ADDED plavix for your heart
ADDED eplerenone for your heart
ADDED furosemide to remove excess fluid
ADDED lisinopril for your heart
ADDED metoprolol succinate for your heart
ADDED warfarin to prevent blood clots
Please DO NOT TAKE your warfarin today. Start tomorrow
([**2109-12-2**]). Take all other medications as prescribed.
If you experience fevers, shortness of breath, chest pain, or
any other symptoms that concern you, please contact your PCP or
go to the Emergency Room.
Followup Instructions:
You will need to follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], in one week. At that time, you will need to have your
blood checked to see if it is appropriately thinned from the
warfarin. This medication may need to be adjusted. You can
contact his office at [**Telephone/Fax (1) 1144**] to set up an appointment.
You will need to follow up with Dr. [**Last Name (STitle) **] for your cardiology
follow-up. This follow up is being scheduled for you. You will
be contact[**Name (NI) **] with the date of your appointment. If you are not
notified within 3-4 days as to the date of your appointment,
please [**Telephone/Fax (1) 62**] to set up an appointment in [**3-6**] weeks.
Completed by:[**2109-12-1**]
|
[
"5070",
"5180",
"4280"
] |
Admission Date: [**2200-6-1**] Discharge Date: [**2200-6-3**]
Date of Birth: [**2122-3-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
body pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78y/o F h/o diabetes, chronic back pain, recurrent SBO requiring
multiple surgeries who presents to the ED with hypotension after
reported fall. Admitted to ICU for monitoring of hypotension.
Pt was seen recently in the ED [**5-30**] for left wrist pain and
itching after splinted [**5-27**] from fall-related ulnar and distal
radius fractures. She had been feeling alright at home but today
felt fatigue, nausea, diffuse body aches and joint aches, with
subjective fevers at home. She had some mild headache but no
altered mental status/confusion or neck stiffness to suggest
meningitis. Patient may have had another fall last night.
.
ED course:
V/s: 97.6 109 127/74 20 95% on 2L NC. Developed fever to 102
(oral).
Pt was noted to have a nonproductive cough.
Interventions:
Pt was given morphine at 10:30 AM for total body aches. Also
given CTX, azithro, nebs for possible PNA and 2L IVF. Pt then
triggered for hypotension to 85 systolic from previous pressures
in 150s, moved from the periphery to the core and given an
additional 2L IVF NS along with vancomycin. Pt received 125mg
methylpred for wheezing. Flu swab sent. After total 4L sbp in
low-mid 90s.
.
On arrival to the ICU, pt noted to be extremely somnolent which
had not been noted before. Could barely whisper her first name
and only opened her eyes for several seconds in response to
sternal rub and voice commands. Pt received 0.4mg narcan and
immediately became more alert, crying out that she was cold and
that her back was cold. Denied pain. Would not answer any
history questions other than , did not know the year. did know
that she was in the hospital and that it was [**Hospital3 **]. Pt was
also administered another liter of NS.
.
Spoke with Pts son who states that she has become increasingly
depressed although fully functional still at home. In the last
year bought a cemetery plot and whenever something happens to
her for example her recent wrist fracture she goes and visits
the plot.
.
Review of systems: unable to obtain fully, pt altered. Son saw
her day before yesterday and denies that she complained of the
following or that he noted any of the following.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
PMHx: DM, obesity, HTN, asthma, OA, jejunal divertic,
peritonitis, perforated viscus, chronic back pain, plantar
fasciitis
.
PSHx: Ex-lap/LOA, trigger finger, SBR, jujunal diverticulotomy,
TAH/BSO, tubal ligation
He surgical history began with a perforated
jejunal diverticulim in [**2191**]. Since that time she has required
multiple Exlaps, LOA for SBOs.
Social History:
- Tobacco: remote
- Alcohol: remote
- Illicits: none
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.5 (tylenol in ED) BP:103/52 P:83 R:21 O2: 99%RA
General: lethargic but arousable (for brief intervals) not
responding verbally appropriately, does not follow commands or
answer questions although oriented to her own name.
HEENT: Sclera anicteric, MMM, oropharynx clear but dry mucous
membranes
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse rhonchorous breath sounds
CV: tachycardic, 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 present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2200-6-1**] 10:25AM BLOOD WBC-12.1* RBC-3.84* Hgb-11.7* Hct-36.2
MCV-94 MCH-30.3 MCHC-32.2 RDW-12.9 Plt Ct-300
[**2200-6-1**] 10:25AM BLOOD Neuts-83.8* Lymphs-6.9* Monos-5.3 Eos-3.6
Baso-0.4
[**2200-6-1**] 11:52AM BLOOD PT-11.8 PTT-28.8 INR(PT)-1.1
[**2200-6-1**] 10:25AM BLOOD Glucose-188* UreaN-12 Creat-0.7 Na-132*
K-4.3 Cl-97 HCO3-24 AnGap-15
[**2200-6-1**] 10:25AM BLOOD ALT-32 AST-43* AlkPhos-74 TotBili-0.3
[**2200-6-1**] 10:25AM BLOOD Lipase-25
[**2200-6-1**] 10:25AM BLOOD proBNP-136
[**2200-6-1**] 10:25AM BLOOD cTropnT-<0.01
[**2200-6-1**] 10:25AM BLOOD Albumin-3.9
[**2200-6-1**] 06:35PM BLOOD TSH-0.37
[**2200-6-1**] 10:25AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS
Barbitr-NEG Tricycl-NEG
[**2200-6-1**] 05:47PM BLOOD Type-ART pO2-109* pCO2-35 pH-7.39
calTCO2-22 Base XS--2
[**2200-6-1**] 10:28AM BLOOD Lactate-1.3
[**2200-6-1**] 01:37PM BLOOD Lactate-0.9
[**2200-6-1**] 05:47PM BLOOD Lactate-0.8 Na-137 K-3.7 Cl-108
[**2200-6-1**] 05:47PM BLOOD freeCa-1.10*
Brief Hospital Course:
78 y/o F h/o DM, multiple abdominal surgeries for SBOs, OA,
falls, presents with hypotension and fever, admitted to the [**Hospital Unit Name 153**]
for hypotension, found to have altered mental status.
