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Admission Date: [**2101-2-16**] Discharge Date: [**2101-2-17**]
Date of Birth: [**2031-3-13**] Sex: F
Service:
CHIEF COMPLAINT: Hypotension, low grade temperatures, and
acute mental status changes.
HISTORY OF PRESENT ILLNESS: A 69-year-old female with
end-stage renal disease requiring hemodialysis, paraplegia
x35 years, and a history of ischemic bowel who began to feel
fatigued last evening. Daughter noticed the patient had a
low grade fever of about 99 and had one episode of shaking
chills. The patient denied cough, sputum production,
dysuria, and frequency, but did have two large [**Location (un) 2452**] colored
jelly-like bowel movements last night. The patient denied
crampy abdominal pain prior to meals or after eating.
According to the daughter, the patient has had very poor po
intake over the past few days, new onset in attentiveness and
somnolence since last night. The daughter denied any
purulent discharge from the femoral A-V fistula site, but
noted some blood at the site yesterday. The patient did not
have any recent travel. No eating undercooked or raw foods
recently. Of note, the patient was recently treated for a
right toe cellulitis with Levaquin 250 mg po q day,
prescribed by Vascular Surgery which she completed. She has
not noticed any increasing erythema or swelling of the right
lower extremity. Due to her paraplegia, she cannot relay any
increased pain at that site.
Per the daughter, the patient has Stage I decubitus ulcers in
the sacral region which have been stable, and they have been
treated with wet-to-dry dressing changes tid.
Patient was also noted to have some dizziness yesterday
evening, but denied palpitations or tachycardia. The patient
did not have any episodes of chest pain, shortness of breath,
PND, or worsening peripheral edema. Over the past few days,
no recent medication changes in her hypertension regimen.
Patient was brought to the Emergency Room, where systolic
blood pressure was initially noted to be 70 mm Hg, but
quickly dropped to 40 mm Hg. The patient had a left femoral
line placed status post repeated attempts at right IJ and
right subclavian lines. The patient was given 1 liter of
normal saline rapidly with systolic blood pressure returning
to 80 mm Hg. Dizziness improved status post the normal
saline infusion. The patient was also given 1 gram of IV
Vancomycin, 1 gram of ceftriaxone, and a MICU evaluation was
requested, but pressors were not initiated in the Emergency
Room.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis secondary to
diabetes Monday, Wednesday, Friday.
2. Diabetes mellitus.
3. Hypertension.
4. Paraplegia x35 years status post secondary to
complications from epidural placement.
5. History of gallstones status post ERCP and sphincterotomy.
6. Ischemic bowel per colonoscopy at [**Hospital 1263**] Hospital
diagnosed in [**2099-11-17**].
7. Urostomy with urinary diversion.
8. Skin and decubitus ulcers status post flap followed by
Vascular Surgery who has been recently considering amputation
of some of the patient's toes due to poor vascular flow.
9. Multiple A-V graft thrombosis and clots in the past
requiring thrombectomy and graft revisions.
10. Hypercholesterolemia.
11. Chronic left shoulder pain.
12. Osteomyelitis of the ankle.
13. Tricuspid regurgitation 1+. Echocardiogram in [**12/2099**]
demonstrated an ejection fraction of greater than 55%, no
wall motion abnormalities.
14. Ulcerative colitis.
MEDICATIONS ON ADMISSION:
1. Albuterol MDI prn.
2. Nephrocaps one tablet po q day.
3. Levaquin 250 mg q day, stopped two weeks ago.
4. Zestril 10 mg po q day.
5. Asacol 800 mg po bid.
6. Humalog insulin 10 units q am, 10 units q hs.
7. Coumadin 3 mg po q hs.
8. Pepcid 20 mg po q hs.
9. Lopressor 12.5 mg po bid.
10. Doxazosin 2 mg po q day.
11. Tums 1,500 mg tid with meals.
12. Sublingual nitroglycerin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco or alcohol use. The patient has
supportive children who are active in her care.
FAMILY HISTORY: Positive family history of diabetes in
parents and siblings.
PHYSICAL EXAMINATION UPON PRESENTATION: Vital signs:
Temperature 96.1, blood pressure 85/54, heart rate 72,
respiratory rate 12. HEENT examination: Mucous membranes
dry, 2 cm cyst in the right anterior cervical region, mobile,
nontender, no erythema or purulence, no jugular venous
distention. Cardiac examination: Normal S1, S2, no murmurs,
rubs, or gallops. Tachycardic rate. Lungs are clear to
auscultation bilaterally. Abdominal examination: Positive
bowel sounds, soft, nontender, nondistended, no rebound or
guarding. Back examination: No costovertebral angle
tenderness. Stage I decubitus ulcers, no purulent discharge,
3 cm in diameter with chronic hypopigmentation, superficial
blisters, and excoriation. Extremities: Cool to touch, 1+
dorsalis pedis pulses, A-V graft with good thrill, no
purulence noted, no erythema. Numerous ulcers between toes
with dry eschar, Stage I-II ulcer on heel with surrounding
erythema. No [**Last Name (un) 5813**] or cords. Neurologic examination:
Alert and oriented times three, mildly sluggish and
responsive.
LABORATORIES UPON ADMISSION: White blood cell count 4.7,
hematocrit 31.7, platelets 229. PT 21.2, PTT 33.8, INR 3.0.
Sodium 133, potassium 4.7, chloride 92, bicarbonate 19, BUN
58, creatinine 5.8, glucose 138, ALT 20, AST 34, alkaline
phosphatase 220, albumin 2.9, T bilirubin 0.6, amylase 32,
lipase 12. CK 71, MB negative, troponin less than 0.3.
Blood cultures: No growth to date.
CHEST X-RAY: No acute cardiopulmonary disease.
ELECTROCARDIOGRAM: Sinus tachycardia at 100 beats per
minute. Q in II, no ST segment changes, but changes compared
to [**2101-1-15**].
ARTERIAL BLOOD GAS: 7.26, 33, 117, lactate 9.1.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit service and monitored very closely with the Surgery
team. Patient's differential returned revealing 46% bands,
36% neutrophils, 2% lymphocytes, and 13% metamyelocytes.
Given the patient's very high bandemia, we were quite
concerned that patient had a very severe infection. The
patient's hypotension which had initially responded to 1
liter of normal saline and IV antibiotics subsequently began
to worsen.
Patient required triple pressors, Levophed, Neo-Synephrine,
and vasopressin. Patient was electively intubated secondary
to severe metabolic acidosis with bicarbs reaching as low as
9 mEq. Patient's mental status continued to worsen. Radial
A-lines were attempted, but could not be placed secondary to
the patient's severe peripheral vascular disease and her low
flow state, as well as one arm which contained an A-V
fistula. A femoral A-line was placed by Anesthesiology.
Abdominal CT scan was done in the setting of a possible
Clostridium difficile infection versus ischemic bowel given
progressively increasing lactate level overnight, increased
up to 11.6. Abdominal CT scan revealed no gross
intraabdominal process. No thickened bowel or free air.
Patient was subsequently also given 2 units of packed red
blood cells and 5 liters of normal saline to provide volume
resuscitation. Patient was found to be in DIC subsequently
with INR rising to 7.8. Decision was made not to reverse
anticoagulation given risk of graft rethrombosis given her
past medical history.
Patient was also subsequently given 6 amps of bicarb
throughout the night, 2 mg of magnesium, 6 mg of calcium for
electrolyte replacement.
Due to the patient's severe sepsis and lack of response to
aggressive fluid resuscitation and IV antibiotics, and given
her poor prognosis, the patient was started on Xigris with a
hope that this may provide some marginal mortality benefit.
Subsequent blood cultures revealed [**11-18**] gram-positive cocci in
pairs and clusters drawn from the night before. The Surgery
team continued to follow the patient very closely and agreed
with our management, and did not believe that the patient was
a surgical candidate even if she was to have ischemic bowel.
Family meeting was called, and the patient's grave condition
was explained to the family. The patient continued to
deteriorate given Xigris therapy, Vancomycin, ceftriaxone,
Flagyl, as well as triple pressors, and aggressive
electrolyte replacement with bicarbonate and other
electrolytes. The family understood the patient's condition,
and decided to make the patient comfort measures only after
thorough discussion amongst themselves.
At that time, all antibiotics and Xigris were stopped and
patient passed away within moments of cessation of pressor
therapy. The family discussed amongst themselves and decided
that there would be no reason to pursue autopsy. Patient's
time of death was 4:30 pm on [**2101-2-17**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-697
Dictated By:[**Name8 (MD) 4712**]
MEDQUIST36
D: [**2101-4-25**] 23:00
T: [**2101-4-26**] 06:03
JOB#: [**Job Number 97998**]
|
[
"0389",
"40391",
"2762",
"51881",
"2767",
"99592"
] |
Admission Date: [**2173-5-18**] Discharge Date: [**2173-5-24**]
Date of Birth: [**2108-5-14**] Sex: F
Service: MEDICINE
Allergies:
Banana / Melon Flavor / Avocado / IV constrast / Lorazepam
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 year old female with hx of stage [**Doctor First Name **] squamous cell cervical
cancer, status post combined chemoradiation with b/l nephrostomy
tubes and a recent history of multiple UTIS with both coag pos
staph and E.coli transferred from onc clinic to ED for
hypotension. Patient was feeling well until yesterday when
started feeling fatigue, and then had sudden onset of chills
last night with weakness and a fall onto bilateral knees on her
way to the bathroom. No LOC or head strike. This Am temp at home
was 101. Pt also had multiple bouts of explosive diarreha this
AM without abdominal pain or nausea. Later in morning was unable
to come in to onc clinic for urgent visit and was instructed on
phone to come to ER as pt was febrile to 101.5 with SBP 90's
although mentating well. Was due to have nephrostomy tube check
[**5-28**] with plan to remove L sided tube [**5-28**]. Of note, her
electrolytes have needed aggressive repletion as outpatient has
well with pt on standing K and Mag until recently when K was
stopped.
.
In the ED, initial vs were: Temp 101, HR 104, BP 76/44, RR 16,
Sats 97%. She was started on peripheral levo initially and given
Vanco/zosyn. Nephrostomy tubes have urine c/w with UTI. Lactate
initally 6 improved to 3.5 with fluids and pressors. Given
thiamine as study drug. Labs notable for Cr to 2.2 (baseline
1.1), bandemia to 10%, hypoK, hypophos, and hypoMag. Given K and
Mag in ED. BCx, UCx sent. She had a femoral CVL placed as left
IJ couldn't be obtained but was attempted. Post procedure CXR no
ptx per resident. She had received 6L of IVF by time of transfer
to floor. Pt has a port which was accessed. ? L hematoma.
Femoral line for access. On prednisone 5mg daily at baseline.
Given 125mg solumedrol in ED. Prior to leaving ED vitals showed
P 82 BP 110/40 R16 O2 sat 99%2L.
.
In the ICU, pt in NAD complaining mostly of knee pains and
tiredness. Reporting no diarrhea since this morning. BP in low
100s on 0.3 of norepi.
.
Review of sytems:
Denies dysuria, hematuria, or frequency. Reports continuing
feverish/chills sensation. Denies abdominal pain, headache,
confusion, dizziness, difficulty breathing, chest pain.
Past Medical History:
-Status post resection of a benign pituitary adenoma at age 21
at [**Hospital1 2025**] with resultant hypopituitarism; she was previously
followed at [**Hospital1 2025**], last saw Endocrinology at [**Hospital1 **]-[**Location (un) **] in [**Month (only) 547**]
[**2172**].
-Cervical cancer: followed by Dr. [**Last Name (STitle) 4149**], discovered after [**1-22**]
post-menopausal vaginal bleeding/hematuria and was found to have
a cervical mass w/ invasion of the posterior bladder wall.
Biopsies revealed a locally advanced, stage [**Doctor First Name **] squamous cell
cervical carcinoma. Underwent nephrostomy tubes [**2-23**] for
hydronephorosis. She initiated radiation therapy on [**2173-2-19**]
with her last session [**2173-4-28**]. She completed 6 sessions of
weekly cisplatin on [**2173-4-12**].
-Multiple UTIs since nephrostomy tube placement earlier this
year
-Osteoporosis
-Multiple food allergies
Social History:
She grew up in the West End of [**Location (un) 86**]. She lives in [**Location 4628**], MA
with her husband [**Name (NI) **]. They have two daughters, her eldest [**Name (NI) 1785**]
lives nearby, her [**Name (NI) 1685**] daughter [**Name (NI) 6480**] lives in New
[**Name (NI) **]. Her sister from [**Name (NI) 4565**], [**Name (NI) **], is back in
[**State 4565**]. [**Known firstname **] hopes to travel to [**State 4565**] later this
spring. The patient smoked approximately one-third to [**2-14**] pack
per day for 33 years, recently quitting. She had one alcoholic
beverage daily until her illness.
Family History:
[**Name (NI) 1094**] brother died of leukemia at age 64 in [**2164**].
Pt was a match, donated peripheral blood stem cells. Both
parents
had heart disease.
Physical Exam:
EXAM ON ADMISSION:
Vitals: T: 97.9 / BP: 133/49 / P: 81 / R: 15 / O2: 99% on RA
General: Alert, oriented although very tired, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils slightly
constricted but equal and reactive bilaterally
Neck: supple, JVP not elevated, no LAD, autramuatic
Lungs: trace crackles at R base, rest of lung fields CTAB with
no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds
hypoactive, no rebound tenderness or guarding, no organomegaly
GU: foley in place, pale urine in foley bag
Back: no pain at midline with sitting/lying movements, bilateral
CVA tenderness with light touch in areas around urostomy tubes.
Both urostomy tubes in place without surrounding
erythema/induration
Ext: warm, well perfused, 2+ pulses at DP and radial, no
clubbing, cyanosis or edema, bilateral knees are painful to
palpation just below kneecap (R>L) with small purple bruise
below R kneecap, limited active ROM due to pain with better
passive flexion and extension, no skin breaks on either knee. R
upper arm is painful to palpation on lateral aspect. No bruises
or masses noted on exam. Limited ability to raise R shoulder due
to pain.
.
Pertinent Results:
Labs on Admission:
[**2173-5-18**] 11:00AM BLOOD WBC-13.1*# RBC-2.95* Hgb-9.5* Hct-26.5*
MCV-90 MCH-32.3* MCHC-36.0* RDW-16.0* Plt Ct-169
[**2173-5-18**] 11:00AM BLOOD Neuts-83* Bands-10* Lymphs-3* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-5-18**] 11:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+
[**2173-5-18**] 07:10PM BLOOD PT-17.3* PTT-30.4 INR(PT)-1.6*
[**2173-5-19**] 05:07AM BLOOD Fibrino-509*
[**2173-5-18**] 11:00AM BLOOD Gran Ct-[**Numeric Identifier **]*
[**2173-5-18**] 11:00AM BLOOD UreaN-16 Creat-2.2*# Na-133 K-2.8* Cl-96
HCO3-25 AnGap-15
[**2173-5-18**] 11:00AM BLOOD ALT-29 AST-38 CK(CPK)-163 AlkPhos-108*
TotBili-0.3
[**2173-5-18**] 11:00AM BLOOD Albumin-3.3* Calcium-8.4 Phos-1.1*#
Mg-1.1*
[**2173-5-18**] 11:00AM BLOOD Cortsol-6.9
[**2173-5-18**] 01:12PM BLOOD Lactate-5.9* K-3.1*
[**2173-5-18**] 11:00PM BLOOD freeCa-1.17
.
Labs on Discharge:
[**2173-5-24**] 06:45AM BLOOD WBC-9.6 RBC-3.28* Hgb-10.2* Hct-29.4*
MCV-90 MCH-31.0 MCHC-34.6 RDW-17.3* Plt Ct-123*
[**2173-5-24**] 06:45AM BLOOD Glucose-75 UreaN-11 Creat-0.9 Na-138
K-3.5 Cl-97 HCO3-32 AnGap-13
[**2173-5-24**] 06:45AM BLOOD Vanco-32.3*
.
MICROBIOLOGY:
Blood Culture, Routine (Final [**2173-5-24**]):
STAPH AUREUS COAG +.
_______________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ 1 S
.
.
URINE CULTURE (Final [**2173-5-22**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.
ENTEROCOCCUS SP. >100,000 ORGANISMS/ML.
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
.
IMAGING:
CXR: No acute pulmonary process. Stable chest x-ray exam.
.
ECHO: The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60%). 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, but cannot be fully
excluded due to suboptimal image quality. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve,
but cannot be fully excluded due to suboptimal image quality.
Mild to moderate ([**2-14**]+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. No masses or
vegetations are seen on the pulmonic valve, but cannot be fully
excluded due to suboptimal image quality. There is no
pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of [**2172-2-21**], the findings are similar but the technically
suboptimal nature of both studies precludes definitive
comparison.
.
IMPRESSION: Suboptimal image quality. No vegetations seen
.
Brief Hospital Course:
The patient is a 65 year-old female with hx of stage [**Doctor First Name **]
squamous cell cervical cancer, status post combined
chemoradiation with bilateral nephrostomy tubes admitted with
urosepsis.
.
# Urosepsis: Initially admitted to ICU, requiring pressors given
hypotension in setting of sepsis. Urinary source believed to be
most likely given positive UA and bilateral CVA tenderness. CXR
and c.diff returned negative. The patient was started on
vancomycin and cefepime empirically given recent staph aureus
UTIs and the possiblity of resistant organisms. The patient was
also given two days of stress dose hydrocortisone. The patient's
symptoms resolved with broad-spectrum antibiotics, and she was
weaned off pressors and transferred to the floor.
.
The patient's urine culture grew methicillin-resistant staph
aureus and enterococcus; her blood culture grew
methicillin-resistant staph aureus. Urology was consulted during
her stay with Dr.[**Doctor Last Name **] recommendation to keep tubes in place
until outpatient follow-up. ECHO returned negative for
vegetation. ID service was consulted. Her cefepime was
discontinued. The patient will continue a two week course of
vancomycin (through [**6-3**], two weeks through last positive blood
culture). Prior to discharge, the patient's vanco level was
greater than 30. Her dose was adjusted, and she was instructed
to skip a dose when returning home (trough to be measured by
VNA). Upon completetion of the vancomycin, she will initiate
treatment with Macrobid, which she will continue for one week
beyond removal of nephrostomy tubes. Dr. [**First Name (STitle) 1075**] of ID will oversee
this transition.
.
Prior plan was to have left nephrostogram on [**2173-5-28**] with
potential removal of tube.
.
# Status-post fall: No LOC or head strike, likely in setting of
hypotension and weakness related to sepsis. Only trauma appears
to be bilateral knees and perhaps R arm where patient caught
herself while falling. She was continued on home dose oxycodone
5mg Q6hrs PRN pain for her L back/CVA tenderness.
.
# Anemia: No evidence of bleeding on exam/history. Normal T.bili
not indicative of hemolysis. Remained stable after 2 units of
PRBCs.
.
# Elevated INR: Elevated at 1.6 at time of ICU arrival. No
evidence of DIC on lab work-up. Mild INR elevation may also be
due to recent antibiotic use wiping out gut flora and
inhibititon of vit K utilization. Started on 3 day course of Vit
K. INR trended to 1.1 at the time of discharge.
.
# Panhypopituitary: Secondary to surgery many years ago. On
synthroid and prednisone as outpatient for years. Given 2 days
of stress dose steroids, and then re-started on home prednisone
5 mg po daily dose 04/07. She was continued on home synthroid at
home dose 125mcg daily.
.
# Cervical cancer: S/p treatment with chemo and radiation. Her
last chemotherapy was on [**2173-4-12**], and her last radiation
treatment on [**2173-4-28**].
.
# Transitions of Care:
- VNA will check weekly labs prior to follow-up with ID (CBC,
chem7, vanco trough)
- ID will oversee transition to macrobid following vancomycin
completion
- Urology will evaluate/manage timing or nephrostomy tube
removal
Medications on Admission:
BACTRIM DS [**Hospital1 **] for 14 days started on [**2173-5-17**]
LEVOTHYROXINE - 125 mcg Tablet - one Tablet(s) by mouth daily
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - 2.5grams topically to
PORT site as directed as needed for prior to accessing PORT
OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - [**2-14**] Tablet(s) by mouth Q6
hours and QHS as needed for anxiety, insomnia
OXYCODONE - 5 mg Tablet - [**2-14**] Tablet(s) by mouth every four (4)
hours as needed for Pain
POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - 1 packet by
mouth daily as needed for constipation
PREDNISONE - 5 mg Tablet - one Tablet by mouth daily
PROCHLORPERAZINE MALEATE - (Prescribed by Other Provider) - 10
mg Tablet - 1 Tablet(s) by mouth every 6 hours as needed for for
nausea
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet -
1- 2 Tablet(s) by mouth every six (6) hours as needed for
Pain/Fever
CALCIUM CARBONATE - (Prescribed by Other Provider) - 200 mg (500
mg) Tablet, Chewable - 2 Tablet(s) by mouth twice a day
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
MAGNESIUM OXIDE - (Prescribed by Other Provider; Dose adjustment
- no new Rx) - 400 mg Tablet - 1 Tablet(s) by mouth three times
a day
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (OTC) - 20 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) appl
Topical once a day: topically to
PORT site as directed as needed for prior to accessing PORT.
3. olanzapine 2.5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for anxiety.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO twice a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) for 10 days: Please
continue through [**6-3**].
Disp:*QS mg* Refills:*0*
13. Macrobid 100 mg Capsule Sig: One (1) Capsule PO once a day:
Please start on [**6-4**] and continue through your appointment with
Dr. [**First Name (STitle) 1075**].
Disp:*30 Capsule(s)* Refills:*0*
14. Outpatient Lab Work
Please check vancomycin trough, CBC with differential, and
chemistry panel on [**5-27**] and [**6-3**]. Please fax results to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1075**] at [**Telephone/Fax (1) 1419**] (Infectious Disease clinic).
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnosis:
- Methicillin-resistant Staph Aureus Bacteremia
- Urosepsis
.
Secondary Diagnosis:
- Cervical Carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 5936**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with an
infection in your urine stream and in your blood. You were
started on antibiotics for these infections, and you improved
dramatically over the course of your hospital stay. You will
continue with antibiotic treatment after leaving the hospital as
outline below.
.
Please START the following medication after discharge:
VANCOMYCIN 750 mg every 12 hours through [**2173-6-3**]
*Please DO NOT take your evening dose on the day of discharge
([**2173-5-24**]).
.
Please STOP the following medications:
BACTRIM
MAGNESIUM OXIDE
.
On [**6-4**] (after completing vancomycin), you will begin therapy
with an oral antibiotic called Macrobid (Nitrofurantoin). You
will continue with this antibiotic likely until after your
nephrostomy tubes are removed. When you follow-up in Infectious
Disease clinic, they will help you determine the ultimate course
of antibiotics.
.
Please continue all other medications as they have been
prescribed. Should you experience any symptoms that concern you
after leaving the hospital, please call your oncologist or
return to the emergency room.
.
Followup Instructions:
Department: RADIOLOGY CARE UNIT
When: FRIDAY [**2173-5-28**] at 7:00 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: RADIOLOGY
When: FRIDAY [**2173-5-28**] at 8:30 AM [**Telephone/Fax (1) 8243**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2173-6-11**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: SURGICAL SPECIALTIES
Specialty: Urologic Surgery
When: MONDAY [**2173-6-7**] at 8:30 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 277**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2173-6-7**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You will only see Dr. [**Last Name (STitle) 4149**] at this appointment since Dr. [**Last Name (STitle) **]
will be on vacation.
.
|
[
"78552",
"99592",
"2875",
"5990"
] |
Admission Date: [**2131-11-20**] Discharge Date: [**2131-11-26**]
Date of Birth: [**2109-10-26**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Peri-anal abscess
Major Surgical or Invasive Procedure:
None
History of Present Illness:
22yF with no PMH other than recent diagnosis of genital herpes
started on acyclovir. Presented to an outside hospital with
perirectal pain x 1
week. CT scan of the pelvis there demonstrated some
rectosigmoid
stranding as well as some stranding in the left buttock. The CT
scan did not image all the way through the buttock. She was
taken to the OR where she was found to have a necrotizing
infection involving mostly the skin with some minimal soft
tissue. A large area of skin was debrided on the left buttock
near the anal verge, and smaller amount on the right buttock
near
the anal verge. She had some moderated hypotension and
tachycardia responsive to fluids and was then transferred to
[**Hospital1 18**] for further
management and evaluation for additional surgery.
Past Medical History:
Genital herpes [**7-/2131**], Chlamydia, Bacterial vaginosis, Chronic
constipation
PSH: left buttock debridement
Family History:
Noncontributory
Physical Exam:
Upon presentation:
VS: 97.6 110 110/70 18 99RA
Gen: NAD
CV: tachy
Pulm: unlab, CTA b/l
Abd: soft, NT, ND
GU: debrided area on left buttock near anal verge approx 6x6cm
in size, no residual necrotic tissue or purulence. There is a
large area of indurated and tender tissue through the majority
of
the medial buttock lateral to the debrided area. No erythema.
There is a smaller area on the right buttock near the anal verge
about 2 x 3cm in size that has been debrided, mostly skin, that
also appears healthy without necrosis or purulence.
Pertinent Results:
[**2131-11-20**] 09:59PM GLUCOSE-98 UREA N-19 CREAT-0.7 SODIUM-139
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-19* ANION GAP-17
[**2131-11-20**] 09:59PM ALT(SGPT)-17 AST(SGOT)-15 ALK PHOS-112* TOT
BILI-0.6
[**2131-11-20**] 09:59PM CALCIUM-8.6 PHOSPHATE-2.6* MAGNESIUM-1.7
[**2131-11-20**] 09:59PM WBC-39.9* RBC-3.00* HGB-9.4* HCT-27.0* MCV-90
MCH-31.2 MCHC-34.6 RDW-13.8
[**2131-11-26**]
WBC RBC Hgb Hct
22.7* 3.64* 11.1* 33.1*
CT abd/pelvis:
IMPRESSION:
1. Heterogenous attenuation to the liver likely related to phase
of contast enhancement. Haemangioma segment VIII with a further
are of subtle enhancement and possible mass effect in segment 5.
An underlying FNH/adenoma cannot be excluded, and ultrasound can
be considered to evaluate this further.
2. Perirectal debridement with perineal inflammatory change. No
discernable perirectal abscess or extension in to the anal
orifice / rectum.
3. Pelvic left kidney.
Brief Hospital Course:
She was admitted to the ACS service from an outside hospital for
further evaluation of her peri-anal wound. She was given
antibiotics and twice daily dressing changes. Her WBC was very
high initially (39.9) and trended downward so that at time of
discharge it was 22.
She did have pain control issues requiring intravenous narcotics
for dressing changes. Her oral narcotics were increased which
have been effective in controlling her pain. She was given a
bowel regimen and started on [**Last Name (un) **] bath.
She consented to HIV testing which came back negative.
She was seen by Social work for coping and providing emotional
support given her current illness.
At time of discharge she was tolerating a regular diet, her pain
adequately controlled on an oral pain regimen and ambulating
independently. She was provided instruction for following up
with her primary surgeon.
Medications on Admission:
Valacyclovir 500mg daily
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Peri-anal abscess
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 evaluation of your wound.
You were treated with intravenous antibiotics and pain
medication. Twice daily dressing changes were performed and will
need to continue once discharged to home by the visiting nurses.
It is importnat that you do the warm [**Last Name (un) **] baths at least 2x/day
after discharge.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 88161**] within the next week for assessment of
your wound. You will need to call for an appointment.
Completed by:[**2131-12-4**]
|
[
"0389"
] |
Admission Date: [**2165-4-29**] Discharge Date: [**2165-5-14**]
Date of Birth: [**2117-4-3**] Sex: M
Service:
PRESENT ILLNESS: Upper GI bleeding.
HISTORY OF PRESENT ILLNESS: This is the first admission to
[**Hospital1 **] [**First Name8 (NamePattern2) **] [**Known firstname **] [**Known lastname 32978**] who is a 48-year-old
male, who works as an interior design contractor, who has a
past medical history significant for AIDS. The patient states
that he was feeling well and was in his usual state of health
until 3 weeks prior to admission when he developed what he
thought was the flu which was manifested by chills, myalgias,
and night sweats. During this time the patient denied nausea,
vomiting, or abdominal pain but did note a decreased
appetite. The patient took occasional ibuprofen for relief
and noted improvement in his symptoms until 2 days prior to
admission when he began to notice bright red blood per
rectum. The patient states he first noticed normal stool
streaked with blood early in the morning on [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1017**].
Over the course of the day the patient noted increasingly
bloodier bowel movements approximately every 2 hours that
eventually developed into bright red blood per rectum. On the
following day the patient noted continued blood per rectum.
In addition, the patient noted increased shortness of breath
and dyspnea with walking across the room which prompted the
patient to call 911, and he was brought to the [**Hospital1 346**] for evaluation and treatment of his
bleeding.
PAST MEDICAL HISTORY: The patient has a past medical history
significant for AIDS with a recent CD4 count of 53 and a
viral load of 84,000; anal condyloma; hypothyroidism;
depression; and chronic back pain. The patient notes a
hospitalization in [**2159**] for anemia, during which time an
upper endoscopy demonstrated 2 bleeding esophageal ulcers and
a gastric mass with an indeterminate biopsy that was presumed
to Kaposi sarcoma.
PAST SURGICAL HISTORY: The patient's past surgical history
is significant only for fulguration of anal condyloma.
MEDICATIONS AT HOME: Medications include Dapsone, Kaletra,
Videx, Viread, Diflucan, Synthroid, AndroGel, and Wellbutrin.
Of note, the patient has been poorly compliant with his
antiretroviral regimen secondary to his recent illness.
SOCIAL HISTORY: Social history includes a 18-pack-year
history of smoking; 9 years x 2 packs per day. The patient
states that he quit smoking 7 weeks ago. He also states that
he engages in social drinking on the weekends, though he
admits to a remote history of alcohol dependency. The patient
states that he is a homosexual but denies recent anal
intercourse.
FAMILY HISTORY: Insignificant for bleeding disorders, GI
cancers, or vascular malformations.
PHYSICAL EXAMINATION: On initial examination his temperature
was 103.2, with a pulse of 130, the blood pressure was
114/60, a respiratory rate of 16, oxygen saturation of 97% on
2 liters. His mucous membranes were dry. Cardiovascular exam
revealed tachycardia with a normal S1 and S2 without murmurs.
Mild crackles were noted on auscultation of the lungs at the
left base without dullness to percussion and normal tactile
fremitus.
LABORATORY DATA: His initial laboratory studies showed a
white blood cell count of 9.1, a hematocrit of 25.3, and a
platelet count of 182. Coag's were a PT of 13.1, a PTT of
23.5, INR of 1.1. Electrolytes showed a sodium of 155,
potassium of 3.4, chloride of 103, bicarbonate of 22, BUN and
creatinine were 26/1.0.
BRIEF HOSPITAL COURSE: A nasogastric tube was placed, and
lavage revealed only bilious return without evidence of
occult blood. A chest x-ray on admission showed left lower
lobe pneumonia. A CT scan was obtained but showed no
pathology. The patient was admitted to the internal medicine
service and transfused 2 units of packed red blood cells. On
hospital day 1, the patient was transfused a total of 4 units
of blood. His hematocrit's remained between 18 and 25. A
bleeding scan on hospital day 2 showed bleeding in the left
upper quadrant, and a flexible sigmoidoscopy showed blood
clots without any source of bleeding. An EGD showed a fibrous
bridge which was noted at 35 mm from the incisors, indicative
of an esophageal ulcer now healed. A small punctate erosion
in the stomach body was cauterized, and erythema was noted in
the stomach body/antrum and patchy areas of the fundus
consistent with gastritis. However, these findings did not
account for the patient's large gastrointestinal bleed. The
patient was kept on supportive therapy by the medical service
during this time. Angiography showed no extravasation of
contrast, and as such a source was not found.
On hospital day 3 the patient's hematocrit dipped to 16.3,
and the patient was transfused with an additional 6 units of
packed red blood cells. The patient underwent a push
endoscopy which showed erosion in the stomach body, blood in
the 4th part of the duodenum and jejunum, and angioectasia's
in the 4th part of the duodenum. These were treated with
thermal therapy. An angiography on hospital day 3 showed
active extravasation involving the proximal jejunum and just
beyond the ligament of Treitz, and the patient continued to
bleed. He continued to have melanotic stools on the following
- hospital day 4 - and required several units of blood
products, bringing the total of 21 units of packed red blood
cells on hospital day 4.
On hospital day 4 the patient was seen by the surgical
service, and at the time the decision was made to take the
patient to surgery for definitive surgical treatment of his
upper GI bleeding. The patient underwent an exploratory
laparotomy and excision of the proximal jejunum as well as
retroperitoneal exploration. Please see the operative note
for details of this procedure. The patient tolerated the
procedure well and was transferred to the floor in stable
condition. The postoperative course was remarkable only for a
prolonged postoperative ileus and postoperative oliguria. It
was noted that after surgery the patient remained massively
edematous and required continuous fluid boluses to maintain
urine output. This continued up until postoperative day 6,
when the patient required transfer to the intensive care unit
for intense monitoring. A central venous line was placed, and
the central venous pressure was monitored during this time.
The patient remained in the ICU only for a brief amount of
time, during which his hematocrit's were noted to be stable
and his urine output continued to improve as he began to
diurese third-space fluid that he accumulated after receiving
many units of blood products preoperatively and crystalloid
solution intraoperatively and postoperatively. The patient
was able to pass flatus after some time postoperatively, and
he diet was advanced as tolerated. The patient's central line
was removed as was his Foley catheter and was noted to be
stable and able to ambulate well. His antiretroviral regimen
was restarted prior to his discharge.
DISCHARGE DISPOSITION: The patient was discharged home on
postoperative day 12.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE: The patient was discharged on his
preadmission regimen of antiretroviral therapy as well as
prophylaxis therapy.
DISCHARGE INSTRUCTIONS: Specific instructions to follow up
with Dr. [**Last Name (STitle) **] in 2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**]
Dictated By:[**Doctor Last Name 32979**]
MEDQUIST36
D: [**2165-8-6**] 13:59:17
T: [**2165-8-6**] 14:57:13
Job#: [**Job Number 32980**]
|
[
"486",
"2851",
"2762",
"5845",
"2449",
"311"
] |
Admission Date: [**2134-8-27**] Discharge Date: [**2134-8-29**]
Date of Birth: [**2099-2-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
brain mass seen on MRI
Major Surgical or Invasive Procedure:
sub-occipital craniectomy for tumor resection
History of Present Illness:
35 year old female h/o breast CA s/p mastectomy and
reconstruction presents with 3 month h/o neck pain which has not
improved. She came to hospital yesterday because pain was
unchanged and relative suggested that she go to a doctor. [**First Name (Titles) **] [**Last Name (Titles) **]P
had been treating her with Advil and muscle relaxants. She
thought the neck pain was related to sleeping in a bad position
in the bed at [**Hospital3 1810**] where her 4 year-old child was
being treated for a brain tumor. The pain was [**6-5**] at its worst
and is currently [**3-5**]. When the pain is at its worst, she also
notices right weakness with writing as well as slight slurring
of
"s" while speaking. Patient was sent home yesterday after
C-spine
MRI was read as negative and was called back in today when final
MRI read showed question of cerebellar mass.
Past Medical History:
[**2130**] - breast CA
[**2131**] - mastectomy, radiation
[**2132**] - reconstruction of breast
[**2133-9-26**] - left oophorectomy
Social History:
married, has 2 children 4 and 6 years old, sister is a nurse
practitioner
Family History:
father died of lymphoma at age 50, 4 year old child has
medullablastoma
Physical Exam:
T:98.3 BP: 117/74 HR: 109 RR: 18 O2Sats: 99%
Gen: WD/WN, comfortable, obviously upset by diagnosis
HEENT: Pupils: equal, reactive, 2mm EOMs intact, with lateral
nystagmus to both sides
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-30**] throughout. No pronator drift
.
Sensation: Intact to light touch.
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+
.
Toes downgoing bilaterally
.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
Admission Labs:
[**2134-8-27**] 03:52PM GLUCOSE-123* UREA N-17 CREAT-0.7 SODIUM-140
POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-24 ANION GAP-12
[**2134-8-27**] 03:52PM CALCIUM-8.3* PHOSPHATE-3.6 MAGNESIUM-2.0
[**2134-8-27**] 03:52PM WBC-8.8# RBC-3.48* HGB-12.2 HCT-33.4* MCV-96
MCH-35.1* MCHC-36.6* RDW-13.8
[**2134-8-27**] 03:52PM PLT COUNT-162.
.
NON-CONTRAST HEAD CT SCAN: There has been recent right
occipital craniotomy and resection of the previously described
right cerebellar mass lesion. Hemorrhage is seen within the
resection bed. There is hypodensity of the surrounding
cerebellar parenchyma consistent with edema as previously
described. The fourth ventricle appears slightly larger in
axial plane compared to the preoperative study of [**8-22**].
There is postoperative pneumocephalus. There is a small amount
of hyperdensity along the right tentorium, also consistent with
postoperative blood at this locale. The lateral and third
ventricles are not significantly changed from the preoperative
study. The [**Doctor Last Name 352**]-white matter differentiation in the cerebral
hemispheres is preserved. The visualized paranasal sinuses and
mastoid air cells are clear. There are postoperative changes of
the calvarium, and staples at the posterior scalp.
.
IMPRESSION: Postoperative changes of the posterior fossa, with
a small amount of hemorrhage in the resection bed and possibly a
small amount associated with the tentorium.
Brief Hospital Course:
Pt. was taken to the OR on [**2134-8-27**] by Dr. [**Last Name (STitle) 26803**] for
sub-occipital craniotomy and removal of cerebellar tumor. Final
pathology pending at time of discharge and will be followed up
in Brain tumor clinic. MRI head performed after the procedure
showed full resection of tumor per Neurosurgery read, final read
pending at discharge and should be checked in follow up. Pt.
tolerated the procedure with no complications, pain controlled
post-op with Tylenol #3, which she was discharged with. She was
also discharged on Valium for muscle spasm and a soft collar for
comfort. Pt. seen by Dr. [**Last Name (STitle) 4253**] of Neuro-oncology, who
recommended LP after discharge to eval for leptomeningeal spread
prior to consideration of XRT -> pt was asked to call after
discharge to set up an appointment for this. She was covered
with IV Decadron in house and discharged on 6 mg PO TID per Dr. [**Name (NI) 23016**] recs, she will titrate this off in follow up. Pt.
had a CT Chest, Abd, and Pelvis for staging prior to d/c, read
of this was pending at time of discharge and should be followed
up in f/o in Brain tumor clinic on [**9-6**].
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*1*
3. Dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO three
times a day.
Disp:*140 Tablet(s)* Refills:*1*
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
5. Valium 5 mg Tablet Sig: One (1) Tablet PO three times a day.
Disp:*90 Tablet(s)* Refills:*1*
6. soft cervical collar
dispense: #1
for patient comfort
Discharge Disposition:
Home
Discharge Diagnosis:
s/p sub-occipital craniectomy for tumor resection
Discharge Condition:
Stable
Discharge Instructions:
Please keep incision dry until 1 day after your staples are
removed.
Please call [**Telephone/Fax (1) 1669**] if you have any questions or concerns.
Please call immediately if you have any nausea, vomiting,
confusion, lethargy, headache, change in mental status, seizure,
fever, drainage or redness around incision.
Followup Instructions:
Please call [**Telephone/Fax (1) 1844**] to set up an appointment to be seen on
[**2134-9-6**] in the Brain tumor clinic by Dr. [**Last Name (STitle) 4253**] and Dr.
[**Last Name (STitle) 26803**]. You should have your staples removed at this
appointment.
Please call [**Doctor First Name 2411**], Dr.[**Name (NI) 29259**] coordinator, at
[**Telephone/Fax (1) 1844**], on Tuesday ([**2134-8-31**]) and ask her to set you up for
an appointment to have an LP (spinal tap) performed on Wednesday
or Thursday ([**9-1**] or [**9-2**])
Previously scheduled appointments:
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2134-10-8**] 9:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2134-9-27**] 11:00
Provider: [**Name10 (NameIs) 26**] [**Name8 (MD) 28**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2134-9-27**]
9:30
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2134-8-29**]
|
[
"49390"
] |
Admission Date: [**2104-1-17**] Discharge Date: [**2104-1-20**]
Date of Birth: [**2044-6-27**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 59 year old man
with a history of stage IV adenocarcinoma of the lung, who
originally presented with a neck mass in [**2102-8-8**] and was
found to have stage IV lung cancer with metastases to his
left neck and subcarinal lymph nodes, status post a right
upper lobe wedge resection in [**2102-10-8**]. He completed a
course of carboplatin and Taxol as well as radiation therapy.
A follow-up CT scan in [**2103-6-8**] and [**2103-9-8**] showed
interval worsening of the pulmonary nodules as well as
retroperitoneal lymph nodes. He was started on taxotere
therapy in [**2103-8-8**]. In [**2103-10-8**], an isolated brain
metastases was discovered, status post suboccipital
craniotomy with resection of tumor and stereotactic
radiosurgery in [**2103-11-8**].
The patient presented to [**Hospital3 417**] Hospital the Saturday
prior to admission with atypical right sided chest pain.
There, a CT angiogram showed small filling defects of
tertiary branches of his pulmonary vasculature and a
pericardial effusion. He was started on heparin, with a drop
in his platelet count from 244,000 to 130,000 in three days.
He was believed to have HIT and was transferred to
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for Hirudin therapy.
In the Emergency Room, the patient was comfortable, with a
heart rate in the 120s and a blood pressure 110 to 120/70.
His oxygen saturation was 98% on two liters. A repeat CT
angiogram showed tiny nonocclusive filling defects in the
lower lobes bilaterally, consistent with emboli, and a large
pericardial effusion with a pulsus of 30. An emergent
echocardiogram was performed that was consistent with
tamponade. The patient was taken to the catheterization
laboratory for pericardiocentesis under fluoroscopy.
PAST MEDICAL HISTORY: 1. Stage IV adenocarcinoma with clear
cell features of lung, as described above. 2. Hypertension.
MEDICATIONS ON ADMISSION: Accupril 10 mg p.o.q.d.,
Prednisone 10 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient smoked one pack per day for
forty years and occasionally uses alcohol. He has no history
of drug abuse. He is married and lives with his wife.
PHYSICAL EXAMINATION: On physical examination, the patient
was a pleasant male in no acute distress who was afebrile
with a heart rate of 115, respiratory rate 20s, blood
pressure 90s/60s with an oxygen saturation of 98% on two
liters. Head, eyes, ears, nose and throat: Unremarkable.
Neck: No jugular venous distention. Lungs: Clear to
auscultation bilaterally. Cardiovascular: Tachycardiac with
no murmurs but a rub in systolic and diastole loudest at the
apex. Abdomen: Benign. Extremities: Without edema, groin
sites looked good.
LABORATORY DATA: White blood cell count was 11.6, hematocrit
29.7, platelet count 237,000 and normal differential.
Coagulation studies showed a prothrombin time of 14.6, INR
1.5 and partial thromboplastin time 34.1. Chem-7 showed a
sodium of 135, chloride 101, bicarbonate 20, BUN 22 and
creatinine 1.4. Electrocardiogram revealed sinus tachycardia
with biphasic P waves but normal voltage criteria after
catheterization.
HOSPITAL COURSE: Mr. [**Known lastname 26762**] was admitted to the Coronary Care
Unit after a pericardial drain was placed in the
catheterization laboratory. He was observed to have a large
amount of serosanguinous drainage that tapered off over two
days. The drain was successfully removed after a repeat
echocardiogram showed minimal reaccumulation and he had
drained less than 25 cc over 24 hours.
A repeat echocardiogram performed 24 hours after the drain
was pulled showed no further reaccumulation of fluid. The
drainage fluid was positive for malignant cells and so was
likely secondary to lung metastases.
As anticoagulation for his pulmonary embolism was
contraindicated secondary to his bleeding pericardial
metastases, an inferior vena cava filter was placed to lower
the risk of future pulmonary embolism.
The patient's oncologists, Dr. [**Last Name (STitle) 26763**] and Dr. [**Last Name (STitle) **], had a
discussion with him regarding his life expectancy, which is
about one month secondary to his underlying disease. The
patient understood this and wished to remain a full code.
After the repeat echocardiogram after drain removal was
negative, the patient was discharged home to follow up with
an echocardiogram in three days to evaluate for recurrence of
the fluid.
CONDITION AT DISCHARGE: Improved.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Tamponade secondary to pericardial metastases.
2. Pulmonary embolism, status post inferior vena cava filter
placement.
3. Stage IV metastatic adenocarcinoma of the lung.
4. Hypertension.
DISCHARGE MEDICATIONS:
Prednisone 10 mg p.o.q.d.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2104-1-24**] 18:48
T: [**2104-1-27**] 17:16
JOB#: [**Job Number 26764**]
|
[
"4019"
] |
Admission Date: [**2164-10-8**] Discharge Date: [**2137-3-18**]
Date of Birth: Sex: M
Service:
CHIEF COMPLAINT: Fevers.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old male with
a past medical history significant for end-stage renal
disease, hypertension, type 2 diabetes, status post right
pontine CVA, retinopathy, left brachiocephalic DVT, and
several admissions in the past for CVA, rule out myocardial
infarction, and change in mental status. The patient was
recently discharged on [**9-25**] for a chief complaint of
change in mental status and for repair of a left upper
extremity fistula thrombus.
The patient presented during this admission with a chief
complaint of temperatures of 102 on [**10-4**] and fevers
and chills. He was seen in the Emergency Department, where
his potassium level was measured to be 7.9. The patient
received calcium gluconate, glucose, Kayexalate. He had no
EKG changes. The patient also had a period of hypotension
with systolic blood pressure in the 80s. At that point,
Dopamine was started. Many attempts were made at placing an
intrajugular central line, but were unsuccessful. The
patient was then transferred to the Medical Intensive Care
Unit.
On admission to the Medical Intensive Care Unit, the patient
would open his eyes to voice. He was moaning occasionally.
He did not follow any commands.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis.
2. Type 2 diabetes.
3. Status post right pontine CVA in [**2164-1-18**].
4. Hypertension.
5. Retinopathy.
6. Hypertriglyceridemia.
7. Tinnitus.
8. Past alcohol abuse.
PAST SURGICAL HISTORY:
1. Right common femoral-dorsalis pedis bypass.
2. Left brachiocephalic thrombectomy with angioplasty in
early of [**2164-9-17**].
3. Status post right femoral fracture repair.
MEDICATIONS:
1. Plavix 75 mg q.d.
2. Lipitor 10 mg q.d.
3. Renagel.
4. Zoloft 25 mg q.d.
5. Colace 100 mg b.i.d.
6. Folate 1 mg q.d.
7. B12 25 mg q.d.
8. Lopressor 12.5 mg b.i.d.
9. Captopril 12.5 mg t.i.d.
10. Aspirin 325 mg q.d.
11. NPH insulin, regular insulin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient resides in a nursing home.
PHYSICAL EXAM: On admission to the Medical Intensive Care
Unit, the patient was afebrile with a temperature of 98.0,
blood pressure 141/78, respiratory rate 21, heart rate 109,
and 100% on nonrebreather mask. He was an elderly-appearing
man lying in bed, tachypneic, and responsive to voice, but
unable to follow commands. His pupils were small and
minimally reactive to light. His mucous membranes were dry.
His conjunctivae were injected. His neck had bilateral
hematomas secondary to central line placement attempts. His
heart had a normal S1, S2 with distant heart sounds, but no
murmurs, rubs, or gallops appreciated. His lungs were
difficult to assess secondary to patient's cooperation, but
were diffusely rhonchorous. His abdomen was soft with mild
voluntary guarding. He had no hepatosplenomegaly. His left
and right upper extremities were edematous. He had an area
of a hematoma over the left fistula site. The hematoma was
warm to touch. Bruit could be auscultated over the hematoma.
He had faint dorsalis pedis pulses bilaterally.
LABORATORIES: In the Emergency Department, the patient's CBC
was as follows: White blood cell count 11.3, hematocrit
33.5, platelets 324. His INR was 1.2. His electrolytes were
as follows: Sodium 134, potassium 7.9, chloride 94, bicarb
31, BUN 71, creatinine 8.3, glucose 343. His calcium was
10.4, albumin 2.6, magnesium 2.3. His AST was 69, ALT 40, CK
50, alkaline phosphatase 160. His amylase was 66. T
bilirubin 0.4, lipase 60. His urinalysis was positive for
trace blood, 50 of protein, 1,000 of glucose, no ketones, no
leukocyte esterase, no white blood cells, and no bacteria.
HOSPITAL COURSE BY PROBLEMS:
Fevers: In the Medical Intensive Care Unit, the patient was
temporarily placed on dopamine to restore his blood
pressures. He immediately became hemodynamically stable.
The source of his fevers even after transfer to the floor on
hospital day three was unclear. His blood cultures had been
obtained several times during his hospital course. Out of
his many sets of blood cultures, only one set grew
gram-negative Staphylococcus. His urinalysis done on the day
of admission was negative. His chest x-rays continuously
showed bibasilar atelectasis.
He was started empirically on Zosyn, Flagyl, and Vancomycin
was dosed randomly for a level less than 15. Since it was
unclear exactly what the source of his fevers was, and
because the patient was complaining of left hip pain, there
was a question of whether he might have a retroperitoneal
abscess. At that point, it was decided to do a CT of his
chest, abdomen, and pelvis to rule out any abscesses. the CT
was negative except for right lung atelectasis.
Also during his hospital stay, his central line, which had
been placed in his right subclavian, was changed after one
week since the patient continued to spike temperatures with
the highest temperature of 100.5 on hospital day seven. A
new line was placed in the right internal jugular vein.
It is also unclear whether the hematoma over his left arm
fistula could potentially be infected leading to his
continued temperatures. Transplant Surgery was consulted
regarding whether the hematoma needed to be evacuated. They
did not find that this was necessary at the time.
After the central line had been changed, it was decided that
the antibiotics should be discontinued since it was unclear
what we were treating. The antibiotics were stopped. The
patient did not spike a temperature for 24 hours. It was
determined at this point, that it would best for the patient
to be transferred back to his nursing home from an infectious
disease standpoint. The patient symptomatically, towards
the end of his hospital stay had significantly improved. He
was able to have a conversation with the physicians as well
as the nursing staff.
Arteriovenous fistula: On [**10-9**], the patient
underwent an ultrasound of his left arm due to the left
hematoma over his A-V fistula site. The ultrasound showed a
patent deep venous system, patent left arteriovenous graft,
and a large hematoma. Transplant Surgery was consulted, who
recommended a fistulogram to rule out a pseudoaneurysm. The
fistulogram showed a small pseudoaneurysm with no
communication with the hematoma.
The Surgery team suggested that a repair be done for the
pseudoaneurysm, but that it was not emergent, and the
patient's fever should be cleared prior to surgery. At that
point, his Plavix was restarted. After the patient's
temperatures had resolved towards the end of his hospital
stay, Transplant Surgery was reconsulted. They determined
that it was not necessary to operate at this time, and could
be done at a future date. They stated that the hematoma over
the fistula site was an unlikely source of his temperatures.
Type 2 diabetes mellitus: The patient was placed on a
regular insulin-sliding scale throughout his hospital stay.
His blood glucose levels were monitored daily through
fingersticks. His blood glucose levels were well controlled
during his hospital course.
End-stage renal disease on hemodialysis: The patient
received hemodialysis on the same schedule as prior to
admission. He was sent down to hemodialysis on Mondays,
Wednesdays, and Fridays. He was closely monitored by the
Renal team, and his electrolytes were closely monitored.
Fluids, electrolytes, and nutrition: Patient's diet was
slowly advanced during his hospital stay. Towards the end of
his admission, he was tolerating thicken liquids and puree
solids.
Orthopedics: During his hospital stay, the patient had
complaint of left hip pain, and there was continued
tenderness on palpation of his left hip. Plain x-rays were
done, which did not reveal any signs of fracture, but did
show degenerative joint disease. A CT of the pelvis was also
done to rule out any abscess. The CT was negative for any
signs of abscess.
The patient steadily improved during his hospital stay. His
mental status had improved. The source of his temperatures
was still unclear. However, the patient was afebrile for a
period greater than 24 hours prior to discharge. His white
blood cell count was well within normal range. His blood
cultures continue to show no growth to date. Thus, it was
decided that all antibiotics could be stopped and the patient
would be discharged back to his nursing facility.
DISCHARGE STATUS: Discharged to nursing facility.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Fevers of unknown origin.
2. Chronic renal failure.
3. Hyperkalemia.
4. Left arm hematoma.
5. Left arm arteriovenous fistula pseudoaneurysm.
6. Confusion.
DISCHARGE INSTRUCTIONS: The patient was told to call his
doctor if he experienced any further fevers, increased pain,
or other worrisome symptoms. He was told to followup with
his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**].
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q.d.
2. Atorvastatin calcium 10 mg p.o. q.d.
3. Renagel 800 mg p.o. t.i.d.
4. Zoloft 25 mg p.o. q.d.
5. Colace 100 mg p.o. b.i.d.
6. Folic acid 1 mg p.o. q.d.
7. Vitamin B12 250 mcg p.o. q.d.
8. Metoprolol 12.5 mg b.i.d.
9. Aspirin 81 mg p.o. q.d.
10. Regular insulin regimen prior to admission.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**MD Number(1) 20316**]
Dictated By:[**Name8 (MD) 4955**]
MEDQUIST36
D: [**2164-10-17**] 13:54
T: [**2164-10-17**] 13:56
JOB#: [**Job Number 24882**]
|
[
"5849",
"40391",
"5180"
] |
Admission Date: [**2168-9-10**] Discharge Date:[**2168-9-20**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85 year old
female who was admitted on [**2168-9-10**]. She complained of
two days of generalized abdominal pain, increasing abdominal
distension and vomiting times one.
PHYSICAL EXAMINATION: On physical exam her temperature was
100.4 degrees. She was markedly distended. She did not
display guarding, but she had mild diffuse tenderness. CT
scan of the abdomen and pelvis was done which showed a
perforated appendix and a small loculated fluid collection at
the base of the appendix with air.
HOSPITAL COURSE: The patient was taken to the operating room
on the 28th and underwent open appendectomy. Surgeon was
Dr. [**Last Name (STitle) **]. Findings included a necrotic appendix tip
perforated at the base and with stool in the abdomen.
Peritoneal fluid grew out 4+ gram positive rods, 2+ gram
positive cocci. She was put on levofloxacin, Flagyl,
ceftazidime. The patient was then transferred to the SICU.
She was then transferred to the floor. The patient had blood
culture that grew out gram negative rods which eventually
were typed as Bacteroides fragilis. Thus, the patient was
continued on levofloxacin and Flagyl.
By [**9-19**] the patient's central venous line was taken out.
The patient was advanced to a full [**Doctor First Name **] diet. The patient was
put back on all her p.o. medications. She was afebrile,
passing gas and deemed ready for discharge to rehabilitation
as of [**9-19**].
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**]
Dictated By:[**Dictator Info 96004**]
MEDQUIST36
D: [**2168-9-19**] 07:39
T: [**2168-9-19**] 14:57
JOB#: [**Job Number 96005**]
|
[
"25000",
"2449",
"496",
"4019"
] |
Admission Date: [**2134-8-23**] Discharge Date: [**2134-9-4**]
Date of Birth: [**2060-10-15**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Macrobid / Sulfa (Sulfonamide Antibiotics) / vancomycin
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Left hip wound dehisence
Major Surgical or Invasive Procedure:
Ultrasound-guided drainage of left hip fluid collection
History of Present Illness:
Ms. [**Known lastname 80702**] is a 73yo female with history of HTN, COPD, anxiety,
and bilateral hip replacement s/p left THA in [**10/2133**] c/b poor
healing, wound dehiscence and possible infection, who is
transferred to [**Hospital1 18**] from OSH for further evaluation of possible
infection.
.
Patient underwent L THA at [**Hospital3 **] in [**10/2133**], and has
had a complicated post-op course including prolonged rehab stay,
poor wound healing and wound dehiscence, but per report multiple
work-ups (including cultures) for L hip infection have been
negative. However, was some concern for infection, and patient
has been on empiric antibiotics with penicillin VK for
approximately 2 months. Two days ago, patient states she lost
her balance while going up stairs, but denies falling or hitting
her hip. Was caught by her husband. She later noted a feeling
of warmth at her incision site, and found the wound had opened
and was draining blood and whitish material. Denies any odor to
the drainage. Has had intermittent fevers at home, but she
cannot state how often these occur or how high her temp has
been. Did have temp of 100.3 last evening. Also reports she
has had some drainage of the wound before, but she cannot
clarify details. Given worsening pain in left hip and difficulty
ambulating [**1-20**] pain, presented to OSH ED and was then
transferred to [**Hospital1 18**] for further evaluation.
.
In the ED, initial VS were 97.7 78 106/56 16 95%. Exam notable
for 1 cm wound dehiscence with serosanguinous drainage,
surrounding induration and warmth, but no fluctuance or
erythema. She had limited flexion, internal and external
rotation of left hip secondary to pain. Labs notable for ESR
80, CRP 54. No leukocytosis, and chem7 WNL. Hct 28.5 with MCV
81. Imaging notable for 11x16x9-mm subcutaneous heterogeneous
fluid collection communicating with skin, which does not appear
to communicate with bone per ortho resident who spoke with
radiologist. Patient seen by ortho consult resident, who will
staff patient with attending in morning. Recommended admission
to medicine, and will discuss need for possible L hip
aspiration.
.
Given concern for infection, patient started on empiric abx in
ED with vancomycin 1gm. However, she developed acute onset of
dyspnea concerning for anaphylatic reaction, with desat to low
80s. RR increased to 20s-30s, and patient appeared cyanotic per
report. CXR did not show any evidence of flash pulm edema. Had
already received albuterol nebs. Was placed on NRB, and
received pepcid 20mg IV, diphenhydramine 50mg IV, and solumedrol
125mg IV with improvement in symptoms. Was quickly weaned to 2L
NC, with sats in high 90s. Was observed in ED, given dose of
linezolid, and then admitted to floor.
.
On arrival to floor, patient appears comfortable and states
dyspnea has resolved. She has ongoing left hip pain.
.
ROS: Has dyspnea at baseline, currently improved from acute
worsening in ED. Chest tightness that improves with Symbicort.
Denies frank CP. Reports occasional palpitations and
non-productive cough. Intermittent fever/chills/diaphoresis at
home. Has chronic HA for which she takes fioricet. HA not
associated with vision changes. Patient does have left eye
blindness s/p injury several years ago. Had nausea in ED during
reaction to vanco, but no nausea. Denies abdominal pain,
diarrhea, constipation, melena, or hematochezia. Has lost
weight, unclear amount. No dysuria, but has had urinary
incontinence since her surgery. No sore throat or nasal
congestion. No myalgias or arthralgias other than left hip/leg
pain as above.
Past Medical History:
MEDICAL HISTORY:
HTN
COPD
Anxiety
h/o UTIs
Urinary incontinence
.
SURGICAL HISTORY:
s/p bilateral hip replacement, left THA was in [**10/2133**]
s/p cholecystectomy
s/p appendectomy
s/p hysterectomy
Social History:
Patient retired. Lives with husband and has daily [**Name (NI) 269**] for wound
care. Denies any tobacco, alcohol, or illicit drug use at
present. Former smoker for ~20 years, quit >12 years ago.
Using walker to ambulate.
Family History:
Father had heart disease.
Physical Exam:
VS: 100.8 151/73 101 22 97% 2L, weight 130 pounds
ADMISSION PHYSICAL EXAM:
GENERAL: elderly female, resting in bed, NAD
HEENT: NC/AT, right pupil reactive, patient blind in left eye
[**1-20**] to prior accident, EOMI, sclera anicteric, MMM, OP clear
NECK: supple, no cervical LAD, no JVD
HEART: borderline tachycardic, regular, no r/m/g
LUNGS: CTAB, no wheezes/crackles/rhonchi, good air movement,
respirations unlabored
ABDOMEN: bowel sounds present, soft, non-distended, mild
tenderness to palpation in RUQ with minimal guarding but no
rebound, no organomegaly
EXTREMITIES: warm, well-perfused, DP/PTs 2+ bilaterally, no
edema, left lateral thigh incision with 1cm wound dehiscence
with serosanguinous drainage, surrounding induration and warmth,
possible 1cm area of fluctuance, no surrounding erythema, no
purulent drainage noted
MSK: patient able to flex and extend left hip, does report pain
with active ROM, has only mild pain on passive flexion,
internal/external rotation
NEURO: alert, oriented to person, date, hospital/[**Location (un) 86**] (thought
she was at [**Hospital1 112**]), patient with blindness left eye otherwise CN
[**1-30**] grossly intact, strength 5/5 throughout, sensation intact
to light touch, patellar reflexes 2+ bilaterally
.
DISCHARGE PHYSICAL EXAM:
GEN: NAD
Ab: soft, non-distended
LLE: left lateral thigh incision with 1cm wound dehiscence with
serosanguinous drainage, SILT s/s/t/dp/sp, [**4-22**] gs/ta/[**Last Name (un) **], 2+
dp/pt
Pertinent Results:
ADMISSION EXAM:
---------------
[**2134-8-23**] 04:50PM SED RATE-80*
[**2134-8-23**] 04:50PM PLT COUNT-356
[**2134-8-23**] 04:50PM NEUTS-67.0 LYMPHS-22.3 MONOS-7.7 EOS-2.6
BASOS-0.3
[**2134-8-23**] 04:50PM WBC-6.1 RBC-3.51* HGB-9.8* HCT-28.5* MCV-81*
MCH-28.0 MCHC-34.6 RDW-14.8
[**2134-8-23**] 04:50PM CRP-54.0*
[**2134-8-23**] 04:50PM proBNP-745*
[**2134-8-23**] 04:50PM ALT(SGPT)-13 AST(SGOT)-21 ALK PHOS-92 TOT
BILI-0.2
[**2134-8-23**] 04:50PM estGFR-Using this
[**2134-8-23**] 04:50PM GLUCOSE-96 UREA N-17 CREAT-0.8 SODIUM-137
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
[**2134-8-23**] 05:01PM GLUCOSE-107* LACTATE-1.1 NA+-136 K+-4.2
CL--101 TCO2-25
[**2134-8-23**] 05:01PM COMMENTS-GREEN TOP
[**2134-8-23**] 07:40PM PT-12.8 PTT-18.8* INR(PT)-1.1
.
IMAGING:
INJ/ASP MAJOR JT W/FLUORO
IMPRESSION:
1. Left hip aspiration procedure with approximately 0.5 mL of
serosanguineous aspirate sent for Gram stain and culture, which
were carried directly to the laboratory after completion of
examination. Not enough aspirate was obtained for cell count and
crystals.
2. Radiopaque contrast material in the left hip joint space
courses at the
lateral aspect of the left total hip arthroplasty hardware in
the proximal
aspect of the left femur and into the subcutaneous soft tissues
of the
proximal left lateral thigh and into the skin through soft
tissue defect.
Findings indicate communication of external skin defect in left
lateral thigh with left hip joint space consistent with a left
hip articular-cutaneous fistula.
3. Small amount of contrast material is seen between metal
hardware and bone interface at medial aspect of proximal left
thigh hardware at level of second cerclage wire (1:7),
indicative of hardware loosening.
--------
MICROBIOLOGY:
JOINT FLUID LEFT HIP JOINT:
GRAM STAIN (Final [**2134-8-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2134-8-25**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
-------------
Brief Hospital Course:
Please see above HPI for more details.
Ms. [**Known lastname 80702**] had adequate pain management and worked with physical
therapy while in the hospital. The remainder of her hospital
course was uneventful and she is being discharged to home with
services on [**2134-8-26**] in stable condition in time to make her PAT
appointment at [**Hospital1 18**]. She will return for surgery with Dr.
[**Last Name (STitle) 90724**] on [**2134-8-30**].
Medications on Admission:
Metoprolol 25mg PO BID
Naproxen 250 mg PO BID
Penicillin VK 250mg [**Hospital1 **]
Symbicort 160mcg/4.5mcg 1 puff [**Hospital1 **]
Vicodin 5/500 mg prn pain
Fioricet 50/325/40 1 tab prn headache
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*56 Tablet(s)* Refills:*0*
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-20**]
Tablets PO Q8H (every 8 hours) as needed for headache.
6. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) puff Inhalation twice a day.
7. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous HS
(at bedtime) for 4 days.
Disp:*4 * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Left hip articular-cutaneous fistula.
.
Secondary diagnosis:
HTN
COPD
Anxiety
Urinary incontience
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 80702**],
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 69**]. You were hospitalized
after a fall associated with increasing leg pain. Through the
hospital course you had no fevers. During this admission, you
were found to have a fluid collection in your left hip that was
drained under ultrasound guidance. This fluid was sent for
culture, which are still pending. Imaging showed a connection
between your skin and your hip-replacement hardware, known as an
articular-cutaneous fistula. Orthopedics was consulted during
this admission, and they have recommended follow-up with Dr.
[**Last Name (STitle) 5322**] for further management of your left hip
articular-cutaneous fistula.
.
Please take your medications as directed. Please note the
following medication changes:
**NEW: Enoxaparin 1 injection SQ daily in PM
**CHANGED: None.
**STOP: Penicillin VK 250mg [**Hospital1 **]
Please keep all follow-up appointments as scheduled. Please make
a hospital follow-up appointment within 2 weeks of discharge
with your primary care doctor regarding this hospital admission.
Followup Instructions:
Department: PAT-PREADMISSION TESTING
When: THURSDAY [**2134-8-26**] at 10:40 AM
With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**]
Building: CC [**Location (un) 591**] [**Location (un) **]
[**2134-8-30**] RESECTION ARTHROPLASTY / REMOVAL OF THR IMPLANTS LEFT
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"2851",
"5990",
"4019",
"496"
] |
Admission Date: [**2173-3-2**] Discharge Date: [**2173-3-18**]
Date of Birth: [**2094-11-19**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Percocet
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
acute confusional state
Major Surgical or Invasive Procedure:
lumbar puncture
mechanical ventillation
History of Present Illness:
The patient is a 78 year old left handed man with hypertension,
status post aortic valve replacement in [**2166**] (porcine),
hypercholestrolemia, status post partial lung resection
[**2172-12-4**], who was brought to the ED [**3-2**] after confusion x1 day.
.
A fellow priest noted that the patient was confused in the
morning of the day of presentation. The confusion progressed and
by pm the patient was only able to mumble. He also had an acute
onset of frontal headache and eye pain that started 10 hours
following the onset of confusion.
.
The PCP was [**Name (NI) 653**] and after evaluation he was brought to the
ED per EMS. The code stroke team was activated as it was not
clear at that time that the confusion had [**Doctor First Name **] going on for half
a day. The patient was noted per ED note to have phonemic
paraphasias, R sided neglect, and ? R hemianopsia. NIHSS~6. A
CT head with motion artifact showed no apparent hemorrhage,
mass, edema, and no obvious infarct except for a chronic
appearing infarct in the L caudate head. At that time, the
patient was deemed a candidate for IV tPA. After tPA he was
tranferred to the unit for further observation and management.
.
Additionally, pt denied HA, diplopia, blurry vision, tinnitus,
vertigo, dysphagia, dysarthria, incoordination, focal
weakness/numbness. No fever or chills, weight loss, SOB, chest
pain or pressure, palpitations, nausea, vomitting, abdominal
pain, constipation, diarrhea, muscle aches, joint pains, rash or
dysuria.
Past Medical History:
1. Aortic valve replacement/Coronary artery bypass graft with
LIMA graft [**2166**]
2. Right-hip replacemt [**2164**] with revision
3. Hypertension
4. Ankylosing spondylitis
5. Right thoracoscopy with multiple wedge excisions [**2172-12-4**],
with multiple intercostal nerve blocks
6. Left pleural effusion, trapped left lower lobe (fibrothorax)
in [**10-12**]
7. Hypertension
Social History:
[**Hospital1 13820**] Priest x 60 [**Name2 (NI) 1686**], lives [**Street Address(1) 95767**]- [**Location (un) **]-
gets meals there
Is still working as a Priest. Drinks alcohol socially.
Family History:
non-contributory
Physical Exam:
Per ED note:
VS: afebrile 80s 194/90s 18 95%ra
General: WNWD, NAD
HEENT: Anicteric, MMM without lesions, OP clear
Neck: Supple, no LAD, no carotid bruits, no thyromegaly
CV: RRR s1s2 2/6 SEM
Resp: CTAB no r/w/r
Abd: +BS Soft/NT/ND no HSM/masses
Ext: No c/c/e, distal pulses intact
Skin: No rashes, petechiae
.
MS: alert, oriented to person, place, cannot name date,
interactive, following most midline and appendicular commands
Memory [**4-9**] immediately & w/o prompting at 5 minutes
difficulty naming and repeating; multiple phonemic paraphsias
Evidence of R sided neglect with visual and tactile stimulation
CN: I - not tested, II,III - PERRL([**5-10**] bilat), apparent R
hemianopsia versus neglect; III,IV,VI - EOMI though attends
moreso to the left, no ptosis, no nystagmus; V- sensation
intact
to LT/PP, responds to nasal tickle, masseters strong
symmetrically; VII - no apparent facial weakness/asymmetry; VIII
- hears finger rub B; IX,X - voice normal, palate elevates
symmetrically, gag intact; [**Doctor First Name 81**] - SCM/Trapezii [**6-11**] B; XII - tongue
protrudes midline, no atrophy or fasciculations
Motor: nl bulk and tone, no tremor, rigidity or bradykinesia.
No
pronator drift.
Deltd Bicep Tricp ECR/U ExDig FlDig DorsI OppPB
Axill mscut [**Month/Day (1) 21443**] [**Name6 (MD) 21443**] [**Name8 (MD) 21443**] md/ul ulnar medin
C5 C5-6 C7 C6-7 C7 C8 T1
C8-T1
L 5 5 5 5 5 5 5
5
R 5 5 5 5 5 5 5
5
Ilpso Qufem Hamst TibAn [**First Name9 (NamePattern2) 2778**] [**Last Name (un) 938**]
Femor femor [**First Name9 (NamePattern2) 21444**] [**Last Name (un) 18709**] tibil dpper
L1-2 L3-4 L5-S2 L4-5 S1-2 L5
L 5 5 5 5 5 5
R 5 5 5 5 5 5
DTRs: [**Name2 (NI) **] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar
L 2 2 2 2 2 down
R 2 2 2 2 2 down
Sensory: w/d to pinch throughout, though extinguishes to DSS on
right
Coord: no apparent dysmetria or ataxia with mvmnts
Gait: not assessed
Pertinent Results:
[**2173-3-2**] 10:00PM WBC-6.4 RBC-3.95* HGB-12.2* HCT-36.7* MCV-93
MCH-30.8 MCHC-33.2 RDW-13.4
[**2173-3-2**] 10:00PM NEUTS-76* BANDS-0 LYMPHS-9* MONOS-13* EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2173-3-2**] 10:00PM PLT COUNT-206
[**2173-3-2**] 09:00PM GLUCOSE-110* UREA N-23* CREAT-1.0 SODIUM-133
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-29 ANION GAP-16
[**2173-3-2**] 09:00PM CK(CPK)-104
[**2173-3-2**] 09:00PM CK-MB-3 cTropnT-<0.01
[**2173-3-2**] 08:00PM GLUCOSE-112* UREA N-23* CREAT-1.0 SODIUM-132*
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-28 ANION GAP-16
[**2173-3-2**] 08:00PM PT-11.7 PTT-26.4 INR(PT)-0.9
.
CT head [**3-2**]: These images are all markedly limited by motion
artifact in spite of being repeated three additional times. Even
the last series is significantly limited. However, there is no
obvious intracranial hemorrhage. There are mild age-related
involutional changes, and greater atrophy within the cerebellum.
There is no mass effect, hydrocephalus or shift of the normally
midline structures. The [**Doctor Last Name 352**]-white matter differentiation
appears preserved but there are hypodensities in the right
subinsular cortex, and one in the left subinsular cortex as well
as left cerebellum, probably from small prior infarctions.
The visualized mastoid air cells and paranasal sinuses are
clear.
There are calcifications of the vertebral and cavernous carotid
arteries.
IMPRESSION: No evidence of intracranial hemorrhage or acute
process.
.
CT head [**2-22**]:
Comparison is limited by motion on the prior scan. However,
there appears to be a new focus of hyperdensity in a right
frontal gyrus (image 22). Although partly obscured by motion on
the prior study, this focus was not seen previously. A tiny
calcification in the left cental sulcus. In retrospect, this
focus was probably present on the prior study.
There is no evidence of infarction, and there are no other areas
of suspicion for hemorrhage.
Conclusion: Possible tiny focus of hemorrhage in the right
frontal lobe, possibly an acute bleed. This appears new since
[**2173-3-2**], but the prior scan was limited by motion. There is a
tiny calcification in the left central sulcus.
No other evidence of hemorrhage or infarction.
.
CXR: IMPRESSION: Markedly suboptimal film with possible process
involving the left parenchymal base.
.
ECHO: The left atrium is mildly dilated. There is asymmetric
left ventricular hypertrophy. The left ventricular cavity is
small. Left ventricular systolic function is hyperdynamic (EF
70-80%), with apical cavity obliteration. An apical
intracavitary gradient is identified (rest: 7 mmHg, Valsalva: 58
mmHg). No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The aortic prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. No masses or vegetations are seen on
the aortic valve. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The left ventricular
inflow pattern suggests impaired relaxation. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2172-10-8**], probably no major
change. The absence of a vegetation by 2D echocardiography does
not exclude endocarditis if clinically suggested.
.
US Carotids: 40-59% right ICA stenosis. Less than 40% left ICA
stenosis
.
VIDEO SWALLOW [**2173-3-17**]:
Pt presents with a mild oral and pharyngeal dysphagia
characterized by mildly reduced oral control, mild swallow delay
and delayed laryngeal valve closure. The pt had one episode of
trace aspiration when taking a larger sip of thin liquid.
Aspiration was silent, but cued coughs were effective at
clearing
the aspirate material. The risk for trace aspiration was reduced
by taking single, small sips of thin liquid. The pt was also
noted to have increased oral control compared to the last
videoswallow and is now able to tolerate a PO diet of thin
liquids and soft consistency solids. Pt should only take single,
small sips of thin liquid. Pt was unable to swallow the barium
tablet whole during the study, and should continue to have his
pills crushed with purees.
.
RECOMMENDATIONS:
1. Suggest advancing to a PO diet of thin liquids and soft
consistency solids. 2. Pt should only take single, small sips of
thin liquid. No Straws! 3. Please crush all pills and give them
with purees.
Brief Hospital Course:
78M with hx of AVR/CABG, s/p lung resection who presented to
[**Hospital1 18**] on [**3-2**] with confusion and found to have global aphasia
s/p tPA for presumed stroke but no positive imaging who was
initially given TPA and admitted to the ICU. He was then
re-transfered to the ICU for acute bradycardia with hypotension
and unresponsiveness. The bradycardia and hypotension was felt
to be due to IV lopressor effect, and possibly due to pneumonia
and sepsis. An ABG at that time returned 6.94/151/101 and he
was emergently intubated. Femoral central access was obtained
and he was transiently on Levophed for pressure support. He was
intubated from [**3-8**] - [**3-11**], and his mental status then resolved
after treating his hypercapnea and pneumonia. He was continued
on a course of levaquin for staph aureus pneumonia, and his
mental status remained stable. He was re-evaluated by neurology
after his mental status improved and was felt to have no focal
neurologic deficits. In fact, there was sufficient doubt as to
whether or not he actually had a stroke on presentation since no
evidence of a stroke was ever found. His mental status changes
may have been due to sepsis and respiratory failure -
toxic/metabolic etiologies.
.
For the 3-4 days prior to discharge his mental status remained
clear and he continued to have improving swallowing function.
He completed a course of Levaquin for his penumonia, and he was
afebrile.
.
His code status is DNR/DNI.
Medications on Admission:
ASPIRIN 325MG--One tablet by mouth every day
ATENOLOL 25MG--Take [**2-8**] tablet daily
LIPITOR 20MG--One tablet by mouth every day
NAPROSYN 375MG--One tablet by mouth every day
UNIVASC 7.5MG--One tablet by mouth every day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain: not to exceed 4g/day.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 59514**] Friary
Discharge Diagnosis:
stroke
respiratory failure
aspiration pneumonia
hypertension
Discharge Condition:
good
Discharge Instructions:
Please follow-up with your primary care doctor or with a new
primary care doctor in [**2-8**] weeks.
Followup Instructions:
Please follow-up with your primary care doctor or with a new
primary care doctor in [**2-8**] weeks.
.
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Date/Time:[**2173-3-8**] 2:30
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2173-3-8**] 4:00
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**], MD Phone:[**Telephone/Fax (1) 7477**] Date/Time:[**2173-3-22**]
9:45
|
[
"51881",
"5070",
"99592",
"2760",
"4280",
"42789",
"4019",
"2859"
] |
Admission Date: [**2106-3-1**] Discharge Date: [**2106-3-6**]
Date of Birth: [**2032-12-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
[**2106-3-1**] Aortic Valve Replacement (23mm CE pericardial tissue
valve)
History of Present Illness:
73 y/o female hospitalized in [**11-25**] for congestive heart
failure. Improved with diuresis. Work-up revealed severe aortic
stenosis.
Past Medical History:
Aortic Stenosis, Congestive Heart Failure, Hypertension,
Hypercholesterolemia, Diabetes Mellitus, Obesity,
Osteoarthritis, Left cataract, Hemorrhoids
Social History:
Denies tobacco and ETOH use.
Family History:
Father died of CVA at 55
Brother with CAD
Physical Exam:
VS: 70 12 114/72 62" 169#
General: Obese female in NAD
HEENT: EOMI, PERRLA, NC/AT
Neck: Supple, FROM, -JVD
Lungs: CTAB -w/r/r
Heart: RRR, 4/6 SEM (murmur radiates to carotids)
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
Echo [**3-1**]: PRE-CPB: 1. The left atrium is normal in size. No
spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage. A left-to-right shunt across
the interatrial septum is seen at rest. A small secundum atrial
septal defect is present. 2. There is mild symmetric left
ventricular hypertrophy with normal cavity size. 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%). Transmitral Doppler and tissue velocity imaging are
consistent with Grade I (mild) LV diastolic dysfunction. 3.
Right ventricular chamber size and free wall motion are normal.
Right ventricular chamber size is normal. Right ventricular
systolic function is normal. 4. There are simple atheroma in the
aortic root. There are simple atheroma in the ascending aorta.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. 5. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. No masses or vegetations are seen on the
aortic valve. There is severe aortic valve stenosis (area
<0.8cm2). Trace aortic regurgitation is seen. 6. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Mild (1+) mitral regurgitation is
seen. 7. There is no pericardial effusion. POST-CPB: The
Bioprosthetic (#23 Perimount) Aortic Valve is well seated
without any paravalvular leak. No Aortic Regurgitation is seen.
The LV systolic function is well preserved. The RV systolic
function is also well preserved. There is no evidence of aortic
dissection.
Brief Hospital Course:
Ms. [**Known lastname **] was a same day admit after undergoing work-up as
an outpatient. On [**3-1**] she was brought to the operating room
where she underwent a aortic valve replacement. Please see
operative report. Following surgery she was transferred to the
CSRU for invasive monitoring in stable condition. Later on op
day she was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one chest tubes were removed and
diuretics and beta blockers were started. She was gently
diuresed towards her pre-op weight. Later this day she was
transferred to the SDU. On post-op day three her epicardial
pacing wires were removed. Physical therapy worked with patient
during hospital course for strength and mobility. She continued
to improve other the next several days with adjustment in her
medications and appeared ready for discharge home on post-op day
****.
Medications on Admission:
Aspirin 325mg qd, Lopressor 25mg qd, Lasix 40mg qd, KCl 20 mEq
qd, Zocor 10mg qd
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Congestive Heart Failure, Hypertension,
Hypercholesterolemia, Diabetes Mellitus, Obesity,
Osteoarthritis, Left cataract, Hemorrhoids
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) **] (cardiologist) in [**1-23**] weeks
Dr. [**Last Name (STitle) **] (PCP) in [**12-22**] weeks
Completed by:[**2106-3-6**]
|
[
"4241",
"4280",
"5859",
"25000",
"2720",
"40390"
] |
Unit No: [**Numeric Identifier 60907**]
Admission Date: [**2150-4-6**]
Discharge Date: [**2150-4-22**]
Date of Birth: [**2109-6-6**]
Sex: M
Service: TRA
ADMITTING DIAGNOSIS: Multiple trauma.
Mr. [**Known lastname 1557**] was a 40-year-old male who was brought into the
emergency room on the day of admission after a motorcycle
crash. He had been helmeted and crashes his motorcycle on the
highway. Subsequently, he stood up and was struck by an
oncoming car. This car did not stop at the scene, but
pedestrians phoned EMS. He was med flighted to the [**Hospital1 18**] and
en route became hypotensive and was intubated. Also en route,
he had angiocath decompression of his left chest, and he was
felt to have a pneumothorax.
On arrival to the trauma bay, his hemodynamics were unstable,
and he was tachycardic and hypotensive. He had bilateral
chest tubes placed. He had an obvious right femur deformity
and pelvic instability on exam. He had gross hematuria upon
placement of the Foley. He had his pelvis wrapped in a sheet
for stability, and with ongoing hemodynamic instability and
the requirement of blood transfusions and crystalloid, he had
a diagnostic peritoneal lavage done. This revealed no gross
blood, and white count and red count later came back at 156
and 62,500 respectively.
His chest x-ray revealed a right scapular fracture, left
clavicular fracture, multiple bilateral rib fractures, and
subcutaneous air. Pelvic fracture revealed an open-book
pelvis with a wide diastasis. Significant labs were that of a
hematocrit of 26.4, a lactate of 6.9, and a creatinine of
1.7.
After initial resuscitation and after interpretation of the
diagnostic peritoneal lavage as being negative, he was taken
to the angio suite, where he had bilateral internal pudendal
arteries and bilateral anterior gluteal arteries embolized
for active bleeding. He also had an aortogram of the arch to
rule out any aortic injury. He was brought to the ICU, where
he continued to be hemodynamically unstable requiring nearly
30 units of pack cells in total, and 22 units of plasma, and
22 units of platelets. His lactate remained elevated and his
blood pressure was still not stable. His abdomen had become
distended, and the following morning, he was taken for CT
scan. On CT scan, he had a gross amount of fluid in the
abdomen consistent with blood and was felt to be
extravasating from his spleen.
He was taken immediately to the operating room where
exploratory laparotomy was performed and a splenectomy done.
Also in the operating room, there was an external fixator
placed by orthopedics on his pelvis as well as his femur. He
stabilized to some degree after that, and was brought back to
the intensive care unit. His significant events from that
point included an inferior vena cava filter that was placed
on hospital day 3 for prophylaxis against the complications
of DVT. He had returned to the operating room on hospital day
#5 for internal fixation of his femur and pelvis. On hospital
day #6, he returned to the operating room for closure of his
abdomen.
Initially, his abdomen had been left open and secured with a
[**Location (un) 5701**] bag as he was too distended to be closed. From a
neurological standpoint, he was showing some evidence of
movement and had a CAT scan of his head that showed no
damage. His kidneys were starting to show evidence of
failure, and he had rhabdomyolysis with elevated CKs, which
was being treated with alkalinization of his urine.
On approximately hospital day #10, after attempts at
ventilator weaning had failed, decision was made to place a
percutaneous tracheostomy tube. After discussions with the
family and consent was obtained, this was attempted at the
bedside. This was complicated by mild hypoxia in conjunction
with hyperkalemia that led to a cardiac arrest. CPR was
initiated immediately, and he regained a rhythm and a blood
pressure. Subsequent to that event, his neurologic status
deteriorated, and he slowly showed worsening of brainstem
function. He was kept ventilated with a tracheostomy for the
days to follow.
His gastrointestinal system was intact for feeding purposes,
but he did have an elevated bilirubin in the mid portion of
his hospital course as high as 28. This was presumed to be
from his massive blood transfusion requirement. His bilirubin
came down, but later in his course after the cardiac arrest,
he started to have an elevation of his transaminases. On
consulting with cardiology and hepatology, it was felt that
this was secondary to right heart failure that had come about
after his cardiac arrest. They had no specific prescription
for this.
From an infectious disease standpoint, he had multiple
cultures taken for intermittent fevers throughout his
admission. He had blood cultures that grew out both coag-
negative Staph and later vancomycin-resistant Enterococcus.
This is treated initially with vancomycin until the
enterococcal species came back, and he was eventually changed
to linezolid. All lines were changed appropriately, and at
the time of discharge, those results are still pending.
On the weekend prior to his eventual expiration, he underwent
a MRI of his head and spine as his neurological condition was
not improving and there was some note of decreased rectal
tone to go alone with the spiking fevers that he was having.
There was some concern that he had hypoxic brain injury as
well as a small concern that he could have a spinal cord
abscess causing neurological dysfunction and fever. While in
the MRI scanner, despite frequent suctioning, he had mild
episodes of hypoxia and again in the setting of some mild
hyperkalemia, experienced a second cardiac arrest. Of note,
he had been undergoing daily hemodialysis around this time to
combat this hyperkalemia. This arrest lasted approximately 3
minutes, and he was stabilized and again brought to the
intensive care unit.
He subsequently had worsening of his neurologic status and
neurology became involved. Because of the arrest, the MRI of
the head was never completed. On neurological exam, he
eventually lost nearly all brainstem reflexes including cold
calorics, corneals, and pupillary reflexes. He had an EEG
done, which showed severe diffuse encephalopathy, but did not
necessarily fulfill the criteria for lack of cerebral
activity.
On the morning of his eventual demise, he underwent an apnea
test, which he passed. He, after approximately 1.5 minutes
off the ventilator, did start to have spontaneous
respirations. Therefore, the criteria for brain death was not
met. Subsequent to this, a family meeting took place after
consulting with nephrology between the family, the ICU team,
and the trauma team. After long discussion as to his current
condition and grave prognosis, the family decided to pursue
comfort measures only and withdrew ventilator support. He
expired shortly thereafter. The medical examiner was
contact[**Name (NI) **] and accepted the case for postmortem examination.
DATE OF EXPIRATION: [**2150-4-22**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Last Name (NamePattern1) 60908**]
MEDQUIST36
D: [**2150-4-22**] 16:43:22
T: [**2150-4-23**] 08:32:59
Job#: [**Job Number 60909**]
|
[
"2851",
"5845",
"2767",
"4280"
] |
Admission Date: [**2157-12-2**] Discharge Date: [**2157-12-11**]
Date of Birth: [**2079-7-2**] Sex: F
Service: SURGERY
Allergies:
Hydromorphone / Vicodin / Percocet
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Right Colon Infarction
Major Surgical or Invasive Procedure:
open right hemi-colectomy
History of Present Illness:
Ms [**Known lastname 79974**] is a 78 yo F with a history of severe vascular
disease including s/p fem/[**Doctor Last Name **] bypass. The patient was discharged
from [**Hospital1 18**] on [**11-29**] after placement of a celiac stent complicated
by a brachial artery pseudoaneurysm. The patient was doing well
s/p stent when she presented to an OSH with acute right sided
abdominal pain. Given her history the patient underwent a CT
scan that showed pneumatoses with portal venous gas and was
transferred to [**Hospital1 18**] for surgical management. Prior to transfer
the patient was given zofran and morphine.
.
In the [**Hospital1 18**] ER the patient was initially found to be febrile to
99 with BP 195/70, HR 75 and 100 % RA. She was given morphine
IV, Zofran, hydralazine, zofran phenergan, vancomycin, zosyn and
lopressor. Also possibly unasyn given.
.
Patient was initially admitted to the surgical service and had a
right colectomy done [**12-2**]. Intraoperative findings included a
pale right colon without perforation and clear transition points
that was resected with primary anastamoses. The patient
received IV fluids, labetolol and hydralazine perioperatively
and had a brief episode of hypotension requiring pressors.
.
Past Medical History:
Chronic mesenteric ischemis/celiac artery stenosis and SMA
occlusion
Crohn's disease
HTN
GERD
PVD
Hyperlipidemia
CAD
Past surgical history:
Ileocecectomy [**2154**]
R fem-[**Doctor Last Name **] bypass [**2152**]
L fem-[**Doctor Last Name **] bypass [**2150**]
Social History:
Occasional EtOH. 50 PY tobacco, quit 4 years ago. The patient's
son lives with her. She is independent of all ADLS and IADLs.
She still drives. She walks without a walker or cane. She fell
twice in [**Month (only) **] but not since. + spectacles. + dentures. no
hearing aides. No home services. Her son helps her with the
housework. She is a retired homemaker. She was widowed 22 years
ago. She has a 54 pkyear smoking history.
Family History:
She suspects that her mother had [**Name (NI) 4522**] disease but was never
diagnosed. Her father was in good health and died at 90. All 4
children and grandchildren in good health.
Physical Exam:
VS 98.0 70 180/68 20 97 RA
Gen: WN, NAD
HEENT: NCAT, neck is supple
CV: RRR, S1S2. There is b/l LE pitting edema, 2+
Lungs: CTAB, good BS b/l
Abd: Soft, mildly distended, appropriatley tender, incision is
c/d/i. There are several areas of ecchymosses throughout her
abdomen
Ext: several areas of ecchymosses in all 4 ext
Pertinent Results:
[**2157-12-2**] 06:05AM BLOOD WBC-19.0*# RBC-4.15* Hgb-12.6 Hct-36.8
MCV-89 MCH-30.4 MCHC-34.2 RDW-16.4* Plt Ct-347
[**2157-12-2**] 03:20PM BLOOD WBC-15.0* RBC-3.83* Hgb-12.2 Hct-33.7*
MCV-88 MCH-31.9 MCHC-36.3* RDW-15.8* Plt Ct-312
[**2157-12-3**] 04:25AM BLOOD WBC-10.5 RBC-2.49*# Hgb-7.7*# Hct-22.0*#
MCV-88 MCH-30.8 MCHC-34.9 RDW-16.1* Plt Ct-275
[**2157-12-3**] 03:15PM BLOOD Hct-24.6*
[**2157-12-4**] 12:36AM BLOOD Hct-27.7*
[**2157-12-4**] 04:22AM BLOOD WBC-9.8 RBC-3.28*# Hgb-10.0*# Hct-27.7*
MCV-84 MCH-30.5 MCHC-36.2* RDW-17.0* Plt Ct-208
[**2157-12-4**] 01:00PM BLOOD WBC-10.8 RBC-3.65* Hgb-11.1* Hct-31.1*
MCV-85 MCH-30.6 MCHC-35.8* RDW-16.4* Plt Ct-207
[**2157-12-5**] 10:36AM BLOOD WBC-11.1* RBC-3.93* Hgb-12.2 Hct-34.4*
MCV-88 MCH-31.2 MCHC-35.6* RDW-16.3* Plt Ct-306
[**2157-12-5**] 01:15PM BLOOD WBC-9.4 RBC-3.82* Hgb-11.7* Hct-33.8*
MCV-89 MCH-30.6 MCHC-34.6 RDW-16.2* Plt Ct-277
[**2157-12-7**] 05:31AM BLOOD WBC-6.6 RBC-3.41* Hgb-10.1* Hct-29.5*
MCV-87 MCH-29.7 MCHC-34.4 RDW-15.8* Plt Ct-274
[**2157-12-7**] 05:31AM BLOOD WBC-6.6 RBC-3.41* Hgb-10.1* Hct-29.5*
MCV-87 MCH-29.7 MCHC-34.4 RDW-15.8* Plt Ct-274
[**2157-12-8**] 03:15PM BLOOD WBC-6.6 RBC-3.47* Hgb-10.9* Hct-30.1*
MCV-87 MCH-31.4 MCHC-36.1* RDW-15.8* Plt Ct-323
[**2157-12-2**] 06:05AM BLOOD PT-12.0 PTT-19.3* INR(PT)-1.0
[**2157-12-3**] 07:44AM BLOOD PT-14.4* PTT-28.7 INR(PT)-1.3*
[**2157-12-4**] 04:22AM BLOOD PT-13.9* PTT-26.7 INR(PT)-1.2*
[**2157-12-2**] 07:55AM BLOOD Glucose-118* UreaN-10 Creat-0.5 Na-139
K-2.8* Cl-100 HCO3-30 AnGap-12
[**2157-12-2**] 03:20PM BLOOD Glucose-194* UreaN-8 Creat-0.4 Na-137
K-3.5 Cl-105 HCO3-26 AnGap-10
[**2157-12-3**] 04:25AM BLOOD Glucose-83 UreaN-11 Creat-0.6 Na-135
K-3.9 Cl-104 HCO3-28 AnGap-7*
[**2157-12-4**] 04:22AM BLOOD Glucose-95 UreaN-12 Creat-0.4 Na-142
K-3.5 Cl-107 HCO3-28 AnGap-11
[**2157-12-5**] 10:36AM BLOOD Glucose-151* UreaN-15 Creat-0.5 Na-141
K-3.1* Cl-103 HCO3-29 AnGap-12
[**2157-12-5**] 01:15PM BLOOD Glucose-46* UreaN-14 Creat-0.5 Na-141
K-3.2* Cl-101 HCO3-27 AnGap-16
[**2157-12-6**] 04:13PM BLOOD Glucose-134* UreaN-11 Creat-0.5 Na-138
K-4.9 Cl-102 HCO3-28 AnGap-13
[**2157-12-7**] 05:31AM BLOOD Glucose-92 UreaN-10 Creat-0.4 Na-134
K-3.9 Cl-98 HCO3-30 AnGap-10
[**2157-12-8**] 05:00AM BLOOD Glucose-102 UreaN-9 Creat-0.6 Na-132*
K-3.7 Cl-91* HCO3-32 AnGap-13
[**2157-12-2**] 03:20PM BLOOD ALT-21 AST-24 AlkPhos-67 TotBili-1.2
[**2157-12-2**] 03:20PM BLOOD Albumin-3.0* Calcium-7.7* Phos-2.9
Mg-1.5*
[**2157-12-3**] 04:25AM BLOOD Calcium-7.9* Phos-4.1 Mg-2.0
[**2157-12-4**] 04:22AM BLOOD Calcium-8.1* Phos-1.9*# Mg-2.0
[**2157-12-5**] 10:36AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.1
[**2157-12-5**] 01:15PM BLOOD Calcium-8.5 Phos-2.6* Mg-2.2
[**2157-12-6**] 04:13PM BLOOD Calcium-8.3* Phos-2.8 Mg-1.9
[**2157-12-7**] 05:31AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.7
[**2157-12-8**] 05:00AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1
[**2157-12-2**] 06:11AM BLOOD freeCa-1.08*
[**2157-12-2**] 12:51PM BLOOD freeCa-1.06*
[**2157-12-2**] 01:57PM BLOOD freeCa-0.94*
CTA abd/pelvis [**2157-12-2**]:
IMPRESSION:
1. Patent celiac artery stent. Heavily calcified SMA, likely
occluded with
distal flow, probably from collaterals. Patent [**Female First Name (un) 899**].
2. Significant worsening of right and transverse colon
pneumatosis, new
portal venous gas, new free fluid, new free air and new
thickening of the
distal ileum. These findings all suggest worsening of mesenteric
ischemia.
3. Occluded right femoropopliteal bypass graft. Almost complete
occlusion of right iliofemoral bypass.
4. Atherosclerotic aorta and peripheral arteries.
5. Stable small hiatal hernia. Stable gallstones. Stable kidney
hypodensities, likely cysts.
6. Bladder distention.
7. Status post remote ileocecectomy for Crohn's disease.
Abd Xray (supine) [**2157-12-8**]:
Non dilated loops of bowel with air fluid levels . Contrast seen
within
rectum. Vascular stent in mid abdomen. Free air, pneumatosis,
and portal
venous gas seen on prior CT is not well identified on today's
study.
LLE doppler [**2157-12-9**]:
Brief Hospital Course:
The patient was transferred from an OSH and admitted from the ED
to the surgical service. She was taken to the OR for a right
hemi-colectomy and she tolerated the procedure well. She was
initially transferred to the [**Hospital Ward Name 332**] ICU. In the ICU, she
received 3 units of PRBCs, and her HCT increased appropriately.
She remained in the ICU in stable condition until [**12-4**], when
she was transferred to the 5 [**Hospital Ward Name 1950**] general [**Hospital1 **].
Due to her history of mesenteric ischemia and recent stent
placement with the vascular surgery service, she was restarted
on her home doses of ASA and Plavix on POD 1. She remained on
these medications without complication throughout her hospital
stay.
Pain:
Her pain was initially treated with IV pain medication, but she
was tolerating oral pain medication with good pain control when
she began tolerating PO.
GI/Diet:
The patient remained NPO, until post-op day 2 when she began
tolerating sips. She was slowly advanced with the return of
bowel function. She was tolerating regular food by POD 4.
However, she became nauseous on POD 5 and one episode of emesis.
She was revereted back to an NPO diet. A KUB at that time showed
some air/fluid levels. Her nausea/vomiting resolved on it's own.
She began toleratin a regular diet again prior to discharge.
Hypertension:
Throughout her hospital stay, she had transient episodes of
hypertension with SBP in the 170-200 range. This was controlled
with IV and PO metoprolol and hydralazine.
Hyponatremia:
The patient was noted to have a sodium level of 134 on POD 5.
She was treated conservatively with free water restrictions and
her sodium increased appropriately.
Lower extremity edema:
The patient was noted to have b/l LE edema on POD 3. She was
given IV lasix and this resolved. However, she was noted to have
unilateral LE edema (left) on POD 7. An ultrasound of her LE
showed no DVT.
The patient was discharged home in good condition on POD 8.
Medications on Admission:
ASA 81, plavix 75, pentasa [**2148**]", toprol 75, protonix 40,
prednisione 40, trazadone PRN
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 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
12. Metoclopramide 5 mg/mL Solution Sig: [**12-22**] Injection Q6H
(every 6 hours).
13. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 days: switch to 5mg on [**12-12**].
16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: start [**12-12**].
17. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO
three times a day.
Disp:*180 Tablet(s)* Refills:*0*
18. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Pneumatosis and portal venous air in patient with chronic
mesenteric ischemia.
2. Ischemic right colon.
3. Acute blood loss anemia
.
Secondary:
Hypertension, chronic mesenteric ischemia (celiac stenosis, SMA
out on [**10-29**] MR); Crohns; SBO '[**53**], CAD, MI, hypercholesteremia,
PVD, GERD
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
1.Please follow up with Dr. [**Last Name (STitle) 1120**] by calling her office ASAP to
make an appointment ([**Telephone/Fax (1) 3378**].
2.Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7640**] [**Telephone/Fax (1) 79975**]
as soon as possible.
.
Scheduled appointments:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2157-12-20**] 10:00
SUMMARY NEITHER DICTATED NOR READ BY ME
Completed by:[**2157-12-11**]
|
[
"2851",
"2761",
"4019",
"53081",
"2724",
"41401"
] |
Admission Date: [**2157-4-26**] Discharge Date: [**2157-5-12**]
Date of Birth: [**2110-9-29**] Sex: F
Service: GENERAL SURGERY BLUE TEAM
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
African-American woman that presented on [**4-26**] to the
Emergency Department complaining of abdominal pain, vomiting
and chills. She was recently discharged home with VNA
services after she underwent a left below the knee popliteal
bypass reverse saphenous vein graft on [**2157-4-18**] by Dr.
[**Last Name (STitle) 1391**]. It was described as an uneventful procedure which
she tolerated well. She was transferred postoperatively to
the VICU which was monitored over the next couple of days.
She was then restarted on her immunosuppressant agents which
she takes for past cadaveric renal transplant. Through that
time, she required transfusion as her hematocrit was dropping
with no clear evidence of a bleeding source. On
postoperative day 3 after this operation, she did need to be
taken back to the Operating Room for reexploration in the
Operating Room. A pulsatile arterial bleeder that appeared
to be a branch of the common femoral artery was found and was
oversewn with Prolene suture. The patient then continued to
improve and she was discharged to home on postoperative day
7. At the time of her discharge, she was afebrile and did
not have any abdominal pain. However, the next morning at
around 1 a.m., the patient then developed acute onset of
sharp abdominal pain that localized in the periumbilical
region with no radiation. She then went to the Emergency
Department for further evaluation.
PAST MEDICAL HISTORY:
1. Systemic lupus erythematosus
2. Dilated cardiomyopathy
3. Mitral regurgitation
4. Aortic insufficiency
5. End stage renal disease status post cadaveric renal
transplant in [**2151**]
6. Hypothyroidism
7. Peripheral vascular disease
8. Osteoarthritis
9. Distant history of bipolar disease
PAST SURGICAL HISTORY: (As previously mentioned)
1. Left femoral BK [**Doctor Last Name **] on [**4-18**]
2. Multiple AV fistula placements
3. Right femoral [**Doctor Last Name **] in the past
MEDICATIONS:
1. Calcitriol
2. Colace
3. CellCept [**Pager number **] [**Hospital1 **]
4. Cyclosporin 50 [**Hospital1 **]
5. Zantac
6. Roxicet
7. Methadone in the past
8. Diltiazem 240 mg po q day
9. Lopressor 25 mg po bid
10. Prednisone 10 mg po q day
ALLERGIES: THE PATIENT HAS AN ALLEGED ALLERGY TO HEPARIN
WHICH IS ACTUALLY JUST BLEEDING SECONDARY TO HEPARIN AND
ERYTHROMYCIN CAUSES NAUSEA.
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Her temperature is 98.2??????. She is in obvious
discomfort. She is tachycardic to 104. Blood pressure is
105/58.
ABDOMEN: Distended, firm. There is decreased bowel sounds,
positive rebound, positive shake tenderness.
IMAGING: CT scan showed a large 8 x 7 cm intraabdominal
abscess with free air, thus the patient immediately went to
the Operating Room for an ischemic colon. The patient
underwent a total abdominal colectomy with end ileostomy.
Dr. [**Last Name (STitle) **], the surgeon of record, Dr. [**First Name (STitle) 2819**] and Dr. [**Last Name (STitle) **]
are the first and second assistants. The findings included
an ischemic perforated transverse colon.
HOSPITAL COURSE: The patient required an extended Intensive
Care Unit stay in which she was sustained on a respirator.
She also suffered a small myocardial infarction
postoperatively and cardiology was thus involved in her care.
She was extubated on [**4-28**] and seemed to be doing well
at this time. She was, of course, npo up to this time and
her prednisone 10 mg q day and cyclosporin 50 mg [**Hospital1 **] were
restarted on [**4-29**]. She was also started on sips at
this time.
Throughout her stay in the Intensive Care Unit, one of the
major issues was constant spiking of fevers. The source was
initially unclear, although her left thigh incision appeared
to be erythematous. Two small areas were opened up and the
patient was sent to ultrasound for drainage of fluid
collection around the staple line. This fluid grew out
Methicillin resistant Staphylococcus aureus, thus the patient
was started on vancomycin. The patient continued to spike
fevers despite being put on vancomycin and she was
re-cultured in several areas. On [**5-5**], her
[**Location (un) 1661**]-[**Location (un) 1662**] culture that was collected grew out Pseudomonas
aeruginosa and infectious disease was consulted. In addition
to being on vancomycin, she was started on imipenem,
aztreonam and fluconazole. The aztreonam and imipenem is for
double coverage of Pseudomonas and the fluconazole is empiric
therapy. Renal continued to follow the patient's cyclosporin
levels and was happy with the trough levels which were in the
150 range. The patient was placed on TPN for additional
nutrition support.
NOTE: This is the end of the first dictation. An addendum
will follow.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 4039**]
MEDQUIST36
D: [**2157-5-12**] 09:24
T: [**2157-5-12**] 09:32
JOB#: [**Job Number 1738**]
|
[
"0389"
] |
Admission Date: [**2133-1-13**] Discharge Date: [**2133-1-23**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2133-1-16**] Aortic Valve Replacement(21mm St. [**Male First Name (un) 923**] Porcine Tissue
Valve)
History of Present Illness:
This is a 84 yoM with PMH of Hypertension, Aortic Stenosis,
Paroxysmal Atrial Fibrillation, Congestive Heart Failure who is
transferred from [**Hospital **] Hospital for Cardiac catheterization
for evaluation of Aortic Stenosis and possible need for surgical
correction.
.
The patient reports that he has never had SOB. His SOB began
the day of his 1st admission to [**Location (un) **]. The patient states
that he was lying in bed and became SOB, he denies CP,
palpitations, N/V or diaphoresis. He called EMS and was
admitted to [**Location (un) **] and discharged with a diagnosis of CHF. The
patient states that he was feeling much better when he got home.
The following day he awoke from sleep with bad SOB. He tried
walking to the bathroom but was severely SOB and called EMS.
Again, he denied CP, palpitations, N/V or diaphoresis. He also
denies recent fevers, chills, or cough. Prior to these episodes
he denies DOE. The patient states he was very active and was
able to perform activities such as mowing his lawn for 2 hours
without SOB.
.
Per report from [**Location (un) **], Aortic valve area is 0.9cm2 with a mean
gradient of 71mmHG.
Patient is now s/p cardiac cath. Currently he denies SOB, CP,
orthopnea, palpitations, N/V or diaphoresis. He has no other
complaints.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
*** Cardiac review of systems is notable for absence of chest
pain, palpitations, syncope or presyncope.
Past Medical History:
AS, HTN, PAF, CHF, maculare degeneration, bilateral hernia
repair, bilateral knee replacement, arthroscopy of left shoulder
Social History:
works as welder
quit tobacco 22 years ago
rare etoh
Family History:
NC
Physical Exam:
NAD HR 75 RR 13 BP 129/72
Bilateral incision both knees, healed
Lungs CTAB
Heart RRR 3/6 SEM
Abdomen benign
Extrem warm, no edema
Neuro grossly intact
Pertinent Results:
[**2133-1-13**] 07:13PM BLOOD WBC-7.6 RBC-4.52* Hgb-14.9 Hct-43.4
MCV-96 MCH-33.0* MCHC-34.3 RDW-12.5 Plt Ct-208
[**2133-1-13**] 07:13PM BLOOD PT-13.5* PTT-28.4 INR(PT)-1.2*
[**2133-1-13**] 07:13PM BLOOD Glucose-142* UreaN-19 Creat-0.9 Na-143
K-4.0 Cl-104 HCO3-30 AnGap-13
[**2133-1-13**] 07:13PM BLOOD %HbA1c-5.4
[**2133-1-14**] 05:55AM BLOOD Triglyc-87 HDL-39 CHOL/HD-3.4 LDLcalc-76
[**2133-1-13**] Cardiac Cath:
1. Selective coronary angiography of this right dominant system
revealed single vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting stenoses. The LAD had a
distal
100% occlusion with collaterals from the RCA. The LCX had a 40%
proximal stenosis. The RCA had no angiographically apparent
coronary
artery disease.
2. Resting hemodynamics revealed normal right sided filling
pressures
with RVEDP of 7 mm Hg. There were mildly elevated left sided
filling
pressures with LVEDP of 22 mm Hg and PCWP mean of 20 mm Hg.
Cardiac
index was preserved at 2.7 l/min/m2. There was moderate to
severe
aortic stenosis with mean gradient of 33 mm Hg and calculated
valve area
of 0.7 cm2. There was mild pulmonary arterial hypertension of
41/17 mm
Hg. Systemic arterial pressure was normal at 136/71 mm Hg.
3. Left ventriculography was deferred.
[**2133-1-14**] Carotid Ultrasound:
Minimal plaque with bilateral less than 40% carotid stenosis.
[**2133-1-14**] Transthoracic ECHO:
The left atrium is mildly dilated. Color-flow imaging of the
interatrial septum raises the suspicion of an atrial septal
defect, but this could not be confirmed on the basis of this
study. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild to
moderate regional left ventricular systolic dysfunction with mid
to distal septal, anterior and apical hypokinesis. No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are severely
thickened/deformed. There is moderate to severe aortic valve
stenosis (area 0.8 cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-10**]+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
[**2134-1-18**] Chest CT Scan:
1. No evidence of sternal dehiscence or sternotomy wire
fracture.
2. Subcutaneous air, pneumomediastinum, and pneumopericardium
consistent with post-surgical state. Small right basilar
pneumothorax.
3. Small bilateral effusions and bibasilar atelectasis.
[**2133-1-23**] 06:45AM BLOOD WBC-8.0 RBC-2.92* Hgb-9.1* Hct-28.0*
MCV-96 MCH-31.0 MCHC-32.3 RDW-12.6 Plt Ct-299
[**2133-1-23**] 06:45AM BLOOD PT-12.9 PTT-30.7 INR(PT)-1.1
[**2133-1-22**] 11:30AM BLOOD PT-12.9 PTT-29.7 INR(PT)-1.1
[**2133-1-21**] 06:20AM BLOOD PT-13.3 INR(PT)-1.1
[**2133-1-23**] 06:45AM BLOOD Glucose-104 UreaN-44* Creat-1.4* Na-140
K-4.7 Cl-107 HCO3-26 AnGap-12
[**2133-1-22**] 06:35AM BLOOD Glucose-113* UreaN-45* Creat-1.5* Na-139
K-4.5 Cl-106 HCO3-25 AnGap-13
[**2133-1-21**] 06:20AM BLOOD Glucose-125* UreaN-41* Creat-1.6* Na-140
K-4.5 Cl-106 HCO3-25 AnGap-14
[**2133-1-21**] 06:20AM BLOOD Mg-2.3
Brief Hospital Course:
On admission, he underwent cardiac catheterization which
confirmed aortic valve stenosis. Angiography revealed a right
dominant system and single vessel coronary artery disease(see
result section for further detail). Cardiac surgery was
consulted and additional preoperative evaluation was performed.
A carotid ultrasound showed only minimal disease while
preoperative echocardiogram showed an LVEF of 45%, mod-severe
aortic stenosis with mild aortic insufficiency, and only mild to
moderate mitral regurgitation. Preoperative workup was otherwise
unremarkable, and he was cleared for surgery.
On [**1-16**], Dr. [**Last Name (STitle) **] performed an aortic valve
replacement. Given his hospital stay was greater than 24 hours,
Vancomycin was utilized for perioperative antibiotics. For
surgical details, please see seperate dictated operative note.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. He was noted to have
a slight decline in renal function. His creatinine peaked to 1.8
on postoperative three. Due to mild hypotension, he was
gradually weaned from Neosynephrine. His hemodynamics gradually
improved and he eventually converted back to atrial fibrillation
and was restarted on Coumadin. On postoperative day four, he was
transferred to the SDU for further care and recovery. His renal
function continued to improve. Over several days, medical
therapy was optimized and he continued to make clinical
improvements with diuresis. He remained in a rate controlled
atrial fibrillation and tolerated low dose beta blockade. By
postoperative day seven, he was medically cleared for discharge
to rehab. Dr. [**Last Name (STitle) 40075**] will continue to monitor his INR as an
outpatient.
Medications on Admission:
procardia XL 30', lisinopril 20', folic acid 1', spironolactone
25', sotalol 30", lasix 20', ASA 81', mucomyst 600", coumadin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 6-8 hours as needed for pain.
10. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO qpm: Take as
directed. Daily dose may vary according to INR. Adjust dose to
maintain INR between 2.0 - 3.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 21341**] Rehab and Nursing Center
Discharge Diagnosis:
Aortic Stenosis - s/p AVR
Coronary Artery Disease
Atrial Fibrillation
Acute on Chronic Diastolic Congestive Heart Failure
Hypertension
Discharge Condition:
Good.
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
6)INR should be monitored several times per week until INR
stablizes. Coumadin should be adjusted to maintain INR between
2.0 - 3.0. Please make arrangements with Dr. [**Last Name (STitle) 40075**] prior to
discharge from rehab for outpatient Coumadin management.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4-5 weeks, call for appt
Dr. [**Last Name (STitle) 40075**] 2-3 weeks, call for appt
Dr. [**Last Name (STitle) 40149**] 2-3 weeks, call for appt
Completed by:[**2133-1-23**]
|
[
"4280",
"42731",
"41401",
"4019"
] |
Admission Date: [**2152-1-17**] Discharge Date: [**2152-2-5**]
Date of Birth: [**2092-8-23**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted with abdominal pain.
Major Surgical or Invasive Procedure:
Status Post Ex Laparotomy for Small Bowel Resection for internal
hernia.
History of Present Illness:
Patient presented with 2 days of abdominal pain. Accompanied
with nausea and vomiting. OR for Closed loop obstruction with
concern
for strangulated bowel.
Past Medical History:
PMH: Depression
PSH: C-section
[**Last Name (un) 1724**]: Paxil 40
Social History:
Lives with husband and son.
Family History:
Non applicable
Physical Exam:
On discharge:
Afebrile, VSS
Gen: NAD A+Ox3
CVS: Reg
Pulm: no resp distress
Abd: Soft/approp tender/non-distended. Staples intact from
surgical incision except for middle portion there is 2-3cm
opening of skin packed.
LE: no lower limb edema
Pertinent Results:
[**2152-1-18**] 12:15AM BLOOD WBC-6.5 RBC-3.54* Hgb-11.0* Hct-32.5*
MCV-92 MCH-31.0 MCHC-33.8 RDW-13.2 Plt Ct-202
[**2152-1-18**] 06:25AM BLOOD WBC-8.9 RBC-3.15* Hgb-9.8* Hct-29.0*
MCV-92 MCH-31.1 MCHC-33.7 RDW-13.3 Plt Ct-202
[**2152-1-19**] 06:50AM BLOOD WBC-9.0 RBC-2.96* Hgb-9.3* Hct-27.5*
MCV-93 MCH-31.4 MCHC-33.8 RDW-13.3 Plt Ct-192
[**2152-1-21**] 03:45PM BLOOD WBC-7.0 RBC-3.12* Hgb-9.7* Hct-28.4*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.6 Plt Ct-326#
[**2152-1-22**] 07:20AM BLOOD WBC-5.9 RBC-2.76* Hgb-8.4* Hct-25.0*
MCV-90 MCH-30.2 MCHC-33.5 RDW-13.6 Plt Ct-344
[**2152-1-22**] 09:55AM BLOOD WBC-4.8 RBC-2.69* Hgb-8.3* Hct-24.0*
MCV-89 MCH-31.0 MCHC-34.7 RDW-13.8 Plt Ct-292
[**2152-1-25**] 06:40AM BLOOD WBC-8.7# RBC-3.69*# Hgb-10.9*# Hct-32.7*#
MCV-88 MCH-29.5 MCHC-33.4 RDW-14.4 Plt Ct-443*
[**2152-1-25**] 10:05PM BLOOD Hct-27.1*
[**2152-1-25**] 11:35PM BLOOD WBC-8.2 RBC-2.88* Hgb-9.0* Hct-25.6*
MCV-89 MCH-31.2 MCHC-35.0 RDW-14.7 Plt Ct-365
[**2152-1-26**] 06:34AM BLOOD WBC-8.3 RBC-3.42* Hgb-10.3* Hct-30.1*
MCV-88 MCH-30.0 MCHC-34.1 RDW-14.8 Plt Ct-342
[**2152-1-26**] 09:34AM BLOOD Hct-28.8*
[**2152-1-26**] 02:27PM BLOOD Hct-29.1*
[**2152-1-26**] 05:18PM BLOOD Hct-28.4*
[**2152-1-26**] 09:15PM BLOOD WBC-5.5 RBC-4.56# Hgb-13.6# Hct-39.2#
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.9 Plt Ct-223
[**2152-1-27**] 03:48AM BLOOD WBC-11.4*# RBC-4.81 Hgb-14.1 Hct-40.6
MCV-84 MCH-29.4 MCHC-34.9 RDW-15.2 Plt Ct-247
[**2152-1-27**] 10:07AM BLOOD Hct-38.7
[**2152-1-27**] 08:09PM BLOOD Hct-32.4*
[**2152-1-28**] 01:05AM BLOOD Hct-32.7*
[**2152-1-28**] 10:34AM BLOOD Hct-29.9*
[**2152-1-28**] 08:49PM BLOOD Hct-32.0*
[**2152-1-29**] 04:06AM BLOOD WBC-9.4 RBC-4.14* Hgb-12.4 Hct-36.4
MCV-88 MCH-29.8 MCHC-34.0 RDW-15.0 Plt Ct-247
[**2152-1-30**] 04:50AM BLOOD WBC-7.8 RBC-4.19* Hgb-12.9 Hct-37.2
MCV-89 MCH-30.8 MCHC-34.8 RDW-14.8 Plt Ct-310
[**2152-2-1**] 10:28AM BLOOD WBC-8.8 RBC-4.43 Hgb-13.0 Hct-39.3 MCV-89
MCH-29.2 MCHC-33.0 RDW-14.1 Plt Ct-452*
[**2152-2-2**] 04:48AM BLOOD WBC-7.9 RBC-4.21 Hgb-12.3 Hct-37.5 MCV-89
MCH-29.2 MCHC-32.8 RDW-13.9 Plt Ct-489*
[**2152-2-4**] 10:19AM BLOOD WBC-7.7 RBC-4.03* Hgb-12.3 Hct-36.4
MCV-90 MCH-30.5 MCHC-33.7 RDW-13.5 Plt Ct-516*
[**2152-1-18**] 12:15AM BLOOD Glucose-190* UreaN-14 Creat-0.7 Na-139
K-3.9 Cl-105 HCO3-25 AnGap-13
[**2152-1-25**] 06:40AM BLOOD Glucose-129* UreaN-8 Creat-0.6 Na-135
K-3.8 Cl-100 HCO3-25 AnGap-14
[**2152-2-4**] 10:19AM BLOOD Glucose-130* UreaN-13 Creat-0.7 Na-137
K-4.3 Cl-100 HCO3-29 AnGap-12
[**2152-1-26**] 06:34AM BLOOD ALT-134* AST-87* AlkPhos-106*
Amylase-107* TotBili-0.6
[**2152-1-26**] 09:15PM BLOOD ALT-82* AST-72* LD(LDH)-160 AlkPhos-89
Amylase-117* TotBili-0.8
[**2152-1-28**] 03:44AM BLOOD ALT-108* AST-104* AlkPhos-68 TotBili-0.5
[**2152-1-30**] 04:50AM BLOOD ALT-68* AST-45* AlkPhos-155* TotBili-0.6
[**2152-1-26**] 06:34AM BLOOD Lipase-214*
[**2152-1-26**] 09:15PM BLOOD Lipase-112*
[**2152-1-18**] 12:15AM BLOOD Calcium-7.2* Phos-3.9 Mg-1.4*
[**2152-1-18**] 06:25AM BLOOD Calcium-7.4* Phos-3.3 Mg-2.6
[**2152-1-19**] 06:50AM BLOOD Calcium-8.1* Phos-1.6*# Mg-2.0
[**2152-1-22**] 07:20AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.9
[**2152-1-22**] 09:55AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.8
[**2152-1-25**] 06:40AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.1
[**2152-1-25**] 11:35PM BLOOD Calcium-7.8* Phos-3.3 Mg-1.9
[**2152-1-26**] 06:34AM BLOOD Albumin-2.6* Calcium-7.5* Phos-3.2 Mg-1.9
Iron-33 Cholest-106
[**2152-1-26**] 09:15PM BLOOD Albumin-1.7* Calcium-7.3* Phos-3.0
Mg-1.3*
[**2152-1-27**] 03:48AM BLOOD Calcium-6.9* Phos-3.4 Mg-1.2*
[**2152-1-27**] 05:35PM BLOOD Calcium-7.4* Phos-3.9 Mg-1.7
[**2152-1-28**] 03:44AM BLOOD Calcium-7.1* Phos-2.7 Mg-1.6
[**2152-1-29**] 04:06AM BLOOD Albumin-2.2* Calcium-7.0* Phos-2.9 Mg-1.8
[**2152-1-30**] 04:50AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.0
[**2152-1-31**] 05:58AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.9
[**2152-2-1**] 07:03AM BLOOD Albumin-2.6* Calcium-8.4 Phos-4.5 Mg-2.0
Iron-29*
[**2152-2-2**] 04:48AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.9
[**2152-2-4**] 10:19AM BLOOD Calcium-8.6 Phos-4.6* Mg-1.8
[**2152-1-26**] 07:42PM BLOOD Type-ART pO2-190* pCO2-33* pH-7.44
calTCO2-23 Base XS-0 Intubat-INTUBATED
[**2152-1-26**] 09:24PM BLOOD Type-ART pO2-362* pCO2-37 pH-7.39
calTCO2-23 Base XS--1
[**2152-1-27**] 04:00AM BLOOD Type-ART pO2-154* pCO2-33* pH-7.46*
calTCO2-24 Base XS-1
[**2152-1-28**] 10:52AM BLOOD Type-ART pO2-72* pCO2-40 pH-7.47*
calTCO2-30 Base XS-4 Intubat-NOT INTUBA
[**2152-1-26**] 07:42PM BLOOD Hgb-12.3 calcHCT-37
Brief Hospital Course:
Patient taken to OR for with closed loop obstruction with
concern
for strangulated bowel for exploratory laparotomy on [**1-16**].
Intraoperatively patient found to have: Meckel diverticulum
with volvulus and gangrene of the distal ileum. Patient
underwent:
PROCEDURE:
1. Exploratory laparotomy.
2. Adhesiolysis.
3. Ileocolic resection and ileocolonic anastomosis.
Post operatively the patient the patients course was complicated
by a fever on [**2152-1-24**] to 101.4 and she was pancultured. Blood
cultures showed no growth and urine culture grew ENTEROBACTER
AEROGENES. CXR showed atelectasis however PNA could not be
ruled out.
[**1-25**] Patient had nausea and poor PO intake, KUB showed ?ileus vs
small bowel obstruction and was very distended. NG was placed
but patient self-dc'ed the NG and refused another tube. She
also had large melanotic stool and HCT was checked:27.1->25.6,
patient agreed to have NG placed, and after being transfused 2
units Hct went to 30.1 however continued melena her Hct
continued to drop as low as 24. 2 large bore iv's were placed
and she was fluid resuscitated in addition to recieving PRBC's.
She underwent colonoscopy on [**1-26**] which showed blood in rectal
vault and patient was taken to OR as it was believed this was
most likely a bleed from the anastamotic site.
Patient was found intraoperatively to have SBO and underwent LOA
and had revision of ileocolic anastomosis in hopes to resolve
her bleeding. Post operatively she was transferred to the ICU
and remained intubated overnight. In the ICU she was weaned to
extubation and nutrition support was given via TPN. She was also
given IV abx. On [**1-28**] CXR showed no PNA and improvement in
dilation of bowels. When the patient was stable she was
transferred out of the ICU to the floor and continued to
improve. Once she had bowel function her NG was removed and her
diet was advanced slowly and she was continued on TPN. Her
abdomen was softer and she tolerated her diet. Her abdominal
staples were removed, and it was noticed that she did have some
drainage from the middle portion of her surgical site and this
was opened and packed. By time of discharge patient had been
off TPN and tolerating regular diet, pain was controlled on PO
meds. She was ambulating and feeling much stronger. She will
have VNA for dressing changes and will follow up in clinic.
Medications on Admission:
Paxil 40
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis: SBO, post operative bleeding
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**11-3**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower 48 hours after surgery, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) 470**] - Please call
[**Telephone/Fax (1) 2723**] to make an appointment two weeks after discharge.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12293**], MD (Psychiatry) Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2152-2-29**] 9:40. Location: [**Hospital Ward Name 452**], [**Location (un) 551**], [**Hospital Ward Name 516**].
|
[
"5990",
"2851",
"311"
] |
Admission Date: [**2200-3-4**] Discharge Date: [**2200-4-1**]
Date of Birth: [**2143-8-4**] Sex: M
Service: MEDICINE
Allergies:
Aldactone
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
EGD
Attempt at capsule endoscopy x 2
PICC placement [**2200-3-14**]
History of Present Illness:
56 y/o M with PMH congenital heart disease s/p VSD repair, PVR
and MVR, CHF, DM, afib on coumadin and mult. GIB who presents
from [**Hospital1 1501**] with 2 days of black stools. Of note the patient was
recently discharged from [**Hospital1 18**] on [**2-14**] after an admisison for
GIB. He underwent EGD with small bowel enteroscopy as well as
colonoscopy. EGD showed mild gastritis and no active bleeding.
Capsule endoscopy was also performed on [**2-13**] that showed a few
mild erosions in the duodenum and proximal small bowel as well
as a few nonbleeding redspots in the mid and distal small bowel.
Since discharge from [**Hospital1 18**] the patient reports that he has had
dark stools but has not had any BRBPR. On sunday night the
patient developed a tightness in his abdomen which he describes
as a knot. He also had some nausea, however denied abdominal
pain, SOB, CP, or LH. Labs at his [**Hospital1 1501**] this morning showed Hct
20.1 (down from 27 on [**2-27**]) and he was sent to [**Hospital1 18**] for further
workup.
.
In ED VS were T 97 HR 85 BP 96/53 86% TM. Rectal exam showed
guaiac pos. black stool, no blood. He was given a total of 4L NS
as well as 2 units RBCs. He also received protonix 40mg IV. On
arrival to the ICU the patient reported feeling much better. he
cont. to deny abdominal pain, SOB, CP. He had an additional
black, guaiac pos. stool on arrival to the ICU.
Past Medical History:
#congenital heart disease
-s/p pulmonic valvulotomy in [**2160**]
-s/p VSD repair [**2185**]
-[**2199-12-24**]: redo sternotomy, PVR (porcine), MVR (porcine), VSD
closure, PFO closure
#CHF
#s/p trach, open J-tube in [**1-10**]
#DM
#anxiety
#depression
#A fib
#RBBB
#RLE varicosities
#s/p R hernia repair
#s/p appy
Social History:
disabled
never used tobacco
occasional ETOH
Family History:
father had MI at age 55
Physical Exam:
VS: Temp 98.0 98.0 113/51 97% trach.
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist, trach in place
Neck - no JVD, no cervical lymphadenopathy
Chest - [**Month (only) **]. BS at bases, otherwise clear to auscultation
bilaterally
CV - Irregular, III/VI SEM loudest at RUSB
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No clubbing, cyanosis, 2+ pitting edema b/l LE with
chronic venous stasis changes
Neuro - Alert and oriented x 3, cranial nerves [**1-14**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rashes
Rectal: guaiac positive stool
Pertinent Results:
[**2200-3-4**] 11:15AM BLOOD WBC-9.0# RBC-2.39* Hgb-6.9* Hct-21.9*
MCV-91 MCH-28.9 MCHC-31.6 RDW-14.1 Plt Ct-323#
[**2200-3-9**] 06:30AM BLOOD WBC-6.4 RBC-3.33* Hgb-10.0* Hct-30.6*
MCV-92 MCH-30.0 MCHC-32.7 RDW-15.2 Plt Ct-284
[**2200-3-4**] 11:15AM BLOOD PT-11.9 PTT-29.9 INR(PT)-1.0
[**2200-3-4**] 11:15AM BLOOD Glucose-118* UreaN-73* Creat-2.0*# Na-139
K-4.1 Cl-93* HCO3-37* AnGap-13
[**2200-3-9**] 06:30AM BLOOD Glucose-141* UreaN-9 Creat-0.7 Na-151*
K-4.2 Cl-111* HCO3-33* AnGap-11
[**2200-3-4**] 11:15AM BLOOD ALT-17 AST-34 CK(CPK)-135 AlkPhos-140*
TotBili-0.1
[**2200-3-4**] 11:15AM BLOOD cTropnT-0.04*
[**2200-3-4**] 11:15AM BLOOD Calcium-8.9 Phos-4.4 Mg-3.2*
[**2200-3-7**] 05:30AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.8
[**2200-3-6**] 06:35AM BLOOD VitB12-851 Folate-GREATER TH Hapto-197
[**2200-3-4**] 12:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2200-3-4**] 12:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2200-3-4**] 12:00PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2200-3-9**] 06:54AM URINE Hours-RANDOM UreaN-855 Creat-119 Na-45
[**2200-3-9**] 06:54AM URINE Osmolal-572
.
CT ABD W&W/O C [**2200-3-6**] 2:23 PM
CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: source of GI bleeding.Please administer PO and IV
contrast.C
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with congenital heart dz, s/p VSD repair, GI
bleeding.
REASON FOR THIS EXAMINATION:
source of GI bleeding.Please administer PO and IV
contrast.Concer for small bowel source, CT enterography please.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: GI bleeding, query source, concern for small bowel
source, CT enterography please.
COMPARISON: [**2200-1-23**].
TECHNIQUE: Multiple MDCT images were obtained through the
abdomen and pelvis after the administration of 150 cc of Optiray
intravenously. There are technical limitations to this study
since it appears that the patient was not administered the
VoLumen and this limits the accuracy of this study. Multiplanar
reformations were derived.
FINDINGS:
CT ABDOMEN WITH IV CONTRAST AND WITH LIMITED ORAL CONTRAST:
Again there is evidence of median sternotomy and four-chamber
cardiac dilatation consistent with a history of conigential
cardiac disease. There are essentially unchanged bilateral
pleural effusions and associated compressive atelectasis. The
IVC and hepatic veins appear dilated but otherwise the liver,
gallbladder, pancreas, spleen, adrenal glands and kidneys appear
unremarkable. Within the limitations of the study there is no
evidence of a gross mass within the bowel or for extravasation
of intravenous contrast into the bowel lumen. A ventral defect
previously seen has resolved with residual soft tissue being
demonstrated. There is no free fluid or free air within the
abdomen or pelvic lymphadenopathy. There is left gynecomastia. A
J-tube is again seen.
CT OF THE PELVIS WITH IV CONTRAST AND WITH LIMITED ORAL
CONTRAST: No intravenous contrast is seen within the lumen of
the pelvic loops of bowel though enteric contrast is seen in the
rectosigmoid area. There is no significant free fluid or free
air or pelvic lymphadenopathy and the bladder and distal ureters
appear normal. There is an unchanged small fluid collection
measuring 3.9 x 2.6 cm overlying the left common femoral (2,
111).
MUSCULOSKELETAL: Persistent severe thoracolumbar scoliosis but
no suspicious lytic or blastic lesion.
IMPRESSION:
1. Technically limited study without sufficient oral contrast;
within these limitations no GI bleed is unambiguously defined
and no gross mass is identified. Enteric contrast is seen in the
sigmoid rectum of unknown origin. For further clarification
consider a tagged red blood cell nuclear medicine study with
delayed views if bleed is intermittent.
2. Essentially unchanged bilateral pleural effusions with
associated compressive atelectasis.
3. Unchanged massive cardiomegaly with associated mege-pulmonary
artery and a seroma overlying the left common femoral artery.
.
G/GJ/GI TUBE CHECK PORT [**2200-3-8**] 1:07 PM
G/GJ/GI TUBE CHECK PORT
Reason: eval for correct placement of J-tube
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with J-tube that fell out today, was replaced at
the bedside. please eval for proper replacement, and that the
tube is in correct position to resume tube feeds. thanks
REASON FOR THIS EXAMINATION:
eval for correct placement of J-tube
EXAMINATION: Injection of J-tube.
Injection of a J-tube was performed without a radiologist
present and shows contrast in several loops of non-distended
small bowel.
Brief Hospital Course:
56 y/o M with PMH congenital heart disease s/p VSD repair, PVR
and MVR, CHF, DM, afib on coumadin and mult. GIB who presents
from skilled nursing facility with 2 days of black stools.
.
# Anemia/black stools: Has had extensive workup this month
without discovering active bleeding source, including EGD, small
bowel enteroscopy, capsule endoscopy and colonoscopy. He did
have some erosions in duodenum and small bowel which may be
source of chronic slow bleed. He received 3 units of PRBCs upon
admission and an additional 7 spread out through his course. He
never had a notable large bleed but hematocrit continuously
drifted down slowly. His bleeding is complicated by the need to
keep him anticoagulated due to Afib and large atrial size. GI
followed him while here. At one point there was consideration
of transfer to [**Hospital6 **] for double balloon
enteroscopy, as repeat EGD was thought to be low yield as most
of the erosions were not within reach. However, he had some
respiratory distress requiring placement on the ventilator and
the GI team at [**Hospital1 2177**] recommended deferring the procedure at this
time. Repeat capsule endoscopy was attempted this admission but
he could not swallow enough in order to tolerate capsule
placement (with or without endoscopy). He is considered
transfusion dependent at this time. We recommend checking
hematocrits weekly and transfusing for Hct < 25.
.
# Acute on chronic resp. failure: Trached during admission in
[**Month (only) 404**] for heart surgery due to difficulty weaning. No longer
on vent at rehab per patient. His trach mask was continued.
Inhalers and nebulizers were continued. He was transferred to
the MICU twice for respiratory distress requiring mechanical
ventilation. His first transfer was in the the setting of
volume overload and mucous plugging which improved with
treatment of the MRSA/stenotrophomonas in his sputum. The
second incident of respiratory failure was in the setting of
getting high doses of IV ativan leading to likely respiratory
depression. He completed a 5 day course of Bactrim for
Stenotrophomonas and completed a 7 day course of vanco.
.
# Acute renal failure: He was diuresed given volume overload
affecting respiratory status. After being diuresed for 3 days,
he developed oliguria with urine microscopy consistent with ATN.
Diuresis has been held and can be restarted when needed for
volume overload and creatinine allows. His creatinine has
currently plateaued at 2.1. Good urine output currently, and as
his creatinine remained at approximately 2, his lasix was
restarted at 20mg po bid. His creatinine should be checked one
week after discharge and adjusted accordingly.
.
# Paroxysmal Atrial Fibrillation:Patient was previously on
coumadin. Given his large atrial size (>8 cm), anticoagulation
with coumadin was restarted (INR will need to be monitored at
rehab and coumadin adjusted prn). Cardiology was consulted.
Rate control was acheived with a beta blocker. In light of his
chronic lower GI bleed, it was decided by the ICU team that his
anticoagulation would be discontinued. His PCP was notified via
voice mail.
.
# Congenital heart disease: s/p recent surgery. No CAD on cath
in [**12-10**]. Cardiology was consulted for periop risk assessment
given his history - feel no increased risk since no CAD on cath.
LVEF 45-50% on TTE [**1-10**]. Continued on outpatient regimen of
lipitor, metoprolol, ASA.
.
# Anxiety/depression: increased fluoxetine to 30. Held benzos
given resp depression as above.
.
# DM: Cont. outpatient glargine and RISS
Medications on Admission:
1. Atorvastatin 20 mg Daily
2. Ascorbic Acid 500 mg [**Hospital1 **]
3. Fluoxetine 20 mg DAILY
4. Docusate Sodium 50 mg/5 mL [**Hospital1 **]
5. Miconazole Nitrate 2 % Powder QID
6. Albuterol Sulfate 2.5 mg/3 mL Inhalation Q6H PRN
7. Ipratropium Bromide 0.02 % Solution Q6 PRN
8. Clonazepam 0.5 mg Tablet PO BID PRN
9. Lansoprazole 30 mg Tablet Daily
10. Aspirin 81 mg TabletDaily
11. Ferrous Sulfate 300 mg/5 mL Daily
12. Metoprolol Tartrate 25 mg Tablet PO twice a day.
13. Insulin Glargine Twenty (20) UNITS Subcutaneous at bedtime.
14. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: Sliding Scale
Coverage Subcutaneous four times a day.
15. Nutrition Tube Feeds Glucerna Tube Feeds 90cc/hour
16. lasix 20mg PGT [**Hospital1 **]
17. ? coumadin at rehab, INR here normal
Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
2. 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.
3. Fluoxetine 10 mg Capsule [**Hospital1 **]: Two (2) Capsule PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day): please hold for SBP < 95 or HR < 55.
5. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
8. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
9. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. insulin
see attached sliding scale
11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day) as needed for anxiety.
13. Clotrimazole 10 mg Troche [**Last Name (STitle) **]: One (1) Troche Mucous
membrane QID (4 times a day) as needed for thrush.
14. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID (4 times a day) as needed for shortness of
breath or wheezing.
15. Ferrous Sulfate 300 mg/5 mL Liquid [**Last Name (STitle) **]: Five (5) mL PO once
a day.
16. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
17. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Topical four
times a day.
18. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
19. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Twenty (20)
units Subcutaneous at bedtime.
20. Insulin Lispro 100 unit/mL Cartridge [**Last Name (STitle) **]: as per sliding
scale units Subcutaneous qachs.
21. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
22. Outpatient Lab Work
please draw chem 7 to monitor creatinine on lasix
23. Ciprofloxacin in D5W 400 mg/200 mL Piggyback [**Last Name (STitle) **]: Four
Hundred (400) mg Intravenous Q12H (every 12 hours) for 7 days.
24. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime).
25. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily) as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary
GI Bleed
Respiratory failure-hypercarbia
enterococcus bacteremia
.
Secondary
Mitral and Pulmonic tissue valve replacement
Congenital heart Disease
Acute renal failure [**1-4**] ATN
MRSA/Stenotrophomonas HAP
Discharge Condition:
Stable, afebrile, ambulatory with assistance
Discharge Instructions:
.
You were admitted to the hospital after you were found to have
dark black stool. You have had extensive workup for GI bleeding
in the past and again this admission. You were administered
several units of blood for low hematocrit, and we feel that you
may need to continue transfusions chronically. In addition you
developed problems with your breathing that were related to a
class of medications called benzodiazepines, as well as a likely
pneumonia. You required mechanical ventilation at night. You
also had an infection of your bloodstream that was treated with
ciprofloxacin that you will have to take for a total of 14 days.
You will not be taking coumadin for your atrial fibrillation for
now as you have had bleeding.
.
Please keep all of your appointments with your doctors and take
[**Name5 (PTitle) **] of your medications as prescribed.
.
Please return to the hospital if you have bloody vomit, large
amounts of blood in your stool, large drop in hematocrit at
rehab, dizziness, low blood pressure, poor urine output, or any
new symptoms that you are concerned about.
Followup Instructions:
Please followup with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24305**], at
[**Telephone/Fax (1) 24306**] within 1 week of leaving rehab.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2200-4-22**]
|
[
"51881",
"5849",
"2760",
"4280",
"42731",
"311"
] |
Admission Date: [**2200-7-14**] Discharge Date: [**2200-7-24**]
Service: VSU
CHIEF COMPLAINT: Progressive calf claudication.
HISTORY OF PRESENT ILLNESS: This is a patient who is well-
known to Dr. [**Last Name (STitle) 1391**] and underwent an aortobifemoral bypass
graft in [**2175**] and has had recurrent symptoms of claudication
since [**2197**], which have progressed and have diminished her
ability to walk more than 20 feet. The patient now is
admitted for elective right leg revascularization.
ALLERGIES: Penicillin and Procardia.
MEDICATIONS ON ADMISSION: Amiodarone 100 mg daily; aspirin
325 mg daily; atenolol 25 mg daily; Lasix 20 mg q48 hours;
levothyroxine 75 mcg daily; Prilosec 20 mg daily; potassium
(K-Dur) 10 mEq every other day.
PAST MEDICAL HISTORY: Illnesses: Peripheral vascular
disease, status post aortobifemoral bypass graft in [**2175**];
history of dyslipidemia - on a statin; history of
dysrhythmia/atrial fibrillation, status post pacemaker
implantation; history of hypertension; history of ischemic
heart disease with a myocardial infarction in [**2198-3-31**];
history of arthritis and gout; history of thyroid disease -
supplemented; history of glucose tolerance impairment - not
under treatment; history of gastric reflux - on omeprazole
and asymptomatic; history of pancreatitis - remote; history
of chronic renal disease; history of oral cancer, status post
right palate excision in [**2183**]; history of glaucoma - on
eyedrops; history of venous stasis of lower extremity with
skin changes.
PAST SURGICAL HISTORY: Cholecystectomy in [**2197**].
PHYSICAL EXAMINATION: VITAL SIGNS: Pulse 69; O2 sat 100% on
room air; blood pressure 158/96. GENERAL APPEARANCE: A thin,
elderly female in no acute distress. The patient was
cooperative and oriented x 3, but is very hard of hearing.
HEENT: Unremarkable exam. LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm. ABDOMEN: Soft; nontender;
with a well-healed midline incision. EXTREMITIES: Exam
showed mild edema of the left lower extremity. The foot was
cool and pale. Skin was dry. There were areas of scattered
ecchymosis over the legs. Pulses were not palpable.
NEUROLOGIC: Nonfocal exam.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2200-7-14**]. She underwent a
right femoral to AK popliteal bypass with PTFE. She was
transferred to the PACU in stable condition. In the PACU, the
patient had difficulties with hypotension. The femoral pulse
was palpable, with a dopplerable posterior tibial and an
absent DP. The patient required 1 unit of packed cells.
Troponins were cycled. The patient's hypotension improved
with volume resuscitation. Cardiology was consulted because
of the patient's hypotension. They recommended diuresis with
Lasix as required and fluid resuscitation as required. I also
recommended that the EP service come by and interrogate the
pacer and increase the heart rate to 90. The pacemaker was
interrogated, and the patient remained in a VVI mode with a
base rate of 90 beats per minute. The autocapture is off. The
pulse amplitude was 3.50. The pulse width was 0.4, and the
sensitivity was 2.0, with improvement in the patient's
hemodynamic status. It was noted at this time that there was
a pulse change. The patient was reintubated because of her
hypotension and pulse change, and the patient returned to the
OR and underwent a right femoral-AK popliteal embolectomy and
was transferred to the ICU on a vent. Serial troponins were
0.01 to 0.02. The patient remained on heparin at 500
units/hour, with a PTT of 71. The patient was transfused a
second unit of packed cells for her hematocrit of 28 to 26.
BUN was 38. Creatinine was 1.7. The recommendation was to
begin weaning of pressor support to maintain a systolic blood
pressure of greater than 90.
On postoperative day 2, the patient developed new aortic
insufficiency with hypotension. The patient required urgent
cardioversion with 200 W/sec and was V-paced. The patient
remained in the ICU. The patient continued on heparin. She
continued on vasopressor support. There was a small hematoma
noted in the right groin area and this was stable.
Postoperative day #4, the patient remained on heparin. She
remained on her amiodarone drip at 0.5. She continued to be V-
paced. Her post-transfusion hematocrit was 37. Her Swan was
discontinued. Subcu heparin was instituted, and her diet was
advanced as tolerated. The patient's amiodarone IV load was
completed. On postoperative day 4, EP was requested to
decrease the ventricular pacing rate from 90 beats per minute
to 70. The battery is 2.73 V. The patient is in VVI. The V
threshold is 1.50, and the MS is 0.4. Lead impedance is 520.
The patient remains in V-pacing with an intrinsic regular
rhythm at a rate of 88 beats. At 3:30 in the afternoon, the
patient developed acute congestive failure requiring
diuresis, with improvement in her clinical state.
On postoperative day 5, the patient had episodes of
hallucinations. The geriatric service was requested to see
the patient. Recommendations were 1-to-1 observation and
frequent reorientation and if family could be with the
patient that would be of assistance. A recommendation was
made to avoid Haldol secondary to drug interactions and QT
prolongation. A recommendation was made to consider Zyprexa
2.5 mg if agitated and aggressive and this may be repeated up
to 10 mg per 24 hours as necessary. The amitriptyline and
Ambien were discontinued.
The patient was transferred to the VICU on [**2200-7-21**].
Fever workup was done. Postoperative day 7, the patient had
recurrence of atrial fibrillation and cardiology was
reconsulted for consideration of cardioversion. They felt
that this was possibly more atrial tachycardia versus atrial
fibrillation, which was probably secondary to the patient's
increased catecholamine, anemia, and hypovolemia, which had
improved. Recommendations were to discontinue the amiodarone
drip, a goal CVP of 10 to 12, that we should continue the IV
heparin, and to institute metoprolol 25 mg q.8 hours and
increase as needed for a heart rate goal of less than 90.
Physical therapy did see the patient and felt that she would
require rehab. The patient continued to require increases in
her metoprolol doses for a heart rate of less than 90.
Anticoagulation was instituted for a goal INR of 2.0 to 3.0.
Heparin will be continued until the patient has reached the
INR goal. The patient's general condition remained stable.
She did require continued adjustment in her metoprolol dosing
because of hypotension on the night of [**Month (only) 205**] __________, [**2199**].
Her dose at the time of the hypotensive episode was 100 mg
t.i.d. This was changed to 75 mg t.i.d. with improvement in
her blood pressure control. The patient will be discharged to
rehab. The patient's O2 should be weaned to maintain an O2
sat greater than 90%.
DISCHARGE INSTRUCTIONS: Please wean O2 to maintain O2 sat
greater than 90%. Her INR should be monitored as required
over the next several days to maintain a goal INR of 2.0 to
3.0 both for her atrial fib/flutter and her PTFE graft
patency. The patient should follow up with Dr. [**Last Name (STitle) 1391**] in 2
weeks' time and call for an appointment at [**Telephone/Fax (1) 1393**]. The
patient should also follow up with the cardiology service
within the next 2 weeks. The patient should follow up with
Dr. __________ in 1 to 2 weeks post discharge or with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please call for an appointment at [**Telephone/Fax (1) 78546**].
DISCHARGE DIAGNOSES:
1. Progressive claudication.
2. History of peripheral vascular disease, status post
aortobifemoral in [**2175**].
3. History of dyslipidemia.
4. History of atrial fibrillation, status post pacemaker.
5. History of hypertension.
6. History of hypothyroidism secondary to amiodarone.
7. History of impaired glucose tolerance - not medicated.
8. History of gastric reflux disease.
9. History of pancreatitis - remote.
10.History of chronic renal disease.
11.History of oral cancer, status post right palate
resection in [**2183**].
12.History of glaucoma.
13.History of venous stasis changes.
14.History of ischemic heart disease, status post
myocardial infarction in [**2198-3-31**].
15.History of gallbladder disease, status post
cholecystectomy in [**2197**].
16.Postoperative hypotension secondary to hypovolemia,
requiring vasopressor support.
17.Postoperative blood-loss anemia - transfused.
18.Postoperative acute congestive heart failure - resolved.
MAJOR SURGICAL PROCEDURES: Right femoral to AK popliteal
bypass with PTFE on [**2200-7-14**]; right femoropopliteal
embolectomy on [**2200-7-15**]; pacer interrogation with reset
on [**2200-7-15**] and [**2200-7-17**]; reintubation on [**2200-7-15**]; cardioversion on [**2200-7-15**].
DISCHARGE MEDICATIONS: Simvastatin 20 mg daily; travoprost
0.004% drops to left eye; pilocarpine 2% ophthalmic drops
b.i.d.; timolol 0.5% drops b.i.d.; brimonidine 0.15% drops
b.i.d.; Quixin 0.5% drops to left eye every other day as
needed; aspirin 325 mg daily; acetaminophen 325 mg q.6 hours
p.r.n.; Colace 100 mg b.i.d.; magnesium hydroxide 400 mg/5 mL
30 mL q.6 hours p.r.n.; albuterol sulfate 2.5 mg/3 mL
nebulization q.6 hours as needed; ipratropium bromide 0.02%
solution inhalation q.6 hours as needed; olanzapine 2.5 mg at
bedtime; metoprolol 75 mg q.8 hours to maintain a heart rate
at less than 90, but greater than 60; miconazole nitrate 2%
cream to groin areas b.i.d.; Coumadin 4 mg daily for a goal
INR of 2.0 to 3.0; levothyroxine 75 mcg daily; Protonix 40 mg
daily; Lasix 20 mg daily.
TRANSFER CODE STATUS: She is a full code. She may be
defibrillated and intubated. No chest compressions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2200-7-24**] 11:13:10
T: [**2200-7-24**] 13:36:30
Job#: [**Job Number 78547**]
|
[
"9971",
"2851",
"42731",
"4280",
"2875"
] |
Admission Date: [**2103-12-17**] Discharge Date: [**2103-12-24**]
Date of Birth: [**2044-7-17**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
woman who comes for a chief complaint of exertional dyspnea
and syncope. She has a known history of cardiac murmur who
has also been followed for aortic stenosis. All
echocardiogram after admission revealed moderately severe
stenosis. Cardiac catheterization was subsequently performed
which suggested a 67 mm peak gradient with an ejection
fraction of 60%. Coronary arteries were normal at that time.
She continued to have fairly significant exertional dyspnea
and reported two episodes of chest pain. A repeat
echocardiogram suggested a peak gradient of 100 mm with a
valve area calculated to 2.6 cm2. She was referred for
evaluation for aortic valve replacement.
PHYSICAL EXAMINATION: Vital signs: Blood pressure 134/92,
heart rate 80, respirations 16. Cardiovascular: Regular.
There was a hard systolic ejection murmur heard best over the
upper chest. No gallop or rub. No mitral regurgitation.
Pulmonary: Clear to auscultation. Abdomen: No organomegaly
or masses. Extremities: No edema.
HOSPITAL COURSE: The patient was admitted on [**2103-12-17**], for limited access aortic valve replacement
(mechanical) performed by Dr. [**Last Name (STitle) 1537**]. The patient was admitted
postoperatively to the CSRU, and postoperative events
included a labile blood pressure and decreased CVP and CI,
increase urine output and blood pressure and CI which
responded well to fluid boluses. The patient was transiently
put on Neo-Synephrine drip to maintain a systolic blood
pressure of greater than 95. The patient was extubated later
that night.
On postoperative day #1, the patient was extubated and
breathing well on nasal cannula. There were no leaks in the
patient's chest tube, and the patient's filling pressures
were adequate, as well as cardiac index (3.1) and an SVR of
1200.
The patient received several doses of Vancomycin
postoperative and was subsequently transferred to the
Surgical Floor without incident. The patient subsequently
was started on Heparin drip to cover her for antibiotics
while Coumadin was also started simultaneously. Subsequently
she received 5 mg p.o. q.d. and finally 7.5 mg one day, and
her INR eventually on the day of discharge was 1.7.
Her cardiologist was [**Name (NI) 653**], and it was agreed upon that
he would follow the INR to achieve therapeutic level of
2.0-2.5 for appropriate anticoagulation in aortic valve
replacement which was mechanical.
CONDITION ON DISCHARGE: Excellent.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Aortic stenosis, status post aortic
valve replacement with mechanical valve.
DISCHARGE MEDICATIONS: Coumadin 7.5 mg p.o. q.d.
DISCHARGE INSTRUCTIONS: The patient is to follow-up in four
weeks with Dr. [**Last Name (STitle) 1537**]. The patient is to follow-up on Thursday
with her cardiologist and have an INR drawn.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2103-12-24**] 19:51
T: [**2103-12-24**] 20:19
JOB#: [**Job Number 20332**]
|
[
"4241",
"2449",
"V1582"
] |
Admission Date: [**2182-1-26**] Discharge Date: [**2182-2-8**]
Date of Birth: [**2153-12-30**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
28 y/o M unresponsive after MVA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
28 M unrestrained passenger in MVA. Severe damage to vehicle,
airbags deployed per report. Patient found under dashboard of
car. Unresponsive, taken to OSH where noted GCS 6. Patient
received induction medications for intubation and
lorazepam. CT head, c-spine, chest/abd/pelvis done, patient
transferred for higher level of care. On admission, patient not
responsive, motor exam abnormal. Neurosurgery called for
consult.
Past Medical History:
none
Social History:
portugese speaking
Family History:
NC
Physical Exam:
T: BP: 135/79 HR: 92 R 18 O2Sats 100
Gen: Intubated, c-collar in place, sedation (propofol) held x 15
minutes
HEENT: 2 cm laceration right frontal area, full thickness 2.5 cm
x 2.5 cm skin avulsion right parietal area.
Pupils: [**5-4**], brisk
EOM: UTA, does not attend, roving
Corneal reflexes present bilaterally Right > left
Gags with movement of ETT
Neck: rigid c-collar in place
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS 6-T
Language: Intubated.
Cranial Nerves:
II: Pupils equally round and reactive to light bilaterally.
III, IV, VI: roving eyes, does not attend
V, VII: UTA
VIII: UTA
IX, X: gags with ETT manipulation.
[**Doctor First Name 81**]: UTA.
XII: UTA.
Motor: Normal bulk and tone bilaterally. Non-purposeful movement
spontaneously x 4 ext. non-posturing movement of UE to deep
stim. Does not localize to deep stim, w/d vs. 3-flex LE to deep
stim.
Sensation: UTA
Toes downgoing bilaterally
Upon discharge:
ambulating in halls, wounds well healed
Pertinent Results:
[**2182-1-26**] 07:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2182-1-26**] 07:12AM HGB-15.9 calcHCT-48 O2 SAT-86 CARBOXYHB-2 MET
HGB-0
[**2182-1-26**] 08:30AM PT-12.4 PTT-23.4 INR(PT)-1.0
[**2182-1-26**] 08:30AM WBC-18.8* RBC-5.60 HGB-15.9 HCT-46.6 MCV-83
MCH-28.3 MCHC-34.1 RDW-13.5
CT HEAD [**1-26**]
1. Large left frontoparietal scalp hematoma.
2. Tiny foci of high attenuation, likely hemorrhage at the
[**Doctor Last Name 352**]-white
junction in the left frontal lobe. Given that the patient is
unresponsive,
MRI is recommended to evaluate for traumatic shear injury.
MRI HEAD [**1-27**]
1. Several areas of susceptibility and diffusion abnormalities
in the brain are consistent with diffuse axonal injury.
2. Subtle foci of hyperintensity in the right sylvian fissure,
probably due to small amount of subarachnoid blood.
3. Thin rim of subdural collection in the right parietal region
and along the tentorium.
4. No evidence of mass effect or hydrocephalus
MRI C SPINE [**1-27**]
No evidence of ligamentous disruption. Mild increased soft
tissue signal indicating soft tissue trauma in posterior
soft-tissues of upper cervical spine. No abnormal signal within
the spinal cord. Subtle signal abnormality posterior to C2-C4
vertebra in the epidural space appears to be due to slightly
prominent epidural veins, as this was not confirmed on the axial
images. No compression of the spinal cord.
Brief Hospital Course:
Mr. [**Known lastname **] [**Known lastname **] was admitted to the neurosurgery service and the
ICU for continued treatment including strict blood pressure
control and q1 neurochecks. While admitted his neurological exam
began to improve and he started to follow commands and open his
eyes. He was safely extubated on [**1-27**]. In order to evaluate for
further injury and MRI of the cervical spine and of the head
were obtained. His MRI cervical spine was negative and his
collar was safely removed. The MRI head did show areas of axonal
injury. Also on [**1-27**], he was extubated and gen surgery repaired
his scalp lacerations. On [**1-28**], he was unable to bear weight on
RLE and an x-ray ruled out fracture. He received propranolol for
Tachycardia. He was transfered to the step down unit. He passed
a bedside swallow evaluation. Overnight on [**1-29**] he fell getting
OOB overnight but there were no signs of injury and his exam was
stable. On [**1-30**], the team and case management spoke to the
brother about guardianship and insurance issues.
A family meeting was held on [**2-7**] and the brother and patient
seemed to understand the follow up instructions and reasons to
call the office.
He continued to get PT on the floor and was cleared by PT for
discharge to home with his family.
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day): over the counter.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Frontal contusion
Subdural hematoma
Diffuse Axonal Injury
UTI
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Take your medicine as prescribed.
?????? 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.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
?????? You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2182-3-8**]
|
[
"5990"
] |
Admission Date: [**2126-5-12**] Discharge Date: [**2126-5-20**]
Date of Birth: [**2082-4-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
left temporal contusion and SDH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
44yoM w/ recent loss of job/depression/EtOH abuse up until 2d
ago. Was found down at end of driveway today by wife - ? amount
of time. CT at OSH shows bilat frontal contusions and ? R SDH.
GCS 15
Past Medical History:
EtOH abuse, GERD, depression, anxiety, L knee surgery
Social History:
EtOH abuse
Family History:
unknown
Physical Exam:
O: T:101.8 BP:170 / 116 HR:120 O2Sats98%
Gen: WD/WN, very agitated requring multiple personnel to
restrain
pt. Mult ecchymosis, abrasions, contusions throughout body.
HEENT: Pupils:R 4.5 brisk reactive, L 4 brisk react EOMs grossly
appear full
Neck: in hard collar
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, uncooperative with exam but
clearly very [**Last Name (un) 29916**] strength throughout.
Cranial Nerves:
I: Not tested
II: Pupils round with right slightly larger and reactive to
light
III, IV, VI: Extraocular movements appear intact bilaterally.
V, VII: Facial strength appears symmetric.
VIII: Hearing could not be assessed.
IX, X,[**Doctor First Name 81**],XII: no obvious abnls
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-5**] throughout.
Toes downgoing bilaterally
Pertinent Results:
[**2126-5-20**] 06:00AM BLOOD WBC-8.5 RBC-3.23* Hgb-11.2* Hct-32.6*
MCV-101* MCH-34.8* MCHC-34.5 RDW-13.3 Plt Ct-456*
[**2126-5-20**] 06:00AM BLOOD Plt Ct-456*
[**2126-5-16**] 01:16AM BLOOD PT-11.2 PTT-18.7* INR(PT)-0.9
[**2126-5-12**] 03:05PM BLOOD Fibrino-188
[**2126-5-20**] 06:00AM BLOOD Glucose-96 UreaN-5* Creat-0.6 Na-136
K-4.3 Cl-100 HCO3-24 AnGap-16
[**2126-5-18**] 01:32PM BLOOD CK(CPK)-259*
[**2126-5-12**] 03:05PM BLOOD ALT-61* AST-110* LD(LDH)-390* AlkPhos-73
Amylase-71 TotBili-2.1*
[**2126-5-18**] 01:32PM BLOOD CK-MB-1 cTropnT-<0.01
[**2126-5-20**] 06:00AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.1
[**2126-5-20**] 06:00AM BLOOD Phenyto-6.1*
[**2126-5-12**] 03:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2126-5-17**] 11:13 AM
INDICATION: 44-year-old man with known head bleed.
HEAD CT WITHOUT CONTRAST: Comparison is made to the prior head
CT dated [**2126-5-14**]. There is left frontal subdural hematoma,
which has not increased compared to the prior study; however,
may have redistributed to the dependently. There is small amount
of subarachnoid hemorrhage bilaterally within the sulci of
frontal lobes, overall unchanged compared to the prior study.
There is left temporal intraparenchymal hemorrhagic contusion,
measuring 3.5 cm, associated with somewhat increased edema and
mild mass effect. There is mild shift of normally midline
structures, overall unchanged compared to the prior study. Again
note is made of bifrontal atrophy. Again note is made of
air-fluid level in sphenoid, ethmoid, and maxillary sinuses with
mucosal thickening. The osseous structure is unremarkable.
IMPRESSION: Overall unchanged appearance of left frontal
subdural hematoma and bilateral subarachnoid hemorrhage. Left
temporal intraparenchymal hemorrhage contusion, with somewhat
increased pathogenic edema. Air-fluid levels in paranasal
sinuses.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 7210**] [**Name (STitle) 7211**] [**Doctor Last Name 7205**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 21104**]
Approved: FRI [**2126-5-17**] 5:45 PM
Brief Hospital Course:
This patient was cared for by the Trauma service for the first 6
days of his stay. Please see inpatient chart for indepth care.
Briefly he was admitted to the TSICU where he was monitored for
with Q1 neurochecks, and DT prophylaxis. He was loaded with
Dilantin followed with serial CT's which showed left frontal
subdural hematoma and bilateral subarachnoid hemorrhage. Left
temporal intraparenchymal hemorrhage contusion, with somewhat
increased pathogenic edema. Air-fluid levels in paranasal
sinuses. They did not enlarge after admission. He received
both an IV drip of Ativan and later Ativan IV as he was actively
withdrawing from alcohol he was noted have high BP and later
started on PO Lopressor.
On hospital day 3 he was extubated and daily his neurological
exam improved. On discharge he had no neurological problems
noted. [**Name2 (NI) **] showed no signs of withdrawl from alcohol. He was
cleared by both PT and OT for discharge. He was tolerating a
regular diet.
Medications on Admission:
protonix
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: [**12-3**] PO Q4-6H (every
4 to 6 hours) as needed.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*1*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): use while on percocet.
Disp:*60 Capsule(s)* Refills:*1*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*1*
7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO NOON (At Noon).
Disp:*60 Capsule(s)* Refills:*1*
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
left temporal contusion and SDH
Discharge Condition:
good
Discharge Instructions:
- you should take pain medication as needed
- every day you take pain medication you should take a stool
softener: colace, senna, or dulcolax are all good options
- do not drive while taking pain medication
- [**Name8 (MD) 138**] MD or return to ED if T>101.5, chills, anusea, vomiting,
chest pain , shortness of breath, severe confusion or dizziness,
changes in vision or hearing or mental status changes.
Followup Instructions:
Follow up w/Dr. [**Last Name (STitle) 548**] in 1 month have a head CT prior to
appointment call [**Telephone/Fax (1) 1669**] for an appointment continue with
medications (Dilantin) until follow up
Completed by:[**2126-5-20**]
|
[
"53081"
] |
Admission Date: [**2143-12-27**] Discharge Date: [**2144-1-6**]
Date of Birth: [**2086-5-12**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS:
The patient is a 57-year-old female with a history of
high-grade dysplasia within her esophagus consistent with
Barrett's esophagus. She has a long history of esophageal
problems, history of vigorous achalasia, and esophageal
spasms status post long myotomy which she did well for a
period of time. She then developed achalasia and Dr.
[**Last Name (STitle) **] performed a laparoscopic myotomy after which she
has done well.
At this time she has had some biopsies which showed
adenomatous mucosa without any evidence of dysplasia. Since
her myotomy, she has actually done quite well and has been
quite happy, and eating, and had no regurgitation, or other
problems. She had a recent biopsy of her distal esophagus
which showed high-grade dysplasia. Hence, the decision was
made to do a Ivor-[**Doctor Last Name **] esophagogastrectomy.
PAST MEDICAL HISTORY:
Good general health. She denies heart disease, lung disease,
or diabetes. She has had an open cholecystectomy, a
bilateral TAH/BSO, as well as a laparoscopic [**Doctor Last Name **] myotomy.
She is status post knee replacement one year ago and walks
with a cane.
MEDICATIONS:
1. Amitriptyline 300 mg po q day.
2. Prilosec 20 mg po q day.
3. Trazodone 100 mg po q day.
PHYSICAL EXAMINATION:
On physical exam by Dr. [**Last Name (STitle) **], she was a well-developed
overweight woman who walks with a cane. She had a normal
head and neck examination. Neck was supple without mass,
nodes, or thyromegaly. Chest was clear to auscultation and
percussion. She has well-healed scar on the left. Her
abdomen is soft without hernias or masses. Extremities were
well perfused.
HOSPITAL COURSE:
She is admitted on [**2143-12-27**] as mentioned previously, an
Ivor-[**Doctor Last Name **] esophagogastrectomy. Postoperatively, she went to
the Surgical Intensive Care Unit. She had some issues with
low blood pressure which was in the 80s/40s and requiring
very small amount of Levophed.
She was extubated on postoperative day one, and her vital
signs remained stable. She did well and her pain was
controlled with her epidural. She remained in the unit on
postoperative day two, however, was transferred to the floor
on postoperative day two in stable condition. However, over
the course of the evening of postoperative day two, she
developed some confusion and pulled out her chest tube and
her Foley. Decision was made to remove Dilaudid from her
epidural, and the patient did better. The chest tube was
completely removed given that the chest x-ray confirmed it
was improperly positioned and out of the pleural cavity.
Given that there was drainage into her pleural cavity and
noted that the chest tube was no longer in place to drain the
fluid, the patient did have some difficulty with her oxygen
saturation. However, she maintained her O2 sats in the mid
90s on 50% facemask.
On the evening of postoperative day three, the patient had
been doing well all day. On the evening of postoperative day
three, the patient became confused again despite the Dilaudid
no longer being in her epidural, and she pulled out her
nasogastric tube as well as her Foley once again. Decision
was made to put her in soft restraints, and to replace the
nasogastric tube under fluoroscopic guidance on the following
day, which was done on postoperative day number four.
On the evening of postoperative day number four, the patient
had shortness of breath and her O2 saturation decreased to
the low 90s and she is having labored breathing, and was
slightly tachycardic. A chest x-ray was done which showed a
right pleural effusion which is consistent with fluid left
from her surgery. Decision was made to try to
fluoroscopically place a chest tube as well as
fluoroscopically replace her nasogastric tube.
On the following day, postoperative day number five, her
vital signs continued to remain stable. It was felt that
there was no enough fluid in her lungs to warrant putting a
chest tube in, however, a nasogastric tube was placed
fluoroscopically and the patient did well. At this point the
patient continued to improve clinically. Her tube feeds were
increased. She was tolerating them well with aggressive
pulmonary toilet. Patient's O2 sats continued to improve.
Her nasogastric tube was kept in place and continued to drain
fluid. Assumptions was made that the patient had a partial
delay of gastric emptying.
On postoperative day number eight, the patient's nasogastric
tubes were clamped and residuals were minimal. Hence, on
postoperative day number nine, the decision was made to start
the patient on sips. Patient remained afebrile. Vital signs
remained stable, and the patient was discharged home on tube
feeds in stable condition.
DISCHARGE DIAGNOSIS:
Status post Ivor-[**Doctor Last Name **] esophagogastrectomy.
DISCHARGE MEDICATIONS:
1. Amitriptyline 300 mg po q day.
2. Trazodone 100 mg po q day.
3. Nexium 40 mg tid.
4. Levaquin 100 mg po q day x2 days.
5. Albuterol inhaler two puffs qid prn.
6. Tylenol elixir 650 mg po q six prn.
7. Isocal tube feeds 70 cc/hour through the J tube.
DISCHARGE INSTRUCTIONS:
The patient will follow up with Dr. [**Last Name (STitle) **]. The patient
will get VNA services for help with her J tube and wound
care.
CONDITION ON DISCHARGE:
Is discharged home in stable condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 2649**]
MEDQUIST36
D: [**2144-1-6**] 13:31
T: [**2144-1-8**] 08:03
JOB#: [**Job Number 14042**]
|
[
"5119"
] |
Admission Date: [**2200-4-11**] Discharge Date: [**2200-4-17**]
Date of Birth: [**2162-7-8**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Latex
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hepatic masses, abdominal pain
Major Surgical or Invasive Procedure:
[**2200-4-11**] extended right hepatectomy
History of Present Illness:
Per Dr.[**Name (NI) 1369**] note: 37-year-old female with a history of right
upper quadrant abdominal pain and periumbilical abdominal pain,
along with a history
of enlarging liver masses thought to represent either hepatic
adenoma or focal nodular hyperplasia. She underwent an MRI
with BOPTA at [**Hospital1 18**] on [**2200-3-26**]. This demonstrated
a large, rounded, lobulated, 5.7 x 6.6-cm solid lesion in
segment [**Year (4 digits) 7060**] extending into segment [**Doctor First Name 690**] and segment I, the
caudate lobe. The bulk of the lesion was situated between the
right and middle hepatic veins. This was higher-intensity due
to the underlying hepatic parenchyma on T2 weighted images,
and the lesion contained a central scar. On the delayed
BOPTA images, there was some central washout from the
dominant central lesions, as well as some small arterial
enhancing lesion in the inferior aspect of the right lobe
with residual peripheral right of contrast. This was thought
to be slightly unusual, but still most left compatible with
FNH. There is a second solid, 1.7-cm lesion in the inferior
aspect of the right lobe thought to represent FNH, and is a
3.1-cm hemangioma in the inferior and lateral aspect of the
right lobe. These lesions were increased in size. The largest
mass measured 3.8 cm in [**2194**].
Due to the patient's symptoms, the enlarging mass, and its
difficult location should it continue to enlarge and require
resection, the patient has elected to proceed with hepatic
resection. She has provided informed consent and is now
brought to the operating room for possible right hepatic
lobectomy, caudate lobe resection, segment [**Doctor First Name 690**] resection, or
possible segment [**Doctor First Name 7060**] and [**Doctor First Name 690**] resection depending on the
intraoperative findings.
Past Medical History:
abdomiinal pain, htn, hyperlipidemia, allergic rhinitis, atopic
disease, depression, irritable bowel syndrome, anxiety, hiatal
hernia, and hepatic lesions noted in the history
Hysterectomy, bunionectomy of right 1st toe, right arthroscopic
knee surgery, ear tubes as a child
Social History:
Denies cigarette or recreational drugs, one ETOH beverage per
day.
Married
Physical Exam:
T HR 94 RR 16 BP 118/65 98% RA
A&O
anicteric,
Lungs clear
abd soft, NT/ND, no masses palp
ext no edema
Pertinent Results:
[**2200-4-17**] 05:15AM BLOOD WBC-18.9* RBC-2.97* Hgb-8.9* Hct-27.4*
MCV-93 MCH-30.1 MCHC-32.6 RDW-15.6* Plt Ct-364
[**2200-4-12**] 01:05AM BLOOD PT-14.8* PTT-34.7 INR(PT)-1.3*
[**2200-4-16**] 05:30AM BLOOD ALT-105* AST-42* AlkPhos-93 TotBili-0.4
Brief Hospital Course:
On [**2200-4-11**] she underwent
extended right hepatic lobectomy, segment [**Doctor First Name 690**] resection,
cholecystectomy, caudate lobe resection, and intraoperative
ultrasound for mass in segments [**Last Name (LF) 7060**], [**First Name3 (LF) 690**], and caudate lobe.
Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please see operative note for
further details. A single JP was placed. EBL was 5 liters and
this was replaced with 4 units PRBC, cellsaver, FFP and
crystalloid. She remained intubated due to large fluid
replacement and was transferred intubated to the SICU over
night. She was extubated without event and transferred out of
the SICU.
Diet was slowly advanced and IV fluid stopped. The JP drainage
was serosanguinous and the incision remained without erythema or
drainage. The foley was removed on pod 3. Pain was well
controlled. Vital signs remained stable. BP remained on the low
side with sbp's in the 90's. Her usual home meds included
toprol,lisinopril and caduet. Cadue and lisinopril were held.
Lopressor was continued without dizziness.
LFTs trended down. Hct stabilized at 26-27 from 31 immediately
postop. Preop hct was 41. The JP was removed on pod 5 when
output averaged 100cc/day.
Of note, the wbc trended up on pod 3 to 11.8. This continued to
increase each day up to 18.9. CVL was removed on pod 4. A UA
was negative and urine culture was contaminated. She remained
afebrile and breath sounds were only slightly diminished in
bases. The urine culture was repeated on pod 6.
She also experienced bilateral leg edema for which iv lasix was
administered x1. The right leg appeared slightly more edematous
than the left. Non-invasive u/s studies were done on [**4-17**]. This
was negative for any DVT.
She was discharged home in stable condition tolerating a regular
diet and ambulatory.
Medications on Admission:
Xanax 0.5"', caduet 1', wellbutrin-XL 450', lexapro 30',
zestril 10', lithium carbonate 600', toprol 25', nortriptyline
25', tylenol prn, maalox prn, hyocyamine 0.5"'prn, gas-x prn
.
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Lithium Carbonate 300 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
4. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
6. Wellbutrin XL 300 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
7. Wellbutrin XL 150 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
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*
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic FNH
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take medications/food, increased
abdominal pain, jaundice, constipation, incision
redness/bleeding/drainage or any concerns
No heavy lifting
No driving while taking pain medications
[**Month (only) 116**] shower
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2200-6-20**] 11:20
[**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN will call you with follow up appointment
([**Telephone/Fax (1) 673**]) to schedule follow up appointment with Dr. [**Last Name (STitle) **]
in 1 week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2200-4-17**]
|
[
"4019",
"2724"
] |
Admission Date: [**2167-9-29**] Discharge Date: [**2167-10-9**]
Date of Birth: [**2129-5-22**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
recurrent ascites
Major Surgical or Invasive Procedure:
Transjugular intrahepatic portosysyemic shunt placement
Therapeutic paracentesis
Transesophageal Echocardiogram
History of Present Illness:
Briefly, 38 yo M with a h/o hep C cirrhosis, episode of SBP,
s/p liver transplant in [**6-8**], recent admission at [**Hospital1 **] for ARF in
the setting of new diuretic regimen, now transfered from an OSH
for evaluation of worsening LFTs, which developed during a
hospitalization for MI. AS above the pt was recently admitted to
[**Hospital1 **] for ARF that developed after starting a regimen of lasix.
With d/c of lasix, the pt's renal failure had largely resolved
at the time of discharge from [**Hospital1 **] on [**2168-9-25**]. The day following
discharge the pt had an episode of severe b/l neck pain that
radiated down into his chest, associated with dyspnea. EMS was
called and pt's pain continued until he was electively intubated
for catheterization, given EKG with ST elevations in V1-V3. Cath
revealed a proximally occluded LAD that underwent successful PCI
with a vision stent placed with a good result. Pt was extubated
on [**2167-9-27**]. His LFT's were elevated with AST of 345 and ALT of
127. The pt was transferred to [**Hospital1 **] and was initially admitted to
the CCU to ensure cardiac stability. He is now being transfered
to the hepatorenal service for further evaluation of his
elevated LFTs. Presently he is denying CP/SOB/HPs/abdominal
pain. He denies n/v. Had loose BMs last night.
Past Medical History:
1 chronic hepatitis C -> cirrhosis
- h/o ascites, encephalopathy, SBP
- orthotopic deceased donor liver transplant on [**2166-6-21**]
- one nodule of HCC found at time of transplant
- c/b recurrent hep C after transplant
- tx with interferon and ribavirin -> no response
- VL 12,600,000 on [**2167-8-6**]
- IFN, ribavarin d/c on [**2167-9-8**]
- also c/b biliary anastamotic stricture s/p dilation and
stenting
- stent removed [**2167-9-2**]
- liver bx [**2167-9-11**] shows recurrent, progressive hep C but no HCC
- recurrent ascites
2 h/o hemochromatosis
3 DM2
4 h/o DVT and bilateral PE
5 h/o splenic infarct
6 ho STEMI ([**9-9**])
Social History:
Currently living with his Mom.
h/o etoh - quit in '[**60**]
h/o ivdu - quit in '[**59**]
Family History:
non-contrib
Physical Exam:
Temp 98
BP 100/50
Pulse 76
Resp 20
O2 sat 100% RA
Gen - Alert, no acute distress
[**Year (2 digits) 4459**] - extraocular motions intact, anicteric, mucous membranes
dry
Neck - no JVD, no cervical lymphadenopathy
Chest - diminished breath sounds R base
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, mildly distended, RUQ tenderness to deep palpation,
normoactive bowel sounds
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - non-focal
Skin - No rash
Pertinent Results:
[**2167-9-29**] 08:19PM GLUCOSE-167* UREA N-42* CREAT-1.7* SODIUM-140
POTASSIUM-4.8 CHLORIDE-112* TOTAL CO2-22 ANION GAP-11
[**2167-9-29**] 08:19PM ALT(SGPT)-115* AST(SGOT)-304* LD(LDH)-322*
CK(CPK)-29* ALK PHOS-342* AMYLASE-15 TOT BILI-2.2*
[**2167-9-29**] 08:19PM LIPASE-9
[**2167-9-29**] 08:19PM ALBUMIN-2.1* CALCIUM-7.5* PHOSPHATE-3.5
MAGNESIUM-1.9
[**2167-9-29**] 08:19PM WBC-4.1# RBC-3.00* HGB-10.1* HCT-31.2*
MCV-104* MCH-33.7* MCHC-32.4 RDW-15.6*
[**2167-9-29**] 08:19PM NEUTS-64 BANDS-0 LYMPHS-20 MONOS-15* EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2167-9-29**] 08:19PM PLT COUNT-84*
[**2167-9-29**] 08:19PM PT-14.0* PTT-37.3* INR(PT)-1.2*
[**2167-10-6**] 04:30AM BLOOD WBC-3.9* RBC-3.46* Hgb-11.2* Hct-33.8*
MCV-98 MCH-32.4* MCHC-33.2 RDW-16.8* Plt Ct-79*
[**2167-10-6**] 04:30AM BLOOD Plt Ct-79*
[**2167-10-6**] 04:30AM BLOOD PT-14.4* PTT-40.1* INR(PT)-1.3*
[**2167-10-6**] 04:30AM BLOOD Glucose-182* UreaN-38* Creat-1.1 Na-139
K-4.7 Cl-111* HCO3-22 AnGap-11
[**2167-10-6**] 04:30AM BLOOD ALT-138* AST-361* AlkPhos-351*
TotBili-2.8*
[**2167-10-6**] 04:30AM BLOOD Calcium-7.2* Phos-3.5 Mg-2.0
[**2167-10-4**] 09:11PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.018
[**2167-10-4**] 09:11PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-0.2 pH-5.0 Leuks-NEG
[**2167-10-3**] 12:00PM ASCITES WBC-248* RBC-3889* Polys-1* Lymphs-78*
Monos-18* Macroph-3*
[**2167-10-3**] 12:00PM ASCITES TotPro-1.8 LD(LDH)-141 Albumin-1.1
[**2167-10-3**] 11:01 am PERITONEAL FLUID
GRAM STAIN (Final [**2167-10-3**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2167-10-6**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2167-10-3**] BLOOD CULTURE pending
[**2167-10-1**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2167-10-1**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2167-10-1**] Immunology (CMV) CMV Viral Load-FINAL negative
___________________
Doppler U/S [**9-30**]
IMPRESSION:
1) Patent hepatic vasculature with unremarkable Doppler
waveforms.
2) Coarsened, heterogeneous appearance of the transplant liver,
largely new from [**2167-8-6**], significance uncertain.
3) Large amount of ascites; a site was marked in the right lower
quadrant for paracentesis.
4) Splenomegaly.
TTE [**9-30**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is preserved except for probable mild mid
anteroseptal
hypokinesis. Right ventricular chamber size and free wall motion
are normal.
The aortic valve leaflets are mildly thickened. No aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is
normal. There is a small pericardial effusion.
Compared with the prior study (images reviewed) of [**2167-9-25**],
there is now a
mobile echodense structure on the ventricular side of the mitral
valve that
may represent vegetation. Left ventricular systolic function is
now minimally
depressed.
TEE [**10-1**]:
Conclusions:
1. Left ventricular wall thicknesses and cavity size are normal.
Overall left
ventricular systolic function is mildly depressed.
2. Mild (1+) mitral regurgitation is seen.
3. no vegetations
Duplex U/S, [**10-7**]:
CONCLUSION: Fully patent TIPS with main portal velocity of 39 cm
per second and intra TIPS velocities ranging from 85-143 cm per
second.
Brief Hospital Course:
A/P: 38 yo M s/p liver transplant in [**6-8**], h/o recurrent
hepatitis C transferred from OSH for eval of elevated LFTs s/p
MI.
.
#Elevated LFTs: chronically elevated since [**9-8**]. Initially s/p
tx pt's AST/ALT were normal. However, in [**8-5**] were ranging
40s to low 100s. Acute bump occured in late [**Month (only) **]. AST/ALT
have remained on the high 100s to 300s since that time. As this
has been a chronic change post transplant, this may be [**2-5**] to
known recurrence of hep C and/or hemachromatosis. Of note, the
pt's interferon therapy was discontinued a few weeks ago, but
the pt had not appeared to respond to the therapy. More
concerning these changes may be associated with rejection. RUQ
showed patent vasculature, no e/o cirrhosis. Pt. was continued
on lactulose, and his LFTs remained stable throughout his stay.
Given his recurrent ascites, he was given a paracentesis taking
off 3L, which recurred over the next few days, so TIPS was
placed by IR. Post, TIPs, bili rose slightly, but stabilized by
discharge with edema and ascites stable. Post-TIPS U/S showed
TIPS patency.
.
#STEMI: pt symptomatically stable, VSS on tele throughout his
stay without chest pain or shortness of breath. A TTE was
performed which showed minimally depressed LV function and an
echodense structure on the mitral valve worrisome for
endocarditis. Subsequent TEE ruled this out. He was coninued
on BB/asa/ticlopidine with no statin, given concurrent liver
dz.
.
#Hyperkalemia: pt. was hyperkalemic, peaking at 5.9 in the
context of ARF. He was placed on a low potassium diet and
kayexylate tid with resultant decrease in his potassium. He
will require close follow up as outpt. to ensure that he does
not develop hyperkalemia.
.
#ARF: early in year, Cr 0.7, but had been trending up. Baseline
prior to previous admissions 1.0-1.1. Initially presented a few
weeks back with ARF in setting of increased diuretics. Cr. had
been trending down to 1.3 at previous discharge. Upon current
discharge, Cr returned to baseline 1.1, after peaking at 2.0.
ARF thought to be prerenal vs. hepatorenal vs. contrast during
cath/ FK506 toxicity. His urine lytes were consistent with
prerenal ARF, and gentle fluids and transfusion of 2U helped to
return his Cr to baseline upon discharge. His FK506 dose was
decreased, maintaining level of [**5-11**] at trough, given his
concurrent renal failure and his diuretics were held throughout
his stay. His Cr returned to his baseline by discharge.
Diuretics were not restarted upon discharge
.
#Anemia: hct drop since last d/c to present admit (31 at
admission). Likely [**2-5**] to bleeding at cath site. Had hct drop to
28 prior to therapeutic paracentesis, 24 immediately afterwards
and received 2U pRBCs with correction back to 33. suspect that
the hct of [**5-27**] have been measurement issue. Stools were
guaiac negative, and hct was stable for the last few days of his
stay.
.
#Ascites/Pleural effusions: Diminished breath sounds with known
R pleural effusions, CXR stable. Pt. with increasing ascites as
has not been receiving diuretics [**2-5**] renal status. received 3.5L
therapeutic tap on [**10-3**], with TIPS done by IR on [**10-6**].
Post-TIPS doppler U/S showed patent TIPS prior to discharge.
.
#DM2: sugars continued to be high during admission, initially
with sugars into the 300s. Given recent MI, pt.'s sugars were
more aggressively controlled. At discharge he was taking 16U
NPH (up from 10U on admit) with an increased ISS.
Medications on Admission:
Asa 325mg qd
lopressor 12.5mg [**Hospital1 **]
ticlopidine
Colace 100mg qd
Protonix 40mg qd
Tacrolimus 1mg [**Hospital1 **]
Remeron 15 mg qhs
Bactrim DS one tab qd
Sliding scale insulin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. 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*
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
take 1 tab SL for chest pain. [**Month (only) 116**] repeat after 5 minutes x 2.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed for back pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
Disp:*30 Capsule(s)* Refills:*2*
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen
(16) units Subcutaneous twice a day: give 16U in AM and 16U in
PM.
Disp:*3 bottles* Refills:*2*
13. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale units Injection four times a day: Give number of units per
sliding scale.
Disp:*2 qs* Refills:*2*
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*27 Tablet(s)* Refills:*0*
15. Lactulose (for Encephalopathy) 10 g/15 mL Solution Sig:
Thirty (30) mg PO three times a day: titrate lactulose to [**3-7**]
bowel movements per day.
Disp:*3 qs* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent Ascites
s/p liver transplant
Diabetes Mellitus
________________
s/p STEMI
Recurrent Hepatitis C
Discharge Condition:
Good, amblating, afebrile tolerating POs, satting well on RA.
Discharge Instructions:
please seek medical attention should you develop any of the
following symptoms: increased confusion, lethargy, chest or
abdominal pain, shortness of breath, bleeding from your rectum,
henatemesis, decreased urine output, or increased abdominal
distension.
Please adhere to a strict low potassium diet (<1g/day) for now
until further notified by your PCP.
Take all medications as prescribed, including your tacrolimus at
0.5mg qday.
Take your lactulose regularly and titrate it to >3 bowel
movements per day.
Take your ciprofloxacin, the antibiotic for your urinary
infection twice a day for two more weeks. it is important to
complete this antibiotic course.
Follow up with Dr. [**Last Name (STitle) 497**] at the appt. outlined below next week.
HAve your labs drawn on monday prior to that appointment.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 497**] on Wed. [**10-14**] at 11:30AM to
follow up your prograf levels, bilirubin, potassium and
creatinine. In conjunction with your cardiologist dr. [**Last Name (STitle) **],
he may decide to start you on a statin medication for your
cholesterol as you have recently had an MI.
Please also attend the following appointments:
Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3265**] [**2167-10-20**] 3:00 PM. [**Street Address(2) 58548**], [**Location (un) 8973**], MA [**Telephone/Fax (1) 58549**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2167-10-15**] 11:40
|
[
"2851",
"5849",
"2767",
"25000",
"41401",
"V4582"
] |
Admission Date: [**2165-1-16**] Discharge Date: [**2165-1-21**]
Date of Birth: [**2094-11-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine-Iodine Containing / adhesive tape
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB and left arm burning
Major Surgical or Invasive Procedure:
[**2165-1-16**] CABG x4 (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to
PDA)/MV repair (28 mm [**Company 1543**] CG Future ring)
History of Present Illness:
70 year old female who complains of
SOB. She awoke from sleep with burning chest pain. She reported
stuttering chest pain all day today as with some associated
shortness of breath. She states she was last admitted 3 weeks
ago with similar symptoms and was diagnosed with a CHF
exacerbation. She has been taking her diuretics faithfully
since that time. Referred for cardiac catheterization which
showed 3V CAD. Subsequently referred for surgery.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-diastolic CHF
3. OTHER PAST MEDICAL HISTORY:
-Hypothyroidism
-Squamous cell carcinoma of left forearm.