#AMS - on arrival to the [**Hospital Unit Name 153**] noted to be lethargic not
responding well to commands, oriented only to name. Mental
status improved with one dose of narcan, making medication
effect likely source of AMS as patient had received morphine in
ED, in addition to home morphine/oxycodone. In addition,
patient had received medications during her observation stay in
the Emergency Room just a day prior to this admission. She
insists that her chronic pain medications were not the cause of
her change in mental status and her hypotension, but rather that
the additional medications she received in the ED during her
observation stay were culprit. SHe insisted on being very
responsible regarding her medications. As medications have worn
off, patient is now awake and alert. Head CT negative for
subdural in the setting of fall. Patient was febrile in the ED,
but is now hemodynamically stable without other fevers and CXR
negative for pneumonia, making infection unlikely source of AMS.
Patient remained lucid for the remainder of the admission,
and was seen to be extremely anxious to go home.
#hypotension: Patient with hypotension to SBP 80s in the ED
(baseline SBP 110-160). BP now stable in 120??????s since admission
to the ICU. Given blood pressure normalized following clearance
of opioids, likely opioid-induced. No further evidence of
infection to support sepsis as etiology. Troponin x 2 negative
for evidence of cardiac ischemia. Systolic blood pressures
started to rise to 150 at the time of discharge so patient was
instructed to continue all of her home antihypertensives.
#h/o asthma
- pt was reportedly wheezy in ED. s/p 125mg solumedrol. Lungs
clear for the remainder of the admission.
#h/o anxiety - holding home diazepam in setting of AMS, but
patient was clearly anxious to be discharged from the hospital,
and insisted on repeating every detail of her history.
#h/o left wrist fracture - on long acting morphine and oxycodone
at home. in setting of AMS and lethargy/unresponsiveness, these
medications were initially held. However, these are patient's
long standing medications, so she will continue to use them, as
they have not caused lethargy or change in mental status in the
past. Vitamin D level ordered and is pending at time of
discharge.
#chronic back pain- patient to resume home medications on
discharge
Medications on Admission:
Medications: per pcp [**Name Initial (PRE) 626**] [**2200-5-16**]
Medications - Prescription
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 vial inhaled four times a day as needed for
shortness of breath
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 (Two)
puffs(s)
inhaled q 4h for one month then qid as needed for as needed for
asthma - No Substitution
BETAMETHASONE DIPROPIONATE - 0.05 % Cream - apply [**Hospital1 **] twice a
day
as needed for itching
CHLOROQUINE PHOSPHATE - 250 mg Tablet - 1 Tablet(s) by mouth
twice a week
CLONIDINE - 0.1 mg Tablet - 1 Tablet(s) by mouth twice a day
CLOTRIMAZOLE - 1 % Cream - APPLY TO FEET ONCE A DAY ONCE A DAY
as
needed for FUNGAL INFECTION DISCONTINUE IF YOU EXPERIENCE ANY
ADVERSE REACTIONS OR RASHES
DIAZEPAM - 5 mg Tablet - 1 Tablet(s) by mouth qhs prn
FLUTICASONE - 50 mcg Spray, Suspension - 1 puff(s) each nostril
twice a day for allergies/running nose
FLUTICASONE - 0.05 % Cream - apply to affected area twice a day
as needed for pruritis
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff po twice a day for asthma
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day for
swelling and blood pressure
GABAPENTIN - 600 mg Tablet - 1 Tablet(s) by mouth three times a
day for neuropathy
GLIPIZIDE - 10 mg Tablet - 1 Tablet(s) by mouth once a day for
sugar
HYDROXYZINE HCL - 25 mg Tablet - 1 Tablet(s) by mouth three
times
a day as needed for itching
IPRATROPIUM-ALBUTEROL - 0.5 mg-2.5 mg/3 mL Solution for
Nebulization - 1 vial inhaled three times a day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day for
blood pressure
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth 2 q pm for
diabetes (also called GLUCOPHAGE)
MORPHINE - 30 mg Tablet Extended Release - 1 Tablet(s) by mouth
twice a day as needed for pain
OLOPATADINE [PATANOL] - 0.1 % Drops - 1 drop eqch eye twice a
day
OXYCODONE - 15 mg Tablet - 1 Tablet(s) by mouth three times a
day
as needed for pain
POLYETHYLENE GLYCOL 3350 - 17 gram Powder in Packet - 1
packet(s)
by mouth qd, as needed for hard stool
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth at bedtime for
cholesterol
SERTRALINE - 50 mg Tablet - 1 Tablet(s) by mouth once a day for
sadness, depression also called ZOLOFT
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for sleep
.
Medications - OTC
ACETAMINOPHEN - 500 mg Tablet - 1 Tablet(s) by mouth three times
a day as needed for pain also called TYLENOL
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
CARBAMIDE PEROXIDE - 6.5 % Drops - 3 drops(s) to right ear daily
as needed to soften ear wax
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s)
by mouth DAILY (Daily)
DEXTRAN 70-HYPROMELLOSE - Drops - 1 drop both eyes twice a day
DEXTRAN 70-HYPROMELLOSE [ARTIFICIAL TEARS] - Drops - 1 drop OU
four times a day as needed for eye irritation
bedtime as needed for constipation
NEOMYCIN-POLYMYXIN-PRAMOXINE [ANTIBIOTIC + PAIN RELIEF] - 0.35
%-10,000 unit-[**Unit Number **] mg/gram Cream - apply to biopsy site tid-qid
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day for acid
POLYVINYL ALCOHOL - 1.4 % Drops - 1 gt ou three times a day
SENNOSIDES [SENNA] - 8.6 mg Capsule - [**2-10**] Capsule(s) by mouth
once a day as needed for constipation - No Substitution
WHITE PETROLATUM-MINERAL OIL - Cream - pply to feet and hands
bidd as needed for dry, cracking skin
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
3. Patanol 0.1 % Drops Sig: 1 drop Ophthalmic twice a day: for
both eyes.
4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO qhs prn as
needed for insomnia.
11. Valium 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea,
wheezing.
13. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for itching.
14. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day as needed for pain.
15. oxycodone 15 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
16. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
17. polyethylene glycol 3350 Powder Sig: 1 pouch
Miscellaneous once a day.
18. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
three times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Sedation, hypotension, from medication effect
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with sedation and low blood
pressure, and this appears to have been caused by medications
that you received in the Emergency Room for your wrist pain.
Your blood pressures are now normal and you are in stable
condition. You may continue to take all of your home
medications.
Followup Instructions:
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: MONDAY [**2200-6-9**] at 10:45 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 8268**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
*Dr. [**Last Name (STitle) **] works with Dr. [**Last Name (STitle) 8499**]
|
[
"4019",
"49390"
] |
Admission Date: [**2146-6-3**] Discharge Date:
Date of Birth: [**2069-3-20**] Sex: M
Service: CME
CHIEF COMPLAINT: Chest pain.