- h/o varicella zoster
- vitreous hemorrhage- R and L eye.
- L hemispheric stroke [**4-20**]
Social History:
Married, lives at home with husband, denies tobacco, alcohol,
illicits.
Family History:
No early CAD, DM, or HTN.
Physical Exam:
Pulse:89 Resp:16 O2 sat: 98/RA
B/P Right:175/73 Left:160/52
Height:63" Weight:195 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
[x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right:- Left:-
Pertinent Results:
[**2165-1-21**] 06:00AM BLOOD WBC-7.4 RBC-3.87* Hgb-11.5* Hct-34.9*
MCV-90 MCH-29.8 MCHC-33.0 RDW-14.9 Plt Ct-247
[**2165-1-21**] 06:00AM BLOOD Glucose-222* UreaN-44* Creat-1.6* Na-137
K-4.9 Cl-98 HCO3-29 AnGap-15
[**2165-1-21**] 06:00AM BLOOD Mg-2.2
Conclusions
PRE BYPASS The left atrium is moderately dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thicknesses are
normal. Overall left ventricular systolic function is mildly
depressed globally(LVEF= 45 %). The right ventricle displays
borderline normal free wall function. There are simple atheroma
in the ascending aorta. There are simple atheroma in the aortic
arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
regurgitation is mostly central but has a slight posterior lean.
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 AV paced. There is normal
biventricular systolic function with a left ventricular ejection
fraction of 55-60%. A mitral valve annuloplasty ring is in situ.
It appears well seated. There is trace mitral regurgitation.
There is no mitral stenosis. The remainder of valvular function
remains unchanged. The thoracic aorta appears intact after
decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2165-1-16**] 16:12
Brief Hospital Course:
Admitted [**1-16**] and underwent surgery with Dr. [**First Name (STitle) **]. Transferred
to the CVICU in stable condition on titrated phenylephrine and
propofol drips. Extubated early on POD #1. Sleep medicine was
consulted for possible sleep apnea risks. Transferred to the
floor on POD #2 to begin increasing her activity level. Chest
tubes and pacing wires removed per protocol. PICC placed for
access and subsequently removed. Gently diuresed toward pre-op
weight. Made good progress and was cleared for discharge to
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] rehab on POD #5. All f/u appts were
advised. Metformin to be restarted at discretion of Dr. [**Last Name (STitle) **]
when creatinine normalizes.
Levemir to be restarted at discretion of rehab provider.
Medications on Admission:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at
bedtime.
2. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAYS
(MO,TU,WE,TH,FR).
3. levothyroxine 150 mcg Tablet Sig: Two (2) Tablet PO DAYS
([**Doctor First Name **],SA) .
4. lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Avalide 300-25 mg Tablet Sig: One (1) Tablet PO once a day.
7. hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Insulin Sliding Scale
Humalog Insulin Sliding Scale
As directed by your primary care physician
14. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
15. insulin detemir 100 unit/mL Insulin Pen Sig: Fourteen (14)
units Subcutaneous at bedtime.
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day: hold for
K+ >4.5.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): on lovastatin 40 mg daily at home.
7. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO MON TUES
WED [**Last Name (un) **] FRI ().
8. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO SAT SUN
().
9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED): humalog per sliding scale .
14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
15. METFORMIN to be restarted at discretion of Dr. [**Last Name (STitle) **] when
creatinine normalized
16. LEVEMIR to be restarted at rehab provider [**Name Initial (PRE) 8469**]
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 388**]
Discharge Diagnosis:
CAD/mitral regurgitation s/p cabg x4/MV repair
Dyslipidemia
Hypertension
diastolic Congestive heart failure
Diabetes Mellitus type 2
Hypothyroidism
Squamous cell carcinoma- left forearm and chest
h/o varicella zoster
vitreous hemorrhage- Right and Left eye (post Heparin)
Left hemispheric stroke [**4-20**]
Anemia- baseline Hct=27 (per patient)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon:Dr. [**First Name (STitle) **] [**2-11**] @ 1:45 pm
PCP/Cardiologist:Dr. [**Last Name (STitle) **] [**2-27**] at 2:45 pm ([**Location (un) 4628**] office)
**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:[**2165-1-21**]
|
[
"41401",
"4240",
"4280",
"4019",
"4168",
"2724",
"2449",
"2859"
] |
Admission Date: [**2143-11-16**] Discharge Date: [**2143-11-26**]
Date of Birth: [**2096-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 y/o m w h/o DM1, h/o DKA, h/o medication/diet noncompliance,
h/o alcohol and drug abuse, htn, CRI, presented with weakness
and fatigue and found to be in DKA in ED. Pt. reports that he
was discharged [**11-12**] and he was not able to fill his insulin
script, so he had to go to the ED for insulin. Pt. denied HA,
nausea, SOB, chest pain, abd pain, dysuria, diarrhea, sick
contacts or recent travel. While in the [**Hospital Unit Name 153**] he was treated with
an insulin gtt, and his DKA resolved, however he was found to
have slightly elevated cardiac enzymes, concerning for NSTEMI.
Cardiology was consulted, no changes were seen on ECG, but a TTE
showed an area of hypokinesis corresponding with a possible LCx
lesion. A stress test was done which showed a defect in LCx
territory. Pt. was treated with maximal medical management.
Past Medical History:
# HTN - not currently being treated
# DM - now insulin dependent
- has had multiple admissions for DKA in setting EtOH use
- currently on NPH + Regular insulin [**Hospital1 **], no sliding scale
- last HgbA1C 7.6 ([**2143-10-31**])
- has peripheral neuropathy, retinopathy
# CRI - thought to be due to diabetic and hypertensive
nephropathy
# Sarcoid
- CT [**6-/2129**] = hilar/subcarinal [**Doctor First Name **], nodules in parenchyma
- [**1-/2134**] = L eye proptosis -> CT showed L maxillary mass -> bx
showed non caseating granulomas c/w sarcoid
- decision was made not to begin systemic tx since pt asx
# H/o Chronic RUQ pain
- Present for over 13 yrs (by [**Hospital1 18**] records), evaluated with at
least 12 abdominal/RUQ ultrasounds and multiple abdominal CT's
without evidence of suspicious pathology
# Polysubstance abuse
- Pt drinks regularly 2-3drinks daily; occasionally uses cocaine
Social History:
Lives w/ girlfriend, no children. Sister (?[**Doctor Last Name 2270**]) is very
supportive. Works part time as a tire-changer. No tobacco, but +
EtOH (2-3 beers/day) and cocaine use (snorted last week).
Family History:
Mother had diabetes, niece has diabetes, no coronary artery
disease, no hypertension, no cancer, no liver disease, no renal
disease in the family.
Physical Exam:
T 98.3 HR 86 BP 110/60 R 20 sat 93% RA
gen: NAD, A+OX3
HEENT: mmm
CV: RRR 2/6 hsm
pulm: CTAb
abd: s/nt/nd +BS
ext: 1+ edema bilat
Pertinent Results:
[**2143-11-16**] 08:44PM GLUCOSE-551*
[**2143-11-16**] 08:40PM GLUCOSE-657* UREA N-57* CREAT-4.7* SODIUM-133
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-11* ANION GAP-26*
[**2143-11-16**] 04:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2143-11-16**] 04:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2143-11-16**] 04:25PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2143-11-16**] 04:00PM GLUCOSE-718* UREA N-57* CREAT-4.6*
SODIUM-129* POTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-13* ANION
GAP-26*
[**2143-11-16**] 04:00PM CK(CPK)-303*
[**2143-11-16**] 04:00PM CK-MB-18* MB INDX-5.9 cTropnT-0.28*
[**2143-11-16**] 04:00PM WBC-4.7 RBC-3.76* HGB-11.7* HCT-36.1* MCV-96
MCH-31.1 MCHC-32.4 RDW-12.5
[**2143-11-16**] 04:00PM NEUTS-62.3 LYMPHS-29.4 MONOS-3.8 EOS-3.3
BASOS-1.3
[**2143-11-16**] 04:00PM PLT COUNT-268
.
CXR ([**11-16**]): Tiny pleural effusion. Increased prominence of
bilateral hilar adenopathy. While non-specific, sarcoid and
lymphoma should be considered. No evidence of focal
consolidation. Poorly defined small nodular densities seen
projecting over the posterior right 6th and 7th ribs. Followup
imaging recommended following treatment to document resolution.
.
TTE ([**11-19**]):
IMPRESSION: Mild regional left ventricular systolic dysfunction
suggestive of
CAD (? Left dominant circulation with LCX lesion). Mild mitral
regurgitation
most likely due to papillary muscle dysfunction. Mild pulmonary
artery
systolic hypertension.
Based on [**2134**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a low risk (prophylaxis not recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2143-11-19**]
14:44.
[**Location (un) **] PHYSICIAN:
.
exMIBI ([**11-20**]):
IMPRESSION: Abnormal myocardial perfusion study at sub-optimal
level (57% MPHR)
demonstrating a mild reversible inferior defect, LV enlargment
and transient
cavitary dilatation.
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] informed of results by Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] at
2:55pm
[**0-0-0**].
CXR ([**11-23**]):
Persistent right mid and lower lung opacity. Diagnostic
considerations include pneumonia.
Brief Hospital Course:
1. DKA- Thought to be [**3-14**] non-compliance and ? cardiac ischemia.
Came in with sugar 700 and Ag 21. Gave IVF, insulin gtt and
repleted K and now AG is 9 and sugars all less than 200. On his
normal home regimen. Needs more diabetes teaching and should f/u
with Dr. [**Last Name (STitle) **] at [**Last Name (un) **].
2. NSTEMI-cardiology was consulted . CKs and troponins trending
down, no significant ekg changes compared to [**2142**]. Started
asa/plavix and is on beta blocker. Started statin. TTE revealed
regional wall motion abnormality concerning for possible LCx
lesion. exMIBI also revealed a defect consistent with LCx lesion
but there was also some transient dilation observed raising the
question of 3VD. On the day of discharge the cardiology team was
still deciding whether he should undergo cath, and this would be
with renal involvement as his Cr is 3.5-4 at baseline. Pt. did
not want to stay for catheterization and preferred medical
management as he was tired of being in the hospital. He was told
of the risks of sudden cardiac death and heart attack and
understood this. He will follow up with Dr. [**Last Name (STitle) 1445**] of
cardiology.
3. Chronic abd pain- long-term issue. RUQ US normal. LFTs
normal. AP chronically elevated. GI consulted. Think may be PUD
or gastritis although pt denies hematochezia/melena. Also
concern for gastroparesis although pt does not report fullness,
nausea, vomit after meals. Started on PPI.
4. Acute on chronic renal failure-creatinine elevated on
admission and trended down to baseline at 3.7. Recently d/c in
early [**Month (only) **] and on that admission had acute on chronic renal
failure thought ot be [**3-14**] ATN from cocaine abuse. Chronic
component [**3-14**] DM and HTN. Pt needs outpt nephro appt. Followed
by renal in house, follow up with Dr. [**First Name (STitle) 805**].
5. ETOH/drug abuse-on CIWA scale but didnt require ativan.
Started thiamine,
MVI, folate.
6. FEN-cardiac, diabetic diet, euvolemic on d/c, kept on daily
40 mg lasix.
7. HTN- not compliant with meds. Poorly controlled BP in house.
Labetalol increased to 800 mg po tid, continued on nifedipine
120 mg, added imdur 30 mg daily. Will need to follow up with
cardiology and renal.
Medications on Admission:
Nifedipine 120 mg daily
NPH insulin 14 units sc qam, 10 units sc qpm
Lasix 40 mg po daily
Labetalol 400 mg tid
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day): DO NOT TAKE IF YOU USE COCAINE, Can be fatal.
Disp:*240 Tablet(s)* Refills:*2*
7. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as dir as
dir Subcutaneous twice a day: Please take 14 units sc qam and 10
units sc with dinner.
10. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: as dir as
dir Subcutaneous four times a day: sliding scale 4 times daily
with meals and at bedtime.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
16. Erythromycin 5 mg/g Ointment Sig: One (1) app Ophthalmic HS
(at bedtime) for 1 weeks: apply to L eye at bedtime.
Disp:*qs 1 week* Refills:*0*
17. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Non-ST-Elevation Myocardial Infarction (MI)
Hypertension
Type 1 Diabetes
Polysubstance Use
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital if you have chest pain, confusion,
Inability to urinate, fever, nausea/vomitting. Please make sure
you follow up with your kidney doctor, Dr. [**First Name (STitle) 805**]. Please also
call for an appointment with the cardiologist in the next week.
You may need to have a cardiac catheterization.
Followup Instructions:
1. Please follow up with your cardiologist. Provider: [**Name10 (NameIs) **] [**Name Initial (NameIs) **]
[**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2143-12-9**] 11:20
2. Please schedule an appointment with Dr. [**First Name (STitle) 805**], your kidney
doctor. Please call [**Telephone/Fax (1) 3637**] for an appointment.
3. Please also follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in the next
2 weeks. Call [**Telephone/Fax (1) 250**] for an appointment.
4. Please call toProvider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], RNC
Date/Time:[**2143-12-3**] 11:40
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5085**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2143-12-9**] 2:00
Provider: [**Name10 (NameIs) **] WEST,ROOM TWO GI ROOMS Date/Time:[**2143-12-9**] 2:00
|
[
"41071",
"5849",
"5070",
"5859",
"40390"
] |
Admission Date: [**2194-4-9**] Discharge Date: [**2194-4-18**]
Date of Birth: [**2131-5-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
alcohol withdrawal, delirium tremens
Major Surgical or Invasive Procedure:
endotracheal intubation [**2194-4-10**]
History of Present Illness:
Pt is a 62 yo male with a h/o etoh abuse transferred from [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] for etoh withdrawal and question of intraventricular
hemorrhage. Pt was found down with a right forehead abrasion and
reported at the OSH that he tripped and fell on pavement. He
denies any loss of consciousness. Head and C-spine at the OSH
were concerning for possible intraventricular hemmorhage. He was
hypertensive, tachycardic and hyperpertensive and there was
concern for alcohol withdrawal and he was given 1 mg of ativan
at the OSH before transfer. His potassium was also found to be
2.9 and he was given 40 mEq K in his IVF.
.
On arrival to [**Hospital1 18**], his initial VS were 150, RR: 22, BP:
152/93, O2Sat: 97 on 2 L NC. He was tremulous and agitated
requiring 5 people to place him in restraints. In the ED he was
given 28 mg of IV lorazepam within the first 30 minutes. He
received a total of 36 mg iv lorazepam. His OSH head showed
focal rounded area of hyperdenisity within temporal [**Doctor Last Name 534**] of L
lateral ventricle, may represent acute IV
hemorrhage.Neurosurgery evaluated the pt and recommended loading
with dilantin 750 mg iv x1. He also received IVF with thiamine
and folic acid. Repeat K here was 3.6. Prior to transfer his, BP
dropped to 50/57 and his dilantin infusion was slowed. His VS
prior to transfer were: 98 ??????F, P: 67, RR: 15, BP: 89/58, O2 Sat
100% on 2 L NC.
.
On arrival to the ICU, patient was tremulous, unable to assess
for pain.
Past Medical History:
EtOH dependence, h/o withdrawal
Hypertension
GERD
HCV
Social History:
Per patient, has a house and lives with a girlfriend (has not
been able to contact her). Reports having a daughter. Drinks 18
[**Name2 (NI) 17963**]/day, +tobacco.
Family History:
noncontributory
Physical Exam:
On admission:
Vitals: T: 96.9 BP: 133/82 P: 95 R: 10 O2: 98% 2L NC
General: tremulous on arrival and mumbled speech then obtunded
HEENT: large contusion over right forehead, Sclera anicteric,
dry MM, oropharynx clear
Neck: c- collar in place
Lungs: Clear to auscultation over anterior chest
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Pupils 3 mm ->1 mm bilaterally, equally reactive,
initially moving all extremites with tremor, then with rest,
withdraws to pain equally in all extremities
.
Pertinent Results:
ADMISSION LABS:
[**2194-4-9**] 03:45AM BLOOD WBC-6.1 RBC-3.67* Hgb-12.3* Hct-36.8*
MCV-100* MCH-33.6* MCHC-33.4 RDW-12.2 Plt Ct-109*
[**2194-4-9**] 03:45AM BLOOD Neuts-78.9* Lymphs-11.9* Monos-8.3
Eos-0.2 Baso-0.7
[**2194-4-9**] 03:45AM BLOOD PT-12.2 PTT-27.3 INR(PT)-1.1
[**2194-4-9**] 03:45AM BLOOD Glucose-139* UreaN-7 Creat-0.8 Na-136
K-3.6 Cl-100 HCO3-22 AnGap-18
[**2194-4-9**] 03:45AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.4*
TOXICOLOGY:
[**2194-4-9**] 03:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
MICROBIOLOGY:
MRSA SCREEN: NEGATIVE
IMAGING:
[**2194-4-9**] CXR: Compared to the previous radiograph, there is a
subtle right medial and basal opacity, consistent with
aspiration in the appropriate clinical setting. Otherwise,
unchanged normal chest radiograph with normal size of the
cardiac silhouette. The observation was made at 10:08 a.m. on
[**2194-4-9**] and the findings were communicated at the same
time to the referring physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and the findings were
discussed over the telephone.
[**2194-4-10**] CXR: AP single view of the chest has been obtained with
patient in
semi-upright position. Comparison is made with the next previous
similar
study of [**2193-4-8**]. On previous examination identified
right lower
parenchymal density partially overshadowed by the heart contours
and
apparently located in the right lower lobe posterior segment has
cleared up. No new pulmonary abnormalities are identified and no
pulmonary vascular congestion is found. Similar as on the
preceding examination of [**4-9**], there is a rounded mass
overlying the contour of the ascending arch. This abnormality
has not changed significantly since yesterday. Comparison with a
supine chest examination transferred from [**Hospital3 26615**] Hospital,
this mass is new. Unfortunately, the transferred image is not
identified by date.
[**2194-4-10**] CXR: Patient with alcohol withdrawal and concern for
aortic
dissection, intubated for sedation for CT.
Comparison is made with prior study performed five hours
earlier.
ET tube tip is in standard position, 4.2 cm above the carina.
There are lower lung volumes with increasing bibasilar
opacities. There is no evident pneumothorax. Cardiomediastinal
silhouette is unchanged.
[**2194-4-10**] CTA CHEST: 1. No acute aortic pathology. No CT
abnormality to account for the radiographic abnormality
described on chest radiographs [**2194-4-10**].
2. Bibasilar atelectasis with volume loss in the lower lobes
bilaterally.
Supervening aspiration cannot be excluded. No pneumonia.
Secretions in the left main stem bronchus.
3. 4-mm right middle lobe nodule. If the patient has no risk
factors for
malignancy, no followup is needed. If the patient has risk
factors for
malignancy, followup with dedicated chest CT in one year is
recommended if there is no prior imaging documenting stability.
4. Fatty liver.
[**2194-4-12**] CT HEAD: IMPRESSION: Study is somewhat limited by
motion; within this limitation, no acute abnormality is seen.
ATTENDING NOTE: Study limited. Outside CT shows blood near left
temporal [**Doctor Last Name 534**] which is not apparent on current study. The scalp
hematoma is decreased.
.
[**2194-4-17**] CT HEAD:
IMPRESSION: No acute intracranial hemorrhage or mass effect.
Previously seen left temporal [**Doctor Last Name 534**] blood products are no longer
present.
Brief Hospital Course:
HOSPITAL COURSE:
Patient is a 62 yo male with history of alcohol abuse who was
brought to OSH after fall and found to be in ETOH withdrawal at
OSH with question of intraventricular hemorrhage and transferred
to [**Hospital1 18**] for further eval who required 36 mg iv lorazepam in the
ED for signs of ETOH withdrawal, intubated for CTA given concern
for question of aortic dissection and for increasing agitation.
Patient was kept on propofol and IV ativan prn while intubated.
He was started on standing ativan for agitation and extubated
successfully on [**4-13**].
.
# Alcohol withdrawal/Delirium Tremens: Patient had evidence of
delirium tremens and severe alcohol withdrawal in the ED with
tachycardia to 150s, BP to 153/93, agitation and question of
hallucinations. He received 36 mg iv lorazepam in ED. Patient
was first maintained on IV ativan prn on CIWA, however, he
required increasing doses of IV ativan, up to 16 mg at a time.
He was intubated and placed on propofol gtt with prn ativan for
increasing agitation, and for the need for CTA of chest (as
below) given question of aortic dissection. His agitation and
ativan requirement decreased over time and he was started on
standing PO ativan and extubated successfully. He was started
and continued on thiamine, folate and MVI daily. His Mg and K
were repleted aggressively throughout the hospital stay. He
required intermittent doses of IV haldol for acute agitation. Pt
remained stable and was transferred to the floor [**2194-4-15**].
.
# Intraventricular hemorrhage vs contusion s/p fall: Patient
presenting to outside ED with evidence of trauma given his large
R forehead hematoma and lacerations on extremities. CT head was
done at OSH and showed possibility of intraventricular
hemorrhage and transferred to [**Hospital1 18**] for neurosurgery eval.
Patient seen in ED by neurosurgery who reviewed the imaging,
which showed a hypodensity in R temporal [**Doctor Last Name 534**]. C-spine was
cleared by CT and by exam. It was thought to be due to artifact
and no hemorrhage seen. He had no edema on head CT from OSH.
Neurosurgery recommended Dilantin 100 mg q8hrs x7 days for
prophylaxis. Patient had an episode of oversedation and
unresponsive, and given change on neuro exam on [**4-12**], repeat
head CT was obtained without acute abnormality. Had f/u head CT
on [**4-17**], which continues to show no evidence of acute
abnormaility or bleed.
.
# Question of aortic dissection: Patient has a new finding on
CXR of potential aortic dissection. Given discordant blood
pressure of 150/90 right arm and 130/85 left arm, and as patient
was unable to relate clear history given his agitation, he was
intubated and CTA of chest was obtained. The imaging did not
show aortic dissection.
.
# History of GERD: Pt has hx of GERD per OSH, on pantoprazole
daily per OSH record. He was continued on pantoprazole in house.
.
# Social: patient reports living in a house with a girlfriend,
and also reports a daughter. Unable to contact any of these
people, social work was consulted to assist with locating family
members and to assist with his alcohol dependence. Daughter was
able to be located, is amenable to becoming health care proxy.
#Conjunctivitis: erythema, injection, and exudate on R eye
present on [**4-18**]. Rx for erythromycin drops started
Medications on Admission:
none known
Discharge Medications:
1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day).
Disp:*1 tube* Refills:*0*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]/[**Hospital1 8**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Alcohol withdrawal
Acute delirium
HCV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted with a fall while intoxicated. You were sent
here as there was concern that you had bleeding in your brain.
Your follow-up head imaging showed resolution of bleeding in
your brain. You were briefly on precautionary (prophylactic)
anti-seizure medication. You were seen by the S/W regarding
your alcohol abuse history, and you were provided with
information regarding resources for alcohol abuse treatment.
You Should not be driving.
Medication changes:
STARTED Thiamine and Folate
Started Erythromycin eye ointment
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] [**Location (un) **]
Address: [**Doctor Last Name **], [**Location (un) **],[**Numeric Identifier 89216**]
Phone: [**Telephone/Fax (1) 84402**]
Appt: [**4-24**] at 9:15am
|
[
"4019",
"53081"
] |
Admission Date: [**2155-10-10**] Discharge Date: [**2155-10-15**]
Date of Birth: [**2083-8-7**] Sex: M
Service: Medicine Oncology
HISTORY OF PRESENT ILLNESS: This is a 72-year-old male with
a history of non-small cell lung cancer, diagnosed in [**2155-5-13**] who initially presented with dyspnea on exertion and
discovered to have a right sided malignant effusion that was
subsequently treated with talc pleurodesis. He has had an
indwelling pleural catheter, which was used to drain his
pleural space q3 days and has previously had a negative work
up for metastasis, who then underwent six cycles of
carboplatin and Taxol, which was completed one week ago. He
felt well until the day prior to admission when he developed
mild dyspnea, malaise and a productive cough with green
sputum. He had a routine visit in the oncology clinic on the
day prior to admission for blood work and administration of
Aranesp. His ANC was found to be 180, it was previously 3850
on the 22nd. Later that evening the patient checked his
temperature and it was 101, so he went to the ER and was
found to have a temperature of 102.5. He was hypotensive, as
low as 80/48. The patient was pancultured, received 4 to 5
liters of IV normal saline and 2 grams of cefepime. The
blood pressure remained low, so he was started on peripheral
dopamine which caused increased tachycardia, so the dopamine
was discontinued. A right IJ triple lumen catheter was
placed and he was started on Levophed and admitted to the
intensive care unit. The patient denied chest pain, dysuria,
anorexia, melena, bright red blood per rectum, pain at the
chest tube site. He does have numbness and paresthesias of
his hands and feet, which started at the time of initiating
chemotherapy.
PAST MEDICAL HISTORY:
1. Nonsmall cell lung cancer diagnosed in [**2155-5-13**] by
right malignant effusion, talc pleurodesis with Pleurovac in
[**2155-5-13**], status post six cycle of carboplatin and Taxol
therapy, completed one week ago.
2. Dupuytren's contractures correction in the right hand.
3. Hard of hearing.
4. Right hip arthroplasty at [**Hospital6 2910**] in
[**2154**].
5. Seasonal allergies.
ALLERGIES: Bone scan tracer causes a rash, Percocet leads to
nausea and vomiting.
MEDICATIONS: He is on GCSF, it was left given on [**10-5**],
he is on Aranesp last given [**6-10**] and has completed his
course, multi-vitamin.
SOCIAL HISTORY: He had asbestos exposure while in the
military; he worked in the engine room of a ship for 4 years,
which was lined with asbestos. He is a former tobacco
smoker; he smoked one pack a day and pipe smoking for 4
years, he quit in [**2155-4-12**]. Alcohol - he drinks 12 to
24 beers a week. He has no history of drug use. He lives
with his wife, he is a retired mechanic and is DNR and DNI.
FAMILY HISTORY: Father had a history of blood clots. His
mother died of an intracerebral bleed, no history of lung
cancer or any malignancies.
PHYSICAL EXAMINATION: Vital signs in the ER, temperature of
102.0, heart rate 116, blood pressure 131/68, oxygen
saturation 94% on room air. He is an elderly white male in
no apparent distress. HEENT - PERRL, EOMI, anicteric, mucous
membranes are moist. Neck - right IJ catheter in place, no
lymphadenopathy. Lungs - decreased breath sounds on the
right, an indwelling chest tube catheter, generally clear,
but with mild expiratory wheezes throughout. Cardiovascular
is tachycardia, normal S1 and S2, regular rhythm, no murmurs,
rubs or gallops. Abdomen is mildly distended, hypoactive
bowel sounds, no masses, nontender. Extremities - no
clubbing, cyanosis or edema, he has 2+ DP pulses bilaterally.
Skin - there are no rashes. Neurologic - decreased sensation
to light touch on his feet, strength 5/5 on the lower
extremities, globally decreased strength to [**5-17**] on his right
lower extremity, hip, knee and ankle and the patient
attributes this to his hip replacement and sciatica.
LABS ON ADMISSION: White count was 1.7, differential - 4
neutrophils, 4 bands, 50% lymphocytes, 18% monos, 8 meta and
12 myelocytes. His ANC was 320, hematocrit 28, platelets
100. PT 14, PTT 60.4. His INR 1.3. His chem-7 was normal
with the exception of potassium of 3.4. His urinalysis was
negative. Blood cultures and urine cultures were sent from
the emergency room. A chest x-ray showed persistent right
hydrothorax. The left lung was clear. A repeat chest x-ray
showed the right IJ catheter tip in the distal superior vena
cava.
The patient was admitted to the intensive care unit for
febrile neutropenia and hypotension and requiring pressor
therapy.
HOSPITAL COURSE BY SYSTEMS:
1. Febrile neutropenia: He was started on cefepime 2 grams
IV q8 hours for empiric coverage. Blood cultures and urine
cultures were followed. Although the chest x-ray did not
show signs of an infiltrate the right sided effusion could
have been obscuring a pneumonia on the right. The pleural
space was drained and cultured. On the first day the patient
was hemodynamically stable and was transferred to the general
floor on 3 liters of oxygen nasal cannula. Throughout his
hospital course he was started on Levaquin for suspected
pneumonia. At the time of discharge his blood cultures were
negative to date. His pleural cultures had grown greater
than 3 colony types with first growth coag negative organisms
and his sputum had been consistent with oropharyngeal flora.
2. Pulmonary: The patient had pneumonia as stated above.
He also had an increasing effusion in his right lung.
Interventional pulmonary was contact[**Name (NI) **] regarding further
recommendations with how to manage his malignant effusion.
CT surgery was also contact[**Name (NI) **] regarding his candidacy for a
VATS procedure, however, CT surgery decided that given his
overall picture he was not a candidate for the VATS
procedure, so they recommended leaving the drain to gravity,
however, the patient received interventional pulmonary, the
fluid would be drained on [**10-14**] and they would continue
to follow fluid cultures. The initial pleural fluid studies
were not consistent with empyema. At the time of discharge
he went home continuing his regular catheter care.
3. Anemia: Over the hospital course he was transfused 2
units. His hematocrit remained stable, in the low 3-0 silk
for the rest of his hospital course.
4. Heme: The patient was noted to have an elevated PT and
PTT, his fibrinogen level was elevated, so it was felt that
this was likely secondary to a vitamin K deficiency. The
patient was given one dose of p.o. vitamin K on [**10-12**].
5. Neutropenia: The patient's neutropenia resolved without
the use of GCSF. No further precautions were taken at the
time.
6. The patient was seen by physical therapy during this
hospital course and it was felt that he would need follow up
about 3 to 5 times a week for gait training and endurance
training.
The patient was discharged home on [**2155-10-15**] with the
following discharge instructions of an antibiotic.
FINAL DIAGNOSES:
1. Small cell lung cancer with malignant right pleural
effusion.
2. Febrile neutropenia.
3. Pneumonia.
FOLLOW UP: Follow up with oncologist, Dr. [**Last Name (STitle) **].
INVASIVE PROCEDURES: He had his effusion drained.
DISCHARGE MEDICATIONS: He was discharged home on home oxygen
by nasal cannula and titrate the oxygen so that his
saturation remained above 93% with ambulation and activity.
He was also discharged home on multi-vitamin one capsule p.o.
q.day as well as the admission medications and Levaquin for 3
more days 500 mg p.o. and Albuterol with ipratropium bromide
inhalers to use p.r.n..
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-160
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2155-10-30**] 16:41
T: [**2155-11-3**] 09:32
JOB#: [**Job Number 34059**]
|
[
"486"
] |
Admission Date: [**2152-7-27**] Discharge Date: [**2152-8-4**]
Date of Birth: [**2087-8-18**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Zoloft
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
UTI- Indwelling Catheter, Fever and R UVJ stone
Major Surgical or Invasive Procedure:
Colonoscopy
Percutaneous Nephrostomy Tube
Central Venous Line
PICC Line Placement
History of Present Illness:
64M with long standing paraplegia who was admitted on [**7-27**] with
fevers, on zosyn since [**7-30**] for pseudomonal UTI. Due to
persistent fevers, CT abdomen was obtained on [**7-28**] which was
significant for R UVJ stone. Pt is s/p IR perc nephrostomy tube
placement on [**7-31**]. He had also had an episode of ~500cc BRBPR
on [**7-29**] and is s/p colonoscopy on [**7-31**] as well, findings notable
for ulcerative colonic mass. That evening he reported an episode
of chills without rigoring, then triggered for fever to 101.9
with hypotension to 80/D. Abx coverage was broadened with the
addition of daptomycin given history of VRE swab positive. He
was given 2.5L of IVF and placed in trendelenberg. Repeat BP was
70/50. The patient was alert and oriented, mentating normally.
Continued to have brisk urine output. His Hct had been stable
during the admission despite the GIB at around 28-30. He was
transferred to the MICU.
In the MICU, patient received pressors via a central line. He
received 2 units of PRBCS, and his Zosyn and Daptomycin were
continued. He clinically stabilized and was transferred back to
medicine on [**8-3**], after waiting for a bed for two days.
The day of discharge, Mr. [**Known lastname 3803**] was pleasant and in no apparent
distress. He was able to tolerate food well. A PICC line was
placed for him to continue
Zosyn at home, and ID recommended switching the daptomycin to
Augmentin. The pathology from his colonic biopsy will be
followed with GI and
Surgery. Also, he is to follow-up with Urology for definitive
treatment of his
nephrolithiasis after his infection is fully treated. His other
chronic conditions are stable.
Past Medical History:
#. paraplegia- Pt is a C5-C6 paraplegic secondary to a
waterskiing injury in [**2109**]. He is wheelchair bound. He has a PCA
at home but is very high functioning. Pt was involved in a MVA
in [**3-23**] and was found to have a C2 odontoid fracture. Unclear
if this is new or subacute. He was treated with a hard collar
and repeat imaging on [**6-23**] was stable. Most likely an old
non-[**Hospital1 **] from an old fracture. Pt was offered fusion at that
time but has declined.
#DVT: After noting Left lower extremity edema was found to have
chronic DVT of the Left Lwer extrmity on [**2150-6-5**], which was
shown to be persistent on repeat LE Venous Dupplex on [**2150-7-3**].
Coumadin stopped [**2150-8-19**].
#. Vertebral osteomyelitis- Pt had vertebral osteo in 06/[**2145**].
At that time, he had high grade S aureus bacteremia. A spinal MR
showed thoracic discitis which was thought to be the source.
Repeat MR in [**7-/2145**] showed progression with some vertebral
collapse and cord impingement despite antibiotic treatment. Pt
required surgical debridement. Subsequent path was consistent
with osteomyelitis. Cultures were negative. The treatment course
was complicated by Pseudomonas and [**Female First Name (un) 564**] line infections.
#. Neurogenic bladder- Secondary to quadriplegia. Low pressure
system with bladder sphincter dysnergia. Pt with suprapubic tube
in place. Replaced on every six days by his wife. [**Name (NI) **] by Dr [**Last Name (STitle) **]
[**Last Name (STitle) **] urology clinic.
#. Depression
#. Anxiety
#. Hyponatremia- Baseline roughly 134. First noted in [**2146**]. Pt
with normal ACTH stim test in 01/[**2148**]. Urine lytes and osm
consistent with SIADH at that time. Thought to be due to
pulmonary disease.
#. Pleural effusions- Pt with refractory left pleural effusion
in setting of osteo in 07/[**2145**]. Underwent talc pleurodesis x3
and had a prolonged chest tube. He now has chronic scarring and
loculations s/p the talc.
#. Osteoporosis
#. Erectile dysfunction
#. Colonic polyps- Found on screening colonoscopy in 01/[**2144**].
Plan repeat in [**5-28**] years.
#. S/P right hip fracture- Occurred [**3-/2148**] after MVA. Treated
with ORIF. Complicated by a distal femoral fracture which was
treated with a fixed brace.
#. Superficial thrombophlebitis- Diagnosed [**2149-2-13**]. Involved
the greater saphenous vein extending to confluence with the deep
femoral system. Coumadin stopped by PCP in [**2150-8-19**].
#Osteoporosis
Social History:
Pt is married and lives with his wife, and has an adopted child
who is 25. He works as a tax accountant. He has home help aides
at home. He denies tobacco or drugs and occasionally drinks
ETOH.
Family History:
[**Name (NI) **]
Father died of prostate CA in age 90s
Mother died of MI, aged 90s
Physical Exam:
Vitals: T 98.2 BP 162/88 HR 59 RR 20 O2 sat 98%
General: Pale, alert, articulate. No acute distress.
HEENT: MMM
Neck: R IJ in place, C/D/I
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Obese, soft, + BS. Suprapubic catheter in place.
Ext: Perc nephrostomy drain in place on right flank, No
extremitiy edema, some distal extremity wasting.
Pertinent Results:
Admission Labs [**2152-7-27**]:
WBC-11.2* RBC-3.59* Hgb-10.1* Hct-30.5* MCV-85 MCH-28.1 Plt
Ct-340
Neuts-88.6* Bands-0 Lymphs-6.9* Monos-3.8 Eos-0.7 Baso-0.0
Glucose-114* UreaN-27* Creat-0.9 Na-126* K-3.9 Cl-91* HCO3-24
AnGap-15
ALT-24 AST-25 LD(LDH)-150 AlkPhos-284* TotBili-0.6
Albumin-3.1* Calcium-8.2* Phos-3.0 Mg-1.7
Lactate-1.1
URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-1 pH-7.0 Leuks-MOD
URINE RBC-[**6-28**]* WBC->50 Bacteri-MANY Yeast-NONE Epi-0
[**2152-7-31**] 11:00PM BLOOD Hct-21.3*
[**2152-8-3**] 04:03AM BLOOD CEA-1.5
.
Micro:
[**2152-7-31**] Urine Culture:Gram negative rods and Pseudomonas and
yeast
PSEUDOMONAS AERUGINOSA Sensitivity
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
Other Studies:
CHEST (PA & LAT) Study Date of [**2152-7-27**] 10:47 AM
[**2152-8-1**] CT abdomen/pelvis without contrast: Little overall short
interval change since recent comparison aside from new right
percutaneous nephrostomy tube in expected position. No
hydronephrosis or etroperitoneal hematoma identified. Large
1.3-cm stone in the right UPJ is again appreciated and unchanged
in position.
[**2152-7-28**] CT chest with contrast: 1. Moderate hydronephrosis of
the right kidney with an obstructing 14 mm right proximal
ureteral stone. Perinephric stranding, relative [**Name (NI) 20534**]
of the right kidney as compared to the left with irregular
enhancement of the right renal collecting system and small
periureteral collections concerning for superimposed infection.
Multiple other non-obstructing right renal calculi layering
within the right renal collecting system.
2. Compression deformities involving the L1 and T5 vertebral
bodies and
likely post-traumatic deformity involving the thoracolumbar
spine and thoracic vertebrae, unchanged.
[**2152-7-28**] TEE: No vegetations or clinically-significant
regurgitant valvular disease seen (reasonable-quality study).
Normal global and regional biventricular systolic function.
Colonscopy [**2152-7-31**]:
Localized ulcerated area was noted in the proximal sigmoid colon
with large overlying clot/mass. The overlying clot could not be
removed with flushing / manipulation, suggesting underlying
lesion. This could be a malignant ulcer or ischemic - favor
former. Cold forceps biopsies were performed for histology at
the sigmoid colon.
KUB [**2152-8-4**]:
FINDINGS: A right percutaneous nephrostomy tube is present in
expected
position within the right renal pelvis. 1.3 cm radiopaque
calculus is noted approximately at the level of the right
ureteropelvic junction. There is prominent amount of gas seen
throughout the colon and the rectum as well as in the small
bowel. Non-dilated air-filled loops of small bowel are seen. A
right femoral intramedullary rod with interlocking screw is
present. Wedge compression deformity involving L1 is noted,
which was also reported in patient's CT dated [**2152-8-1**].
IMPRESSION: 1.3 cm radiopaque calculus is noted in location of
the right ureteropelvic junction.
Right Sigmoid Colonoscopy - Verified [**2152-8-4**]
DIAGNOSIS: Sigmoid colon biopsy: Colonic mucosa with active
inflammation and ulceration; see note. Note: Macrophages are
positive for CD68 and negative for cytokeratin cocktail. Five
levels were examined.
PICC Line Placement: REASON FOR EXAMINATION: Evaluation of left
PICC line placement. Portable AP chest radiograph was reviewed
in comparison to [**2152-8-1**]. The left PICC line tip is most
likely at the level of superior SVC/junction of left
brachiocephalic vein and SVC. The previously seen right internal
jugular line has been removed. The left basal atelectasis has
improved, although still involving the left lower lobe. The
imaged portion of the right lung and the left upper lobe are
unremarkable. Dextroscoliosis of the thoracic spine is
unchanged. Note is made that the lateral portion of the right
chest was not included in the field of view.
Brief Hospital Course:
This is a 64M with paraplegia and multiple prior infections,
presents with fevers and hypotension.
.
# Hypotension (at time of transfer to MICU on [**7-31**]): Pt does
have autonomic dysfuntion at baseline, but given the severity
and refractoriness of this hypotension combined with a fever,
this would be a diagnosis of exclusion in a setting where there
are multiple more likely diagnoses. Ddx includes, sepsis, with
either bacterial showering from nephrostomy tube, or
introduction of skin flora during procedure. Pt's infectious
history is complicated as he appears to have relapsing UTIs
despite having completed a course of appropriate abx. The
presence of an obstructing stone is likely etiology for
persistent infections. Pt now s/p decompression with nephrostomy
tube. Also high on ddx is acute bleed, pt has both h/o recent
GIB with colonoscopy and biopsy as well as the nephrostomy tube
placement. The sedation he received for the colonoscopy in
addition to his BB, lack of PO intake x ~3 days and percocet he
received in the afternoon may have played a role in the severity
of his hypotension. His lactate and UOP are reassuringly normal
at this time after fluid rescusitation. Urine cultures were
collected that grew pseudomonas and yeast that was sensitive to
Zosyn. He was started on Zosyn, as well as Daptomycin to cover
for for both staph as well as VRE given h/o positive swab. He
will continue Zosyn through PICC line as outpatient with PO
Augmentin.
.
# Colon mass: Mass biopsy revealed colonic inflammation and
ulceration. The patient will have follow up with a [**Month/Year (2) 5059**]
regarding resection and future treatment.
.
# Obstructing ureteral stone. s/p perc nephrostomy tube. Patient
will follow up with urology as outpatient. Antibiotic managment
discussed above.
.
# Hyponatremia: Likely due to SIADH. At baseline, monitor
.
# HTN - Patient has had labile blood pressures. Currently well
controlled with metoprolol and amlodopine. His home dyazide was
stopped because it was thought that it could worsen his
hyponatremia.
.
# Depression/anxiety: Continue fluoxetine, Quetiapine.
clonazepam PRN, and Lorazepam prn .
.
# OSA - CPAP per home
.
Medications on Admission:
1. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for fungal infection.
2. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q HS ().
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. Testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
8. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for bladder spasm.
9. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QOD ().
12. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO QOD ().
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H prn
fever, pain.
2. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] prn
fungal infection.
3. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One Tablet,
Chewable PO TID.
5. Testosterone 5 mg/24 hr Patch 24 hr Sig: One Patch 24 hr
Transdermal Q24H
6. Oxybutynin Chloride 5 mg Tablet Sig: One Tablet PO TID prn
bladder spasm.
7. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO QOD ().
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two
Tablets PO QOD.
10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H prn anxiety.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID.
Disp:*60 Tablet(s)* Refills:*2*
12. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
13. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
14. Guaifenesin 100 mg/5 mL Syrup Sig: [**5-28**] mL PO every six
hours prn cough.
15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
16. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
17. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) injection Intravenous Q8H for 11 days: Last day of
antibiotic is [**2152-8-14**].
Disp:*33 injections* Refills:*0*
18. Augmentin 875-125 mg Tablet Sig: One Tablet PO twice a day
for 11 days: last day [**8-14**]. Disp:*22 Tablet(s)* Refills:*0*
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. Outpatient Lab Work: Please have the following labwork drawn
and faxed to the infectious disease department at [**Hospital3 **].
You will need a CBC, BUN, Creatinine drawn weekly starting on
Friday, [**8-11**]. Please fax results to the following number:
[**Telephone/Fax (1) 1419**], attn: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary:
obstructive uropathy with right Hydronephrosis
Urinary tract infection
Lower GI bleeding secondary to colonic mass
Secondary:
C5-6 paraplegia
hx Spinal Discitis/Osteomyelitis
SIADH
Obstructive Sleep Apnea
Benign Hypertension
Depression
Anxiety
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2152-7-27**] for a fever after being
discharged with appropriate antibiotic coverage for a UTI.
While at the emergency room, you were given one dose of
cefepime, an antibiotic. A chest x-ray was taken that was
unchanged from your last admission. A urine analysis was
performed that indicated bacteria in your urine. You were
admitted to the medicine service for unknown fever etiologies
and a UTI.
While admitted, you underwent an Echo that did not show any
valvular disease. You had a CT of your pelvis that showed an
obstructing 14 mm right proximal ureteral stone. On [**7-29**], you
had a GI bleed, and you had a colonoscopy on [**7-31**]; a mass was
biopsied and the results are pending. On [**7-31**], a percutaneous
nephrostomy tube was placed. That night, your blood pressure
dropped and you had high fevers. You were transferred to the
ICU, and you were given 2 units of packed red blood cells,
pressors (drugs that help to increase your blood pressure), and
you were started with a more broad spectrum antibiotic. Your
blood pressure stabilized, and your temperature decreased while
you were in the MICU; you were transferred back to the medical
floor on [**8-2**]. A PICC line was placed on [**8-2**], and you will
continue to receive one of your antibiotics through it. You
will take another antibiotic by mouth. An x-ray was taken of
you abdomen to determine the composition of your stone.
The urology team has followed you while you were at [**Hospital1 18**]. You
will follow up with them concerning your ureteral stone after
you are discharged.
Dr. [**Last Name (STitle) 1120**], a general [**Last Name (STitle) 5059**], has followed you while you were at
[**Hospital1 18**]. After you are well from your hospitalization, they will
be in contact with you about surgical evaluation of your sigmoid
colon.
You will need to have labwork drawn and faxed to the infectious
disease department at [**Hospital3 **]. You will need a CBC, BUN,
Creatinine drawn weekly. Please fax results to the following
number: [**Telephone/Fax (1) 1419**].
Please keep all medical appointments.
If any of the following symptoms arise, please contact your
physician or go to the emergency room:
1. High fevers
2. Shortness of breath
3. Bleeding from catheter site
4. Bleeding from rectum
5. Nausea, vomiting
Please keep all medical appointments.
Please continue to take all your medications as prescribed. The
following medications have been changed:
1. Your Metoprolol was changed from 50 mg twice daily to 25 mg
twice daily. This was requested by you per your primary care
physician's recommendations.
2. You will continue IV Zosyn through [**2152-8-14**] every 8 hours.
You will have home IV nursing to help with this
3. You will need to continue Augmentin 875/125 mg by mouth twice
daily through [**2152-8-14**]
Please keep all medical appointments.
If you develop any of the following symptoms, please contact
your physician or go to the emergency room:
1. High fevers
2. Blood in urine
3. Nausea/vomiting
4. Chest pain
Followup Instructions:
You have the following appointments scheduled. Please call if
you need to change or cancel an appointment.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**], a colorectal [**Last Name (LF) 5059**], [**First Name3 (LF) **] call you on
Monday. If you do not hear from her office by the afternoon,
please call at ([**Telephone/Fax (1) 15721**] to schedule an appointment.
Dr. [**Last Name (STitle) 3748**], a urologist, will have his team contact you about
following up with him in two weeks. If you do not hear from him
by Monday afternoon, please call his office at ([**Telephone/Fax (1) 93963**].
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. (PRIMARY CARE)
Date/Time:[**2152-8-9**] 8:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD (INFECTIOUS DISEASE) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2152-8-18**] 10:00 ***If you have had your urological
procedure by [**8-18**], you do not need to see Dr. [**First Name (STitle) **] and may
cancel this appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6310**], NP (PRIMARY CARE) Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2152-10-24**] 4:00
BONE DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2152-10-17**] 12:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. (Endocrine) Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2152-10-17**] 1:30
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. (PRIMARY CARE)
Date/Time:[**2152-12-19**] 4:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2152-8-8**]
|
[
"5990",
"2851",
"32723"
] |
Admission Date: [**2125-8-29**] Discharge Date: [**2125-9-10**]
Date of Birth: [**2102-1-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Tylenol overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 23 y/o male with a PMH significant for bipolar
disorder, past suicide attempts x 2, who initially presented on
[**2125-8-29**] s/p significant tylenol overdose of 100 tablets of
extra-stength tylenol on [**2125-8-28**] at 1 am. He then presented to
an OSH at [**2047**] and was found to have a tylenol level of
approximately 125 at that time. He was given a dose of NAC and
transferred to [**Hospital1 18**] MICU for further management.
In the MICU, he was followed by both hepatology and transplant
surgery. His peak transaminases were around 16,000 and peak INR
of 10.3. He was started on a NAC drip and continued until his
INR<2. He was taken off the transplant list given his improving
condition; however, while in the MICU he went into acute renal
failure, likely [**12-22**] ATN from tylenol toxicity. His creatinine
continued to rise, however he makes good urine of >100cc/hr and
electrolytes have been stable. Nephrology has been following.
He was never intubated and his mental status has been
appropriate. He has been having symptoms of epigastric
pain/discomfort while in the MICU, which has been attributed to
gastritis vs gastropathy [**12-22**] hepatic congestion. He has been
treated with PPI, GI cocktail, and carafate.
Currently, he only reports his epigastric symptoms. No f/c/s,
n/v/diarrhea. No dysuria, LE edema. No headaches.
Past Medical History:
- Bipolar disease with ?psychotic features - followed by a
psychiatrist in RI, has had prior suicidal attempts at psych
admissions in RI, with no medical consequences.
Social History:
Lives with his parents in RI. Smokes marijuana. No other ilicit
drugs. Has not drank ETOH in "long time." No current tobacco.
Family History:
CAD on mothers side of family; father has hypercholesterolemia;
no diagnosed psych illnesses.
Physical Exam:
VS: Tc 99.6, Tm 100.0, BP 120-140/60-80, HR 74-80, RR 18-27,
96%/RA, [**Telephone/Fax (1) 74864**], UOP 100-150cc/hr
General: pleasant, comfortable, NAD with flat affect
HEENT: PERLLA, EOMI, no scleral icterus, no sinus tenderness,
MMM, op without lesions
Neck: supple, no LAD or TMG
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, with slight TTP over epigastrum. NABS. Liver 3-4 cm
below costal margin, no tenderness. No splenomegaly.
Ext: no c/c/e, pulses 2+ b/l
Neuro: AO x 3, flat affect. CN II-XII intact. MS [**3-24**] throughout,
sensation to light touch intact.
Pertinent Results:
[**2125-8-28**] 11:58PM PT-32.7* PTT-35.6* INR(PT)-3.5*
[**2125-8-28**] 11:58PM PLT COUNT-172
[**2125-8-28**] 11:58PM NEUTS-89.5* LYMPHS-8.3* MONOS-1.9* EOS-0.2
BASOS-0.1
[**2125-8-28**] 11:58PM WBC-14.8* RBC-4.70 HGB-15.0 HCT-43.1 MCV-92
MCH-32.0 MCHC-34.9 RDW-13.4
[**2125-8-28**] 11:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-94.6*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2125-8-28**] 11:58PM ACETONE-NEGATIVE
[**2125-8-28**] 11:58PM LIPASE-16
[**2125-8-28**] 11:58PM ALT(SGPT)-2623* AST(SGOT)-2265* LD(LDH)-1590*
ALK PHOS-116 AMYLASE-29 TOT BILI-4.2*
[**2125-8-28**] 11:58PM estGFR-Using this
[**2125-8-28**] 11:58PM GLUCOSE-132* UREA N-12 CREAT-0.9 SODIUM-139
POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
[**2125-8-29**] 03:17AM FIBRINOGE-104*
[**2125-8-29**] 03:17AM PT-40.5* PTT-38.4* INR(PT)-4.6*
[**2125-8-29**] 03:17AM PLT COUNT-158
[**2125-8-29**] 03:17AM HCV Ab-NEGATIVE
[**2125-8-29**] 03:17AM WBC-13.3* RBC-4.47* HGB-14.7 HCT-41.2 MCV-92
MCH-32.9* MCHC-35.7* RDW-13.4
[**2125-8-29**] 03:17AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-NEGATIVE
[**2125-8-29**] 03:17AM ALBUMIN-4.4 CALCIUM-8.7 PHOSPHATE-2.8
MAGNESIUM-2.5
[**2125-8-29**] 03:17AM LIPASE-16
[**2125-8-29**] 03:17AM ALT(SGPT)-5337* AST(SGOT)-4898* ALK PHOS-112
AMYLASE-27 TOT BILI-4.2* DIR BILI-1.5* INDIR BIL-2.7
[**2125-8-29**] 03:17AM GLUCOSE-146* UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-3.2* CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2125-8-29**] 08:15AM HIV Ab-NEGATIVE
[**2125-8-29**] 08:18AM FIBRINOGE-110*
[**2125-8-29**] 08:18AM PT-43.0* PTT-39.4* INR(PT)-4.9*
[**2125-8-29**] 08:18AM PLT COUNT-153
[**2125-8-29**] 08:18AM WBC-12.3* RBC-4.56* HGB-14.9 HCT-42.3 MCV-93
MCH-32.7* MCHC-35.3* RDW-13.1
[**2125-8-29**] 08:18AM ALBUMIN-4.3 CALCIUM-9.0 PHOSPHATE-2.3*
MAGNESIUM-2.4
[**2125-8-29**] 08:18AM LIPASE-18
[**2125-8-29**] 08:18AM ALT(SGPT)-7900* AST(SGOT)-6853* ALK PHOS-116
AMYLASE-30 TOT BILI-4.4*
[**2125-8-29**] 08:18AM GLUCOSE-92 UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17
[**2125-8-29**] 01:19PM FIBRINOGE-87*
[**2125-8-29**] 01:19PM PT-50.9* PTT-40.6* INR(PT)-6.0*
[**2125-8-29**] 01:19PM PLT COUNT-152
[**2125-8-29**] 01:19PM WBC-12.9* RBC-4.53* HGB-14.5 HCT-42.0 MCV-93
MCH-32.0 MCHC-34.5 RDW-13.1
[**2125-8-29**] 01:19PM TSH-0.13*
[**2125-8-29**] 01:19PM CALCIUM-8.5 PHOSPHATE-2.8 MAGNESIUM-2.2
[**2125-8-29**] 01:19PM LIPASE-18
[**2125-8-29**] 01:19PM ALT(SGPT)-[**Numeric Identifier 74865**]* AST(SGOT)-8651* ALK PHOS-115
AMYLASE-27 TOT BILI-4.6*
[**2125-8-29**] 01:19PM GLUCOSE-124* UREA N-20 CREAT-0.9 SODIUM-142
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-18
[**2125-8-29**] 08:01PM FIBRINOGE-79*
[**2125-8-29**] 08:01PM PT-67.4* PTT-42.8* INR(PT)-8.5*
[**2125-8-29**] 08:01PM PLT COUNT-107*
[**2125-8-29**] 08:01PM WBC-11.0 RBC-4.29* HGB-13.8* HCT-38.6* MCV-90
MCH-32.3* MCHC-35.8* RDW-13.2
[**2125-8-29**] 08:01PM CALCIUM-8.0* PHOSPHATE-2.6* MAGNESIUM-2.4
[**2125-8-29**] 08:01PM LIPASE-27
[**2125-8-29**] 08:01PM ALT(SGPT)-[**Numeric Identifier 74866**]* AST(SGOT)-[**Numeric Identifier **]* ALK
PHOS-118* AMYLASE-32 TOT BILI-3.7* DIR BILI-1.7* INDIR BIL-2.0
[**2125-8-29**] 08:01PM GLUCOSE-196* UREA N-23* CREAT-1.0 SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
Brief Hospital Course:
23 y/o male s/p tylenol OD with resulting hepatotoxicity now
improving, now with acute renal failure likely [**12-22**] ATN.
# s/p tylenol overdose - The patient was admitted after taking
50g of tylenol. His initial tylenol level was 125 (18 hours
after ingestion). Original AST 800/ALT 600/INR 3 at the OSH.
He was transferred to [**Hospital1 18**] for potential transplant. Over the
next few days his LFT's trended up to AST [**Numeric Identifier 20629**]/ALT [**Numeric Identifier **]/INR
10.3. Throughout this time, he never had mental status changes.
Fortunately, his LFT's and INR then began to trend down.
# Acute renal failure - The patient was admitted with a
creatinine of 0.9. It remained in the normal range until 3 days
after admission when it started to climb. Urine sediment was
consisent with ATN. This was thought most likely to be
secondary to direct acetaminophen toxicity. Throughout the
hospital course, the patient continued to make good urine and
electrlytes remained within normal limits. His creatinine
reached a peak of 7.6 on hospital day #7. It quickly started to
the trend down. At the time of transfer his creatinine was 1.6.
It was felt that he would have a complete recovery.
# SI - The patient was followed by psychiatry throughout his
hospital course. His seroquel was held during his medical stay
secondary to liver and renal failure. A 1:1 sitter was with the
patient at all times. He was transferred to the psychiatry team
on [**2125-9-10**].
Medications on Admission:
Risperidone q2 weeks
Seroquel 100 tid
Discharge Medications:
Pantoprazole 40mg PO BID
Ondansetron 4mg ODT PO q8 PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Tylenol Overdose
Liver Failure
Acute Renal Failure - Secondary to ATN
Secondary Diagnosis:
Bipolar
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital after a tylenol overdose.
This ingestion caused severe liver and kidney injury. You were
severely ill and almost required a liver transplant. Luckily,
your liver and kidney function improved.
Please avoid taking more than [**11-21**] tylenol at a time.
If you experience any thoughts of hurting yourself or others,
severe depression, or any other concerning symptoms please
contact your psychiatrist immediately or go directly to the ER.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week of discharge.
Please see your psychiatrist within 1-2 days of discharge.
|
[
"5845",
"2760"
] |
Admission Date: [**2194-3-16**] Discharge Date: [**2194-3-21**]
Service:
HISTORY OF PRESENT ILLNESS: Patient is an 81-year-old male
with a past medical history of coronary artery disease and
CRI, who was recently admitted to [**Hospital1 190**] on [**3-8**] through [**3-10**] for a urinary tract
infection and hypernatremia, who is now found at nursing home
to be less responsive and hypotensive. The patient had been
admitted on [**2194-3-8**]. Urinalysis in the Emergency Room
revealed greater than 50 white cells, and patient was started
on Levaquin 250 po q day for a 14 day course. Urine culture
was negative. The patient was also hyponatremic, and he was
treated with free water boluses. For his change in mental
status, a MRI was performed which showed no acute
cerebrovascular accident.
Since hospitalization, the patient continued to exhibit
confusion, although this improved until the morning of
presentation for the current admission with hypotension with
a blood pressure of 60/palpable and unresponsiveness.
In the Emergency Room, the patient's vital signs were
temperature of 97.2, blood pressure 84/76, pulse 123,
respiratory rate 34, O2 saturation 94% on 100% face mask. A
Foley catheter was placed which drained frank pus. A femoral
line was attempted x2 and a left subclavian cordis line was
inserted. The patient was hypotensive to a blood pressure of
76/42, and was started on Neo-Synephrine drip. Cultures were
obtained. The patient was treated with Flagyl 500 mg IV,
Levaquin 500 mg IV, ceftriaxone 2 grams IV. Potassium in the
Emergency Department was 6.3, so the patient was treated with
calcium gluconate, insulin, and D50. He received 4 liters of
normal saline and was admitted to the MICU.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery bypass
graft x2 in [**2182**] with a myocardial infarction in [**2181**].
2. Meningioma of the sphenoid ridge with a right frontal
craniotomy in [**2188**], suspected residual was seen on [**11-23**].
3. Cerebrovascular accident with a left facial droop.
4. CRI with baseline creatinine of 2.0.
5. Dementia.
6. Hypercholesterolemia.
7. Status post hemorrhoidectomy.
8. Peptic ulcer disease.
9. [**Doctor Last Name 3646**]-[**Doctor Last Name **] while a WWII POW.
10. Eczematous dermatitis.
11. Diabetes type 2.
12. Hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Levaquin 250 mg po q day on day 9 of 14.
2. Baby aspirin.
3. Pyridoxine.
4. Prozac 5 mg q day.
5. Zyrtec 10 mg q day.
6. Atarax 25 mg q hs.
7. Had been on Elavil and Lopressor, which was discontinued
on [**2193-3-11**] secondary to a rash.
EXAMINATION ON ADMISSION: Vital signs: Temperature 97.2,
blood pressure 100/39, O2 saturations 99%. General: The
patient was awake, alert, answering questions appropriately
in no acute distress. Pupils are equal, round, and reactive
to light. Moist mucous membranes. Conjunctivae were pale.
The neck was supple with 8 cm of jugular venous pressure. He
was clear to auscultation bilaterally with no wheezes, rales,
or rhonchi. Regular, rate, and rhythm, normal S1, S2 with no
murmur appreciated. Abdomen was soft, full, nondistended,
and nontender. Skin: Positive cyanosis, but intact
capillary refill. Neurologic: Was responsive, following
commands. Rectal was positive for guaiac.
LABORATORIES ON ADMISSION: White count 21.4, hematocrit
38.0, platelets 636. INR of 1.5. Sodium 150, potassium 6.3,
chloride 113, bicarb 19, BUN 62, creatinine 4.8, glucose 185,
calcium 8.5, magnesium 2.3, phosphorus 5.3. Urinalysis
showed greater than 50 white cells with many bacteria,
moderate leukocyte esterase, and positive nitrates. ALT was
45, AST 66, alkaline phosphatase 126, T bilirubin 0.4,
amylase 41, albumin 3.2.
Chest x-ray in the Emergency Room showed central venous line
with tip in the left brachiocephalic vein, no pneumothorax.
Shows near total resolution of previously identified left
lower lobe opacity.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for likely urosepsis and hypertension
likely secondary to urosepsis and acute renal failure likely
prerenal secondary to volume depletion. The patient was
weaned off pressors while in the MICU. The patient was
treated for a resistant E. coli urinary tract infection with
Zosyn and patient responded well and was hemodynamically
stabilized.
The patient's hematocrit dropped while in the MICU with no
identified source of bleeding. The patient was transfused
with 2 units packed red blood cells due to his history of
coronary artery disease. Patient's acute renal failure
gradually improved throughout his hospital course.
The patient was evaluated by the GI Service, and watchful
waiting for the guaiac positive stool was recommended at that
time. No further imaging or endoscopy was performed. The
patient's hematocrit remained stable, and there were no
further signs of GI bleeding.
The patient was restarted on his Lopressor ramping up towards
his goal of his original outpatient dose as tolerated. Blood
and urine cultures were all negative throughout the [**Hospital 228**]
hospital course, so the patient was continued to be treated
for presumed resistant urinary tract infection with Zosyn.
A swallow study was completed, and diet was adjusted for
nectar thick liquid. The patient had loose bowel movements
which were Clostridium difficile negative x3. A renal
ultrasound was performed to rule out a perinephric abscess in
the setting of persistent urinary tract infection and this
ultrasound was negative for perinephric abscess, masses, or
stones.
The patient was transferred to the Medicine floor in stable
condition. While on the floor, the patient continued to
complain of diffuse pruritic rash which had been noted since
admission. This had been reportedly worked up previously and
had been sustained to be eczematous rash. A Derm consult was
ordered, and a diagnosis of Norwegian scabies was made based
on skin scrapings. The patient was treated with Lindane
lotion. The nursing home, where the patient had been a
resident, was notified, and they acknowledged that they had
an outbreak of Norwegian scabies and were aware of the
problem. [**Name (NI) **] had been in close contact with the patient
were notified through the Infection Control Service, and were
recommended to use Lindane or Prometh to prevent contraction
of Norwegian scabies.
The patient was accepted for transfer back to [**Hospital 100**] Rehab
Nursing Home, where he had been previously been a resident.
DISCHARGE DIAGNOSES:
1. Urosepsis.
2. Norwegian scabies.
3. Coronary artery disease status post coronary artery bypass
graft x2.
4. Meningioma status post craniotomy.
5. Cerebrovascular accident with a left facial droop.
6. Chronic renal insufficiency.
7. Acute renal failure resolved.
8. Peptic ulcer disease.
9. Diabetes type 2.
10. Hypertension.
11. High cholesterol.
12. Dementia.
DISCHARGE MEDICATIONS:
1. Fluoxetine 10 mg po q day.
2. Zosyn 2.25 grams IV q8h through [**2194-3-29**].
3. Lopressor 50 mg po bid.
4. Protonix 40 mg po q day.
5. Lindane lotion 60 mg td x1 dose to be given [**2194-3-27**].
6. Colace 100 mg po bid.
7. Senna two tablets po q hs.
8. Multivitamin one capsule per day.
9. Hydroxyzine 25 mg po q4-6h prn.
FOLLOWUP: The patient was to followup with his primary care
physician, [**Name10 (NameIs) **] was to have repeat dose of Lindane for
Norwegian scabies as described above.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 45008**]
Dictated By:[**Name8 (MD) 29946**]
MEDQUIST36
D: [**2194-6-18**] 16:08
T: [**2194-6-20**] 21:40
JOB#: [**Job Number **]
|
[
"0389",
"5990",
"5849",
"2760",
"25000",
"4019",
"41401"
] |
Admission Date: [**2128-11-3**] Discharge Date: [**2128-11-9**]
Date of Birth: [**2077-3-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
EGD with banding
Intubation with mechanical ventilation
History of Present Illness:
51 yo man with PMH significant for alcohol abuse and a history
of GI bleed was transferred from [**Hospital 1562**] Hospital, intubated,
with a variceal bleed, for possible TIPS placement. He initially
presented to [**Hospital1 1562**] ED after 6 hours of hematesis with visible
clots. He was tachycardic to 140s and had abdominal tenderness
on palpation. He vomited 750 cc bloody emesis in ED. His BP has
remained stable. He underwent an upper endoscopy that revealed
Grade 3 varices from the gastroesophageal junction to the
mid-esophagus with adherent clots and blood and clots in his
stomach. He had 5 variceal bands placed. During the EGD he had
hematemesis and was intubated for airway protection with versed
and propofol. His INR was 1.5, platelets 87, and initial HCT was
33 (down from 40 10/[**2123**]). His Hct dropped to 25. He received 1
liter of IVFs and 4 units of pRBCs. Also, he received 1g
magnesium for a level of 1.0, potassium repletion, MVI,
thiamine, vit K and folate.
Past Studies:
EGD-[**2-10**]- nonerosive gastropathy
Colonoscopy-[**2-10**]- Diverticula, prolapsed ileocecal valve.
Past Medical History:
History of upper GI bleed
Hypercholesterolemia
Cholelithiasis
Pancreatitis
Abdominal hernia
HTN
Depression
Diverticula
Social History:
Daily ETOH (vodka, scotch). Married.
Family History:
Colon Cancer
Physical Exam:
On admission:
PE: weight 103 kg, T 97.8, HR 92, BP 133/77, RR 18, SaO2 100%
Genl: Intubated white middle-aged male. Unresponsive.
HEENT: Perrl. Supple neck. No JVD.
Neck: Right IJ in place.
CV: tachy s1/s2, no murmurs
Pulm: CTA anteriorly
Abd: distended, soft, no HSM appreciated, NABS
Back/Chest: Spider Nevi.
Ext: 4 peripheral IVs. B/l shins with erythematous plaques. Some
petechiae on arms.
Pertinent Results:
On admission:
wbc-5.3, hct 27.6, plt-47, mcv-91, ptt-35.1, inr-1.7,
fibrinogen-229
Chemistries: 146/3.9/108/26/22/0.8/133, ag-12, alt 30, ast 97,
ldh 231, cpk 212, ap 135, tb 3.5, lipase-34, alb 3.2, ca-7.9,
phos-2.0, mg-1.2, lactate- 1.7.
ABG on admission: 7.44/39/158
Discharge labs:
CBC: WBC-8.1 RBC-3.60* Hgb-11.2* Hct-32.4* Plt Ct-120*
Chem 7: Glucose-99 UreaN-13 Creat-0.8 Na-136 K-3.7 Cl-100
HCO3-25 Mg-1.4*
TotBili-4.8*
Hepatitis panel:
HBsAg-NEGATIVE HBsAb-POSITIVE HAV Ab-NEGATIVE HCV Ab-NEGATIVE
Micro: blood cx negative, RIJ tip culture negative
EKG: nl sinus, 90bpm, flattened T-waves inferiorly, nl
intervals, normal axis
CXR: IJ in position, rotated but appears ett too high, slight
haziness at left base.
ULTRASOUND ABDOMEN WITH DUPLEX:
INDICATION: Variceal bleeding, intubated, evaluate for ascites
and perform liver Dopplers.
A portable ultrasound of the liver was performed. The liver
demonstrates no focal mass lesions. The echotexture is
coarsened. A small amount of ascites is noted in Morison's pouch
between the right lobe and the kidney. No other areas of ascites
are identified. The gallbladder is unremarkable apart from edema
within the wall and several small shadowing stones. The right
kidney is 11.6 cm in length with no stones or hydronephrosis.
The spleen is enlarged measuring over 17 cm in diameter. The
left kidney measures 12.5 cm in length with no stones or
hydronephrosis.
Doppler studies were performed to evaluate the hepatic
vasculature. Portal vein is patent with antegrade flow and
normal waveform. The vena cava has appropriate directional flow.
The main left and right hepatic arteries are patent with
appropriate directional flow. The right and left intrahepatic
portal veins are patent with appropriate flow. All three hepatic
veins are patent with normal waveforms.
IMPRESSION:
1. Patent hepatic vasculature.
2. Minimal ascitic fluid identified only in the right subhepatic
space. This volume is far too small to attempt _____.
Brief Hospital Course:
Assessment: 51 yo man with ETOH abuse and history of GI bleed in
the past was transferred with recent Grade 3 variceal bleed, s/p
banding x5, falling Hct despite transfusions, and worsening
coagulopathy.
Hospital course is reviewed below by problem:
1. Variceal bleed: He was treated with 5 days of octreotide and
7 days of levofloxacin for SBP prophylaxis in the setting of
variceal bleeding, as well as IV PPI. He had a repeat EGD with
repeat banding. He received 4 units pRBC at the OSH and 2 units
at [**Hospital1 18**], as well as FFP and platelets. His Hct remained stable
for days prior to discharge. He was started on nadolol prior to
discharge. He will follow-up with gastroenterology and have an
EGD in [**2-12**] weeks with banding as needed.
2. Respiratory status: He was intubated for airway protection in
the OSH. There was a concern about possible aspiration during
intubation given a low grade temperature and increased
secretions. However, he defervesced quickly without treatment.
He was extubated [**11-5**] without difficulty.
3. EtOH abuse - He was maintained on CIWA scale in the MICU, but
did not need any benzodiazepines once transferred to the floor.
The patient was given thiamine, folate, and a multivitamin. An
addictions consult was called. She and the social worker
facilitated contact between the patient and [**Location (un) 22870**]. Upon
discharge, he was endorsing the need and desire to stay sober
and expressed several outlets if he were to feel the need to
drink alcohol upon discharge. He was given the number for the
substance abuse hotline and the addictions consult upon
discharge.
4. Thrombocytopenia: Likely from liver disease. There was no
evidence of DIC.
Medications on Admission:
NKDA (from [**Hospital1 1562**] records)
.
Home Meds:
Zetia 10mg
Atorvastatin 10mg
Atenolol 25
.
Meds on Transfer:
Octreotide gtt
Protonix gtt
Propofol gtt
Versed gtt
MVI
Thiamine
Folate
Odansetron
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for 1 weeks.
Disp:*qs ml* Refills:*0*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Upper gastrointestinal bleed
2. Alcohol dependence and withdrawal
3. Anemia
4. Cirrhosis
5. Hypomagnesemia
6. Candidal thrush
Discharge Condition:
Stable; the patient's hematocrit is stable and he no longer has
any GI symptoms, including melanotic stool.
Discharge Instructions:
Please take all medications as prescribed below. These are the
medications you were taking prior to hospitalization and several
new medications.
Follow up with your PCP and your gastroenterologist as scheduled
below.
It is very important that you do not drink any alcohol. Attend
your daily AA meetings. If you are having trouble abstaining
from alcohol and need help, call the substance abuse hotline at
[**Telephone/Fax (1) 60237**]. If you have further questions, call [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 12471**]
at [**Telephone/Fax (1) 57081**].
Call your doctor or go to the emergency room if you have any
bright red blood in your stools or black, tarry stools, fevers >
101, lightheadedness, difficulty breathing, chest pain,
abdominal pain, nausea, vomiting, or any other concerning
symptoms.
Followup Instructions:
Please go to the following appointments:
Dr.[**Name (NI) 62645**] ([**Telephone/Fax (1) 62646**]) office:
Friday, [**11-12**] at 8:15am with the phlebotomist
Monday, [**11-15**] at 10:45am with Dr. [**Last Name (STitle) 3003**]
Please make sure you go for repeat endoscopy with banding in [**1-11**]
weeks, Dr. [**Last Name (STitle) 3003**] will arrange this.
[**Location (un) 22870**] Outpatient Treatment ([**Telephone/Fax (1) 62647**], [**Street Address(2) **],
[**Location (un) 3320**], MA, Thursday, [**11-18**] at 2pm, must arrive by
1:45pm.
|
[
"51881",
"2851"
] |
Admission Date: [**2141-5-18**] Discharge Date: [**2141-5-19**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Massive intracranial hemmorhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o female admitted to the MICU throught the ED with a severe
intracranial hemorrhage. Pt was found unresponsive at home by
her family midmorning. She had been in her normal state of
health at 6:30 AM. When EMS arrived, her respiratory rate was 4.
Per their notes, she did hava a pulse. She was diaphoretic and
having agonal respirations. Per notes, her color was greyish.
Finger stick was 194. The pt was intubated in the field and
brought to [**Hospital6 10353**] for further care.
At the OSH, the pt's VS were 97.9 135 126/68 10 100% on a FiO2
of .100. She was noted to be in atrial fib. CT of the head was
significant for a very large right frontal-temporal lobar
hemorrhage with extensive subarachnoid and ventricular extension
and mass effect. Pt was given 2 units of FFP for an elevated INR
of 3.7. She also received potassium and dilantin. Per notes, her
pupils were 2 mm and equal. Pt was then transferred to [**Hospital1 18**] for
further care.
In the ED, the pt's VS were 104 191/126 16 100% on FiO2 of .100.
She was initially started on a nipride drip with a goal SBP of
130-160 but was later discontinued. The pt also received minitol
50 gm IV x1, FFP, and vitamin K. A neurosurgery consult was
obtained to review the CT from the OSH and speak with the
family. They discussed the pt's very poor prognosis with the
family and the decision was made to gather the rest of the
family and then most probably discontinue ventilation. The pt
will be admitted to the MICU until the family can gather at
[**Hospital1 18**].
Past Medical History:
1. S/P CVA
2. Past LE cellulitis
3. Hypertension
4. Hypercholesterolemia
5. Left shoulder pain
6. Atrial fib
Social History:
Pt lives at home with her daughter. [**Name (NI) **] ETOH, tobacco, or drugs.
Family History:
Noncontributory.
Physical Exam:
PE:
96.4 105 130/88 18 100% on FiO2 of .100
Gen- Unresponsive, intubated lady. Does not respond to verbal or
physical stimuli.
HEENT- NC AT. Intubated. Pupils fixed. Right 3-4 mm. Left [**2-9**]
mm.
Cardiac- Irregularly irregular. No m,r,g.
Pulm- CTA anteriorly and laterally.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- No c/c/e.
Neuro- Does not respond to voice or touch. Appears to withdraw
her legs to pain. Pupils fixed. Right pupil appears blown.
Negative gag reflex. Negative pupilary reflex. Upgoing toes
bilaterally.
Pertinent Results:
[**2141-5-18**] 02:50PM BLOOD WBC-13.5*# RBC-4.70 Hgb-13.3 Hct-39.1
MCV-83 MCH-28.2 MCHC-33.9 RDW-13.2 Plt Ct-248
[**2141-5-18**] 02:50PM BLOOD Neuts-80.9* Lymphs-15.6* Monos-2.9
Eos-0.4 Baso-0.2
[**2141-5-18**] 02:50PM BLOOD Plt Ct-248
[**2141-5-18**] 02:50PM BLOOD PT-21.6* PTT-26.4 INR(PT)-3.1
[**2141-5-18**] 02:50PM BLOOD Glucose-269* UreaN-15 Creat-1.0 Na-139
K-5.0 Cl-102 HCO3-22 AnGap-20
[**2141-5-18**] 02:50PM BLOOD CK(CPK)-126
[**2141-5-18**] 02:50PM BLOOD CK-MB-8 cTropnT-0.34*
[**2141-5-18**] 02:50PM BLOOD Calcium-9.0 Phos-3.2 Mg-1.5*
[**2141-5-18**] 03:03PM BLOOD pO2-459* pCO2-30* pH-7.42 calHCO3-20*
Base XS--3
Brief Hospital Course:
1. Intracranial hemorrhage- Pt with a devestating intracranial
hemorrhage as described above. Seen by neurosurgery in the ED. I
spoke to them and per the team she is not a surgical candidate.
At this time, she has evidence of brain death. This was
discussed with the pt's family and they gathered in the MICU for
a family meeting. After a long discussion, the family decided
that she would not wish to be maintaned on the ventilator with
no meaniful hope of any recovery. The pt was extubated and died
approximatley 2 hours later.
[**Name (NI) 1094**] son is [**Name (NI) 25965**] [**Name (NI) 25966**]. His home phone number is [**Telephone/Fax (1) 25967**]
and his cell phone number is [**Telephone/Fax (1) 25968**].
Spoke to pt's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] so he was aware of the situation
throughout the admission. I also called him once the pt died.
Medications on Admission:
1. Coumadin
2. Atenolol
3. Lipitor
4. Maxzide 25 mg daily
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracranial hemorrhage
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
|
[
"42731",
"4019",
"V5861",
"2720"
] |
Admission Date: [**2112-11-10**] Discharge Date: [**2112-11-24**]
Date of Birth: [**2080-7-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Dyspnea
Chest pain
Major Surgical or Invasive Procedure:
1. Thoracentesis [**11-14**]
2. Pericardiocentesis [**11-16**]
3. VATS, Chest Tube, Pericardial Window dilation, [**11-17**]
History of Present Illness:
This is a 32 y.o. male with history of aortic valve replacement
for strep. viridans endocarditis that was complicated by aortic
insufficiency who presents with progressive dyspnea. Patient has
experienced exertional dypsnea since [**2112-11-7**]. Prior to this,
patient had been able to walk several walks without any
difficulty in breathing. Since [**11-7**], he becomes dypsneic after
walking 1 block on level ground. He has never had dyspnea before
and denies any cough or pleuritic chest pain. Patient reports 4
pillow orthopnea. He denies any lower exremity oedema. He
reports reproducible chest pain that is at baseline from his
sternotomy incision, which is relieved with ibuprofen. He also
reports back pain when bending down to pick something up.
.
In the ED, bedside echocardiogram was obtained and demonstrated
large pericardial effusion, without any tamponade physiology.
Chest x-ray revealed large chest x-ray. Although patient was
dyspneic, he did not have any hemodynamic instability or
significant pulsus paradoxus. He was admitted to CCU for
hemodynamic monitoring.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for dyspnea and chest pain
as above. No history of ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
Bicuspid aortic valve
Aortic regurgitation
Anemia
AV Endocardiitis (Strept Veridans)
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T:99.1 , BP:137/80 , HR:100 , RR:14 , O2 96% on RA, Pulsus
of 5mmHg
Gen: WDWN Spanish speaking male in NAD, resp or otherwise.
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 6cm, negative Kussmaul's sign.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diminished breath
sounds and dullness to percussion at right base. No crackles,
wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; 2+ DP
Pertinent Results:
EKG demonstrated Sinus rhythm at 66 bpm with decreased relative
voltage compared with prior dated [**6-/2112**], at which time patient
had met criteria for LVH. Secondary TWI from LVH, but otherwise
no new ST-T wave changes.
2D-ECHOCARDIOGRAM performed on [**11-10**] demonstrated:
Borderline dilation of LV cavity, normal LV systolic function
(EF 55%), normally-functioning mechanical aortic valve
prosthesis, [**1-26**]+ MR, large circumferential pericardial effusion,
no echographic evidence of tamponade.
Cx-ray on [**11-10**]:
A large right pleural effusion associated with compressive
atelectasis, cardiomegaly.
[**2112-11-10**] 12:30PM GLUCOSE-84 UREA N-17 CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-27 ANION GAP-11
[**2112-11-10**] 12:30PM WBC-3.9* RBC-4.50* HGB-12.5* HCT-38.1* MCV-85
MCH-27.8 MCHC-32.9 RDW-17.4*
[**2112-11-10**] 12:30PM PLT COUNT-224
[**2112-11-10**] 12:30PM NEUTS-67.3 LYMPHS-24.4 MONOS-5.9 EOS-2.1
BASOS-0.4
[**2112-11-10**] 12:30PM PT-29.8* PTT-31.6 INR(PT)-3.1*
Brief Hospital Course:
ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS
.
## Pericardiocentesis: Patient admitted to CCU w/ cocern for
impending tamponade. Was monitored in CCU and deemed to be
stable for floor after an appropriate period of time. Coumadin
was held and heparin gtt started for anticoagulation when
patient's INR near 2.5. Pericardiocentesis drain placed in Cath
Lab on [**11-16**]. Post-drainage showed near complete resolution of
the effusion. Patient was then taken to OR by thoracics for
VATS (out of concern for hemothorax), chest tube placement, and
pericardial window. OR course notable for open pericardial
window (as noted in prior operative reports) that was further
dilated in OR. 2L of fluid removed that was sanguinous and
clotted prior to being able to check Hct - suggesting
significant blood component. Patient with small pneumothorax s/p
procedure, and w/ air leak. Chest tube left in place until
[**2112-11-21**] when deemed safe to remove.
.
## Pleural effusion - Large right-sided pleural effusion. Once
patient's INR subtherapeutic, patient underwent diagnostic and
therapeutic thoracentesis on [**11-14**] removing 1L of sanguinous
fluid from the R-pleural space. Hct of fluid 13% consistent
with prior bleeding. LDH and protein consistent with exudative
process as well. After pericardiocentesis as above, patient had
some improvement in pleural effusions indicating communication
between the pleural and pericardial space. Given concern for
lung entrapment with bloody effusions, definitive drainage of
pleural space was performed in OR w/ VATS and chest tube
placement as above. Ultimately upwards of 3L of fluid was
removed from the R-lung. F/u imaging showed near complete
resolution of the patient's effusions. Patient remained
comfortable on room air throughout his hospitalization.
.
## Valves - 25mm mechanical aortic valve prosthesis
- On admission, patient's coumadin held. Heparin gtt started
when INR near 2.0. CT surgery recommended the patient to be on
ASA and coumadin on discharge due to added benefit of preventing
thrombosis in mechanical valves with minimal increase in risk of
significant GI bleeding. Patient was restarted on coumadin
prior to discharge. Target INR [**2-27**] with aortic mechanical
valve. Will be followed in coumadin clinic.
.
## Remainder of the patient's hospitalization was uneventful.
Medications on Admission:
1. ASA 81g daily
2. Ibuprofen 400mg daily
3. Warfarin 6mg qHS
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
- Post-pericardotomy Syndrome with pericardial and pleural
effusion
Secondary Diagnosis:
- Mechanical Aortic Valve (INR 1.5-2.0)
Discharge Condition:
Good. Chest tube removed, patient comfortable on room air w/o
increased work of breathing.
Discharge Instructions:
You were admitted to the hospital for evaluation of increasing
shortness of breath. Tests done on admission indicated that you
had an accumulation of fluid around your heart and in your
lungs. This fluid is likely the result of an infrequent
complication of your prior aortic valve surgery and is known as
post-pericardotomy syndrome. While in the hospital you had this
fluid removed by first a bedside thoracentesis to drain some
fluid from your lung. Second, a pericardiocentesis was
performed to drain fluid from around your heart. Lastly, to
ensure that all the fluid was removed effectively a chest tube
was placed in the OR and any remaining fluid was removed from
the lung and around the heart.
Please follow-up with your Cardiologist Dr.[**Doctor Last Name 3733**] as below
and follow-up with your PCP as directed below. Should you
experience any sudden shortness of breath, chest pain,
increasing difficulty with breathing, or any other symptom
concerning to you please contact your doctor, or return to the
Emergency Department as soon as possible.
Followup Instructions:
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2112-12-6**]
2:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2112-12-21**] 3:30
[**Hospital 197**] Clinic- [**2112-11-25**] to have INR checked Goal INR 1.5-2.0
|
[
"V5861"
] |
Admission Date: [**2197-2-2**] Discharge Date: [**2197-2-14**]
Date of Birth: [**2153-7-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2197-2-2**] - AVR(19mm St. [**Male First Name (un) 923**] Regent SA Mechanical Valve)
[**2197-2-7**] - Placement of [**Month/Day/Year 4448**] ([**Company 1543**] Sigma SDR303 D - DDD
mode)
History of Present Illness:
The patient is a 43-year-old woman who has a history of aortic
stenosis with syncope. Workup demonstrated severe aortic
stenosis with aortic valve area calculated to be less than 1 cm
squared. The patient had a diagnostic
cardiac cath done approximately a year ago, which showed normal
coronaries with a left dominant system. The patient was
therefore referred for an aortic valve replacement.
Past Medical History:
Migraines
Bicuspid aortic valve
?Hypothyroid
Social History:
Lives in [**State 3908**] with husband and 3 children. Denies smoking
history. Drinks socially ([**1-11**] drinks/week).
Family History:
Father CABG in 60's / Mother with cardiomyopathy in 60's
Physical Exam:
AVSS
HEENT: NCAT, PERRL, Anicteric sclera, OP benign, teeth in good
repair
HEART: RRR, 4/6 SEM->Carotids
Lungs CTAB
Extrem warm, no edema
Pertinent Results:
[**2197-2-2**] ECHO -
POST CPB There is normal biventricular systolic function. Left
ventricular diastolic size is small, consistent with decreased
preload. There is a bileaflet mechanical prosthesis located in
the aortic position. It is well
seated and both leaflets can be seen moving. There is mild AI in
total, which is normal for this valve. There may be a small
perivalvular jet though this can not be well seen. The maximum
gradient through the valve is about 16 mm Hg (the recorded table
showing a gradient of 28 is an error). Initially when coming off
of CPB, there was a rhythm abnormality that resulted in
increased MR. [**First Name (Titles) **] [**Last Name (Titles) **] rhythm was reestablished, the MR was
back down to pre-CPB levels.
CXR [**2-10**]
Status post median sternotomy and AVR. Heart size is within
normal limits. There are small bilateral pleural effusions with
associated atelectasis at the lung bases, but no definite
pulmonary edema. There is a dual-chamber left-sided [**Month/Day (2) 4448**]
with atrial and ventricular leads in situ, in good location. No
pneumothorax.
IMPRESSION: Bilateral pleural effusions, slightly smaller than
on prior film. No evidence for pulmonary edema. No pneumothorax
or CHF. No change in location of pacer leads.
[**2197-2-9**] 07:50AM BLOOD WBC-8.6 RBC-2.91* Hgb-9.1* Hct-27.6*
MCV-95 MCH-31.2 MCHC-33.0 RDW-13.4 Plt Ct-289
[**2197-2-10**] 07:45AM BLOOD PT-17.2* PTT-29.5 INR(PT)-1.6*
[**2197-2-9**] 07:50AM BLOOD PT-23.6* PTT-98.2* INR(PT)-2.4*
[**2197-2-8**] 09:52PM BLOOD PT-19.9* PTT-52.1* INR(PT)-1.9*
[**2197-2-8**] 06:35AM BLOOD Glucose-104 UreaN-9 Creat-0.6 Na-137
K-4.2 Cl-102 HCO3-29 AnGap-10
Brief Hospital Course:
She was taken to the operating room on [**2197-2-2**] where she
underwent an AVR with a [**Street Address(2) 17167**]. [**Male First Name (un) 923**] Regent SA Mechanical
Valve. She was transferred to the CSRU in critical but stable
condition. She was extubated and weaned from her vasoactive
drips later that same day. Postoperatively she was found to be
in complete heart block requiring epicardial pacing. She was
seen in consultation by electrophysiology who followed closely.
She was started on heparin for her mechanical valve. She
remained in complete heart block and a permenant [**Male First Name (un) 4448**] was
placed on [**2197-2-7**]. She was then transferred to the floor. She
was started on coumadin for her mechcanical valve. She awaited
therapeutic INR, and was ready for discharge on POD #****.
Medications on Admission:
mucinex, synthroid, lasix, augmentin, lisinopril, kcl
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Bicsupid aortic valve
Migraine
Hypothyroid
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
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeks.
6)No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**].
Follow-up with cardiologist Dr. [**Last Name (STitle) 68366**] ([**Telephone/Fax (1) 68367**] [**Street Address(2) 68368**]. St. [**Hospital **] Medical Center [**2197-2-15**] 8:45
AM for pacer check and coumadin check.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2197-2-13**]
9:30
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2197-2-21**]
5:30
[**Hospital Ward Name 23**] Lab Monday [**2197-2-13**] for INR check
Completed by:[**2197-2-10**]
|
[
"4241",
"9971",
"2762",
"5180",
"2449"
] |
Admission Date: [**2146-5-16**] Discharge Date: [**2146-6-28**]
Date of Birth: [**2079-5-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / latex
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
- Central Line Placement and Removal
History of Present Illness:
Ms. [**Known lastname **] is a 67 year old woman with a history of prior CVA's.
She has left sided hemiparesis at baseline and speaks only a few
words. She lives at a nursing facility. Her daughter visited her
on her birthday ([**5-11**]). She reports that the patient was
less responsive and kept her mouth open during the whole visit.
It is unclear if she improved back to her baseline. This AM she
was reportedly less responsive than normal per the staff at the
nursing facility. She was also diaphoretic. An ambulance was
called and she was brought to the [**Hospital1 18**] ED. Her blood glucose en
route was 117.
.
In the ED, initial vital signs were 84/60 116 99% on room air.
She spiked a temp to 102 while in the ED. Labs were significant
for sodium of 173, creatinine of 2.7, troponin of 0.14, and
lactate of 1.3 (after fluid). Urinalysis showed large leuk
esterase. She received 4.5 L of normal saline. Her chest xray
was clear. There was no evidence of new stroke on CT. Her BP's
continued to drop in the ED. A central line was placed and she
was started on levophed.
.
On arrival to the MICU, patient did not respond to questions or
movement.
Past Medical History:
- s/p thromboembolic CVA w L hemiplegia, nonverbal
- Atrial fibrillation on coumadin
- Hyperlipidemia
- Hypertension
- Seizures
Social History:
Patient lived at a nursing facility. She was a phlebotomist at
[**Hospital1 18**].
Family History:
Unable to obtain
Physical Exam:
ADMISSION EXAM:
Vitals: T:99.0 BP:112/63 P:91 RR:17 O2:98% on RA
General: Awke, nonverbal, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI grossly
intact but unable to follow commands to track finder, PERRL
Neck: JVP not elevated
CV: Tachycardic and irregular, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally on the anterior, no
wheezes, rales, rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact grossly, able to move RUE, did not see
patient move LUE/LLE or RLE.
.
DISCHARGE EXAM:
Physical Exam:
Is/Os: incontinent of urine, In was about 1600cc
Vitals: T97.1, BP 136/58, HR 61, RR 17, O2Sat 100% RA
General: asleep, sometimes opens eyes to voice, nonverbal,
unable to follow commands, no acute distress, comfortable
appearing
CV: RRR, irregular, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally on anterior exam, no
wheezes/rales/rhonchi
Abdomen: soft, non-distended, bowel sounds present, feeding tube
in place in epigastric region with clean dry bandage
GU: no Foley, diaper, healing stage 1 ulcer with clean dry
bandage
Ext: RLE and LLE warm, well-perfused, 1+ DP pulses bilaterally,
2+ popliteal pulses bilaterally. Slow capillary refill
bilaterally
Neuro: deferred
Pertinent Results:
Blood Counts
[**2146-5-16**] 12:20PM BLOOD WBC-11.6* RBC-4.83 Hgb-13.8 Hct-45.2
MCV-94 MCH-28.6 MCHC-30.6* RDW-14.4 Plt Ct-190
[**2146-5-17**] 05:03AM BLOOD WBC-14.8* RBC-4.00* Hgb-11.5* Hct-38.5
MCV-96 MCH-28.9 MCHC-29.9* RDW-14.2 Plt Ct-194
[**2146-6-1**] 07:30PM BLOOD WBC-4.1 RBC-3.62* Hgb-10.4* Hct-32.5*
MCV-90 MCH-28.8 MCHC-32.2 RDW-15.5 Plt Ct-132*
[**2146-6-3**] 08:35AM BLOOD WBC-3.2* RBC-3.49* Hgb-10.1* Hct-31.2*
MCV-89 MCH-29.0 MCHC-32.5 RDW-15.5 Plt Ct-144*
[**2146-6-5**] 07:15AM BLOOD WBC-2.5* RBC-3.37* Hgb-9.6* Hct-30.0*
MCV-89 MCH-28.5 MCHC-32.0 RDW-15.1 Plt Ct-148*
[**2146-6-24**] 07:25AM BLOOD WBC-2.9* RBC-4.09* Hgb-11.6* Hct-36.4
MCV-89 MCH-28.3 MCHC-31.8 RDW-14.9 Plt Ct-194
[**2146-6-24**] 07:25AM BLOOD Neuts-41.2* Lymphs-44.8* Monos-11.3*
Eos-2.4 Baso-0.4
.