He is a 72-year-old man with history of coronary disease
status post CABG in [**2128**], multiple percutaneous
interventions, aortic stenosis, and chronic neck pain, who
was in his usual state of health until 3:30 in the morning,
when he woke up with his usual neck pain, however, at this
time it spread to his chest and both his arms. He described
the pain as substernal and [**6-16**] in intensity. He thought it
was his chronic neck condition and took four Tylenol without
relief. The pain persisted and then worsened. The patient
went to [**Hospital6 4620**] at 6 in the morning, and
was found to have to have ST elevations in his inferior
leads. He was started on aspirin, Heparin drip,
nitroglycerin drip, tirofiban drip, and was transferred to
[**Hospital3 **] with continued pain.
He then underwent cardiac catheterization, which revealed a
normal left main with a previous stent patent. The LAD was
occluded proximally. The left circumflex had a previous
stent that was patent. There was also noted to be a 50
percent tubular lesion distal to the stent without change in
[**2143**]. The RCA was not injected as it was known to be
occluded. The SVG to the OM was nonoccluded. The SVG to the
RCA was occluded proximally and the LIMA to the LAD was not
injected. The patient had two AngioJets to the saphenous
vein graft. The patient had a total of five stents to the
SVG. Patient was then transferred to the CCU for further
intensive monitoring.
MEDICATIONS ON ADMISSION:
1. Procardia XL 30 mg p.o. q.d.
2. Allopurinol.
3. Hydrochlorothiazide (unclear dose).
4. Zocor.
5. Ambien.
6. Folate.
7. Vitamin B.
8. Vitamin E.
9. Hydralazine (unclear dose).
10. Prilosec.
ALLERGIES: Niacin, which causes hypouricemia.
Elavil, which causes agitation.
Propanolol, which causes anxiety.
Questionable history to Lipitor, which causes elevated CK's.
PAST MEDICAL HISTORY: Coronary artery disease status post
CABG in [**2128**]. At this time, he had a LIMA to the LAD, SVG to
the D1, a SVG graft to the OM, and a SVG graft to the RCA.
In [**2136**], the patient had recurrent chest pain with the D1 and
OM grafts down. At that time, he had a left main PTCA for 80
percent stenosis. In [**2141**], the patient had recurrent chest
pain, and his left main was restented. In [**2142**], the patient
had chest pain, and his SVG to the PDA was stented. The left
main also had some restenosis and that was stented.
Severe aortic stenosis with a valve area of 0.7.
hypercholesterolemia.
Hypertension.
Gout.
Peripheral neuropathy.
Right total knee replacement.
Upper GI bleed secondary to NSAID use.
Nephrolithiasis.
SOCIAL HISTORY: The patient does not smoke tobacco. He is
married with two children. He works as an architect.
FAMILY HISTORY: Is only remarkable for a MI in his mother at
age 59 after hiatal hernia surgery.
PHYSICAL EXAMINATION: Temperature 95.1, heart rate of 41,
blood pressure 158/68, and he was saturating 97 percent on 2
liters. His exam was only remarkable for a grade [**3-12**] harsh
systolic ejection murmur at the left mid sternal border.
An EKG from the outside hospital showed sinus bradycardia at
50 with a first degree A-V prolongation. There was [**Street Address(2) 4793**]
depressions in I. There were [**Street Address(2) 1766**] depressions in II and [**Street Address(2) 8206**] elevations in III and F. There is also T-wave
flattening in V6 and Q waves in III and F.
A potassium was 3.0. CK was 317. MB was 17 and troponin was
0.11 initially.
HOSPITAL COURSE: Patient was monitored after his stenting x5
of the SVG to the RCA. He was continued on aspirin and
Plavix. Patient denied any subsequent chest pain after the
procedure. Patient had a peak CK of 1317. His home blood
pressure medicines were held, and the patient was started on
captopril for blood pressure control. He was not started on
a beta blocker as he had some sinus bradycardia. The
captopril was titrated up during his hospital stay. His
primary cardiologist, Dr. [**Last Name (STitle) **] can determine if he should
remain on this blood pressure medicine in the future,
however, given patient's known coronary disease, it is
reasonable for him to continue on this as it has a mortality
benefit.
During the [**Hospital 228**] hospital course, he denied any
subsequent chest pain. It was thought that his sinus
bradycardia was likely secondary to his IMI.
I will dictate the remainder of the [**Hospital 228**] hospital course
as an addendum.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 106002**]
Dictated By:[**Doctor Last Name 10457**]
MEDQUIST36
D: [**2146-6-6**] 17:20:51
T: [**2146-6-7**] 11:42:54
Job#: [**Job Number 106003**]
|
[
"41071",
"4241",
"2720",
"4019",
"41401"
] |
Admission Date: [**2107-9-9**] Discharge Date: [**2107-10-4**]
Date of Birth: [**2046-7-15**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape / Percocet
Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
Altered mental status, tachycardia
Major Surgical or Invasive Procedure:
Lumbar puncture attempted [**9-11**]
History of Present Illness:
HPI obtained from patient, medical records and brother.
Ms. [**Known lastname 68938**] is a 61F with pancreatic adenocarcinoma s/p Whipple
[**2102**] now with metastatic recurrence to liver s/p placement of
biliary stents x 2 [**2-/2107**] currently undergoing chemotherapy
cycle 2 Day 17 capecitabine/oxaliplatin admitted with altered
mental status.
Per brother who lives with patient, she woke up this am around 9
and initially seemed normal but he realized within approxiamtely
one hour around 9am that she was having balance and gait
difficulty as well as difficulty speaking coherently and in
complete sentences. She was also repeating phrases. He did not
note slurred speech. This episode was similar to although less
severe than prior episode in [**Month (only) **] attributed to narcotics.
Since last admitted [**Date range (1) 68940**], he has been monitoring her
narcotic use and she has only take dilaudid 2mg PO x 2 and
morphine 15mg PO x 1 last 24 hours. She also took compazine,
zofran, and meclizine. He does not think she took any other
narcotics or had any other ingestions. She has had no new
medications other than recently being restarted on lasix.
Otherwise, he states she developed dry cough today and has had
rash/sores on lower extremitites since right after she started
2nd cycle of chemo but denies fever, chills, any recent change
in lower extremity edema.
In the ED, initial vs were: 98.2 118 183/76 18 97%RA. Exam was
significant for confusion, asterixis, and erythema bilateral R>L
LEs concerning for cellulitis. CT head was unremarkable and CXR
revealed small to mdoerate right pleural effusion. She received
Vancomycin, Azithromycin and Ceftriaxone for pulmonary vs
skin/soft tissue infection, lactulose for asterixis and elevated
ammonia and potassium for hypokalemia K 3.1. She was reportedly
persistently tachycardic sinus with HR 130s despite 1.5L IVF.
There was concern she would trigger on the floor so she was
admitted to MICU. VS prior to transfer: 98.2 157/55 121 30
98%RA.
On the floor, she states "I'm fine, thank you" repeatedly or
"I'm ok". She perseverates on words and repeats phrases. Her ROS
is completely negative.
Past Medical History:
ONCOLOGIC HISTORY:
- diagnosed with pancreatic adenocarcinoma in [**2102**], in the
context of an 80 lb. weight loss
- [**2103-10-9**] Whipple --> well differentiated T3N0 tumor.
- adjuvant chemoradiation with Xeloda and standard external beam
radiotherapy, completed in [**2104-1-17**]
- 4 cycles of adjuvant Gemcitabine chemotherapy with the final
dose on [**2104-6-25**]
- [**1-25**] adnexal mass on surveillance imaging
- [**3-27**] obstructive jaundice, dual biliary drains placed; she was
found to have recurrent adenocarcinoma
- [**2106-5-24**] TAH/BSO: adnexal mass was thought to be metastatic
pancreatic ca
- [**2106-7-14**] palliative chemotherapy with Gemzar three out of four
weeks
- dose was reduced by 25% with her third cycle, due to
thrombocytopenia, but she was still unable to get the third of
three doses
- starting with her fourth cycle she received Gemzar on two of a
three week cycle
- last dose of gemcitabine given on [**2107-6-8**]
- Started Xelox on [**2107-8-3**], currently C1D13
PAST MEDICAL HISTORY:
- 2 metal biliary stents placed on [**2107-3-11**]
- h/o asthma/rhinitis
- hypertension: currently resolved, as per pt
- L4-L5 fusion: fell 10 years ago and broke L4
- cholecystectomy 3 years ago
- duodenal ulcer (per patient): resected as part of Whipple
surgery
- recurrent pancreatitis
- hives (treated with benadryl prn)
- h/o C. difficile
Social History:
The patient lives with her brother. She was previously caring
for her elderly father but he passed away recently. Before
caring for her father, she worked as a medical technologist in
the blood bank at both [**Hospital1 1774**] and the [**Hospital1 **] hospitals. She
denies ever using IV drugs. No EtOH or tobacco. Uses walker at
baseline.
Family History:
Father with type I DM, several other family members with type 2
DM. No family history of pancreatitis or pancreatic cancer. Her
mother had endometrial cancer and her father's mother had
cervical cancer. Her maternal aunt had cancer of some type.
Physical Exam:
ADMISSION PHYSICAL EXAM
General: Appears scared, intermittently crying, agitated,
gripping siderails, only oriented to brother's name. Does not
state her own name, states she is at "[**Hospital6 **]" and
unable to state date, year or month.
HEENT: Sclera anicteric, MM dry, no thrush or mucositis,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Faint crackles R base and occ scant exp wheezes.
CV: Tachycardic. Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops. + pericardial rub.
Abdomen: soft, tender periumbilically whic pateint states is
old, slightly distended, bowel sounds present, no rebound
tenderness or guarding, enlarged liver and spleen palpated just
below costal margin
Ext: 3+ pitting edema B/L ;warm, well perfused, 2+ pulses, no
clubbing, cyanosis
Skin: Erythematous papular rash anterior shin with left more
confluent with surrounding erythem and warmth
Neuro: Able to raise both arms symmetrically. No pronator drift.
+ asterixis. PERRL although dilated approx 5->4mm. Tongue
protrusion midline. Moving lower extremitites symmetrically.
Follows some commands.
DISCHARGE PHYSICAL EXAM
General: NAD, alert and oriented x 3
HEENT: Sclera anicteric,
Lungs: clear to auscultation anteriorly bilaterally, limited
posterior exam given pt's difficulty/pain with sitting up and
turning
CV: Regular rate and rhythm, no murmurs, rubs, gallops.
Abdomen: mildly distended, mild tenderness in epigastric region,
no rebound tenderness or guarding, + ascites,
Skin: no erythema, 1+ edema bilaterally
GU: erythematous groin/buttock rash
Back: no rash evident
Pertinent Results:
[**2107-9-9**] 07:11PM LACTATE-3.6*
[**2107-9-9**] 07:12PM AMMONIA-142*
[**2107-9-9**] 07:15PM PT-18.1* PTT-25.8 INR(PT)-1.6*
[**2107-9-9**] 07:15PM PLT SMR-NORMAL PLT COUNT-172
[**2107-9-9**] 07:15PM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ PENCIL-1+
[**2107-9-9**] 07:15PM NEUTS-62 BANDS-0 LYMPHS-23 MONOS-15* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2107-9-9**] 07:15PM WBC-4.2# RBC-2.93* HGB-9.1* HCT-27.1* MCV-93
MCH-31.1 MCHC-33.6 RDW-24.5*
[**2107-9-9**] 07:15PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2107-9-9**] 07:15PM TSH-2.6
[**2107-9-9**] 07:15PM OSMOLAL-278
[**2107-9-9**] 07:15PM calTIBC-168* FERRITIN-405* TRF-129*
[**2107-9-9**] 07:15PM ALBUMIN-3.0* CALCIUM-8.3* PHOSPHATE-3.1
MAGNESIUM-1.7 IRON-79
[**2107-9-9**] 07:15PM LIPASE-14
[**2107-9-9**] 07:15PM ALT(SGPT)-19 AST(SGOT)-48* LD(LDH)-327* ALK
PHOS-129* TOT BILI-1.4
[**2107-9-9**] 07:15PM estGFR-Using this
[**2107-9-9**] 07:15PM GLUCOSE-114* UREA N-18 CREAT-1.1 SODIUM-134
POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-21* ANION GAP-15
[**2107-9-9**] 08:40PM URINE MUCOUS-FEW
[**2107-9-9**] 08:40PM URINE HYALINE-[**4-28**]*
[**2107-9-9**] 08:40PM URINE RBC-[**10-8**]* WBC-[**4-28**]* BACTERIA-FEW
YEAST-NONE EPI-[**4-28**]
[**2107-9-9**] 08:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR
[**2107-9-9**] 08:40PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2107-9-9**] 08:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2107-9-9**] 08:40PM URINE UHOLD-HOLD
[**2107-9-9**] 08:40PM URINE HOURS-RANDOM
Brief Hospital Course:
61F with metastatic pancreatic cancer on palliative chemotherapy
admitted to ICU [**9-9**] for altered mental status and tachycardia,
found to have cellulitus, who developed GI bleed and oliguria
during hospital course, with transfer to oncology floor [**9-13**],
discharged to [**Hospital1 1501**] [**10-4**].