Coagulation Panel
[**2146-5-16**] 03:05PM BLOOD PT-56.0* PTT-43.9* INR(PT)-5.6*
[**2146-6-3**] 08:35AM BLOOD PT-21.2* PTT-36.0 INR(PT)-2.0*
[**2146-6-23**] 07:45AM BLOOD PT-24.7* PTT-45.2* INR(PT)-2.4*
.
Chemistries
[**2146-5-16**] 12:20PM BLOOD Glucose-144* UreaN-73* Creat-2.7* Na-173*
K-4.6 Cl-140* HCO3-23 AnGap-15
[**2146-5-18**] 09:56AM BLOOD UreaN-26* Creat-1.2* Na-151* K-3.2*
Cl-124*
[**2146-5-21**] 09:54AM BLOOD Glucose-106* UreaN-20 Creat-1.0 Na-143
K-3.6 Cl-110* HCO3-26 AnGap-11
[**2146-6-3**] 08:35AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-141
K-4.0 Cl-106 HCO3-29 AnGap-10
[**2146-6-23**] 07:45AM BLOOD Glucose-94 UreaN-17 Creat-0.8 Na-142
K-3.8 Cl-106 HCO3-27 AnGap-13
[**2146-6-23**] 07:45AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
.
Microbiology
URINE CULTURE (Final [**2146-5-18**]):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
IMAGING:
[**2146-5-16**] CXR: No acute cardiopulmonary process.
.
[**2146-5-16**] Head CT: Encephalomalacia, no evidence of acute
hemorrhage, several chronic changes.
.
[**2146-5-19**] TTE
Biatrial enlargement. Moderate symmetric left ventricular
hypertrophy with normal cavity size and preserved global and
regional biventricular systolic function. Increased left
ventricular filling pressure. No valvular vegetations or
abscesses appreciated. Indeterminate pulmonary artery systolic
pressure.
.
[**2146-6-2**] R Lower Extremity Arterial Duplex
No evidence of fixed arterial obstruction. Mild atherosclerotic
disease with biphasic waveforms.
.
[**2146-6-2**] R Arterial Doppler Study
Mild right lower extremity peripheral vascular disease based on
ABIs and Doppler waveforms. No significant left-sided arterial
vascular
disease. PVRs seem discordant and are likely artifactually low.
Brief Hospital Course:
This is a 67yo F PMhx Afib w prior thromboembolic CVAs w
resulting nonverbal state and L hemiparesis who presented with
hypotension, hypernatremia to 160, found to have a urinary tract
infection, treated with antibiotics and fluids, course
complicated by seizure, now with lab values returning to
baseline
ACTIVE ISSUES
# Septicemia / UTI / Hypovolemia: Patient was admitted w
hypotension, fever, positive UA, requiring 2d of vasopressors
and aggressive fluid resuscitation. She was initially covered
with cefepime, which was narrowed to ciprofloxacin once Ucx grew
Proteus. Additionally, she had coag negative staph grow from 2
blood cultures, thought to be contaminant, but for which she
received 4d of vancomycin. She completed a 7-day course of
Cipro (completed on [**2146-5-23**]).
# Hypernatremia: The was admitted with Na 173, thought to be
secondary to a free water deficit (estimated at 5 liters). She
was volume resuscitated and given free water to correct her
sodium over 3 days. Subsequently, the patient received
increased free water flushes for treatment of her hypernatremia
and serum Na remained stable in the low 140s.
# Metabolic Encephalopathy: On admission, patient was
unresponsive to voice or light touch. With correction of her
hypotension and UTI, her mental status improved to baseline
level of alertness: responsive to voice and touch, making vocal
sounds (though not speaking words), not following verbal
commands.
# Seizures: The patient's MICU course was c/p seizures, thought
to be secondary to her metabolic abnormalities. EEG showed
diffuse slowing, worse in the left temporal region, with
frequent spikes which can be seen in the post-ictal state. A CT
head showed evidence of her prior strokes but no acute process.
Neurology was consulted and patient was treated with Keppra for
seizure prophylaxis. The patient developed leukopenia to 2.5
after starting Keppra so the patient was transitioned to Vimpat
with which the WBC count has been stable at ~2.9-3.5.
# Acute Renal Failure: Admission creatinine was 2.7 (baseline is
~1.4 per the [**Hospital 228**] nursing home). This was likely pre-renal
and improved to her baseline with fluids. Cre at discharge was
0.8.
# Atrial fibrillation: Patient with a history of thromboembolic
CVA [**12-30**] afib; patient's coumadin was uptitrated during a
subtherapeutic episode. Given her history of prior CVA's she
will need to be bridged with enoxaparin for future INR<2.0. The
patient was also started on metoprolol for rate control.
# Peripheral Vascular Disease: Patient was noted to have
decreased pulses in R lower extremity on exam. Initially given
history of afib and a subtherapeutic INR there was concern for
arterial thromboembolism, however, pulses remained dopplerable
and arterial ultrasound did not demonstrate any fixed
obstruction. Mild peripheral vascular disease was noted. As
patient was already optimized from a cardiovascular perspective
(atorvastatin, metoprolol, ezetimibe, coumadin) no additional
medications were initiated.
# CAD - Continued atorvastatin, ezetimibe. Started metoprolol
for improved rate control.
# Hypertension - Patient was previously on amlodipine and
ramipril. These medications were held in the MICU. Amlodipine 5
mg was restarted. She was started lisinopril 10 mg daily
(therapeutic interchange while in hospital, given ramipril was
non-formulary).
# Leukopenia. Mild. Thought to be [**12-30**] drugs, such as Kappra.
She had recurrence of very mild leukopenia (2.9) and ranitidine
was held on [**2146-6-26**]. She will need to have repeat lab on
[**2146-7-1**] to check CBC.
INACTIVE ISSUES
# GERD. Patient was continued on ranitidine until [**2146-6-26**]
given mild leukopenia. She is on a ranitidine free trial to see
if the leukopenia is from medication.
.
TRANSITIONAL
1 - Full code
2 - Patient should be bridged with enoxaparin for INR < 2.0
3 - Given seizures during this visit, patient was scheduled for
follow-up with neurology
4 - Repeat CBC on [**2146-7-1**] to monitor for leukopenia
5 - Repeat INR, PT, PTT on [**2146-7-1**] to monitor warfarin therapy
Medications on Admission:
1. potassium daily 20 mEq
2. metoclopramide 10 mg q8 hours
3. jevity 1.2 50 cc/hr, 30 cc flush q8 hours, 200 cc flushes TID
4. lipitor 80 mg
5. ramipril 10 mg [**Hospital1 **]
6. amlodipine 5 mg
7. ranitidine 150 mg [**Hospital1 **]
8. ezetimibe 10 mg
9. warfarin 3 mg daily
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. Lacosamide 100 mg PO BID
4. Warfarin 4 mg PO DAYS (MO,WE,FR)
M,W,F. Second order for Saturday.
5. Warfarin 5 mg PO DAYS (TU,TH)
Tues, Thurs. second order for Sunday
6. Amlodipine 5 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO TID
hold for HR<60, SBP<90
8. Ramipril 10 mg PO BID
9. Outpatient Lab Work
Please draw CBC, INR, PT, PTT on [**2146-7-1**]. This is for
leukopenia and atrial fibrillation on warfarin. Please fax the
result to the rehab center.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2251**] Nursing and Rehabilitation - [**Location (un) 2251**]
Discharge Diagnosis:
PRIMARY
- Septicemia with Urinary Tract Infection
- Metabolic Encephalopathy
- Seizure
SECONDARY
- s/p thromboembolic CVA w L hemiplegia, nonverbal
- Atrial fibrillation on coumadin
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 69**]
because you had a urinary tract infection and dehydration.
Your sodium level was also very high, causing you to have a
seizure. You were treated with course of antibiotics and you
received fluids. Your sodium improved. You were started on a
medication called Vimpat to prevent seizures. You were also
started on a medication called metoprolol because of your fast
heart rate, and you are now ready for discharge. We
discontinued your ranitidine because you have a very mild low
white blood cell count, and you will need to have repeat lab on
[**2146-7-1**]. This can be monitored in the rehab setting.
Thank you for allowing us to participate in your care. All best
wishes in your recovery.
Followup Instructions:
Department: NEUROLOGY
When: THURSDAY [**2146-6-23**] at 4:00 PM
With: DRS. [**Name5 (PTitle) 540**]/[**Last Name (un) 7745**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2146-6-28**]
|
[
"78552",
"2760",
"5849",
"5990",
"99592",
"42731",
"2724",
"41401",
"53081",
"V5861"
] |
Admission Date: [**2185-8-28**] Discharge Date: [**2185-9-19**]
Date of Birth: [**2145-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fever, abdominal pain
Major Surgical or Invasive Procedure:
1. Debridement of abdominal wall abscess
History of Present Illness:
Mr. [**Known lastname 34682**] is a 39 year-old male with h/o Prader-Willi
Syndrome, T2DM, HTN, s/p trach and PEG, recent treatment for c.
diff, recent treatment for VAP and UTI, and recent initiation of
HD [**3-3**] ARF on CRI of unclear etiology, who presents from [**Hospital 100**]
Rehab after experiencing fever and diffuse abdominal pain. On
[**8-26**], his temp was found to be 100.5, with slight tachycardia
to 105. He was given 1 dose vanc IV at HD on [**8-26**] for erythema
and discharge from G-tube site, and restarted on PO vanco for
suspicion of c. diff, although pt had no diarrhea. His vent
settings had been stable at PS 15/5 on FIO2 35% with RR 20-24
and Vt 300-400mL with mod white secretions, but on [**8-27**], RT
noted increased secretions and decreased Vt to 240-300mL with
temp climbing to 102F. CXR was reportedly non-diagnostic [**3-3**]
large body habitus. BCx were sent on [**8-26**], which had no growth
after 24h. Sputum was also sent for culture, and gram stain
demonstrated many GNR and mod GPR, with 5-10 PMNs/HPF and 0-5
epis/HPF. UA was turbid and positive for UTI, with UCx pending.
Wbc was found to be elevated to 32, with elevated alk phos to
500s. Given one dose ceftaz 2gm on [**8-27**] and sent to ED for
further evaluation.
.
Per [**Hospital 100**] Rehab notes, Mr. [**Known lastname 34682**] has bilateral heel decubs.
He also is thought to have possible DVTs, but with inconsistent
exam, d-dimer, and inconclusive LENIs. He is being
anticoagulated, but found to be subtherapeutic on Coumadin 7.5mg
PO qD, and was being treated with IV heparin bridge.
.
In the ED, initial VS were T 102.4F, BP: 124/93, HR: 121, RR:
29, SaO2 96% His initial labs were notable for an elevated wbc
to 32.5 (83% PMN, 5% bands) with lactate 1.8, a mild
transaminitis (AST 59, ALT 73), elevated alk phos at 1178 with a
normal tbili of 0.8, and normal amylase/lipase. INR was elevated
at 1.8. CXR was uninterpretable. Due to his morbid obesity, Mr.
[**Known lastname 34682**] could not undergo CT scan, and had no informative
imaging done. He was given vancomycin and cefepime, and
transferred to the [**Hospital Unit Name 153**] for further management.
.
Mr. [**Known lastname 34682**] was last discharged from [**Hospital1 **] on [**8-2**] after a
prolonged stay for ARF of unclear etiology. After multiple
failed attempts at HD access in OR, had cut-down tunneled L IJ
Perma Cath placed. Also had acetinobacter PNA and Klebsiella UTI
during this admission, s/p Unasyn x 14 days, ending [**7-31**].
Covered prophylactically for recent c. diff with PO vanc, ending
[**8-14**].
Past Medical History:
Prader Willi Syndrome
Morbid obesity
T2DM
CRI with baseline creatinine 1.8-2.0
OSA
Mental retardation
Hypothyroidism
Status post tracheostomy and PEG tube placement
Social History:
Resident at [**Hospital 100**] Rehab. No smoking, ethanol or drug use.
Family History:
Family history of diabetes.
Physical Exam:
VS: Tmax: 100.9 yesterday afternoon, Tc: 97.8 BP: 128/41 HR: 86
AC 450x16 FiO2 0.35 SaO2 99%, PEEP 8
General: Morbidly obese AA male, sleeping, arouses to voice but
not responding to questions.
HEENT: NC/AT, JVD unable to appreciate [**3-3**] habitus.
Neck: Trach c/d/i.
Pulmonary: clear anteriorly
Cardiac: Distant HS, RR, nl. S1,S2 no rub appreciated.
Abdomen: Obese, soft, foley catheter taped into place in former
PEG site. dressing soaked with clear drainage. no clear
tenderness. absent bowel sounds.
Extremities: 1+ BLE edema, abd wall edema.
Pertinent Results:
[**2185-8-28**] 02:11AM PT-18.9* PTT-33.8 INR(PT)-1.8*
[**2185-8-28**] 02:11AM PLT COUNT-329#
[**2185-8-28**] 02:11AM NEUTS-83* BANDS-5 LYMPHS-4* MONOS-5 EOS-1
BASOS-0 ATYPS-1* METAS-1* MYELOS-0 NUC RBCS-2*
[**2185-8-28**] 02:11AM WBC-32.5*# RBC-3.37* HGB-8.3* HCT-27.1*
MCV-81* MCH-24.5* MCHC-30.4* RDW-18.7*
[**2185-8-28**] 02:11AM FREE T4-0.5*
[**2185-8-28**] 02:11AM TSH-38*
[**2185-8-28**] 02:11AM ALBUMIN-2.7* CALCIUM-9.0 PHOSPHATE-4.9*#
MAGNESIUM-1.9
[**2185-8-28**] 02:11AM LIPASE-22 GGT-687*
[**2185-8-28**] 02:11AM ALT(SGPT)-59* AST(SGOT)-73* ALK PHOS-1178*
AMYLASE-27 TOT BILI-0.8
[**2185-8-28**] 02:11AM GLUCOSE-182* UREA N-50* CREAT-4.3* SODIUM-138
POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-28 ANION GAP-20
[**2185-8-28**] 02:21AM LACTATE-1.8
[**2185-8-28**] 03:30PM PTT-51.4*
Brief Hospital Course:
Plan:
1) Shock:
Patient was admitted in septic shock secondary to abdominal wall
abscess surrounding his G tube insertion site. Patient's
additional sources included acinetobacter pneumonia, VRE in
abdominal wound, pseudomonal pneumonia, and yeast in the
abdominal wound. For antibiotics, patient was started on a
course of caspofungin, tobramycin, and daptomycin. Given
patient's obese body habitus, most radiological imaging is not
useful in this patient. Patient completed a two week course of
antibiotics s/p OR debridement.
2) Respiratory failure:
Patient was started on a trach during his last admission and per
his family would like to maintain current settings. Patient had
moderate secretions during this admission and was started on
daptomycin and tobramycin for treatment of acinetobacter and
pseudomonal pneumonia.
3) Renal failure:
During [**7-5**], patient developed renal failure of unclear etiology
and has been on hemodialysis since [**7-5**]. During this admission,
patient initially required CVVH due to poor renal function and
then was transitioned back to hemodialysis without
complications.
4) h/o DVT:
This diagnosis was made clinically, due to patient's calf pain
and inability to obtain adequate imaging. Patient was
supratherapeutic while taking coumadin and heparin. Given the
risks of maintaining patient on heparin or coumadin, coumadin
was discontinued.
5) Anemia:
Likely secondary to renal failure and chronic phlebotomizing.
Patient's Hct remained stable during this admission.
6) T2DM:
Has always been poorly controlled (HbA1C 11.2 [**3-6**]). Patient's
blood sugars however have been adequately controlled with
current regimen of Glargine 60U with breakfast and sliding scale
insulin. Pt's sliding scale upon discharge was to start with
8units of regular insulin from 121-160 and then increasing by 4
units for every 40 increase in BG above 160.
7) Hypothyroidism:
Patient's TSH suggests hypothyroidism, although unclear the
accuracy of the diagnosis since thyroid levels were assessed
while patient was already in the ICU. Patient was initially
started on just Levothyroxine PO 75 which was then converted to
IV levothyroxine 150 for improved absorption.
8) FEN:
Patient was maintained on Nepro Full strength with Beneprotein,
40 gm/day at a goal rate of 45 mL/hour. Residual Check: q4h Hold
feeding for residual >= : 150 ml
Flush w/ 50 ml water Before and after each feeding
Medications on Admission:
MV 1 Cap PO qD
Heparin IV gtt at 1800U/hr
Coumadin 7.5mg PO qD
Bupropion 75mg PO qD
Lactinex x 2 [**Hospital1 **]
Albuterol-Ipratropium MDI 8 puffs q4h
Vitamin C
SSI, Lantus 24U qD, Lispro 6U with lunch
Levothyroxine 100mcg IV
Calcium Acetate 667mg x 2 PO TID with meals
Oxycodone-Acetaminophen 5-325mg PO Q4-6H prn
Nepro 45mL/hr
Discharge Medications:
1. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO DAILY (Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q6H (every 6 hours).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
7. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 60 units
Subcutaneous q breakfast.
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection q ACHS: Please administer insulin according to the
following sliding scale. If BG 141-200, please give 8 units. If
BG 201-240, give 12 units. If BG 241-280, give 16 units. If BG
281-320, give 20 units. If BG 321-360, give 24 units. If BG
361-400, give 28 units. .
12. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
1. Septic Shock
2. Abdominal Wall Debridement s/p abdominal abscess surrounding
G tube insertion site
3. Pseudomonal and Acinetobacter pneumonia
Discharge Condition:
Fair. Patient is alert, interacting appropriately, and
tolerating tube feeds and dialysis.
Discharge Instructions:
- Please take all medications as prescribed.
- Please follow-up with your primary care physician 1-2 weeks
after discharge.
Followup Instructions:
- Please follow-up with your primary care physician 1-2 weeks
after your discharge.
|
[
"78552",
"5990",
"40391",
"2449"
] |
Admission Date: [**2116-12-2**] Discharge Date:
Service: Medicine
CHIEF COMPLAINT: Fever and hypoxia.
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
female, [**Hospital3 **] resident, with a history of
hypothyroidism, peripheral neuropathy, and a remote history
of endometrial cancer who presents with one day of fever with
a temperature of 102 degrees Fahrenheit and hypoxia to 60% on
room air with an increase to 96% on 4 liters.
One day prior to admission, nasopharyngeal aspirate was
positive for influenza A, and the patient was started on
amantadine and empiric Levaquin therapy.
The patient states her symptoms started a couple of days ago
with a cough productive of green sputum and a runny nose. No
myalgias. No dysuria. No nausea, vomiting, or diarrhea.
She refused her flu shot this year.
In the Emergency Department, the patient's temperature was
100 degrees Fahrenheit, her heart rate was 87, her blood
pressure was 154/80, her respiratory rate was 18, and her
oxygen saturation was 72% on room air and 100% on
nonrebreather. She appeared comfortable but unable to wean
the oxygen to nasal cannula at this time. The patient was
lethargic but easily arousable. The patient was
pan-cultured. A chest x-ray revealed left lower lobe
pneumonia. The patient denied any pain. She was breathing
more comfortably.
REVIEW OF SYSTEMS: Review of systems revealed right lower
extremity tenderness after recent trauma.
PAST MEDICAL HISTORY:
1. Endometrial cancer; status post total abdominal
hysterectomy, and bilateral salpingo-oophorectomy,
chemotherapy, and radiation therapy. Complicated by
radiation enteritis (23 years ago).
2. Hypothyroidism.
3. Peripheral neuropathy.
4. Hiatal hernia.
5. Status post partial small-bowel resection.
6. Status post cholecystectomy.
7. Status post appendectomy.
8. Urinary incontinence and fecal incontinence.
9. Right nasolacrimal duct obstruction.
10. Anemia.
11. Hypocalcemia.
12. Coronary artery disease (with stable angina).
13. Status post right open reduction/internal fixation.
MEDICATIONS ON ADMISSION: (The patient's medications
included)
1. Levofloxacin times one day.
2. Amantadine times one day.
3. Synthroid 200 mcg by mouth every day.
4. Fentanyl patch 50 mcg per hour every three days.
5. Neurontin 800 mg by mouth three times per day.
6. Lopressor 25 mg by mouth twice per day.
7. Ativan 0.5 mg by mouth once per day.
8. Prevacid 30 mg by mouth once per day.
9. Maprotiline 150 mg by mouth at hour of sleep.
10. B12 1000 mcg intramuscularly.
11. Tylenol 650 mg by mouth three times per day.
12. Multivitamin one tablet by mouth once per day.
13. Calcium carbonate.
14. Vitamin D.
ALLERGIES:
SOCIAL HISTORY: The patient lives at [**Hospital3 **].
Her niece is her health care proxy; name [**First Name9 (NamePattern2) 99851**] [**Doctor Last Name **]. No
tobacco.
FAMILY HISTORY: Family history is significant for liver
cancer.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient's temperature was 97.5 degrees
Fahrenheit, her blood pressure was 121/41, her heart rate was
in the 80s, and her oxygen saturation was 100% on a 100%
nonrebreather, and her respiratory rate was 19. In general,
the patient was resting but easily arousable and able to hold
a conversation. The patient was in no acute distress. The
mucous membranes were dry. There were coarse breath sounds
with no wheezes. Cardiovascular examination revealed a
regular rate. The abdomen was soft and nontender. There
were positive bowel sounds. Extremity examination revealed
the right lower extremity with erythema, and focal
ecchymosis, and mild tenderness. There was bilateral edema
of 1 to 2+.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
white blood cell count was 7.2 (with 88 neutrophils, 0 bands,
8 lymphocytes, 3 monocytes, 0.4 eosinophils, and 0.5
basophils), her hematocrit was 37, and her platelets were
282. Her INR was 2.1. The patient's sodium was 135,
potassium was 3.9, chloride was 92, bicarbonate was 31, blood
urea nitrogen was 13, creatinine was 0.6, and her blood
glucose was 83. Urinalysis revealed slightly hazy with a
specific gravity of 1.03, pH was 5, moderate blood, negative
leukocytes, negative nitrites, 30 protein, and 15 ketones. A
nasopharyngeal swab was positive for influenza A and negative
for influenza B. The culture was pending. Blood cultures
and urine cultures were pending.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed probable
left lower lobe pneumonia with pleural thickening at the left
costophrenic angle. Could not rule out fluid. No
pneumothorax. No congestive heart failure.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was admitted to the Medicine Service for fever,
hypoxia, and respiratory distress. The patient was found to
have influenza and a left lower lobe infiltrate. Her
hospital course by issue/system was as follows:
1. INFLUENZA/PNEUMONIA ISSUES: The patient was placed on
droplet precautions. She was started on amantadine 100 per
day for a total of a 5-day course. She was continued on
Levaquin. She was initially able to be weaned off the
nonrebreather to nasal cannula with continued attempts to wean
her oxygen further.
2. FEVER ISSUES: The patient was pan-cultured, and the
culture data was pending at the time of this dictation. It
was also felt that perhaps her right lower extremity erythema
could be contributing as well to her fevers from cellulitis.
However, this improved on Levaquin. She was given Tylenol
around the clock.
3. LETHARGY ISSUES: The patient's lethargy was found to
improve with continued intravenous fluid hydration.
Initially, she was only placed on a half dose of her usual
Fentanyl and Ativan, but this was eventually brought back to
her baseline level.
4. CORONARY ARTERY DISEASE ISSUES: The patient was placed
on Lopressor, and her blood pressures were well controlled.
5. HYPOTHYROIDISM ISSUES: The patient was maintained on
her Synthroid.
6. HYPOCALCEMIA ISSUES: The patient was maintained on her
calcium carbonate and vitamin d.
7. HISTORY OF ANEMIA: The patient's hematocrit was stable.
8. PERSONALITY DISORDER ISSUES: The patient was maintained
on maprotiline.
9. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient's
oral intake was poor initially secondary to desaturation with
removal of the nonrebreather and lethargy. However, she was
restarted on oral intake the following morning. She was
maintained on supplemental intravenous fluids until she was
able to take in full oral intake. She complained of mouth
dryness and throat soreness with swallowing. The patient was
given a humidified tent in order to help improve her mouth
discomfort.
10. CODE STATUS ISSUES: The patient is do not resuscitate/do
not intubate; however, during her hospitalization she was
switched to full code given her respiratory distress in the
setting of an acute illness that was being treated. However, the
expectation was that once this resolved that the patient will go
back to do not resuscitate/do not intubate (to be determined by
her current primary care physician).
This dictation was current only through [**2116-12-3**]. The remainder
of the dictation will be completed by the next house officer to
care for the patient.
DISCHARGE DIAGNOSES:
1. Influenza A.
2. Left lower lobe pneumonia.
CONDITION AT DISCHARGE: Patient died in the hospital.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1037**] 12-ACL
Dictated By:[**Last Name (NamePattern1) 4988**]
MEDQUIST36
D: [**2116-12-3**] 13:58
T: [**2116-12-3**] 14:40
JOB#: [**Job Number **]
|
[
"51881",
"0389",
"2761",
"4019",
"2449"
] |
Admission Date: [**2156-1-22**] Discharge Date: [**2156-2-12**]
Date of Birth: [**2104-9-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
s/p redo AVR/CABG x1 (19mm St. [**Male First Name (un) 923**] mechanical valve/LIMA to
LAD)
History of Present Illness:
51 yo M with prior endocarditis, AVR in [**2145**]. Followed for DOE
and recent back pain resulting in hospitalization in [**11-21**]. Echo
showed severe AI. Blood cultures showed coag negative staph
bacteremia. PICC placed for IV antibiotics. Diskitis but no
abcsess. Referred for surgery.
Past Medical History:
PMH thrombocytopenia, COPD, HepC, endocarditis/diskitis,
depression, anxiety, AVR '[**45**]
Social History:
+ tobacco 20 pack years
denies etoh
unemployed
Family History:
NC
Physical Exam:
Slightly SOB at rest, pale
Stasis changes BLE
Right eye strabismus
Lungs CTA left, right base crackles
Healed sternotomy
RRR 6/6 diastolic murmur, [**1-21**] sytolic murmur
Abdomen ventral hernia
Extrem warm, 2+ edema BLE
Neur grossly intact
Pertinent Results:
[**2156-2-12**] 06:15AM BLOOD WBC-6.3 RBC-3.79* Hgb-11.5* Hct-33.5*
MCV-88 MCH-30.2 MCHC-34.3 RDW-15.2 Plt Ct-211
[**2156-2-12**] 06:15AM BLOOD Plt Ct-211
[**2156-2-12**] 06:15AM BLOOD PT-19.5* PTT-28.4 INR(PT)-1.8*
[**2156-2-11**] 03:19AM BLOOD PT-18.0* INR(PT)-1.6*
[**2156-2-10**] 05:57AM BLOOD PT-19.0* PTT-28.5 INR(PT)-1.8*
[**2156-2-9**] 05:13AM BLOOD PT-18.1* PTT-26.9 INR(PT)-1.7*
[**2156-2-8**] 05:49AM BLOOD PT-16.3* INR(PT)-1.5*
[**2156-2-12**] 06:15AM BLOOD Glucose-93 UreaN-16 Creat-0.7 Na-138
K-3.6 Cl-100 HCO3-32 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76735**]Portable TTE
(Focused views) Done [**2156-2-11**] at 10:10:42 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2104-9-3**]
Age (years): 51 M Hgt (in): 72
BP (mm Hg): 110/70 Wgt (lb): 151
HR (bpm): 60 BSA (m2): 1.89 m2
Indication: s/p AVR redo with 19mm St. [**Male First Name (un) 923**] mechanical valve.
CABG with subsequent tamponade and pleural evacuation. Assess
for residual effusion,
ICD-9 Codes: 423.9
Test Information
Date/Time: [**2156-2-11**] at 10:10 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**]
[**Last Name (NamePattern1) 4135**], RDCS
Doppler: Limited Doppler and color Doppler Test Location: West
Inpatient Floor
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: 0.30 >= 0.29
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Aortic Valve - Peak Velocity: *2.7 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *29 mm Hg < 20 mm Hg
Aortic Valve - Valve Area: *1.4 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.33
Mitral Valve - E Wave deceleration time: 212 ms 140-250 ms
TR Gradient (+ RA = PASP): 22 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2156-2-5**].
LEFT VENTRICLE: Mild global LV hypokinesis. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR well
seated, normal leaflet/disc motion and transvalvular gradients.
[The amount of AR is normal for this AVR.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion. No
echocardiographic signs of tamponade. No RA or RV diastolic
collapse.
Conclusions
There is mild global left ventricular hypokinesis (LVEF = 45-50
%). Right ventricular chamber size and free wall motion are
normal. A bileaflet aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. [The amount of
regurgitation present is normal for this prosthetic aortic
valve.] Moderate [2+] tricuspid regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
a trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade. No right atrial or right
ventricular diastolic collapse is seen.
IMPRESSION: Tiny residual echo lucent area anterior to the right
ventricle. No evidence of tamponade. Normally functioning aortic
bioprosthesis. Mild global LV hypokinesis.
Compared with the prior study (images reviewed) of [**2156-2-5**],
there is now no evidence of cardiac tamponade.
CHEST (PA & LAT) [**2156-2-10**] 11:06 AM
CHEST (PA & LAT)
Reason: evaluate rt ptx
[**Hospital 93**] MEDICAL CONDITION:
51 year old man with s/p avr
REASON FOR THIS EXAMINATION:
evaluate rt ptx
HISTORY: AVR repair.
FINDINGS: In comparison with the study of [**2-9**], there is no
change. Again there is a tiny right apical pneumothorax.
Moderate cardiomegaly persists with relatively small bilateral
pleural effusions, more marked on the right. No evidence of
acute pneumonia.
Brief Hospital Course:
He was admitted to cardiac surgery. He was seen by hepatology.
He was cleared for surgery by dental. He was seen and followed
by ID. MRI showed diskitis with ? of osteo of the spine. He was
taken to the operating room on [**1-27**] where he underwent a redo
sternotomy, AVR, and CABG x 1. He was transferred to the ICU in
stable condition on epi, neo and propofol. He was extubated on
POD #1. He was given 48 hours of vanocmycin since he was in the
hospital > 24 hours preoperatively. He continued on nafcillin,
and rifampin, and caspofungin for yeast from a blood culture
drawn from a PICC line. He was started on coumadin for his
mechanical valve. He was started on a heparin gtt until his INR
was therapeutic. He was seen by opthamology and fungal eye
infection was ruled out. He developed a small pneumothorax after
his chest tubes were pulled, which was stable on subsequent
chest x rays. He awaited therapeutic INR.
He developed cardiac tamponade and was taken emergently back to
the operating room on [**2-5**]. He was extubated later that same
day. He was transferred back to the floor on POD #1. He was
restarted on coumadin for his mechanical valve. He continued to
have a stable apical pneumothorax. He awaited increasing INR,
and was ready for discharge home on POD #16/7.
He will require completion of a 10 week course of IV nafcillin
and PO rifampin, and has completed a 2 week course of
caspofungin.
[**Doctor First Name **] at Dr. [**Last Name (STitle) 76736**] office has agreed to manage coumadin,
goal INR [**1-18**] for mechanical aortic valve.
Medications on Admission:
naficillin 2gm q4h (staph), ASA, Lasix 40', KCL, Methadone 15"',
Roxicodone 15 prn, rifampin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q 8H (Every 8
Hours) for 10 weeks: 10 weeks from [**12-16**], dosing until [**2-24**].
Disp:*126 Capsule(s)* Refills:*0*
4. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H (every 4 hours) for 10 weeks: 10 weeks from [**12-16**].
dosing until [**2-24**].
Disp:*504 grams* Refills:*0*
5. Outpatient Lab Work
weekly CBC, LFTs, Chem 7 to Dr. [**Last Name (STitle) 76737**], phone number
[**Telephone/Fax (1) 76738**]
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*30 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: Check INR [**1-/2077**] with results to Dr. [**Last Name (STitle) 39975**].
Disp:*60 Tablet(s)* Refills:*1*
9. PICC Line Care
Saline 5-10 cc SASH and PRN;
Heparin Flush (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.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*qs 1 month* Refills:*0*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
1 weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
14. Methadone 10 mg Tablet Sig: 1.5 Tablets PO three times a
day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
s/p redo AVR/CABG x1 (19mm St. [**Male First Name (un) 923**] mechanical valve/LIMA to
LAD)[**2156-1-27**]
endocarditis
tamponade s/p mediatinal reexploration [**2-5**]
acute diastolic CHF
endocarditis [**2145**]
bacteremia [**11-21**]
diskitis
prior Bentall with homograft [**2145**]
Hep C
chronic pain
thrombocytopenia
depression/anxiety
Discharge Condition:
good
Discharge Instructions:
SHOWER daily and pat incisions dry
no lotions, creams, or powders on any incision
no driving for one month
no lfting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness or drainage
IV abx to continue to complete 10 weeks course from [**12-16**].
TARGET INR 2.0-3 for mechanical aortic valve - dosing per Dr.
[**Last Name (STitle) 76736**] office.
Followup Instructions:
see Dr. [**Last Name (STitle) 39975**] in 4 weeks
see Dr. [**Last Name (STitle) **] in 6 weeks
see Dr. [**Last Name (STitle) 914**] in 2 weeks [**Telephone/Fax (1) 170**]
see Dr. [**Last Name (STitle) 76737**] Thursday [**2-19**] @ 4:30
Completed by:[**2156-2-12**]
|
[
"9971",
"4241",
"41401",
"4280",
"496"
] |
Admission Date: [**2107-10-22**] Discharge Date: [**2107-10-31**]
Date of Birth: [**2056-5-8**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: Briefly, the patient is a
51-year-old woman with a history of atrial fibrillation,
rheumatic heart disease, and status post mitral valve
replacement who was transferred for [**Hospital3 934**] Hospital
after being resuscitated for a pulseless ventricular
fibrillation arrest that occurred during admission for
shortness of breath and abdominal discomfort.
In [**Month (only) 958**], the patient had a mitral valve replacement surgery
with a bileaflet mechanical valve with a postoperative course
significant for new onset atrial fibrillation and an ejection
fraction estimated between 35% to 50% (per report).
Since the time prior to admission, the patient experienced
the persistence of atrial fibrillation; and, of note, had 1/6
bottles positive for coagulase-negative Staphylococcus in
[**Month (only) 205**] (as per primary care physician).
Prior to admission, the patient complained of a 4-day history
of increased dyspnea on exertion, nausea, and vomiting. A
transthoracic echocardiogram a her primary care physician's
office (Dr. [**Last Name (STitle) 99683**] revealed an ejection fraction of 10%.
The patient was then sent to [**Hospital3 934**] Hospital where
laboratories were remarkable for a theophylline level of 29
and an INR of 4.3. The patient was also in atrial
fibrillation at this time.
The patient was then taken to Radiology for a right upper
quadrant ultrasound for her abdominal complaints on
presentation. At 2:30 p.m. on [**2107-10-22**], the
technician noticed that she was blue, and the patient was in
pulseless ventricular fibrillation arrest. A code was
called, and the patient was cardioverted with 300 joules and
loaded on 300 mg intravenously of amiodarone, intubated, and
was sent to the Intensive Care Unit.
The initial arterial blood gas in the Intensive Care Unit was
remarkable for a pH of 7.3, a PCO2 of 32, and a PO2 of 550.
This hospital course was also remarkable for an 8-beat run of
nonsustained ventricular tachycardia following the
ventricular fibrillation arrest, and the patient was also
successfully extubated.
The patient was transferred to [**Hospital1 188**]. Upon arrival to the Coronary Care Unit, the patient
was in atrial fibrillation with a rapid ventricular response
of approximately 120 beats per minute to 130 beats per
minute. The patient was given a total of 15 mg of Lopressor
intravenously with a decrease in heart rate between 100 beats
per minute to 110 beats per minute with a stable blood
pressure of 104/72. The patient was given 25 mg of oral
Lopressor times two doses overnight with good rate control in
the 90s.
PAST MEDICAL HISTORY:
1. Rheumatic heart disease.
2. Status post mitral valve replacement in [**2107-4-8**].
3. Hypertension.
4. Asthma.
5. Ulcerative colitis.
6. Atrial fibrillation.
7. Anemia.
8. Status post hysterectomy.
9. Status post appendectomy.
10. Hypercholesterolemia.
11. Chronic renal insufficiency.
12. Dilated cardiomyopathy.
MEDICATIONS ON ADMISSION: (Medications a home included)
1. Lopressor 25 mg p.o. b.i.d.
2. Cardizem 120 mg p.o. b.i.d.
3. Theophylline 600 mg p.o. q.d.
4. Zyrtec 10 mg p.o. q.h.s.
5. Coumadin with alternating doses of 5 mg and 2.5 mg p.o.
6. Protonix 40 mg p.o. q.d.
7. Potassium chloride 20 mEq p.o. q.d.
8. Serevent 2 puffs b.i.d. as needed.
9. Flovent 2 puffs b.i.d. as needed.
ALLERGIES: FLOXIN, 6-MERCAPTOPURINE (with reaction of nausea
and vomiting and gastrointestinal intolerance).
MEDICATIONS ON TRANSFER: Amiodarone drip 0.5, Protonix,
vancomycin (day one), Combivent, salmeterol, and Phenergan.
SOCIAL HISTORY: The patient has approximately a 15-pack-year
of smoking. She reports occasional ethanol use. She denies
any intravenous drug use. The patient is married. She works
in the processing department.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
upon admission revealed vital signs with a temperature
of 98.5, heart rate was 110, blood pressure was 104/78,
respiratory was 18, oxygen saturation was 95% on 2 liters
nasal cannula. Telemetry revealed atrial fibrillation. In
general, the patient was resting comfortably, in no acute
distress. Head, eyes, ears, nose, and throat revealed
normocephalic and atraumatic. Pupils were equal, round, and
reactive to light. Extraocular muscles were intact. Mucous
membranes were moist. Neck was supple without
lymphadenopathy. No jugular venous distention appreciated.
Cardiovascular examination revealed a mechanical first heart
sound, second heart sound, tachycardic, irregular rhythm.
Chest examination revealed crackles at the left lower base.
Good air entry. No wheezes. The abdomen was obese, soft,
mild diffuse tenderness. Extremities revealed no clubbing,
no cyanosis, no edema. No osseus nodes. No [**Last Name (un) 1003**] lesions.
No splinter hemorrhages. Neurologically, the patient was
alert and oriented times three; however, she had some memory
deficits. Normal speech. Moved all extremities.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed sodium was 139, potassium was 3.9,
chloride was 105, bicarbonate was 20, blood urea nitrogen
was 27, creatinine was 2.1, blood glucose was 157. White
blood cell count was 12.1, hematocrit was 34.2, platelets
were 255. PT was 28.1, INR was 5.5, PTT was 34.6. Amylase
was 48, LDH was 395, AST was 21, ALT was 99, albumin was 3.4,
bilirubin was 0.6. Blood cultures upon admission were
negative.
Laboratories from outside hospital revealed creatine kinases
that were flat at 73 to 83 to 134; and troponins that
remained below 0.4.
RADIOLOGY/IMAGING: Echocardiogram revealed atrial
fibrillation at a rate of 101, normal axis, normal intervals,
flattened T waves. No ST changes.
A chest x-ray was remarkable for markedly enlarged heart,
prosthetic mitral valve. No signs of failure.
A catheterization in [**2107-4-8**] revealed the following
pressures; right atrial pressure of 20, right ventricle
was 54/20, pulmonary artery pressure was 54/21, pulmonary
capillary wedge pressure was 25 with a V-wave of 45, cardiac
index of 3.1. Also notable for a mitral valve gradient
of 12.8, mitral valve area of 1.4, ejection fraction of 45%.
No regional wall motion abnormalities. Mitral regurgitation
was 3+, and coronary angiography was normal.
HOSPITAL COURSE BY SYSTEM: The patient was then admitted to
the Coronary Care Unit for further observation, status post
pulseless ventricular fibrillation arrest; awaiting
implantable cardioverter-defibrillator placement.
1. CARDIOVASCULAR: (a) Rhythm/atrial fibrillation: The
patient was found to be in atrial fibrillation upon admission
and was on an amiodarone drip and a Lopressor 50 mg p.o.
b.i.d. Rate well controlled upon admission. Initially, the
patient was switched from an amiodarone drip to oral
amiodarone and captopril was added at 6.25 mg p.o. t.i.d.
The patient remained in atrial fibrillation with good rate
control on amiodarone and Lopressor throughout the majority
of the hospital stay and was successfully cardioverted in the
Electrophysiology Laboratory on hospital day seven. Upon
discharge, the patient's amiodarone and beta blocker were
discontinued; as per Electrophysiology requisition in
response to a decreased heart rate, status post
cardioversion, as well as interactions with implantable
cardioverter-defibrillator capturing.
(b) Rhythm/ventricular fibrillation arrest: The patient
with a low ejection fraction. The patient was scheduled to
be awaiting implantable cardioverter-defibrillator placement
throughout the majority of the hospital stay. Given a
questionable history of positive blood cultures in the past,
Infectious Disease was asked to consult to elucidate whether
or not the patient was at risk for endocarditis and other
risks associated with this history of bacteremia.
After an extensive Infectious Disease consultation, the
patient was cleared for implantable
cardioverter-defibrillator placement.
On hospital day seven, the patient received implantable
cardioverter-defibrillator (as per Electrophysiology) with
interrogation the following day with procedure notable for no
complications and with all parameters stable upon
interrogation. The patient was to follow up in the Device
Clinic on [**11-3**] at 11:30 in [**Last Name (un) 469**] Seven.
(c) Pump: Echocardiogram throughout the hospital course was
notable for a left ventricular cavity enlargement with severe
global diastolic dysfunction, moderate aortic regurgitation,
a well-functioning prosthesis with mild mitral regurgitation,
with an estimated ejection fraction between 10% to 20%. The
patient was continued on a low-dose ACE inhibitor throughout
the remainder of her hospital stay as tolerated by the
patient's history of chronic renal insufficiency.
(d) Valve/status post mitral valve replacement: Given the
patient's questionable history of bacteremia, the patient
needed to be ruled out for a possible recent history of
endocarditis.
Subsequent transthoracic echocardiogram and transesophageal
echocardiogram to assess vegetations were negative for
vegetations of abscesses. Of note, transesophageal
echocardiogram was also notable for no thrombus in the left
atrium, severe left ventricular dysfunction, left cavity
dilation, and ventricular free wall hypokinesis.
Given the patient's history of mitral valve repair, the
patient remained anticoagulated throughout her hospital stay.
Upon admission, the patient's Coumadin was stopped and
heparin was started, with heparin being tapered upon
insertion of implantable cardioverter-defibrillator. The
patient was then restarted on heparin and Coumadin to achieve
a therapeutic goal INR between 2.5 to 3.5 prior to discharge.
(e) Coronary artery disease: The patient with no known of
coronary artery disease with recent catheterization revealing
no coronary artery disease.
2. PULMONARY: The patient has a history of asthma and was
continued on her outpatient regimen throughout her hospital
stay. Of note, the patient had one episode of acute
shortness of breath with chest pain on hospital day five.
The patient reported an epigastric chest pressure without
radiation. No nausea, vomiting, or diaphoresis. Upon
examination, vital signs were stable. The patient was
saturating well on room air. The lungs were clear to
auscultation bilaterally on examination. There was no
jugular venous distention. No electrocardiogram changes were
noted. There were also no events on telemetry, and a chest
x-ray showed no evidence of congestive heart failure.
A covering house officer at the time felt that these symptoms
were due to ischemia given lack of electrocardiogram findings
and clinical scenario, nor was it believed it was due to
symptoms of fluid overload. However, given the patient's
anxiety and desire for diuresis, the patient was given 20 mg
of intravenous Lasix. The patient experienced no further
episodes of chest pain or shortness of breath throughout her
hospital stay.
(3) INFECTIOUS DISEASE: The patient was continued on
vancomycin upon admission as per outside hospital, and given
questionable history of bacteremia in anticipation for
possible implantable cardioverter-defibrillator placement.
The Infectious Disease consultation service followed the
patient to help elucidate the question of possible positive
recent history of bacteremia. As per Infectious Disease,
since positive cultures at primary care physician's office
were different sensitivities and therefore likely different
colonies, it was believed that this culture was most likely
either a contaminant or of little clinical significance; and,
thus was continued with the management planned and
recommended a transesophageal echocardiogram to rule out
vegetations. It was also noted that an implantable
cardioverter-defibrillator was going to be placed and
antibiotics should be given prior to a status post procedure.
Thus, with the results were negative for vegetations,
Infectious Disease felt that despite this possible
questionable history of positive bacteremia, it was not
clinically significant and implantable
cardioverter-defibrillator could be placed without any
Infectious Disease issues if dosed with vancomycin
appropriately prior to and status post procedure.
Of note, on hospital day five, the patient developed a
phlebitis and was being treated on vancomycin, as per
hospital course of bacteremia. Within three days, the
patient's cellulitis was much improved and remained cleared
upon pending discharge.
4. RENAL: The patient has a history of chronic renal
insufficiency. Creatinine was followed throughout the
[**Hospital 228**] hospital stay.
5. ENDOCRINE: The patient had an elevated glucose upon
admission. The patient was written for a regular insulin
sliding-scale and q.i.d. fingersticks with well-controlled
blood glucose levels throughout the remainder of her hospital
stay.
6. HEMATOLOGY: The patient was admitted with a
supratherapeutic INR level. As above, Coumadin was held and
heparin was started when INR was around 2. Once INR was
around 2, the patient was restarted on heparin and continued
on heparin throughout the remainder of her hospital stay.
The patient was then re-dosed on Coumadin prior to discharge.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharged to home.
DISCHARGE DIAGNOSES:
1. Atrial fibrillation.
2. Status post pulseless ventricular fibrillation arrest.
3. Dilated cardiomyopathy.
4. Status post mitral valve replacement.
5. Asthma.
6. Chronic renal insufficiency.
7. Cellulitis.
MEDICATIONS ON DISCHARGE: Unknown at the time of this
dictation; will be added with an addendum to this Discharge
Summary on the patient's discharge date.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**]
Dictated By:[**Last Name (NamePattern1) 7944**]
MEDQUIST36
D: [**2107-10-29**] 18:34
T: [**2107-11-3**] 16:20
JOB#: [**Job Number **]
|
[
"42731",
"4280",
"49390"
] |
Admission Date: [**2167-9-25**] Discharge Date: [**2167-10-10**]
Date of Birth: [**2167-9-25**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname 622**] [**Known lastname 29056**] was born at 33
and 4/7 weeks gestation by cesarean section for decreased
fetal movement and breech presentation. The mother is a 28-
year-old gravida 1, para 0, now 1 woman. Her prenatal screens
are blood type A positive, antibody negative, rubella immune,
RPR nonreactive, hepatitis surface antigen negative and group
B strep unknown. This pregnancy was benign until
oligohydramnios was noted 3 days prior to delivery. An
ultrasound was performed because of decreased fetal movement.
There was no evidence of rupture of membranes. The mother was
admitted and given a complete course of steroids. Biophysical
profile was 8 out of 8, so a decision was made to deliver.
The infant emerged with a spontaneous cry. Apgars were 7 at 1
minute, and 8 at 5 minutes.
The birth weight was 2310 grams, birth length 44 cm, and the
birth head circumference 33 cm.
PHYSICAL EXAMINATION: A pink preterm infant with moderate
respiratory distress. Anterior fontanel soft and flat. Normal
facies, palate intact. Mild to moderate subcostal
retractions. Fair air entry. No murmur. Present femoral
pulses. Abdomen soft, flat and nontender, no masses, no
hepatosplenomegaly, normal external genitalia. Stable hip
examination. Normal perfusion. Normal tone and activity for
gestational age.
NEWBORN INTENSIVE CARE UNIT COURSE BY SYSTEMS: RESPIRATORY:
She initially required nasopharyngeal continuous positive
airway pressure but weaned to room air on day of life 1 where
she has remained. She has had no episodes of apnea or
bradycardia.
On examination her respirations are comfortable, lung sounds
are clear and equal.
CARDIOVASCULAR: She has remained normotensive throughout her
newborn intensive care unit stay. She has a heart with
regular rate and rhythm and no murmur.
FLUIDS, ELECTROLYTES AND NUTRITION: Enteral feeds were begun
on day of life 2 and advanced without difficulty to full
volume feedings by day of life 6. At the time of discharge
she is breast feeding and supplementing with 24 calorie per
ounce breast milk or formula on an ad lib schedule. At the
time of discharge her weight is 2395 grams.
GASTROINTESTINAL: Her peak bilirubin occurred on day of life
4 and was total 10.4, direct 0.3. She never required
phototherapy. Her last bilirubin on [**2167-10-1**], was
total of 8.7, direct of 0.4.
HEMATOLOGY: She has received no blood product transfusions
during her newborn intensive care unit stay. Her hematocrit
at the time of admission was 46.7 and she has had no further
hematocrit drawn. She is received supplemental iron of 2 mg
per kg per day.
INFECTIOUS DISEASE: She was started on ampicillin and
gentamycin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours when the
blood cultures were negative and the infant was clinically
well. She has received no further antibiotics.
SENSORY: Audiology - hearing screen was performed with
automated auditory brain stem responses and the infant passed
in both ears.
PSYCHOSOCIAL: The parents have been very involved in the
infant's care throughout her newborn intensive care unit
stay.
She is discharged in good condition.
She is discharged home with her parents.
NAME OF PRIMARY PEDIATRICIAN: Primary pediatric care will be
provided by Dr. [**First Name (STitle) **] [**Name (STitle) 32729**], [**Street Address(2) 43892**], [**Location (un) 1887**],
[**Numeric Identifier 62347**].
Telephone No.: [**Telephone/Fax (1) 40227**].
CARE RECOMMENDATIONS AFTER DISCHARGE:
1. Feedings. The mother will need some lactation support to
proceed with exclusive breast feeding as is her wish.
Currently she is supplementing with 24 calorie per ounce
breast milk or formula made with Enfamil powder.
2. Medications - Vi-Daylin 1 ml PO daily. Ferrous sulfate
(25 mg per ml) 0.2 ml PO daily.
CAR SEAT POSITION SCREEN: The patient passed the infant car
seat position screen test.
THE STATE NEWBORN SCREEN: The last State Newborn Screen was
sent on [**2167-9-28**].
IMMUNIZATIONS RECEIVED: She received her first Hepatitis B
vaccine on [**2167-9-29**].
FOLLOW UP: Follow up for this infant includes:
1. A hip ultrasound per recommendations of the American
Academy of Pediatrics for breech presentation.
2. Visiting nurse from the Centrus Home Care. Telephone No.
1-[**Telephone/Fax (1) 45165**].
DISCHARGE DIAGNOSIS:
1. Status post transitional respiratory distress.
2. Sepsis ruled out.
3. Status post mild hyperbilirubinemia.
4. Status post breech presentation.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (NamePattern1) 58465**]
MEDQUIST36
D: [**2167-10-10**] 02:55:18
T: [**2167-10-10**] 04:22:01
Job#: [**Job Number 62349**]
|
[
"7742",
"V053",
"V290"
] |
Admission Date: [**2103-12-6**] Discharge Date: [**2104-2-18**]
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
enterocutaneous fistula
Major Surgical or Invasive Procedure:
On [**2104-1-3**] he was taken to the operating room for (1)
Exploratory laparotomy, (2)lysis of adhesions (3.5 hours), (3)
Enterectomy, (4) enteroenterostomy, (5)colostomy, (6) closure of
2 enterotomies, (7) feeding jejunostomy, (8) component
separation and (9) placement of Vicryl mesh to reinforce the
closure.
History of Present Illness:
Patient is an 82 male who underwent a large bowel resection [**4-25**]
for a sigmoid vulvulous at the [**Hospital6 6689**]. His
course was complciated by an enterocutaneous fistula and MRSA
wound infection. On [**2103-8-16**] he was taken back to the operating
room for lysis of adhesions, takedown of the enterocutaneous
fistula, and a small bowel resction. Post-operatively he had a
wound dehisence. On [**2103-8-21**] the patient returned to the OR for
an abdominal exploration with debridement of abdominal wound and
fascia and wound closure with insertion of Sergisis. The
exterocutaneous fistula evidentally recurred. On [**2103-11-27**] he was
taken to the OR for STSG of the abdominal wound. The fistula
was closed with a chromic stitch with fibrin glue. A full
thickness skin graft was laid over this. Postoperatively the
patient continued to have problems with drainage of the inferior
protion of the wound in the location of the fistula. A fistula
again developed. He was transfered to the care of Dr. [**Last Name (STitle) 957**]
at [**Hospital1 18**] on [**2103-12-6**] for definitive care of this fistula.
Past Medical History:
Pacemaker
Loop colostomy
Small bowel resection
Take down of fisutla
Prior J-tube placeement
fx Ri shoulder
Appendectomy
Brief Hospital Course:
Mr. [**Known lastname 25699**] was admited to the general surgery service under Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**]. He was made NPO and TPN was started. His wound
was dressed by the surgical team with the ostomy nurse. [**First Name (Titles) **] [**Last Name (Titles) **]
was used to keep the fistula contents away from the skin. From
[**12-5**] through [**1-2**] this same routine was continued. His
nutritional status was improved, and PT worked with him to
improve his strength. However, given his deconditioning, he was
not able to ambulate prior to surgery.
On [**2104-1-3**] he was taken to the operating room for (1)
Exploratory laparotomy, (2)lysis of adhesions (3.5 hours), (3)
Enterectomy, (4) enteroenterostomy, (5)colostomy, (6) closure of
2 enterotomies, (7) feeding jejunostomy, (8) component
separation and (9) placement of Vicryl mesh to reinforce the
closure. There were no complications but he was transfered to
the SICU from the OR for close monitoring. He was extubated
prior to transfer. On POD 1 his respiratory status declined
likely secondary to fluid shifts; he was re-intubated. He was
able to be weaned from the vent the following day and was
extubated [**1-7**] with success. TF were started at 10cc on POD 1.
Over the next week his tube feeds were advanced daily, he was
diuresed as needed, and he was placed on agressive pulmonary
toliet. His TPN was decreased as TF were slowly advanced. On
[**2104-1-6**] he proved to be positive for heparin-dependent
antiboties; he was diagnosed with heparin induced
throbocytopenia thus all heparin products were discontinued and
prophylaxis was continued with venodynes on at all times. On
[**2104-1-6**] he also spiked a temperature. Blood cx later showed
Vancomycin resistant enterococcus. Bronchoalveolar lavage showed
MRSA. On [**2107-1-10**] he tested positive for Cdiff and he was given
appropriate antibiotics to treat all of these infections.
Gastrograffin study on [**1-13**] demonstrated passage through small
intestine and into colon easily, and the patient was begun on
soft mechanical diet. He demonstrated questionable ability to
eat without coughing and a swallow study was obtained that
demonstrated overt aspiration signs with all consistencies.
Nutrition was therefore continued with TPN and tube feeds alone.
[**1-18**] the patient suddenly became confused with slurred speech
while resting comfortably in bed moments before. While examining
the patient he spiked temperature to 102, became tachycardic to
120s and was not able to follow commands. EKG showed no acute
changes, stat head CT was normal and he proved to have blood
cultures positive for pan-sensitive enterococcus for which he
was appropriately treated and his clinical picture quickly
improved. He remained stable for the next week before he
developed some mild abdominal distension and serial abdominal
plain films showed a persistent dilated loop of bowel in the
LUQ. Tube feeds were held and on [**1-28**] a gatrograffin enema was
obtained that showed no colonic stricture/obstruction however
was not quite normal due to apparent mucosal and anastamotic
abnormalities. Tube feeds were re-initiated and a video swallow
showed evidence that patient could tolerate thin liquids and
pureed diet without significant aspiration risk. He tolerated
this diet for several days with 1:1 feedings, however on [**2-3**] he
had an aspiration event and was transferred back to the
intensive care unit after emergent intubation for respiratory
distress. On [**2-6**] his sputum grew ACINETOBACTER BAUMANNII
sensitive to gent, imipenem and tobramycin and he was started on
imipenem.
He was weaned from the ventilator over several days and
extubated on [**2-7**]. However he was electively re-intubated later
the same day for hypercarbia. Antibiotics, TPN and tube feeds
were continued and the patient was very gently diuresed over the
next week. By [**2-12**] he was felt to be euvolemic and he
successfully extubated on [**2-13**]. His family requested his
transfer to a facility closer to home, and now that he is stable
post-extubation this request can be more safely honored. He is
being transferred afebrile, tolerating tube feeds (half strength
impact with fiber at 40cc/hour) and has completed a 14 day
course of imipenem for an acinetobacter pneumonia. He has a
small open part of his abdominal incision that is nearly
completely granulated but will continue to need wet to dry
dressings until completely healed. He was transferred to
[**Hospital **] Hospital in stable condition and with instructions to
remain NPO with TF for nutrition. Instructions were given to
continue pulmonary toilet with nebulizer treatments.
Medications on Admission:
ASA 81mg po daily
Protonix 40mg po daily
Reglan
Maalox
Tylenol
Albuterol
Ultram
Benadryl
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) as
direc Injection ASDIR (AS DIRECTED).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): pls give via J-tube.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhal
Inhalation Q2H (every 2 hours) as needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhal
Inhalation Q6H (every 6 hours).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) dose PO DAILY (Daily).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q2H (every 2 hours) as needed.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily).
Disp:*100 ML(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 6689**] - [**Location (un) 6691**]
Discharge Diagnosis:
Primary: admitted for care of enterocutaneous fistula, now
repaired.
Secondary: Emphysema/COPD, CAD/ANGINA/MI, Pacemaker, CHF,
paroxysmal a flutter, HTN, anemia, h/o MRSA/VRE, osteoporosis
Discharge Condition:
Good
Discharge Instructions:
Cont TF at 80cc/hr at 1/2 strength, then advance to 3/4 strength
as tolerated. Please use a wet to dry dressing on abdominal
wound twice daily. Absolutely nothing by mouth.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 957**]. Call [**Telephone/Fax (1) 17478**] for an
appointment.
any questions or concerns.
|
[
"5070",
"496",
"4280"
] |
Admission Date: [**2183-4-20**] Discharge Date: [**2183-4-25**]
Date of Birth: [**2129-6-20**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Perianal pain
Major Surgical or Invasive Procedure:
Perianal abcess incision and drainage
History of Present Illness:
53F with DM c/o peri-anal pain x 5 days. She denies a history
of peri-anal abscess. She has not had any hard bowel movements.
She had diarrhea 3 days ago and then no bowel movements since.
She has had upper respiratory symptoms with cough and sputum
production this week. She has also had fevers and chills and
emesis. The emesis is preceded by nausea. She has been
tolerating liquids but hasn't eaten much food because of the
rectal pain.
Past Medical History:
1. Renal failure with a baseline creatinine of 2.8.
2. Type 2 diabetes.
3. Hypertension.
4. Anemia secondary to blood loss and iron deficiency
5. G16 P7. 9 miscarriages
6. Adenomyosis with menorrhagia: First Lupron dose [**2180-12-7**] with
good effect. s/p admission [**11-18**] for anemia and she received 1
unit of red blood cells.
7. D&C.
8. Bilateral tubal ligation.
9. Bilateral surgery on her legs as a child
Social History:
Stay at home mom. Denies tobacco, alcohol or drug
use.
Family History:
None contributory
Physical Exam:
PE: 98.5 88 215/68 15 99 RA
NAD
RRR
CTAB
Abd - soft, nttp, no hernias
Rectal - large abscess to the right of her perineum with
fluctuance. No tenderness or extension into the rectum. No
surrounding cellulitis.
Ext - warm, 2+ pulses
Pertinent Results:
[**2183-4-20**] 11:10PM GLUCOSE-216* UREA N-36* CREAT-3.2* SODIUM-136
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-17
[**2183-4-20**] 11:10PM CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-2.1
[**2183-4-20**] 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-75
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2183-4-20**] 10:20AM GLUCOSE-869* UREA N-42* CREAT-3.6*
SODIUM-125* POTASSIUM-4.4 CHLORIDE-87* TOTAL CO2-20* ANION
GAP-22*
[**2183-4-20**] 10:20AM WBC-12.6*# RBC-3.55* HGB-9.5* HCT-30.4*
MCV-86 MCH-26.7* MCHC-31.1 RDW-14.9
[**2183-4-20**] 10:20AM NEUTS-89.1* LYMPHS-6.7* MONOS-3.6 EOS-0.4
BASOS-0.3
[**2183-4-20**] 10:20AM PLT COUNT-293
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the SICU after having an I+D of a
perianal abscess. She was admitted to the SICU for control of
hyperglycemia and started on an insulin drip which was
transitioned to Lantus and SSI. Once Ms. [**Known lastname 6237**] blood sugar
was controlled her diet was advanced. Her wound was packed and
freely draining. She was discharged on insulin after achieving
adaquate blood glucose control. Her wound was left open and she
was instructed to follow up in clinic.
Medications on Admission:
calcitriol 0.5mg
lasix 20mg daily
insulin unknown dose
iron 325mg daily
lisinopril 40mg daily
lupron 11.25 q 3 months\
oxybutynin 5mcg daily
simvastatin 80mg daily
vit D.
Discharge Medications:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 7 days.
Disp:*40 Tablet(s)* Refills:*0*
6. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Insulin Syringe 1 mL 28 X 1 Syringe Sig: One (1) syringe as
directed Miscellaneous five times a day as needed for as
directed per sliding scale.
Disp:*100 syringe as directed* Refills:*0*
8. Insulin Glargine 100 unit/mL Solution Sig: Thirty Two (32) U
Subcutaneous once a day.
Disp:*2 vials* Refills:*2*
9. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose
Subcutaneous four times a day as needed for per sliding scale.
Disp:*2 vials* Refills:*20*
10. Senna 8.6 mg Capsule Sig: [**12-14**] Capsules PO twice a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Perianal Abcess
Hyperglycemia requiring ICU admission and insulin infusion.
Discharge Condition:
Good
Discharge Instructions:
You will need to monitor your blood sugars diligently. You have
been discharged with a new insulin sliding scale, Please follow
it. While you were in hospital your creatinine was elevated
suggesting your kidney were not working well. Please follow-up
with your PCP with regards to restarting your lisinopril, a
blood pressure pill that may affect your kidneys.
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 driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
*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 call Dr.[**Name (NI) 1482**] office for ([**Telephone/Fax (1) 1483**] for follow
up appointment in [**12-14**] weeks.
Please call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 7538**] for follow-up
appointment as soon as you get home. Issues that need to be
addressed include restarting your lisinopril in the context of
your renal insufficieny and your blood glucose control (you have
been started on a new regimen [**First Name8 (NamePattern2) **] [**Last Name (un) **] Diabetes).
Please call nephrologist Dr. [**Last Name (STitle) **], nephrology, ([**Telephone/Fax (1) 76788**] for follow-up appointment in [**2-13**] weeks regarding your
kidney function.
|
[
"5849",
"40390",
"V5867"
] |
Admission Date: [**2164-9-8**] Discharge Date: [**2164-9-21**]
Date of Birth: [**2106-6-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Aortic Valve Replacement ( 27mm [**Company 1543**] porcine) [**9-17**]
History of Present Illness:
The patient presented to an outside hospital with recurrent
shortness of breath. He had been treated with diuretics
earlier, but symptoms persisted. He was treated for congestive
failure and diuresis was continued. He was transferred here for
further workup and treatment.
Past Medical History:
hypertension
chronic renal insufficiency
Social History:
Tobacco history: Currently smoking
ETOH: Denies
Illicit drugs: Denies
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
Admission
VS 97.5 HR83 BP186/85 RR24 O2sat 99% nonrebreather Ht68"
Wt200
Gen NAD
Neuro A&Ox3
Heent PERRL/EOMI anicteric. MMM, neck supple
CV RRR, S1-S2 4/6 SEM,
Pulm Bilat rales 1/3way up
Abdm soft, NT/ND, +BS
Ext warm, no CCE
Discharge
VS T98 BP 122/85 RR18 O2sat 93%-RA Wt 100.4K
Gen NAD
Neuro nonfocal exam
CV RRR, no murmur. Sternum stable incision CDI
Pulm CTA-bilat
Abdm soft, NT/ND/+BS
Ext warm well perfused. trace edema
Pertinent Results:
[**2164-9-8**] 06:56PM GLUCOSE-242* UREA N-25* CREAT-1.6* SODIUM-140
POTASSIUM-2.7* CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
[**2164-9-8**] 06:56PM ALBUMIN-3.3* CALCIUM-7.5* PHOSPHATE-4.2
MAGNESIUM-1.7
[**2164-9-8**] 05:06PM CK(CPK)-159
[**2164-9-8**] 05:06PM CK-MB-5 cTropnT-0.09*
[**2164-9-8**] 11:18AM URINE HOURS-RANDOM UREA N-276 CREAT-39
SODIUM-110
[**2164-9-8**] 11:18AM URINE OSMOLAL-289
[**2164-9-8**] 09:32AM %HbA1c-5.8
[**2164-9-8**] 01:55AM WBC-5.8 RBC-4.49* HGB-13.8* HCT-39.6* MCV-88
MCH-30.7 MCHC-34.8 RDW-13.4
[**2164-9-8**] 01:55AM PLT COUNT-180
[**2164-9-8**] 01:55AM PT-13.5* PTT-24.9 INR(PT)-1.2*
[**2164-9-21**] 05:00AM BLOOD WBC-6.9 RBC-3.05* Hgb-9.4* Hct-26.8*
MCV-88 MCH-30.9 MCHC-35.2* RDW-12.9 Plt Ct-199
[**2164-9-21**] 05:00AM BLOOD Plt Ct-199
[**2164-9-17**] 12:00PM BLOOD PT-15.1* PTT-43.7* INR(PT)-1.3*
[**2164-9-21**] 05:00AM BLOOD Glucose-94 UreaN-28* Creat-1.4* Na-134
K-3.9
Radiology Report CHEST (PA & LAT) Study Date of [**2164-9-20**] 9:06 AM
[**Hospital 93**] MEDICAL CONDITION:
58 year old man with
REASON FOR THIS EXAMINATION:
??ptx
Preliminary Report !! PFI !!
No significant interval change. No pneumothorax.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
PFI entered: [**Doctor First Name **] [**2164-9-20**] 11:52 AM
Radiology Report RENAL U.S. Study Date of [**2164-9-19**] 4:15 PM
[**Hospital 93**] MEDICAL CONDITION:
58 year old man with
REASON FOR THIS EXAMINATION:
renal doppler to r/o renal artery stenosis
Final Report
HISTORY: 58-year-old male with renal Doppler to evaluate for
renal artery
stenosis.
COMPARISON: None available.
RENAL ULTRASOUND: The right kidney measures 11.0 cm, and the
left kidney
measures 9.8 cm. There is no evidence of stones, mass, or
hydronephrosis.
Doppler waveform analysis of the renal arteries was performed to
evaluate for renal artery stenosis. The right kidney
demonstrates normal arterial
waveforms throughout, with normal resistive indices of
0.62-0.68.
The left renal arteries are difficult to evaluate despite
scanning with
multiple accoustic windows and in multiple patient positions.
However, a
waveform tracing obtained from the upper pole was normal, with a
normal
resistive indicex of 0.69.
The bladder is visualized and is unremarkable.
IMPRESSION:
1. No evidence of stones, mass, or hydronephrosis.
2. No evidence of renal artery stenosis on the right.
3. Despite slight limitation on the left, no evidence of renal
artery
stenosis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 3900**]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 275**] [**Hospital1 18**] [**Numeric Identifier 80024**]Portable TEE
(Complete) Done [**2164-9-10**] at 10:15:54 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] S.
[**Hospital1 **] C
[**Location (un) 830**], E/RW-453
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2106-6-3**]
Age (years): 58 M Hgt (in): 68
BP (mm Hg): 140/65 Wgt (lb): 213
HR (bpm): 83 BSA (m2): 2.10 m2
Indication: Aortic valve disease. ? Aortic dissection.
ICD-9 Codes: 428.0, 424.1
Test Information
Date/Time: [**2164-9-10**] at 10:15 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: Cardiology
Fellow
Doppler: Full Doppler and color Doppler Test Location: West CCU
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W000-0:00 Machine: Vivid i-4
Sedation: Versed: 1.5 mg
Fentanyl: 50 mcg
(See comments below for other sedation.)
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: *3.3 cm <= 2.5 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. 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: Symmetric LVH. Normal LV cavity size.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Mildly dilated descending aorta.
Simple atheroma in abdominal aorta. No thoracic aortic
dissection.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or vegetations on aortic valve, but cannot be fully
excluded due to suboptimal image quality. Moderate (2+) AR.
Eccentric AR jet directed toward the anterior mitral leaflet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No masses
or vegetations on mitral valve, but cannot be fully excluded due
to suboptimal image quality. Mild (1+) MR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The posterior pharynx was
anesthetized with 2% viscous lidocaine. 0.2 mg of IV
glycopyrrolate was given as an antisialogogue prior to TEE probe
insertion. No TEE related complications. Image quality was
suboptimald - poor esophageal contact. Resting tachycardia
(HR>100bpm). MD caring for the patient was notified of the
echocardiographic results by e-mail. Echocardiographic results
were reviewed with the houseofficer caring for the patient.
Conclusions
Technically suboptimal study due to poor contact.
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is prominent symmetric left ventricular
hypertrophy with normal cavity size. There are simple atheroma
in the abdominal aorta. The descending aorta is mildly dilated.
.No thoracic aortic dissection is seen. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. There is no aortic valve stenosis. An
eccentric jet of moderate (2+) aortic regurgitation is seen
directed towards the anterior mitral leaflet. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Moderate aortic regurgitation with thickened
leaflets but without discrete vegetation. Dilated descending
aorta without evidence of aortic dissection. Mild mitral
regurgitation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2164-9-10**] 19:24
Brief Hospital Course:
58yoM presented to [**Hospital3 4107**] with increasing shoertness of
breath, found to be in hypertensive crisis and transferred to
[**Hospital1 18**] for further care. Patient treated initially by cardiology
service. during work up patient was found to have Aortic
insufficiency and cardiac surgery was consulted. He was accepted
for surgery and on [**9-17**] was brought to the operating room for
an aortic valve replacement. Please see OR reportr for details,
in summary he had and AVR with #27 [**Company 1543**] porcine valve. His
bypass time was 86 minutes with a crossclamp of 61 minutes. He
tolerated the operation well and was transferred to the ICU in
stable condition. He remained hemodynamically stable in the
immediate post-op period, anesthesia was reversed he woke
neurologically intact and he was extubated. On POD1 he was
transsferred from the ICU to the stepdown floor.
The remainder of his hospitalization was uneventful. His
activity level was advanced his antihypertensives were titrated
and on POD 4 he was discharged home with visiting nurses.
Medications on Admission:
ASA 325mg
Hydralazine 50mg QID
Labetolol 200mg [**Hospital1 **]
Discharge Medications:
1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(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:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
aortic iinsufficiency
s/p aortic valve replacement(27mm [**Company 1543**] porcine)
hypertension
Chronic renal insufficiency
Acute systolic heart failure
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any fever more than 100.5
report any redness of, or drainage from incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
no driving for 6 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
Followup Instructions:
wound clinic in 2 weeks
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**] in 2 weeks ([**Telephone/Fax (1) 14655**])
Completed by:[**2164-9-21**]
|
[
"4241",
"4280",
"5859",
"41401",
"40390",
"3051"
] |
Admission Date: [**2106-9-11**] Discharge Date: [**2106-9-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
PCP: [**Name Initial (NameIs) **]
.
CHIEF COMPLAINT: GIB
REASON FOR MICU ADMISSION: Hemodynamic monitoring.
Major Surgical or Invasive Procedure:
colonoscopy
EGD
History of Present Illness:
83 y/oF with pAF, valvular disease AVR/MVR, HTN, h/o colon ca
s/p colectomy in [**2099**] transferred from [**Hospital1 **] with GIB. She was
recently hospitalized with a right hip fracture and underwent
ORIF. During that hospitalization, she required 3 units of pRBC.
She has been having progressive fatigue at rehab coinciding with
more loose, dark stools concerning for GIB. Her hematocrit
returned at 23 from 26.6. She has had no increase in SOB nor has
she had any chest pain. Her last BM was yesterday, but
reportedly more normal.
Her review of systemis is also notable for dysuria and
suprapubic pain, and she has recently started cefpodoxime (1 day
ago). Otherwise her ROS is negative.
In the ED, initial VS: 98.5 64 150/30 16 100% on 3L. She was
transfused 2 units. She refused NG lavage, was reportedly guaiac
positive from rectal exam, and was given 40mg IV pantoprazole.
Currently, she feels much improved with one unit transfusion.
Past Medical History:
1. Colon cancer status post right colectomy ([**9-4**])
2. Hypertension
3. Paroxysmal atrial fibrillation requiring cardioversion in the
past
4. S/p AVR/MVR [**2093**] secondary to rheumatic fever
5. Diastolic Heart Failure
6. GERD
7. S/P TAH-BSO
8. Hypothyroidism
9. Depression
Social History:
Home: Lives alone. Very active with physical therapy twice
weekly for right shoulder pain, exercise at least twice weekly.
Has a helper at home once and sometimes twice weekly who does
her grocery shopping. Has two children, four grandchildren.
EtOH: Denies
Drugs: Denies
Tobacco: Denies
Family History:
Mother - possibly heart disease although she is unsure of the
specifics
Father - rectal surgery and colostomy although for unclear
reasons
Physical Exam:
VSS
GENERAL: Well appearing, well groomed elderly female.
HEENT: PERRL. Anicteric. neck supple.
CARDIAC: Mechanical heart sounds, II/VI SM Left sternal border,
lat radiation
LUNG: grossly clear bilaterally
ABDOMEN: NT ND nl BS
EXT: 1+ LE Edema
NEURO: CN II-XII grossly intact. D/WE/IP/TE [**4-6**] b/l.
DERM: No appreciable rashes.
Pertinent Results:
Labs at admission:
[**2106-9-11**] 04:30PM BLOOD WBC-9.5 RBC-2.40* Hgb-8.1* Hct-24.1*
MCV-100* MCH-33.6* MCHC-33.5 RDW-17.3* Plt Ct-311#
[**2106-9-11**] 04:30PM BLOOD Neuts-85.7* Lymphs-8.5* Monos-3.7 Eos-1.8
Baso-0.2
[**2106-9-11**] 04:30PM BLOOD PT-27.3* PTT-29.9 INR(PT)-2.7*
[**2106-9-11**] 04:30PM BLOOD Glucose-117* UreaN-31* Creat-1.2* Na-138
K-3.6 Cl-100 HCO3-30 AnGap-12
[**2106-9-16**] 07:20PM BLOOD ALT-8 AST-24 AlkPhos-58 TotBili-1.4
[**2106-9-12**] 02:37AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
[**2106-9-11**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}
[**2106-9-11**] 04:30PM URINE RBC-0-2 WBC->50 Bacteri-MOD Yeast-NONE
Epi-<1 RenalEp-<1
[**2106-9-11**] 04:30PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-LG
[**2106-9-11**] 04:30PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-<1.005
Labs at discharge:
[**2106-9-19**] 05:45AM BLOOD WBC-4.8 RBC-2.91* Hgb-9.0* Hct-28.8*
MCV-99* MCH-31.0 MCHC-31.3 RDW-17.8* Plt Ct-221
[**2106-9-17**] 05:20AM BLOOD Neuts-75.1* Lymphs-13.5* Monos-6.6
Eos-4.4* Baso-0.5
[**2106-9-20**] 08:40AM BLOOD PTT-60.2*
[**2106-9-20**] 05:40AM BLOOD PT-26.3* PTT-79.9* INR(PT)-2.6*
[**2106-9-20**] 05:40AM BLOOD Glucose-99 UreaN-20 Creat-1.2* Na-141
K-3.4 Cl-102 HCO3-30 AnGap-12
[**2106-9-20**] 05:40AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6
PERTINENT IMAGING STUDIES
PORTABLE CHEST, [**2106-9-12**]
FINDINGS:
Since the prior study, there is mildly increased prominence of
the central
pulmonary vasculature consistent with mild congestive failure.
There has also been development of small bilateral pleural
effusions and mild bibasilar atelectasis. Valvular prosthesis is
present. Heart is mildly enlarged. Aorta is calcified.
[**2106-9-16**] COLONOSCOPY
Impression: Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
[**2106-9-16**] EGD:
Impression: Varices at the lower third of the esophagus
Otherwise normal EGD to third part of the duodenum
[**2106-9-17**] ABDOMINAL U/S
IMPRESSION:
1. Stable appearing hepatic hemangiomas with no new focal liver
lesion
identified.
2. No varices identified.
3. Patent hepatic vasculature.
Brief Hospital Course:
MICU COURSE [**9-11**] - [**2106-9-12**]:
==============================
1. Acute Blood Loss Anemia: [**Month (only) 116**] be upper GI bleed from gastritis
or PUD, suggested by dark stools, or lower source such as
diverticular bleeding, though she has never had this before on
prior colonoscopies. Refused NG lavage, though likely not brisk
upper GI bleed given overall stability. Transfused 2 pRBCs with
appropriate bump in Hct. 2 PIVs. GI consulted and plan for
EGD/Colonoscopy for Tuesday. Pt currently on clear liquid diet.
Hemodynamically stable during ICU stay.
2. Paroxysmal Atrial Fibrillation: Sinus rhythm on admission.
Continued amiodarone. Held coumadin given likely EGD/[**Last Name (un) **].
3. Valvular Disease: Given her slow bleed and s/p MVR/AVR, she
merits anticoagulation between 2.5-3.5. Coumadin held on
admission. Monitored INR. Once INR < 2.5, will need heparin gtt
until EGD/colonscopy.
3. Urinary Tract Infection: Pt was on cefpodoxime at rehab x 3
days. Urine culture from NH pending. UCx here pending. Changed
to IV ceftriaxone with plan for 4 more days. Started pyridium
for bladder spasm.
4. Hypoxia: Pt desaturates off of nasal canula, but promptly
improves with 1-2 L to 100%. [**Month (only) 116**] be related to volume overload,
amiodarone (has been on over 10 years). CXR did not show
effusions, but ? infiltrate in RML. Did not start abx given no
fever, leukocytosis, cough.
5. Hip Fracture: Continue PT as tolerates
6. Chronic Diastolic CHF (EF>60%): Held standing lasix given
GIB, though may need additional lasix between transfusions if
she becomes more hypoxic. Continued carvedilol.
7. Hypothyroidism: Continued LT4
# DISPO: To Medicine Floor on [**2106-9-12**]
MEDICINE FLOOR COURSE: [**9-12**] to [**2106-9-20**]
HOSPITAL COURSE:
89 y/o female with recent hip surgery, mechanical valves and PAF
on warfarin with guaiac positive stools and acute blood loss
anemia. Was transferred from the ICU to the Medicine floor on
[**2106-9-12**]. A brief description of her hospital course is
organized according to problems below.
.
# UGIB / Acute Blood Loss Anemia. Was difficult to tell if the
melena/ +guaiac in the setting of anemia was an upper GI bleed
from gastritis or PUD (suggested by dark stools) or a lower
source such as diverticular bleeding (though she has never had
this before on prior colonoscopies). She refused NG lavage. On
HD6, her INR was decreased to <2.0 and she had upper and lower
endoscopies to further evaluate the bleeding source yesterday.
She was found to have Grade I-II esophageal varices which GI did
not believe to be the cause of her bleeding. No other possible
causes were found. She had not required further PRBC
transfusions and her Hct was stable, so GI believed she could
have further work-up as an outpatient. They recommended
considering a capsule study and will discuss this with her at an
outpatient appointment that has been made.
.
# Esophageal varices: GI found Grade I-II esophageal varices on
EGD. She had an abdominal U/S to look for a cause. U/S found
stable hemangiomas of the liver and no blockage of splenic vein.
No further management or imaging was deemed necessary. She had
LFTs tested and these were found to be normal as well.
.
# pAF on Warfarin: Patient presented in sinus and was
anticoagulated on warfarin at home. Her amiodarone was
continued. See below for a description of her anticoagulation
course. Her INR was 2.6 on day of discharge.
.
# Valvular Disease: Patient s/p MVR/AVR and merits
anticoagulation between 2.5-3.5. She needed to be below 2.0 for
the colonoscopy and EGD studies. She was taken off her coumadin
and when her INR reached 2.5 she was started on a heparin gtt.
Her heparin gtt was stopped 6 hours before her colonoscopy and
EGD and restarted immediately after because no biopsies were
taken. Her coumadin was restarted and when her INR was >2.5,
her heparin gtt was stopped. She was discharged home after a
therapeutic INR was achieved (2.6 day of discharge).
.
# Urinary Tract Infection. She started cefpodoxime at rehab. A
urine culture taken her day of admission grew pseudomonas
sensitive to cipro. She was started on Cipro and a repeat U/A
and culture were done the day before d/c and were found to be
clear. She will continue the Cipro for one more week.
.
# Hypoxia
Pt desaturated when she came to the floor, but improved with
1-2 L to 100%. This was probably related to volume overload,
amiodarone (has been on over 10 years). CXR confirmed volume
overload and CHF. Home lasix started with improvement of her
sats. Now >94% on RA.
.
# Hip Fracture: An A/P and Lateral Xray of the hip was taken and
patient was evaluated by orthopaedics while in house. She is
FWB and does not need surgical intervention at this time. An
appointment has been made for discussion of future treatments.
.
# Chronic Diastolic CHF (EF>60%): Continued carvedilol,
restarted lasix, and monitored her fluid status.
.
# Hypothyroidism: continued levothyroxine. Si/Sx of
hypothyroidism were monitored.
.
# FEN: Patient was NPO for procedures, but tolerating normal
diet the remainder of the stay and was tolerating oral diet and
medications the day of discharge.
.
# PPX: PPI, therapeutic warfarin, holding dose today, bowel
regimen on hold
.
# ACCESS: PIV
.
# CODE: FULL
.
# CONTACT: daughter
.
# DISPO: back to facility on HD 10
Medications on Admission:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO Q M W F SAT
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
4. Clonazepam 0.5 mg Tablet Sig: 0.5 (half) Tablet PO QHS (once
a day (at bedtime)) as needed for insomnia, anxiety.
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID
7. Pantoprazole 40 mg Tablet PO daily
8. Atorvastatin 20 mg Tablet PO daily
9. Furosemide 20 mg Tablet [**Hospital1 **]
10. Multivitamin Daily
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO tu-th-sa-[**Doctor First Name **].
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO m-w-f.
13. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H PRN Pan
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
15. Docusate Sodium 100 mg [**Hospital1 **]
16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for apply to hip for pain.
17. Acetaminophen 500 mg 2 tabs q6h prn pain
18. Atorvastatin 20 mg daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO EVERY MON,
WED, FRI, SAT ().
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. Atorvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Adhesive Patch, Medicated(s)
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: 1 Tablet(s) by mouth tu-th-sa-[**Doctor First Name **]; 2 tabs mo-we-fr .
Disp:*60 Tablet(s)* Refills:*5*
19. Phenergan 25 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
GI bleed
Discharge Condition:
stable, tolerating oral diet and medications
Discharge Instructions:
You were hospitalized because of blood found in your stool that
was causing you to become anemic. While in the hospital, you
received studies to look for bleed in your stomach, esophagus,
colon, and some of your small bowel. No cause of the bleed was
found. This could be because the cause has resolved or because
the cause falls in the area of your small bowel that was not
visualized.
Since, you are no longer losing, blood, we believe the best
thing is to return and home and monitor your symptoms and bowel
movements. If the bleeding returns, you can return for a study
called a "capsule study" that looks at your small bowel that
could not be seen by colonoscopy and endoscopy.
Ways of knowing that you are bleeding are dark/black stools,
bloody stools, feeling weak or light-headed. Please call your
doctor if you have those symptoms.
You will need to be seen at the [**Hospital 191**] clinic for monitoring of
your INR. I will send them an email regarding your discharge.
Please return to the ER or call your doctor if you spike a fever
>101, have chest pain, or shortness of breath as well.
You have the following appointment to discuss future treatment
of your hip fracture. At this time, no treatment is needed.
[**2106-10-26**] 09:30a [**Last Name (LF) **],[**First Name3 (LF) **] K.
[**Hospital6 29**], [**Location (un) **]
[**Hospital **] CLINIC (SB)
This image should be obtained before your hip appointment:
[**2106-10-26**] 09:10a X-RAY ORTHO SCC2
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
X-RAY ORTHO SCC2
You have the following appointment to make sure your GI bleed is
managed:
[**2106-10-5**] 02:00p [**Last Name (LF) **],[**First Name3 (LF) 1948**] S.
RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
GI FACULTY (SB)
Please your PCP at the following appointment in order to assure
that you are doing all right after your discharge from the
hospital.
[**2106-10-1**] 09:50a [**Company 191**] POST [**Hospital 894**] CLINIC
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
Followup Instructions:
You have the following appointment to discuss future treatment
of your hip fracture. At this time, no treatment is needed.
[**2106-10-26**] 09:30a [**Last Name (LF) **],[**First Name3 (LF) **] K.
[**Hospital6 29**], [**Location (un) **]
[**Hospital **] CLINIC (SB)
This image should be obtained before your hip appointment:
[**2106-10-26**] 09:10a X-RAY ORTHO SCC2
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
X-RAY ORTHO SCC2
You have the following appointment to make sure your GI bleed is
managed:
[**2106-10-5**] 02:00p [**Last Name (LF) **],[**First Name3 (LF) 1948**] S.
RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
GI FACULTY (SB)
Please your PCP at the following appointment in order to assure
that you are doing all right after your discharge from the
hospital.
[**2106-10-1**] 09:50a [**Company 191**] POST [**Hospital 894**] CLINIC
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
Completed by:[**2106-9-20**]
|
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"5119",
"5990",
"2761",
"4280",
"311",
"2449",
"53081",
"4019",
"42731",
"V5861"
] |
Admission Date: [**2128-5-22**] Discharge Date: [**2128-6-10**]
Date of Birth: [**2128-5-22**] Sex: M
Service: NB
This is an interim summary covering the hospital course for
the month of [**Month (only) 547**].
HISTORY: The infant is a 24 and [**3-22**] week gestational age.
The infant was admitted with respiratory distress after
precipitous delivery on the antepartum [**Hospital1 **].
MATERNAL HISTORY: Mother is a 40 year-old, Gravida I, Para 0
to I mother with unremarkable past medical history and the
following prenatal screens: A positive, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
Rubella immune, GBS unknown.
ANTENATAL HISTORY: Estimated gestational age of 24 and 2/7
weeks on day of delivery. Pregnancy was complicated by
premature rupture of membranes at 23 and 2/7 weeks which
initially yielded clear amniotic fluid. A 7 day course of
Ampicillin was initiated at that time and Betamethasone was
given at 23 and 5/7 weeks. Today, there was spontaneous
progression, leading to spontaneous vaginal delivery without
anesthesia on the antepartum [**Hospital1 **]. No antepartum fever or
other clinical evidence of chorioamnionitis.
NEONATAL COURSE: Infant was apneic, hypotonic, but with well
maintained heart rate, greater than 110 delivery orally.
Nasopharynx was suctioned and the infant was dried. Bagged
mask ventilation was applied for 30 seconds and then
intubated with a 2.5 endotracheal tube. There were marked
intercostal retractions but good excursion with a positive
pressure ventilation. Apgars were four at one minute, six at
five minutes and eight at ten minutes.
PHYSICAL EXAMINATION: Birth weight was 595 grams; head
circumference was 21 cm; length was 30 cm; heart rate was
148; respiratory rate 40; temperature 94.5; blood pressure
55/43 with a mean of 46. Saturations were 94% in 30% FI02
after Surfactant. Anterior fontanel was soft and flat. Non
dysmorphic with the palate intact. Neck and mouth were
normal. Normocephalic. Oral ET tube in place. Eyelids
fused. Chest was noted to have initially marked sternal
retractions with spontaneous breath. Good movement with HI-
FI oscillating ventilation. Cardiovascular: Well perfused
with capillary refill 2 to 3 seconds. Regular rate and
rhythm. Femoral pulses were normal. No murmur noted.
Abdomen: Soft, nondistended, with no organomegaly. No
masses. Active bowel sounds with patent anus and a three
vessel umbilical cord. Genitourinary: Normal preterm
genitalia with testes descended bilaterally. He responded to
stimulation. Tone was decreased in symmetric distribution;
moves all extremities bilaterally and gag was intact. Skin
examination showed extensive ecchymosis on legs, buttocks,
trunk and neck and skin was friable, consistent with his
gestational age. He had normal spine, limbs, hips and
clavicle examination.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: The patient was initially started on
conventional mechanical ventilation. Due to increasing
respiratory distress as well as a chest x-ray which began
to show signs of PIE, the patient was placed on the
oscillator on day of life zero with initial MAP of 13 and
amplitude of 33. The patient remained stable on HI-
FI oscillating ventilation and MAPs were able to be
weaned to 7 by day of life 9. Therefore, a trial on
conventional mechanical ventilation was attempted on day
of life 10. However, due to increasing respiratory
distress, increasing oxygen need and worsening blood
gases, the decision was made to place the child back on
the HI-FI oscillating ventilator where he has remained
since. Current settings include a map of 12 with an
amplitude of 28. For the last 24 hours, he has been in
FI02 between 44 and 75%. Most recent chest x-ray shows
changes of significant chronic lung disease.
2. Cardiovascular: The patient was noted to have a murmur on
day of life number one. Therefore, Indomethacin was begun.
The patient had a follow up echocardiogram on day of life
number three which demonstrated no patent ductus
arteriosus. The patient had a follow up ultrasound on day
of life 12 which also showed no PDA.
The patient was briefly on Dopamine which started on day of
life zero after two normal saline boluses. The Dopamine
was able to be weaned to off by day of life number two.
He has been hemodynamically stable since that point.
3. Fluids, electrolytes and nutrition: The patient was
initially n.p.o. and started on total fluids of 110 cc per
kg per day. Over the first few days, because of rising
sodium and dehydration, fluids were increased to 170 cc
per kg per day. The patient initially had a UVC and UAC
placed. UAC was removed on day of life four. On day of
life five, the patient began on trophic feeds of Special
Care 20 or breast milk 20 at 10 cc per kg per day. Feeds
have been slowly advanced and currently, the patient is on
140 cc per kg per day of breast milk, 32 calories per
ounce. He currently has a PICC line in place which is
in place for antibiotics and with normal saline running
through it to keep it open when the antibiotics are not
being given.
4. Gastrointestinal: The patient was begun on phototherapy
on day of life zero with an initial bilirubin of 1.9 over
0.2. He remained on phototherapy until day of life 10
when it was stopped and rebound bilirubin level was 2.7
over 0.4
5. Hematology: The patient did receive his first packed red
blood cell transfusion on day of life number one. His
most recent packed red blood cell transfusion was on day
of life 18 for a hematocrit of 31.5.
6. Infectious disease: The patient was started on Ampicillin
and Gentamycin due to preterm labor. Initial CBC showed a
left shift and, therefore, although the blood cultures
were not positive, the decision was made to treat the
infant for a full course of antibiotics. A lumbar
puncture was obtained on day of life number five which,
although had numerous red cells also had 150 white cells.
Therefore, the decision was made to extend the antibiotic
course to 14 days. Cerebral spinal fluid cultures
subsequently grew one colony of [**Female First Name (un) 564**] albicans. At this
point, Amphotericin was added to his regimen and an
infectious disease consult was obtained. Because of
positive yeast culture, a follow up lumbar puncture was
obtained, which remained no growth. A repeat blood
culture was sent which also was no growth, as well as a
urine culture. The patient's eyes were examined for signs
of fungus and no fungus was detected. An echocardiogram, as
well as an abdominal and renal ultrasound were also
performed because of the positive fungal culture, both
of which no fungus was demonstrated. On day of life 12,
due to increasing secretions as well as increasing
ventilatory support, a tracheal culture was obtained.
Tracheal culture returned positive for 4+ pseudomonas.
At this point, the patient was taken off of
Ampicillin and Ceftazadime was added. The patient is
currently on Ceptaz, day 7, out of a 14 day planned
course. The infant is also on Amphotericin. Today is day
13 of 14 for that positive yeast culture from his cerebral
spinal fluid. The plan is for a repeat cerebral spinal
fluid culture at the end of the Ceftazidime treatment.