# Altered Mental Status: Most likely secondary to infection vs
med effect. Sources of infection include lower extremity
cellulitus vs C diff as outlined below. No fevers. Head CT on
admission negative. Patient has had recent admission for similar
complaint attributed largely to medication effect although
narcotic regimen was reduced at that time. On admission, TSH
1.1, folate 15.1, B12 1111 [**2107-8-16**]. Narcotics were withheld
initially and her mental status gradually improved. She is A&O
x 3 on discharge. Her pain regimen at discharge consists of
Morphine SR (MS Contin) 15 mg PO Q12H, tylenol prn pain, and
oxycodone 5 mg q6 prn severe pain.
.
# GIB: Pt developing maroon stools morning of [**9-10**] x1 and an
episode of bloody emesis later that day. Received 1 U and
vitamin K. Hct remained stable at 28.4. GI was consulted and
recommended conservative management with no need for
endoscopy/colonoscopy. Of note, pt with hx of diverticulosis,
and hemmorhoids on prior c-scope which could be contributing
cause of GI bleed. No further episodes of GI bleeding
throughout hospital course. Hcts stable.
.
# Oliguria: Patient developed oliguria prior to transfer from
[**Hospital Unit Name 153**] to the floor on [**9-13**]. Likely in setting of GIB and blood
loss. Pt with poor urine output despite multiple fluid boluses
and maintenance fluids. She was > 11L positive for LOS upon
transfer from [**Hospital Unit Name 153**] to floor. Cr also elevated. Renal team was
consulted and recommended aggressive diuresis. She was
initially diuresed with lasix and after an initial Cr bump, her
oliguria resolved and her Cr trended down. She had low
potassium levels and was switched from lasix to torsemide.
Spironolactone as added as well. She was placed on standing
potassium supplements. Will discharge on tosemide,
spironolactone, and potassium. Please check potassium levels in
1 week and adjust accordingly.
.
# Sinus Tachycardia: Tachycardic on admission to [**Hospital Unit Name 153**]. Likely
multifactorial secondary to anxiety/pain, hypovolemia, infection
with sources of infection including cellulitis and PNA. No
leukocytosis or fever. TSH 2.6. LENIs negative. Resolved as
infxn was treated.
.
# Rash: Patient reportedly developed sores on lower extremities
after starting 2nd cycle of chemo. RLE also appeared
superinfected as it was warm and mildly TTP c/w cellulitis.
Capecitabine also causes rash in 27-37% of patients. resolving
on right leg and slightly worsening on left. Completed course
of bactrim/dicloxacillin for cellulitis. Resolved prior to
discharge.
.
# LE edema: Bilateral lower extremity edema. Unclear baseline.
Diuresed as above. Continues to have LE edema upon discharge.
.
# Metastatic pancreatic cancer: On admission, was on cycle 2
palliative chemo capecitabine/oxaliplatin. Outpatient
oncologists Dr. [**Last Name (STitle) **] and [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 11309**] were contact[**Name (NI) **] and
saw patient intermittently during hospital stay. No further
chemotherapy. Patient intermittently complains of abdominal
pain that is abated with redirection and/or tylenol.
.
#Ascites: likely secondary to metastatic pancreatic cancer as
well as volume overload. A diagnostic paracentesis was
performed and was negative for infection and malignancy.
Patient intially had blood discharge from site of paracentesis,
which resolved over several days. Further paracentesis for
therapeutic benefit was not performed given prognosis and lack
of respiratory or severe abdominal symptoms.
# Pleural effusion: Patient has new right pleural effusion and ?
pneumonia on CXR but no focal infiltrate and no fever or
leukocytosis. Lack of cough, SOB, or sputum production also
argued against PNA. Could be secondary to metastatic disease or
sympathetic effusion from abdominal processes. Pleural effusion
stable in size. Diuresed as above.
.
# Coagulopathy: Likely nutritional in additional to
capecitabine. Patient was given vitamin K with little
improvement in INR. DIC labs were trended for several days and
remained negative. Smear showed abnormal burr cells but no
schistocytes. Stool studies for E.coli were negative. No
interventions made. Stable at discharge.
.
# Asthma/rhinitis: Continued fluticasone inhaled and nasal
spray, albuterol inhaler prn
.
#Thrush: treated with nystatin swish and swallow
.
#Buttock rash: treated with miconazole powder
Medications on Admission:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet
Sustained Release(s) *Refills:*0*
4. Capecitabine 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 10 days: please take as directed by Dr. [**First Name (STitle) 11309**].
5. PLEASE NOTE WE DISCONTINUED YOUR LASIX. THIS WILL NEED TO BE
RE-ASSESSED BY YOUR DOCTOR AT YOUR NEXT APPOINTMENT.
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for ANXIETY OR NAUSEA: PLEASE NOTE WE
DECREASED THE FREQUENCY TO EVERY 8 HOURS INSTEAD OF 6.
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain: PLEASE NOTE WE DECREASED THE DOSE
TO 2MG FROM 4MG. PLEASE READ YOUR PILL BOTTLES AT HOME
CAREFULLY. Disp:*30 Tablet(s)* Refills:*0*
8. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
PLEASE NOTE WE DECREASED THE DOSE FROM 15mg. Disp:*30 Tablet(s)*
Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) PUFFS Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
11. Recently restarted back on Lasix, unsure of dose
Discharge Medications:
1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for nausea or anxiety.
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
6. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-20**] Inhalation Q4H (every 4 hours) as needed
for SOB or wheezing.
9. torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Three (3) Tab Sust.Rel. Particle/Crystal PO twice a day:
Please hold for K >5.0.
13. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 4-6 hours as needed for nausea.
14. Outpatient Lab Work
Please check chem 7 in 1 week.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 37**] House Rehab & Nursing Center - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
Altered mental status, NOS
GI Bleed, NOS
ARF, likely pre-renal
cellulitis, bilateral lower extremity
C diff infection
coagulopathy, likely nutritional
Secondary:
metastatic pancreatic carcinoma
asthma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 68938**],
It was a pleasure participating in your health care. You were
admitted to [**Hospital1 69**] for altered
mental status. You were found to have a gastrointestinal bleed,
low urine output, lower leg cellulitis, and C. diff infection.
You were treated with antibiotics and fluids. You were
transfused 1 unit of blood. You were treated with vitamin K for
bleeding. You were given diuretics to help remove excess fluid
from your body. The fluid in your stomach was removed during a
procedure called a paracentesis and the cytology results were
negative for cancer. Your potassium level was consistently low
because of the diuretics and you were given potassium
supplements.
.
Please START the following medications:
ZOFRAN 8 mg every 4-6 hours as needed for nausea
Torsemide 60 mg twice a day
Spironolactone 50 mg daily
Pantoprazole 40 mg daily
Potassium 60 mEq twice a day
Please continue all other home medications. Please be cautious
when taking pain medications.
Followup Instructions:
Please schedule a follow-up appointment with heme/onc clinic
([**Telephone/Fax (1) 22**]). Please see your physician as needed.
|
[
"5849",
"5119",
"2762",
"2761",
"4019",
"49390",
"2859",
"2875"
] |
Admission Date: [**2114-12-3**] Discharge Date: [**2114-12-26**]
Date of Birth: [**2040-9-14**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Zocor
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
CC:[**CC Contact Info 23073**]
Major Surgical or Invasive Procedure:
1. ERCP
2. EGD x2 with injection of ampulla and gastric ulcer
3. IR Embolization x2 (L gastric artery)
4. Vascular surgery repair of left groin hematoma s/p JP drain
placement x2
5. AV graft thrombectomy x2
6. R femoral Quinton catheter placement (and subsequent removal)
7. Tunneled HD catheter placement in R IJ
History of Present Illness:
HPI: 74 y/o F s/p liver tx, ESRD on HD p/w concerns for
anastamotic stricture and biliary stone. Patient does not have
any recent h/o icterus, abdominal pain, nausea/vomiting,
yellowish discoloration of urine. Patient however complains of
black colored stools for the past few months. Per patient, MRCP
showed biliary dilatation w/ stones.
ROS: no palpitations, chest pain, SOB, cough, fevers, change in
bowel or bladder habits, weight loss or change in apetite.
.
[**Hospital Ward Name 516**]:
She had ERCP on the [**Hospital Ward Name **] on [**12-3**] which showed Biliary
tree narrowing. However procedure had to be terminated as the
patient did not tolerate it (elevated HR, BP and desatting to
80's on RA). A repeat procedure to be performed under anesthesia
on [**12-5**]. She was transferred to [**Hospital Ward Name 517**] for Dialysis.
Past Medical History:
Liver transplant in '[**92**]
ESRD on HD
Hypercholesterolemia
Gout
GERD
Social History:
lives with her husband, no ETOH/Tobacco
Family History:
Not contributory
Physical Exam:
Vitals: Aferbile, 136/80, 68, 93/RA (98/2L)
Gen: comfortable, NAD
HEENT: PERRLA, EOMI, MMM, no JVD appreciated
Lungs: CTAB
Heart: S1/S2, frequent ectopics, no m/r/g
Abd: soft/NT/ND, BS+
Ext: no edema/erythema/rash
Neuro: no focal deficits, AAOx3
Pertinent Results:
[**2114-12-26**] 05:35AM BLOOD WBC-6.8 RBC-3.58* Hgb-10.7* Hct-31.4*
MCV-88 MCH-30.0 MCHC-34.2 RDW-16.4* Plt Ct-261
[**2114-12-26**] 05:35AM BLOOD Plt Ct-261
[**2114-12-23**] 06:25AM BLOOD PT-11.7 PTT-31.0 INR(PT)-0.9
[**2114-12-26**] 05:35AM BLOOD Glucose-103 UreaN-54* Creat-7.2*# Na-132*
K-4.7 Cl-97 HCO3-23 AnGap-17
[**2114-12-26**] 05:35AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.6
[**2114-12-11**] 12:10AM BLOOD Hapto-25*
[**2114-12-10**] 04:30PM BLOOD Ferritn-400*
[**2114-12-10**] 04:30PM BLOOD PTH-65
[**2114-12-13**] 01:23AM BLOOD Cortsol-25.7*
[**2114-12-14**] 04:14AM BLOOD Cyclspr-107
[**2114-12-5**] 05:12AM BLOOD Cyclspr-126
.
ERCP [**12-6**]
IMPRESSION: No evidence of stricture or obstruction
.
pCXR [**12-11**]
Tip of the left internal jugular introducer projects over the
left margin of the mediastinum a cm above the apex of the aortic
arch. Location is indeterminate from a single plain radiograph
but could be in a large central vein. Slight widening of the
superior mediastinum indenting the trachea to the right at the
thoracic inlet is longstanding likely due to enlarged thyroid
gland, not an indication of hematoma. There is no pleural
effusion or pneumothorax. Moderate cardiomegaly persists, and
there is mild vascular engorgement in the mediastinum consistent
with volume overload explaining increased perfusion to the
lungs. New irregular largely linear opacification in the right
lower lung zone is probably atelectasis. There is no
pneumothorax.
.
ECHO [**12-13**]
Conclusions:
1. The left atrium is mildly dilated.
2. There is 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 normal (LVEF>55%).
3. The aortic valve leaflets are mildly thickened. There is a
minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) aortic regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. There is
severe mitral
annular calcification. There is severe thickening of the mitral
valve chordae. Trivial mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.]
5. There is mild pulmonary artery systolic hypertension.
6. Compared with the findings of the prior report (tape
unavailable for
review) of [**2110-1-28**], there has been no significant change.
.
Tunneled Line [**12-25**]
1. Successful placement of a tunneled hemodialysis catheter via
the right internal jugular vein with the tip in the right
atrium. The catheter is ready for use.
2. Air embolism in the heart was encountered. The patient was
kept in the left decubitus position and then was transported to
the floor in stable condition.
Brief Hospital Course:
CONSULT KIDNEY/PANCREAS
HD 22, POD2
Neoral 100 (cyclo-107), sulumed 125'''
74 F s/p OLT [**2092**] with UGIB from sphincterotomy ([**12-5**])
PMHx: OLT [**2092**] (PBC (?)), ESRD on HD (likely due to CsA), ^chol,
GERD, PVD s/p L fem-? BPG, s/p L knee surgery
[**12-3**]: ERCP unable to perform due to poor tolerance of anesthesia
[**12-5**]: ERCP/sphincterotomy
[**12-10**]: EGD - bleeding from eroision in proximal stomach and
sphincterotomy site
[**12-10**]: angio - no active bleeding
[**12-11**]: angio embolized gastric a. to bleeding GU
[**12-12**]: OR c Vascular to repair fem a.