7. Neurologic: The patient had a head ultrasound on day of
life number two which showed bilateral grade II
intraventricular hemorrhage. A repeat head ultrasound on
day of life four continued to show a grade II
intraventricular hemorrhage without any evidence of
ventricular dilatation. Head ultrasound on day of life 10
showed resolving hemorrhage but a slight increase in
ventricular size and, therefore, head ultrasound was
repeated on day of life 13, which showed the ventricles to
be stable in size with completely resolved hemorrhages.
Plan is for repeat head ultrasound on day of life number
23.
CONDITION AT TIME OF SUMMARY: Fair.
NAME OF PRIMARY CARE PEDIATRICIAN: Unknown.
CARE/RECOMMENDATIONS: Feeding is currently at 132 cc per kg
per day, with total fluids of 140 cc per kg per day.
MEDICATIONS: The patient is currently on Ceftazidime day 7
of 14 as well as Amphotericin day 13 out of 14.
The patient is also receiving sodium chloride for a slightly
low sodium.
IMMUNIZATIONS: The patient did not receive any
immunizations.
DISCHARGE DIAGNOSES:
1. Prematurity at 24 and 2/7 weeks gestation.
2. RDS
3. PDA, status post Indomethacin.
4. Hyperbilirubinemia, resolved.
5. Presumed sepsis.
6. Pseudomonas tracheitis.
7. Fungal cerebral spinal fluid culture.
8. Grade II IVH.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 58729**]
MEDQUIST36
D: [**2128-6-10**] 14:30:26
T: [**2128-6-10**] 16:00:24
Job#: [**Job Number 61249**]
|
[
"7742",
"V053"
] |
Admission Date: [**2176-3-17**] Discharge Date: [**2176-3-24**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 37 year-old woman with
no known past medical history who presents to the Emergency
Room with three day history of fever, generalized myalgias
and ten hour history of cough and progressive shortness of
breath. The patient was in her usual state of health until
three days prior to admission when she experienced fevers and
generalized myalgias on the night prior to admission. The
patient has an onset of cough that was unproductive and
progressively worse with progressive shortness of breath at
rest. The patient reports that her daughter had been sick
with a upper respiratory infection and otitis media on the
week prior to admission and her husband had a fever and sore
throat three days prior to admission. The patient denies
recent travel. Took Advil and Tylenol with no decrease in
temperature.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives with her husband and three
children. She is a housewife. No smoking. Social alcohol.
PHYSICAL EXAMINATION: In the MICU the patient's temperature
is 100.3. Blood pressure 80 to 90s/40s. Pulse was 130s.
The patient was sating 100% on a nonrebreather. The patient
was awake, alert, speaking in full sentences slightly
dyspneic. No accessory muscle usage for respiration. The
patient was tachypneic. The patient was tachycardic with no
murmurs, rubs or gallops. Lungs were scattered rhonchi right
greater then left no wheezes, crackles or egophony. The
patient had no edema and 2+ capillary refill.
LABORATORY: White blood cell count was 20.8, hematocrit
35.3, platelets 177, 92 neutrophils, 6 bands, 1 lymphocytes,
1% monocytes. Mean corpuscular volume was 64, RDW 143,
sodium 139, potassium 3.4, chloride 97, bicarb 22, BUN 10,
creatinine .7, glucose 69, gap 15, PT 17.5, INR 2.0, PTT
33.7, fibrinogen 555, lactate was 3.3 with an arterial blood
gas of 7.4, 3, 31 and 124 respectively. Blood cultures were
negative. Electrocardiogram was sinus tachycardia with [**Street Address(2) 28585**] depression in V4 through V5 thought to be related to the
rate. Urinalysis was negative. Blood cultures showed no
growth. Urine cultures showed no growth. Legionella urinary
antigen was negative. Chest x-ray revealed multifocal
opacities consistent with multifocal pneumonia. CTA revealed
no pulmonary embolus, multifocal pneumonia.
HOSPITAL COURSE: 1. Multilobar pneumonia: The patient was
treated with broad spectrum antibiotics to treat what was
thought to be a community acquired pneumonia. The patient
received Vancomycin to cover resistant strep pneumonia and
Levaquin to cover gram positive gram negative atypicals and
Legionella. The patient's sputum studies were negative for
influenza, Legionella and the patient's sputum did not grow
out any suspicious pathogens in the sputum sample. There was
no predominance of respiratory pathogens, however, there was
greater then 10 epithelials and this was a poor sample. The
patient improved gradually with supplemental oxygen by face
mask and a trial of CPAP, which was successful in temporizing
the patient's respiratory status and avoiding intubation.
The patient's respiratory status improved to the point where
she no longer needed MICU care. The patient was transferred
to the floor on the [**9-19**] at which point she was
taken off Vancomycin and continued on Levaquin as the patient
had no evidence of resistant gram positive organisms 48 hours
after the initiation of Vancomycin. The patient was
discharged to home on the [**9-23**] with discontinuation
of oxygen, complete improvement in dyspnea on exertion and
resolution of the patient's fever, which had reached as high
as 103 degrees during her hospitalization.
Upon further review of the patient it was discovered the
patient has a known history of thalassemia trait with
possible iron deficiency superimposed, which was the likely
etiology of the patient's microcytic anemia. The patient was
encouraged to pursue iron supplementation with repeat iron
studies at a future date, however, further workup of her
known thalassemia trait is not necessary. It is unclear if
the patient's history of thalassemia trait has anything to do
with her current infection. Patient's with thalassemia trait
are usual immunologically competent with minimal symptoms
from there thalassemia.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS: Levaquin 500 mg po q day to complete
a 14 day course.
DISCHARGE DIAGNOSES:
1. Community acquired pneumonia.
2. Respiratory distress.
3. Anemia microcytic.
4. Thalassemia trait.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 7942**]
MEDQUIST36
D: [**2176-4-30**] 04:05
T: [**2176-5-3**] 07:07
JOB#: [**Job Number 109052**]
|
[
"51881",
"486",
"2762",
"42789"
] |
Admission Date: [**2140-11-30**] Discharge Date: [**2140-12-10**]
Date of Birth: [**2063-7-22**] Sex: F
Service: TRANSPLANT SURGERY
HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname **] is a 77-year-old
female with a history of atrial fibrillation and end-stage
renal disease secondary to glomerulonephritis. She presented
to the [**Hospital6 256**] on [**2140-11-30**] for a cadaveric renal transplant. Prior, she had been
on hemodialysis since [**2132**] through a left arm AV fistula.
PAST MEDICAL HISTORY:
1. End-stage renal disease secondary to glomerulonephritis.
2. Hypertension.
3. Atrial fibrillation.
4. Hypothyroidism.
5. Status post open cholecystectomy.
6. Right inguinal hernia repair.
ADMISSION MEDICATIONS:
1. Quinine 325 mg q.d.
2. Neurontin 200 mg in the morning, 100 mg q.h.s.
3. Coumadin 2 mg on Monday and Wednesday, 3 mg on Tuesday,
Thursday, Saturday, and Sunday.
4. Renagel 1,200 t.i.d.
5. PhosLo 2 mg t.i.d.
6. Iron sulfate 325 mg p.o. b.i.d.
7. Nephrocaps one capsule p.o. q.d.
8. Levoxyl 75 micrograms p.o. q.d.
9. Percocet p.r.n.
ALLERGIES: The patient is allergic to penicillin.
SOCIAL HISTORY: She denied any tobacco abuse, occasional
ethanol.
REVIEW OF SYSTEMS: Negative.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
was afebrile, blood pressure 110/60, heart rate 88,
respiratory rate 16, 93% on room air. Preoperative weight 48
kilograms. General: She was awake, alert, in no acute
distress. HEENT: Normocephalic, atraumatic. The
extraocular movements were intact. The oropharynx was clear.
The chest was clear to auscultation bilaterally. Heart:
Regular rate and rhythm. Abdomen: Soft, nondistended,
normoactive bowel sounds. There was a well healed incision
from a prior cholecystectomy as well as an umbilical hernia
repair. Extremities were without any clubbing, cyanosis or
edema.
LABORATORY/RADIOLOGIC DATA: WBC 6.1, hematocrit 37.7,
platelets 176,000. Sodium 146, potassium 4.8, chloride 98,
bicarbonate 34, BUN 32, creatinine 5.9, glucose 76.
Coagulations: PT 17.1, PTT 32.4, INR 1.4, ALT 11, AST 24,
alkaline phosphatase 49, T. Bilirubin 0.5. Her blood type is
A positive.
HOSPITAL COURSE: Ms. [**Known lastname **] is a 77-year-old female with
end-stage renal disease secondary to glomerulonephritis who
presented to the [**Hospital6 256**] for a
cadaveric renal transplant on [**2140-11-30**]. Surgery went
without any technical complications. The patient was
extubated in the PACU. However, it was noted that she was
slightly hypotensive and she was tachycardiac with an
irregular rhythm. She required at that point IV Lopressor
for rate control. She was transferred to the ICU for close
monitoring as well as for rate control and for pressure
support. She was originally placed on an Amiodarone drip as
well as a Neo drip. These were eventually weaned. The
patient did require cardioversion and the patient has
remained in normal sinus rhythm since. She was placed on a
p.o. regimen of Amiodarone which was adjusted by Cardiology.
The patient ruled out for a myocardial infarction.
Her postoperative course was noted for delayed graft
function. She required three episodes of hemodialysis as
well as one ultrafiltration. Her urine output still
continues to be minimal. Her creatinine at baseline was 5.9.
By the time of discharge, it had decreased to 3.6. Her urine
output is slowly improving.
Postoperatively, she was placed on the usual Solu-Medrol
taper. She was placed on CellCept 1,000 mg p.o. b.i.d. which
was eventually weaned to 500 p.o. b.i.d. She received a
total of four doses of ATG and was started on Tacrolimus on
postoperative day number four and was transferred to the
floor on postoperative day number seven. Her diet was
advanced as tolerated. Physical Therapy consulted on the
patient. She continued, however, to have delayed graft
function. It was felt best that the patient be discharged to
a rehabilitation center.
The patient is to continue with her regular dialysis schedule
at the rehabilitation center as she was started on her
preoperative Coumadin dose as well as Amiodarone 200 p.o.
q.d. She is to continue this and to be carefully monitored
and followed up with her personal cardiologist. Her
laboratories will be redrawn at the rehabilitation center.
Of note, the patient underwent two renal ultrasounds of the
transplanted kidney. The first one was on postoperative day
number one which showed just a small fluid collection around
the kidney, otherwise, the duplex ultrasound was normal. She
had a follow-up duplex ultrasound on postoperative day number
nine which indicated resolved fluid collection and indices
around 0.7.
CONDITION ON DISCHARGE: To rehabilitation center.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSIS:
1. Status post cadaveric renal transplant for end-stage
renal disease secondary to glomerulonephritis on [**2140-11-30**].
2. Delayed graft function.
3. Postoperative atrial fibrillation.
4. Postoperative hypotension.
DISCHARGE MEDICATIONS:
1. Bactrim SS one tablet p.o. q.d.
2. Pantoprazole 40 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Tylenol 650 mg p.o. q. six hours p.r.n.
5. Benadryl 25 to 50 mg p.o. q. 12 hours or q.h.s. p.r.n.
sleep.
6. Heparin 5,000 units subcutaneously q. eight hours.
7. Insulin sliding scale; the patient is to follow the
provided sliding scale.
8. Albuterol nebulized solution, one nebulized inhalation q.
six hours p.r.n.
9. Valcyte 450 mg p.o. q.o.d.
10. Nystatin swish and swallow.
11. Sevelamer 1,600 mg p.o. t.i.d.
12. Levothyroxine sodium 175 micrograms p.o. q.d.
13. Haloperidol 1 mg p.o. b.i.d. p.r.n.
14. Prednisone 20 mg p.o. q.d.
15. Coumadin 3 mg p.o. q.d. This is to be adjusted based on
daily INR.
16. Amiodarone 200 mg p.o. q.d. This is to be adjusted by the
patient's cardiologist.
17. Metoprolol 50 mg p.o. b.i.d., hold for systolic blood
pressures less than 100 or heart rates less than 60.
18. CellCept [**Pager number **] mg p.o. b.i.d.
19. Zofran 4 mg IV q. eight hours p.r.n. nausea.
20. Of note, the patient is additionally on Tacrolimus. Her
current dose is being held until her Tacrolimus level is
obtained and it will be adjusted accordingly.
FOLLOW-UP PLANS: The patient is to follow-up with Dr. [**Last Name (STitle) 15473**]
at the Transplant Center, phone number [**Telephone/Fax (1) 673**] on
[**2140-12-13**] at 9:10 a.m. She is additionally to
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2140-12-20**] at 3:40
p.m. as well as with Dr. [**Last Name (STitle) **] on [**2140-12-26**] at 12:00
p.m. She is to be discharged to the rehabilitation center
where she is to receive daily laboratories which should
include a CBC, Chem-10, PT/PTT/INR as well as a daily
tacrolimus level which should be drawn before the tacrolimus
a.m. dose is given. She is to follow-up with her personal
cardiologist to wean her off Amiodarone and to adjust her
anticoagulation. She is to continue with her scheduled
dialysis on Tuesday, Thursday, and Saturday at the
rehabilitation center until her delayed graft function has
resolved. Please contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or Dr. [**Last Name (STitle) **] at
the Transplant Center at [**Telephone/Fax (1) 673**] with any further
questions.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (STitle) 28927**]
MEDQUIST36
D: [**2140-12-9**] 03:13
T: [**2140-12-9**] 17:02
JOB#: [**Job Number 34185**]
|
[
"40391",
"42731",
"4240",
"2767",
"2449",
"4168",
"V5861"
] |
Admission Date: [**2199-4-2**] Discharge Date: [**2199-4-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
84 year old diabetic female s/p LAD and CX DES admitted from the
cath lab w/ MI. Stented in [**4-8**], recathed [**2199-2-1**] d/t +ETT,
atypical symptoms. Second cath:patent LAD stent with a stable
distal occlusion,80% ostial ramus lesion with a 70% mid lesion
in the vessel with moderate tortuosity. 30% LCX, mid LCX stent
widely patent. RCA known occluded. Ramus felt to be unchanged
from cath [**4-8**]. Site thought to be difficult for intervention,
so medical management recommended. Pt was admitted on [**2199-4-2**]
to [**Location (un) **] with heart failure, back and arm pressure. Ruled in
w/ trop 20.48 ,sat is only 90-93% on 100% NRB. Did not respond
to 80mg Lasix, rec'd 1U PRBC's for Hct 26.
Past Medical History:
1. Diabetes mellitus on oral agents
2. Hypertension
3. Hyperlipidemia
4. A questionable history of transient ischemic attacks
5. Chronic renal insufficiency at baselin around 2.5
6. Peripheral vascular disease with left leg claudication
7. Gastroesophageal reflux disease- but no hx of EGD per pt
8. Anemia secondary to chronic renal insufficiency, iron
deficiency- on iron and procrit.
9. CAD with known 3VD s/p LAD and LCX stent
[**04**]. pacer for bradycardia post cath
11. Mild diastolic heart failure
Social History:
The patient has never smoked and does not drink alcohol. She
lives alone. She has a daughter who lives next door.
Family History:
No family history of early coronary artery disease. Her brother
had a myocardial infarction in his 80s.
Physical Exam:
Unresponsive, breathless, pulsless
Brief Hospital Course:
The patient developed hypotension and bradycardia after the
right femoral venous sheath was pulled. She was given atropine
0.5 mg twice for presumed vagal response, hypotension persisted
and she was started on dopamine gtt and given IVF as a bolus.
Minutes later she developed respiratory distress, a code was
called for PEA and respiratory arrest. The patient was
intubated, given epinephrine 1mg IV x3, as well as atropine and
bicarb, resuscitative efforts were stopped after 25 minutes.
[**Name (NI) **] granddaughter was present at the bedside for the large
part of the resuscitation. She declined the autopsy, medical
examiner declined the case.
Medications on Admission:
Lasix, nitroglycerin, heparin gtt
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
PEA arrest
Respiratory Arrest
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
[
"41071",
"4280",
"41401",
"25000",
"4019",
"2720"
] |
Admission Date: [**2130-1-10**] Discharge Date: [**2130-4-29**]
Date of Birth: [**2130-1-10**] Sex: M
Service: NB
SERVICE: Neonatology.
HISTORY OF PRESENT ILLNESS: This infant was born weighing
899 grams, the product of a 27 week gestation, born to a 28
year-old, prima parous woman after pregnancy that was
apparently uncomplicated until the week prior to birth when
the mother noticed whitish vaginal discharge. She was
admitted the day prior to delivery with PPROM. She was given
betamethasone and antibiotics as well as tocolysis with
nifedipine. The biophysical profile was [**3-21**]. There were
concerns for abnormalities of fetal heart rate, prompting a
Cesarean section for delivery. There was no notation of fever
and the amniotic fluid was noted to be meconium stained.
Prenatal screens were blood type 0 positive, antibody
negative, HBSAG negative, RPR nonreactive, Rubella immune,
Group beta strep status unknown.
FAMILY/SOCIAL HISTORY: Notable for mother working as a
social worker at [**Hospital6 1129**]. Mother and
father lived in [**Name (NI) 1468**].
At delivery, the patient emerged vigorous. There was a foul
smell noted. The heart rate was over 100. The infant was
given facial CPAP followed by intubation for increased work
of breathing. Apgars were 6 and 8 and the infant was brought
to the NICU, after briefly visiting with parents.
Measures at birth showed a birth weight of 899 grams which is
25th percentile. Length of 34.5 cm which is 25th to 50th
percentile. Head circumference of 24.5 cm which is 25th
percentile.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
infant had respiratory distress syndrome and required 2 doses
of Surfactant therapy. He weaned to CPAP on day of life one
and remained on CPAP until [**2130-2-19**], at which time, he weaned
to a nasal cannula on room air. This was done to help with
episodes of apnea and bradycardia. He transitioned to room air
on [**3-4**].
He was started on caffeine citrate for apnea of prematurity
prior to extubation on [**2130-1-11**] and weaned off caffeine on
[**2130-3-3**]. He was free of any significant apnea/bradycardia of
prematurity for greater than 5 days prior to discharge.
Cardiovascular: He had an audible murmur on [**2130-1-13**] and had
an echocardiogram done at that time which showed a large PDA
with left to right flow. He was treated with Indocin and had
a follow-up echocardiogram on [**2130-1-16**] which showed a very tiny
PDA and a tiny, muscular VSD. He was not treated at that
time. On [**2130-1-24**], he had a follow-up echocardiogram when a
murmur persisted and there was no PDA by echocardiogram, but
the status of the tiny VSD was not commented on. The ongoing
presence of a soft intermittant murmur was thought to be
secondary to PPS. Murmur very soft and heard only
intermittantly. F/U with [**Location (un) 2274**]/Cardiology if murmur heard 2
months post discharge.
Fluids, electrolytes and nutrition: The infant was n.p.o. on
admission to the NICU. A UAC was placed and a UVC was unable
to be placed. The UAC was subsequently discontinued on
[**2130-1-12**]. A central PICC line was placed on [**2130-1-14**]. Enteral
feedings were initiated on [**2130-2-8**]. The infant achieved full
enteral feedings on [**2130-1-26**]. Prior to discharge he is being
fed Enfacare 22 cals/oz.
The weight prior on discharge is 2970 grams.
Gastrointestinal: The infant developed hyperbilirubinemia
with a peak bilirubin level of 5.1 over 0.3 on day of life 3.
The infant required a total of 5 days of
phototherapy. The hyperbilirubinemia has resolved.
Hematology: The hematocrit at birth was 43.6 with a platelet
count of 298,000. The most recent hematocrit/retic on
[**3-17**] was 28/5.7.
The infant required a red blood cell transfusion on [**2130-1-24**]
for a hematocrit of 25 at that time.
He is on ferrous sulfate.
Infectious disease: A CBC and blood culture was screened on
admission to the NICU due to concerns for chorioamnionitis.
The CBC was left shifted with the white blood cell count of
21,000, 17 polys and 33 bands. The infant was started on
ampicillin and gentamicin and completed a 7 day course of
ampicillin and gentamicin. A lumbar puncture was done on day
of life 1 which was within normal limits. Blood culture and
CSF both remained sterile. Mother's placental pathology
culture showed acute chorioamnionitis and funisitis. The
infant also was given triple antibiotic ointment for
breakdown in the nares while on CPAP which has since
resolved.
On [**2040-2-22**] he was treated with Keflex for thick nasal
secretions, thought to be secondary to long term nasal CPAP.
Neurology: The infant has had 3 head ultrasounds done on
[**2130-1-13**], [**2130-1-18**] and [**2130-2-9**], all within normal limits.
Immunizations: Hepatitis vaccine #1 given [**1-/2051**]
Pediarix given [**3-11**]
HIB given [**3-11**]
Pneumococcal vaccine given [**3-11**]
Skin: There is a fading 1x0.3 cm fading hemangioma located
at the level between the scrotum and anus on the R thigh. On
[**3-15**] he began developing several pinpoint lesions on the
boarder of the hemangioma which are increasing slowly. No
erythema to surrounding area.
Circumcision performed on [**3-29**].
Sensory: 1. Audiology: Passed
2. Ophthalmology: Exam on [**3-20**] was mature zone 3
ou.
Psychosocial: A [**Hospital1 18**] social worker has been in contact with
the family. Mother is a social worker at [**Hospital3 2576**]
[**Hospital3 **]. Both parents are Somalian.
DISCHARGE MEDICATIONS: Ferrous sulfate
NAME OF PRIMARY PEDIATRICIAN:Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 47145**]/[**Location (un) 2274**]/MFD
Medications: Ferrous Sulfate
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.
CAR SEAT POSITION SCREENING:
STATE NEWBORN SCREENS: Sent on [**2130-1-24**], [**2130-2-13**]:
IMMUNIZATIONS RECOMMENDED: .
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.
FOLLOWUP: Dr. [**Last Name (STitle) 47145**]/[**Location (un) 2274**]/MFD [**2130-4-4**].
VNA day post discharge.
Early Intervention referral done.
[**Location (un) 2274**]/Cardiology if murmur present 22 months post
discharge.
DISCHARGE DIAGNOSES:
1. Prematurity born at 27 and 0/7 weeks gestation.
2. Respiratory distress syndrome, resolved.
3. Sepsis treated.
4. Hemangioma on right thigh.
5. S/P Apnea of Prematurity.
6. Patent ductus arteriosus, resolved.
7. Muscular ventriculoseptal defect.
8. Hyperbilirubinemia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], MD,MPH
Job#: [**Job Number 76863**]
|
[
"7742",
"V053"
] |
Admission Date: [**2112-9-15**] Discharge Date: [**2112-9-21**]
Date of Birth: [**2039-9-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Staging laparoscopy and liver biopsy
History of Present Illness:
Patient is a 72M w/ h/o CAD and DM2 who presents to [**Hospital1 18**]
with a 1 month h/o decreased energy, abdominal bloating and
intermittent dizziness. The patient states that his bloating
sensation feels like "gas pains" but has not limited his PO
intake. He notes difficulty sleeping but nothing else
exacerbating or alleviating the discomfort. He notes moving
bowels regularly but over the past week notes a "tan color" to
stools. He reports occasional blood in toilet bowl after bowel
movements but attributes this to known "fissures". He reports
dizziness upon standing from recumbency and experience an
episode
today while seeing endocrinologist at [**Last Name (un) **]. He was found to be
hypotensive to SBP 80's and was sent to ED for further workup.
Past Medical History:
PMH: CAD s/p coronary stent x4 years, CKD (? diabetic
nephropathy), HTN, hypercholesterol, BPH, gout, obesity
PSH: c-scope x10 years
[**Last Name (un) 1724**]: Levemir 24U/day, plavix 75', atenolol 50', amaryl 4",
lisinopril 20', Diltia XT 180', lipitor 80', ASA 325',
allopurinol 300'
Social History:
No ETOH/Tob or illicits
Family History:
Noncontributory
Physical Exam:
(On Discharge)
VS 98.3 98.3 63 90/54 18 92RA
Gen: NAD A&Ox3
Card: RRR
Lungs: CTAB
Abd: Soft, NTND, -guarding/rebound
Wound: CDI, steris in place
Brief Hospital Course:
Pt was seen in the ED for dizziness/hypotension as described in
the above HPI. CT, US and labs were consistent with obstructive
jaundice [**12-21**] a pancreatic head mass and the patient was admitted
to the pancreaticobiliary service for further management in the
intensive care unit. The patient had an ERCP that showed a 2.5
cm strictured in the intrapancreatic portion of the common bile
duct and a stent was placed. The patients total bilirubin on
admission was 7.9 and this trended down following stent
placement. Blood cultures were sent, and final cultures were
negative. Following ERCP the patient returned to the unit for an
uncomplicated recovery and was transferred to the floor. He was
restarted on clears and advanced to general diet. EUS was
planned and obtained and final results are pending. The patient
was taken to the OR on hospital day 6 for a staging laparoscopy
and biopsy of his pancreatic head mass in preparation for a
whipple procedure on [**9-29**]. This was performed without
complication and the patient had an uneventful recovery from
anesthesia. After discussion with the patients cardiologist, it
was decided that his aspirin and plavix should be held until
after his whipple.
Medications on Admission:
Levemir 24U/day, plavix 75', atenolol 50', amaryl 4",
lisinopril 20', Diltia XT 180', lipitor 80', ASA 325',
allopurinol 300'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain for 7 days.
Disp:*50 Tablet(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain for 1 weeks.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Mass
Discharge Condition:
Good
Discharge Instructions:
Your operation is scheduled with Dr. [**Last Name (STitle) **] on Thursday,
[**9-29**]. Please return to the hospital as instructed by
the clinic. Do not eat or drink anything after midnight the
night before your procedure. Do not take your aspirin or plavix
(clopidogrel) between the time you are discharged and when you
return to the hospital. Continue to take the remainder of your
medications.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**3-27**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of 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.
Followup Instructions:
Please return to the hospital as above. The remainder of your
follow up will be scheduled after your operation.
|
[
"5849",
"2851",
"41401",
"5859",
"40390",
"2720",
"V4582"
] |
Admission Date: [**2180-8-18**] Discharge Date: [**2180-8-21**]
Date of Birth: [**2127-5-30**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
chest heaviness
Major Surgical or Invasive Procedure:
IABP placement, central line and swan ganz placement, myocardial
biopsy
History of Present Illness:
53 yo female with PMH of HTN and new history of heart block and
myocarditis s/p pacemaker on [**8-7**] who was subsequently readmitted
to [**Hospital3 35813**] Center on [**8-14**] for fatigue and
lightheadedness and transfered here today for increased level of
care. Pt last felt well in the beginning of [**Month (only) **] when she had
an episode of diarrhea and viral illness. A couple weeks later
in [**Month (only) **] she started experiencing syncopal episodes and presented
to the ED where she was found to have myocarditis and AV block
requiring pacer placement (type unknown). At that time, her
trops were 1.06, WBC 15.9, cpk 186, SGOT 51, SGPT 39. Negative
lyme, adenovirus, [**Location (un) **] A&B, echovirus. Positive parvovirus.
Blood cx negative. Furthermore a cardiac cath was done which
was reported as "negative" although we do not have these
documents.
She was then discharged the following day but continued to
experience lightheadedness and difficulty breathing. This
progressively worsened until she was readmitted to LMC on [**8-14**].
At that time her EKG was sinus tachycardia showing ventricular
pacing. Notable labs include: troponins were 2.34 -> 2.11 ->
2.06 -> 2.02, CK-MB 197 -> 176 -> 168 -> 147. Serum ferritin 75
(nml), SGOT 294, SGPT 232. Hep A,B,C pending. ESR 45. proBNP:
[**Numeric Identifier 2249**]? CXR showed pulmonary congestion and pleural effusion. U/S
liver revealed fatty liver. Echo [**8-15**] showed EF 30%.
Last night, pt did have an episode of chest pressure,
nausea/vomiting, and extreme diaphoresis. No intervention was
made at that time. Since that time she has had increasing
nausea, SOB, fatigue and anorexia.
Upon arrival to the floor, pt is ill-appearing reliant on O2 NC.
In no acute distress, denying chest pain/pressure. Vitals:
T98, 112/78, 111, 20, 96 2L NC.
REVIEW OF SYSTEMS:
Positive for mild hip arthritis. She denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
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.
Past Medical History:
- Myocarditis & heart block s/p pacer placement [**2180-8-7**], however
no cardiac history prior to [**7-/2180**]
-Hypertension
-GERD
-Appendectomy
-Cholecystectomy
-B/L Salpingoopherectomy
Social History:
Works in a nursing home. Denies smoking, drinking or illicits.
Family is very involved.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION on admission to [**Hospital1 1516**] C:
VS: T 98 , BP 117/78, HR 111, RR 20, 96 2L NC
GENERAL: Obese female, ill-appearing, oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry mucous membranes
NECK: Supple with JVP to angle of jaw at 45 incline.
CARDIAC: Distant heart sounds, tachycardic, normal S1, S2. No
m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Obese, soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Cool extremities.
NEURO: CN II-XII tested and intact, strength 5/5 throughout,
sensation grossly normal. Gait not tested.
SKIN: No rashes or ulcers.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Discharge exam:
T 36.1 , BP 90/54, HR 115, RR 17, 96% 2L NC
GENERAL: NAD, NT, ND, alert and oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 17-19 cm.
CARDIAC: distant heart sounds, no murmurs, rubs, or gallops
appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diminished breath
sounds in both bases, evolving over the course of the night, at
times scattered rales in the mid-lung fields. No rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: trace edema in bilateral LE.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: palpable DPs b/l ?1+
Pertinent Results:
Labs on admission to [**Hospital1 1516**] C:
[**2180-8-18**] 09:00PM BLOOD WBC-11.3* RBC-3.89* Hgb-10.9* Hct-33.7*
MCV-87 MCH-28.0 MCHC-32.2 RDW-14.4 Plt Ct-396
[**2180-8-18**] 09:00PM BLOOD Glucose-140* UreaN-17 Creat-0.7 Na-134
K-3.8 Cl-95* HCO3-26 AnGap-17
[**2180-8-18**] 09:00PM BLOOD ALT-224* AST-234* AlkPhos-73 TotBili-0.3
[**2180-8-18**] 09:00PM BLOOD CRP-28.6*
[**2180-8-19**] 06:30AM BLOOD CK-MB-94* MB Indx-1.9 cTropnT-2.29*
[**2180-8-18**] 09:00PM BLOOD CK-MB-94* cTropnT-2.34*
[**2180-8-21**] 04:43AM BLOOD WBC-11.7* RBC-3.96* Hgb-11.0* Hct-33.8*
MCV-85 MCH-27.8 MCHC-32.6 RDW-14.3 Plt Ct-371
[**2180-8-18**] 09:00PM BLOOD WBC-11.3* RBC-3.89* Hgb-10.9* Hct-33.7*
MCV-87 MCH-28.0 MCHC-32.2 RDW-14.4 Plt Ct-396
[**2180-8-20**] 01:47PM BLOOD PT-13.8* PTT-24.0* INR(PT)-1.3*
[**2180-8-20**] 01:47PM BLOOD Plt Ct-388
[**2180-8-18**] 09:00PM BLOOD PT-13.6* PTT-27.5 INR(PT)-1.3*
[**2180-8-18**] 09:00PM BLOOD Plt Ct-396
[**2180-8-20**] 10:49PM BLOOD ESR-20
[**2180-8-21**] 04:43AM BLOOD Glucose-186* UreaN-17 Creat-0.8 Na-136
K-4.0 Cl-89* HCO3-37* AnGap-14
[**2180-8-18**] 09:00PM BLOOD Glucose-140* UreaN-17 Creat-0.7 Na-134
K-3.8 Cl-95* HCO3-26 AnGap-17
[**Numeric Identifier 112105**] Immunology (CMV) CMV Viral Load-PENDING INPATIENT
[**2180-8-20**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG
AB-PENDING; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-PENDING; [**Doctor Last Name **]-[**Doctor Last Name **]
VIRUS VCA-IgM AB-PENDING INPATIENT
[**2180-8-20**] SEROLOGY/BLOOD LYME SEROLOGY-PENDING
INPATIENT
[**2180-8-19**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2180-8-21**] 04:43AM BLOOD ALT-216* AST-280* AlkPhos-73 TotBili-0.4
[**2180-8-18**] 09:00PM BLOOD ALT-224* AST-234* AlkPhos-73 TotBili-0.3
[**2180-8-21**] 04:43AM BLOOD CK-MB-113*
[**2180-8-18**] 09:00PM BLOOD CK-MB-94* cTropnT-2.34*
[**2180-8-21**] 04:43AM BLOOD Albumin-3.8 Calcium-8.4 Phos-3.8 Mg-2.2
[**2180-8-20**] 10:49PM BLOOD Ferritn-PND
[**2180-8-18**] 10:53PM BLOOD %HbA1c-PND
[**2180-8-20**] 10:49PM BLOOD TSH-PND
[**2180-8-20**] 10:49PM BLOOD HBsAg-PND HBsAb-PND
[**2180-8-20**] 10:49PM BLOOD ANCA-PND
[**2180-8-20**] 11:02AM BLOOD [**Doctor First Name **]-PND
[**2180-8-18**] 09:00PM BLOOD CRP-28.6*
[**2180-8-20**] 10:49PM BLOOD HCV Ab-PND
[**2180-8-21**] 04:43AM BLOOD ALDOLASE-PND
[**2180-8-20**] 10:49PM BLOOD MI-2 AUTOANTIBODIES-PND
[**2180-8-20**] 10:49PM BLOOD ALDOLASE-PND
[**2180-8-20**] 10:49PM BLOOD SM ANTIBODY-PND
[**2180-8-20**] 10:49PM BLOOD RO & [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) 21195**]
[**2180-8-20**] 10:49PM BLOOD RNP ANTIBODY-PND
[**2180-8-20**] 10:49PM BLOOD POLYMYOSITIS ASSOCIATED (PM-1)
ANTIBODY-PND
[**2180-8-20**] 10:49PM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-PND
[**2180-8-20**] 10:49PM BLOOD [**Location (un) 5099**] VIRUS B ANTIBODIES-PND
[**2180-8-20**] 10:49PM BLOOD ANTI-JO1 ANTIBODY-PND
[**2180-8-20**] 10:49PM BLOOD ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-PND
Portable TTE (Complete) Done [**2180-8-19**] at 2:19:08 PM FINAL
IMPRESSION: Biventricular cavity dilatation with extensive left
ventricular systolic dysfunction suggestive of a non-ischemic
cardiomyopathy. Moderate functional mitral regurgitation.
Moderate-severe tricuspid regurgitation with possible
underestimation of pulmonary artery systolic pressure.
CXR Approved: SAT [**2180-8-19**] 8:37 AM
FINDINGS: Left pectoral pacemaker. The leads are in expected
position in the right atrium and right ventricle. Normal course
of the leads, no fracture.
Borderline size of the cardiac silhouette without pulmonary
edema, but with moderate bilateral pleural effusions, right more
than left. The effusions cause atelectasis at the lung bases.
No evidence of pneumonia. No pneumothorax.
Brief Hospital Course:
The patient is a 53 year old woman with a history of untreated
hypertension and recent diagnosis of possible viral myocarditis
with complete AV block who is now status post pacer placement on
[**2180-8-7**] (type of pacer unknwon) who continues to complain of
shortness of breath, periodic chest pressure, nausea, vomiting
and was transfered to [**Hospital1 **] for a higher level
of care.
# Acute systolic heart failure: The patient presented with
continued shortness of breath and chest pressure in the setting
of elevated troponins and CK-MB suggestive of lymphocytic
myocarditis, especially given the history of a prior diarrheal
illness. There was also a complete AV block requiring pacer
placement (type of pacer unknown). Left heart catheterization at
that time was negative, thus symptoms were thought to be
unlikely ischemic in orgin. Infiltrative cardiomyopathy
(although ferritin low rather than high) or giant cell
myocarditis were also considered. On the floor, the patient
worsened and showed signs of poor forward flow with cool limbs
and increased heart rate. The patient was transferred to the
CCU for a higher level of care, stat echo and swan ganz
placement. We monitored for signs of cardiogenic shock. An
echocardiogram showed global hypokinesis with an estimated EF of
approximately 20%. The patient was placed on a Lasix drip and
titrated up to 20mg/hr, to which she generally put out 100-200
cc/hour. She was started on milrinone, which was gradually
up-titrated to 0.75 mcg/kg/min. Dobutamine was started on
[**2180-8-21**] at approximately 4am at 0.25 mcg/kg/min in response to
an unchanging cardiac index of 1.8 in the setting of brisk
diuresis and an SVR of 1000 and increasing CVP (up to 17-20 from
13 earlier in the day). The patient responded poorly to 0.5
mcg/kg/min; she became very anxious and several pacer beats
failed to capture. Her dobutamine was reduced to 0.25 with
resolution of both pacer failure to capture and anxiety. Despite
diuresis in the range of 100-200 cc/hr, her CVP continued to
rise and fluctuated between 17 and 20 on [**8-21**]. She became
increasingly orthopneic and denied any such symptoms prior to
hospitalization. Her breath sounds gradually decreased over the
lower lobes bilaterally. Based on deterioration of the clinical
exam and refractoriness to inotropes, the decision was made to
begin an intra-aortic balloon pump and concomitantly biopsy the
heart before transfer to [**Hospital 3278**] Medical Center for possible
ventricular assist device
#Rhythm: Pt currently in sinus tachycardia with rate of 110.
Awaiting OSH records to confirm dx of complete heart block.
Pacer was interrogated by electrophysiology service and the
device was found to be functioning appropriately with good
sensing and pacing thresholds 2 weeks after implantation. The
pacemaker was dependent with
no underlying AV conduction and no ventricular escape.
#Transaminitis: Elevated AST and ALT has been trending downward
in setting of heart failure and hepatic congestion. US suggests
fatty liver without specific findings. ALT and AST remained in
the 200-300 range.
# Elevated CK: Pt with CK levels >5x upper limit of normal.
Likely secondary to myocarditis. We could not offer IVF in the
setting of CHF. A lactate was normal. Her creatinine remained
within normal limits without evidence of ATN.
# Normocytic anemia: The patient's shortness of breath could
also partly be explained by the finding of anemia. Low ferritin
levels would suggest iron deficiency anemia although MCV is
normal. Iron studies were still pending at the time of
discharge. Ruled out folate and B12 deficiency already.
Transitional Issues
-Please start heparin gtt as ordered at 2 pm today for
anticoagulation given IABP.
-In the cath lab during IABP placement, the femoral line was
kinked- the patient may have a right groin
-The patient's bicarbonate was elevated to 37 at time of
transfer, which was thought to be primary a reflexive increase
in proximal tubular reabsorption in response to prolonged,
high-dose lasix diuresis.
-Large rheumatologic panel ordered at [**Hospital1 18**] is pending
-continue to trend CPK and CK-MB
-may need to interrogate pacer again
-Full code
-[**Name (NI) **] (sister) HCP [**Telephone/Fax (1) 112106**]
Medications on Admission:
MEDICATIONS on transfer from [**Hospital3 35813**] Center:
1. Ibuprofen 600 mg PO BID
2. Lisinopril 2.5 mg PO DAILY
3. Hydrocodone-Acetaminophen (5mg-500mg [**2-7**] TAB PO Q8H:PRN pain
4. Metoprolol Tartrate 12.5 mg PO BID
5. Pantoprazole 40 mg PO Q24H
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. DOBUTamine 2-5 mcg/kg/min IV DRIP TITRATE TO CI > 2
hold for SBP < 85, hold for HR > 130
3. Furosemide 5-20 mg/hr IV DRIP INFUSION
4. Milrinone 0.75 mcg/kg/min IV INFUSION
hold for SBP < 80
5. Lorazepam 0.5 mg IV ONCE Duration: 1 Doses
To be given immediately prior to transport to [**Hospital1 3278**]
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Pantoprazole 40 mg PO Q24H
8. Heparin IV per Weight-Based Dosing Guidelines
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Myocarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 112107**],
It was a pleasure caring for you while you were hospitalized at
the [**Hospital1 69**]. As you know, you were
diagnosed with an inflammation of your heart muscle called
myocarditis, and transferred here for further work-up. It was
thought that your heart inflammation was due to a virus and you
were treated with medications to encourage your heart to pump
more forcefully and lower your blood pressure, making it easier
for your heart to pump. Unfortunately, your illness was very
severe and required transfer to [**Hospital 3278**] Medical Center since there
was the possibility that you might need a very specialized
procedure to help your heart pump.
Followup Instructions:
Please consult your discharging physician at [**Name9 (PRE) 3278**] Medical
Center regarding follow-up.
|
[
"4280",
"4019",
"53081",
"2859"
] |
Admission Date: [**2156-2-5**] Discharge Date: [**2156-2-12**]
Date of Birth: [**2088-10-10**] Sex: M
Service: TRAUMA SURGERY
CHIEF COMPLAINT: Status post fall.
HISTORY OF THE PRESENT ILLNESS: The patient is a 67-year-old
gentleman who was found at the bottom of the stairs in the
basement by a family member around 4:00 p.m. on the day of
admission. Circumstances of the fall were unknown. The
patient was not fully clothed. He was last seen around noon
by family members and was in his normal state of health.
He was taken to an outside hospital, at which time he was
found to have a right subdural hematoma and intraparenchymal
hemorrhage. He was hemodynamically stable and intubated and
transferred to [**Hospital6 256**] for
further workup.
The patient, on arrival to [**Hospital1 **], was
sedated, intubated, and hemodynamically stable.
PAST MEDICAL HISTORY: Hyperlipidemia.
PAST SURGICAL HISTORY: Unknown.
MEDICATIONS ON ADMISSION: Zocor.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: No tobacco. No ETOH use.
PHYSICAL EXAMINATION ON ADMISSION: The patient's temperature
was 99.5, heart rate 117, pressure 170/palpable, 98% on
assist control ventilator, GCS 80. The pupils were 2 to 1.5
bilaterally. Space was stable. TMs were clear. There was a
right scalp hematoma. The trachea was midline. No crepitus
deformity. The patient was clear to auscultation
bilaterally. The heart was regular. The abdomen was soft,
nontender. The rectal examination was heme-negative, normal
tone. The pelvis was stable. There was palpable DP, PT,
femoral, and radial pulses bilaterally. The back had no
step-off or deformities.
LABORATORY DATA/OTHER STUDIES ON ADMISSION: White blood
count 21, hematocrit 41, platelets 301,000. PT 13.1, PTT
22.3, INR 1.1. Sodium 140, potassium 3.4, BUN 16, creatinine
0.8, glucose 201, calcium 1.17. Blood gas 7.39, 40, 116, 25,
0. Lactate was 4.1. CK with a troponin I of 0.06.
Fibrinogen 335, amylase 220. Serum tox was negative.
EKG showed sinus rhythm at 70 with normal axis, no ST
changes.
Chest x-ray showed ET in good position. No pneumothorax,
clear.
Pelvic film was negative.
CT of the head showed a right subdural hematoma and a left
temporal intraparenchymal hemorrhage and a posterior left
frontal subarachnoid hematoma. There was no shift. The
ventricles were normal.
The C-spine CT was negative. The abdomen and pelvis CT were
negative. The TLS plain films were negative.
HOSPITAL COURSE: The patient was admitted with an acute
subdural hematoma and intraparenchymal hemorrhage. He was
transferred to the Intensive Care Unit stable but intubated
for a close neurologic monitoring and careful blood pressure
control.
Neurosurgery was consulted who agreed with the current
management and felt that there was no immediate need for
surgical or an operative treatment. The patient was stable
over the first night. The patient had good blood pressure
control and had a repeat head CT which demonstrated no new
hemorrhages and no change in the previously seen hemorrhages.
The patient's sedation was weaned. The patient became
increasingly alert, was following commands. The patient did
continue to have an increased AA gradient and was hypoxemic
on the ventilator. The patient had a chest CTA which
demonstrated multiple subsegmental pulmonary emboli
bilaterally. He had an IVC filter placed by Interventional
Radiology and bilateral chest tubes were placed secondary to
the hypoxemia to rule out any intrapleural collections.
On SICU day number four, the chest tubes were discontinued.
The patient self-extubated and remained stable not requiring
reintubation. He had bilateral lower extremity Doppler
studies which were negative. The patient received pulmonary
toilet. The patient continued to improve neurologically.
After close observation for 24 hours, the patient was felt to
be stable to be transferred to the floor. He was diuresed
with loop diuretics from which he responded well. The
patient's pulmonary status continued to improve.
He was transferred to the floor on hospital day number five
from which he continued to recover. During his time on the
floor, Hematology/Oncology consult was obtained to assist in
the workup of a hypercoagulable state which may explain his
bilateral pulmonary emboli. The workup is currently in
progress and the laboratory work is pending currently.
The patient has had a repeat head CT which is slightly
improved and not worsened. The patient has been seen by
Physical Therapy and is receiving rehabilitation. The
patient's diet has been advanced to a house diet with Boost
supplements which he is tolerating. The patient has been
restarted on aspirin for cardiac prophylaxis.
The patient is now stable and ready for discharge to neuro
rehabilitation.
DISCHARGE DIAGNOSIS:
1. Status post fall, unknown inciting event, with right
subdural hematoma, left intraparenchymal hemorrhage.
2. Bilateral pulmonary emboli, status post IVC filter
placement.
3. Hypercholesterolemia.
MEDICATIONS ON DISCHARGE:
1. Dulcolax 10 mg p.r. p.r.n.
2. Acetaminophen 650 mg p.o. q. four hours p.r.n.
3. Aspirin 325 mg p.o. q.d.
4. Lopressor 25 mg p.o. b.i.d.
5. Zocor 20 mg p.o. q.d.
FOLLOW-UP: The patient will follow-up with Neurosurgery and
Trauma Clinic in approximately seven to ten days.
DR [**First Name (STitle) **] [**Doctor Last Name **] 02.349
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2156-2-12**] 13:32
T: [**2156-2-12**] 13:35
JOB#: [**Job Number 47445**]
|
[
"41071",
"2724"
] |
Admission Date: [**2153-2-10**] Discharge Date: [**2153-2-26**]
Date of Birth: [**2075-1-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bactrim / Lipitor
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Intubation, extubation. Mechanical Ventilation.
Arterial line placement (in [**Hospital1 18**] ED)
Central venous line placement (in [**Hospital1 18**] ED)
Bronchoscopy
Picc Line Placement
Tracheostomy and G-tube placement ([**2-23**])
History of Present Illness:
78 y/o F bronchiectasis, severe COPD with baseline 2L 02
requirement, tracheobronchomalacia s/p Y-stent who presents with
acute respiratory distress. Patient initially presented to
[**Hospital 26580**] Hospital speaking in 1 word sentances, tripoding, found
to have an ABG 7.22/110/176/43 and was consequently intubated.
Patient was given solmedrol 125 mg IV, levofloxacin and zosyn.
Per records patient had a CXR which demonstrated right pleural
effusion and RLL infiltrate.
.
In [**Hospital1 18**] ED, initial vs were: T 98 P 120 BP 137/70. Patient was
felt to be desynchronous on vent, started on propofol became
hypotensive and was switched over to versed. Central line was
placed and 3 L NS given. Patient was also given vancomycin. Labs
pertinent for a lactate of 4, left shift N 91.5%, platelets 122.
.
According to family patient demonstrated increasing respiratory
distress the past week and yesterday "lungs sounded junky". She
was also increasingly somnelent and confused the past week. They
denie fever, chills, abdominal pain, nausea, vomiting,
headaches, vision changes, neck stiffness or chest pain. The do
report decreased fluid intake.
.
Of note, patient was recently admitted [**Date range (3) 80818**] for
H1N1 Influenza, COPD exacerbation with pseudomonas growing from
sputum, urinary tract infection (+ ESBL). Patient discharged on
Ertapenem for 10 days total.
.
Review of systems: Patient intubated.
Past Medical History:
COPD/tracheobronchomalacia s/p Y stent placement [**2152-1-18**]. 3
other admissions and 9 therapeutic bronchoscopies since Y stent
placement. Patient had bronchoscopy [**2152-12-13**] which ensured
patent stent, minimal secretions, small amount of granulation
tissue at the distal limb of the stent. PFTs FEV/FVC 44%
[**2152-9-28**].
bronchiectasis
HTN
GERD
hypothyroid
hyperlipidemia
anxiety
recurrent UTI
anemia
hysterectomy at 33yo from anemia
b/l cataract sx
total knee replacement 2yrs ago
bladder sling
Social History:
Has 4 children, all live locally; daughter is nurse. Worked as
a store clerk, retired 3 years ago. volunteered at [**Hospital1 3325**] until 4-5 months ago. Drinks wine infrequently. No h/o
tobacco or illicit drug use. Husband smoked until ~22 yrs ago.
Daughter is a nurse. Reports decreased appetite and enthusiasm
for eating in past year, markedly decreased activity and
exercise tolerance, weight loss.
Family History:
Mother had MI, brother died from heart disease and had minor
stroke. No family history of lung disease/COPD/asthma. 4
children and 7 grandchildren are generally healthy; grandaughter
has spherocytosis and was recently hospitalized for 5 days with
flu
Physical Exam:
GENERAL: thin, elderly female, intubation
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. dryMM. OP clear.
CARDIAC: Distant heart sounds. Regular rhythm, normal rate.
Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: limited air movement bilaterally, no wheezes or crackles
ABDOMEN: NABS. Soft, NT, mildly firm. No HSM.
EXTREMITIES: No clubbing/ cyanosis/ edema or calf pain, 2+
dorsalis pedis/ posterior tibial pulses. Cool extremity.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Will squeeze hands to name.
Pertinent Results:
Chem 10
139 99 21 195 AGap=13
3.8 31 0.6
Ca: 8.1 Mg: 1.1 P: 2.7
.
CK: 24 MB: Notdone Trop-T: <0.01
.
ALT: 22 AP: 45 Tbili: 0.2 Alb:
AST: 34 LDH: 187
.
CBC
91
7.9 > 10.0 < 122 ∆
31.2
N:91.5 L:6.8 M:1.5 E:0 Bas:0.2
.
PT: 13.2 PTT: 27.7 INR: 1.1
.
Micro:
Blood culture ngtd
Urine culture ngtd
.
Prior Micro:
[**2152-11-13**] sputum:
PSEUDOMONAS AERUGINOSA
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
.
Urine Culture [**2152-11-13**]:
ESCHERICHIA COLI
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
Images:
CXR: My read - hyperinflated. Increased hilar vasculature. No
infiltrate.
.
EKG:
[**Last Name (un) 26580**] [**2153-2-9**]: EKG HR 99, ST depressions II, III, aVF.
[**Hospital1 18**] on admission: HR 103, ST depressions resolved. Difficult
baseline.
.
CTA (prelim): 1. No pulmonary embolus or aortic dissection is
seen.
2. Emphysematous changes with diffuse bronchiectasis. There are
new
scattered opacities in the bibasilar regions which most likely
represent
atelectasis, less likely pneumonia. Clinical correlation
recommended.
3. Stable ET tube and tracheal Y stent.
4. Scattered 5 mm pulmonary nodules, some new. In a high-risk
patient
continued followup is recommended to assess stability.
.
LENIs:
RIGHT LOWER EXTREMITY ULTRASOUND: [**Doctor Last Name **]-scale and Doppler
son[**Name (NI) **] of the
right common femoral, femoral, popliteal, and calf veins was
performed. There is normal flow, compressibility and
augmentation of the veins.
IMPRESSION: No evidence of DVT in the right lower extremity.
.
[**2-24**] CXR:
FINDINGS:
Frontal chest radiograph is compared to the prior study from
[**2153-2-23**].
Endotracheal tube terminates in the thoracic inlet. Lungs are
clear.
Mediastinum is within normal limits.
Brief Hospital Course:
78 y/o F bronchiectasis, severe COPD, tracheobronchomalacia s/p
Y-stent who presents with respiratory distress and hypotension.
S/p trach and PEG tube this admission, now being discharged to
pulm rehab. See below for specific discussion of each problem.
# Respiratory Distress: Thought to be likely due to COPD
exaerbation with underlying component of tracheobronchomalacia
and bronchiectasis. Initial work-up revealed troponins negative
for myocardial ischemia, PE CTA negative for pulmonary embolus,
and bronchoscopy/bronchoalveolar lavage with Y-stent for
tracheobronchomalacia in appropriate place. She was started on
IV methylprednisolone 125mg IV q6H for presumed COPD
exacerbation, and this was gradually tapered. Remained on Q4h
ipratropium and albuterol inhalers. Respiratory cultures from
[**2-10**] grew gram negative rods. Given previous respiratory
cultures positive for pseudamonas, she completed a 12-day course
of vancomycin and levofloxacin and an 11-day course of
levofloxacin. For respiratory support, she was intubated on [**2-10**]
on AC ventilation. Failed multipled trials of PSV until finally
on [**2-15**] was successfully transitioned from AC to PSV. Was
extubated on [**2-16**] for 10 hours, then re-intubated due to
respiratory distress and hypertension to 200s requiring a nitro
drip. Subsequently failed several spontaneous breathing trials
(became hypertensive and tachycardic during these periods) with
significant distress. Discussed treatment options with
healthcare proxy (daughter) and rest of family, who ultimately
decided on tracheostomy and G-tube placement. Proceeded with
trache/G-tube placement on [**2153-2-23**] and worked with respiratory
therapist to wean off mechanical ventilation. On the trach mask,
she has been weaned slowly but still continues to be pretty
symptomatic when PS is <10. Has been stable on [**5-2**] for
approximately a day. Mostly seen is tachycardia when she becomes
uncomfortable.
# Hypotension: Patient arrived to MICU with elevated lactate
concerning for shock, however there was no evidence of end organ
damage (adequate urine output, normal creatinine). Concern for
sepsis based on left shift and prior ESBL urinary tract
infection and pseudomonas pneumonia. However, UA was negative,
CXR showed no infiltrate, negative blood cultures to date and
patient remained afebrile. CVP 8 following 3 L NS suggesting
hypovolemia from poor PO intake and unlikely cardiac shock.
Treated with broad spectrum antibiotics for possible infection
as above. Has been stable with SBPs in 120s when awake.
Intermittently drops to the 80s when sleeping, usually in
conjunction with getting ativan.
# Respiratory acidosis: Initial ABG showed respitory acidosis
without adequate compensation most likely secondary to overlying
metabolic acidosis from elevated lactate. Patient's ABG resolved
quickly during MICU stay, on mechanical ventilation. Lactate
normalized with fluid hydration.
# Acute on chronic anemia: Slightly down on arrival at 27.7,
from baseline 34-37. Guaiac negative on exam. Transfused 1U
PRBCs on [**2-10**] and to a Hct 31.7. Hematocrit remained stable for
duration of hospital stay.
# Tachycardia: patient was initially tachycardic with temporary
improvement with blood transfusion. Patient remained
intermittently tachycardic, usually during times of respiratory
distress or anxiety. HR improved with sedation, optimization of
ventilator settings and initiating of beta-blocker. She is on
metoprolol 25 mg [**Hospital1 **]; we tried to go to TID and she did not
tolerated with moderately low BPs in the 90s.
# Anxiety: Patient has baseline anxiety. She was continued on
home mitrazapine 15 mg hs. Additional anxiolytic effects
achieved with IV sedation (propofol) while on ventilator as well
as ativan (0.25-0.5mg Q6h, which is close to patient's home
dose). She is on standing ativan and PRN ativan per her home
regimen. She still has intermittent anxiety. She seems to
repsond well to sublingual zyprexa, too.
# Tracheobronchomalacia s/p Y stent placement: Continued
outpatient stent care. Patient underwent bronchoscopy by
Interventional Pulmonary which confirmed good Y-stent placement
and patent airways. Patient was continued on home regimen of
Guaifenesin 600 mg Tablet [**Hospital1 **] and Acetylcysteine 20 % (200
mg/mL) every 8 hours.
# New thrombocytopenia: Platels on admission 122 from baseline
300. Platelets were trended daily and climbed to a normal
baseline range during hospital stay.
# Impaired glucose control: blood sugar noted to be high in 200s
in the hospital, felt to be secondary to steroids. Placed on
insuline sliding scale which was adjusted with the prednisone
taper. Will continue at rehab.
# HTN: Was continued on lopressor 25mg [**Hospital1 **], held when BP was
low. Held home dose of amlodipine. She has variable blood
pressures based on her activity and anxiety levels. No flash
edema noticed when she was high.
# Pain Control: Patient's pain was controlled with fentanyl
12.5-25 mcg IV Q4H prn. She is still on fentanyl PRN with good
control.
# GERD: Remained on famotidine while intubated.
# Hypothyroid: Continued outpatient Levothyroxine. Had TSH of
0.91 around admission. Continued her home dose but should be
rechecked when more stabalized.
# Hyperlipidemia: Continued outpatient Simvastatin.
# FEN: Tube feeds via PEG at 40ml/hr. At goal, tolerating well.
Zofran PRN.
# Constipation: Intermittent constipattion controlled on bowel
regimen of colace 100 [**Hospital1 **] and senna prn.
.
# Discharged to rehab. Foley removed this afternoon. Family
aware and at bedside at the time of discharge.
Medications on Admission:
- Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
- Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO bid.
- Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
- Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
- Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
- Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q 8H (Every 8 Hours).
- Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
- Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
- Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation PRN (as needed) as needed
for see below: please use when giving mucinex.
- Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed for wheezing,
dyspnea.
- Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () for 3
days.
- Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
- Methenamine Hippurate 1 gram Tablet Sig: One (1) Tablet PO
twice a day.
- Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QCHS.
- ASA 81 mg
- Norvasc 10 mg qd
- Ativan 0.25 mg po q6 hours anxiety
- BiPap at night with setting [**7-26**]
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q2H (every 2 hours) as needed for
respiratory distress.
4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: 50-100 mg PO BID (2
times a day) as needed for constipation.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H
(every 6 hours): in place of mucinex.
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for aggitation:
given sometimes before trach mask trials.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
19. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): 30mg for 3 days ([**Date range (1) 60917**]) then 20mg for 3 days
([**Date range (1) 57020**]) and then 10mg for 4 days ([**Date range (1) 80819**]) and then stop.
20. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED): please give as directed in the
attached insulin sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1263**] Hospital Transitional Care Unit - [**Location (un) 686**]
Discharge Diagnosis:
Primary: COPD, tracheobronchomalacia s/p Y-stent placement,
bronchiectasis
Secondary: HTN, HL, Hypothyroidism, GERD, Anxiety, Depression
Discharge Condition:
discharged on trach mask with PSV of [**5-5**]. Tolerating well with
intermittent symptomatic anxiety. HR in 100s-110s. Is awake
and alert and can mouth words, likley intermittently
hallucinating, too, but difficult to tell based on understanding
when she mouths words
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the [**Hospital3 **] [**Hospital 1225**] Medical Center
due to difficulty breathing. To help support your breathing you
were placed on mechanical ventilation with a breathing tube. You
were also given steroids to support your lung function and
antibiotics (meropenem, vancomycin, and levofloxacin) for
treatment of a presumed lung infection. To evaluate what was
causing you to have such difficulty breathing, we conducted a
number of tests, including a CT scan of your chest to look for
blood clots, blood tests to determine if you had an injury to
your heart, and a bronchoscopy to look at the stent in your
airways. All of these tests came back negative for any injury.
We believe that your respiratory distress is due to poor lung
function from your underlying lung disease. We tried to wean you
off of mechanical ventilation several times, including at one
point taking the breathing tube out completely, but you became
significantly distressed with all of these attempts. After
ongoing discussion with your family, it was decided to insert a
tracheostomy tube to help support your breathing. We also placed
a G-tube to allow you to receive nutrition. You tolerated this
procedure well. You will continue to work with a respiratory
therapist in managing your breathing with the tracheostomy tube.
Followup Instructions:
- Please follow up with your primary care physician [**First Name4 (NamePattern1) 2398**]
[**Last Name (NamePattern1) **] as needed per doctors at the pulmonary rehab facility
Completed by:[**2153-2-26**]
|
[
"5119",
"2875",
"2859"
] |
Admission Date: [**2194-2-24**] Discharge Date: [**2194-2-28**]
Date of Birth: [**2130-6-19**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Nortriptyline
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 yo woman with history of copd/chf/morbid obesity, OSA,
multiple admissions and intubations for respiratory failure, not
taking meds for past 4 days, not complaint on cpap, who was
found unresponsive in lobby on the [**Hospital Ward Name **]. Code blue was
called and she was transferred to the ED where she was agitated,
violent towards staff, biting and spitting.
.
In the ED, initial vs were not recorded in ED dash. Patient was
given 10 mg haldol for agitation. Blood gas concerning for
hypercarbic respiratory failure. CXR concerning for pleural
effussions. EKG showed sinus tach with PAC, mildly elevated BNP
at 717, nl cardiac enzymes. She was given 40 mg furosemide,
albuterol and ipratroprium nebs. She was transferred to the
floor however on arrival to the floor was somnolent and not
responsive to sternal rub. Facemask was placed with O2 sats
rising to the 90s, and improvement in mental status. Repeat [**Hospital Ward Name **]
showed persistent hypercarbic respiratory failure. She was
given an additional 40 mg IV lasix while on the floor and
transferred to the ICU for further management.
.
On arrival to the ICU, she continued to be minimally responsive.
She was started on BIPAP with some improvement in MS [**First Name (Titles) **] [**Last Name (Titles) **].
Past Medical History:
CAD
OSA on CPAP
CHF diastolic
Afib
COPD/Asthma on home O@
DM
HTN
Polysubstance abuse
Alcoholism
UGIB
Depression
Migraines
Gallstones
s/p hysterectomy
Social History:
h/o smoking, EtoH, marijuana and cocaine. Denies currently.
Lives at [**Location 4367**] [**Hospital3 **].
Family History:
DM, HTN
Physical Exam:
ADMISSION EXAM:
Vitals: T:97.5 BP:141/91 P:92 R: 24 O2: 98%
General: Not responsive to voice or sternal rub intially, then
opens eyes to voice
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils minimally
reactive
Neck: supple, JVP not elevated, no LAD
Lungs: Rhonchi and rales throughout
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no CCE
Neuro: unable to assess
.
DISCHARGE EXAM:
Vitals: 96.2 120/70 57 20 99%RA
General: Middle aged female, obese, NAD, comfortable
HEENT: PERRL, sclera anicteric, MMM, OP clear
NECK: supple, JVD 6cm, no LAD
LUNGS: Sparse crackles/wheezes, good air movement, improved from
prior, no rales/ronchi
ABD: Soft, obese, NT/ND naBS, no rebound/guarding
Ext: WWP, 2+ DP/PT/radial pulses, trace pedal edema, signs of
chronic venous stasis changes bilaterally, venous ulcer over R
shin c/d/i Neuro: AOx3, moving all extremities, gait wnl
Pertinent Results:
Blood Counts
[**2194-2-24**] 07:00PM BLOOD WBC-8.4 RBC-5.74* Hgb-14.8 Hct-51.3*
MCV-89 MCH-25.8* MCHC-28.8* RDW-18.3* Plt Ct-324
[**2194-2-27**] 07:30AM BLOOD WBC-8.0# RBC-5.38 Hgb-14.0 Hct-46.8
MCV-87 MCH-26.0* MCHC-29.9* RDW-18.9* Plt Ct-321
Chemistry
[**2194-2-24**] 07:00PM BLOOD Glucose-146* UreaN-15 Creat-0.9 Na-137
K-4.4 Cl-98 HCO3-30 AnGap-13
[**2194-2-25**] 03:37PM BLOOD Glucose-165* UreaN-14 Creat-0.8 Na-145
K-5.0 Cl-101 HCO3-33* AnGap-16
[**2194-2-27**] 07:30AM BLOOD Glucose-154* UreaN-36* Creat-1.0 Na-135
K-5.0 Cl-95* HCO3-30 AnGap-15
Cardiac
[**2194-2-24**] 07:00PM BLOOD cTropnT-<0.01 proBNP-717*
[**2194-2-25**] 02:55AM BLOOD CK-MB-4 cTropnT-<0.01
[**2194-2-25**] 01:32PM BLOOD CK-MB-3 cTropnT-<0.01
Tox
[**2194-2-25**] 10:24AM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Blood Gas
[**2194-2-24**] 07:46PM BLOOD Type-ART pO2-64* pCO2-66* pH-7.26*
calTCO2-31* Base XS-0 Intubat-NOT INTUBA
[**2194-2-25**] 02:06PM BLOOD Type-ART pO2-66* pCO2-73* pH-7.27*
calTCO2-35* Base XS-3
TTE [**2194-2-25**]
The left atrium is dilated. The right atrium is moderately
dilated. The estimated right atrial pressure is 0-5 mmHg. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of [**2193-11-13**], the right ventricle may now be more
dilated and hypokinetic (however views are suboptimal for
comparison). Estimated pulmonary artery systolic pressure is now
higher. Findings are suggestive of pulmonary embouls or other
intercurrent pulmonary process.
Brief Hospital Course:
HOSPITAL COURSE
This is a 63yo female PMHx COPD and CHF, multiple prior
admissions for respiratory failure, who presented w hypercarbic
respiratory failure requiring Bipap in MICU, thought to be
secondary to COPD and CHF, diuresed and started on steroid pulse
with improved respiratory status to baseline, discharged back to
[**Hospital3 **].
.
ACTIVE
# Acute sCHF and COPD Exacerbation - Patient a/w hypercarbic
respiratory failure requiring Bipap (usually on CPAP at home),
thought to be [**1-15**] CHF and COPD exacerbations. Exacerbating
factors were potential medication non-compliance, worsening of
pulmonary HTN (noted on TTE during this hospitalization),
cigarette smoking. COPD was treated with azithro x5d and
extended prednisone taper; CHF with diuresis. She improved to
baseline respiratory status, and was cleared by PT to return to
[**Hospital3 **]. Given prior non-compliance with O2, and
recommendation from PCP in prior note, patient was not
discharged on home O2. She was given script for prednisone
taper. Home inhalers (spiriva, symbicort, albuterol,
fluticasone/salmeterol) were continued and patient was counseled
on smoking cessation. Lasix dose was increased to [**Hospital1 **] dosing
for improved diuresis and will need to be followed up in
outpatient setting.
.
# Hypertension: Continued lisinopril. Given borderline
admission blood pressure, isosorbide mononitrate was held.
Pressures remained well-controlled and it was not restarted at
discharge; could be restarted as outpatient if blood pressures
become difficult to control
.
INACTIVE
# CAD: Continued [**Last Name (LF) 99970**], [**First Name3 (LF) **], simvastatin, metoprolol
.
# DM 2: Continued metformin
.
# Depression Continued abilify and fluoxetine
.
TRANSITIONAL
1. Code status: Full code for duration of the admission
2. Pending: No labs/studied were pending at time of discharge
3. Transfer of Care: Patient reported that [**Hospital3 **]
provided at-home PCP [**Name Initial (PRE) 2176**]. Discharge summary faxed to
[**Hospital3 **].
4. Barriers to Care: Recurrent readmissions with respiratory
distress are concerning for potential medication non-compliance
or environmental exacerbating factor.
Medications on Admission:
Medications (per last DC summary, pt not responsive to
questioning):
1. depends adult diapers
Please give patient 3 diapers per day x30 days, with 12 refills
all in size XL
2. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. isosorbide mononitrate 120 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
16. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
17. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
18. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation Q6hrs PRN as needed for shortness of
breath or wheezing.
19. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
20. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
21. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Inhalation twice a day.
5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day.
11. Lasix 20 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*0*
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. prednisone 20 mg Tablet Sig: as directed Tablet PO once a
day for 12 days: 60mg for 3days, 40mg for 3days, 20mg for 3days,
10mg for 3days.
Disp:*qs Tablet(s)* Refills:*0*
15. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation twice a day.
16. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
17. 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.
18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
19. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY
COPD Exacerbation
SECONDARY
Acute Diastolic Congestive Heart Failure
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 2450**] [**Known lastname 6930**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with shortness of breath and
confusion. This was caused by worsening of your congestive
heart failure and a worsening of your COPD. You were treated
with diuresis and steroids and your breathing improved.
You have had frequent admissions to the hospital recently for
similar problems. It is important that you continue to take
your medications and use your CPAP. If you feel as if your
symptoms are worsening, or if you gain more than 3 lbs in one
day, please contact your primary care doctor.
During this hospitalization the following changes were made to
your medications
- INCREASED your lasix
- STARTED prednisone (take 60mg for 3days, then 40mg for 3days,
then 20mg for 3days, then 10mg for 3days, then stop)
- STOPPED your imdur (isosorbide mononitrate)
Followup Instructions:
Your primary care doctor will see you at your [**Hospital3 **]
facility.
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2194-5-29**] at 1:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"4280",
"32723",
"25000",
"4019",
"3051",
"41401"
] |
Admission Date: [**2122-6-4**] Discharge Date: [**2122-6-11**]
Date of Birth: [**2048-8-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
jaw pain on exertion
Major Surgical or Invasive Procedure:
s/p CABG x4(LIMA->LAD, SVG->Diag,SVG->OM2,SVG->RCA)/AVR ( 19 mm
CE Magna pericardial valve) [**2122-6-5**]
History of Present Illness:
73 yo female with recent jaw pain on exertion admitted to [**Hospital 40796**] and had cardiac cath. Prior abnormal perfusion
scan showed ischemia and EF 64%. Transferred to [**Hospital1 18**] for
evaluation. Cath showed [**Location (un) 109**] 1.7 cm2, 90% LAD, 90%, diag, 90%
RCA, 70-80-% CX. Referred to Dr. [**Last Name (STitle) **] for surgery.
Past Medical History:
HTN
right cataract ( needs surgery)
hypothyroidism
glaucoma
s/p left cataract [**Doctor First Name **]
s/p TAH
Social History:
no tobacco
drinks couple of glasses of wine per week
last dental visit 1.5 years ago
Family History:
non-contributory
Physical Exam:
NAD
RRR 3/6 systolic murmur heard best at RUSB
CTAB anterior/laterally
transmitted murmur versus carotid bruit
anbd obese, NT, ND
extrems warm, + peripheral pulses, no edema
right groin, some swelling, no bruit
96% RA sat, 77kg, 97.5 HR 56 RR 20 154/56
Pertinent Results:
[**2122-6-10**] 09:55AM BLOOD WBC-9.2 RBC-3.48* Hgb-10.8* Hct-30.4*
MCV-87 MCH-30.9 MCHC-35.4* RDW-14.8 Plt Ct-150#
[**2122-6-11**] 06:20AM BLOOD Hct-30.6*
[**2122-6-10**] 09:55AM BLOOD Plt Ct-150#
[**2122-6-8**] 05:26AM BLOOD Glucose-89 UreaN-22* Creat-1.0 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
[**2122-6-11**] 06:20AM BLOOD K-4.2
[**2122-6-4**] 09:15PM BLOOD ALT-12 AST-16 AlkPhos-102 Amylase-63
TotBili-0.4
[**2122-6-7**] 02:47AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.9
[**2122-6-10**] 09:55AM BLOOD Mg-2.2
[**2122-6-4**] 09:15PM BLOOD %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE
[**Known lastname 67143**],[**Known firstname **] M: Microbiology Detail - CCC Record #[**Numeric Identifier 67144**]
[**2122-6-4**] 10:19 pm URINE
**FINAL REPORT [**2122-6-6**]**
URINE CULTURE (Final [**2122-6-6**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**Known lastname 67143**],[**Known firstname **] M:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 67144**]
FINAL REPORT
EXAM ORDER: Chest.
HISTORY: Chest preop for CABG.
CHEST: A single AP upright portable exam shows borderline
cardiomegaly. The
lungs are clear without evidence of pneumonia or pulmonary
edema. No pleural
effusion is seen. Note is made of a small right sided cervical
rib.
IMPRESSION: No evidence of acute pulmonary disease.
DR. [**First Name (STitle) 4344**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4345**]
Approved: FRI [**2122-6-5**] 7:11 PM
Procedure Date:[**2122-6-4**]
Brief Hospital Course:
Admitted [**6-4**] for pre-op eval. Underwent AVR/CABG x4 on [**6-5**]
with Dr. [**Last Name (STitle) **]. Transferred to the CSRU in stable condition on
epinephrine, neosynephrine, and propofol drips. Drips weaned off
and extubated on POD #1. Chest tubes and JP drain removed on POD
#2. Platelets decreased to 67K, and HIT screeen sent. Gentle
diuresis started and transferred to the floor to begin
increasing her activity level. Developed rapid AFib on POD #3
converted to SR with lopressor. Pacing wires and foley
removed on POD #3. Developed AFib again on the morning of POD
#4, and converted to SR again. ACE inhibitor started and beta
blockade titrated. Continued to make good progress and
discharged to home with VNA on POD #6. Patient is to follow up
with Drs. [**Name5 (PTitle) 8098**]/ [**Doctor Last Name 5017**]/ [**Doctor Last Name **].
Medications on Admission:
atenolol 50 mg [**Hospital1 **]
lisinopril 20 mg [**Hospital1 **]
maxzide [**Hospital1 **]
hydralazine 10 mg [**Hospital1 **]
KCL 20 mEq [**Hospital1 **]
norvasc 10 mg daily
synthroid 88 mcg daily
protonix 40 mg daily
xalatan eye drops
zymar eye drops
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): resume preop schedule.
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): resume preop schedule.
6. Gatifloxacin 0.3 % Drops Sig: One (1) gtt Ophthalmic once a
day: resume preop schedule.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily) for 2 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **]
Discharge Diagnosis:
AVR/ CABG x4
CAD
PMH:HTN, Hypothyroid, L cataract [**Doctor First Name **], glaucoma,TAH, right
cataract
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no baths. No lotions,
creams or powders to incisions.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds, or weight
gain more than 2 pounds in one day or five in one week.
Followup Instructions:
wound clinic in 2 weeks
Dr [**First Name4 (NamePattern1) 67145**] [**Last Name (NamePattern1) **] in [**2-27**] weeks
Dr [**Last Name (STitle) 5017**] 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2122-6-26**]
|
[
"4241",
"41401",
"4019",
"2449"
] |
Admission Date: [**2187-1-25**] Discharge Date: [**2187-1-30**]
Date of Birth: [**2117-6-18**] Sex: M
Service: SURGERY
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Fever, rigors s/p PTC placement
Major Surgical or Invasive Procedure:
cholangiogram and pigtail drain placement
History of Present Illness:
Pt is a 69M who underwent right hepatic lobectomy,
cholecystectomy and small bowel resection [**2186-5-22**] for a primary
metastatic GI Stromal Tumor; his course was complicated by a
bile leak, pneumonia, and bacteremia.
Pt has had ~100cc per day, light bilious drainage from his
sub-hepatic JP drain for the past several months. Drainage was
complicated by perforation of the diaphragm and subsequent
bilio-pleural fistula. He has a pleural drain attached to a
heimlich valve. A CT performed on [**2187-1-8**] showed communication
between the left lateral segments and the sub-hepatic
collection.
Today, Pt underwent placement of a percutaneous trans-hepatic
catheter into the left biliary tree in hopes to decompress the
system and have the leak spontaneously close.
Post-operatively he developed fevers to 103 with rigors which
has now resolved. He also developed an obstructed foley which
resolved with manipulation and flushes.
Past Medical History:
GIST
Hypertension
Hypercholesterolemia
Benign esophageal growth
h/o prostate CA s/p resection in [**2179**]
Social History:
Denies tobacco, drinks 2 glasses of wine after dinner, retired,
married
Family History:
Non-contributory
Physical Exam:
VS: 98.1 HR 85 BP 100/40 RR 18 O2 sat 98% on RA
Gen: NAD, looks very well. Moves easily
Lungs: CTA bilaterally
Card: RRR, no M/R/G
Abd: soft, completely ND, +BS, right side pigtail drain, PTC,
and
pleural drain with heimlich valve.
Extr: warm, no edema
Neuro: A+Ox3, no focal deficits noted
Pertinent Results:
[**2187-1-25**] WBC-5.5 RBC-3.26* Hgb-10.9* Hct-31.8* MCV-97 MCH-33.5*
MCHC-34.4 RDW-15.3 Plt Ct-231
PT-13.3 PTT-25.0 INR(PT)-1.1
Glucose-131* UreaN-18 Creat-1.0 Na-138 K-4.4 Cl-104 HCO3-24
AnGap-14
ALT-31 AST-23 AlkPhos-153* Amylase-68 TotBili-1.1
Lipase-33 Albumin-3.3* Calcium-8.7 Phos-3.1 Mg-1.7
Albumin-3.3* Calcium-8.7 Phos-3.1 Mg-1.7
Brief Hospital Course:
69 y/o male who underwent a right hepatic lobectomy,
cholecystectomy, small bowel resection with primary anastomosis,
in [**2186-5-2**], for GIST. He started Gleevec in [**Month (only) **] for a PET
positive lung nodule. Patient developed a biloma which was
accessed and drained with pigtail catheter back in [**Month (only) 359**] of
[**2186**]. Drain has been replaced a few times over the past months.
He has continued to put out about 120cc/day of greenish fluid
from the catheter. A frank communication between the segment
II/III biliary radicles in the perihepatic collection were
found, with dense opacification of the biliary system. He
underwent cholangiogram on day of admission which demonstrated
leakage from the left hepatic duct into the perihepatic
collection.
He then underwent successful placement of an 8 French
transhepatic internal-external biliary drain placed with the tip
in the perihepatic collection and the side holes withing the
left hepatic duct. This catheter was left open to an external
bag.
In the post-procedure period the patient developed fever to 103
and rigors. he immediately received Vanco and Zosyn and fluid
resuscitation.
In addition he required adjustemnt to the Foley catheter in
response to concern for low urine outputs, which were deemed to
be from Foley malfunction.
Cultures from the drain fluid grew Enterobacter and Pseudomonas
for which he received a total of 5 days antibiotic coverage.
Blood cultures were no growth at 4 days. Urine culture was
negative as was the stool C diff.
Patient remained afebrile after the first day, was tolerating
diet and ambulating in the [**Doctor Last Name **].
He will discharge home on no IV or PO antibiotics. He will
complete the final 3 days of PO Vanco for C diff prophylaxis and
has followup scheduled with Dr [**Last Name (STitle) **].
Medications on Admission:
Tylenol prn, Lipitor 10', Fe 325', fluticasone 50 mcg [**Hospital1 **],
Toprol XL 25', Gleevec 400', Pro-Bionate
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days.
5. Gleevec 400 mg Tablet Sig: One (1) Tablet PO once a day.
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
7. Fluticasone 50 mcg/Actuation Disk with Device Sig: One (1)
Inhalation twice a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Continue if taking narcotic pain medication.
9. Pro-Bionate-C Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p cholangiogram and drain replacement following right hepatic
lobectomy, cholecystectomy and small bowel resection [**2186-5-22**] for
a primary metastatic GI Stromal Tumor; his course was
complicated by a bile leak, pneumonia, and bacteremia.
Discharge Condition:
Good
Discharge Instructions:
Please call Dr [**Last Name (STitle) 37914**] office at [**Telephone/Fax (1) 673**] if you experience
fever > 101, chills, nausea, vomiting, diarrhea, inability to
eat or take medications.
Monitor for increased abdominal pain, yellowing of skin or eyes.
Drain and record all drain output daily. Bring a copy with you
to the clinic visit with Dr [**Last Name (STitle) **]. Monitor drainage for changes
in drain output, (increased or completely stopped) as well as
foul odor to drainage.
Continue medications as prescribed for home
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-1-31**]
9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-1-31**] 9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2187-2-7**]
9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2187-1-30**]
|
[
"4019",
"2720"
] |
Admission Date: [**2121-9-7**] Discharge Date: [**2121-9-17**]
Date of Birth: [**2081-5-7**] Sex: F
Service:
ADMISSION DIAGNOSIS: Septic abortion.
DISCHARGE DIAGNOSES:
1. Septic abortion.
2. Respiratory failure acute.
3. Septic shock.
4. Acidosis.
5. Cardiomyopathy primary.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATION: Ciprofloxacin 500 b.i.d. for three
weeks.
HISTORY OF PRESENT ILLNESS: Patient is a 40-year-old gravida
6 para 5 0-0-5 at 17-6/7 weeks with an EDC of [**2121-2-8**], who
presents as a transfer from an outside hospital with an IUFD
diagnosed the day of transfer. She is also noted to have a
temperature of 105, headache, which did not resolve with
Tylenol, shaking chills. Head CT and LP that were performed
were within normal limits. White count was 9.7 with 34%
bands and 35 hematocrit. She was noted to be A- blood type.
She is [**Location 7972**] and Portuguese speaking only. Having
difficulty communicating.
Initial visualization of the patient revealed difficulty
breathing and has been afebrile since 5 p.m. getting Rocephin
1 gram x2 IV, clindamycin 900 IV, and gentamicin 150 IV.
Patient was noted to be feeling contractions and having
increased vaginal bleeding. Vaginal bleeding began the day
of transfer status post lumbar puncture. She received 5
liters IV fluids and was noted to have minimal urine output.
She was transferred to [**Hospital1 69**]
for further care.
OB HISTORY: Significant for five normal vaginal deliveries
without complications.
GYN HISTORY: No abnormal Pap smears and no sexually
transmitted diseases.
PAST MEDICAL HISTORY: Negative.
PAST SURGICAL HISTORY: Negative.
MEDICATIONS:
1. Prenatal vitamins.
2. Tylenol.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She was married, lives in [**Country 3587**], and
visiting cousins in this country. She notably received
prenatal care and underwent amniocentesis three days prior to
this visit to the ED.
VITAL SIGNS ON ADMISSION: Her blood pressure was notably
87/48, which after an IV fluid bolus, this resulted to
110s/60s. Her heart rate was 128. Her O2 saturation was 87%
on room air, which improved to 98% on 15 liters nasal
cannula.
PHYSICAL EXAMINATION: She was noted to be having difficulty
breathing. She had rales bilaterally. She was tachycardic.
She had soft and tender abdomen, positive bowel sounds,
palpable contractions every 5-10 minutes. Extremities were
nontender with 2+ edema. Vaginal examination was 190 and
high. Transvaginal ultrasound confirmed IUFD.
Her laboratories were sent off at time of admission. A chest
x-ray was performed.
She is a 40-year-old gravida 6 para 5 0-0-5 at 17-6/7 weeks
with a diagnosis of IUFD and sepsis. She was started on
Zosyn 4.5 q.6h. and taken to the OR for a D&E. An a-line and
central line were placed. Chest x-ray to evaluate for
pulmonary edema and ARDS, and she was transferred to the MICU
after the operating room. Six units of packed red blood
cells, 4 units of FFP, and 6 pack of platelets were called
for.
Shortly thereafter initial examination at 9:45 p.m., patient
was noted to be having worsening decompensation. She was
intubated by the Anesthesia team. The vaginal examination
was repeated. She was found to be fully dilated. The
membranes delivered, a foul odor was noted. Delivery of a
stillborn fetus was accomplished. Twenty units of HIT were
given, 1,000 mg of Cytotec were given rectally. The cord was
clamped and cut and placenta was noted to be retained. She
was taken immediately to the OR for a D&C.
She underwent the D&C, and was transferred to the Medical
Intensive Care Unit after her D&C.
HOSPITAL COURSE:
1. Respiratory failure: She was maintained on ventilation
through hospital day one until hospitalization day three and
a half at which time she had been modified on the ventilator
settings to optimize her pulmonary condition. Chest x-rays
were repeated with at one point showed worsening, however,
there was concern that the chest x-ray was lagging behind her
clinical picture. She was extubated on hospitalization day
#4 and was without difficulty. She was maintained on nasal
cannula for her O2 saturation and maintained with improved
respiratory status throughout her hospitalization. She had a
chest x-ray two days after extubation on hospital day six,
which revealed overall improvement. She was weaned off her
nasal cannula, and her respiratory function improved
throughout her hospitalization.
2. Hypotension: She was noted to be hypotensive on arrival.
Pressor support was given while in the Intensive Care Unit.
On postoperative day four, hospitalization day four, she was
weaned off her pressor support and was able to maintain her
own blood pressure without difficulty. She improved
throughout her hospitalization and was not requiring pressor
support at the time of discharge.
3. ID: She had notable high bandemia upon arrival. She had
multiple cultures sent. Urine culture was negative. The
placenta was cultured and was found to have gram-negative
rods and PMNs. She had blood cultures that were positive for
E. coli. Throughout her hospital course, she came on
Rocephin, clindamycin, and gentamicin. She was changed to
Zosyn from [**9-7**] to [**9-10**] and then began a course of
levofloxacin on day six, on [**9-10**]. She was transferred out
of the MICU and was on levofloxacin. At the time of
discharge, she was converted to ciprofloxacin, which would
cover for E. coli and was discharged home with that on an
outpatient basis. She remains afebrile.
At the time of discharge, she did have a notably high white
count three days prior to discharge, so a CT was performed to
evaluate for abscess. She clinically appeared well. The CT
was read as negative for fluid collections or abscesses, and
she was discharged home on Cipro.
4. Cardiovascular system: She was noted to be high output
failure and a transthoracic echocardiogram was performed
initially at the time of admission and cardiac enzymes were
sent. At the time she was on pressors. Her first
transthoracic echocardiogram demonstrated she had severe
global left ventricular hypokinesis. No vegetations were
seen, but her ejection fraction was approximately 30%. She
had a repeat echocardiogram on the 15th, which showed a left
ventricular ejection fraction of 55%. Overall, as her fluid
status improved and sepsis resolved and her cardiac function
improved. There was a question of myocarditis related to
this, however, no evidence for cardiac infection was found on
any of her examinations. Her cardiac status improved and at
the time of discharge, she had no difficulty and was in
normal cardiac function.
5. Fluids, electrolytes, and nutrition: Initially, patient
was maintained NPO with IV fluids. Electrolytes were checked
on a frequent basis and repleted as needed. She was found to
be in metabolic acidosis which was resolved as her infection
cleared and as her overall general health improved, as needed
she was maintained.
She, on postoperative day four, after extubation and transfer
out of the Intensive Care Unit, she was maintained on a
regular diet and advanced as tolerated. She tolerated her
diet well and was doing well and was in stable condition.
6. GI: She notably had increased liver function tests
thought likely secondary to multisystemic organ injury
related to her shock. Her liver function tests were
monitored throughout her hospitalization and had been
decreasing at the time of discharge.
7. Psychosocial: Patient had met with social worker and
interpreters on multiple occasions during her hospitalization
to explain the events that had occurred over that period of
time. Emotional support had been provided to her throughout
her hospitalization and continually offered at the time of
discharge.
CONDITION ON DISCHARGE: The patient was discharged home in
stable condition.
FOLLOW-UP INSTRUCTIONS: She was to followup with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 724**], and she was discharged on [**2121-9-17**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 50722**]
Dictated By:[**Last Name (NamePattern1) 38853**]
MEDQUIST36
D: [**2121-10-6**] 14:57
T: [**2121-10-7**] 09:33
JOB#: [**Job Number 50723**]
|
[
"51881",
"2762",
"4280",
"2875",
"78552"
] |
Admission Date: [**2174-9-19**] Discharge Date: [**2174-10-21**]
Date of Birth: [**2136-7-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Intubation
Repeat Intubation
EGD
Bronchoscopy
Attempted Right Subclavian line placement
Placement of left IJ central line
Repeat placement of left IJ central line
History of Present Illness:
38 y/o F with hx. ETOH cirrhosis, mult osh admissions for
withdrawals and DTs (continues to drink 2 pints of Vodka daily)
and mult osh dicharges 'ama' was found by police 'down' and
intoxicated with multiple bruises. Brought to [**Hospital1 3793**], where she was noted to have an etoh level of 389 (at
1300h [**9-19**]), a bp of 75/44 (up to 124 sbp s/p 3 litres NS), LUL
infiltrate and ? mediastinal pathology; Head CT: showing no
acute pathology, brain atrophy, bilateral maxillary air fluid
levels.
Stated that she had not been eating or drinking for weeks
(except vodka). The hospitalist there saw her, felt that she
needed ERCP (due to a hypoechoic mass of the pancreas seen under
his care there one month previously for a similar admission).
They gave her CTX/Azithro, lactulose, 10 of KCl IV, and
transferred her here "for ERCP".
On arrival at our ED, she was noted to be diffusely rhonchorous,
satting in the 80's, adamantly refusing foley, rectal exam. had
"coffee ground emesis" on her shirt, but denied vomiting. She
had mult bruises apparent. She was put on a NRB and was
persistently tachy to the 130's (133 94/65 18 94% NRB). She
then had a melanotic stool per the ED (approx 200 cc, guaiac
pos), and protonix was started. She was intubated. An OGT was
placed. GI was called per the ED resident, and suggestion was
made to call the Liver team. Liver recommended Octreotide gtt,
and this was started. She was given 4 mg ativan and ptopofol
was up titrated for agitation/tremulousness to 40 mcg/kg/min and
she was sent to CT for head and torso scans en route to the
TSICU under the MICU Green service.
Notable initial labs in our ED:
K:3.0
Lactate:4.4
Ammonia: 60
Serum EtOH 239
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
Past Medical History:
ETOH abuse (ongoing) with hx. mult admissions, w/d Sz./DT
Hypoechoic area on pancreas noted on abd. U/S at osh [**7-20**] -
refused w/u
Depression
Asthma
Tobacco use
Thrombocytopenia attributed to alcoholism and liver disease in
records from osh, but plts normal here
ETOH hepatitis
Social History:
Has 3 kids, all minors
No hx. IVDU per boyfriend
Chronic ETOH, drinks 2 pints vodka daily
Family History:
Unknown
Physical Exam:
100 114 112/67 21 100% on FiO2 of 1.0
Vent: AC 20X500 Peep 5 FiO2 1.0 Peak 37 plat 26
Sedated, but grimacing, writhing in bed, tremulous
Sclerae jaundiced, pupils equally round, sluggishly reactive
No JVD or LAD
Skin dry
Tachy, reg, no MRG
Diffusely rhonchorous with wheezing
Abdomen distended, hepatomegaly, bowel sounds present
No edema or rash
Moves all four estremities
Foley in place
3 PIV's in UE's
Discharge physical examination
T 98 P90-110 BP150s/70s R12-20
PSV 14/5 FiO2 0.4 98-100%
Gen- Up in chair, awake, alert
HEENT- mild scleral icterus, PERRLA, EOMI, moist mucus membrane,
trach site intact
CV- regular, no r/m/g
RESP- clear bilaterally
ABDOMEN- soft, distended, nontender, normal bowel sounds, G tube
site intact
EXT- no edema
Pertinent Results:
Admission Labs:
[**2174-9-19**] 06:40PM PT-14.5* PTT-34.3 INR(PT)-1.3*
[**2174-9-19**] 06:40PM PLT SMR-NORMAL PLT COUNT-201 LPLT-1+
[**2174-9-19**] 06:40PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2174-9-19**] 06:40PM NEUTS-92.7* BANDS-0 LYMPHS-4.8* MONOS-1.6*
EOS-0.4 BASOS-0.6
[**2174-9-19**] 06:40PM WBC-15.3* RBC-2.91* HGB-11.3* HCT-31.6*
MCV-109* MCH-38.9* MCHC-35.9* RDW-18.8*
[**2174-9-19**] 06:40PM ASA-NEG ETHANOL-239* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2174-9-19**] 06:40PM AMMONIA-60*
[**2174-9-19**] 06:40PM ALBUMIN-2.6* CALCIUM-6.7*
[**2174-9-19**] 06:40PM LIPASE-78*
[**2174-9-19**] 06:40PM ALT(SGPT)-131* AST(SGOT)-478* ALK PHOS-313*
AMYLASE-56 TOT BILI-14.1*
[**2174-9-19**] 06:40PM GLUCOSE-86 UREA N-6 CREAT-0.4 SODIUM-127*
POTASSIUM-3.2* CHLORIDE-82* TOTAL CO2-28 ANION GAP-20
[**2174-9-19**] 07:00PM LACTATE-4.4* K+-3.0*
Pertinent Labs/Studies:
.
Imaging:
[**2174-9-19**]: CT Head
1. No intracranial hemorrhage or mass effect is identified.
2. There is prominence of the ventricles and sulci, which is
slightly unusual in a patient of this age, and is consistent
with cerebral atrophy.
3. Fluid within the sphenoid sinus is likely related to
patient's intubation.
.
[**2174-9-19**]: CT C/A/P
1. Endotracheal tube tip within the right bronchus intermedius
with
associated bilateral upper lobe atelectasis. This was discussed
with Dr. [**Last Name (STitle) **] at the time of the examination.
2. Enlarged, fatty liver consistent with the patient's given
history of liver disease.
.
[**2174-9-21**]: Abdominal US - IMPRESSION: No evidence of ascites.
.
[**2174-9-26**]: Echocardiogram (TTE)
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.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
[**2174-9-29**]: CT C/A/P
1. Patent mesenteric vasculature. No significant bleeding
source identified.
2. Patchy opacities, most prominently involving the upper
lobes. Given the recent bilateral upper lobe collapse, this
most likely represents reexpansion edema.
3. Markedly enlarged fatty attenuation liver.
4. Severe anasarca.
.
[**2174-9-29**]: CT Sinus - IMPRESSION: Fluid within the sphenoid and
ethmoid sinuses, which may be secondary to intubation. Mild
sinus mucosal thickening.
.
[**2174-10-9**]: CT A/P -
1. Possible thickening in the upper cecum and ascending colon.
This
appearance is difficult to evaluate due to underdistension, but
there is
apparent stratification of the wall which is also suspicious for
colitis.
2. Increased ascites since the prior study. This may be due to
an edematous state, but can also be seen in infectious colitis.
3. Improved upper lobe opacities in the lungs.
4. Left lower lobe collapse. This was discussed with Dr. [**First Name (STitle) 3037**]
at 11 pm on the same day.
5. Fatty infiltration of the liver.
.
[**2174-10-10**]: Portable CXR
FINDINGS: Upright radiograph of the chest. Endotracheal tube
is identified with its tip approximately 4.5 cm from the carina.
Left-sided internal jugular line is seen with its tip unchanged
in position and overlying the upper to mid SVC.
Cardiomediastinal silhouette is unchanged. Left retrocardiac
density representing atelectasis Vs. airspace disease appears
stable. Some improvement in the right basilar atelectasis is
noted. No pleural effusion or pneumothorax is identified.
Nasogastric tube is identified with its proximal side port below
the diaphragm.
IMPRESSION: Stable left retrocardiac density representing
atelectasis Vs.
airspace disease.
.
.
PROCEDURES:
EGD- no bleeding etiology
.
.
MICROBIOLOGY
Blood cultures:
[**2174-10-4**]: 1/4 bottles VRE
[**2174-10-5**]: 1/4 bottles VRE
[**10-6**]; [**10-7**]; [**10-9**]: NGTD
[**10-6**] to [**2174-10-18**]: NGTD
.
Urine Cultures:
[**2174-10-3**]: > 100K Yeast
[**2174-10-7**]: > 100K Yeast
.
Sputum Cultures:
[**2174-9-20**] to [**2174-10-8**]: Multiple cultures growing yeast, no
bacterial growth
.
BAL:
[**2174-10-2**]: cultures negative including fungal, AFB, PCP,
[**Name Initial (NameIs) 14616**]
[**2174-10-2**]: Viral screen - cultures growing HSV-I
.
Stool:
[**9-20**] - [**2174-10-8**]: C. Diff negative x 5
.
[**2174-10-9**] CMV Ab - negative
Brief Hospital Course:
The patient is a 38 year old female with history of chronic
significant alcohol abuse who was found down, intubated in the
E.D. [**12-16**] respiratory distress with course complicated by sepsis.
.
#. Respiratory Failure
The patient was initially seen in the E.D. able to answer
questions, but decompensated shortly thereafter requiring
intubation for airway protection and hypoxia. The patient was
admitted to the MICU on a vent. After initial treatment for
potential Sepsis with Levo, Flagyl, and Aztreonam the patient
was extubated.
However, the patient developed significant tachypnea and
respiratory distress requiring repeat intubation. Imaging at the
time of repeat intubation demonstrated likely volume overload
vs. less likely an early ARDS like pattern. Despite completion
of antibiotics for potential VAP there has been considerable
difficulty weaning the patient from the ventilator. Imaging has
revealed intermittent lobar collapse and re-expansion and
Bronchoscopy did not reveal any bronchial lesions or
obstruction. Multiple sputum cultures performed have revealed
only growth of yeast. BAL performed on [**2174-10-2**] revealed no
bacterial growth but did demonstrate HSV-I growth on viral
culture, for which acyclovir therapy was started on [**2174-10-10**].
The patient was initially thought to be volume overloaded given
her need for aggressive volume resuscitation on admission.
However, weaning from the vent has been limited despite adequate
diuresis. Difficulty to wean was also attributed to muscle
deconditioning and her persistent agitated state.
Patient eventually had tracheostomy/PEG tube on [**10-12**]. This was
complicated by bleeding as discussed below. She completed
treatement of VAP with levo/flagyl. SHe started autodiuresing
with intermittent help from lasix and her CXR became clear.
Scheduled nebs and fluticasone were started with good effect.
She also completed 3 days course of solumedrol for acute
wheezing episode. On discharge, she tolerated intermittent
courses of PSV on [**3-18**].
.
#. ID - Given the patient's respiratory distress on admission,
the patient was initially treated with Levo/Flagyl for potential
aspiration PNA. Given rising WBC and Lactate as well as
hypotension, Vancomycin and Aztreonam was additionally added
empirically for extended spectrum in the setting of likely
Sepsis. Stress dose steroids were initiated but discontinued
when labs were not consistent with Adrenal insufficiency. Given
persistent fevers and interstitial pattern on plain films,
Azithromycin was additionally added for atpyical coverage. The
patient completed a [**8-27**] day course of anti-biotics but again
developed fevers and rising WBC for which a course of Flagyl was
started for possible C. Diff colitis. Blood cultures from
[**2174-9-3**] subsequently grew VRE for which the patient has been
started on a course of Linezolid. As above, cultures from BAL
performed on [**2174-10-2**] demonstrated no bacterial growth but viral
cultures have subsequently revealed HSV-I for which treatment
with acyclovir has been started for potential HSV-I PNA.
In summary, besides +VRE(which she received full course of
Linezolid) and +HSV on BAL(which she received treatment dose of
acyclovir), all other cultures(blood, urine, sputum, stool) had
not demonstrated any growth since admission. She does
occasionally have low grade temperature of 100 which resolves
spontaneously. Her hemodynamics had remained stable.
.
#.Bleeding -
On admission from the E.D. the patient was reported to be
experiencing recent hematemesis with what appeared to be coffee
ground material on her shirt. After intubation the patient
underwent EGD which revealed a fragment of a tooth near the
vocal cords but demonstrated no significant esophageal varices
and revealed no evidence for recent UGI bleeding. The patient
was guaiac negative and initially had no clinical episodes of GI
bleeding during her hospitalization.
Later in her course the patient experienced significant oral
mucosal bleeding from oral lesions requiring multiple PRBC
transfusion and FFP. ENT packed it multiple times. Oral mucosal
bleeding eventually stopped after ETT changed to tracheostomy.
Post tracheostomy, this was complicated by bleeding from trach
site and new subclavian site that required multiple [**2-17**] unit of
PRBC transfusion, 4u FFP, 4u cryoprecipitate and also 24hours of
Amicar. Bleeding eventually stopped and her hematocrit had been
stable since then. All the coagulation and DIC studies have
remained normal. Hematology was consulted but could not figure
out the etiology of her bleeding.
.
# sedation/agitation
Agitation thought to be due to anxiety, delirium and
encephalopathy. She required high dose fentanyl/versed drip
initially. This was weaned off to standing and tapering doses of
fentanyl patch and valium after her acute issues were settles.
On discharge, she was doing well and sitting up in chair.
.
#. Alcoholic Hepatitis/Cirrhosis - On admission the patient had
abdominal imaging revealing the liver to be enlarged and with
fat infiltration but not definitively cirrhotic. No ascites was
present on multiple abdominal imaging studies. On admission the
patient had a MELD score of 19 with subsequent worsening
synthetic function, rising INR and bilis during this admission.
The patient was maintained on Lactulose and rifaximin and was
ultimately started on Pentoxyfilline for acute alcoholic
hepatitis given desire to avoid steroid treatment in the setting
af acute infection. Her liver function test improved throughout
hospital stay.
# prophylaxis
Patient was maintainted on GI prophylaxis and pneumoboots. No
heparin was given because of her bleeding tendency.
# access:
Her central line and A line was pulled on discharge. She had not
required IV medication for days leading up to discharge
# nutrition
Patient remained on Tube feeds and tolerated that well.
# communication
Daily plans have been communicated to patient's sister and
mother. [**Name (NI) **] will remain full code and go to rehab for
ventilatory wean.
Medications on Admission:
(patient reported to be non-compliant)
Advair
Albuterol
Dilantin
Prozac
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup [**Name (NI) **]: Thirty (30) ML PO TID (3
times a day).
2. Rifaximin 200 mg Tablet [**Name (NI) **]: Two (2) Tablet PO TID (3 times a
day).
3. Folic Acid 1 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily).
4. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet [**Telephone/Fax (3) **]: Two
(2) Packet PO BID (2 times a day).
5. Thiamine HCl 100 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO DAILY
(Daily).
6. Ursodiol 300 mg Capsule [**Telephone/Fax (3) **]: One (1) Capsule PO TID (3 times
a day).
7. Albuterol 90 mcg/Actuation Aerosol [**Telephone/Fax (3) **]: Six (6) Puff
Inhalation Q4H (every 4 hours).
8. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Telephone/Fax (3) **]: Six (6)
Puff Inhalation Q6H (every 6 hours).
9. Fluticasone 110 mcg/Actuation Aerosol [**Telephone/Fax (3) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: to skin 12 hrs on then 12 hrs off .
12. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: Two (2) Tablet,
Rapid Dissolve PO BID (2 times a day).
13. Fentanyl 50 mcg/hr Patch 72HR [**Hospital1 **]: One (1) Patch 72HR
Transdermal Q72H (every 72 hours): please wean as tolerated.
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. Diazepam 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours): wean as tolerated.
16. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: 1-2 mg Injection every [**2-17**]
hours as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. respiratory failure, failure to wean from ventilator post
tracheostomy [**10-12**]
2. bleeding tendency, believed to be from her liver disease, no
definitive etiology
3. hypertension
4. anxiety
5. aloholic hepatitis
6. depression
Discharge Condition:
stable, trach
Discharge Instructions:
PLease return to the hospital or call your doctor if you have
bleeding, shortness of breath, fever, chills, chest pain or if
there are any concerns at all
Followup Instructions:
1. Please follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 70247**]
within 2 weeks of your discharge from rehab.
2. PLease call([**Telephone/Fax (1) 1582**] to set up appointment at the liver
center.
Completed by:[**2174-10-21**]
|
[
"4280",
"5180",
"5070",
"2760",
"99592"
] |
Admission Date: [**2152-7-24**] Discharge Date: [**2152-7-28**]
Date of Birth: [**2152-7-24**] Sex: F
Service: NB
DATE OF INTERIM: [**2152-7-27**].
HISTORY OF PRESENT ILLNESS: This interim dictation covers
from [**7-24**] through [**2152-7-27**]. Baby Girl [**Name2 (NI) **] [**Known lastname 1968**] is a now
three day old, ex 28 and [**2-5**] weeker, corrected gestational
age of 28 and [**6-5**], who was born to a 33 year old, A positive,
antibody negative, hepatitis B surface antigen negative, GBS
unknown, RPR nonreactive Mom.
Prenatal history was remarkable for IVF pregnancy with di/di
twinning and cervical shortening. The cervical shortening
required admission at 23 weeks and placement of a cerclage.
Mom had chronic treatment with Magnesium sulfate and received
a full course of Betamethasone. The morning of delivery,
there was spontaneous rupture of membranes at the time of
onset of contractions. With breech presentation, this
necessitated delivery by cesarean section.
This infant was vigorous at resuscitation with Apgars of
seven and eight. She had moderate evidence of respiratory
distress with grunting, flaring and contractions. She was
intubated in the DR [**First Name (STitle) **] [**Name (STitle) **] Protocol with administration of
prophylactic Surfactant. She subsequently was transferred to
the Neonatal Intensive Care Unit for further care.
PHYSICAL EXAMINATION: Birth weight 1115 grams. Head
circumference 26 cm. Length 37.5 cm. General: Small
infant, appropriate appearance for gestational age. HEAD,
EYES, EARS, NOSE AND THROAT: Anterior fontanel open and
soft. Normal facies. Non dysmorphic. Respiratory: Mild
retractions with fair entry, on ventilatory support.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2,
no murmur present. 2 plus pulses in the lower extremities.
Abdomen: Nontender, nondistended, soft. NO masses or
hepatosplenomegaly. Genitourinary: Normal external
genitalia. Extremities: Stable, warm and well perfused.
Neurologic: Tone and activity appropriate for gestational
age.
HOSPITAL COURSE: Respiratory: As mentioned above, the
patient was intubated and DR [**First Name (STitle) **] [**Name (STitle) **] protocol. She received a
dose of Surfactant and remained ventilated until six hours of
life. At that time, she was extubated to C-Pap and has been
quite stable since on low FI02. Originally, she was
requiring approximately 30 percent FI02 but most recently has
been on room air. This patient is also on caffeine for apnea
of prematurity but has minimal spells.
Cardiovascular: This infant had early concern for
hypotension, requiring normal saline boluses and a brief
course of Dopamine. Ultimately, she only received about two
hours of Dopamine, after which her blood pressure issues
resolved. At present, she has been hemodynamically stable
without any concerns of murmur.
Fluids, electrolytes and nutrition: This patient has had
significant weight loss with current weight being down
approximately 17 percent from birth weight. She has been
advanced on fluids aggressively for this concern. She
currently is on 150 cc per kg per day with PN and
intralipids. In addition, we started trophic feeds today at
10 cc per kg per day. Most recent electrolytes show a
concern for hypernatremia with a sodium of 156. Intention
was for these to be redrawn this afternoon.
Gastrointestinal: Infant has mild hyperbilirubinemia and is
currently on one light phototherapy for a bilirubin of 7.8
yesterday. This laboratory is to be followed up this
afternoon.
Hematology: Admitting CBC with a hematocrit of 40.9 and
platelet count of 281.
Infectious disease: Infant had a low white count at delivery
of 4.4 with 29 percent polys and 0 bands. Follow-up CBC was
more reassuring with a white count of 6.6 with 66 percent
neutrophils. Infant has received a full 48 hour course of
antibiotics with negative cultures. She is now off
antibiotics and doing well.
Social: A family meeting has been held and parents are up to
date.
INTERIM DIAGNOSES: Premature infant at 28 and [**2-5**] week
gestation, twin II.
HMD, status post Surfactant.
Hypotension, resolved.
Hyperbilirubinemia.
Rule out sepsis, negative.
Hypernatremia.
Apnea of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern4) 55784**]
MEDQUIST36
D: [**2152-7-28**] 01:31:17
T: [**2152-7-28**] 05:37:56
Job#: [**Job Number **]
|
[
"7742"
] |
Admission Date: [**2195-6-8**] Discharge Date: [**2195-6-11**]
Date of Birth: [**2195-6-8**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**Known lastname 402**] [**Known lastname **] is the former
2.54 kg product of a 36 week gestation pregnancy born to a
24-year-old G4, P2 to 3 Asian woman. Prenatal screens:
Blood type O+, antibody negative, Rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group Beta
antibody positive. The pregnancy was uncomplicated. The
infant was born by repeat cesarean section, had Apgars of 7
at 1 minute and 8 at 5 minutes. She was admitted to the
Neonatal Intensive Care Unit for respiratory distress.
After resolution of resp distress she was transferred to the
Newborn nursery. She was seen in NICU again for car seat test.
Was initailly unable to pass [**Known firstname **]s and had several desaturations
PHYSICAL EXAM:
VITAL SIGNS: Upon admission to the Neonatal Intensive Care
Unit, weight 2.54 kg, length 47.5 cm, head circumference 31.5
cm.
GENERAL: Non dysmorphic Asian infant with mild grunting,
flaring and retracting.
HEAD, EARS, EYES, NOSE AND THROAT: Anterior fontanele level
and flat, symmetric facial features. Positive red reflex
bilateral. Palate intact.
CHEST: Clear to auscultation, good air entry.
CARDIOVASCULAR: Regular rate and rhythm, no murmur. Femoral
pulses +2.
ABDOMEN: No masses.
GENITOURINARY: Normal female.
NEUROLOGIC: Age appropriate tones and reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. RESPIRATORY: The grunting and retracting resolved within
a few hours of birth. Infant remained at room air throughout
her entire Neonatal Intensive Care Unit admission. At the
time of discharge, she was breathing 30s to 50s with O2
saturations greater than 95% in room air. She did not have
any episodes of spontaneous apnea. FOllowing observation in the
NICU after her initail car seat test, patient did well with
feeds, temp control and resp control. She is discharged home
after passing repeat car seat test.
2. CARDIOVASCULAR: No murmurs were noted during the
admission. [**Known lastname 402**] maintained normal heart rates and blood
pressures.
3. FLUIDS, ELECTROLYTES AND NUTRITION: [**Known lastname 402**] required
treatment for [**Known lastname 25194**]. Her initial glucose was 44. Her
low blood glucose had cleared on day of life #2 at 37. She
was treated with intravenous 10% dextrose solution. She was
able to totally wean off by approximately 48 hours of age.
She maintained on po feedings of Enfamil 20 calories per
ounce. At the time of discharge, her glucoses were 6280 on
every three hour feeds. Her weight on the day of transfer is
2.4 kg.
4. INFECTIOUS DISEASE: Due to her prematurity, the unknown
group B strep status and the initial respiratory distress,
[**Known lastname 402**] was evaluated for sepsis. Her white blood cell
count was 15,200 with 53% polys, 3% bands. Her blood culture
was no growth at 48 hours. She was not treated with
antibiotics.
5. GASTROINTESTINAL: Initial serum bilirubin on day of life
#2 totaled over 0.2 direct. Repeat on day of life #3 was
12.5, total over 0.3 direct.
6. NEUROLOGIC: [**Known lastname 402**] maintained a normal neurological
exam throughout admission.
TRANSFER CONDITION: Good
DISCHARGE DISPOSITION: Transfer to the newborn nursery.
Primary pediatric coverage will be through the [**Hospital3 9732**], [**State 14091**], [**Location (un) 86**] [**Numeric Identifier 41651**]. Phone number ([**Telephone/Fax (1) 41652**].
CARE AND RECOMMENDATIONS: At the time of [**Known firstname **]s discharge,
feeding Enfamil 20 every three hours ad lib. No medications.
Car seat position screening testing recommended prior to
discharge. State newborn screen was sent on day of life #3
with no notification of abnormal results to date. Hepatitis
B vaccine ordered prior to discharge.
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: a) born at less than 32 weeks, b) born between 32
and 35 weeks with plans for daycare, during RSV season, with
a smoker in the household or with preschool siblings, c) with
chronic lung disease. 2. Influenza immunization should be
considered annually in the fall for preterm infants with
chronic lung disease once they reach six months of age.
Before [**Known firstname **]s age, the family and other caregivers should be
considered for immunization against influenza to protect the
infant.
DISCHARGE DIAGNOSES:
1. Prematurity at 36 weeks gestation
2. Transitional respiratory distress
3. Suspicion for sepsis ruled out
4. [**Known lastname **]
5. Unconjugated hypobilirubinemia
[**Name6 (MD) **] [**Name8 (MD) 352**] m.d. [**MD Number(1) 36143**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2195-6-12**] 07:43
T: [**2195-6-12**] 07:56
JOB#: [**Job Number **]
|
[
"7742",
"V053",
"V290"
] |
Admission Date: [**2153-12-23**] Discharge Date: [**2153-12-23**]
Date of Birth: [**2120-12-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
cough, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname **] is a 32 yo woman with no PMH who presented to the ED
with three days of cough and fever. She reports that her cough
was non-productive and that she had no hemoptysis.
She saw her PCP on the day of presentation, who prescribed her
azithromycin. After taking the first dose, however, she had
three loose stools, and so she presented to the [**Hospital1 18**] ED.
In the ED, her initial VSs were 102.2, 148, 130/79 18 98% on RA.
She received 4 L NS and levofloxacin 750 mg IV and was
transferred to the [**Hospital Unit Name 153**] for futher care.
In the [**Hospital Unit Name 153**], her only other complaint is of some mild chest pain
with coughing.
Past Medical History:
None
Social History:
denies tobacco, alcohol, drug use
Family History:
non-contributory
Physical Exam:
Vitals: T: 99.5 BP: 104/79 P: 98 R: 15 SaO2: 96% RA
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: no scleral icterus, MMM, no lesions noted in OP
Neck: supple, no significant LAD
Pulmonary: left lower lung field crackels, no wheezes or ronchi
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Pertinent Results:
[**2153-12-22**] 11:20PM WBC-3.4* RBC-3.79* HGB-11.4* HCT-33.1* MCV-87
MCH-30.1 MCHC-34.4 RDW-13.0
[**2153-12-22**] 11:20PM NEUTS-47* BANDS-46* LYMPHS-6* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2153-12-22**] 11:20PM PLT COUNT-161
[**2153-12-22**] 10:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2153-12-22**] 10:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2153-12-22**] 10:10PM URINE RBC-[**3-5**]* WBC-[**3-5**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2153-12-22**] 11:20PM GLUCOSE-125* UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12
[**2153-12-22**] 11:48PM LACTATE-2.4*
[**2153-12-23**] 02:36AM LACTATE-1.3
[**2153-12-23**] 11:56AM WBC-4.9 RBC-3.55* HGB-10.4* HCT-31.0* MCV-87
MCH-29.2 MCHC-33.5 RDW-12.7
[**2153-12-23**] 11:56AM NEUTS-78* BANDS-11* LYMPHS-10* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2153-12-23**] 11:56AM PLT COUNT-129*
[**2153-12-22**] Chest Xray: Left lower lobe pneumonia.
Brief Hospital Course:
Ms. [**Known lastname **] is a 32 yo woman admitted with LLL pneumonia and evidence
of systemic inflammatory response on admission with hypotension,
fever, bandemia.
1)Left lower lobe pneumonia: Seen on chest xray, responded well
to initiation of IV antibiotics and IV fluids. Initially she
had a bandemia which improved on repeat following antibiotics.
She remained afebrile on the day of admission with stable blood
pressure. She had no respiratory distress and had a low PORT
score. She was discharged on the day of admission to complete a
7 day course of levofloxacin 750mg po. She was instructed to
follow up with her primary care doctor in [**1-2**] weeks and to
return to the hospital if her symptoms do not continue to
improve.
2)Hypotension - she was transiently hypotensive in ED with SBP
80's-90's, unclear baseline blood pressure. She was given 4L NS
and remained normotensive with resolution of tachycardia.
Hypotension likely due to early systemic inflammatory response
which resolved with IV levofloxacin.
3) Code status: FULL CODE
Medications on Admission:
none
Discharge Medications:
1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days: Please take all of this prescription. Do not stop
early even if you are feeling better. .
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower lobe pneumonia
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital because you have a bad
pneumonia which caused low blood pressure and high fever. You
were treated with antibiotics and intravenous fluids.
It is very important that you take the antibiotics as prescribed
for a total of 7 days to treat the pneumonia.
You should follow up with your primary care doctor within [**1-2**]
weeks to be sure that the pneumonia is fully treated and to have
a repeat chest xray.
You should call your doctor or go to the emergency department if
you experience fever >100.4, light headedness or fainting,
worsening cough or any other concerning symptoms.
Followup Instructions:
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment
to follow up within 1-2 weeks.
|
[
"0389",
"486"
] |
Admission Date: [**2112-10-8**] Discharge Date: [**2112-10-12**]
Date of Birth: [**2048-1-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
"I drank too much."
Major Surgical or Invasive Procedure:
Intubation
Lumbar puncture
History of Present Illness:
45yo M with a history of alcoholism who presents after 6 days of
alcohol binge drinking. Mr. [**Name13 (STitle) 84342**] recently returned from
[**Country 7192**] on [**2112-10-2**] where he had "many problems." Upon return,
he began to drink beer, rum, liquor, and rubbing alcohol
incessantly. He did not eat all week. During that time, he
described himself as "like crazy." According to family members,
he continued to demand more alcohol and was "getting worse," so
2 cousins brought him to the Emergency Department for evaluation
on [**2112-10-7**]. He had mild abdominal pain from "drinking too
much." Mr. [**Name13 (STitle) 84342**] reports being sober for 5 years, but his wife
denied that, saying that he has been hospitalized at [**Hospital 8**]
Hospital for alcoholism and has frequent relapses during which
he drinks for 1-2 weeks at time.
Past Medical History:
s/p ex-lap for gunshot wound
Social History:
Lives at home with wife. Travels frequently between US and
[**Country 7192**] (spends winter months in [**Country 7192**]). Works in
landscaping (lawn-mowing) and as a janitor. Has 28yo married
son. [**Name (NI) **] been alcoholic since adulthood. Denies smoking history
or recreational drug use.
Family History:
Mother recently passed away in traffic accident in [**Country 7192**].
Did not know his father. [**Name (NI) **] multiple siblings in reportedly
good health. No other known alcoholics in family.
Physical Exam:
VS: 98 92 140/93 18 96%RA
General: somewhat desheveled-appearing man with poor denition
lying in bed, excited to converse, NAD
Skin: no rashes
HEENT: normocephalic, atraumatic, injected conjunctivae, PERRLA,
moist mucous membranes, no oropharyngeal lesions, supple neck,
no cervical/supraclavicular LAD
Cardiac: RRR, normal S1, S2, no murmurs, rubs, gallops
Pulm: CTAB, good air entry to bases
Abd: well healed scar adjacent to midline, +bs, soft, nontender,
nondistended
Ext: warm, well perfused, strong dp/pt pulses, no edema, no
asterixis
Neuro: A+Ox3, CNII-XII intact, moves all 4 extremities to
command, no focal deficits
Pertinent Results:
ADMISSION LABS [**2112-10-8**]:
BLOOD
[**2112-10-8**] 12:25AM WBC-8.6 Hgb-14.0 Hct-39.4* Plt Ct-198
[**2112-10-8**] 12:25AM Neuts-71.8* Lymphs-21.9 Monos-5.8 Eos-0.3
Baso-0.2
[**2112-10-8**] 12:25AM Glucose-144* UreaN-10 Creat-1.2 Na-135 K-3.4
Cl-97 HCO3-23 AnGap-18
[**2112-10-8**] 12:25AM ALT-116* AST-195* LD(LDH)-516* AlkPhos-66
TotBili-0.7
[**2112-10-8**] 12:25AM Lipase-81*
[**2112-10-8**] 09:35PM Calcium-8.1* Phos-2.0* Mg-2.3
[**2112-10-8**] 12:25AM Osmolal-313*
[**2112-10-8**] 07:05AM Ammonia-23
[**2112-10-8**] 12:25AM ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2112-10-8**] 04:46AM Type-ART pO2-114* pCO2-39 pH-7.43 calTCO2-27
Base XS-2 Intubat-INTUBATED
[**2112-10-8**] 07:43AM Lactate-0.9
URINE
[**2112-10-8**] 02:30AM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2112-10-8**] 02:30AM Blood-MOD Nitrite-NEG Protein-30 Glucose-250
Ketone-150 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2112-10-8**] 02:30AM RBC-0-2 WBC-0 Bacteri-RARE Yeast-NONE Epi-0-2
[**2112-10-8**] 02:30AM bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
CSF
[**2112-10-8**] 06:45AM WBC-1 RBC-208* Polys-8 Lymphs-48 Monos-44
[**2112-10-8**] 06:45AM WBC-7 RBC-2925* Polys-61 Lymphs-25 Monos-14
[**2112-10-8**] 06:45AM TotProt-30 Glucose-87
[**2112-10-8**] 09:14AM HERPES SIMPLEX VIRUS PCR-negative
LFTs:
[**2112-10-8**] 12:25AM ALT-116* AST-195* LD(LDH)-516* AlkPhos-66
TotBili-0.7
[**2112-10-8**] 09:35PM ALT-108* AST-189* LD(LDH)-523* AlkPhos-59
TotBili-0.7
[**2112-10-9**] 03:39AM ALT-104* AST-165* AlkPhos-57 TotBili-0.8
[**2112-10-10**] 06:14AM ALT-96* AST-96* LD(LDH)-371*
[**2112-10-11**] 06:52AM ALT-92* AST-70* LD(LDH)-313* TotBili-0.8
MICROBIOLOGY:
[**2112-10-8**] CSF gram stain, fluid Cx - negative
[**2112-10-8**] BCx - negative
[**2112-10-8**] MRSA screen - negative
[**2112-10-8**] Influenza DFA - negative
[**2112-10-8**] Sputum Cx - sparse growth
[**2112-10-9**] RPR - non-reactive
STUDIES:
[**2112-10-8**] EKG - Sinus tachycardia. Left axis deviation. There is
a late
transition with tiny R waves in the anterior leads consistent
with possible prior anterior myocardial infarction
[**2112-10-8**] CT abd/pelvis -
1. No acute intra-abdominal or pelvic trauma.
2. Bibasalar atelectasis-consolidation may represent aspiration.
3. Fatty liver.
[**2112-10-8**] CT head -
No acute intracranial abnormality
[**2112-10-8**] CT C-spine -
No fracture or misalignment of the cervical spine. Evaluation
for
ligaments and cord is limited on CT and MRI is a better modality
to evaluate these structures
DISCHARGE LABS:
[**2112-10-10**] 06:14AM WBC-4.7 Hgb-14.1 Hct-41.1 Plt Ct-164
[**2112-10-10**] 06:14AM Glucose-102 UreaN-9 Creat-1.0 Na-138 K-3.8
Cl-101 HCO3-29 AnGap-12
[**2112-10-11**] 06:52AM ALT-92* AST-70* LD(LDH)-313* TotBili-0.8
Brief Hospital Course:
Mr. [**Name13 (STitle) 84342**] is a 64 year old man with h/o EtOH abuse for 50
years, presented to the hospital after 1 week of heavy drinking,
abdominal pain.
In the ED, Mr. [**Name13 (STitle) 84342**] was answering questions appropriately
initially, but then became febrile to 101, tachycardic to 130,
and progressively more delerious/agitated. He would initially
follow commands but was easily distracted and would try to get
out of bed. He did not have a tremor or focal neuro signs at any
time. Serum and urine tox were negative. Because of
distractability, he was intubated for CT head and LP. CT head
was negative and LP showed 200 RBCs, 1 wbc, glucose 87, protein
30. CT abdomen/pelvis for his abdominal pain showed bibasilar
consolidation, ED felt that he had likely aspirated
perintubation. He was given Ceftriaxone 2 grams for suspected
meningitis and levofloxacin for PNA as well as valium and a
banana bag. He remained hemodynamically stable, satting high 90s
on FiO2 48% and PEEP of 8. Blood cultures were drawn after Abx
administered.
In the MICU, he received acyclovir for possible HSV
encephalitis, levofloxacin/vancomycin for CAP. He was extubated
without difficulty. He was noted to be tachycardic, agitated,
and sweaty, so was given 75mg total of valium for suspected
withdrawal.
Upon arrival to the floor, Mr. [**Name13 (STitle) 84342**] was noted to be agitated
and easily distracted. He had increased energy and was seen
walking into other patients' rooms. He expressed great concern
about obtaining a letter for his employer about being in the
hospital for these missed days of work. Psychiatry evaluated the
patient and felt that he showed signs of mania. They were
uncomfortable sending him home on hospital day 3 without
contextualizing his behavior with his baseline. Upon further
evaluation, Mr. [**Name13 (STitle) 84342**] showed signs of Wernicke's
encephalopathy. He frequently confabulated stories to fit each
conversation. He exhibited bizarre behavior throughout his
hospitalization (exposing himself, lying on another patient's
empty bed, unable to report consistently his date of birth), but
his mental status improved overall. He was given IV thiamine
100mg for 5 days and discharged with PO MVI, thiamine, and
folate.
Medications on Admission:
None
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: Alcohol abuse, Wernicke's encephalopathy
Secondary diagnoses: malnutrition, dehydration
Discharge Condition:
Stable, baseline mental status
Discharge Instructions:
You were seen in the hospital for your alcohol abuse. Imaging of
your head showed no bleeding. Imaging of your abdomen showed a
fatty liver and possible signs of aspiration. Imaging of your
cervical spine showed no fracture. The labs did not indicate
that you had an infection, but you were given several
antibiotics to treat an infection that may not have showed up in
the labs. You were seen my Psychiatry who diagnosed you with
alcohol dependence and delirium secondary to alcohol dependence.
Due to your chronic alcohol abuse, you may have a condition
called "Wernicke's encephalopathy." There is no cure for this
condition. To stop this condition from getting worse, you should
stop drinking alcohol. Please continue to take a thiamine
supplement and eat healthy meals.
The following additions were made to your medications:
1. Please take a multivitamin, folate, and thiamine daily to
supplement your diet and keep you healthy
2. Please take Famotidine daily to help with your abdominal pain
If you have any signs of confusion, strange behavior, belly
pain, headache, difficulty remembering, chest pain, or shortness
of breath, please seek care immediately in the Emergency
Department.
Followup Instructions:
Please follow up at [**Hospital **] Health Center, located at [**Hospital1 84343**] [**Location (un) 686**], [**Numeric Identifier 12201**].
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Date/Time: [**2112-10-24**] 9am
Phone: [**Age over 90 7976**]
You can try calling the number for an earlier appointment.
Here are some other resources that may be helpful for you:
Latino Health Insurance Program
Contact: [**Name (NI) 20752**] [**Last Name (NamePattern1) **]
Phone: [**Telephone/Fax (1) 84344**] 2
She can help you get health insurance.
Substance Abuse Hotline
1-[**Telephone/Fax (1) 60237**]
Call this number if you ever feel like you need help with your
alcohol use. They can help you find ways to stop drinking
alcohol.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"5070"
] |
Admission Date: [**2171-8-22**] Discharge Date: [**2171-8-29**]
Date of Birth: [**2125-11-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Throat tightness
Major Surgical or Invasive Procedure:
[**2171-8-23**] - CABGx5 (Left internal mammary->Left anterior
descending artery, Saphenous vein graft(SVG)->Diagonal artery,
SVG->Obtuse marginal artery, SVG->Ramus artery, SVG->Posterior
descending artery)
History of Present Illness:
This 45-year-old patient with a 1-month history of chest
tightness was investigated and was found to have severe
triple-vessel disease with diminished
left ventricular function with an ejection fraction of about 35%
with inferior hypokinesia. He also had a moderate to left
mainstem lesion. Based on anatomy and findings, he was
transferred for urgent coronary artery bypass grafting.
Past Medical History:
CAD
Dyslipidemia
HTN
Social History:
Custodian. Smokes 1 cigarette daily. Lives with wife. Drinks 3
[**Name2 (NI) 17963**] per week. last dental exam was 2 months ago.
Family History:
Father with CABG at age 45
Physical Exam:
76 123/89 98.6 RA sat 100%
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM. No LAD.
LUNGS: CTA bilaterally
HEART: RRR, Nl S1-S2, No M/R/G
ABD: Soft, ND/NT/NABS
EXT:warm, well perfused, no bruits, no varicosities, No
peripheral edema
NEURO: No focal deficits.
Pertinent Results:
[**2171-8-22**] 04:35PM GLUCOSE-101 UREA N-10 CREAT-0.9 SODIUM-141
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-16
[**2171-8-22**] 04:35PM %HbA1c-6.3*
[**2171-8-22**] 04:35PM WBC-7.7 RBC-5.29 HGB-15.3 HCT-46.0 MCV-87
MCH-29.0 MCHC-33.3 RDW-13.4
[**2171-8-22**] 04:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2171-8-22**] 04:35PM ALT(SGPT)-25 AST(SGOT)-23 LD(LDH)-166 ALK
PHOS-65 TOT BILI-0.9
[**2171-8-22**] Carotid duplex ultrasound
No hemodynamically significant stenosis in the internal carotid
arteries bilaterally. This is a baseline examination at the
[**Hospital1 18**].
[**2171-8-23**] ECHO
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Moderate LV systolic dysfxn. Akinesis of inferior, infero-septal
and infero-lateral walls. Akinesis of apex.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**2-6**]+) mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
Patient is in SR on infusions of epinephrine and NTG.
The LV systolic fxn remains moderately depressed. The inferior,
lateral and infero-septal walls, and apex, are hypokinetic.
RV systolic fxn is preserved.
MR is 1+.
No AI. Aorta intact.
[**2171-8-24**] CXR
In comparison with study of [**8-23**], all tubes have been removed
except for the right IJ sheath. Specifically, no evidence of
pneumothorax. Low lung volumes accentuate the size of the heart
and fullness of the pulmonary vasculature. Some atelectatic
changes persist at the left base.
[**8-27**]:
PROCEDURE: CT head without contrast.
HISTORY: 45-year-old man with status post coronary artery bypass
graft.
Right-sided weakness with slurring of words. Please evaluate to
rule out
bleed.
TECHNIQUE: Contiguous axial images were obtained through the
brain. No
contrast was administrated.
COMPARISON: There are no previous studies for comparison done
before this CT.
FINDINGS: There is a hypodense area in the left side of the
pons,
representing acute infarct confirmed on MRI done subsequently.
There is no
evidence of edema, masses, and mass effect. The ventricles and
sulci are
normal in configuration and size. NO osseous lytic or sclerotic
lesions are
noted.
CONCLUSION: Hypodense area in left side of the pons,
representing acute
infarct confirmed on MRI done subsequently.
[**8-28**] echo:
Conclusions
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is top
normal/borderline dilated. There is mild to moderate regional
left ventricular systolic dysfunction with basal to mid inferior
and infero-lateral akinesis. There is a basal infero-lateral
aneurysm. No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. There is abnormal septal
motion/position. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**2-6**]+) mitral regurgitation is seen. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of [**2171-8-27**],
the LVEF has improved.
IMPRESSION: No intracardiac thrombus seen.
Brief Hospital Course:
Mr. [**Known lastname 79109**] was admitted to the [**Hospital1 18**] via transfer from [**Hospital1 **] for surgical management of his coronary artery
disease. He was worked-up by the cardiac surgical service in the
usual preoperative manner. A carotid duplex ultrasound was
obtained which showed no significant disease. On [**2171-8-23**], Mr.
[**Known lastname 79109**] was taken to the operating room where he underwent
coronary artery bypass grafting to five vessels. Please see
separate dictated operative note for details. Postoperatively he
was taken to the cardiac surgical intensive care unit for
monitoring. Within 24 hours, Mr. [**Known lastname 79109**] [**Last Name (Titles) 5058**] neurologically
intact and was extubated. Beta blockade, aspirin and a statin
were resumed. He was then transferred to the step down unit for
further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility.
The pt developed right sided weakness and slurred speech on the
morning of [**8-27**], POD 4. Neurology consult and subsequent workup
revealed acute embolic CVA in the left pons, confirmed by MRI.
The pt was treated with aspirin and statin as well as
anticoagulation. TEE and TTE were performed, intracardiac
thrombus was ruled out, and anticoagulation was discontinued.
Some improvements in motor function were made with physical
therapy. Additionally, speech improved within 24 hours. On
[**8-29**] he fell on his hip, grazing his head as he fell. No
hematoma was seen on his head and a subsequent wet read of a
head CT revealed no mass effect and no shift. He was seen in
consultation by physical therapy and was sent home with physical
therap, occupational therapy, speech tehrapy, skilled nursing,
and a nursing aide.
Medications on Admission:
Aspirin 81mg daily
Toprol XL 50mg daily
Zocor 40mg daily
TNG PRN
Discharge Medications:
1. Outpatient Physical Therapy
home physical therapy 5 times per week for two weeks with
transition to outpatient therapy when appropriate
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*60 Tablet(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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. 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*
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Ultram 50 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*1*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
CAD s/p CABGx5
Dyslipidemia
HTN
CVA
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 79110**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Follow-up with Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] (stroke neurologist) in [**3-10**]
months [**Telephone/Fax (1) 1694**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2171-8-29**]
|
[
"41401",
"4019",
"2724"
] |
Admission Date: [**2174-7-8**] Discharge Date: [**2174-7-11**]
Date of Birth: [**2133-6-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
DKA, hypotension
Major Surgical or Invasive Procedure:
cardiac catheterization [**2174-7-8**]
History of Present Illness:
Mrs. [**Known lastname 11818**] is a 41-year-old female with history of type 1 DM Type
1, coronary artery disease (CAD) s/p MI and cardiac
catheterization with bare metal stent to her left anterior
descending in [**2173-2-20**] who presented with acute onset of
nausea and vomiting at 8 AM this AM. She reports that she was
jogging at the time. In the [**Location (un) 620**], emergency department she
was found to have an elevated blood sugar of 420 with an anion
gap of 17. She had trace ketones in her urine. She was started
on an insulin drip for diabetic ketoacidosis. She was given IV
fluids and transferred to the [**Location (un) 620**] ICU.
.
At the [**Location (un) 620**] intensive care unit, she developed [**3-31**]
substernal chest pain radiating to her arms associated with
nausea and vomiting; her chest pain was similar to prior MI in
[**2173-2-20**]. She denied palpitations but did endorse the
sudden onset of dyspnea. She became diaphoretic; her systolic
blood pressure decreased to the 80s. In the first set of
cardiac enzymes, troponin was less than 0.01. Second set of
cardiac enzymes: CK of 137, MB of 1.2, index 0.9, troponin <
0.01. She was given 2 sublingual nitroglycerine which caused a
further decrease in her blood pressure without improvement of
her chest pain which continued to be [**3-31**] and substernal. Fluids
were started through two peripheral IV's (approx. 2.5 L). Her
SBP decreased to the low 70's and she was then started on
dopamine drip.
.
She was given morphine 0.5 mg for her chest pain. She was placed
on supplemental oxygen, 2 liters nasal cannula. EKG did not
reveal acute ST changes. She was transferred to [**Hospital1 771**] for cardiac catheterization on heparin
and integralin drip given her ongoing chest pain. (Initial
heparin bolus of 3600 units followed by 600 units per hour.
Initial integrelin bolus of 180 followed by 10 ml/hr.) She also
received 325 mg of aspirin PR but did not take Plavix as her
blood pressure decreased when she sat up. She was given a dose
of levofloxacin 500 mg IV. Blood cultures were not obtained
prior to transfer.
.
On review of systems, she reported a recent diagnosis of
hepatitis A in sister's child recently adopted from [**Country 4812**].
Pt. not previously tested for hepatitis but concerned recent
nausea, vomiting could be related. She denied weight loss,
fatigue, fever or chills, night sweats, visual changes, dry
mouth, chest pain, hematemesis, abdominal pain, diarrhea,
hematochezia, rashes, or weakness.
.
Past Medical History:
- DM, type I: dx 10y ago, on insulin pump, followed at [**Last Name (un) **]
- HTN: reports SPBs in high 130s, on quinapril
- Major depressive disorder: on bupropion and Trileptal
- Cervical disc herniation: C5-6, moderate spinal stenosis,
stable
- vitamin B12 deficiency: monthly injections
Social History:
married, 2 children, works at [**Company 2267**], exercises
daily, denies tobacco and drugs; her husband is involved in her
care.
Family History:
no heart disease or DM
Physical Exam:
VITAL SIGNS: Temperature 99.1, blood pressure 108/52, heart rate
100,
respiratory rate 21.
.
GENERAL: She was alert and oriented x3.
HEENT: Sclerae anicteric. Pupils are equal, round and reactive
to light. Neck supple. No LAD.
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. Normal S1 and S2. No
JVD.
ABDOMEN: Soft, nontender, nondistended.
NEUROLOGIC: Cranial nerves II through XII intact.
Pertinent Results:
AT [**Location (un) **], LABORATORY DATA:
Sodium 133, K 4.2, chloride 96, bicarbonate 20, BUN 12,
creatinine 0.9,
glucose 384, anion gap is 17, white count 11.9, hematocrit 35,
platelets
259, ALT 29, AST 18, albumin 3.9, calcium 8.7. Urinalysis:
Glucose greater than 1000, ketones greater than 80, trace blood.
Serum with small ketones. EKG with sinus rhythm at a rate of
114. She had T waves inversions in V1.
At [**Location (un) 620**], Chest x-ray was unremarkable, no mediastinal
widening.
At [**Hospital1 18**]:
[**2174-7-8**] 10:39PM GLUCOSE-250* UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-17* ANION GAP-16
[**2174-7-8**] 10:39PM estGFR-Using this
[**2174-7-8**] 10:39PM WBC-19.2*# RBC-3.06* HGB-10.4*# HCT-29.7*
MCV-97 MCH-33.9* MCHC-35.0 RDW-15.3
[**2174-7-8**] 10:39PM WBC-19.2*# RBC-3.06* HGB-10.4*# HCT-29.7*
MCV-97 MCH-33.9* MCHC-35.0 RDW-15.3
[**2174-7-8**] 10:39PM NEUTS-93.8* BANDS-0 LYMPHS-3.4* MONOS-2.7
EOS-0.1 BASOS-0.1
[**2174-7-8**] 10:39PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
[**2174-7-8**] 10:39PM PLT SMR-NORMAL PLT COUNT-280
[**2174-7-8**] 10:39PM PT-13.0 PTT-46.0* INR(PT)-1.1
[**2174-7-8**] 09:20PM O2 SAT-96
[**2174-7-8**]: [**Hospital1 18**] Cardiac catherization- mean PA pressure 20, RA
18, Wedge 25, MAP 77. By report decreased SVR. No flow
limiting lesions were seen but mild restonsis of LAD was noted.
Brief Hospital Course:
41-year-old female with type 1 diabetes, coronary artery
disease, hypertension, and depression who presents with an acute
episode of nausea and vomiting.
.
#. Diabetic Ketoacidosis/DM: h/o DM1 x 10 years, mild HTN, mild
hyperlipidemia. Patient initially with FS glucose in 300-400
range at [**Location (un) 620**] ED, (BS >400 on presentation), with low
bicarbonate, and anion gap, consistent with DKA. She was placed
on a insulin drip in ED and then continued on insulin pump in
ICU at [**Location (un) 620**], which was continued upon transfer. Pt was also
supported with IV fluids. Her anion gap had closed by the time
the patient was admitted to [**Hospital1 18**] MICU and the patient was
started on an insulin drip for better glucose control. She was
transitioned back to home insulin pump on [**8-3**] and given
glargine 3 hours before transfer to pump. She was continued on
glargine 10 units q AM [**First Name8 (NamePattern2) **] [**Last Name (un) **] consult recommendations and
was instructed to continue this daily glargine regimen at home
in adddition to her pump. She was instructed also to followup
with [**Last Name (un) **]. DKA of unclear etiology. She was admitted last
year ([**2-/2173**])to [**Hospital1 18**] with precipitant of DKA thought to be an
actue MI. Ruled out at [**Hospital1 18**] for acute MI with negative cardiac
catheterization. UA negative for infection but with >1000
glucose, >80 ketones, trace blood. Urine culture were negative.
Blood culures showed no growth at discharge (but were drawn
after one dose of antibiotics at OSH). However, leukocytosis
(19.2) notable on repeat CBC here. No obvious precipitant to
DKA- cardiac and infectious workup negative. Of note, hepatitis
A assay was negative; pt was concerned she had had an exposure.
Considering the presentation of acute nausea and vomiting, DKA
may have been precipitated by a gastroenteritis which quickly
resolved.
.
# Hypotension: Hypotension was thought to be secondary to
dehydration on admission. Home dosages of beta-blocker and ACE
inhibitor (for chronic hypertension) were held as the patient
was hypotensive. She was also given NTG at [**Location (un) 620**] for chest
pain which likely exacerbated the hypotension. She was volume
repleted at [**Location (un) 620**]. A CTA for r/o PE showed pulmonary edema
which was likely secondary to fluid overload; we did not replete
her volume further. Upon discharge the patient was normotensive
off her home antihypertensive regimen. She was instructed to
follow up with her cardiologist regarding restarting the beta
blocker and ACE inhibitor.
.
#. Chest pain: Given her negative cardiac enzymes there was
concern for PE, dissection,or possible sepsis. BP was equal in
both arms. CXR w/o mediastinal widening. A d-dimer VTE was
postive at 1.55 (0-0.99 normal [**First Name8 (NamePattern2) **] [**Location (un) 620**] lab) but CTA showed
no pulmonary embolism or other concerning findings.
.
#. CAD: h/o ST elevation myocardial infarction, s/p bare metal
stent to mid-LAD [**2173-2-20**]. Repeat cath yesterday negative for
new lesion, mild restenosis of LAD. Risk factors include
suboptimally managed DM1 x 10 years, mild HTN, mild
hyperlipidemia. No tobacco, no family Hx early MI. Cardiac
enzymes negative X2 at [**Location (un) 620**]. Third set of cardiac enzymes at
[**Hospital1 18**] was not concerning for acute MI. We continued ASA and
atorvastatin as an inpatient. Her beta blocker was held
secondary to hypertension.
.
# History of depression: clinically stable. Continued on
outpatient trileptal.
.
# FEN: Maintained on a cardiac, diabetic diet. Electrolytes were
repleted as needed.
.
# Prophylaxis: She was on heparin drip for possible PE until a
PE was ruled out with CTA; otherwise, the patient was maintained
on SC heparin for DVT prophylaxis. She was eating well so was
not on a PPI.
.
# Assess: peripheral IVs.
.
# Communication: Patient and husband.
.
# Code status: FULL CODE.
.
.
Medications on Admission:
1. Insulin pump regular 0.4 units per hour
2. Aspirin 325 mg daily
3. Quinapril 10 mg daily
4. Atenolol 25 mg daily
5. Lipitor 40 mg daily.
6. Oxcarbazepine 300 mg daily
7. Minocycline 50 mg every other day.
8. Vitamin B12 IM qmonth
Discharge Medications:
1. Insulin Pump with Novolog
2. Aspirin 325 mg daily
3. Lipitor 40 mg daily.
4. Oxcarbazepine 300 mg daily
5. Minocycline 50 mg every other day.
6. Vitamin B12 IM qmonth
7. Glargine 10u daily
Discharge Disposition:
Home
Discharge Diagnosis:
1. Chest Pain.
2. Diabetic ketoacidosis.
3. Hypotension.
Discharge Condition:
Stable
Discharge Instructions:
1. Please return to the ER if you have symptoms of chest pain,
nausea, vomiting, dizziness or any other concerning symptoms.
2. Please call your Endocrinologist at [**Last Name (un) **], Dr. [**Last Name (STitle) 11819**],
within one week of discharge for followup.
3. We have changed your insulin pump dosage [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recommendation, please continue with the current dosing. We
have also started you on basal insulin, Glargine 10u daily.
|
[
"41401",
"4019",
"412",
"V5867",
"V4582"
] |
Admission Date: [**2163-1-21**] Discharge Date: [**2163-1-24**]
Date of Birth: [**2132-10-6**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 30-year-old gentleman
with a history of autoimmune chronic acute hepatitis with
cirrhosis with a recent admission to [**Hospital3 417**] Hospital
for increased bilateral lower extremity edema.
On admission, the patient's sodium was noticed to be 135,
blood urea nitrogen was 13, and creatinine 1.2, and ammonia
was 52. The patient was given Lasix, Aldactone, vitamin K,
ceftriaxone, and lactulose. During the admission, Mr.
[**Known lastname 42226**] became progressively more lethargic with ammonia
increasing to 63, CO2 decreasing to 14, and white blood cell
count increasing to 21.
At that time, the patient was transferred to [**Hospital1 346**] for evaluation for a liver
transplant.
Of note, the patient has become progressively hypoxemic with
his arterial blood gas revealing numbers of 7.41/34/and 60.
A Pulmonary consultation was obtained, and an abdominal
computed tomography revealed bilateral airspace disease with
significant effusions. A human immunodeficiency virus test
was refused, and the patient was admitted for further
management.
PAST MEDICAL HISTORY:
1. Chronic active autoimmune hepatitis with an
esophagogastroduodenoscopy in [**2161-11-9**] revealing
varices, gastritis, and encephalopathy.
2. Pneumonia times three.
3. Cocaine use.
5. Hypertension.
6. Depression.
ALLERGIES: Unknown.
MEDICATIONS ON TRANSFER: Renally dosed dopamine.
SOCIAL HISTORY: The patient has four children. He lives
with his girlfriend. A positive history of cocaine use in
the past.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed heart rate was 81, blood pressure was 123/56, and
oxygen saturation was 97 on 35% ventilation mask. In
general, the patient was somnolent. The patient appeared to
open eyes to stimulation. Head, eyes, ears, nose, and throat
examination revealed scleral icterus. Cardiovascular
examination revealed normal first heart sounds and second
heart sounds. No murmurs, rubs, or gallops. Pulmonary
examination revealed diffuse upper airway rhonchi. Abdominal
examination revealed a soft and distended abdomen with
decreased bowel sounds. Extremity examination revealed 2+
bilateral nonpitting edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed white blood cell count was 21, hematocrit was 38,
and platelets were 102. Sodium was 127, potassium was 4.4,
chloride was 100, bicarbonate was 17, blood urea nitrogen was
63, creatinine was 10.2. Total protein was 6.3. Albumin was
1.3, total bilirubin was 6.2, AST was 209, alkaline
phosphatase was 167, ALT was 108, amylase was 172, lipase was
9, and LDH was 468. Ammonia was 63. Alpha-fetoprotein was
less than 5. Urinalysis revealed 12 red blood cells and 10
to 15 white blood cells. Microbiology of [**1-15**] revealed
stool was negative for Salmonella, Shigella, Campylobacter,
Yersinia, and Escherichia coli. Sputum Pneumocystis carinii
pneumonia on [**1-18**] was negative urine. On [**1-16**],
less than 10,000 coagulase-negative staph.
RADIOLOGY/IMAGING: Transthoracic echocardiogram revealed an
ejection fraction of 65% with left ventricular hypertrophy.
Normal right-sided pressures.
A computed tomography of the abdomen revealed perihepatic
ascites with positive dilated umbilical veins, bilateral
airspace disease in the lungs, and positive bowel wall
thickening.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit and was intubated subsequently for noncardiogenic
pulmonary edema and impending respiratory failure.
The patient was continued on pressors due to his hypotension.
The patient was followed closely by the Hepatology Service,
but it was felt that the patient had a very poor prognosis
and was thought to have spontaneous bacterial peritonitis.
Vancomycin was started, and ceftriaxone was started
empirically. He had worsening mental status, febrile
episodes, and worsening hypotension.
The patient continued to be coagulopathic secondary to liver
dysfunction. The patient received one unit of packed red
blood cells and vitamin K on numerous occasions without
resolution of his coagulopathy. The Hepatology Service
deemed that the patient was not a candidate for a liver
transplant and advocated less aggressive measures given his
progressively deteriorating condition; including his
worsening encephalopathy.
The patient continued to be hyponatremic throughout his
hospital stay; which was thought to be secondary to volume
retention, and the patient could not be volume restricted
secondary to low blood pressures. The patient was continued
on normal saline.
As far as the patient's renal failure, ultrafiltration was
considered but was not an option given the patient's low
blood pressures. The patient was given bicarbonate 150 mEq
over four to five hours to compensate for his metabolic
acidosis, and Amphojel was administered (per the Renal
Service recommendations) for his hyperphosphatemia.
Over the next few days it became apparent that the patient
was not improving, and a family discussion was undertaken
under the direction of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Dr. [**First Name (STitle) **] discussed
with the family the futility of the patient's care and that
further medical management would not result in any
improvement of the patient's condition and that change to
comfort measures only would be the most appropriate. The
family members understood the gravity of the situation. They
discussed the patient's interests and preferences amongst
themselves and decided that change to comfort measures only
care would be most appropriate with stopping all pressors.
The patient was changed to comfort measures only and had his
pressors stopped at 1:30 p.m. on [**2163-1-24**]. A
morphine drip was started. The patient became asystolic
without any measurable blood pressure at 4:55 p.m. There
was no audible heart beat or breath sounds. Pupils were
nonreactive. The patient was not responsive to sternal rub
or pinprick. The family expressed their wishes not to go
ahead with a postmortem. The attending was notified.
A Death Certificate was completed, and the patient passed
quietly and comfortably at 4:55 p.m. on [**2163-1-24**].
The Hepatology Service and Renal Service attendings were made
aware of the patient's passing, and Dr. [**Last Name (STitle) 497**] spoke with the
family and offered some comforting words as well.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 39096**]
Dictated By:[**Name8 (MD) 4712**]
MEDQUIST36
D: [**2163-3-29**] 19:20
T: [**2163-3-29**] 19:21
JOB#: [**Job Number 37995**]
|
[
"5849",
"2851",
"2762",
"486"
] |
Admission Date: [**2154-1-1**] Discharge Date: [**2154-1-6**]
Date of Birth: [**2103-1-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 922**]
Chief Complaint:
new onset exertional angina
Major Surgical or Invasive Procedure:
1. Coronary artery bypass graft x3 with left internal
mammary artery to left anterior descending coronary
artery, reverse single saphenous vein graft from the
aorta to the first obtuse marginal coronary artery,
reverse single vein saphenous vein graft from the aorta
to the first diagonal coronary artery.
2. Endoscopic left greater saphenous vein harvesting [**2154-1-2**]
History of Present Illness:
50 yo male with new onset exertional angina. Admitted [**1-1**] for
cath which revealed 95% LAD, 95% OM1, nl. RCA, EF 54%. Unable to
pass wire for PCI. Referred for CABG.
Past Medical History:
elev. chol.
no PSH
Social History:
married, lives with wife
high school physics teacher
no tobacco use
1-2 drinks per week
Family History:
father and grandfather with CAD <55 years old
Physical Exam:
NAD
CTAB
RRR no murmur
abd benign
right groin cath sitewith small amt. bleeding on dressing, no
hematoma
extrems warm and well-perfused, no edema
+ pulses DP/PTs bilat.
no varicosities noted
99% RA sat 69" 83.4 kg
124/74 SR 60-70 RR 18
Pertinent Results:
[**2154-1-5**] 07:30AM BLOOD WBC-8.3 RBC-2.97* Hgb-9.3* Hct-26.7*
MCV-90 MCH-31.4 MCHC-34.9 RDW-13.0 Plt Ct-138*
[**2154-1-5**] 07:55PM BLOOD Hct-28.2*
[**2154-1-5**] 07:30AM BLOOD Plt Ct-138*
[**2154-1-5**] 07:30AM BLOOD Glucose-108* UreaN-16 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
[**2154-1-1**] 07:15PM BLOOD ALT-36 AST-25 LD(LDH)-198 AlkPhos-59
TotBili-0.2
[**2154-1-5**] 07:30AM BLOOD Mg-2.1
[**2154-1-1**] 07:15PM BLOOD %HbA1c-5.8
RADIOLOGY Final Report
CHEST (PA & LAT) [**2154-1-5**] 4:41 PM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
50 year old man s/p CABG x3
REASON FOR THIS EXAMINATION:
evaluate effusion
Comparison to [**2154-1-3**]. The very small pre-existing
pleural effusion in the left is of slightly different
distribution but unchanged in extent. The pre-existing
retrocardiac atelectasis is unchanged. Otherwise, no relevant
interval changes.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: SUN [**2154-1-6**] 11:28 AM
Conclusions
Pre bypass: There is mild symmetric left ventricular
hypertrophy. There is mild regional left ventricular systolic
dysfunction with apical hypokineis. LVEF 45-55%. Basal septal
hypokiesis can not be excluded due to image quality. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch and the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen.
Post bypass: Patient is paced on phenylepherine infusion. No
change in wall motion. Aortic contours intact. Remaining exam is
unchanged. All finidngs discussed with surgeons at the time of
the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
?????? [**2149**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted [**1-1**] and underwent CABG x3 with Dr. [**Last Name (STitle) 914**] on [**1-2**].
Transferred to the CVICU in stable condition on phenylephrine
and propofol drips. Extubated that evening and transferred to
the floor on POD #1 to begin increasing his activity level.
Chest tubes and pacing wires removed without incident. He was
gently diuresed toward his preoperative weight. Beta blockade
titrated and motrin started for a pericardial rub. Right neck
pain resolved with motrin and ice. Cleared for discharge to home
with services on POD #4. Pt. to make all followup appts. as per
discharge instructions.
Medications on Admission:
zocor 40 mg daily
lisinopril 10 mg daily
atenolol 25 mg daily
ASA 81 mg daily
plavix 75 mg ( dose at cath per RCH)
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 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:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] care
Discharge Diagnosis:
Coronary artery disease s/p cabg x3
Elevated cholesterol
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Dr [**Last Name (STitle) 914**] in 2 weeks [**Telephone/Fax (1) 170**]
Dr [**Last Name (STitle) 39975**] in 4 weeks
Dr [**Last Name (STitle) **] in 6 weeks [**Telephone/Fax (1) 75345**]
Completed by:[**2154-1-11**]
|
[
"41401",
"5119",
"5180",
"2720",
"4240"
] |
Admission Date: [**2152-7-22**] Discharge Date: [**2152-7-28**]
Date of Birth: [**2116-3-15**] Sex: F
Service: [**Hospital **] MEDICAL
HISTORY OF THE PRESENT ILLNESS: The patient is a 36-year-old
female with a history of hepatitis C and hepatitis A who was
found unresponsive in her home when EMS arrived to respond to
a call for a "nosebleed". Per reports, she was sitting in a
chair, looking cyanotic and unresponsive. The initial vital
signs revealed a heart rate of 30, blood pressure
80/palpable, 50% 02 saturation, respiratory rate 60.
Endotracheal tube intubation was attempted in the field
without success but a nasopharyngeal airway was placed. The
02 saturations came up to 96% and the patient was taken to
[**Hospital3 3583**]. The patient was given 0.4 mg Narcan times
two in the ambulance and did not become more responsive. The
patient also received lidocaine 100 mg IV, Etomidate 20 mg
IV, succinylcholine 160 mg IV, Norcuron 10 mg, and Ativan 4
mg IV in the [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **]. The patient's blood pressure and
heart rate were better at [**Hospital1 46**] apparently without pressors.
The head CT was reportedly normal. The patient was
transferred to [**Hospital6 256**] for
further care. The patient received 50 grams of charcoal in
transit. Significant laboratories included a white blood
count of 27,000, 12% bands, hematocrit 41.3, tox screen
positive for cocaine and opioids. The patient was initially
normotensive on arrival but then became hypertensive with a
systolic blood pressure in the 70s. The patient received IV
fluids and dopamine drip. The patient was given ceftriaxone
and vancomycin in the Emergency Department and successfully
intubated in the ED. The patient's EKG showed sinus rhythm
at 98 beats per minute with ST depressions and wide QRS and
alternate beats.
PAST MEDICAL HISTORY:
1. Hepatitis C.
2. Hepatitis A.
SOCIAL HISTORY: The patient has two children,
Spanish-speaking only.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
94, pulse 98, blood pressure 96/55. General: The patient
was an obese woman, intubated, eyes closed, opens eyes to
voice at 5:00 p.m. At 9:00 p.m., she opens eyes to voice and
was able to follow simple commands. HEENT: The pupils were
2 mm, minimally reactive to light. Anicteric sclerae. The
nares were full of bloody nasal discharge. Lungs: Coarse
breath sounds bilaterally. Cardiovascular: Regular rate and
rhythm. Good heart sounds. No murmurs, rubs, or gallops.
Abdomen: Obese, soft, nontender, nondistended, minimal bowel
sounds. Extremities: No pedal edema, bilateral DP pulse
present. Neurologic: Opens eyes to voice, moving all four
extremities spontaneously. Follows simple commands in
Spanish.
LABORATORY/RADIOLOGIC DATA: Sodium 143, potassium 4.0,
chloride 111, bicarbonate 20, BUN 20, creatinine 1.0, glucose
246. CK 1,024, MB 46.5, MBI 4.5, troponin 24. Calcium 7.9,
magnesium 2, phosphate 3.8, ALT 59, alkaline phosphatase 101,
total bilirubin 0.7. AST 141, amylase 214, lipase 39. Serum
was negative for aspirin, ethanol, acetaminophen, benzos,
barbiturates, and tricyclics. Positive for opiates and
cocaine. The urine was negative for benzos, barbiturates,
amphetamines, and methadone.
White count 19.6, hemoglobin 11.8, platelets 343,000,
hematocrit 36.7, 91.7 neutrophils, 0 bands, 4.2 lymphs. PT
13.8, PTT 30.4, INR 1.3. ABGs 7.21, 53, 92, lactate 2.1.
Chest x-ray revealed no infiltrates, no cardiomegaly.
Endotracheal tube 2.5 cm from the carina.
HOSPITAL COURSE: 1. UNRESPONSIVENESS: The etiology most
likely was secondary to cocaine plus/minus opioid overdose.
The patient's mental status quickly improved, following
commands, and was able to be extubated the following day on
[**2152-7-23**]. The patient tolerated extubation well and was
maintained on 02 nasal cannula.
2. COCAINE-INDUCED MYOCARDIAL INFARCTION: Regarding
increased CK MB and troponin, Cardiology was consulted.
Cardiology recommended 48 hours of heparin drip, aspirin, and
an echocardiogram. Cocaine-induced coronary spasm was
suspected cause for MI. Troponins steadily declined. The
patient remained chest pain-free. Echocardiogram showed
normal left ventricular ejection fraction.
On [**2152-7-26**], the patient experienced chest pain times
three overnight relieved by sublingual nitrogen. The pain
was positional and related to cough and deep inspiration.
The pain was thought likely pulmonary in nature. Cardiology
was reconsulted. Cardiology recommended workup by cardiac
catheterization. The cardiac catheterization showed a LVEF
of 55% with no mitral regurgitation, right dominant coronary
arteries with normal vasculature. At the time of discharge,
the patient was chest pain-free.
3. ASPIRATION PNEUMONIA: The patient was with a fever and
leukocytosis. Sputum culture was performed with grew
Staphylococcus aureus. The patient was treated with Levaquin
and metronidazole for a total course of ten days. The
patient remained afebrile for 72 hours prior to discharge.
The patient was discharged to complete final three days of a
ten day course of antibiotics.
4. DEPRESSION: Psychiatry was consulted and felt that the
patient was not a suicide risk, did not need one-to-one
monitoring. The patient was restarted on her Paxil and
Seroquel in the evening and Psychiatry recommended consult of
addiction services.
5. DRUG ADDICTION: [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**] was consulted regarding
drug addiction. The patient reported willing to undergo
inpatient treatment for dual-diagnosis therapy. At the time
of dictation, the patient was to be evaluated for transfer to
Dual Diagnosis Center.
6. RHABDOMYOLYSIS: The patient was with elevated CKs and
deceased calcium, again thought induced by cocaine. The
patient was placed on IV fluids. The CKs rapidly trended
downward with no renal sequelae.
CONDITION ON DISCHARGE: Good.
DISCHARGE INSTRUCTIONS: The patient was instructed to seek
medical care for recurrent chest pain or shortness of breath.
The patient was instructed to finish the final three days of
ten day antibiotic course and to follow-up for treatment with
Psychiatry and for drug addiction.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg one tablet q.d. for three days.
2. Metronidazole 500 mg one tablet three times a day for
three days.
3. Paxil 20 mg one tablet q.d.
4. Seroquel 50 mg at bedtime for insomnia, may repeat once
as necessary.
FINAL DIAGNOSIS:
1. Respiratory failure secondary to drug overdose.
2. Cocaine-induced myocardial infarction.
3. Aspiration pneumonia.
4. Depression.
5. Drug addiction.
ADDENDUM: The patient was noted to have high blood glucose
levels throughout the hospital stay. The patient was
instructed to follow-up with primary care physician regarding
diabetes screen.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Name8 (MD) 13747**]
MEDQUIST36
D: [**2152-7-28**] 06:05
T: [**2152-7-28**] 18:54
JOB#: [**Job Number 48084**]
|
[
"51881",
"5070",
"41071",
"4168"
] |
Admission Date: [**2162-4-17**] Discharge Date: [**2162-5-7**]
Date of Birth: [**2099-10-19**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Shellfish / Penicillin G / Bactrim
Attending:[**First Name3 (LF) 21114**]
Chief Complaint:
Syncope, altered mental status
Major Surgical or Invasive Procedure:
[**2162-4-28**] Colonoscopy
History of Present Illness:
62M with AIDS on HAART, last CD4 [**3-21**] was 29 presenting with
syncope, fever, hypotension. PMHx significant for disseminated
[**Doctor First Name **] on treatment, severe cryptospiridial diarrhea ([**2156**]). He was
hospitalized at [**Hospital1 18**] [**Date range (1) 91669**] requiring ICU admission with
fevers, diarrhea, hypotension and syncope. He had a thorough
work up at that time where no etiology was identified for his
symptoms. He represents with a similar presentation today, he
was found down in bathroom after syncope. Initially his SBP
noted to be in 70s HR 140s. Alert in ED, amnestic to events
prior. No complaints other than diarrhea x 2 weeks. No fevers or
abd pain. Febrile on arrival to 101.2, other VS: 120s 108/68, BP
was as low as 80 in ED (per report, not documented). Initially
received vanc/levo/flagyl and fluconazole. CXR neg. UA neg.
Lactate 1.7. He became more altered in ED. Pulled off leads,
tried to get OOB. This raised concern for a CNS infection. He
had a CT head which was unremarkable. LP was similar to last
admission, with very few WBC with a lypmocytic predominance,
opening pressure 13. ID was called in ED. Agreed with coverage
and suggested some tests for LP (fungal, AFB, and cryptococcal
ag/cultures). They will follow in house. He received 4L IVF in
the ED with associated MS clearing.
Vitals at time of transfer 98.8 101/60 96 19 100% RA. He was
transfered the ICU for further work up and monitoring in the
setting of altered mental status, hypotension.
.
On arrival to the [**Hospital Unit Name 153**] the patient is comfortable and with out
complaint. Says he is fatigued and asking for something to
drink. Describes feeling dizzy in his home, both vertiginous and
lightheaded, worse with standing. Fell while walking about
house, witnessed by roommate, no trauma, denies LOC. States this
has happened before. + Chills, no subjective fevers. Has been
having loose stools ~ 3-4 times a day, notes a steady
improvement in his diarrhea since his last admission. No
nausea/vomiting, GERD, odynophagia, abd pain, BRBPR,
hematochezia or melena. No new rashes, chest pain, shortness of
breath, headache, vision or hearing changes. Tolerating regular
PO diet, no decrease in UOP. He has chronic peripheral
neuropathy. Reports med adherence. No recent sick contacts.
.
ROS was otherwise essentially negative.
Past Medical History:
HIV serodiagnosed [**2142**] with history of noncompliance to ART
[**Female First Name (un) 564**] esophagitis
Pyelonephritis [**7-29**] E. coli
MRSA anterior chest wall abscess [**5-29**]
Overactive bladder
L foot numbness
Diverticulosis
Sinusitis
Anogenital HPV s/p OR excision [**9-25**], [**12-28**], [**10-29**]
Crystal meth use leading to nonadherence to HAART
Severe cryptosporidial diarrhea [**9-26**]
HTN
Dyslipidemia
Social History:
Home: Lives with his partner, [**Name (NI) 1158**].
Occupation: retired accountant
Tobacco: Denies
Drugs: Denies current drug use but previous history of sniffing
crystal meth
EtOH: Denies
Pets: 2 pet cats
Sick contacts: None
Travel: Denies any recent travel, although does report a history
of travel to [**Country 3399**]
Family History:
Mother - alive in her 90s w/ dementia
Father - died of copd
Brother - Diabetes [**Name (NI) **] and Hypertension
Physical Exam:
Vitals: T: 100.8 BP:103/65 P:105 R:24 SaO2:97% RA
ED Total IN: 4500/OUT 1400
General: Sleeping, arousable, cachectic chronically ill
appearing man in NAD.
HEENT: NCAT, temporal wasting. MMM, no thrush or oral lesions.
No scleral icterus
Neck: supple, neck veins flat. No meningismus
Pulmonary: Lungs CTA bilaterally, very slight crackles on right
base.
Cardiac: Regular, tachycardic, no murmurs
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Skin: Diffuse hyperpigmented irregular lesions on scalp, torso,
back (pt reports taking metrogel for this), as 1.5cm irregular
discolored lesion on left heel.
Neurologic: Arousable, oriented, responding appropriately to
questions, though with 1 word answers, responses frequently
inconsistent. Poor short term memory. CN II-XII intact. Stregth
intact all 4 extremities.
Pertinent Results:
Admission Labs
[**2162-4-17**] - 5pm
Na 132 / K 4.4 / Cl 102 / CO2 19 / BUN 19 / Cr 1.1 / BG 91
Lactate 1.7
CK 237 / MB 5 / Trop T < .01
WBC 3.2 / Hct 36.2 / Plt 214
N 77 / L 14 / M 8 / E 1 / B 1
---------------
[**2162-4-17**] CXR - No acute cardiopulmonary process.
---------------
[**2162-4-17**] CT Head - No evidence of acute hemorrhage or enhancing
mass lesion.
---------------
[**2162-4-28**] CT Abd/Pelvis - Stable lymphadenopathy since [**2162-4-2**]. The
differential diagnosis is wide and includes infection, lymphoma
and metastasis. HIV related lymphadenopathy is also
considered.No obvious cause for diarrhea seen.
---------------
[**2162-5-3**] CXR - Within Normal Limits
---------------
[**2162-5-4**] CT Abd/Pelvis -
1) New focal area mesenteric low density with surrounding
mesenteric
stranding, which is concerning for phlegmon versus early
abscess. This is too small for aspiration or drainage, and the
location posterior to small bowel loops currently also not
amenable to radiology guidance.
2) Multiple enlarged mesenteric and retroperitoneal lymph nodes
unchanged
since the prior study. Again, the differential diagnosis
includes infection versus HIV related lymphadenopathy versus
lymphoma.
3) No evidence of colitis.
MICRO Data
C. difficile positive [**2162-4-20**], [**2162-4-28**]
Brief Hospital Course:
62M with AIDS, [**Doctor First Name **] [**2-1**] and distant history of cryptospiridial
diarrhea presenting with hypotension, syncope, fevers and C.
difficile diarrhea.
# Diarrhea/C diff: Patient was initially admitted to MICU with
hypotension and syncope and persistent diarrhea. He was fluid
resuscitated with >8-10L of IVF and did not require pressors. He
was initially started on Vanco/Ceftriaxone and Flagyl for
empiric coverage. Stool studies and [**Month/Year (2) **] cx were sent and stool
studies were ultimately positive for Clostridium difficile from
[**4-19**]. At this time, vancomycin and ceftriaxone were discontinued
and he was continued on PO flagyl. Fevers resolved early in
course and he was afebrile >1week prior to discharge. Symptoms
persisted and he continued to have [**4-29**] watery BMs per day.
Vanco po was added to the regimen and symptoms of diarrhea still
persisted. Due to persistence, and previous history of diarrhea
with negative C diff, GI was re-consulted (consulted previous
admission for EGD and duodenal biopsy) and he had colonoscopy.
Repeat studies [**2162-4-30**] also positive for C diff. At this point
Flagyl po was changed to IV Flagyl on [**2162-5-1**] and had subsequent
improvement in symptoms. Stool studies repeatedly have been
negative for other etiologies. Cryptosporidia, microsporidia,
urine histo antigen and viral cx all negative. Cryptosporidia
and microspridia testing also done on duodenal bx from [**4-7**] and
was negative as well. CMV VL negative x 2. Colonoscopy biopsy
results showed no abnormalities.
After 72 hours without diarrhea patient developed LLQ
abdominal pain. Pain persisted overnight and CT Abd/pelvis was
performed. CT showed no sign of colitis but showed a mesenteric
hypodensity that may be represent phlegmon vs early abscess.
Patient was started on cipro and continued on flagyl. Because
pain persisted over the next 24 hours General Surgery was
consulted. They did not believe that findings on CT represented
a need for surgical intervention but suggested that the lesion
on CT may represent necrotic lymphadenopathy. Patient was
continued on antibiotic course of cipro, vanco po, and flagyl po
and all symptoms resolved. Patient was discharged on a 10 day
course of cipro/flagyl and a 13 day course of vancomycin po.
Patient was enouraged to follow up with primary care provider
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within two weeks of discharge and to return to the
hospital if symptoms should return.
.
# Hypotension: Patient fluid resuscitated as above in MICU.
After tranfer to the floor, he continued to require IVF for
orthostatic hypotension but BP overall remained improved. At
time of discharge, he was normotensive, tolerating PO intake and
not orthostatic. Free T4 0.62. Had [**Last Name (un) 104**] stim test which was
normal in MICU. Random am cortisol 24.9 on [**2162-5-2**].
# AIDS: Has previous history of poor compliance with HAART, now
continued on current regimen of darunavir boosted with
ritonavir, raltegravir and etravirine. OI prophyllaxis continued
with azithro and dapsone (bactrim allergy)
and continued on fluconazole for recurrent thrush.
.
# h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: Pt has been on treatment, however does have a history
of poor compliance. Currently on azithromycin and ethambutol. He
had been on clarithromycin, rifabutin and ethambutol which was
changed this admission. Repeat cx NGTD.
.
# Leukopenia: Improved. Not neutropenic.
.
# Enlarged retroperitoneal and mediastinal LN: Patient had
lymphadenopathy on previous CT abdomen/pelvis [**2162-4-2**]. Unclear
whether from [**Doctor First Name **] vs lymphoma or malignant process. Flow
cytometry consistent with T cell lymphoid process, nonspecific.
Repeat CT abdomen/pelvis this admission with stable
lymphadenopathy. He should have PET scan as an outpatient and
consideration of biopsy pending results. EBV PCR and CMV VL
negative. Urine histo Ag negative.
.
# Anemia: Pt has anemia with HCT 30-36. Likely fluctuating from
fluid shifts and low from chronic inflammation/myelosuppression.
Stable throughout remainder of course.
.
# Code status: DNR/DNI
Medications on Admission:
Medications on admission:(from [**Doctor First Name **] d/c)
1. Dapsone 100 mg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY (Daily).
2. Etravirine 100 mg Tablet [**Doctor First Name **]: Two (2) Tablet PO BID (2 times
a day).
3. Fluconazole 200 mg Tablet [**Doctor First Name **]: Two (2) Tablet PO Q24H (every
24 hours).
4. Fluoxetine 20 mg Capsule [**Doctor First Name **]: One (1) Capsule PO DAILY
(Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Darunavir 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
7. Raltegravir 400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
8. Ritonavir 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times
a day).
9. Azithromycin 600 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO once a
week.
10. Clarithromycin 250 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2
times a day).
11. Ethambutol 400 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO DAILY (Daily).
12. Metronidazole 1 % Gel [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for eosinophilic pustular folliculitis.
13. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day.
14. Rifabutin 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO EVERY OTHER
DAY (Every Other Day).
15. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day as
needed for constipation.
16. Zofran 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO every eight (8)
hours.
Discharge Medications:
1. Dapsone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Etravirine 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
3. Fluconazole 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q24H (every
24 hours).
4. Fluoxetine 20 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
5. Darunavir 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
6. Raltegravir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
7. Ritonavir 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times
a day).
8. Ethambutol 400 mg Tablet [**Hospital1 **]: 2.5 Tablets PO DAILY (Daily).
9. Azithromycin 250 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H (every
6 hours) for 10 days: Last dose [**2162-5-17**].
Disp:*40 Capsule(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: Do not exceed 8 pills per
day.
13. Metronidazole 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every
eight (8) hours for 7 days: Last dose on [**2162-5-14**].
Disp:*21 Tablet(s)* Refills:*0*
14. Cipro 500 mg Tablet [**Date Range **]: One (1) Tablet PO twice a day for 7
days: Last dose [**2162-5-14**].
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Art of care
Discharge Diagnosis:
Primary Diagnosis:
Clostridium Difficile Infection
Diffuse lymphadenopathy
Secondary Diagnosis:
AIDS
[**Doctor First Name **] bacteremia [**2-1**]
Acute renal failure
Discharge Condition:
Hemodynamically stable, afebrile, asymptomatic.
Discharge Instructions:
You were admitted to the hospital with diarrhea, fever, and low
[**Month/Year (2) **] pressure. Your symptoms were most likely from an infection
called, C. difficile. We treated you for this infection with an
antibiotic called metronidazole (flagyl) and vancomycin and your
symptoms slowly improved. You also received intravenous fluids
and your [**Month/Year (2) **] pressure and dehydration improved. You developed
abdominal pain during this admission. Imaging was performed
which showed this pain was likely due to your infection or your
enlarged lymph nodes. It is recommended that you follow up with
your primary care physician to discuss the possibility of future
lymph node biopsy if your symptoms persist.
We made the following changes to your home medications:
1. CHANGE your clarithromycin to azithromycin
2. STOP your rifabutin
3. START metronidazole (flagyl) 500 mg by mouth every 8 hours x
7 days (last dose on [**2162-5-17**]).
4. START vancomycin 125 mg by mouth every 6 hours x 10 days
(last dose on [**2162-5-17**]).
5. START ciprofloxacin 500 mg by mouth twice a day x 7 days
(last dose [**2162-5-14**]).
Please continue all other home medications as previously
directed.
Please return to the ER or call your primary care physician if
you develop worsening diarrhea, abdominal pain, dizziness,
nausea, vomiting, chest pain, shortness of bretah or any other
concerning symptoms.
Followup Instructions:
You have the following appointments scheduled:
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 568**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2162-5-27**] 9:30
[**Name6 (MD) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2162-6-8**] 9:45
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2162-9-22**]
11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21117**] MD, [**MD Number(3) 21118**]
|
[
"5849"
] |
Admission Date: [**2125-5-19**] Discharge Date: [**2125-5-24**]
Date of Birth: [**2084-3-8**] Sex: M
Service:
CHIEF COMPLAINT: Transfer from outside medical hospital with
refractory anion gap acidosis.
HISTORY OF PRESENT ILLNESS: Patient is a 41-year-old male
with a past medical history significant for hypertension
(untreated) and asthma with seasonal allergies, who presented
to an outside hospital on [**5-18**] with a five day history of
nausea, vomiting, diarrhea, and progressive weakness and was
transferred to [**Hospital1 69**] with
refractory anion gap acidosis and ketoacidosis.
Patient was reported in his usual state of health until
approximately five days prior to admission, when he reports
acute onset nausea followed by vomiting and watery diarrhea.
The patient reports occasional episodes of vomiting and
diarrhea initially, however, after two days, the frequency
and severity progressively worsened to approximately 10-30
episodes per day of bilious nonbloody vomiting, and 10-30
episodes per day of brown-watery diarrhea with little to no
oral intake for approximately three days.
During this time, the patient reports progressive generalized
weakness (proximal greater than distal muscle groups) with
significant fatigue and lightheadedness. He also reports
unsteadiness secondary to generalized weakness with a
reported fall with subsequent trauma to his right arm prior
to admission. The patient denies fever, chills, rash,
arthralgias, headache, cough, recent travel, sick contacts,
toxic ingestions, as well as exposures. Patient presented to
the outside hospital Emergency Department with the inability
to walk, dyspnea on exertion, and worsening fatigue. By the
time of admission to the outside hospital, the patient's
nausea, vomiting, and diarrhea had [**Hospital1 4351**] resolved.
In the outside hospital Emergency Department, patient was
found afebrile and hemodynamically stable with positive serum
and urine ketones (ABG 7.21/23/86/95% on room air), anion gap
34, normal serum glucose, and negative serum toxin screen
except for salicylates. The patient was treated with 2
liters of normal saline without significant change in his
blood pH, which was subsequently changed to normal saline
with 5 amps of sodium bicarb. The patient was then
transferred to [**Hospital1 69**] for
further management.
Of note, the patient recalls two prior episodes when he
developed similar prodrome of symptoms including nausea,
vomiting, and weakness. The first of these episodes occurred
in his early 20's, when he reports significant nausea and
vomiting with progressive weakness. A family friend, who is
a physician, [**Name10 (NameIs) 4351**] treated the patient with antiemetics
and his symptoms resolved without need for official medical
attention.
The second episode occurred in [**2121-11-17**], when the
patient again developed nausea, vomiting, and weakness,
without clear precipitant. The symptoms were significant
enough to prompt the patient to seek medical attention at an
outside hospital Emergency Department. Per the patient's
primary care physician, [**Name10 (NameIs) **] was found at the time of
presentation to have an anion gap of 23 with a bicarb of 16
and ketonuria. The patient's liver function tests were
elevated with an AST of 354, ALT of 104, GTT 154, and total
bilirubin of 1.2. Patient's LDH at the time was 340 with CKs
greater than 600. Patient was [**Name10 (NameIs) 4351**] treated with IV
hydration that corrected his anion gap acidosis and
discharged to home from the Emergency Department.
A subsequent Gastroenterology workup for his elevated liver
function tests included a right upper quadrant ultrasound, as
well as blood work evaluating possible infectious, toxic, or
immunologic causes. Per the patient's primary care
physician, [**Name10 (NameIs) **] workup was essentially negative, and the
primary care physician was recommended to followup with a
repeat CK at a later date for evaluation for possible primary
muscular abnormality. However, the patient remained
asymptomatic without further exacerbations of his
aforementioned abnormalities, and no further workup was done.
PAST MEDICAL HISTORY:
1. Asthma.
2. Seasonal allergies.
3. Hypertension (untreated).
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Advair.
2. Zyrtec.
SOCIAL HISTORY: The patient lives alone in [**University/College **],
[**State 350**], and is employed as an environmental scientist.
He reports a history of binge drinking in college, however,
denies current alcohol use with last alcoholic intake
approximately six months prior to admission. He also denies
tobacco, illicit drug use, as well as herbal remedies.
FAMILY HISTORY: The patient's mother is alive and well at
the age of 70, patient's father is deceased secondary to an
accident, and patient has a brother who is otherwise healthy.
No known history of diabetes mellitus, cardiac disease,
malignancies, or muscle abnormalities.
PHYSICAL EXAM ON ADMISSION: Temperature 97.8, heart rate
127, blood pressure 133/77, respiratory rate 35, oxygen
saturation 100% on 2 liters nasal cannula. In general, the
patient is a thin middle age male in mild distress appearing
diaphoretic and tachypneic. HEENT exam: Normocephalic,
atraumatic. Pupils are equal, round, and reactive to light
and accommodation. Anicteric sclerae. Extraocular movements
are intact bilaterally. Moist mucous membranes, with no oral
lesions. Neck exam: Supple without lymphadenopathy or
thyromegaly. No jugular venous distention was appreciated.
Pulmonary examination: Clear to auscultation bilaterally, no
wheezes, rales, or rhonchi. Cardiovascular exam:
Tachycardic, regular, normal S1, S2 with no murmurs, rubs, or
gallops. Abdominal exam: Soft, normoactive bowel sounds,
nontender, and nondistended with no masses appreciated.
Extremities: Warm and well perfused with intact distal
pulses, no rashes. Neurological examination: Alert, awake,
oriented x3, appropriate, cranial nerves II through XII
intact, diffusely weak 4+/5 motor strength throughout with no
focal signs of weakness, reflexes 2+ patellar, 2+ brachial
symmetric bilaterally. Sensation intact. Gait deferred,
cerebellar intact, finger-to-nose and rapid-alternating
movements.
LABORATORIES AND STUDIES ON ADMISSION: At [**Hospital6 48670**]: Complete blood count with a white blood cell count
of 13.3, hematocrit 40.2, MCV 104, and platelets of 183 with
a white blood cell differential of 89% polys, 4% lymphocytes,
6% monocytes. Chem-7 with a sodium of 137, potassium 4.9,
chloride 92, bicarb 11, BUN 23, creatinine 1.2, and glucose
of 72. Serum tox screen is notable for a salicylate level of
4.5, Tylenol less than 10, otherwise negative. Large serum
acetone was measured. Arterial blood gas at the outside
hospital: 7.21/23/86 with 95% on room air. Initial CK of
2,543 with a negative MB index of 0.9, lactic acid 2.3, TSH
0.36 and urinalysis with greater than 80 ketones.
Initial blood work at [**Hospital1 69**]:
Chem-7 with a sodium of 134, potassium 6.9, chloride 96,
bicarb 10, BUN 19, creatinine 1.2, and glucose of 105
(notable for a gross hemolysis). AST 393, ALT 173, LDH
1,309. CK 3,704, alkaline phosphatase 48, amylase 27, total
bilirubin 0.9, albumin 4.4, calcium 8.0, magnesium 1.1, and
phosphorus 3.7. Calculated serum OSM was 295.
HOSPITAL COURSE: Patient was admitted to [**First Name (Titles) **] [**Last Name (Titles) 15593**] Care Unit, where he remained
afebrile, tachycardic to the 130s, tachypneic to the 40s with
adequate oxygen saturation on 2 liters nasal cannula, and
normotensive. The patient received aggressive hydration,
initially with D5 half normal saline (x3 liters), eventually
changed to lactated ringers with the addition of bicarbonate
drip (2 liters with 3 amps of sodium bicarb) for persistent
metabolic acidosis. Despite patient's persistent laboratory
abnormalities, the patient demonstrated significant clinical
improvement with no further episodes of nausea, vomiting, or
diarrhea. Patient's strength also progressively improved
with downtrending heart rate as well as respiratory rate.
Serial laboratories were notable for a persistent anion gap
acidosis, mild transaminitis, AST greater than ALT,
uptrending creatinine kinase to greater than 4,000,
macrocytosis, and persistent large blood acetone.
On transfer to the Medical floor, the patient continued to
complain of diffuse weakness with nonfocal neurologic
examination. After aggressive IV hydration in the Medical
[**Last Name (Titles) 15593**] Care Unit, the patient began to auto-diurese with
approximately 13 liters urine output over duration of four
days. Despite diuresis, the patient maintained adequate oral
hydration without orthostasis.
Despite clinical improvement, the patient continued to have
large serum acetone with ketonuria. His anion gap gradually
began to close with increase metabolic (iatrogenic)
alkalosis. Patient's creatinine kinase continued to rise
with a peak CK of 6,435. The trend in liver function tests
paralleled the patient's CKs with a peak ALT of 417, AST
1,230, LDH 2,670, with normal total bilirubin and alkaline
phosphatase.
A Neurology consult was obtained on [**5-22**] for evaluation of
potential metabolic myopathy. The Neurology evaluation
revealed an essentially negative neurologic examination
except for mildly decreased muscle strength ([**4-21**]) in the
patient's deltoids bilaterally. Based on their evaluation,
Neurology suggested a primary myopathy as the source of the
patient's metabolic derangements and proximal muscle
weakness. The differential diagnosis for myopathy includes
metabolic causes such as lipid metabolism, glycolytic and/or
glyconeolytic causes, and/or mitochondrial defects,
post-viral causes such as EBV, HSV, HIV, etc, or inflammatory
myopathy such as polymyositis, or vasculitis. The Neurology
service recommended obtaining EMG to differentiate between
inflammatory or noninflammatory myopathy as well as a
metabolic workup including serum pyruvate, ammonia, and
carnitine.
The blood work was sent, however, the EMG was not obtained
secondary to scheduling. All blood work is pending at the
time of dictation. Although it was felt that the elevated CK
and LFT abnormalities were most likely secondary to primary
muscle source, hepatitis serologies including hepatitis A, B,
C, as well as EBV and CMV serologies were obtained. All
serologies are negative at the time of dictation.
CONDITION ON DISCHARGE: Stable, ambulating without
difficulty, tolerating po, with downtrending CKs and LFTs.
INSTRUCTIONS ON DISCHARGE: The patient was discharged to
home and instructed to followup with his primary care
physician in two days postdischarge for followup blood work.
The patient was instructed to return to the Emergency
Department incase of recurrent nausea, vomiting, and
intolerance of oral intake, generalized weakness, or
orthostatic symptoms. The patient was scheduled to followup
with the [**Hospital 7817**] Clinic with Dr. [**Last Name (STitle) **] and Benetar at
[**Hospital1 69**] on [**6-18**] at 1 pm on
the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical Center for further
workup.
DISCHARGE DIAGNOSES:
1. Metabolic abnormalities, with anion gap acidosis, elevated
CK, and transaminitis of unclear etiology undergoing workup
for possible metabolic myopathy.