[**12-17**] GI says no EGD may ? get flex sig / colonoscopy
[**12-21**] graft thrombectomy but reclotted
Plan: IR permacath [**12-25**] and d/c home.
Assessment and Plan:
74 y/o F s/p liver tx, ESRD on HD, admitted for ERCP to r/o
biliary stricture/sphinterotomy.
.
# GI bleed admitted for ERCP
Post-sphincerotomy, patient had bleeding from the sphincterotomy
site. She had EGD x2 with injection of epinephrine but this did
not stop the bleeding. She eventually got IR angio which did
not demonstrate any bleeding. A second IR angio showed a
gastric bleed which was considered secondary to EGD induced
trauma and the gastric bleeding vessel was embolized. The next
day, the left femoral arterial sheath was pulled which caused a
massive bleed into the thigh. Vascular surgery was consulted
and they performed a vascular repair after draining the hematoma
and placed 2 JP drains. She was extubated after which she
developed some stridor which was most likekly from edema [**2-28**]
volume overload and intubation. She was given short course of
steroids for this stridor. She also developed mild chest pain
after angio which resolved with NTG, IV Metoprolol. EKG was
unchanged from before. CE's were cycled.
She developed sepsis with a temperature spike, and was placed on
empiric Abx coverage. 2/2 Blood Cx's from [**12-13**] eventually grew
Coag neg Staph. She received a short course of Unasyn
prophylaxis while in the MICU. She was also started on
Vancomycin which was continued throughout her admission when JP
drain's remained in. On the day of discharge, one of her JP
drain's had put out less than 100cc/day, and it was pulled. Her
other JP drain was left in placed at time of discharge to have
vascular surgery pull the drain as an outpatient. Pt was sent
home with VNA services to monitor the drain.
.
2. Groin bleed:
Patient developed a L groin hematoma/bleed after pulling the
angio sheath s/p angiography/embolization. Vascular surgery was
consulted and they took the pt to the OR for surgical repair of
the L femoral artery along with placing 2 JP drains.
Vancomycin was continued for prophylaxsis while drains were in
place due to her h/o MRSA. Pt had 1 JP drain pulled on day of
discharge since it's output had declined to less than 100cc/day.
Pt was to have vascular surgery follow up with Dr. [**Last Name (STitle) **] and
was due to have her drain pulled as an outpatient.
.
3. ESRD:
Pt with ESRD who received HD through an AV graft in her R arm.
During her admission to the MICU, it was found that her AV graft
had become clotted, and was unusable for HD. A R femoral
Quinton catheter was placed in order to provide her with HD
access. Pt was taken to the OR twice during this admission for
an AV graft embolectomy, and these procedures were both
unsuccessful at disloding the clot. Pt refused any further
intervention at this admisssion, stating that she would rather
follow up with her outpatient transplant surgeon who placed her
AV graft. At time of discharge, there was no palpable thrill or
bruit throught the graft, and no dopplerable flow could be
appreciated. Pt had a tunneled HD line through her R IJ was
placed by IR the day prior to discharge, and pt received a short
HD course through her newly placed tunneled HD line prior to
discharge which functioned successfully. Her R femoral line was
pulled on the day of discharge, and pt was to follow up in
outpatient HD.
.
5. Liver Tx: Pt is s/p liver tx. Neoral was continued during
this admission without any complications.
.
6. DISPO - Pt was discharged with newly placed tunneled HD line
in place, along with L groin JP drain. Pt was to f/u with her
PCP, [**Name10 (NameIs) **] GI doctor, nephrologist, as well as vascular surgery to
have her JP drain pulled as an outpatient.
Medications on Admission:
Protonix 20 mg [**Hospital1 **]
Cyclosporine 100 mg QD
Allopurinol 100 mg QD
Baby ASA
[**Name2 (NI) **] 800 mg
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
Disp:*1 inhaler* Refills:*2*
7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 inhaler* Refills:*2*
8. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Tablet(s)* Refills:*2*
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
11. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
with HD 3x/week until drain is pulled for 10 days: Continue
vanco with HD until L groin JP drain is pulled. .
Disp:*qs units* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
* Common Bile duct stricture s/p sphincterotomy
* Bleeding from Sphincterotomy site s/p embolization x2
* Upper and Lower GI bleed s/p EGD x 2 and angioembolization of
gastric bleeder
* Left groin bleed after angio s/p vasc surgery repair
* Right arm AV graft clot s/p failed AV thrombectomy x2
.
Secondary Diagnoses:
* s/p liver transplant
* ESRD on HD
* Hypercholesterolemia
* Gout
* GERD
Discharge Condition:
Afebrile, pain free, stable to be discharged home.
Discharge Instructions:
1. Please take all your medications and follow up with all your
appointments.
.
2. Please see Dr. [**Last Name (STitle) **] in 1 week after discharge to have your
drain and staples removed. Call ([**Telephone/Fax (1) 1798**] to schedule that
appointment.
.
3. Please report to the ED or to your physician if you have any
further bleeding per rectum, dark colored stools, vomiting
blood, bleeding from your groin, dizziness/weakness or any other
concerns.
Followup Instructions:
Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **]
[**8-5**] days.
.
Please make an appointment to see your Gastroenterologist in 10
days.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2114-12-31**]
|
[
"40391",
"99592",
"4280"
] |
Admission Date: [**2181-2-12**] Discharge Date: [**2181-2-15**]
Date of Birth: [**2145-5-31**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
nausea, vomiting, weakness, hyperglycemia
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Pt is 35 yo F with Type 2 DM, gastroparesis, hx of past
admissions for DKA, who presents with N/V/D, weakness, and
hyperglycemia. She has had 4 days of N/V/D (1 episode of N/V and
1 episode of diarrhea today), associated with LLQ pain and
pleuritic SOB (but no CP). She has been non-compliant with
insulin for 4 of the last 5 days.
.
In the [**Name (NI) **], pt was started on an insulin gtt, and was also given
4L IVF, KCl 40meq, Anzemet 12.5mg IV, and Morphine 6mg IV. A R
SC cenntral line was attempted, but was unsuccessful, so a R
femoral line was placed. Finger sticks were initially 700's, but
then improved to 300's on the insulin gtt.