2. Hypertension.
3. Asthma.
4. Seasonal allergies.
MEDICATIONS ON DISCHARGE:
1. Flovent 110 mcg two puffs [**Hospital1 **].
2. Salmeterol 21 mcg 1-2 puffs [**Hospital1 **].
3. Multivitamins one po q day.
4. Lopressor 25 mg po bid.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2125-6-12**] 14:25
T: [**2125-6-12**] 14:30
JOB#: [**Job Number 48671**]
|
[
"2762",
"49390",
"4019"
] |
Admission Date: [**2105-8-4**] Discharge Date: [**2105-8-12**]
Date of Birth: [**2048-10-2**] Sex: M
Service: MEDICINE
Allergies:
Bacitracin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Dyspnea, hypoxia and pleuritic chest pain
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
This is a 56 y/o male with coronary artery disease s/p LAD stent
placement, IDDM, and tracheomalacia s/p tracheal stent, who
presented to the ED after 5 days of progressive shortness of
breath and cough. His symptoms first developed 5 days ago as
progressive SOB (can walk 2 flights of stairs at baseline, then
down to 1/2 flight), cough productive of yellow and pink tinged
sputum, and pleuritic right-sided chest pain, rated [**2108-7-9**]. The
pain was present all of the time and worse with coughing or
movement. He also began using home O2 that he does not normally
require. In addition he complained of increasing bilateral lower
extremity edema and increasing abdominal girth. He called his
primary care physician and was told to take extra lasix
(apparently up to 240mg daily per patient report) without
success. He then presented to an episodic visit yesterday where
a chest xray showed a new right upper lobe pneumonia. He was
hypoxic (87% on RA) in clinic and he was referred to the ED for
further evaluation. He denies any recent sick contacts,
antibiotic exposure, or travel. He has had no chest pain,
fever, chills, night sweats, abdominal pain, diarrhea, bright
red blood per rectum, melena, or rash. He denies orthopnea or
paroxysmal nocturnal dyspnea.
Of note, patient was pushed down a flight of stairs in spring
[**2104**], and he sustained multiple rib fractures and continues to
experience low back pain. In the ED, his BLE edema was evaluated
with LENIs which showed no evidence of DVT. Initial O2 Sat in
the ED was 90% on 4L NC.He was also given levofloxacin for
pneumonia prior to being admitted to the floor. On exam he was
resting and talking comfortably in bed with mild wheezing and
productive cough. Cough and small movements elicited extreme
pain.
The pt was scheduled to get a CTA on his first night. He was
sitting watching television and had sudden onset worsening of
his right pleuritic chest pain. He got up to try to walk it off
but as he walked he developed a tightening/pressure sensation in
his mid-abdomen which then moved up towards his chest and
ultimately developed acute "throat-closing" sensation. He called
the nurse and was found to be 83% 6L NC. He was acutely short of
breath and had difficulty speaking. He was most comfortable in a
standing position. Initial SBP 170s. He was given 2 mg IV
Morphine, 2 SL NTG, 125 solumedrol, combivent neb, 20 mg Lasix
and was started on heparin IV with initial bolus, empirically.
Pt was transferred to the MICU for respiratory distress and
hypoxia. He responded to 97% on 5L at transfer to the MICU.
When transferring from the stretcher to the bed, the patient
again had an acute shortness of breath with pressure in his
chest and a throat-closing sensation. He responded to standing
and slow deep breathing after approximately 1 minute. The pt was
started on Heparin drip empirically for presumed PE and
vancoymcin was added to antibiotic regimen. CTA the next day did
not show evidence of PE, hypoxia was resolved, and patient was
transferred back to medicine floor.
Past Medical History:
1. IDDM - complicated by gastroparesis and peripheral
neuropathy. On insulin pump.
2. Hypothyroidism
3. Hyperlipidemia
4. CAD - s/p LAD stent in [**2097**]
5. Bipolar disorder
6. ADD
7. OSA - on BIPAP at home but has not been using it.
8. Tracheobronchomalacia s/p tracheal bronchoplasty [**2104-6-5**]
9. Right pleural effusion s/p pleurodesis(FEVI 1.95, FVC
2.13)[**2104-7-4**]
10. Osteoarthritis
11. GERD
12. Lactose intolerance
13. Constipation
14. H/O fundic gland polyp with focal low grade dysplasia [**11-3**]
Social History:
Married with 4 children (2 daughters and 2 adopted sons). [**Name2 (NI) 1403**]
as a teacher for 6th-8th grade special education children.
Denies any tobacco, EtOH, or drug use
Family History:
Mother with CAD and DM. Father with HTN. Brother healthy. [**Name2 (NI) **]
history of UC/Crohn's.
Physical Exam:
INITIAL MEDICINE ADMISSION EXAM:
GENERAL: Resting comfortably in bed, with obvious pain when
coughing, and no acute distress. Pleasant and cooperative during
exam.
VITALS: T98.1 BP118/58-68 HR66 RR18 O2Sat96% on 3.5L Pain [**6-9**]
at rest and [**8-10**] with movement.
HEENT: NC/AT. PERRL. EOMI. Sclera anicteric. Conjunctiva pink.
MMM. No oropharyngeal exudate or erythema.
CV: Regular rate and rhythm. Normal S1/S2. No murmurs, rubs,
gallops appreciated. No JVD or pulsatile liver appreciated.
LUNGS: >20cm arc-shaped scar from posterior to anterior on R
side at site of prior pleuridisis. Lungs largely clear to
auscultation with vesicular breath sounds. E/A changes noted
over posterior and anterior R upper lung fields. No wheezes,
rales, rhonchi appreciated.
ABD: Normoactive bowel sounds. Tense abdomen, dull to precussion
and difficult to palpate. Hepatosplenomegaly not appreciated. No
fluid wave.
EXT: 2+ pitting edema to the high right shin. Trace pitting
edema on left to mid-calf. DP pulses 1+.
SKIN: Warm and dry. No ecchymoses, rashes, or petechiae.
NEURO: Appropriate in conversation. Ambulates easily without
assistance. UE and LE strength 5/5. Sensation to light touch
midly decreased in feet, right>left. Proprioception grossly
intact bilateral LE and UE. Cranial Nerves II-XII grossly
intact.
MICU ADMISSION EXAM:
PE: 98.6, 140/62, 72, 19, 97% 5L
Gen: Sitting in chair, speaking in full sentences, no distress,
pleasant
HEENT: MMM, O/P clear, EOMI
Neck: no JVD
CV: RRR, no M/R/G appreciated
Lungs: R mid field, anterior and basilar crackles, clear left,
no wheezes, no crackles
Abd:distended, tense, nontender, +BS
Ext: 1+ LE pitting edema to the high shins bilaterally-symmetric
Neuro: Appropriate in conversation, moves all extremities, CN
II-XII intact
Pertinent Results:
LABS:
.
CBC: [**2105-8-4**] 05:10PM WBC-6.0 RBC-3.76* HGB-11.2* HCT-32.6*
MCV-87 MCH-29.7 MCHC-34.2 RDW-15.9* [**2105-8-4**] 05:10PM PLT
COUNT-176
[**2105-8-4**] 05:10PM NEUTS-75.5* LYMPHS-13.7* MONOS-7.5 EOS-2.8
BASOS-0.5
.
ELECTROLYTES:
[**2105-8-4**] 05:10PM GLUCOSE-126* UREA N-17 CREAT-1.2 SODIUM-139
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-30 ANION GAP-13
.
OTHER:
[**2105-8-4**] 05:10PM LACTATE-0.7
.
STUDIES:
MICROBIOLOGY:
BLOOD CULTURE [**2105-8-4**]: No growth.
BLOOD CULTURE [**2105-8-4**]: No growth.
.
URINE CULTURE [**2105-8-5**]: NEGATIVE FOR LEGIONELLA SEROGROUP 1
ANTIGEN.
.
EXPECTORATED SPUTUM [**2105-8-6**]:
GRAM STAIN
[**9-24**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2105-8-8**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
ACID FAST SMEAR (Final [**2105-8-7**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
.
BRONCHOALVEOLAR LAVAGE [**2105-8-7**]:
GRAM STAIN (Final [**2105-8-7**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2105-8-9**]):
>100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
ACID FAST SMEAR (Final [**2105-8-10**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
.
ECHO [**2105-8-6**]: The left atrium is mildly dilated. The right
atrium is moderately dilated. A left-to-right shunt across the
interatrial septum is seen at rest through an ostium secundum
atrial septal defect. No right-to-left shunt is seen. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Secundum-type ASD with left-to-right shunting.
Normal global and regional biventricular systolic function.
Mild pulmonary hypertension.
.
CTA CHEST [**2104-8-6**]:
1. No pulmonary embolism or aortic dissection.
2. Enlarged mediastinal lymph nodes along with ill-defined
patchy opacities in the right upper lobe, likely represent
pneumonic consolidation and reactive mediastinal lymph nodes.
This may be followed up with chest radiographs or a CT as per
clinical need to assess resolution.
3. Tracheobronchomalacia with soft tissue in the upper trachea,
likely representing tracheal secretions.
.
BRONCHOSCOPY WITH BRONCHOALVEOLAR LAVAGE [**2105-8-7**]
1.BRONCHIAL WASHINGS CYTOLOGY: Atypical. Rare groups of atypical
cells, probably reactive. Numerous pulmonary macrophages and
inflammatory cells.
2.TBNA: NON-DIAGNOSTIC, insufficient cellular material.
Scattered bronchial cells and macrophages. No lymphoid cells of
lymph node sampling seen.
.
MRI/MRA ABDOMEN and PELVIS [**2105-8-12**]:
No evidence of inferior vena cava or of pelvic venous
thrombosis. No pelvic mass identified.
Brief Hospital Course:
This is a 56 y/o male with coronary artery disease s/p LAD stent
placement, IDDM, and tracheomalacia s/p tracheal stent, found to
have community acquired pneumonia. Brief hospital course
presented below by problem.
1.Community-acquired Pneumonia: Chest XRay obtained on day of
admission showed right upper lobe infiltrate. Pt started on
levofloxacin and continued while in hospital with good response.
Pt started vancomycin while in MICU, but this was d/c'd three
days later. Blood cultures x2 were negative. Induced sputum
cultures and BAL cultures grew oropharyngeal flora. Patient
afebrile throughout hospital course. Patient maintained on
supplemental O2 for several days and albuterol nebulizers prn.
Due to mediastinal adenopathy and calcified granuloma seen on
CTA, and RUL infiltrate, suspicion was raised for TB despite low
risk factors. Pt was on respiratory precautions for several days
until TB ruled out with induced-sputum and BAL AFB smears.
Patient was discharged on levofloxacin to complete 14-day
course.
.
2.Hypoxia/Respiratory distress: Pt noted to be hypoxic (87% on
RA) in outpatient clinic on day of admission. O2 Sat improved
with supplemental O2 on medicine floor to 100% on 3L NC. Pt
became markedly hypoxic with respiratory distress while lying
down on his first night in hospital and did not respond to
atavan, nebs, or O2 via non-rebreather mask. Pt was transferred
to MICU but O2 Sats improved markedly without intubation.
Positional hypoxia may have been related to anatomic
problem(blood vs. secretions in trachea) and/or anxiety. CTA was
obtained and was negative for PE. Cardiac enzymes were negative
for MI. Pt had no further hypoxic episodes following transfer
back to medicine floor. He was weaned from O2 several days prior
to discharge and ambulatory O2 sats were 95%. Follow-up
appointment was scheduled with pulmonology.
.
3. Abdominal distention and LE swelling: Pt had had increasing
concern over abdominal and bilateral lower extremity swelling
for the past year. Pt has history of diabetic gastroparesis and
chronic constipation, as well as an admission for abdominal pain
and bowel ischemia in 12/[**2103**]. Abdominal ultrasound showed no
ascites. Hypoalbuminemia, nephrotic syndrome, DVT, and severe
right-sided heart failure were ruled out during admission.
Abdominal distention and tenderness resolved somewhat with bowel
movements. LE edema improved dramatically with compression
stockings. MRI/MRA of pelvis and abdomen showed no mass lesions
and no evidence of IVC thrombus. Echocardiogram showed new
atrial septal defect with mild pulmonary HTN. LE edema
attributed to mild right-sided heart failure in setting of mild
pulmonary HTN and venous insufficiency. Abdominal distention
likely due to constipation and recent weight gain. Follow-up
appointment was scheduled with cardiology and PCP.
.
4. CAD: We continued outpatient medical management with
metoprolol and statin.
.
5. HTN: Pt had one hypertensive episode in setting of
respiratory distress. He was maintained on outpatient
metoprolol.
.
6. IDDM: Pt maintained on insulin pump and was seen multiple
times by [**Last Name (un) **] consult service. Patient's blood glucose was not
well-controlled despite adjustments made by [**Last Name (un) **]. Patient will
follow-up with PCP regarding tighter glucose control. Neurontin
for neuropathy and reglan for gastroparesis were continued.
.
7. Acute Renal Failure: Patient's Cr slightly elevated on
admission, with bump to 1.3 following CTA. ARF resolved over
several days. Pt did receive mucomist and NAHCO3 before CTA, but
ARF was likely due to contrast-induced nephropathy. Creatinine
was stable at discharge.
.
8. Hypothyroidism: Levothyroxine was continued.
.
9. Bipolar disorder/ADD: Abilify, adderal, lamotrigine, amd
fluoxetine were continued.
10. Pulmonary nodule noted on CT chest - defer to PCP for
followup. CT chest as below scheduled (non-contrast) in a few
weeks.
Medications on Admission:
- Abilify 15mg''
- Adderal XR 20mg'
- Atorvastatin 80mg'
- Levothyroxine 225mcg'
- Doxazosin 8mg'
- Lamotrigine 100mg''
- Gabapentin 800mg'''
- Nortriptyline 100mg'
- Fluoxetine 40mg'
- Modafinil 100mg'
- Lanzoprazole 30mg''
- Metoprolol 37.5mg''
-Amitiza 1 capsule''
- Finasteride 5mg'
- Reglan 10mg''''
Salsalate 1000mg''
- Trazodone 50-150mg prn
- Furosemide 80mg'
- oxygen 2liters as needed
- Novalog insulin pump (0.9u/h basal rate w/ 20:1 carb counting)
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Last Name (un) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Levofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
5. Aripiprazole 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
6. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24
hr [**Hospital1 **]: One (1) Capsule, Sust. Release 24 hr PO daily ().
7. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Levothyroxine 75 mcg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
9. Doxazosin 4 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime).
10. Lamotrigine 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
11. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2
times a day).
12. Gabapentin 400 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3
times a day).
13. Nortriptyline 25 mg Capsule [**Hospital1 **]: Four (4) Capsule PO HS (at
bedtime).
14. Fluoxetine 20 mg Capsule [**Hospital1 **]: Two (2) Capsule PO DAILY
(Daily).
15. Lanzoprazole [**Hospital1 **]: One (1) 30 mg tab once a day.
16. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
17. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: One (1) Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
18. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
19. trazodone
20. Modafinil
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Community Acquired Pneumonia
Secondary: Atrial septal defect, Tracheomalacia, reactive airway
disease, diabetes mellitus, Hypothyroidism
Discharge Condition:
Improved respiratory function, normal sat on room air ambulating
Discharge Instructions:
You were admitted with shortness of breath and cough which was
found to be due to a pneumonia. You improved with antibiotics
and nebulizer treatments. You were sent to the intensive care
unit after having an acute episode of shortness of breath. You
were evaluated with a CT scan of your chest that showed you did
not have a any blood clots in your lungs. Additionally you had a
bronchoscopy of your lungs that did not show signs of infection,
including tuberculosis.
You were also put on isolation precautions for several days
before we confirmed that you did not have a tuberculosis
infection. Also you had an echocardiogram that showed you have a
tiny hole between the top [**Doctor Last Name 1754**] of your heart. For this you
should also be followed by your cardiologist. We also did an
abdominal ultrasound and abdominal MRI to evaluate your
increasing abdominal girth and confirmed that there was no free
fluid, masses or clots in your arteries. For your lower
extremity swelling, we got ultrasounds of your legs which showed
no blood clots. Your lower extremity swelling also improved with
using the compression stockings.
Your pneumonia contined to improve through your hospital stay on
antibiotics and you should continue the antibiotics for a total
of 14 days (six more days). Please follow up with a repeat chest
xray within the next 3-4 weeks as directed below. Also, follow
up with all your scheduled physician [**Name Initial (PRE) 4314**].
You should go to the ER or call your doctor if you have any
fever, chills, worsening chest pain, shortness of breath,
passing out or any other concerning symptoms.
Please take all your medications as prescribed and keep all
follow up appointments
Followup Instructions:
1.You should follow up with your primary care physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on Wednesday, [**9-2**] at 11:10am.
[**Telephone/Fax (1) 250**].
2.You should follow up with Dr. [**Last Name (STitle) **] in Interventional
Pulmonology at at appointment on Monday, [**10-5**]. At 11:30
you will have a Chest CT scan on the [**Hospital Ward Name 517**], CC3, and then
see Dr. [**Last Name (STitle) **] at 12:00 at his office. ([**Telephone/Fax (1) 10084**].
3.Please follow up with Dr. [**Last Name (STitle) 120**], your cardiologist, at an
appointment on [**Last Name (LF) 2974**], [**8-28**] at 9:30am. ([**Telephone/Fax (1) 10085**]
4.Please follow up with Dr. [**Last Name (STitle) 6821**] [**Month (only) **] in Dermatology on
[**9-1**] at 11:15am. 67-[**Telephone/Fax (1) **]
.
5.Psychiatry Appointment: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7676**]
Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2105-8-21**] 11:40
.
6.STRESS/EXERCISE LAB Phone:[**Telephone/Fax (1) 1566**] Date/Time:[**2105-10-26**] 7:30
.
7.Rheumatology Appointment: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2105-11-2**] 4:00
.
8.Please obtain a Chest Xray within the next 3-4 weeks. You can
go to [**Hospital Ward Name 23**] 4 on the [**Hospital Ward Name 516**] or Clinical Center 3 on the
[**Hospital Ward Name 516**] anytime, M-F between 8am and 4:30pm. The results
will be sent to Dr. [**Last Name (STitle) **].
|
[
"486",
"5849",
"4280",
"5859",
"49390",
"4168",
"53081",
"32723",
"41401",
"V4582",
"2724",
"2449"
] |
Admission Date: [**2107-8-3**] Discharge Date: [**2107-8-10**]
Date of Birth: [**2033-8-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2107-8-5**] - Off Pump CABGx3 (Left internal mammary->left anterior
descending artery, Vein graft->Diagonal artery, Vein
graft->Posterior descending artery)
[**2107-8-3**] - Cardiac Catheterization
History of Present Illness:
CC: 73 yo Hispanic man admitted to Holding Area from exercise
lab due to EKG changes and chest pain during outpt ETT today.
HPI: Information obtained from pt. with assistance of
interpreter services. This 73 yo man with no known prior hx CAD,
reports overall good health. Approximately 3 months ago, he
noted the onset of chest pressure associated with physical
activity. He also had periods of DOE both with and without chest
pressure. He works as a janitor. Initially symptoms were
infrequent and relieved by rest. Over the past month he has had
2-3 episodes of chest pain per week. Symptoms relieved by rest.
He was referred for ETT today by PCP Dr [**Last Name (STitle) 1789**]. He completed
11.5 min of a modified [**Doctor First Name **] protocol. Stopped due to symptoms
of chest pressure and fatigue. EKG showed 2.25 mm ST segment
horizontal down sloping in the inferolateral leads. There were T
wave inversions leads V2-V5 noted during the recovery phase. Nuc
imaging revealed nl LV size, mild systolic dysfunction, and
distal anterior HK.
Past Medical History:
HTN
Hyperlipidemia
Headaches
Social History:
Employed custodian. Lives with his son. [**Name (NI) **] his son is not
able to help with discharge to home due to work schedule. No
current tobacco (Quit 30 years ago) or ETOH use.
Family History:
noncontributory
Physical Exam:
Appears comfortable, stating no further episodes of chest pain.
VS: tele SR 50??????s BP 180/80??????s
Lungs: CTA ant/lat
Heart: RRR -MRG
Abd: NT + BS
PV: fems 2+ no bruits. DPs 1+ bilaterally, no [**Location (un) **]. No
variocosties
Pertinent Results:
[**2107-8-10**] 07:10AM BLOOD WBC-8.1 RBC-3.48* Hgb-11.2* Hct-31.7*
MCV-91 MCH-32.1* MCHC-35.2* RDW-14.2 Plt Ct-246#
[**2107-8-3**] 01:15PM BLOOD WBC-5.7 RBC-5.06 Hgb-16.1 Hct-46.2 MCV-91
MCH-31.7 MCHC-34.8 RDW-13.9 Plt Ct-222
[**2107-8-10**] 07:10AM BLOOD Plt Ct-246#
[**2107-8-7**] 01:51AM BLOOD PT-14.1* PTT-33.1 INR(PT)-1.3*
[**2107-8-3**] 01:15PM BLOOD Plt Ct-222
[**2107-8-3**] 01:15PM BLOOD PT-10.9 INR(PT)-0.9
[**2107-8-10**] 07:10AM BLOOD Glucose-107* UreaN-16 Creat-0.8 Na-142
K-3.8 Cl-97 HCO3-32 AnGap-17
[**2107-8-3**] 01:15PM BLOOD Glucose-111* UreaN-21* Creat-1.1 Na-140
K-4.3 Cl-98 HCO3-32 AnGap-14
[**2107-8-6**] 02:46AM BLOOD ALT-9 AST-20 LD(LDH)-193 AlkPhos-35*
Amylase-27 TotBili-0.3
[**2107-8-3**] 04:15PM BLOOD VitB12-268
[**2107-8-3**] 04:15PM BLOOD %HbA1c-6.1*
[**2107-8-3**] 04:15PM BLOOD Triglyc-83 HDL-54 CHOL/HD-3.1 LDLcalc-98
RADIOLOGY Final Report
CHEST (PA & LAT) [**2107-8-9**] 2:27 PM
CHEST (PA & LAT)
Reason: evaluate ptx
[**Hospital 93**] MEDICAL CONDITION:
73 year old man s/p CABG
REASON FOR THIS EXAMINATION:
evaluate ptx
CXR, TWO FILMS
HISTORY: Status post CABG.
FINDINGS: Sternotomy noted. There are small bilateral pleural
effusions and thickening of the fissures. The bibasilar
atelectasis shows considerable improvement compared to the
previous examination of [**2107-8-7**]. No heart failure.
CONCLUSION: Status post CABG. Improving bilateral pleural
effusions and bibasilar atelectasis.
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: TUE [**2107-8-9**] 10:14 PM
Cardiology Report ECHO Study Date of [**2107-8-5**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: Abnormal ECG. Aortic valve disease. Coronary artery
disease. Left ventricular function. Mitral valve disease.
Valvular heart disease.
Status: Inpatient
Date/Time: [**2107-8-5**] at 13:59
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW02-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 30% to 40% (nl >=55%)
INTERPRETATION:
Findings:
Off Pump CABG
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is
seen in the RA. Dynamic interatrial septum. No ASD or PFO by 2D,
color Doppler
or saline contrast with maneuvers.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Moderately depressed
LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal
inferior -
hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo; basal anterolateral - hypo; mid anterolateral - hypo;
anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex -
hypo;
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild thickening of mitral valve chordae.
Physiologic MR (within
normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. The patient was
under general
anesthesia throughout the procedure. Suboptimal image quality -
poor echo
windows.
Conclusions:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is
seen in the body of the left atrium or left atrial appendage. No
atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast
with maneuvers. Left ventricular wall thicknesses and cavity
size are normal.
Overall left ventricular systolic function is moderately
depressed (LVEF= XX
%). The right ventricular cavity is mildly dilated. Right
ventricular systolic
function is normal. There are simple atheroma in the descending
thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral
regurgitation is seen (within normal limits). There is no
pericardial
effusion.
[**Location (un) **] PHYSICIAN:
Cardiology Report ECG Study Date of [**2107-8-5**] 5:47:06 PM
Sinus rhythm with ventricular premature beat. Low limb lead QRS
voltage, is
non-specific. Modest right precordial lead/anterior T wave
changes are
non-specific and unstable baseline makes assessment difficult.
Clinical
correlation is suggested. Compared to the previous tracing of
[**2107-8-3**] sinus
bradycardia is absent, ventricular ectopy and precordial T wave
changes are now
seen.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 158 82 356/394 52 16 50
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2107-8-3**] for further
management of his angina and positive stress test. He underwent
a cardiac catheterization which revealed severe three vessel
coronary artery disease. Given these findings, the cardiac
surgical service was consulted for surgical mananagement. Mr.
[**Known lastname **] was worked-up in the usual preoperative manner. On
[**2107-8-5**], Mr. [**Known lastname **] was taken to the operating room where he
underwent off pump coronary artery bypass grafting to three
vessels. Please see operative note for details. Postoperatively
he was taken to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. Aspirin, beta blockade
and his statin were resumed. Plavix was started as his surgery
was performed off pump and should be continued for three months.
On postoperative day two, he was transferred to the step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. He
continued to progress and was ready for discharge to rehab on
POD 5.
Medications on Admission:
Medications as per [**Company 4916**] Pharmacy: [**Telephone/Fax (1) 38015**]. Patient
unable to identify meds. States takes 4 pills a day.
Aspirin 81 mg daily
Atenolol 50 mg daily
HCTZ 25 mg daily
Tylenol #3 daily for headache
Prazosin 1 mg daily (pt thinks this was stopped, unable to
verify)
Discharge Medications:
1. oxygen
Oxygen 2 L NC wean to room air for sats > 92%
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 40 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11729**] Home - [**Location (un) 686**]
Discharge Diagnosis:
CAD s/p off pump CABG
Systolic heart failure EF 35-40%
Hyperlipidemia
HTN
Headaches
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns. [**Telephone/Fax (1) 170**]
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 1 month ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 1789**] (cardiologist/PCP) after
discharge from rehab [**Telephone/Fax (1) 1792**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2107-8-10**]
|
[
"41401",
"4240",
"4280",
"5180",
"4019",
"2720"
] |
Admission Date: [**2152-7-25**] Discharge Date: [**2152-8-7**]
Date of Birth: [**2082-11-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Keflex / Diovan
/ Ciprofloxacin / Ace Inhibitors / Quinine / Levaquin / Novocain
/ Lidocaine / Heparin Agents / Zosyn / Xylocaine / Lipitor /
vancomycin
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
PICC placement
Hemodialysis
History of Present Illness:
A 69 y/o woman with DM, HTN, HLD and HD dependent ESRD who is
transferred from [**Hospital **] hospital to the CCU for hypotension and
continued management following high risk intervention with
stents placed in the LAD and left main coronary artery.
.
According to the report the patient had been experiencing
dyspnea and weakness x 3 days which was believed to be related
to heart failure. She underwent hemodialysis on Sunday and again
on Monday to remove fluid. Today, she went for hemodyalisis and
became hypotensive to 70/50 she complained of presyncope and
dyspnea and was sent to her routine cardiology follow up
appointment with Dr. [**Last Name (STitle) 8579**] where she was hypotensive to
70/doppler and was referred to the [**Location (un) **] ED.
.
On presentation to [**Location (un) **] her vitals were 98.2 73 60/40 100%
2L, she endorsed worsening SOB but denied CP. She was started on
dopamine and dobutamine drip, and given 3L IVNS. While in the
ED, she complained of chest pain. EKG showed ventricular pacing
at 71 BPM with known LBBB, TWI in aVL. Labs were significant for
Cr. 3.0, K 2.9, Troponin I 0.61 and Hct of 30.9. She was unable
to lay flat and was intubated prior to cardiac catheterization,
which showed the patent SVG-->OM and SVG-->PDA grafts, known
occluded LIMA, RCA and LCX. A 90% L main occlusion and 80%
proximal LAD occlusion were found and 2 DES were placed. RA
pressure was 29mmHg, wedge pressure was 38mmHg.
.
She was then transferred to [**Hospital1 18**] for further management
following high risk intervention. She was received in the CCU
intubated on dopamine and dobutamine Vitals were T 95.9 HR 74 BP
95/43 O2 Sat 100%Vent settings AC 500/16/5/100% FiO2. She was
unable to contribute to the history.
.
BACKGROUND History
She has recently been treated for a chronic ulcer at the base of
her left greater toe x 1 month. She was treated [**2152-7-20**] with
baloon angioplasty to the SFA and anterior/posterior tibial
arteries were found to be occluded. PTA was incompletely opened.
Of note, on [**2152-7-20**] she underwent LLE arteriography and
angioplasty that showed total occulsion of the anterior and
posterior tibial arteries that could not be intervened upon. Her
SFA was partially occluded and was successfully dialted without
complication.
.
She has an extensive cardiac history significant for CABG
'[**39**](LIMA/LAD, SVG/OM1, SVG/RCA) c/b occlusion of LIMA/LAD graft,
s/p DES to LAD '[**46**], NSTEMI due to LAD in-stent stenosis [**2-22**] s/p
repeat DES, and AVR/MVR with [**Hospital 923**] Medical Biocor Epic Supra in
[**3-23**] and s/p pacemaker insertion. She had a recent cath at [**Hospital1 18**]
([**4-24**]) that showed 70% stenosis of the distal LMCA, 90% ostial
stenosis of the LAD, and widely patent mid arterial stents. The
LCx and RCA were totally occluded. She had a successful DES of
distal LAD and successful DES of distal L main/ostial LAD.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: x3 in [**2139**] LIMA/LAD, SVG/OM1, SVG/RCA c/b occlusion of
LIMA/LAD graft s/p DES to LAD '[**46**]
-PERCUTANEOUS CORONARY INTERVENTIONS: NSTEMI due to LAD in-stent
stenosis [**2-22**] s/p repeat [**Name Prefix (Prefixes) **]
-[**Last Name (Prefixes) 12539**]/ICD:
3. OTHER PAST MEDICAL HISTORY:
MVR/AVR in [**3-23**]
ESRD on HD T/T/S
DM
TIA
GIB with ischemic colitis
depression
PVD s/p R BKA
HIT
Social History:
Patient lives iwth her daughter and son-in-law as well as
granddaughter. She does not work. She reports recent significant
stressors as 2 family members have died in the last month and a
great-grandaughter was born.
Tobacco: smoked as a teenager
EtOH: rare glass of wine
Drugs: denies
Family History:
Mother died of colon ca; she also had diabetes. Father died of
heart disease.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS: T 95.9 HR 74 BP 95/43 O2 Sat 100%
GENERAL: Elderly female intubated and mildly sedated, responding
to commands and moving all extremities.
HEENT: PEERLA, EOMI. ET tube in place.
NECK: JVP not assessed due to body habitus
CARDIAC: S1, S2. holosystolic murmur at the LLSB. No S3
apprecited.
LUNGS: Right sided pacer in place. Coarse breath sounds in the
anterior lung fields BL. Equal air entry BL, no wheezes rales or
rhonchi.
ABDOMEN: Overweight, abdominal striae present. Soft,
nondistended normoactive bowel sounds.
EXTREMITIES: S/p right Above Knee Amputation. Right venous
sheath in place. a 2cm diameter eschar is present over medial
aspect of the base of the left greater toe.
PULSES:
Right: s/p BKA
Left: Dopplerable posterior tib/DP
PHYSICAL EXAM ON DISCHARGE
VS: T 99 BP 100/60 HR 83 RR 18 O2 Sat 97% RA
GENERAL: NAD
HEENT: NCAT, MMM
NECK: JVP difficult to asses [**2-16**] plethoric neck
CARDIAC: S1, S2. holosystolic murmur at the LLSB. No S3
apprecited.
LUNGS: Right sided pacer in place. Crackles in dependent lung
fields
ABDOMEN: Overweight, abdominal striae present. Soft,
nondistended normoactive bowel sounds.
EXTREMITIES: S/p right Above Knee Amputation. LLE with lambs
wool dressing between toes and loose dry dressing.
PULSES:
Right:
Left: Dopplerable posterior tib/DP
Pertinent Results:
ADMISSION LABS
[**2152-7-25**] 08:16PM BLOOD WBC-18.4*# RBC-3.32* Hgb-11.0* Hct-33.0*
MCV-100* MCH-33.1* MCHC-33.2 RDW-17.9* Plt Ct-321
[**2152-7-25**] 08:16PM BLOOD Neuts-90* Bands-0 Lymphs-5* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2152-7-25**] 08:16PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Burr-1+
[**2152-7-25**] 08:16PM BLOOD PT-16.3* PTT-33.4 INR(PT)-1.4*
[**2152-7-25**] 08:16PM BLOOD Glucose-244* UreaN-23* Creat-3.6* Na-137
K-4.2 Cl-96 HCO3-20* AnGap-25*
[**2152-7-25**] 08:16PM BLOOD ALT-7 AST-28 LD(LDH)-270* CK(CPK)-76
AlkPhos-110* TotBili-0.3
[**2152-7-25**] 08:16PM BLOOD CK-MB-10 MB Indx-13.2* cTropnT-1.62*
[**2152-7-25**] 08:16PM BLOOD Albumin-3.5 Calcium-9.5 Phos-4.4 Mg-2.1
[**2152-7-26**] 01:12AM BLOOD Lactate-3.7*
DISCHARGE LABS
WBC 11.9 RBC 3.14 Hb 10.6 Hct 33.0 MCV 105 MCV 33.6 Plt 564
Glu 154 Cr 26 K 4.3 Na 134 3.8 Cl 89* HCO3 28 AG 21
PERTINENT LABS
[**2152-7-28**] 04:50AM BLOOD ESR-77*
[**2152-7-31**] 03:31AM BLOOD Ret Aut-7.6*
[**2152-8-2**] 04:55AM BLOOD Fact V-146 FacVIII-362*
[**2152-7-28**] 04:50AM BLOOD ALT-1 AST-16 LD(LDH)-211 AlkPhos-90
TotBili-0.2
[**2152-7-25**] 08:16PM BLOOD CK-MB-10 MB Indx-13.2* cTropnT-1.62*
[**2152-7-26**] 05:20AM BLOOD CK-MB-7 cTropnT-1.78*
[**2152-7-31**] 03:31AM BLOOD VitB12-754 Folate-GREATER TH Hapto-236*
[**2152-8-3**] 04:31AM BLOOD TSH-4.8*
[**2152-7-27**] 05:30AM BLOOD Cortsol-43.0*
[**2152-8-3**] 04:31AM BLOOD Cortsol-18.1
[**2152-7-28**] 04:50AM BLOOD CRP-162.8*
PERTINENT STUDIES
# [**7-26**] TTE
Conclusions
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
septum, dyskinesis of the distal inferior wall and apex, and
severe hypokinesis of the lateral wall Overall left ventricular
systolic function is severely depressed (LVEF= 25 %). No masses
or thrombi are seen in the left ventricle. The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
A bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. No aortic regurgitation is
seen. A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral valve leaflets are thickened. The transmitral
gradient is normal for this prosthesis. There is probable small
vegetation on the mitral valve which appears to be attached to
the posterior mitral leaflet and prolapses through the valve
orifice during the cardiac cycle. Cannot exclude degeneration of
the prosthetic valve but appears consistent with vegetation.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. Moderate [2+] tricuspid regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Prosthetic mitral valve vegetation. Well-seated and
normally functioning Severe regional left ventricular systolic
dysfunction c/w CAD. Moderate tricuspid regurgitation. Mildly
dilated and borderline hypokinetic right ventricle.
Compared with the prior study (images reviewed) of [**2151-3-29**],
left ventricular function has significantly declined. Two
bioprosthetic valves are present, with a probable vegetatation
on the mitral valve.
# [**7-26**] TEE
Conclusions
No spontaneous echo contrast or thrombus/mass is seen in the
body of the left atrium. Mild spontaneous echo contrast is
present in the left atrial appendage but no thrombus is seen. No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium or the right atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. LV systolic function
appears depressed. The right ventricular cavity is dilated with
normal free wall contractility. There are simple atheroma in the
ascending aorta and aortic arch. A bioprosthetic aortic valve
prosthesis is present. The prosthetic aortic valve leaflets
appear normal. The aortic valve prosthesis leaflets appear to
move normally. No masses or vegetations are seen on the aortic
valve. No aortic valve abscess is seen. No aortic regurgitation
is seen. A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral leaflets appear normal. The motion of the
mitral valve prosthetic leaflets appears normal. There is small
vegetation or mass on the left ventricular aspect of the MVR
strut which is not affecting the leaflets (seen starting at
clips 41-44). No mitral valve abscess is seen. Trivial mitral
regurgitation is seen. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. Moderate to severe [3+] tricuspid regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Small, highly mobile vegetation/mass on the inferior
surface of the bioprosthetic MVR which appears to be attached to
the left ventricular aspect of the posterior strut and is not
involving the leaflets. Cannot exclude chordal structures from
prosthetic valve surgery. Trivial mitral regurgitation. No
abscess is visualized adjacent to the MVR or AVR. Depressed LV
function with moderate to severe TR.
When compared to prior intraoperative TEE study ([**2152-4-1**]),
small, linear, mobile structures were seen in a similar location
after mitral valve prosthesis was placed. This finding is now
more apparent and the structure is larger in size.
[**7-27**] Foot X-ray
FINDINGS: Three views of the left foot demonstrate an
age-indeterminate
fracture at the head of the fifth metatarsal. There is no
cortical
destruction to suggest osteomyelitis. However, cannot exclude
early
osteomyelitis on this radiograph. Extensive arterial
calcifications are
present. A plantar based lucency within the soft tissue, best
seen on the
lateral view, may represent an ulcer. The bones are diffusely
osteopenic.
Hallux valgus is present. There is enthesopathy of the
calcaneus.
IMPRESSION: No chronic osteomyelitis present. Age-indeterminate
fracture at the head of the fifth metatarsal.
# [**7-28**] Arterial study
FINDINGS: The right lower extremity was not evaluated due to an
above-knee
amputation. On the left, ABI measurements are considered
inaccurate due to
vessel non-compressibility. Doppler tracings appear monophasic,
volume
recordings appear widened with amplitude loss and are extremely
low at the
metatarsal level.
IMPRESSION: Findings indicating severe arterial insufficiency,
etiology is
proximal to the popliteal artery.
# [**8-3**] Bone scan
FINDINGS: Three views of the left foot demonstrate an
age-indeterminate
fracture at the head of the fifth metatarsal. There is no
cortical
destruction to suggest osteomyelitis. However, cannot exclude
early
osteomyelitis on this radiograph. Extensive arterial
calcifications are
present. A plantar based lucency within the soft tissue, best
seen on the
lateral view, may represent an ulcer. The bones are diffusely
osteopenic.
Hallux valgus is present. There is enthesopathy of the
calcaneus.
IMPRESSION: No chronic osteomyelitis present. Age-indeterminate
fracture at the head of the fifth metatarsal.
# [**8-4**] TTE
Conclusions
Left ventricular wall thicknesses and cavity size are normal.
There is mild to moderate regional left ventricular systolic
dysfunction with mid- and distal septal/apical akinesis. The
remaining segments contract normally (LVEF = 35%). No masses or
thrombi are seen in the left ventricle. The right ventricular
cavity is mildly dilated with normal free wall contractility. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. There is no aortic valve
stenosis. A bioprosthetic mitral valve prosthesis is present.
The prosthetic mitral valve leaflets are thickened. The
gradients are higher than expected for this type of prosthesis.
There is a small echodensity adjacent to the mitral prosthesis
ring; this likely represents a lookse suture. Moderate to severe
[3+] tricuspid regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild to moderate regional left ventricular systolic
dysfunction, most c/w CAD. Mildly dilated right ventricle with
preserved systolic function. Slightly increased prosthetic
mitral valve gradients, normal AVR/MVR function otherwise.
Moderate to severe functional tricuspid regurgitation. At least
moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2152-7-26**], LV
function has slightly improved. Tricuspid regurgitation is more
severe and estimated pulmonary pressures are higher.
Brief Hospital Course:
A 69 y/o woman with DM, HTN, HLD and HD dependent ESRD who is
transferred from [**Hospital **] hospital to the CCU for hypotension and
continued management following high risk intervention with
stents placed in the LAD and left main coronary artery.
.
# Hypotension
It is thought that patient's hypotension is related to
cardiogenic shock. Cardiac catheterization at [**Location (un) **] showed
elevated PCWP and right atrial pressures consistent with
biventricular failure. Pt was started on Dopamine gtt and was
repeatedly hypotensive with hemodialysis. After extubation
attempt to wean Dopamine gtt was initially unsuccessful. Patient
was started on digoxin and midodrine, and was eventually able to
be temporarily weaned off dopamine with a MAP of 40-50 mmHg.
However, without pressor she was only marginally stable, and had
difficulty tolerating ambulation or hemodialysis.
OUTPATIENT ISSUES
- Started midodrine 10 mg tid
.
# Coronary artery disease
Patient had CABG and multiple PTCA. Cardiac cath at [**Location (un) **]
showed patent SVG-->OM and SVG-->PDA grafts, known occluded
LIMA, RCA and LCX and tight stenosis of Left main and LAD which
were treated with 2x DES. Chest pain and elevated troponins
likely represent demand ischemia in the setting of heart failure
and cardiogenic shock. She is not on statin due to myalgias. We
continued her full dose aspirin and plavix and held
nitrates/beta blockers secondary to hypotension. Echo showed
severe regional left ventricular systolic dysfunction with
akinesis of the septum, dyskinesis of the distal inferior wall
and apex, and severe hypokinesis of the lateral wall and an
interval decrease in EF from 45% in [**2149**] to 25-35% on this
admission.
OUTPATIENT ISSUES
- Discontinued Gemfibrozil given change of goal of care.
.
# Congestive heart failure with systolic dysfunction:
On the recent ECHO, patient had LVEF of 25-35%, a decrease from
45% in 3/[**2151**]. Improvement was observed prior to discharge after
multiple attempts of reomval of preload by dialysis and
ultrafiltration. We started digoxin during hospitalization, but
thought it will be unsafe to continue if patient will not have
hemodialysis. Patient's current blood pressure could not
tolerate beta-blockers or ACE inhibitors.
OUTPATIENT ISSUES
- Discontinued digoxin, metoprolol.
.
# ESRD
Patient has ESRD that has receives hemodialysis at [**Location (un) 77066**]with Dr. [**Last Name (STitle) 14252**] ([**Telephone/Fax (1) 77067**]) in the past. Patient
received multiple ultrafiltration and hemodialysis during this
hospitalization in an attempt to remove fluid and increase her
cardiac function. For most of the time, dopamine was needed for
successful completion of these sessions.
.
# Arterial insufficiency ulcer
Patient presented with a nonhealing ulcer at the base of left
greater toe, secondary to arterial insufficiency. She recently
underwent an angioplasty to left SFA. Workup for the ulcer
during this hospitalization include foot x-ray, arterial studies
and bone scan. No evidence of osteomyelosis was found. Patient
recent wound care including lamb's wool and Santyl for chemical
debridement. The wound was found to be stable.
.
# Goal of care
Per discussion with patient and her family, patient expressed
wish to discontinue heoric attempts of care given the prognosis
of her heart failure. Patient was seen by palliative care team,
and decide to continue hospice at as she returns home.
OUTPATIENT ISSUES
- Patient will be followed by hospice care.
.
CHRONIC ISSUES
# Depression
Patient has a documented history of depression and was on
citalopram prior to this hospitalization. We tapered citalopram
given her stable mood and potential detrimental effect from the
medication.
.
# Anemia
Patient has a documented history of anemia, macrocytic in
nature, likely secondary to chronic kidney disease. Patient has
normal levels of folate and vitamin B12.
.
TRANSITIONAL ISSUES
- Patient changed her status to DNR/DNI during this
hospitalization.
- We stopped Nephrocaps, Cinacalcet, Renagel, Metoprolol,
Citalopram, Nitrostat, Gemfibrozil given her change of the goal
of care.
- She will be discharged to home hospice and will stop receiving
HD treatments.
Medications on Admission:
-Nephrocaps 1cap qday
-Cinacalcet 30mg qday
-Colace 100mg [**Hospital1 **] PRN
-Gemfibrozil 600mg [**Hospital1 **]
-Renagel 600mg tid w meals
-Omeprazole 40mg qday
-Metoprolol 25mg [**Hospital1 **]
-Citalopram 30mg qday
-Plavix 75mg qday
-ASA 325 mg qday
-Diclofenac eye drops 0.1% in each eye [**Hospital1 **]
- Nitrostat PRN dose uncertain
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. collagenase clostridium hist. 250 unit/g Ointment Sig: [**1-16**]
Appls Topical DAILY (Daily).
Disp:*60 gram* Refills:*2*
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-16**]
Drops Ophthalmic PRN (as needed) as needed for dry eye.
Disp:*1 bottle* Refills:*2*
5. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. diclofenac sodium 0.1 % Drops Sig: One (1) Ophthalmic twice
a day: Please apply one drops to each eye twice a day.
Discharge Disposition:
Home With Service
Facility:
Steward Home Care and Hospice
Discharge Diagnosis:
End stage renal disease, dialysis dependent.
PICC line placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You came to our hospital for evaluation of your low blood
pressure during hemodialysis. Since admission, you received
medication to increase your blood pressure at the cardiac
intensive care unit. Based on the ECHO studies you underwent,
it appeared that your cardiac function decreased significant
since [**2151-3-15**], which might be a result of heart attack, or
gradually worsening of your ongoing heart condition. As part of
the treatment, you received repeated hemodialysis and
ultrafiltration to remove fluid from your body and to facilitate
the recovery of your heart function. However, after multiple
attempts, it seemed difficult to maintain a minimal blood
pressure without giving you medication that can only be provided
in an intensive care unit. On a separate note, we also looked
at the infection in your left toe. On multiple studies,
including a bone scan, we did not find evidence of infection to
the bone, which might have required a more intensive antibiotics
treatment.
As we understand, it is your wish to go home with hospice
service, who would continue to provide comfort care for you. We
have made the following changes to your medication that would
maximize your comfort at home.
- Please START taking midodrine 5 mg two tablets orally, three
times a day.
- Please START using collagenase clostridium hist Ointment daily
to the lesion of your foot.
- Please STOP taking Nephrocaps.
- Please STOP taking Cinacalcet.
- Please STOP taking Gemfibrozil.
- Please STOP taking Renagel.
- Please STOP taking Metoprolol.
- Please STOP taking Citalopram.
- Please STOP taking Nitrostat unless absolutely necessary for
chest pain.
Most importantly, the hospice team will help you when you need
changes to your medication needs.
It has been a great privilege to provide you care during you
stay at [**Hospital1 18**]. [**Month (only) 116**] peace and happiness be with you and your
family as you return home.
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"40391",
"2762",
"2761",
"25000",
"2724",
"412",
"V4582",
"4280",
"311"
] |
Admission Date: [**2147-4-7**] Discharge Date: [**2147-4-9**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil / Hydralazine / cefepime
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
34 year-old man with hx brittle DM1 c/b HD-dependent ESRD now
admitted with sympomatic early-monrning hypoglycemia, BS 15.
.
Patient reports taking usual dose of lantus (10 units) at 11pm
on the night prior to admission and then he next remembers being
put in an ambulance. His girlfriend gave him glucose tablets
and called 911 because he he was "talking funny" and seemed
confused early that morning. He doesn't remember any of this.
EMS found the patient unresponsive with a FS of 15 - glucagon
and IV dextrose were administered.
.
In the ED the patient was hypertensive but otherwise had stable
VS. Initial FS was 179 & on repeat fell to 44. He was started on
D10W gtt. [**Last Name (un) **] was consulted in the ED and the patient was
admitted to the MICU for BS monitoring. Pt reports that he had
been taking his current insulin regimen for ~1 months without
hypoglycemia. Describes normal PO intake on the day prior to
admission (eats several small meals throughout the day to
prevent gastroparesis), perhaps less protein than usual. Denied
alcohol or drug use. No unusual exercise.
.
Of note, the patient was recently admitted from [**Date range (1) 1396**] for
CHF exacerbation that was notable for flash pulm edema due to
hypertension & required intubation for worsening mental status.
Patient also briefly required nitro drip and IV labetalol as
well as dialysis for blood pressure control. On that admission,
a bronchoscopy was concerning for alveolar hemorrhage, but [**Doctor First Name **],
ANCA and anti-GBM were negative and patient had no further
episodes of bleeding. Repeat echo on that admission showed an
improved EF of 55%. That hospital course was c/b initial
hyperglycemia then subsequent hypoglycemia requiring D20 gtt. On
the floor the patient was again hyperglycemic requiring high
doses of insulin prompting transfer bact to the MICU for insulin
gtt. [**Last Name (un) **] was consulted on that admission and recommended
increasing Lantus dose to 14units qAM and 12 units qPM. Patient
ultimately signed out AMA on [**3-2**].
Past Medical History:
- DM type I since age 19, followed at [**Last Name (un) **]. Complicated by
nephropathy, neuropathy, gastroparesis, retinopathy. Multiple
prior hospitalizations with DKA, nausea/vomiting [**2-9**]
gastroparesis
- ESRD on HD T/Th/S via right arm fistula @ [**Location (un) **] [**Location (un) **],
dry weight 73kg
- Hypoglycemia
- Hyperglycemia/DKA: requiring insulin gtt
- Hypertension
- Nonischemic cardiomyopathy with EF 30-35%
- Anemia: [**2-9**] iron deficiency and advanced CKD
- Depression
- Pulmonary hypertension
- Migraines
Social History:
Lives with girlfriend. Mother also local.
College degree in marketing, worked at [**Company 2475**] previously.
Tobacco: trying to quit; relapsed and smokes ~1 pack per week
EtOH: previously drank heavily (30-40 drinks/week) but has not
used alcohol since [**2144-11-14**]
Denies other drugs.
Family History:
Paternal grandfather had DM2. [**Name2 (NI) **] FH DM1. Hypertension in a few
family members. [**Name (NI) 6419**] [**Name2 (NI) **] and several siblings alive and
healthy, without known medical problems.
Physical Exam:
MICU ADMISSION EXAM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact, no SI
.
DISCHARGE EXAM
VS 98.1 138/95 76 18 97/RA FS 104
GEN: well-appearing young man walking around comfortably, fully
dressed, NAD
HEENT: NCAT, MMM, oropharynx clear, EOMI, PERRL, no JVD
CV: RRR, normal S1/S2, no mrg
Lungs: good aeration throughout, no w/r/r
Abdomen: soft NT ND NABS
Ext: WWP, thin legs, 2+ palpable pulses no edema
Neuro: AOX3, CNII-XII intact, 5/5 strength throughout, gait
stable
Pertinent Results:
MICU ADMISSION LABS
[**2147-4-7**] 08:10AM BLOOD WBC-11.1*# RBC-3.82*# Hgb-11.7*#
Hct-37.5*# MCV-98# MCH-30.7 MCHC-31.2 RDW-14.7 Plt Ct-241
[**2147-4-7**] 08:10AM BLOOD Neuts-84.8* Lymphs-7.4* Monos-2.3
Eos-4.7* Baso-0.7
[**2147-4-7**] 08:10AM BLOOD Glucose-112* UreaN-19 Creat-6.6*# Na-137
K-3.6 Cl-94* HCO3-29 AnGap-18
.
OTHER PERTINENT LABS
[**2147-4-8**] 05:32AM BLOOD Cortsol-15.9
[**2147-4-7**] 08:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
DISCHARGE LABS
[**2147-4-9**] 06:40AM BLOOD WBC-4.5 RBC-3.42* Hgb-10.6* Hct-33.5*
MCV-98 MCH-30.9 MCHC-31.5 RDW-14.2 Plt Ct-282
[**2147-4-9**] 06:40AM BLOOD Glucose-69* UreaN-18 Creat-6.1*# Na-138
K-4.0 Cl-95* HCO3-32 AnGap-15
[**2147-4-9**] 06:40AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.1
.
MICRO - NONE
.
IMAGING
.
[**2147-4-7**] CXR
IMPRESSION:
1. Baseline cephalization of pulmonary vascularity and
cardiomegaly but no evidence for superimposed acute disease.
2. Suspected nipple shadow projecting over the left mid lung.
However, for confirmation, a repeat PA view with the nipple
markers is recommended when clinically appropriate.
Brief Hospital Course:
34M w/hx type 1 diabetes mellitus c/b gastroparesis,
HD-dependent ESRD and chronic systolic heart failure (with
recent documented recovery of EF) brought to the ED by EMS
after being found confused at home with a BS 15. Hospital course
was notable for hypo and hyperglycemia. Patient left AMA prior
to insulin regimen stabilization.
.
#SYMPTOMATIC HYPOGLYCEMIA/Diabetes mellitus type 1:
Patient was initially admitted to the MICU where he was
monitored and given D10 until blood sugars consistently above
100 (137-295). Pt reported no change in diet, alcohol
consumption or exercise to explain different response to usual
insulin dose. Pt history and OMR notes suggested long history of
difficulties controlling labile BS and admission for both hypo
and hyperglycemia. He was followed closely by the [**Last Name (un) **] consult
service in house, who recommended 8U lantus [**Hospital1 **] + humalog
sliding scale. This plan was applied for ~36h with no marked
change in lability of QACHS BS which ranged from 23 to >500.
Plan was for pt to stay inpatient for further insulin dose
adjustment, but pt decided to leave AMA prior to any further
changes. In addition, because pt was very uncomfortable using
*any* qHS lantus at home given his recent hypoglycemic episode,
[**Last Name (un) **] consult adjusted their regimen to 14U lantus qAM +
humalog sliding scale. Risks of leaving the hospital prior to
insulin regimen stabilization were discussed with the patient,
who understood. He was given a printout of final insulin scale
prior to leaving the hospital. Will need close outpatient
follow-up with [**Last Name (un) **] diabetologist and PCP.
.
# [**Name (NI) 40903**] ESRD
Pt's HD schedule is T/Th/S via right arm fistula (dry weight
73kg). Euvolemic on admission, underwent HD on [**4-8**]. All meds
were dosed renally.
# HTN
Hypertensive in MICU on admission. Home [**Month/Day (4) 40899**] patch,
labetalol, lisinopril, amlodipine were restarted.
# CARDIOMYOPATHY, CHRONIC SYSTOLIC HEART FAILURE EF 30-35%
Secondary to long-standing and poorly controlled hypertension.
Euvolemic on admission. Currently asymptomatic, without dyspnea,
hypoxia or exam evidence of volume overload. Continued on ASA
and Labetalol.
.
# HX DIABETIC GASTROPARESIS
On PRN zofran and dilaudid at home. No symptoms during this
admission. Ate regular meals.
.
TRANSITIONAL ISSUES
Pt needs close BS/insulin regimen follow-up. He was instructed
to call his PCP and [**Name9 (PRE) **] [**Name9 (PRE) 766**] morning - we will also attempt
to schedule these appointments for him and communicate details.
Medications on Admission:
amlodipine 10 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO once a day.
aspirin 81 mg Tablet, Chewable [**Name9 (PRE) **]: One (1) Tablet, Chewable PO
DAILY (Daily).
[**Name9 (PRE) 40899**] 0.3 mg/24 hr Patch Weekly [**Name9 (PRE) **]: One (1) Patch Weekly
Transdermal QMON (every [**Name9 (PRE) 766**]) - every friday per patient.
insulin glargine 100 unit/mL Solution [**Name9 (PRE) **]: Fourteen (14) units
Subcutaneous In the morning.
insulin lispro 100 unit/mL Solution [**Name9 (PRE) **]: Sliding scale units
Subcutaneous With meals and at bedtime: home sliding scale.
B complex-vitamin C-folic acid 1 mg Capsule [**Name9 (PRE) **]: One (1) Cap PO
DAILY (Daily).
lisinopril 40 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO once a day.
sevelamer carbonate 800 mg Tablet [**Name9 (PRE) **]: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
sertraline 100 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO once a day.
hydromorphone 4 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO every twelve
(12) hours as needed for pain.
ondansetron 4 mg Tablet, Rapid Dissolve [**Name9 (PRE) **]: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
labetalol per patient 600mg [**Hospital1 **], 300mg qhs
Discharge Medications:
1. amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. [**Hospital1 40899**] 0.3 mg/24 hr Patch Weekly [**Hospital1 **]: One (1) Patch Weekly
Transdermal qMONDAY.
4. insulin glargine 100 unit/mL Solution [**Hospital1 **]: Fourteen (14)
units Subcutaneous qAM.
5. insulin lispro 100 unit/mL Solution [**Hospital1 **]: as directed
Subcutaneous QACHS.
6. B complex-vitamin C-folic acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
7. lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
8. sevelamer carbonate 800 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. sertraline 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
10. hydromorphone 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day) as needed for pain.
11. ondansetron HCl 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
12. labetalol 200 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2
times a day).
13. labetalol 100 mg Tablet [**Hospital1 **]: Three (3) Tablet PO QHS (once a
day (at bedtime)).
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 21822**],
You were admitted to the hospital for blood sugar of 15. You
stayed overnight in the ICU for blood sugar monitoring. Your
blood sugars were very labile - ranging from the 70s to 500s.
Last night your blood sugar dropped from >500 to 29 over 5 hours
because of "insulin stacking" - taking too much insulin over a
few hours.
Because your blood sugars are so unstable, we recommended
staying in the hospital for further insulin dosing modification
and observation.
You are leaving against medical advice.
The attending physician discussed [**Name9 (PRE) 40904**] risks of high
and low blood sugars with you, including confusion, lethargy,
fainting and coma. You were aware of these risks and decided to
leave anyway.
We spoke with the [**Last Name (un) **] diabetes doctors before [**Name5 (PTitle) **] [**Name5 (PTitle) **].
Since you are not willing to take long-acting insulin at night,
they recommended taking 14 units of long-acting insulin (Lantus)
each morning. You should continue using a short-acting insulin
before meals and at bedtime.
We did not make any other changes to your medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You need to see your primary care doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] doctor
before Friday.
.
Please call Dr.[**Name (NI) 40905**] office [**Name (NI) 766**] morning to schedule an
appointment within the next week:
.
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24385**] and/or Dr. [**First Name (STitle) **] RIND
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]
.
Please call [**Last Name (un) **] to schedule an appointment with Dr. [**Last Name (STitle) 978**].
We will also call them to ask them to call you with an
appointment, since you have had trouble scheduling appointments
there on short-notice in the past.
Name: [**Last Name (LF) 978**], [**First Name7 (NamePattern1) 7208**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
|
[
"40391",
"V5867",
"311",
"4168",
"4280",
"3051"
] |
Admission Date: [**2185-8-7**] Discharge Date: [**2185-8-11**]
Date of Birth: [**2105-10-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
HYPOTENSION
Major Surgical or Invasive Procedure:
Right internal jugular central venous catheter placement
History of Present Illness:
Patient is a 79 yo M with a history of respiratory failure and
chronic vent dependence who presented from OSH with hypotension
coupled with history of fever and leukocytosis.
Per report the patient was at his facility and found to have
febrile and congested treated with lasix as CXR showed fluid
overload with possible pneumonia. However, he became hypotensive
and required pressor support. There were no MICU beds at OSH and
was transferred to [**Hospital1 18**].
While in the [**Hospital1 18**] ED, the patient was treated with pressors
(levophed) and ceftazadime as well as kayexelate for
hyperkalemia.
.
Upon arrival to the MICU, the patient was asymptomatic without
shortness of breath, chest pain, headache, fever, chills, nausea
or vomiting. He was able to communicate with mouthing words.
He became tachycardic to the 140s with atrial flutter with
persistent hypotension. For this he was changed to phenylephrine
and given IV fluids
Past Medical History:
Pulmonary hypertension, COPD, CVA, Gout
Social History:
history of tobacco x 50 years, quit 22 years ago, no current
alcohol use, prior to admission in [**Month (only) 205**] lived at home with his
wife.
Family History:
NC
Physical Exam:
T 100.1 BP:116/56 RR: 26 02 98% Vent (AC 550x12 Fi02 0.65 PEEP
10)
GEN: alert and oriented to hospital, person
HEENT: OP clear, MMM
Neck: right IJ placed
CV: tachycardic, regular
Pulm: rhonchi bilaterally with decreased breath sounds on the
right
Abd: soft, nd, nd, PEG with slight drainage around are with mild
erythema
Ext: 1+ edema LE, RUE 2+ edema, LUE 1+ edema
Neuro: moves all extremities on command
Psych: appropriate
Pertinent Results:
[**2185-8-7**] 03:03AM BLOOD WBC-20.5* RBC-2.65* Hgb-8.6* Hct-26.6*
MCV-101* MCH-32.3* MCHC-32.2 RDW-19.4* Plt Ct-153
[**2185-8-11**] 05:06AM BLOOD WBC-22.8* RBC-2.84* Hgb-9.2* Hct-27.9*
MCV-98 MCH-32.2* MCHC-32.8 RDW-20.9* Plt Ct-147*
[**2185-8-7**] 03:03AM BLOOD Neuts-88* Bands-3 Lymphs-1* Monos-6 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2185-8-7**] 03:03AM BLOOD PT-24.1* PTT-33.9 INR(PT)-2.4*
[**2185-8-7**] 03:03AM BLOOD Plt Ct-153
[**2185-8-9**] 05:05AM BLOOD Ret Aut-1.5
[**2185-8-7**] 03:03AM BLOOD Glucose-139* UreaN-64* Creat-1.5* Na-147*
K-5.7* Cl-110* HCO3-30 AnGap-13
[**2185-8-11**] 05:06AM BLOOD Glucose-165* UreaN-33* Creat-1.2 Na-142
K-4.0 Cl-109* HCO3-26 AnGap-11
[**2185-8-7**] 03:03AM BLOOD ALT-26 AST-20 CK(CPK)-24* AlkPhos-57
Amylase-90 TotBili-0.4
[**2185-8-7**] 03:03AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2185-8-7**] 01:02PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2185-8-7**] 03:03AM BLOOD Albumin-2.3* Calcium-8.1* Phos-3.2
Mg-2.9*
[**2185-8-8**] 03:53AM BLOOD calTIBC-129* VitB12-453 Folate-11.5
Ferritn-1587* TRF-99*
[**2185-8-10**] 04:50AM BLOOD Vanco-14.2
[**2185-8-11**] 05:06AM BLOOD Vanco-22.0*
[**2185-8-7**] 03:33AM BLOOD Lactate-2.4*
[**2185-8-10**] 08:46AM BLOOD Lactate-1.8
Initial KUB:
FINDINGS: Nonspecific dilated loops of small bowel are seen,
extending up to approximately 4 cm in diameter, which is similar
in degree when compared to the study of [**2185-7-26**]. A gastrostomy
tube is again seen, with the balloon at the tip projecting over
what is presumed to be the gastric bubble. No contrast was
administered through the tube to verify tube location. There is
a somewhat unusual appearance of the left femoral head,
presumably secondary to patient positioning.
IMPRESSION: Gastrostomy tube balloon and tip projects over what
is presumed to be the gastric bubble. Higher confidence in
localization could be obtained by obtaining a radiograph after
injecting the tube with contrast.
.
CT CHEST W/CONTRAST [**2185-8-8**] 2:55 PM
CT CHEST W/CONTRAST
Reason: eval for interstitial lung disease vs chf
Field of view: 40 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with unclear history asbestosis and COPD, recent
PEA arrest, difficult to wean vent, readmitted with VAP, need to
further delineate lung disease
REASON FOR THIS EXAMINATION:
eval for interstitial lung disease vs chf
CONTRAINDICATIONS for IV CONTRAST: None.
CT CHEST
REASON FOR EXAM: Difficult to wean from vent.
TECHNIQUE: Multidetector CT through the chest following
administration of IV contrast. Five, 1.25 mm collimation images
and coronal reformations were provided and reviewed.
FINDINGS: Tracheostomy tube is in standard position. Multiple
lymph nodes in the prevascular, pretracheal, subcarinal and in
the hila bilaterally measure up to 11 mm in the subcarinal
station. Layering moderate - size bilateral pleural effusions
are nonhemorrhagic and associated with adjacent relaxation
atelectasis. There is no pneumothorax. The airways are patent to
segmental level. Very dense calcifications are in the left main,
LAD, left circumflex and right coronary arteries. There is
moderate cardiomegaly. There is no pericardial effusion. The
aorta is normal in caliber. Ground glass opacity, and
interlobular septal thickening in the upper lobes are consistent
with interstitial pulmonary edema. Ill-defined multifocal areas
of consolidation in the right upper lobe are likely infectious
in origin. There is paraseptal emphysema.
There are no bone findings of malignancy.
The imaged portion of the upper abdomen shows no abnormalities.
IMPRESSION:
1. CHF.
2. Multifocal areas of consolidation in the right upper lobe are
likely due to infectious process.
3. Bilateral pleural effusions.
3. Coronary calcifications.
4. Moderate cardiomegaly.
5. Reactive lymphadenopathy.
.
Last CXR [**8-10**]
CHEST, SINGLE VIEW: Again there is a right internal jugular
catheter with its tip projecting over the distal SVC and
tracheostomy tube in unchanged standard position. Persistent
cardiomegaly. Nontypical interstitial edema suggesting
coexisting emphysema. Layering effusions, right greater than
left, appear marginally increased on today's study.
IMPRESSION: Equivocally increased layering bilateral pleural
effusions. Essentially unchanged nontypical interstitial edema
with likely underlying emphysema.
Brief Hospital Course:
79 yo M with COPD, vent dependence who presents with pressor
dependent hypotension
Sepsis: Patient with persistent hypotension and not responsive
to pressors. Given leukocytosis with left shift and history of
fever, infection is likely. Was initiall treated with broad
spectrum antibiotics and improved however, pressor requirement
again increased several days later and antibiotics were
continued.
Patient was given fluids but began to develop volume overload
.
#) ID: Likely secondary to infection in lungs, though other
sources of infection cannot be ruled out especially given that
the chest x-ray was no significantly different than [**7-30**].
Sputum culture showed pansensitive PSEUDOMONAS AERUGINOSA
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHIDA.
.
#) Cardiac:
- Rhythm:A fib/ flutter: appears to go in and out of this.
Continued on amiodarone.
- Pump: Has likely diastolic dysfunction at baseline. Does have
signs of fluid overload on exam though with low CVP and likely
low filling pressures. Also with possible HOCM on last echo.
Therefore, may be very preload dependent explaining why patient
is sensitive to hypotension.
Diuresis was attempted but patient did not tolerate it and
required fluid boluses
- CAD: no signs CAD currently though does have slight troponin
leak. Will continue to follow ECGs.
.
#) Pulmonary hypertension/vent dependence: Unclear etiology and
treatment. Appears to be on sidenifil at baseline though
pulmonary pressures are not significantly elevated on echo.
Likely has multifactorial lung disease given appearance of
asbestos exposure, pulmonary hypertension and smoking history.
Suspect COPD component as well. These issues ultimitely
worsened and given his overall status was difficult to treat
.
#) Anemia: Chronically anemic suspect secondary to chronic
disease and poor nutrition status.
No clear signs bleeding
.
#) ARF: slight increase in creatinine, likely seconary to
hypovolemia with prerenal azotemia.
.
#) History of thrombus: per records, the patient has a left IJ,
SCV clot. Was on anticoagulation on admission
.
#) FEN: intravascularly hypovolemic, lytes ok now but was
hyperkalemic, will check serially, no tube feeds for now as the
patient has poor PEG treatments.
.
#) PPX: therapeutic on coumadin, pneumoboots
#) Access: right IJ, right PICC
#) DNR: as discussed with patient, no shocks, no cpr, ok with
pressors.
#) Comm with patient, wife.
Patients overall status continued to decline and the decision
was made with the family and patient (who remained intact for
most of the end of his life). The decision was made not to
escalate care (from vent and 1 pressor). Infortunately the
patient died on [**8-11**]
Medications on Admission:
([**First Name8 (NamePattern2) **] [**Hospital1 487**] gen record)
Atrovent
Albuterol
Beclomethasone 80 mcg [**Hospital1 **]
Pepcid 20 mg [**Hospital1 **]
Nystatin
Percocet 5/325
Sildenafil 25 mg tid
reglan 10 mg QID
Coumadin 1 mg daily
amiodarone 400 mg daily
metoprolol tartrate 12.5 mg daily
Linezolid 70 mg sc daily
lasix 40 mg daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
- COPD w/pulmonary hypertension, chronic vent (since [**7-18**])
- PEA arrest
- CHF (EF >75%, diastolic)
- Anemia with previous transfusions
- PAF with occasional flutter and MAT; s/p cardioversion x3,
currently rhythm controlled with amiodarone and on coumadin
- Asbestosis
- gout
- stroke in [**2178**] (patient reports no persistent deficits)
Discharge Condition:
expired
Discharge Instructions:
N/a
Followup Instructions:
N/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"496",
"42731",
"4280",
"2760",
"51881",
"486",
"4168"
] |
Admission Date: [**2167-12-22**] Discharge Date: [**2167-12-28**]
Date of Birth: [**2085-11-27**] Sex: F
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Ruptured AAA
Major Surgical or Invasive Procedure:
[**2167-12-22**] Open repair of ruptured abdominal aortic aneurysm with
Dacron 16-mm tube graft.
History of Present Illness:
82 F with known AAA presented to [**Hospital6 5016**] with acute
onset of R. sided flank and back pain that started at 7 AM
today. Non-contrast CT scan showed a contained leak and she was
transferred to [**Hospital1 18**] for further care.
Past Medical History:
COPD on 3L home O2, CHF, asthma, known AAA
PSH: L. CEA
Social History:
2 children, 6 grandchildren
Family History:
N/C
Physical Exam:
PE: T: 99.5 BP: 142/73 HR: 68 Sats: 98% #LN
A&O x 3, very pleasant female in NAD
EOMI, anicteric sclera
Neck supple, no masses
RRR, no MRG, +S1, S2
CTAB
Abdomen soft, NT, ND. Midline incision clean, dry and intact
Bilateral femoral pulses 2+, pedal pulses dopperable
Feet warm bilaterally
No LE edema
Pertinent Results:
[**2167-12-27**] 04:00AM BLOOD WBC-10.3 RBC-3.41* Hgb-9.9* Hct-28.3*
MCV-83 MCH-29.0 MCHC-34.9 RDW-15.9* Plt Ct-134*
[**2167-12-26**] 04:51AM BLOOD WBC-12.6* RBC-3.59* Hgb-10.1* Hct-29.7*
MCV-83 MCH-28.2 MCHC-34.1 RDW-16.2* Plt Ct-92*
[**2167-12-27**] 04:00AM BLOOD Plt Ct-134*
[**2167-12-26**] 04:51AM BLOOD Plt Ct-92*
[**2167-12-27**] 04:00AM BLOOD Glucose-95 UreaN-22* Creat-1.0 Na-138
K-4.7 Cl-97 HCO3-36* AnGap-10
[**2167-12-26**] 09:36PM BLOOD K-3.7
[**2167-12-25**] 06:55PM BLOOD CK(CPK)-474*
[**2167-12-25**] 06:55PM BLOOD CK-MB-9 cTropnT-0.12*
[**2167-12-25**] 11:02AM BLOOD CK-MB-12* MB Indx-2.1 cTropnT-0.13*
[**2167-12-27**] 04:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.0
[**2167-12-26**] 09:36PM BLOOD Calcium-8.4 Phos-3.1 Mg-2.0
[**2167-12-23**] 06:22PM BLOOD Type-ART pO2-94 pCO2-43 pH-7.39
calTCO2-27 Base XS-0
[**2167-12-24**] 12:06AM BLOOD Glucose-113* K-4.2
[**2167-12-24**] 12:06AM BLOOD O2 Sat-94
[**2167-12-24**] 03:41AM BLOOD freeCa-1.09*
[**2167-12-25**] 11:00AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2167-12-25**] 11:00AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
[**2167-12-25**] 11:00AM URINE RBC-[**11-27**]* WBC-0 Bacteri-FEW Yeast-MOD
Epi-0
[**2167-12-25**] 11:00AM URINE CastHy-0-2
[**2167-12-23**] 01:03AM URINE Hours-RANDOM UreaN-258 Creat-43 Na-126
[**2167-12-25**] 4:12 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2167-12-25**]**
GRAM STAIN (Final [**2167-12-25**]):
>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 [**2167-12-25**]):
TEST CANCELLED, PATIENT CREDITED
Brief Hospital Course:
[**2167-12-22**]
Patient was meflighted to [**Hospital1 18**] from [**Hospital3 **] with ruptured
AAA and flank pain. This was confirmed with CT. She was
emergently taken to the operating room with Dr. [**Last Name (STitle) **].
Tolerated the operation well. She was transferred to the ICU
post-operatively on neo and propofol. Hypothermic- on bear
hugger. Fluid resusitation with 4L bolus and continuous
infusion. Dopperable pedal pulses.
[**2167-12-23**]
Stable overnight. Vent weaned off and extubated. A-line in
place. Heparin SQ. Nitro infusing. IVF heplocked. Continue to
diuresis. BP stable.
[**2167-12-24**]
Transfer to VICU. Stable. OOB with PT. 3LNC Sat 98%.
[**2167-12-25**]
Tolerating clear diet. Continue diuresos. Pain control. Blood
cultures drawn and sent for elevated WBC. afebrile.
[**2167-12-26**]
Episode of Afib which converted with beta blockade. Recieved
1unit of PRBC for HCT of 26.4 due to blood loss during surgery.
CXR negative for pneumonia. Regular diet. All oral medications
started.
[**2167-12-27**]
Tolerating regular diet. Brief episodes of AF- converted to
sinus with increased BB.
[**2167-12-28**]
DC home with PT.
Medications on Admission:
combivent, pulmicort, cozaar, zyrtec, isosorbide,
prednisone, ASA (doses unknown)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for mild pain.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Inhalation [**Hospital1 **] ().
4. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Home Oxygen
Per home regimen of 3LNC continuous
17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Ruputured AAA (pre-op diagnosis)
COPD on 3L home O2
asthma
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:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-15**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-10**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over 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
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2168-1-13**] 3:00
Completed by:[**2167-12-28**]
|
[
"2851",
"42731",
"4280"
] |
Admission Date: [**2116-3-27**] Discharge Date: [**2116-4-8**]
Date of Birth: [**2049-5-10**] Sex: F
Service:
Emergency Department on [**3-26**] with abdominal pain and
cramping, which started at 5:00 a.m. on the 7th. This was
associated with loose stools without nausea or vomiting. She
denied passing flatus. She denied any fevers or chills. Of note,
the patient had been on steroids for severe rheumatoid arthritis.
had a similar event of pain like this approximately ten years
ago but she is a poor historian and cannot recall the
medical details surrounding this event.
PAST MEDICAL HISTORY: Significant for rheumatoid arthritis,
osteoporosis, chronic anemia, asthma, bronchitis, atrial
fibrillation, diabetes mellitus, chronic back pain,
questionable myocardial infarction in [**2093**].
PAST SURGICAL HISTORY: Right elbow surgery, left total knee
replacement. She had right kidney injury during a total
abdominal hysterectomy in [**2081**]. ALLERGIES: Aspirin and
Penicillin. MEDICATIONS ON ADMISSION: Albuterol, Alendronate,
Arava, Avandia, Beclomethasone, calcium carbonate, Celexa,
cyclobenzaprine, Enalapril, Glyburide, Klonopin, Lipitor,
multi vitamin, Prednisone, Vicodin prn, Vioxx, vitamin D,
Zantac and Soma.
PHYSICAL EXAMINATION:
98.8 138/96 94 18 99% RA
The patient appeared to be in no acute distress. There was no
evidence of jaundice. Her external ear, nose and throat exam was
normal. Her lungs were clear bilateral with normal effort. There
was occaisonal wheexing wiytih expiration. Her heart was regular
rate and rhythm. Her abdomen was distended but soft. She had mild
tenderness in the mid-epigastric region without guarding. There
was no evidence of hernias. Her incisions were well- healed. Her
extremities were warm and dry.
LABORATORY: White blood cell count of 8, hematocrit 30.8,
bicarbonate of 27. Liver function tests were within normal
limits. She had an abdominal x-ray, which showed some air fluid
levels in her small intestine and stool in the right colon with
air in the left colon, but no air in the rectum. Of note, there
were surgical clips in the right flank and in the right lower
quadrant. She had a chest x-ray, which showed a gastric air
bubble, but no free air and a clear chest.
CT of her abdomen was performed and showed a abdominal
aortic aneurysm, 3 cm in length, diverticulosis, a small
amount of free fluid in the right pericolic gutter. The
appendix was not well visualized. There was no free air.
HOSPITAL COURSE: She was admitted with an unclear etiology
of her abdominal pain. Given that her appendix was not
visualized the patient had a repeat scan, which was
significant for no further passage of contrast and the
patient was admitted for observation with likely bowel
obstruction. The patient at that time was explained the
risks and benefit of a nasogastric tube, however, the patient
refused nasogastric tube placement. After worsening of her
abdominal pain, which was significant it was discussed the
need for surgical correction for bowel obstruction. However,
the patient had several conversations with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **] as well as several of the surgical senior residents
and the patient felt she did not want to go ahead with
surgery, which was felt to be indicated at this time by the
surgical attending.
The patient then developed significant amounts of emesis,
approximately a liter. She was not passing flatus. She was
burping quite a bit and had some increasing abdominal pain.
A nasogastric tube was then finally agreed to and
approximately 1000 cc of bile was drained. She was finally
convinced to undergo surgery and on [**2116-3-28**] the patient was
taken to the Operating Room. Preoperative diagnosis was small
bowel obstruction. Postoperative diagnosis was small bowel
obstruction high grade with mildly ischemic bowel. She
underwent an exploratory laparotomy, lysis of adhesions, and
small bowel resection with a stapled anastomosis. Of note,
there was a high grade small bowel obstruction secondary to
an adhesion, which was presumed to be the cause of the
patient's symptoms. There was also a proximal Bezoar and the
intestine was found to be mildly ischemic, but not frankly
infarcted. The right ureter was also noted to have hydronephrosis
which appeared chronic.
Postoperatively, the patient remained in the Post Anesthesia
Care Unit for low urine output. The urology service was
consulted for the hydronephrosis. A post-operative CT scan
revealed worsening of the hydrophrosis. There was no
extravasation seen. Their subsequent plan was to obtain a repeat
ultrasound in 24 hours to see if there was any change in the size
of the hydronephrosis. The patient actually had two repeat
ultrasounds, which showed a slightly decrease in the size of
the right hydronephrosis. On postoperative day two, she was
moved to the floor. Her creatinine, which initially went up to
1.5 returned to her baseline of 1.1. She continued to be
followed by urology. We continued to await return of
bowel function to remove her nasogastric tube and started her on
TPN for nutritional support. She was also maintained on IV
Levofloxacin and Flagyl for the contamination at the time of her
bowel resections.
On postoperative day eight, the patient began to complain of
increased shortness of breath. She was treated with aggressive
pulmonary toilet and nebulizer treatments. A CXR revealed left
lower lobe opacities and likely atelectasis. Her abdomen also
appeared to be more distended but remained soft and non-tender. A
WBC was drawn and was elevated. Of note, she was maintained on IV
hydrocortisone for her preoperative Prednisone requirement. A CT
scan was ordered and the patient was transferred to the ICU for
invasive monitoring as her urine output began to decrease.
While placing the contrast through the NGT, the patient vomited
and aspirated. She suffered a respiratory and cardiac arrest
requiring chest compressions, intubation and pressors. On
arrival in the SICU, she required Levophed and dobutamine. She
was cardioverted for atrial fibrillation and treated with
amiodarone. She had continued high dose pressor requirement and
was switched from dobutamine to milrinone without benefit. She
was therefore switched back to dobutamine and a cardiology
consult was obtained. An ECHO revealed a reasonable cardiac
function. Unfortunately, the patient continued to require high
dose pressors and volume and became anuric. She became fluid
overloaded and it became increasing difficult to ventilate the
patient.
Numerous family meetings and discussions took place in regards
to how aggressive to be given her significant illness and poor
prognosis. The decision was made by the staff and family to not
pursue dialysis and therefore the patient was made comfort
measures only. With further discussion, the patient was
withdrawn from ventilatory and pressure support and she expired.
A postmortem was declined.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13187**]
|
[
"9971",
"5849"
] |
Admission Date: Discharge Date: [**2115-10-22**]
Date of Birth: Sex:
Service:
CHIEF COMPLAINT: Syncope and headache.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 94081**] is an 81-year-old
gentleman with a complicated past medical history who
presented from an outside hospital with a large subarachnoid
hemorrhage and subdural hematoma. The patient had a headache
a syncopal event with loss of consciousness for approximately
five minutes. He had no history of trauma. The patient may
have hit his head with the syncopal episode. The patient
does have mild baseline dementia which waxes and wanes.
PAST MEDICAL HISTORY: Shows a right parietal stroke in [**2115-4-13**], prostate cancer, coronary artery disease, carotid
disease, abdominal aortic aneurysm, polycystic kidney
disease, chronic renal insufficiency and renal artery
stenosis, congestive heart failure (with an ejection fraction
of approximately 35 to 40 percent) diagnosed in [**2115-5-14**],
and hypercholesterolemia.
PAST SURGICAL HISTORY: Shows a carotid endarterectomy in
[**2111-9-13**], abdominal aortic aneurysm repair in [**2104-10-13**], and a coronary artery bypass grafting in [**2103-10-14**].
MEDICATIONS ON ADMISSION: Aspirin 325 mg once daily, folic
acid 1 mg once daily, Lasix 40 mg two in the morning and one
in the evening, hydralazine 50 mg three times daily, Lipitor
40 mg once daily, Lopressor 100 mg twice daily, Plavix 75 mg
once daily, and Isordil 10 mg three times daily.
ALLERGIES: He had no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: The temperature was
98.4, the blood pressure was 116/33, the heart rate was 71,
the respirations were 18, and oxygen saturation was 95
percent on 3 liters nasal cannula. The patient was
lethargic. Arousable to stimulation. Followed simple
commands appropriately. Oriented times two - to person and
place. The pupils were equal, round, and reactive to light
and accommodation at 4 to 3 brisk. The extraocular movements
were intact. The face was symmetrical. The tongue was
midline. He had normal palate elevation. He was moving all
extremities. No pronator drift. Difficult to test strength
secondary to lethargy. Sensation was grossly intact. The
toes were upgoing bilaterally.
RADIOLOGIC STUDIES: A CAT scan did show a massive
subarachnoid hemorrhage and left subdural with rightward
subfalcine herniation.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to
Medicine Service for workup of syncope. An arterial line was
placed for blood pressure management. He was placed in a
hard collar. He was also seen in consultation by the Trauma
Service. Dr. [**First Name (STitle) **] [**Name (STitle) 739**], then Neurosurgery
attending, did have a long discussion with the family
regarding his situation and surgical versus nonsurgical
treatment, and all his comorbidities were also discussed.
Based on their wishes, he was to be treated aggressively
medically. His systolic pressure was to be maintained at 130
to 160.
He was admitted to the Intensive Care Unit for close
monitoring. He was started on Nipride to maintain the above-
mentioned blood pressure parameters. The next day he was
arousable, and verbal, and was following commands (left more
so than right) with a noticeable right hemiparesis. The
syncopal workup recommended ruling out myocardial infarction,
obtaining a transthoracic echocardiogram, cardiac monitoring;
which were all performed. The patient was also started on
Dilantin for seizure prophylaxis, and therapeutic levels were
maintained.
On [**10-15**], the patient was more lethargic and hard to
arouse. He did open to stimulation but was not following
commands. A repeat head CT was performed which was stable in
appearance. He did have a central line placed without
difficulty. He also had a cervical spine MRI to assess for a
ligamentous injury which showed no ligamentous disruption.
On [**10-17**], the patient's examination off propofol did
show some purposeful left upper extremity movements. He was
able to withdraw bilaterally in the lower extremities, but
little movement in the right upper extremity. His eyes were
opened and reactive. He did have a question of a pneumonia
seen on chest x-ray and was started on Levaquin. He was
getting tube feedings.
He was transfused with 2 units of packed red blood cells on
[**10-21**] for a hematocrit of 25.9. There was family
meeting with Dr. [**First Name (STitle) **] [**Name (STitle) 739**], and members of the
team, with the family on [**2115-10-21**]. The family did
request that the patient be made comfort measures only
secondary to his prognosis which at best was expected to
recover with significant impairment of functional mobility.
The patient did expire on [**2115-10-22**].
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2116-2-14**] 13:55:17
T: [**2116-2-14**] 18:53:27
Job#: [**Job Number 94082**]
|
[
"4280",
"42731",
"2760",
"4019",
"V4581"
] |
Admission Date: [**2129-5-13**] Discharge Date: [**2129-5-28**]
Date of Birth: [**2078-9-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Ace Inhibitors /
hydrochlorothiazide / Cyclobenzaprine / Norvasc
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Hypertensive crisis, Acute kidney injury
Major Surgical or Invasive Procedure:
Kidney biopsy
Initiation of hemodialysis
AV fistula placement in L arm
History of Present Illness:
50 yo F with h/o anxiety, panic disorder, HTN, and other medical
issues presents today with persistent headache and HTN. Patient
is transferred from [**Hospital1 **]-[**Location (un) 620**]. She was sent to [**Hospital **] from PCP's office because of markedly elevated BP.
Patient states that she has not been herself for several months.
She describes intermittent headache/migraine preceeding it, but
noticed visual changes a few months ago. She thought she was
starting to have migraine with aura. She described her vision
changes as having scintillating scotomata (zig-zag lines with
multiple colors that move). She states that she was on
lisinopril many years ago but developed cough. She was
prescribed HCTZ around [**2129-3-18**] for her BP and had significant
dizziness with it. She was subsequently switched to amlodipine
but had similar symptoms. Finally, she was switched to Cozaar
12.5 mg daily ([**2129-4-11**]). She reports persistent change in her
vision and it evolved to triangular shaped shadow in her left
eye (left lower visual field). The number of triangles
increased over time despite trials of antihypertensives, and she
thought it was the medications that was giving her the vision
changes. The triangles then spread to her right eyes too. They
then became "swiss cheese" like with holes. She also describes
being able to see these triangles with her eyes closed. She
states that her vision seems to be sharper when she focuses on
the gap between the triangles, which is unusual. She states
that she wears corrective lenses. She finally stopped her
Cozaar about 1 week ago.
Patient has had a headache 4 days prior to admission. It
started after a stressful episode dealing with a friend. It was
frontal and temporal, throbbing in nature. The intensity
increased over the course of the days. She was also
experiencing some lightheadedness, nausea, and blurry vision,
[**First Name8 (NamePattern2) **] [**Location (un) 620**] report. She thought it was a sinus infection and
went to the PCP first, but was sent to [**Location (un) 620**] given elevated
BP. She denies rhinorrhea, fever, photophobia, SOB, cough,
chest pain. Her VS at [**Location (un) 620**] were Temp: 98.2 HR: 100 BP:
208/141 Resp: 20 O(2)Sat: 99%. Neurological exam there was
reported to be unremarkable other than significant anxiety.
Labs were notable for WBC 10.9, Hgb 12, Hct 34.2, Plt 116, 85%
neutraphils, Na 132, K 3.2, Cl 90, Bicarb 28, BUN 65, Crt 5.37,
Ca 8.9, trop T 0.018. UA had 100 protein, and large blood with
[**4-7**] RBC, no WBC, and few bacteria. EKG showed NSR, < 1 mm STD
in II/aVF/V4-V6, no q waves, LVH. CT head showed subtle
hypodensities in the posterior white matter, most c/w probable
PRES syndrome and no evidence of hemorrhage. CXR was negative
for acute cardiopulmonary process. She was given 20 mg IV
labetolol x 2, then labetolol gtt (1 mg/min, 60 cc/hr), zofran 4
mg IV, and morphine 5mg IV.
In the [**Hospital1 18**] ED, initial VS were 97.3 77 164/95 18 95%.
Labetolol gtt was discontinued given stable BP. No additional
labs were drawn. Neurological exam was reported to be normal.
Patient was transferred to ICU for frequent neurological exams
and BP monitoring. Her transfer VS were 167/94, 83
On arrival to the MICU, patient's VS 98.2, 83, 151/87, 22, 99%
RA. She states that she also noticed that she is more easily
bruised lately. Her husband told nursing that he felt patient
was not herself for a couple of months but did not specify.
Review of systems:
(+) Per HPI. + constipation, thirst.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies rhinorrhea or congestion. Denies shortness of
breath, cough, dyspnea or wheezing. Denies chest pain, chest
pressure, palpitations. Denies abdominal pain, diarrhea, dark or
bloody stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes.
Past Medical History:
- HTN
- ADD
- Anxiety
- Post-partum panic disorder
- Fibromyalgia
- Chronic fatigue syndrome
- Asthma as a child
- seasonal allergy
- Migraine headache +/- aura
- history of cervical disc herniation
Social History:
- denies any history of tobacco use
- + marijuana use, but not any other illicit drugs
- occasional EtOH
- has 2 teenage children
- married
Family History:
- mother: migraine with aura, CAD, stroke
- father: had floaters, HTN, overweight
Physical Exam:
ADMISSION EXAM
Vitals: 98.2, 83, 151/87, 22, 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucous membrane dry, oropharynx clear,
EOMI, PERRLA
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, mild tenderness to the RUQ, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
normal sensation, 2+ reflexes bilaterally, gait deferred. +
diplopia with upward gaze. No obvious defect in visual fields.
alert and oriented x 3.
Psych: talkative, easily overwhelmed, somewhat of
circumferential
Skin: a couple small ecchymosis in various stage of healing over
her extremities
DISCHARGE EXAM
VS: Temp 98.3 F, BP 147/76, HR 72, R 16, O2-sat 94% (94-99%) RA
General: Alert, oriented, anxious, AO3x.
HEENT: Sclera anicteric, mucous membrane moist, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, no increased work of breathing
Abdomen: soft, ND, bowel sounds present, no organomegaly, no
rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Left arm antecubitus- bandage in place over fistula,
palpable thrill over fistula site.
Neuro: CNII-XII intact, normal gait
Pertinent Results:
ADMISSION LABS
[**2129-5-14**] 12:29AM BLOOD WBC-9.6 RBC-3.44* Hgb-9.7* Hct-26.7*
MCV-78* MCH-28.2 MCHC-36.3* RDW-14.7 Plt Ct-116*
[**2129-5-14**] 12:29AM BLOOD PT-10.4 PTT-28.9 INR(PT)-1.0
[**2129-5-14**] 12:29AM BLOOD Glucose-135* UreaN-66* Creat-5.3* Na-134
K-3.6 Cl-95* HCO3-24 AnGap-19
[**2129-5-14**] 12:29AM BLOOD ALT-16 AST-21 AlkPhos-49 TotBili-0.8
[**2129-5-14**] 12:29AM BLOOD Albumin-3.9 Calcium-8.1* Phos-5.4* Mg-2.1
Iron-50
[**2129-5-14**] 12:29AM BLOOD calTIBC-350 Ferritn-211* TRF-269
[**2129-5-14**] 06:50AM BLOOD CRP-15.4*
.
[**2129-5-27**] 09:32AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Schisto-OCCASIONAL
[**2129-5-27**] 07:29AM BLOOD LD(LDH)-238
[**2129-5-27**] 07:29AM BLOOD Hapto-155
[**2129-5-25**] 01:10PM BLOOD HBsAb-NEGATIVE
[**2129-5-14**] 06:50AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
[**2129-5-14**] 06:50AM BLOOD HCV Ab-NEGATIVE
[**2129-5-14**] 06:50AM BLOOD HCV Ab-NEGATIVE
[**2129-5-14**] 03:17PM BLOOD ANCA-NEGATIVE B
[**2129-5-18**] 12:06PM BLOOD [**Doctor First Name **]-NEGATIVE Cntromr-NEGATIVE
[**2129-5-18**] 12:06PM BLOOD RheuFac-12
[**2129-5-14**] 03:17PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40
[**2129-5-14**] 06:50AM BLOOD PEP-HYPOGAMMAG IgG-401* IgA-34* IgM-26*
IFE-NO MONOCLO
[**2129-5-14**] 06:50AM BLOOD C3-90 C4-40
[**2129-5-19**] 06:21PM BLOOD Metanephrines (Plasma)- Negative
[**2129-5-18**] 12:06PM BLOOD ADAMTS13 EVALUATION-98% (wnl)
[**2129-5-18**] 12:06PM BLOOD SCLERODERMA ANTIBODY-Negative
[**2129-5-18**] 12:06PM BLOOD ANTI-GBM-Negative
.
DISCHARGE LABS
[**2129-5-28**] 07:50AM BLOOD WBC-8.0 RBC-3.17* Hgb-9.0* Hct-26.4*
MCV-83 MCH-28.3 MCHC-34.0 RDW-15.1 Plt Ct-265
[**2129-5-28**] 07:50AM BLOOD Glucose-132* UreaN-36* Creat-6.1*# Na-135
K-4.3 Cl-95* HCO3-28 AnGap-16
[**2129-5-28**] 07:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
.
URINE STUDIES
[**2129-5-14**] 05:02AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2129-5-14**] 05:02AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2129-5-14**] 05:02AM URINE RBC-5* WBC-77* Bacteri-FEW Yeast-NONE
Epi-15
[**2129-5-14**] 05:02AM URINE Hours-RANDOM Creat-84 Na-49 K-29 Cl-45
TotProt-208 Prot/Cr-2.5* Albumin-PND
.
IMAGING
[**5-13**]
- CXR: PA and lateral views. Heart size is normal. Mediastinal
and hilar contours are unremarkable. There is no pulmonary
edema or pleural effusion. No evidence of a pulmonary
consolidation is seen. The imaged bones are unremarkable.