.
Pt currently denies CP or SOB. She c/o mild fatigue, but denies
N/V/D.
.
Past Medical History:
Diabetes mellitus I
Gastroparesis
s/p laparoscopic cholecystectomy in [**4-14**]
s/p C-section in [**12/2173**]
Hypertension
Depression
Social History:
Pt is unemployed currently. She lives with her 3 children. She
denies EtOH or drugs. Tobacco: history of 3 cigarettes per day
for the past 8 years. Pt is sexually active with husband. h/o
chlamydia >15 years ago, no other STDs.
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.9 BP 117/89 HR 106 RR 17 O2 99% RA
Gen: NAD, somewhat sleepy
HEENT: PERRL. OP clear.
Neck: Supple.
Cardio: tachycardic, no m/r/g
Resp: CTAB
Abd: soft, obese, nt, nd, +BS
Ext: no c/c/e
Neuro: A&Ox3
Pertinent Results:
[**2181-2-12**] 07:55PM D-DIMER-283
[**2181-2-12**] 07:55PM PT-12.5 PTT-26.0 INR(PT)-1.1
[**2181-2-12**] 07:55PM PLT COUNT-388
[**2181-2-12**] 07:55PM NEUTS-78.2* LYMPHS-14.5* MONOS-4.1 EOS-1.9
BASOS-1.4
[**2181-2-12**] 07:55PM WBC-8.5 RBC-4.77 HGB-13.8 HCT-41.1 MCV-86
MCH-29.0 MCHC-33.7 RDW-14.2
[**2181-2-12**] 07:55PM ALBUMIN-4.7
[**2181-2-12**] 07:55PM CK-MB-2 cTropnT-<0.01
[**2181-2-12**] 07:55PM LIPASE-15
[**2181-2-12**] 07:55PM ALT(SGPT)-30 AST(SGOT)-17 LD(LDH)-130
CK(CPK)-59 ALK PHOS-128* AMYLASE-33 TOT BILI-0.6
[**2181-2-12**] 07:55PM estGFR-Using this
[**2181-2-12**] 07:55PM GLUCOSE-400* UREA N-17 CREAT-1.2* SODIUM-140
POTASSIUM-3.2* CHLORIDE-100 TOTAL CO2-25 ANION GAP-18
[**2181-2-12**] 08:05PM LACTATE-3.7*
[**2181-2-12**] 08:29PM TYPE-ART PO2-87 PCO2-38 PH-7.44 TOTAL CO2-27
BASE XS-1
[**2181-2-12**] 09:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2181-2-12**] 09:03PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.034
[**2181-2-12**] 09:03PM URINE GR HOLD-HOLD
[**2181-2-12**] 09:03PM URINE HOURS-RANDOM
[**2181-2-14**] 02:00AM BLOOD WBC-6.5 RBC-3.41* Hgb-10.4* Hct-29.1*
MCV-85 MCH-30.5 MCHC-35.7* RDW-14.3 Plt Ct-282
[**2181-2-14**] 02:00AM BLOOD Glucose-62* UreaN-9 Creat-0.9 Na-142
K-3.1* Cl-107 HCO3-29 AnGap-9
[**2181-2-14**] 02:00AM BLOOD Calcium-8.6 Phos-2.2* Mg-1.9
.
CXR: FINDINGS: Single frontal view of the chest demonstrates no
evidence of pneumothorax. The heart size and cardiomediastinal
contours are within normal limits. There is normal pulmonary
vascularity. There is no focal consolidation or pleural
effusion. The bones are within normal limits.
IMPRESSION: No pneumothorax.
Brief Hospital Course:
This is a 35 yo f with Type 2 DM, gastroparesis, who p/w N/V,
weakness, and hyperglycemia. She was admitted to the MICU on an
insulin drip. The following issues were addressed during her
hospitalization:
.
1) hyperglycemia: This pt has had several admissions for DKA [**1-12**]
insulin non-compliance. During this admiision, the pt was
admitted with an AG of 15 and ketones in her urine, indicating
very mild DKA vs starvation ketoacidosis. As the patient
admitted to not taking any insulin in the four days prior to
admission, her DKA was again attributed to medication
non-compliance. The patient was started on an insulin drip until
her anion gap closed. The insuling drip and D5W was continued
until the pt was taking adquate PO. At this point the pt was
transitioned to SQ insulin. [**Last Name (un) **] was consulted and involved in
her care. She was discharged on her home insulin regimen and
advised to check her BS regularly.
.
2) N/V/D: This is likely due to a combination of mild DKA along
with her baseline gastroparesis. HCG was negative, and her UA
did not show signs of a UTI. She is s/p cholecystectomy r/o GB
disease. The pt was afebrile and her LFTs were wnl except AP
128. The patient was treated with morphine for her abdominal
pain and advised to follow up with her gastroenterologist as her
symptoms were described as a chronic problem.
.
3) HTN: The patient was on procardia, HCTZ, and lisinopril at
home which were initially held due to hypovolemia. Upon
discharge her Nifedipine was held but her other
anti-hypertensives were re-started. She was advised to follow up
with her PCP regarding restarting her nifedipine.
.
4) Depression: She was continued on her home meds.
Medications on Admission:
Insulin 75/25 40 U QAM, 40U QPM (per pt)
[**Name (NI) **] 6mg [**Hospital1 **]
Seroquel 400mg qd
Wellbutrin 300 mg qd
Procardia XL 30 mg qd
Protonix
Colace
Senna
Metroprolol 25 mg [**Hospital1 **]
Hydrochlorothyazide 25 mg qd
Lisinopril 10mg qd
Discharge Medications:
1. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Forty
(40) u Subcutaneous at bedtime.
2. [**Hospital1 **] 6 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
11. Compazine 5 mg Tablet Sig: One (1) Tablet PO every [**3-16**]
hours.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA
Discharge Diagnosis:
Primary:
DKA
.
Secondary:
- Type 2 DM
- Gastroparesis
- Hypertension
- Depression
Discharge Condition:
Good.
Discharge Instructions:
Please return to the ER or call your PCP if you experience
worsening abdominal pain, nausea, vomiting or any symptoms that
concern you.
.
.
We have stopped your nifedepine for now. Please see your PCP
prior to restarting this medication.
.
Please follow up with your PCP upon discharge.
Followup Instructions:
Please follow up with your PCP upon discharge.
Completed by:[**2181-2-24**]
|
[
"4019",
"311"
] |
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