- CT head without contrast: There are subtle hypodensities in
the white matter of the posterior occipital lobes and posterior
periventricular regions. These findings can be seen in the
setting of PRES syndrome. There is no evidence of hemorrhage,
edema, mass, mass effect, or large vascular territory
infarction. The ventricles and sulci are normal in size and
configuration. The basal cisterns are patent. No fracture is
identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
1. SUBTLE HYPODENSITIES IN THE POSTERIOR WHITE MATTER MOST
CONSISTENT WITH PROBABLE PRES SYNDROME. MRI CAN BE OBTAINED FOR
FURTHER EVALUATION IF CLINICALLY INDICATED.
2. NO EVIDENCE OF HEMORRHAGE.
EKG:
[**5-13**] EKG showed NSR, < 1 mm STD in II/aVF/V4-V6, no q waves,
LVH
RUS [**2129-5-15**]
IMPRESSION:
1. No evidence of renal artery stenosis with normal wave forms.
Slightly
greater right sided RI measurements likely reflect technically
more limited left sided assessment.
2. Focal area of hypoechogenicity seen in the upper pole of the
right kidney can be reassessed during US guided renal biopsy
planned for [**5-16**]. If not, non-contrast MRI can be considered.
3. Diffusely echogenic kidneys suggest medical renal disease.
.
TTE
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 5-10 mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**11-29**]+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade.
Brief Hospital Course:
50 yo F with a history of HTN, anxiety, panic disorder who
presented with persistent headache with visual changes and
elevated BP to 210s/140s.
#Malignant Hypertension: On admission the patient's blood
pressure was significantly elevated to SBP>210 and DBP>140. She
had evidence of PRES (posterior reversible encephalopathy
syndrome) (see below), retinopathy (see below), and acute renal
failure (see below). She was initially started on labetolol gtt
in the ICU to bring down her blood pressure and was eventually
stabilized on labetolol 300 mg TID, with SBP ranging 110s-140s
and DBP 50s-70s on discharge. The etiology of the malignant HTN
is most likely poorly controlled primary HTN, worsened by OCP,
Neurontin, and Adderall use; OCPs, Adderall, and Neurontin were
held. Work up of secondary causes is thus far negative, with
negative serum metanephrines, no evidence of RAS. [**Male First Name (un) **]/renin is
still pending. Work up for causes of primary renal failure were
negative (see below).
.
#Acute Renal Failure: The patient developed acute renal failure
with Cr reaching 9.2; the patient was hypoxic with significant
SOB and had emergent HD. A tunneled line was placed and she was
stabilized on a MWF dialysis schedule which will be continued
outpatient, with significant improvement in hypoxia and SOB.
Lung exam clear on discharge. AV fistula was placed for chronic
HD, and a nutrition consult was obtained for ESRD dietary
counseling. Significant work up for causes of renal failure were
negative. Note initial labs showed low haptoglobin and elevated
LDH, raising concern for TTP; however, smear showed no schistos,
and repeat LDH and haptglobin were wnl the day prior to
discharge. Negative work up includes: negative hepatitis
virologies (HBV/HCV negative), normal complements, [**Doctor First Name **] neg
(originally [**Doctor First Name **] 1:40), negative ANCA, negative anti-centromere,
smear w/o schisto's, negative SPEP/UPEP, renal US w/o RAS,
ADAMTS13 wnl, negative anti-Scl, negative anti-GBM, negative
cryocrit. Kidney biopsy was consistent with thrombotic
microangiopathy likely in the setting of malignant hypertension.
.
#PRES: Head CT was concerning for PRES, MRI was consistent with
mild PRES. Treatment is BP control. The patient's neuro exam was
stable throughout admission, with persistent visual field
deficits but otherwise unremarkable.
.
#Retinopathy: The patient had bilateral papilledema and cotton
wool spots, likely [**12-30**] malignant HTN; ophthalmology was
consulted. Ophthalmology recommended that blood pressure control
was the only therapy, with plans for formal outpatient visual
field testing on discharge. The patient continued to have visual
field deficits, somewhat waxing and [**Doctor Last Name 688**], throughout her
hospital stay and on discharge.
.
# Anemia: Likely multifactorial with some contribution of her
renal failure, chronic inflammation. There was initial concern
for hemolysis due to low haptoglobin and milidly elevated LDH;
however, she had normal tbili and no schistos on smear.
Vasculitis work up was also done, with ANCA returning negative.
Iron panel without evidence of iron deficiency. The day prior to
discharge, her Hct dropped to 22 and she was symptomatic with
feelings of lightheadedness on walking. Repeat LDH, hapto, and
smear were within normal limits. She was given one unit of PRBC,
with Hct of 26 the morning of discharge and improvement in
symptoms.
.
# ADHD: Home Adderall was held given HTN. Stable throughout
admission.
# Anxiety: She was continued on her home clonazepam. Note
anxiety appeared to contribute to feelings of shortness of
breath.
.
# Hyponatremia: Low Na on admission, most likely hypervolemic
hyponatremia. Improved with HD to 135 on discharge.
.
#Transitions:
1) Follow up [**Male First Name (un) 2083**]/renin, pending
2) Hemodialysis MWF indefinitely
3) Follow up appointments scheduled with Nephrology, Transplant,
Neurology, Ophthalmology
4) OCPs, Adderall, and Neurontin discontinued; will need to
avoid medications that may exacerbate HTN in the future.
Medications on Admission:
- Adderall 20 mg [**Hospital1 **]
- clonazepam 0.5 mg daily
- flonase prn
- neurontin 300 mg QD
- Zovia 1/35 daily
- Cozaar 12.5 mg, stopped for about 1 week
Discharge Medications:
1. Calcium Acetate 667 mg PO TID W/MEALS
RX *calcium acetate 667 mg 1 Capsule(s) by mouth TID with meals
Disp #*90 Tablet Refills:*0
2. Clonazepam 0.5 mg PO DAILY
hold for sedation, RR<10
3. Labetalol 300 mg PO TID
hold for sbp < 110, hr<60
RX *labetalol 300 mg 1 Tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
4. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid 400 mcg 1 Tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
5. Lorazepam 0.5-1 mg PO WITH DIALYSIS anxiety
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth with dialysis
Disp #*10 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute renal failure
Hypertension with end organ damage
Anemia
Thrombocytopenia (resolved)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 4334**],
It was a pleasure participating in your care here at [**Hospital1 18**]. You
were admitted because of very high blood pressure, kidney
failure, retinopathy, and headaches. You were seen by Neurology,
Hematology, Nephrology, and Ophthalmology services. You were
retaining fluid due to your impaired kidney function and
developed fluid in your lungs and shortness of breath. For this
reason, you started hemodialysis, with improvement in your
breathing. You have been set up on a MWF dialysis schedule. A
fistula was placed while you were here for future outpatient
dialysis.
You had a kidney biopsy which showed damage likely due to high
blood pressure. Many lab tests were checked to determine if
there was a cause of kidney damage other than high blood
pressure, and these tests were all negative. Several tests were
done to determine if there was a cause for your high blood
pressure, and these tests were all negative as well. One test
is still pending (aldosterone/renin) and you should follow up
with your outpatient doctors about this [**Name5 (PTitle) **].
You were also noted to have low blood counts, called anemia. You
received one unit of blood. They will recheck your blood counts
at dialysis.
Please make the following changes to your medications:
# START labetalol 300 mg three times a day
# START ativan as needed with dialysis
# START calcium acetate 667 mg three times a day with meals
# START vitamin complex daily
Followup Instructions:
Department: Ophthalmology
With: Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **]
When: Please call the office number below to schedule a follow
up appointment for 9-15 days after your hospital discharge.
Building: [**Hospital1 69**]-[**Hospital Ward Name 23**] Bldg [**Location (un) 6332**]
Address: [**Location (un) **]., [**Location (un) 86**], MA
Phone: ([**Telephone/Fax (1) 5120**]
Department: Nephrology
Name: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]
When: You will be followed by your nephrologist, Dr. [**First Name (STitle) 805**]
during your upcoming dialysis appointment.
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Department: TRANSPLANT CENTER
When: THURSDAY [**2129-6-9**] at 2:45 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: WEDNESDAY [**2129-7-20**] at 4:30 PM
With: DRS. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] & [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone: [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2129-5-30**]
|
[
"5849",
"2761",
"2875"
] |
Admission Date: [**2178-3-24**] Discharge Date: [**2178-4-4**]
Date of Birth: [**2095-5-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Bronchoscopy ([**2178-3-31**])
PICC line placement ([**2178-4-3**])
History of Present Illness:
82 yo M with h/o COPD, AS s/p AVR, afib, right nephrectomy for
RCC, colon ca s/p colectomy admitted with cough and shortness of
breath.
Patient had a recent admission [**2178-3-6**] - [**2178-3-17**] for community
acquired pneumonia right middle and lower lobe, pleural effusion
drained 800ccs (transudative) and melena (no scope due to
respiratory status, discharged on H. pylori treatment). CT torso
demonstrated right pre-bronchial and pretracheal mild adenopathy
with narrowing or part opacification of the right lower lobe
bronchus that could suggest mass. On [**2178-3-24**] patient followed up
at outpatient GI appointment found to have temp 100.2 with
persistent SOB and cough. CXR showed RLL consolidation and
smaller pleural effusion. Patient was given one dose of
Levofloxacin, but antibiotics held as infection felt less
likely. LENI demonstrated new thrombosis in branch of popliteal
vein. CTA [**2178-3-25**] done to r/o PE demonstrated RLL and RML
consolidation recurrence associated retrocrural and extrapleural
adenopathy suspicious for malignancy. Pulmonary consulted and
recommended bronch to evaluate airways and biopsy node (done
today). During admission patient also had a slowly drifting down
HCT - GI consulted and prep was attempted however not completed.
Patient developed abdominal pain from partially obstructed
ventral hernia whic was reproducible, followed by surgery and
improved on repeat imaging. Patient started spiking temperatures
[**3-28**] - work up involved blood cx, urine cx, c. diff, repeat CT
scan which only revealed RLL/RML opacities. ID consulted and
suspected post-obstructive pneumonia that may have been
partially treated and recommended bronch BAL.
Bronchoscopy [**2178-3-31**] demonstrated diffuse TBM, thickened mucosa
of RML and RLL, performed BAL and brushings RLL of superior
segment as well as EBUS TBNA (Transbronchial Needle Aspiration).
Patient was given versed and fentanyl. Around 10 pm night float
was called for acute respiratory distress. Patient 65% on 4 L
(following procedure on 4 L, baseline 2 L), BP 120/60, HR 105,
RR 34. He was given 40 mg laisx and CXR demonstrated white out
right lung concerning for atelactasis/mucus plugging. ABG on 4 L
7.32/58/53. Respiratory suctioned thick sputum. Patient
continued to be in respiratory distress and consequently
transferred to the MICU for care. Repeat CXR and ABG improved
7.31/56/70 (FiO2 70%).
Past Medical History:
1. Congestive heart failure
- Echo ([**9-26**]) with Mild symmetric LVH with normal cavity size
and global systolic function (LVEF>55%). Mild MR; Moderate TR
- Cath ([**1-28**]) with dilated left ventricle with significant
generalized hypokinesis and a global ejection fraction of 28%
(while the patient is in atrial flutter).
2. COPD- moderate to severe per Dr. [**First Name (STitle) **] (PCP)
3. Hypertension
4. s/p AVR for aortic stenosis
5. Atrial fibrillation, cardioversion ([**5-25**])
6. s/p splenic artery aneurysm resection/splenectomy ([**7-26**])
7. GERD
8. History of RCC s/p left nephrectomy ([**8-26**])
9. History of colon cancer status post colostomy ([**9-/2160**])
10. History of B12 deficiency
11. History of ITP
Social History:
Lives with his wife in [**Location (un) 538**]. He quite smoking in [**2172**].
30 etoh per week. Retired electrician. ID note at [**Hospital1 18**] from
[**2172**] documents he had been PPD negative and without TB risk
factors; he confirms he has not been exposed to anyone with TB
to his knowledge. No animal contacts. Was in the Navy many years
ago with travel to [**State 18559**] and [**State 8842**] but not to [**Female First Name (un) 8489**] or [**Country 480**]. No
prison exposure. Limited travel outside [**Location (un) 86**] in recent years.
Family History:
Noncontributory.
Physical Exam:
Vitals: 97.1, 104, 111/64, 20, 98/ 70% Face tent with 5L/NC
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: crackles in RML/RLL, diffuse wheezing
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: large hernia, positive bowel sounds, soft, very mild
diffuse tenderness, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema b/l R>L
Pertinent Results:
ADMISSION LABS
=======================================================
[**2178-3-24**] 05:30PM BLOOD WBC-7.8 RBC-3.03* Hgb-9.4* Hct-29.5*
MCV-97 MCH-31.1 MCHC-32.0 RDW-17.1* Plt Ct-254
[**2178-3-24**] 05:30PM BLOOD Neuts-66.7 Bands-0 Lymphs-22.7 Monos-9.8
Eos-0.7 Baso-0.1
[**2178-3-24**] 05:30PM BLOOD PT-15.2* PTT-38.5* INR(PT)-1.3*
[**2178-3-24**] 05:30PM BLOOD Glucose-101* UreaN-20 Creat-1.8* Na-136
K-4.7 Cl-102 HCO3-26 AnGap-13
[**2178-3-30**] 07:50AM BLOOD ALT-13 AST-28 LD(LDH)-214 AlkPhos-54
TotBili-0.5
[**2178-3-25**] 06:03AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.9 Iron-24*
[**2178-3-25**] 06:03AM BLOOD calTIBC-96* VitB12-331 Folate-13.8
Ferritn-458* TRF-74*
[**2178-3-31**] 10:36PM BLOOD Type-ART pO2-53* pCO2-58* pH-7.32*
calTCO2-31* Base XS-1 Intubat-NOT INTUBA
DISCHARGE LABS
=======================================================
[**2178-4-2**] 03:38AM BLOOD WBC-25.1*# RBC-2.90* Hgb-8.7* Hct-27.3*
MCV-94 MCH-30.0 MCHC-31.8 RDW-17.1* Plt Ct-192
[**2178-4-4**] 06:40AM BLOOD WBC-13.0* RBC-2.72* Hgb-8.5* Hct-27.2*
MCV-100* MCH-31.1 MCHC-31.1 RDW-17.3* Plt Ct-211
[**2178-4-2**] 06:16AM BLOOD Neuts-82.5* Lymphs-6.4* Monos-10.3
Eos-0.2 Baso-0.5
[**2178-4-4**] 06:40AM BLOOD PT-23.2* PTT-93.1* INR(PT)-2.2*
[**2178-4-4**] 06:40AM BLOOD Glucose-129* UreaN-17 Creat-1.4* Na-140
K-3.7 Cl-108 HCO3-26 AnGap-10
[**2178-4-4**] 06:40AM BLOOD Calcium-7.5* Phos-3.1 Mg-1.8
[**2178-4-1**] 07:50AM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2178-4-1**] 05:52PM BLOOD CK-MB-NotDone cTropnT-0.08*
MICROBIOLOGY
=======================================================
[**2178-3-31**] 5:12 pm BRONCHOALVEOLAR LAVAGE RLL BAL.
GRAM STAIN (Final [**2178-3-31**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
SECOND MORHPHOLOGY.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_______________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN----------- =>8 R =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- 4 S 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
VANCOMYCIN------------ <=0.5 S
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final [**2178-4-1**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
REPORTS
=======================================================
UNILAT LOWER EXT VEINS RIGHT Study Date of [**2178-3-24**]
Nonocclusive thrombus in a branch of the right popliteal vein
only. No evidence of DVT in any other region of the left lower
extremity.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2178-3-25**]
1. RLL and RML consolidation, given recurrence in the same
region and
associated retrocrural and extrapleural adenopathy, is
suspicious for
malignancy, correlation with either FDG PET or tissue sampling
is recommended.
2. Unchanged lobulated left splenectomy bed soft tissues, could
represent
regenerated splenic tissue, however, local RCC recurrence is not
excluded.
3. Patchy LLL opacity, could be atelectasis, however, metastatis
is not
excluded and attention on followup is recommended.
4. Coronary and atherosclerotic aortic calcifications.
5. No evidence of pulmonary embolism or acute aortic syndrome.
Portable TTE (Complete) Done [**2178-3-26**]
The left atrium is markedly dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. There is mild
regional left ventricular systolic dysfunction with inferior
hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is moderately dilated. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2176-4-24**],
regional LV systolic dysfunciton is now appreciated.
CT ABDOMEN / PELVIS W/O CONTRAST Study Date of [**2178-3-27**]
1. Partial colonic obstruction at the right anterior abdominal
wall hernia
with transverse colon herniated within. It appears that only the
anterior
wall of the transverse colon is in the hernia but there is
torquing of the
colon such that the large amount of fluid within the cecum,
ascending colon, and proximal transverse colon cannot cross
through the torqued transverse colon distal to the hernia. No
evidence of bowel compromise at this time.
2. Small amount of ascites. Unchanged appearance of splenules.
Left
nephrectomy with hypodense lesions in right kidney, as before
unchanged.
3. Abdominal aortic aneurysm up to 5.5 cm incompletely assessed
without
intravenous contrast.
4. Unusual soft tissue within the presacral space may represent
abnormal
lymph nodes, however, this is uncertain. Attention on followup
in three
months is recommended, preferably using MRI.
5. Urinary bladder containing contrast from CTA chest more than
two days ago suggests some renal insufficiency. Small urinary
bladder diverticulum.
CHEST (PORTABLE AP) Study Date of [**2178-4-3**]
In comparison with the study of [**4-2**], there is increased
opacification involving the right mid and lower lung zones. This
is consistent with increasing pleural effusion and underlying
compressive atelectasis. There is again enlargement of the
cardiac silhouette with evidence of pulmonary vascular
congestion. Postoperative widening of the mediastinum is again
seen.
BRONCHIAL BRUSHINGS Procedure Date of [**2178-3-31**]
NEGATIVE FOR MALIGNANT CELLS.
TBNA 11 R Procedure Date of [**2178-3-31**]
NEGATIVE FOR MALIGNANT CELLS.
Bronchial epithelial cells.
Brief Hospital Course:
82 yo M with h/o COPD, AS s/p AVR, afib, right nephrectomy for
RCC, colon ca s/p colectomy. Recent admission for PNA,
re-admission for shortness of breath and fevers. Transferred to
the MICU for hypoxia following bronchoscopy.
# Acute respiratory distress: Patient with shortness of breath
worse than baseline upon admission on [**2178-3-24**]. Then acutely
decompensated [**2178-3-31**] post-bronchoscopy. Based on chext x-ray
and recent bronchoscopy most likely mucus plugging worsened by
underlying effusion, atelactasis and possible post-obstructive
pneumonia. Patient has known DVT, but based on significant
findings on CXR and current anticoagulation unlikely PE. Patient
febrile on admission which could be related to recent
bronchoscopy, however due to rising leukocytosis, was broadly
covered. Patient never complained of chest pain to suggest ACS
and troponins were stably elevated. His acute worsening was
thought to be less likely congestive heart failure as CXR
findings unilateral and symptoms acute in onset. As below,
patient was continued on antibiotics. He was also positioned on
left side for improved oxygenation His respiratory status
improved with chest PT, [**Name (NI) 55569**] use, vibrating vest
therapy and Acapella therapy. He should continue all these
therapies as aggressive pulmonary toilet upon transfer in to the
MACU. BAL results as above. Started on Advair and Spiriva for
COPD component.
# Fevers with Leukocytosis: During admission, patient was noted
to have frequent febrile episodes. Initial evaluation included
persistant RLL/RML opacities. He also had numerous negative
blood cultures, urine culture and c. diff X 1. Most likely
etiology is post-obstructive pneumonia. His fevers resolved
with initiation of antibiotics post-broncoscopy on [**2178-3-31**]. He
was treated broadly for post-obstructive pneumonia with
Vancomycin, Cefepime and Flagyl. On [**4-4**] his BAL studies came
back as above with one S.Aureus with preliminary findings of
intermediate sensitivity to Vancomycin. Given this, he was
transitioned to Linezolid. On discharge, he is on day 4 of a
total 21 day course of antibiotics. If patient looks markedly
improved with decreased oxygen requirements and improved chest
x-ray, would consider decreasing course to 14 days. Given
Linezolid, patient will need weekly CBC checks. Additionally,
please call the [**Hospital1 18**] Microbiology department at ([**Telephone/Fax (1) 20850**]
on [**Telephone/Fax (1) 766**], [**2178-4-6**], to follow-up additional studies.
# Ventral Hernia: Patient with longstanding ventral hernia.
Some concern during admission that there be an element of
incarceration and CT scan [**2178-3-27**] demonstrated partial colonic
obstruction. Repeat CT scan [**2178-3-29**] with overall improvement.
Upon discharge, hernia easily reduced and without any abdominal
pain.
# Recent Gastroentestingal hemorrhage: HCT relatively stable
with mild intermittent drops. No melena during this admission.
Given that patient is a high colonoscopy perforation risk due to
colonic distension, GI did not perform any endoscopy. He was
continued on IV pantoprazole [**Hospital1 **]. He was transfused a total of
2U PRBC during this admission, the last one on [**2178-3-30**].
# DVT: Patient with Popliteal branch DVT as above. Initially
placed on a Heparing drip and then transitioned to Lovenox /
Warfarin. The day of discharge his INR was therapeutic at 2.2.
Would recommend daily INR checks for several days given newly on
Warfarin and newly therapeutic the day of discharge. Please
elevate the leg as able to decrease swelling and minimize pain.
# Chronic Diastolic CHF (EF>55%): With Echo results as above
concerning for new LV dysfunction. Lasix and beta blocker held
in the setting low blood pressure. Could consider restarting
and oral intake improves.
# COPD: Moderate to severe. Initially started on nebulizer
therapy PRN. Started on Advair and Spiriva while inpatient.
Patient should follow-up with Pulmonary as an outpatient for
continued management.
# Atrial Fibrillation: Rate controlled. Off coumadin temporarily
given recent GI bleeding. CHADS2 score is 3 and bioprosthetic
valve. Echo showed no evidence of thrombus. Restarted on
anticoagulation as above. Also continued on Digoxin. While
inpatient, Metoprolol was held for lower blood pressures in the
setting of poor po intake. Could consider restarting this as an
outpatient if need further rate control and blood pressure
tolerates it.
# GERD: Stable. Continued on Pantoprazole.
# Chronic Kidney Disease: Baseline approximately 1.6. Elevated
to 2.0 on [**3-30**] but resolved to 1.4 upon discharge. All
medications were renally dosed.
# Abdominal aortic anuerysm: Stable, per vascular surgery will
follow-up with Dr. [**Last Name (STitle) 1391**] as outpatient.
# Tachycardia: Initially attribued to atrial fibrillation with
holding of his beta blocker. Other considerations included
hypovolemia or secondary to infection (pneumonia). Given poor
oral intake, he was given maintenance fluid and heart rate
improved from 120s to low 100s. [**Month (only) 116**] need further IVF while in
MACU if oral intake poor.
# History of ITP: Platelets trended and stable during admission.
ACCESS: PICC placed [**2178-4-3**], please discontinue after
completion of antibiotic course. Line care per general
protocols.
Patient was a FULL CODE during his hospital stay.
Medications on Admission:
1. Digoxin 125 mcg PO daily
2. Atrovent 2puff daily
3. Albuterol 1puff q4 prn
4. Pantoprazole 40 mg daily
5. Recently held: Warfarin, Lasix, Metoprol
6. Recently completed: Flagyl and Amoxicillin x 14 days for H.
Pylori
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 18 days.
8. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 18 days.
9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 18 days.
11. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation q4hrs PRN () as needed for SOB, wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Pneumonia
Secondary: atrial fibrillation, COPD, aortic stenosis
Discharge Condition:
Good, afebrile, vital signs stable, O2 sats 94% on face tent,
ambulates out of bed to chair with assistance, AOX3
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital on [**2178-3-24**]. You had initially presented to a GI appointment where you
were found to have a fever, and findings concerning for a
pneumonia. You were subsequently sent to the hospital where you
were evaluated with a procedure called a bronchoscopy. After
this procedure, you were admitted to the medical intensive care
unit after the levels of oxygen in your blood were noted to
drop. While in the ICU, you received a thorough evaluation and
multiple treatments for pneumonia. On [**2178-4-4**] your
condition had improved and you were discharged to the [**Hospital 100**]
Rehab MACU for continued physical therapy.
.
The following changes have been made to your outpatient
medication regimen:
-STARTED Cefepime 2g IV q24 hours. Last day of dosing will be
[**2178-4-21**]
-STARTED Linezolid 600 mg PO/NG, q12h. Last day of dosing will
be [**2178-4-21**].
- STARTED Metronidazole 500 mg IV q8h. Last day of dosing will
be [**2178-4-21**].
-STARTED Fluticasone Salmeterol 250/50, 1 Inh [**Hospital1 **]
-STARTED Tiotropium Bromide 1 cap Inh qD
-STARTED Senna, 1-2 tabs qD, PRN constipation
-STARTED Docusate 100 mg [**Hospital1 **] PRN, constipation
- STOPPED Lasix
- STOPPED Metoprolol
- STARTED Xoponex nebs, 1 neb q4h PRN wheezing or shortness of
breath
- STOPPED Albuterol nebs
- CONTINUE Digoxin 0.125 mg qD
- CONTINUE Pantoprozole 40 mg qD
- CONTINUE Coumadin 2.5 mg qD, until instructed to change the
dose by a physician
.
Please continue regular respiratory treatments with chest PT,
use of a cough assist device and acapella device.
.
It was a pleasure participating in your medical care.
Followup Instructions:
Please make an appointment to follow-up with Dr.[**Last Name (STitle) 575**] from
the Department of Pulmonology at [**Hospital1 18**]. Their office is closed
today so an appointment has not been made for you. Please call
their office at [**Telephone/Fax (1) 55570**] to [**Telephone/Fax (1) **] an appointment within
the next 1 month.
.
You should call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an
appointment and discuss this hospitalization with them. Your
primary care doctor is listed as [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **]. Please call her
office at [**Telephone/Fax (1) 55571**] to [**Telephone/Fax (1) **] an appointment in the next
1-2 months.
.
You will need to have your INR checked daily to ensure that it
remains safely in a therapeutic range. Please have your INR
checked daily at [**Hospital 100**] Rehab and physicians can adjust your
Warfarin level appropriately.
.
Please have a CBC (blood counts) checked weekly to ensure that
your hematocrit is stable.
.
You have the following appointment scheduled with the
gastroenterology appointment.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2178-5-19**]
2:00
|
[
"486",
"5849",
"496",
"42731",
"4280",
"40390",
"5859",
"53081",
"V1582",
"2859"
] |
Admission Date: [**2160-3-18**] Discharge Date: [**2160-3-18**]
Date of Birth: [**2160-3-18**] Sex: M
Service: NEONATALOGY
HISTORY: The infant is a 38-6/7 week, 3155 gram male newborn
with a neural tube defect who was admitted to the Neonatal
Intensive Care Unit for stabilization and transfer to
[**Hospital3 1810**].
The infant was born to a 32 year old Gravida 2, Para 1
mother. Serologies were A positive, antibody negative,
Hepatitis negative, RPR nonreactive, rubella immune, GBS
unknown. Maternal history of a previous term delivery with
shoulder dystocia. Also history of Chlamydia treated in [**2145**]
and sulfonamide hypersensitivity. This pregnancy had an
expected date of confinement of [**2160-3-26**].
Pregnancy was notable for:
1. Gestational diabetes mellitus since approximately 20
weeks controlled with insulin. Last hemoglobin A1C was 5.2.
2. Normal fetal ultrasound on [**2159-8-2**], [**2159-9-19**]
and [**2159-10-22**]. On [**2160-1-28**], a lumbar sacral
cyst was noted at S3 to S4 level. This was confirmed by a
fetal MRI at [**Hospital1 69**]. There
were no associated Chiari malformation or hydrocephalus.
Antenatally, the family met with Dr. [**Last Name (STitle) 37123**], Neurosurgery at
[**Hospital3 1810**] and Neonatology at [**Hospital1 190**].
The infant was delivered by cesarean section. He emerged
pink and active with a good cry. The infant was suctioned,
dried and stimulated. He responded well. Apgars were 8 and
9. The sacral lesion was wrapped with sterile saline-soaked
ClingPads and Saran Wrap. He was shown to his parents and
transported to the Neonatal Intensive Care Unit.
PHYSICAL EXAMINATION: Growth parameters: Weight 3155 grams,
50th percentile; head circumference 32.5 cm which is at the
25th to the 50th percentile; length 50.5 cm which is 75th
percentile. Anterior fontanel is open and flat. Sutures are
approximated at the coronals. Finger-wide split sutures at
the sagittal and lambdoids. There was some cranial molding.
Palate was intact. Lungs are clear to auscultation and
equal. Cardiac was regular rate and rhythm with no murmur;
two plus femoral pulses. Abdomen soft, with good bowel
sounds. Genitourinary showed a normal phallus with testes
down bilaterally. There is a patent anus with an anal wink.
Hips were deferred. He was pink and well perfused,
saturating 96 and above in room air. He had good tone,
moving all extremities well. Sacral lesion was in the lower
sacral area. The cystic structure appeared to have collapsed
and ruptured. There was some thinning of the tissue at the
center or the tip with an opening and leaking of clear spinal
fluid.
IMPRESSION:
1. Appropriate for gestational age full-term male newborn.
2. Infant of diabetic mother.
3. Sacral myelomeningocele.
PLAN:
1. Have discussed immediate plans with Dr. [**Last Name (STitle) 37123**]. Will
arrange for the infant to be transferred to [**Hospital3 18242**] for further management.
2. Will keep him NPO with maintenance intravenous fluids.
3. Draw CBC and blood cultures and begin prophylactic
antibiotics of Ampicillin and Gentamicin given that the
lesion is open.
4. Will monitor glucose levels.
Father has been updated at the bedside.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 1810**],
Neurosurgical Service, Dr. [**Last Name (STitle) 37123**] attending. Name of primary
pediatrician is Dr. [**First Name4 (NamePattern1) 6339**] [**Last Name (NamePattern1) 410**], of [**Hospital 1468**] Pediatrics
Associates, number [**Telephone/Fax (1) 38385**].
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Name8 (MD) 38386**]
MEDQUIST36
D: [**2160-3-18**] 13:11
T: [**2160-3-18**] 13:21
JOB#: [**Job Number 24100**]
|
[
"V290"
] |
Admission Date: [**2133-10-23**] Discharge Date: [**2133-11-10**]
Date of Birth: [**2084-4-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Trans-esophageal echocardiogram
History of Present Illness:
History of Present Illness: 49M with past medical history
significant for alcoholism w/fatty liver (?cirrhosis) and
cocaine abuse, transferred from [**Hospital1 **] [**Hospital1 **] for further
management of rhabdomyolysis and fever. Patient presented to [**Hospital1 **]
[**Hospital1 **] on [**10-19**] with altered mental status. He was staying with
his mother who noted that she found him incoherent and altered,
and so called EMS. Per [**Hospital1 **] [**Hospital1 **] notes, there was concern that
the patient might have had an alcohol withdrawal seizure (has no
h/o seizures), given confusion, bite marks on tongue, slightly
elevated CK on admission. Of note, urine tox screen was positive
for cocaine on admission. He had a negative head CT and CT
abd/pelvis which showed fatty liver, but no evidence of acute
infectious process. Patient was maintained on CIWA protocol
while at [**Hospital1 **] [**Hospital1 **], and received at least 60mg Ativan. He also
received IV fluids given his elevated CK, which was thought to
be related to either known cocaine use or possible seizure.
On the evening of [**10-20**], patient became very agitated,
threatening to leave; security was called, he was placed under
section 12, he received haldol 5mg IM x 2 doses ([**10-20**] @ 20:29
and [**10-21**] @ 00:16), and he was placed in restraints. On the
morning of [**10-21**], CK was found to be elevated 10-fold from the
day prior (22,000 up from 2500). Nephrology was consulted and
patient received IV fluids and bicarbonate. On the morning of
[**10-22**], patient had T 101.5. The following morning [**10-23**] @ 03:30am,
pt had shaking chills and rectal temperature was found to be
105F -> decreased to 101.2 with ice packs (avoided tylenol &
NSAIDs given liver & renal injury). Immediately following this
episode, the patient was hypotensive (unclear how low); he was
briefly put on levophed and received 1.5L NS with improvement in
his blood pressures. Given concern for possible sepsis, he was
pan-cultured and received a dose of Unasyn. There was concern
for encephalitis in light of the fevers, but altered mental
status on presentation was ultimately thought to be related to
alcohol withdrawal and hepatic encephalopathy (elevated
ammonia). Given fevers and elevated CK after receiving Haldol
5mg IM x 2 doses, there was also concern for malignant
hyperthermia. Lastly, patient as noted to be in oliguric renal
failure, with an increase in Cr to 2.9 from 1.4 the day prior.
He was transferred to [**Hospital1 18**] for further management.
On arrival to the MICU, the patient appears comfortable and has
no complaints.
Review of systems:
(+) Per HPI, chronic lower back pain, occasional confusion
(-) 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:
- Alcoholism (25 years)
- Cocaine abuse
- Fatty liver (?cirrhosis)
- H/o Legionella pneumonia (10 years ago) w/renal failure
requiring HD x 1 month
- S/p right knee surgery for torn ligament [**2097**]
Social History:
Reports drinking approximately 0.5 pint of hard liquor (brandy)
and 2 beers daily. Smokes [**9-11**] cigarettes daily. Reported h/o
crack cocaine use, last 18 months ago, but urine tox screen on
[**10-19**] was positive for cocaine. Lives with his long-time
girlfriend, but occasionally stays with his mother. Lost his job
3 months ago; was previously working as a screen printer for
street signs.
Family History:
Reports that mother had a lung removed, unclear why, possibly
cancer. Father had prostate cancer. Has a healthy 28 year-old
daughter.
Physical Exam:
Admission Exam:
T: 100.5 BP: 112/71, P: 93 R: 28 O2: 96% RA
General: Slow to respond, oriented x 3 (person, [**Hospital3 **],
[**2133-10-3**]), no acute distress
HEENT: Sclera anicteric, MMM, left tongue ulceration c/w bite
mark, oropharynx clear, EOMI, PERRL
Neck: supple, JVP difficult to assess given RIJ, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly appreciated
GU: foley in place draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, no asterixis, gait deferred,
finger-to-nose intact very slow & pt with significant
difficulty, unable to do heel to shin, rapid alternating
movements slow & unable to follow.
Discharge exam:
Tm 99.2 Tc 98.2 HR 88 (80s-90s) BP 113/73 (110s-130s/60s-70s)
RR 20 SpO2 98% RA
GENERAL - alert, responding to questions appropriately
HEENT - NC/AT, sclerae anicteric
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - Overweight. NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
BACK - no point tenderness over spine, mild tenderness in the R
paraspinal area, no rashes
SKIN - no rashes
NEURO - awake, A&Ox3, muscle strength 5/5 throughout UE
bilaterally, [**6-6**] plantar and dorsiflexion at the ankles
bilaterally, gait deferred. No asterixis.
EXTREMITIES - no edema, no erythema, non-tender.
Pertinent Results:
[**2133-10-23**] 08:00PM GLUCOSE-106* UREA N-22* CREAT-1.9* SODIUM-144
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-24 ANION GAP-14
[**2133-10-23**] 08:00PM ALT(SGPT)-133* AST(SGOT)-530* LD(LDH)-787*
CK(CPK)-[**Numeric Identifier 104711**]* ALK PHOS-59 TOT BILI-1.3
[**2133-10-23**] 08:00PM ALBUMIN-3.3* CALCIUM-7.0* PHOSPHATE-2.1*
MAGNESIUM-1.9
[**2133-10-23**] 08:00PM WBC-4.7 RBC-3.15* HGB-10.2* HCT-31.0* MCV-98
MCH-32.4* MCHC-33.0 RDW-14.0
[**2133-10-23**] 08:00PM NEUTS-63.8 LYMPHS-26.2 MONOS-8.0 EOS-1.6
BASOS-0.4
[**2133-10-23**] 08:00PM PT-15.2* PTT-37.2* INR(PT)-1.4*
[**2133-10-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2133-10-24**] URINE URINE CULTURE-PENDING INPATIENT
[**2133-10-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2133-10-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2133-10-23**] MRSA SCREEN MRSA SCREEN-PENDING
[**2133-10-24**] 3:52 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2133-10-30**]**
Blood Culture, Routine (Final [**2133-10-30**]): NO GROWTH.
[**2133-10-24**] 3:53 am BLOOD CULTURE Source: Line-TLC.
**FINAL REPORT [**2133-10-30**]**
Blood Culture, Routine (Final [**2133-10-30**]): NO GROWTH.
[**2133-10-24**] 3:53 am URINE Source: Catheter.
**FINAL REPORT [**2133-10-25**]**
URINE CULTURE (Final [**2133-10-25**]): NO GROWTH.
[**2133-10-27**] 7:20 am SEROLOGY/BLOOD
**FINAL REPORT [**2133-10-28**]**
RAPID PLASMA REAGIN TEST (Final [**2133-10-28**]):
NONREACTIVE.
Reference Range: Non-Reactive.
[**2133-10-28**] 4:42 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2133-10-30**]**
C. difficile DNA amplification assay (Final [**2133-10-29**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final [**2133-10-30**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2133-10-30**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2133-10-30**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2133-10-30**]):
NO E.COLI 0157:H7 FOUND.
[**2133-10-28**] CT abdomen/pelvis: IMPRESSION: Limited CT of the
abdomen and pelvis without contrast. No retroperitoneal
hematoma is identified.
[**2133-10-28**] L- and T-spine MRI: IMPRESSION:
1. Transitional anatomy with a partially sacralized L5.
2. No evidence of epidural abscess or discitis.
3. Multilevel endplate STIR hyperintensity with minimal
post-contrast
enhancement are in keeping with degenerative changes. No
definite evidence of osteomyelitis. Recommend clinical
correlations with patient's symptomatology.
4. Congenitally narrow lumbar spinal canal. Moderate L2-L3
spinal stenosis. Various degrees of neural foraminal narrowing
as above.
[**2133-10-29**] TTE: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen (adequate-quality study). Normal global
and regional biventricular systolic function.
In presence of high clinical suspicion, absence of vegetations
on transthoracic echocardiogram does not exclude endocarditis.
[**2133-10-30**] TEE: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Trivial mitral regurgitation is seen. The
tricuspid regurgitation jet is eccentric and may be
underestimated. The estimated pulmonary artery systolic pressure
is normal. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
IMPRESSION: No echocardiographic signs of endocarditis.
Clinically insignificant valvular disease.
Brief Hospital Course:
Assessment and Plan: 49M with past medical history significant
for alcoholism w/fatty liver (?cirrhosis) and cocaine abuse
(positive urine tox screen at OSH), transferred from [**Hospital1 **] [**Hospital1 **]
for further management of rhabdomyolysis, fever, and acute
kidney injury. He was initially admitted to the ICU, then
transferred to the floor on [**10-26**].
# Fever: Possibly related to GNR bacteremia as blood cultures
from [**Hospital1 **] [**Hospital1 **] grew Haemophilus parainfluenza, with neuroleptic
malignant syndrome from haldol seeming unlikely in the absence
of rigidity. He was treated with ciprofloxacin then broadened to
cefepime in the ICU, then narrowed back to ciprofloxacin again.
After transfer to the floor he was afebrile for several days but
then spiked a new fever to 102.1. He was switched to IV
ceftriaxone and infectious disease was consulted given
persistent fever on antibiotics. His infectious workup at [**Hospital1 18**]
was otherwise negative. CXR was negative for pneumonia, stool c.
diff was negative (sent because the patient was having
diarrhea), urine cultures were also negative. TTE was performed
and showed no evidence of endocarditis. As the patient was
complaining of worsened low back pain, T- and L-spine MRI was
performed which showed no evidence of epidural abscess or
osteomyelitis. HIV testing was negative. TEE was performed which
showed no evidence of endocarditis. Blood cultures while at
[**Hospital1 18**] were all NGTD. On [**2133-11-3**] [**Hospital1 **] [**Hospital1 **] was contact[**Name (NI) **] for
final antibiotic susceptibilities of the H. parainfluenza blood
culture, which confirmed susceptibility to ceftriaxone. Despite
his negative workup, he did continue to spike fevers but had
been afebrile for one week prior to discharge; all blood
cultures drawn were negative. Given his bacteremia at the OSH
and persistent back pain, infectious disease recommended that he
complete a total 14-day course of IV ceftriaxone. The patient
completed his course of antibiotics in the hospital and was
discharged to home with plans to follow up for repeat MRI to
evaluate for the possibility of osteomyelitis. Patient was
discharged on oral ciprofloxacin to be taken until further
imaging.
# Rhabdomyolysis: Etiology likely multifactorial. When patient
initially presented to [**Hospital1 **] [**Hospital1 **] on [**10-19**], his urine tox screen
was positive for cocaine. This could explain the initial milder
elevation of his CK 500s -> 2500s. He subsequently received 2
doses of Haldol with 10-fold increase in CK to 25,000; this in
conjunction with fever was concerning for neuroleptic malignant
syndrome, but there was no documented muscular rigidity. Patient
was also was restrained and agitated, which could have caused
muscle injury. He received IV fluids and neuroleptic medications
were avoided. His CK continued to trend downward to the 900s by
the week before discharge.
# Acute kidney injury most likely secondary to pigment-induced
nephropathy from rhabdomyolysis. The patient was aggressively
volume resuscitated and his serum creatinine trended downward,
eventually stabilizing at 0.9-1.0. He maintained good urine
output.
# Toxic-metabolic encephalopathy: Likely multifactorial and
related to alcohol withdrawal, hepatic encephalopathy, possible
post-ictal state, acute kidney injury, and drug effect, as
patient received a large amount of ativan and had decreased
clearance. He was placed on a CIWA scale to monitor for
withdrawal, IV thiamine, lactulose, and was treated for
bacteremia and his mental status improved. After transfer from
the ICU to the floor, he demonstrated no signs of active
withdrawal and his CIWA scale was discontinued. He also had no
asterixis on exam and his lactulose was ultimately discontinued.
TSH and B12 were checked and found to be normal, and RPR was
negative.
# Pancytopenia: He was noted to have pancytopenia. HIV testing
was negative. Possibly secondary to marrow suppression from
alcohol abuse. White count rose to within normal range during
his admission. Iron studies were ordered to work up his anemia
and were consistent with anemia of chronic inflammation. B12 was
within normal limits. Platelets also rose to normal range during
this admission.
#Abdominal hematomas: He was noted to have bilateral lateral
abdominal hematomas after a fall on [**10-27**]. CT abd/pelvis was
negative for retroperitoneal hematoma. His hematomas resolved
during his admission.
# Transaminitis: ASL/ALT were elevated but trended downward
during his admission. Given AST:ALT ratio, clinical history, and
fatty liver seen on CT scan, most likely related to alcohol
abuse. Question of cirrhosis diagnosed at ?[**Hospital1 112**], but no
documentation. Hepatitis serologies were negative for acute
infection.
Transition of care:
-follow-up with primary care physician
[**Name9 (PRE) **] with infectious disease at [**Hospital1 18**] for repeat imaging
of the lumbar spine to further evaluate for the possibility of
osteomyelitis in the setting of new onset back pain. Until that
imaging study, patient will conitnue ciprofloxacin orally.
Medications on Admission:
None
Discharge Medications:
1. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin 750 mg 1 tablet(s) by mouth every 12 hours
Disp #*60 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl [Vitamin B-1] 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Altered mental status
Haemophilus parainfluenza bacteremia
Rhabdomyolysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You were transferred here from another hospital for altered
mental status, bacteremia (bacteria in your blood), fevers,
rhabdomyolysis (breakdown of muscle cells), and kidney injury.
Initially, you were treated in the intensive care unit but were
later transferred to the general medicine floor. While in the
hospital, you were treated with IV antibiotics for the bacteria
in your blood for a total of 14 days. You were evaluated for
damage to the valves of your heart as well as an infection
involving the spinal cord or the bones of the spine, and these
tests were negative. Your kidney function was monitored and
found to improve.
You will need to have another MRI of your thoracic and lumbar
spine, which the infectious disease doctors will follow and [**Name5 (PTitle) **]
notify you when this is scheduled. You will need to take
ciprofloxacin 750mg twice daily until you have the MRI. After
the MRI, you will have an appointment with the infectious
disease doctors regarding the [**Name5 (PTitle) **] going forward for
antibiotics.
It is EXTREMELY IMPORTANT for you to STOP drinking alcohol.
Alcohol has many harmful affects on the body including liver
failure (cirrhosis), heart failure, early dementia. We encourage
you to STOP drinking. It is also very important for you to stop
using drugs like cocaine as this also has harmful affects on
your body. We encourage you to attend alcoholics anonymous
meetings to help you attain sobriety.
Keep your follow-up appointment with your primary care doctor.
Followup Instructions:
Name: [**Last Name (LF) 4322**],[**First Name3 (LF) 1569**] L.
Location: [**Hospital 4323**] MEDICAL
Address: [**Location (un) 4324**], [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 4326**]
Appointment Monday [**2133-11-16**] 11:30am
|
[
"5849",
"3051",
"99592"
] |
Admission Date: [**2123-9-21**] Discharge Date: [**2123-9-25**]
Date of Birth: [**2061-3-14**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
right adrenal pheochromocytoma
Major Surgical or Invasive Procedure:
right adrenalectomy [**9-21**]
History of Present Illness:
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old woman
who is now well known to me. She originally presented a month
or
two back to the hospital with a small-bowel obstruction which
was
managed nonoperatively. During her hospitalization, however, we
noted an adrenal mass and began workup for possible functional
endocrine tumor. This turned out to be positive. After seeing
the patient in clinic two weeks ago, I referred her for
endocrinology
followup to confirm the diagnosis of a pheochromocytoma. This
is now
felt to be firmly confirmed. We have now switched the patient's
medications from a calcium channel blocker to a combination of
alpha blockade and beta blockade. This will allow the exact
management in the perioperative period. The patient is,
otherwise, asymptomatic today, and she comes for her definitive
procedure.
Past Medical History:
Past Medical History: HTN, HL, GERD
Past Surgical History: c-sections
Social History:
Lives at home with husband, retired. Denies
tobacco, social EtOH, no drugs.
Family History:
Mother with melanoma, no history of ovarian,
breast, or endocrine cancers
Physical Exam:
Physical Examination: completed [**2123-8-26**]:
Vitals: Supine: BP 123/74, P 80; Sitting: BP 122/78, P 84;
Standing: BP 119/76, P 92; Weight 155, Height 62"
General: Well appearing, no apparent distress
HEENT: PERRL, EOMI, MMM, no lid lag, proptosis, OP without
lesions
Neck: No lymphadenopathy, no thyromegaly
Heart: Regular rhythm, tachy/normal rate, II/VI flow murmur.
Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended, +BS, no masses palpable.
Extremities: WWP, no edema, 2+ pulses.
Neuro: Normal strength, no tremor. DTR normal.
Skin: No lesions, unremarkable
Pertinent Results:
[**2123-9-24**] 06:10AM BLOOD WBC-4.5 RBC-3.37* Hgb-9.3* Hct-27.9*
MCV-83 MCH-27.6 MCHC-33.4 RDW-14.5 Plt Ct-247
[**2123-9-23**] 06:10AM BLOOD WBC-5.7 RBC-3.47* Hgb-9.5* Hct-28.5*
MCV-82 MCH-27.3 MCHC-33.2 RDW-14.6 Plt Ct-256
[**2123-9-22**] 01:45AM BLOOD WBC-6.3 RBC-3.44* Hgb-9.5* Hct-27.3*
MCV-79* MCH-27.6 MCHC-34.8 RDW-14.4 Plt Ct-271
[**2123-9-21**] 08:36PM BLOOD WBC-8.3# RBC-3.63* Hgb-10.2* Hct-28.9*
MCV-80* MCH-28.0 MCHC-35.2* RDW-14.4 Plt Ct-296
[**2123-9-24**] 06:10AM BLOOD Plt Ct-247
[**2123-9-23**] 06:10AM BLOOD Plt Ct-256
[**2123-9-22**] 01:45AM BLOOD Plt Ct-271
[**2123-9-24**] 06:10AM BLOOD Glucose-88 UreaN-7 Creat-0.6 Na-136 K-3.9
Cl-100 HCO3-30 AnGap-10
[**2123-9-23**] 06:10AM BLOOD Glucose-87 UreaN-8 Creat-0.6 Na-133 K-3.8
Cl-99 HCO3-30 AnGap-8
[**2123-9-22**] 01:45AM BLOOD Glucose-122* UreaN-11 Creat-0.6 Na-138
K-3.9 Cl-104 HCO3-25 AnGap-13
[**2123-9-24**] 06:10AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.8
[**2123-9-23**] 06:10AM BLOOD Calcium-8.2* Phos-2.0* Mg-1.8
[**2123-9-22**] 01:45AM BLOOD Cortsol-41.7*
[**2123-9-21**] 09:09PM BLOOD freeCa-1.20
[**2123-9-21**]:
IMPRESSION: AP chest compared to [**2123-7-26**]:
With the chin down, tip of the endotracheal tube is at the
thoracic inlet, no less than 5.5 cm from the carina, 2 cm above
optimal placement. Left lower lobe atelectasis is mild, probably
explains small left pleural effusion.
Right lung clear. Heart size normal. No pneumothorax. Right
jugular line
ends in the mid SVC and nasogastric tube in the stomach
[**2123-9-22**] 6:16 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2123-9-24**]**
MRSA SCREEN (Final [**2123-9-24**]): No MRSA isolated.
Brief Hospital Course:
62 year old female who on hospitalization for small bowel
obstruction noted to have an adrenal mass. Further work-up was
done and she was reported to have a right pheochromocytoma.
Prior to her surgery, her blood pressure was controlled with
alpha and beta blockers.
She was taken to the operating room on [**9-21**] where she had a
right adrenalectomy. She had an epidural catheter placed for
post-op pain management. She had a 'rocky' operative course, and
required pressors for hemodynamic support after removal of the
pheo. She had an 800cc blood loss. Post-operatively, she was
monitored in the intensive care unit and required levophed for
hypotension for about 12 hours. Once her vital signs stablized
she was extubated. She was seen by the Acute Pain service on
[**9-21**] and her pain regimen was initiated via the epidural
catheter. She was started on a regular diet.
She was transferred to the Acute Care floor on [**9-22**]. Her
vital signs have been stable and she has not required any
anti-hypertensive agents at all. She is afebrile and tolerating
a regular diet. She has been ambulating in the [**Doctor Last Name **]. She has not
moved her bowels. Her epidural is scheduled for removal this
afternoon followed by removal of her foley.
She is preparing for discharge home. She will need follow-up
in 10 days for staple removal and a follow-up appointment with
Dr. [**Last Name (STitle) **].
Medications on Admission:
[**Last Name (un) 1724**]: amlodipine 10', wellbutrin, doxazosin 2', labetalol 100',
lisinopril 20', simvastatin 20', Ca/vitD, vitD3, omeprazole 20
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for Post surgical pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: hold
for diarrhea.
Discharge Disposition:
Home
Discharge Diagnosis:
right adrenal mass w/u for pheochromocytoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are being discharged from the hospital after you were
admitted for an adrenal mass (a 'pheochromocytoma'). You had
removal of the mass and are ready for discharge. You will be
discharged with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**9-3**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please follow up with the Acute Care Service for removal of
staples in 10 days. You can schedule this appointment by [**Last Name (un) **]
#[**Telephone/Fax (1) 600**].
You can also schedule a follow-up appointment with Dr. [**Last Name (STitle) **]
after [**Holiday 1451**]. Again, you can schedule this appointment by
calling #[**Telephone/Fax (1) 600**]
|
[
"2724",
"4019",
"53081"
] |
Admission Date: [**2161-11-8**] Discharge Date: [**2161-11-16**]
Date of Birth: [**2107-5-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
54M who was found down by friends outside. Pt was brought to an
OSH where a Cspine xray showed concern for C3,C4,C5 fx along
with LUE/LLE weakness and was intubated and transferred to [**Hospital1 18**]
for further management. Upon arrival, a CT Cspine was performed
which did not show any cervical fracture. + ETOH
Past Medical History:
Unknown
Social History:
Unknown. + ETOH now
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM:
O: T: BP: 95/74 HR: 81 R 21 O2Sats 97% ETT
Gen: Intubated, on profolol
HEENT: multiple small lacs
Neck: Hard cervical collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awakes to noxious stim
Motor Initially:
RUE: Delt 3, Bic 2, Tri 0, Grasp 0, WE/WF 0
LUE: Delt 2, Bic 0, Tri 0, Grasp 0, WE/WF 0
RLE: triple flexion to stim
LLE: no mvmt to noxious
On repeat exam:
RUE: antigravity, appears stronger than LUE
LUE: localizes, but weaker than RUE
RLE: withdraws
LLE: withdraws L>R
Sensation: Pt grimaces to noxious stim throughout, Nods yes to
sensation to light touch and noxious. Proprioception intact.
Reflexes: B T Br Pa Ac
Right 0 0 0 2 2
Left 0 0 0 2 2
Toes: Mute on left, upgoing on right
Rectal exam normal sphincter control
Exam upon discharge:
motor exam slowly improving daily - weak distally in UEs right
weaker than left; and weaker distally LEs but full proximally
Pertinent Results:
CT Cspine:
No fracture noted, C5-6 osteophytes impinging on the thecal sac.
CT Head:
no acute bleed, incidental finding of a right frontal sinus
osteoma
MRI Cspine:
Cord impingement at C4-5 with hyperintensity on T2 imaging.
Brief Hospital Course:
Pt was admitted to the TSICU and monitored closely. His
thoracic/lumbar spine was cleared in order to attempt
extubation. He was febrile on admission and blood, urine and
sputum cultures were obtained. Urine cultures were negative and
sputum gram stain showed 1+ GPC's and he was started on
levofloxacin and completed 5 day course.
He was safely extubated on [**11-10**] without difficulty and was
kept in the ICU overnight for continued observation and neuro
checks. He did complain of burning sensation in his RUE and was
started on neurontin 300mg three times daily which was then
further increased to 600mg TID. His physical exam at this time
was full strength in LLE, RLE weakness 2/5 proximally and [**4-29**]
gastroc, RUE 3 biceps and 2 in deltoid and triceps with no
finger movements. His LUE had 2 in grips with no other motor
function. He was transferred to the floor in stable condition on
[**11-11**]. His exam continued to slowly improve. He was kept in
cervical collar. He was evaluated by PT/OT and suitable
candidate for rehab. He was on neurontin for neurogenic pain and
this can be titrated slowly to off as it resolves.
Medications on Admission:
Unknown
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): may dc when activity increases.
2. acetaminophen 650 mg/20.3 mL Solution Sig: [**12-27**] PO Q6H (every
6 hours) as needed for pain or fever.
3. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for muscle spasm.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours)
as needed for pain.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for no BM>24hr.
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4339**]
Discharge Diagnosis:
cervical cord contusion
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:
?????? Do not smoke
?????? You are required to wear cervical collar at all times.
?????? You may shower briefly daily without the collar.
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NOT NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2161-11-16**]
|
[
"5070",
"486"
] |
Admission Date: [**2158-6-10**] Discharge Date: [**2158-6-13**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Hypotension, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old male with history of metastatic esophageal
adenocarcinoma (recently diagnosed, s/p GEJ stenting [**2158-6-6**]),
partial colectomy for transverse colon adenocarcinoma ([**2154**]),
restless leg syndrome, GERD who presents with hypotension. The
patient had been at home in his usual state of health when he
tried to have a bowel movement and was noted by his family to be
there for "hours." The patient had generalized weakness and
could not come off the commode. EMS was called and enroute, he
was noted to be febrile to 101.0 with a low blood pressure
~SBP80s on arrival to the [**Hospital1 18**] ED. The patient denies any
subjective fevers/chills, shortness of breath, cough, headache,
abdominal pain, dysuria. Has been "spitting up more" since his
GEJ stenting and has been taking a soft diet with Ensure at
home.
In the ED, initial vitals: T101.0, BP100/61, RR 18, 94% on 4L.
He was volume resuscitated with 3-4L normal saline. The patient
received Vancomycin/Zosyn empirically and Tylenol for his fever.
Urinalysis was bland. Lactate initially 2.9 but decreased to 1.0
after fluids. Troponin 0.02. EKG unchanged from priors. CT head
unremarkable, CT torso given endorsement of diarrhea and
abdominal pain was unremarkable. GI was consulted in the ED and
felt there was nothing else to do re: GEJ stent, especially as
the CT torso showed no fluid collection. CXR suggestive of
possible biateral mid-lung field opacifications so the patient
also received Levaquin 750mg IV X1. VS on transfer: HR81,
BP101/60, RR22, 100% on 3L NC. The patient does not use oxygen
at baseline.
On arrival to the MICU, patient resting comfortably in bed with
wife, daughter at the bedside. Patient asking when he can go
home, wife/daughter would like his toenails to be clipped prior
to discharge.
ROS: Denies fever, chills, headache, rhinorrhea, congestion,
sore throat, cough, shortness of breath, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
* Metastatic esophageal adenocarcinoma
* Partial colectomy for transverse colon adenocarcinoma (T3, NO
[**2154-6-14**])
* Restless legs syndrome
* GERD
* Postoperative atrial fibrillation
* Cdiff colitis ([**2154-6-14**])
Social History:
Lives with wife at home, married for 65-68 years. Daughter lives
in area. Prior asbestos exposure. Retired electrician. Denies
tobacco, alcohol, illicit drugs. Fought in WWII, in [**Country 2559**]; broke
all four extremities, remaining shrapnel in right knee, received
Purple Heart.
Family History:
No family history of sudden cardiac death, son died of lymphoma.
Physical Exam:
VS: Temp: 97.1 BP: 117/102 HR: 82 RR: 12 O2sat 99% on 2L NC
GEN: Pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTA b/l with good air movement throughout, no
wheezing/rhonchi/rales
CV: Regular rate/rhythm, S1 and S2 wnl, no gallops/rubs, [**3-19**]
systolic murmur at [**Doctor Last Name **]/LSB
ABD: Nontender, nondistended, +BS, soft, no palpable masses
EXT: No cyanosis, ecchymosis, trace bilateral edema. TTP of RLE
(chronic since WWII)
SKIN: No rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. Strength and sensation intact.
Sensorineural hearing loss.
Pertinent Results:
[**2158-6-10**] 04:25AM GLUCOSE-107* UREA N-15 CREAT-0.8 SODIUM-137
POTASSIUM-3.2* CHLORIDE-107 TOTAL CO2-21* ANION GAP-12
[**2158-6-10**] 04:25AM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-2.6*
MAGNESIUM-1.8
[**2158-6-10**] 04:25AM WBC-13.1* RBC-2.65*# HGB-8.2* HCT-23.3*#
MCV-88 MCH-30.7 MCHC-35.0 RDW-14.5
[**2158-6-10**] 12:50AM cTropnT-0.01
[**2158-6-9**] 11:02PM LACTATE-1.0
[**2158-6-9**] 06:18PM LACTATE-2.9*
[**2158-6-9**] 06:05PM ALT(SGPT)-20 AST(SGOT)-31 CK(CPK)-175 ALK
PHOS-52 TOT BILI-1.0
[**2158-6-9**] 06:05PM LIPASE-18
[**2158-6-9**] 06:05PM cTropnT-0.02*
[**2158-6-9**] 06:05PM CK-MB-4
[**2158-6-9**] 06:05PM CALCIUM-9.3 PHOSPHATE-1.7* MAGNESIUM-1.9
EKG: Sinus tachycardia, HR108, left anterior fascicular block,
poor R wave progression, no ST elevations/TW inversions. Stable
from priors.
Imaging:
CT head: No actue process.
CT torso:
CT OF THE CHEST WITHOUT AND WITH CONTRAST: The pulmonary
arteries appear
patent to the subsegmental levels. Note is again made of aortic
and mitral
annular calcifications. The heart and great vessels are
otherwise
unremarkable. There are no pleural or pericardial effusions.
Calcified
pleural plaques are again seen which likely reflect prior
asbestos exposure.
Right upper lobe granuloma is stable. There is no
lymphadenopathy. There is
minimal bilateral dependent atelectasis. Note is made of a
bovine aortic arch
with common origin of the innominate and left common carotid
arteries. The
esophagus is dilated with an air-fluid level and wall thickening
particularly
distally. Narrowing of the stent at the GE junction is likely
secondary to
known malignancy.
CT OF THE ABDOMEN WITH CONTRAST: Liver hypodensities are
unchanged. The
spleen contains punctate calcifications, which likely represent
prior
granulomatous disease. The pancreas is atrophic. The adrenal
glands and
kidneys are grossly unremarkable. The gallbladder contains a few
dependent
stones. The patient is status post transverse colectomy and
surgical clips
are seen in the right mid abdomen. Inspissated contrast is seen
within
multiple diverticula; there is no evidence for diverticulitis.
There is no
free air or ascites.
CT OF THE PELVIS WITH CONTRAST: A Foley catheter is seen within
a
decompressed bladder. The prostate and seminal vesicles are
grossly
unremarkable. Severe sigmoid diverticulosis is seen with
inspissated contrast within innumerable diverticula without
evidence for inflammation. There is no free fluid.
There is a large sclerotic lesion in the right iliac bone and
there is marked sclerosis of three mid thoracic vertebral
bodies, all of which is new compared to prior and concerning for
metastatic disease.
IMPRESSION:
1. No evidence for pulmonary embolism or other acute process.
2. New sclerotic lesions in the right iliac bone and mid
thoracic vertebral
bodies, concerning for metastases.
3. Narrowing of the distal esophageal stent compatible with
known malignancy,
and proximal dilatation of the esophagus filled with fluid.
4. Cholelithiasis.
CXR: The heart size is normal. The mediastinal and hilar
contours are unremarkable with mild tortuosity of the thoracic
aorta
identified. There are calcified bilateral pleural plaques which
somewhat limit assessment of the underlying pulmonary
parenchyma. Compared to the prior radiograph, there may be
increased opacification within the mid lung fields bilaterally,
and underlying infection cannot be completely excluded. The
pulmonary vascularity is not engorged. No pleural effusion or
pneumothorax is identified. No acute osseous findings are seen.
IMPRESSION: Bilateral calcified pleural plaques limit assessment
of
underlying pulmonary parenchyma. Given this, there appears to be
slight increased opacification within the mid lung fields
bilaterally, and an underlying infection cannot be completely
excluded.
EGD - [**Age over 90 **] y.o. M with recently discovered esophageal
adenocarcinoma at distal esopahagus. Pt with severe dysphagia,
unable to eat for two weeks.
* A fungating, friable mass of malignant appearance was found in
the distal esophagus extending from 35cm down to the GEJ at
40cm.
The mass caused a partial obstruction. The scope traversed the
lesion. Mass infiltration was noted extending from the esophagus
into the stomach, circumferentially in the fundus and then
unilaterally extending down to the distal body along the lesser
curvature.
The mucosa appeared congested, suggestive of submucosal tumor
infiltration. A 23mm x 120mm [**Company 2267**] Ultraflex Covered
Esophageal metal stent was placed across the mass successfully.
REF: 1421 LOT: [**Numeric Identifier 26960**]
Recommendations: Follow-up with Dr. [**Last Name (STitle) **]
Omeprazole 40mg by mouth twice daily
Full liquids for 72 hours, then may advance to soft diet
CT torso with contrast ([**Hospital1 18**] [**Location (un) 620**], [**2158-5-25**]):
FOCAL ESOPHAGEAL/GASTRIC MURAL THICKENING AND STRANDING WITH AT
LEAST ONE SMALL PARAESOPHAGEAL LYMPH NODE, AT THE
GASTROESOPHAGEAL JUNCTION. THESE FINDINGS COULD
INDICATE PRIMARY ESOPHAGEAL OR GASTRIC MALIGNANCY AND FURTHER
EVALUATION WITH
BIOPSY IS RECOMMENDED; THE POSSIBILITY OF METASTASIS
TO THE
GASTROESOPHAGEAL JUNCTION CANNOT BE EXCLUDED, HOWEVER.
2. MULTIPLE SCLEROTIC AND LUCENT BONE LESIONS CONCERNING
FOR
METASTATIC DISEASE NEW SINCE THE STUDY OF [**2154-6-20**].
3. RETROPERITONEAL LYMPHADENOPATHY. WHILE THIS IS
DECREASED IN
COMPARISON WITH THE [**2154**] CT, THE APPEARANCE IS
CONCERNING
MALIGNANCY AND COULD REPRESENT METASTASIS OR
ALTERNATIVELY PREVIOUSLY SUGGESTED, LYMPHOMA, IF AN APPROPRIATE
HISTORY EXISTS.
4. GALLSTONES AND BILATERAL NONOBSTRUCTING RENAL STONES.
TINY
HYPODENSE RENAL LESIONS ARE TOO SMALL TO CHARACTERIZE
AND IF
SOURCE OF MALIGNANCY IS UNKNOWN AND FURTHER
CHARACTERIZATION, PARTICULARLY OF THE RIGHT LOWER POLE LESION IS
ESSENTIAL, THEN AN ULTRASOUND COULD BE PERFORMED INITIALLY.
5. HYPODENSE HEPATIC LESIONS UNCHANGED IN DISTRIBUTION
FROM [**2154**], AT LEAST ONE OF WHICH REPRESENTS A CYST.
6. 3 MM RIGHT MIDDLE LOBE PULMONARY NODULE FOR WHICH
FOLLOW-UP WITH CHEST CT IN THREE MONTHS IS RECOMMENDED
7. CALCIFIED PLEURAL PLAQUES CONSISTENT WITH PRIOR
ASBESTOS
EXPOSURE
8. COLONIC DIVERTICULOSIS.
Microbiology: [**2158-6-9**] 6:10 pm BLOOD CULTURE #2.
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final [**2158-6-10**]):
GRAM NEGATIVE ROD(S).
Brief Hospital Course:
Assessment and Plan: [**Age over 90 **] year old male with history of metastatic
esophageal adenocarcinoma (recently diagnosed, s/p GEJ stenting
[**2158-6-6**]) called out of the MICU with GNR sepsis.
.
# E. coli sepsis: Likely due to GI etiology, may be associated
with patient's known GE cancer and potential bacterial
translocation in the setting of recent stenting in the past week
([**2158-6-6**]). Blood pressures improved with IVF resusucitation and
patient did not require pressors. WBC downtrended with addition
of IV antibiotics. Pt received 2 days of Zosyn, 2 days of
ertapenem, and was discharged with 3 days of oral cefpodoxime
(once speciation returned as E. coli sensitive to Ertapenem) for
a total of 7 days of treatment for bacteremia/sepsis. A
discussion was held with the family and they were told the
patient could not go home on hospice with IV antibiotics so the
decision was made to pull his midline and send him home on three
days of oral antibiotics.
# Metastatic esophageal adenocarcinoma: s/p GEJ stenting earlier
this week with extensive malignancy noted on EGD and likely has
metastases in retroperitoneal lymph nodes and the bones.
Recently diagnosed secondary to dysphagia. Patient does not
appear to have established care with an oncologist yet.
Continued mechanical soft diet. Changed omeprazole to
lansoprazole on discharge given dysphagia since he was having
difficulty swallowing pills. GI was aware and reports that
nothing to do at this time especially given CT scan without
abscess or perforation.
.
# h/o prostate cancer: Metastatic, continue home flutaide and
leuprolide q3months.
.
# Transverse colon adenocarcinoma: Stable since [**2154**]
.
# Restless leg syndrome: Stable. Continued pramipexole. Added
liquid oxycodone for pain control given going home on hospice.
.
# GERD: Stable. Switched omeprazole to lansoprazole as pt had
difficulty with swallowing omeprazole.
.
# Goals of care: Patient stated multiple times that he wished to
go home on hospice. HIs goals of care included returning home,
and doing his woodwork for whatever amount of time he had left,
and optimizing quality of life. This was discussed in a family
meeting with the patient and the family Esophageal cancer
appears fairly extensive likely with associated metastases.
Goals of care discussed with family and they are aware that
swallowing may become progressively difficult as his esophageal
cancer progresses and once he is unable to eat this will limit
his life span, at which point comfort tastes could be initiated.
Patient was discharged home with hospice Choice for family is:
Life Choice Hospice: [**Telephone/Fax (1) 26961**] Contact = [**Doctor First Name **].
.
#FEN: mechanical soft diet, replete electrolytes prn
#PPX: heparin sq
#Code: DNR/DNI
#Communication: wife [**First Name8 (NamePattern2) **] [**Name (NI) 7356**], HCP [**Telephone/Fax (1) 26962**]), son.
#Dispo: Home with IV abx until Friday, then transition to
hospice.
.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Last Name (Titles) 4207**]-3
[**Pager number 26963**]
Current Clinical Status:afebrile
Medications on Admission:
* Flutamide 125mg daily
* Leuprolide 3.75mg every three months
* Omeprazole 40mg twice daily
* Pramipexole 0.25mg daily
* Docusate 100mg daily
* Multivitamin daily
Discharge Medications:
1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
2. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1)
packet PO DAILY (Daily) as needed for constipation: hold for
loose stools.
Disp:*30 packets* Refills:*0*
3. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
4. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
5. pramipexole 0.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily ().
6. oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) mg PO Q4H (every 4
hours) as needed for pain, anxiety, restless leg.
Disp:*150 mg* Refills:*0*
7. flutamide 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
8. ertapenem 1 gram Recon Soln [**Last Name (STitle) **]: One (1) gram Intravenous
once a day for 3 days.
Disp:*3 grams* Refills:*0*
9. leuprolide 3.75 mg Kit [**Last Name (STitle) **]: One (1) injection Intramuscular
q3months.
10. Hospice
Please provide Hospice Consult
11. cefpodoxime 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
life choice hospice
Discharge Diagnosis:
Primary Diagnosis
Sepsis
Secondary Diagnosis
Esophageal Cancer
Metastatic Prostate Cancer
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 with an infection in your bloodstream, likely
due to bacteria in your GI tract. You required a brief stay in
the ICU due to low blood pressures, where you were given fluids
and IV antibiotics. Your blood pressure improved and you were
discharged on oral antibiotics for three more days to complete
one full week to treat your infection. You should go home and be
evaluated for hospice.
The following changes were made to your medications.
1. Take Cefpodoxime 200 mg by mouth twice a day for three days
(start date is [**2158-6-14**], last day is [**2158-6-16**].)
2. Please change your ompeprazole to lansoprazole (this will be
easier for you to swallow).
3. We have given you some liquid oxycodone as needed for pain.
4. Please discuss discontinuing your prostate cancer medications
with your hospice team and your primary care
physician/oncologist.
Followup Instructions:
Please follow up with your PCP as needed.
Completed by:[**2158-6-13**]
|
[
"5990",
"53081"
] |
Admission Date: [**2195-8-28**] Discharge Date: [**2195-9-10**]
Date of Birth: [**2115-3-1**] Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6736**]
Chief Complaint:
Robotic prostatectomy, cystectomy with ileal conduit, requiring
post-op monitoring
Major Surgical or Invasive Procedure:
[**2195-8-28**]: Robotic prostatectomy, cystectomy with ileal conduit
by Urology
[**2195-8-28**]: intubation and sedation for surgery by Anesthesia
[**2195-8-28**]: extubation by ICU team
History of Present Illness:
80 yo male with bladder cancer
Past Medical History:
Past Medical History (per urology and Cardiology notes):
- CAD, s/p myocardial infarction, CABG [**2173**]
- hypertension
- bladder and prostate cancer
- PVD s/p peripheral stent [**2191**], R Fem-[**Doctor Last Name **]
- GERD
- Hypothyroidism
- L1 compression Fx
- AAA, 3.1 cm on observation
Social History:
Retired from navy and managed in [**Doctor First Name 391**] in [**Location (un) 7188**], [**Doctor Last Name 40074**]for many years and [**State 108**]. He lives with his wife now in
[**Name (NI) 20338**] and enjoys golfing. Quit smoking tobacco many years ago
and drinks in moderation. He denies any illicit drug use.
Family History:
Unremarkable
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.1 BP: 107/57 P: 99 R: 12 SaO2: 100% on AC at
500/12 50/5
General: Intubated, sedated, but does move head to voice
HEENT: PERRL 2-1mm, NG tube in place
Neck: JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally on anterior exam, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended - 2 JP drains with serosanguinous
drainage, abdominal urinary catheter draining bloody urine
GU: no foley
Ext: cool but well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Moves head to voice, PERRL
ICU Discharge Physical Exam:
Vitals: T 36.4 ??????C HR 76 BP 98/43 RR 18 SaO2 96%
General Appearance: No acute distress
HEENT: PERRL, Normocephalic
Lungs: Few scattered rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdominal: Soft, Bowel sounds present, mildly tender around
drains
Extremities: No edema, warm and well-perfused
Neurologic: Attentive, follows simple commands
Pertinent Results:
[**2195-9-7**] 09:25AM BLOOD WBC-7.9 RBC-2.69* Hgb-9.0* Hct-25.6*
MCV-95 MCH-33.5* MCHC-35.1* RDW-12.8 Plt Ct-514*
[**2195-9-6**] 08:25AM BLOOD WBC-8.5 RBC-2.79* Hgb-9.1* Hct-26.4*
MCV-95 MCH-32.7* MCHC-34.5 RDW-12.9 Plt Ct-530*
[**2195-9-7**] 09:25AM BLOOD Glucose-101* UreaN-11 Creat-1.1 Na-139
K-4.3 Cl-108 HCO3-22 AnGap-13
[**2195-9-7**] 07:10AM BLOOD Glucose-104* UreaN-12 Creat-1.1 Na-138
K-4.1 Cl-106 HCO3-22 AnGap-14
[**2195-9-7**] 09:25AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.2 Mg-1.9
Brief Hospital Course:
80-year-old male with PMHx MI s/p CABG in [**2173**], HTN, PVD s/p
left PCI with stenting 4 years ago in [**State 108**] presents to the
ICU s/p urologic surgery for monitoring.
.
# s/p Urologic surgery. In the ICU the patient was able to be
extubated without difficulty, awake and alert afterwards with
complaints of abdominal pain responsive to dilaudid.
Hemodynamically stable. Pain was well-controlled on
toradol/dilaudid prn, and he was transitioned to dilaudid PCA on
POD1. He received maintenance IV fluid rehydration, and a
nasogastric tube was kept for continued post-operative bowel
decompression. Ampicillin & Flagyl + 1 dose Gentamycin were
given for post-op infection prophylaxis.
.
# CAD. Patient with no complaints of chest pain. Breathing is
stable.
Continued on metoprolol PO with IV metoprolol PRN. Aspirin,
plavix, and [**Last Name (un) **] were held per urology recommendation. Lasix and
spironolactone were also held pending creatinine stabilization.
Home zetia and lipitor were restarted on POD1.
.
# Hypertension. BPs in the ICU ranged 95/42(59)-187/87(129).
Acute hypertension was expected in the setting of holding home
diuretics and antihypertensives (as above). Elevated SBP >160
was managed with IV hydralazine PRN.
.
# Hypothyroidism. Continued home levothyroxine at 50mcg daily.
.
# GERD. Continued home nexium.
Mr. [**Known lastname 51305**] is an 80 year old male with PMHx MI s/p CABG in
[**2173**], HTN, PVD s/p left PCI with stenting 4 years ago in [**State 108**]
who is coming to the ICU for monitoring after a Robotic
prostatectomy and cystectomy with ileal conduit. The patient
usually lives in [**State 108**] and was initially diagnosed there, but
came to see Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] a 2nd opinion as one of his relatives
see's Dr. [**Last Name (STitle) **]. It was felt that he had high-grade bladder
cancer with diffuse carcinoma in situ throughout the bladder and
[**Doctor Last Name **] Sum 6 adenocarcinoma of the prostate in two areas of the
prostate and was referred for the above procedure. He did see
Dr. [**Last Name (STitle) **] for pre-operative cardiac clearance at which time he
was started on metoprolol succinate 25mg daily.
.
He underwent the 7 hour procedure [**2195-8-28**]. He was intubated
using a Glide scope. He was fairly hemodynamically stable,
although he did require temporary use of phenylephrine for
hypotension thought to be secondary to anesthesia. His EBL was
200cc, he received a total of 5L crystalloid (4L LR, 1L NS) as
well as 1L 5% albumin and 1 unit PRBC. The procedure was
completed without major complication and the patient was
admitted to the ICU intubated for monitoring.
From the PACU he was taken to the general surgical floor where
he had a [**Hospital 5610**] hospital course secondary to postoperative
ileus. He was eventually discharged on [**9-10**] tolerating a regular
diet but with services to further promote care of his ostomy and
strength. His staples were removed prior to discharge and [**Doctor Last Name **]
his drains had been removed as well. He did have ureteral stents
in place visible at the stoma.
Medications on Admission:
- ASA 81'
- Plavix
- NTG PRN
- Diovan 80'
- Toprol XL 25'
- Lasix 40'
- Aldactone 25'
- Synthroid 50'
- Lipitor 80'
- Zetia 10'
- Vicodin PRN
- Nexium 40'
- [**Doctor First Name **] 180'
- Rhinocort nasal
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever>101.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Macrobid 100 mg Capsule Sig: One (1) Capsule PO twice a day
for 1 days: Take the morning of your appointment with Dr. [**Last Name (STitle) **].
Take until finished.
Disp:*2 Capsule(s)* Refills:*0*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: [**2-8**] Tablet, Chewables PO QID (4 times a day) as needed for
heartburn.
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
14. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
VNA Care [**Location (un) 511**]
Discharge Diagnosis:
Bladder cancer
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:
It has been a pleasure participating in your care. You will be
discharged home with visiting nurse services that will further
assist you with management of your ongoing physical therapy and
postoperative rehabilitation and urostomy care.
-Resume your pre-admission medications unless otherwise noted.
-Also, ibuprofen has been held as well. Do NOT resume NSAID
therapy (ibuprofen/aleve/motrin/advil etc.) UNLESS specifically
advised to do so by your Urologist
-Please also refer to educational materials provided by the
nurse specialist in urostomy care and management
-The maximum dose of Tylenol (ACETAMINOPHEN) is 4 grams (from
ALL sources) PER DAY.
-The prescribed pain medication may also contain Tylenol
(acetaminophen) so this needs to be considered when monitoring
your daily dose and maximum.
-Please do NOT drive, operate dangerous machinery, or consume
alcohol while taking narcotic pain medications.
-Do not drive while urostomy bag is in place and until you are
cleared to resume such activities by your PCP or urologist
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener--it is NOT a laxative.
-You may shower but do not tub bathe, swim, soak, or scrub
incision
-If you have had Skin clips (staples) or drains removed from
your abdomen; Bandage strips called ??????steristrips?????? have been
applied to close the wound. Allow these bandage strips to fall
off on their own over time. You may get the steristrips wet.
-No heavy lifting for 4 weeks (no more than 10 pounds)
[**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
Followup Instructions:
Please contact Dr.[**Name (NI) 10529**] office upon discharge to arrange follow
up appointment for 7-10 days from discharge.
Please call your PCP to arrange [**Name Initial (PRE) **] follow-up and to discuss your
medications and postoperative course.
Please call and schedule an appointment to see the Ostomy nurse
at [**Hospital1 18**] for 2 - 4 weeks from discharge. The clinic number is
[**Telephone/Fax (1) 23664**].
Please call with any questions.
Completed by:[**2195-9-17**]
|
[
"V4581",
"V4582",
"412",
"4019",
"53081",
"2449"
] |
Admission Date: [**2142-12-9**] Discharge Date: [**2142-12-22**]
Date of Birth: [**2090-7-25**] Sex: M
Service: [**Hospital1 **] B
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male with type 1 diabetes mellitus that has been uncontrolled
for many years. Diabetes mellitus is complicated by
gastroparesis, autonomic neuropathy, renal failure, diabetic
eye disease, and peripheral vascular disease. The patient
presented with a change in mental status and hyperglycemia.
The patient denies dysuria, >.....<, chest pain. There was a
question of recent diarrhea. The patient was not sure if he
had taken his glargine the evening before.
PAST MEDICAL HISTORY:
1. Type 1 diabetes mellitus, insulin dependent complicated
by a gastroparesis, autonomic neuropathy, renal failure
(status post renal transplant times two, now with baseline
creatinine 1.4 to 3.2).
2. Right eye blindness with metrectomy.
3. Peripheral vascular disease (status post multiple toe
amputations).
4. Hypertension.
5. Benign prostatic hypertrophy, status post transurethral
resection of the prostate.
OUTPATIENT MEDICATIONS:
1. Aspirin 325 mg per day.
2. Protonix 40 mg per day.
3. Neurontin 100 mg twice a day plus 600 mg before bed.
4. Multivitamin.
5. Celexa 20 mg per day.
6. Prednisone 10 per day.
7. Tacrolimus twice a day.
8. Lasix.
9. Metoprolol.
10. Midodrine.
11. Insulin.
12. Calcium.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Lives in [**Hospital3 **]. Denies history of
alcohol or intravenous drug use. Patient is a pipe smoker.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.8. Blood pressure 129/41. Pulse of 40. Oxygen
saturation of 95% on room air. In general, the patient was
somnolent, disoriented and babbling. His mucosa were
extremely dry. His right eye was noticeably status post a
metrectomy. His extremities were significant for bilateral
superficial healing ulcers with erythema but no induration,
no necrosis or discharge. He was status post multiple toe
amputations. His exam was otherwise unremarkable.
ADMISSION LABORATORIES: His CBC was significant for a white
blood cell count of 12,900. Hematocrit was 37%. His
chemistry was notable for a sodium of 121, chloride 81, BUN
79, glucose of 1025, potassium 5.2, bicarbonate 15,
creatinine 2.5. His urine was significant for large amount
of glucose. His cardiac enzymes were also elevated with an
MB index of 8.2.
ADMISSION STUDIES: His electrocardiogram showed a normal
sinus rhythm with rate in the 80s and T waves that were
flattened diffusely compared with old studies. Chest x-ray
was unremarkable.
HOSPITAL COURSE: By system:
1. Endocrine: The patient was admitted in diabetic
ketoacidosis. An insulin drip was started and blood glucose
was brought under control over the next 24 hours. The
patient was then switched back to glargine Humalog regimen
and then discharged from the Intensive Care Unit on hospital
day number three. The patient was maintained on glargine at
16 and Humalog sliding scale. The patient was given the
option of calculating his glycemic index, but the patient
preferred to defer it to the sliding scale during this
admission.
2. Cardiovascular:
A. Ischemia: The patient was found to have elevated cardiac
enzymes including an elevated MB index on admission.
Decision was made to correct metabolic abnormalities and
proceed with catheterization once blood sugars and creatinine
were stabilized. The patient was taken to cardiac
catheterization on hospital day number five. Catheterization
identified no flow limiting lesions.
B. Pump: Echocardiogram on hospital day number two revealed
a 35% ejection fraction, [**1-11**]+ mitral regurgitation. Patient
was started on an ACE inhibitor and restarted on Lasix.
C. Hypertension: Patient was started on an ACE inhibitor
after creatinine was found to be stable. The patient also
restarted on intravenous Lasix. The patient refused to take
beta-blocker secondary to report of a hypotensive episode
while on beta-blockers. Of note, this was more likely
related to his autonomic neuropathy. Nevertheless, the
patient wishes to not take a beta-blocker were respected.
3. Renal: The patient is status post two renal transplants
and was maintained on tacrolimus and prednisone during this
admission. Tacrolimus level was checked and was found to be
therapeutic. Patient now has chronic renal insufficiency.
On admission, creatinine was 2.5 which is consistent with
previous baseline; however, the patient was felt to be dry
and this creatinine was felt to reflect some acute renal
failure secondary to dehydration. Creatinine decreased after
hydration. Patient received hydration and Mucomyst and a
peri cardiac catheterization, and creatinine remained stable
after catheterization. Creatinine increased from a nadir of
0.9 on hospital day number nine to 1.3 on discharge after
restarting of Lasix on hospital day number nine.
4. Infectious Disease: The patient developed sepsis on
hospital day number six and required intravenous pressors,
intubation and readmission to the Medical Intensive Care
Unit. Patient was then stabilized and was discharged back to
the General [**Hospital1 **] on hospital day number nine. Right IJ
catheter tip and blood sugars grew Methicillin resistant
Staphylococcus aureus. Patient was treated with intravenous
vancomycin. Patient also found to have vancomycin resistant
enterococcus on urinalysis, but analysis was negative for
white blood cells and nitrates. On informal consultation,
Infectious Disease felt that this reflected colonization
rather than infection and felt treatment was not warranted.
Healing ulcers on tibial surfaces bilaterally remained stable
and showed no evidence of recurrent cellulitis during this
admission.
5. Vascular: On hospital day number nine, patient developed
swelling in the right arm, greater than the left. A thrombus
was found in the right IJ at the site of the former infected
central venous catheter. Patient was started on a heparin
drip and then started on Coumadin. On hospital day number
13, INR was found to be therapeutic and heparin was
discontinued.
6. Autonomic neuropathy: Midodrine held in the setting of a
myocardial infarction during this admission.
7. Fluid, electrolytes and nutrition: During this
admission, the patient was maintained on a diet that met
requirements for his diabetes, renal and cardiac risk
factors. Electrolytes and fluids were repleted as necessary.
DISCHARGE MEDICATIONS:
1. Prednisone: Patient was placed on a rapid prednisone
taper, 40 mg on the 14th, 20 mg on the 15th, 10 mg per day
from then on.
2. Vancomycin 1000 mg per day times two weeks.
3. Captopril 25 mg three times a day.
4. Furosemide 40 mg twice a day (of note, the patient was
felt to have peripheral edema that was likely to take several
weeks to resolve). Outpatient physicians were cautioned to
avoid assessing volume status by level of peripheral edema.
It was felt that attempting to decrease peripheral edema too
rapidly would result in dehydration and elevation in the
patient's creatinine. Outpatient physician's were instead
instructed to assess In's and Out's carefully and adjust for
furosemide dosing accordingly.
5. Warfarin 5 mg po q.d.
6. Atorvastatin 10 mg po q.d.
7. Protonix 40 mg po q.d.
8. Aspirin 325 mg po q.d.
9. Calcium carbonate 500 mg t.i.d.
10. Neurontin as on admission 100 mg po b.i.d. and 600 mg
before bed.
11. Tacrolimus 2 mg po b.i.d.
12. Oxycodone 3300 every six hours as needed for pain.
13. Multivitamin.
14. Folic acid 1 mg po q.d.
15. Celexa 20 mg po q.d.
DISCHARGE DIAGNOSES:
1. Diabetes mellitus type 1, as complicated by
gastroparesis, autonomic neuropathy, renal failure, right eye
blindness with metrectomy (diabetic eye disease), peripheral
vascular disease.
2. Myocardial infarction.
3. Acute renal failure.
4. Sepsis.
5. Deep vein thrombosis.
6. Chronic pain.
7. Peripheral neuropathy.
8. Autonomic neuropathy.
9. Hypertension.
PATIENT'S CODE STATUS: The patient's code status is full.
DISCHARGE FOLLOW-UP: The patient was instructed to follow-up
with Dr.[**Doctor Last Name 4849**] within two weeks.
[**Known firstname **] [**Last Name (NamePattern4) 19519**], M.D. [**MD Number(1) 19520**]
Dictated By:[**First Name3 (LF) 22506**]
MEDQUIST36
D: [**2143-2-18**] 12:03
T: [**2143-2-18**] 16:28
JOB#: [**Job Number 22507**]
|
[
"41071",
"5849",
"4280"
] |
Admission Date: [**2128-6-11**] Discharge Date: [**2128-6-17**]
Date of Birth: [**2057-2-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Fall from roof
Major Surgical or Invasive Procedure:
1. Irrigation and debridement of open tibia fracture with
an inclusive of level of bone.
2. Open reduction and fixation right tibia proximal
fracture with 55 mm locking plate.
3. Open reduction internal fixation of left distal radius
fracture with locking plate.
4. Closed treatment of radius fracture without
manipulation.
5. Inferior vena cava filter placement
History of Present Illness:
71 year old man who fell 25 feet off a roof. Was brought to
[**Hospital1 18**] from the scene of the accident. Says he was cleaning out
gutters and the ladder fell out from under him. No loss of
consciousness.
Past Medical History:
PMHx: Multiple admissions for falls from roofs, severe
kyphoscoliosis
Surgical History: Fixation left pelvic fracture [**2119**], bilateral
sinus, right nasal/ethmoid fractures [**2125**]
Social History:
Worked as a construction worker. Married.
Family History:
Non-contributory
Physical Exam:
Afebrile, HR 90, BP 99/50, RR 12, O2 sat 100% via 2L NC
Gen: Awake, alert, oriented, recalls accident
CV: RRR No M/R/G
Resp: Clear to ausculation bilaterally
Abd: Soft/NT/ND
HEENT: Obvious left facial trauma
Ext: Deformity of left wrist, left leg
Pertinent Results:
[**2128-6-11**] 09:56AM PT-12.7 PTT-24.8 INR(PT)-1.1
[**2128-6-11**] 09:56AM PLT COUNT-250
[**2128-6-11**] 09:56AM WBC-11.5* RBC-4.20* HGB-13.3* HCT-38.0*
MCV-91 MCH-31.8 MCHC-35.1* RDW-13.7
[**2128-6-11**] 09:56AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2128-6-11**] 10:05AM GLUCOSE-121* LACTATE-2.8* NA+-141 K+-4.1
CL--104 TCO2-22
[**2128-6-11**] 11:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2128-6-11**] 11:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2128-6-11**] 05:47PM WBC-13.1* RBC-2.99*# HGB-9.6*# HCT-27.6*#
MCV-92 MCH-32.2* MCHC-34.8 RDW-13.3
[**2128-6-11**] 05:47PM CALCIUM-7.7* PHOSPHATE-4.1 MAGNESIUM-1.5*
[**2128-6-11**] 05:47PM GLUCOSE-160* UREA N-16 CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-23 ANION GAP-11
[**2128-6-11**] 06:31PM TYPE-ART TEMP-35.9 RATES-[**10-19**] TIDAL VOL-600
O2-50 PO2-217* PCO2-44 PH-7.34* TOTAL CO2-25 BASE XS--2
INTUBATED-INTUBATED VENT-IMV
EKG [**6-11**]: Sinus rhythm
CT Head [**6-11**]: IMPRESSION:
1. No acute intracranial hemorrhage.
2. Extensive fractures of the right facial bones with evidence
of old injury s/p hardware fixation. Please refer to dedicated
facial bone CT for furtherdetail.
CT C-spine [**6-11**]:
IMPRESSION:
1. Exaggerated cervical lordosis with levoscoliosis. No fracture
or
malalignment.
2. Extensive fractures involving the right maxilla with
premaxillary hematoma.
Please refer to dedicated CT of the facial bones for further
detail.
3. Cervical spine degenerative changes with multilevel neural
foraminal
stenosis.
CT Torso [**6-11**]:
IMPRESSION:
1. No acute sequelae of trauma in the chest, abdomen, or pelvis.
2. Bilateral renal hypodensities, likely cysts.
3. Right lower lobe nodular opacity, stable from [**2119**], likely
rounded
atelectasis.
4. Chronic right rib cage deformity, right scapular deformity,
left
acetabular hardware with advanced arthritis at the left hip
joint. No
evidence of acute fractures.
5. Moderate sized hiatal hernia is present.
CT Facial Bones [**6-11**]:
IMPRESSION:
1. Acute fractures involving the right maxilla as described with
extensive
premaxillary soft tissue swelling.
2. Acute fracture through the medial and lateral right orbital
wall with
extraconal hematoma along the medial orbit and blood noted
within the ethmoid
air cells.
3. Right nasal bone fracture. Possible fracture of the nasal
septum.
4. Possible right zygomatic arch fracture.
5. Chronic injury to the frontal bone with hardware in place.
6. Fractured upper incisor. Periapical lucency along the right
canine tooth - correlate clinically.
Left leg xrays [**6-11**]:
1. Markedly comminuted fracture of the left tibial plateau with
associated
lipohemarthrosis. CT is recommended to further evaluate prior to
surgical
repair.
2. Post-surgical changes at the left acetabulum with advanced
degenerative
disease at the left hip joint.
Right wrist XR [**6-11**]:
IMPRESSION:
1. Right distal radius intraarticular and impacted acute
fracture.
2. Acute fracture of the right third metacarpal shaft.
3. Limited views of the left wrist with acute fracture (probably
intra-
articular) of the left distal radius.
4. Possible foreign bodies in the soft tissues of the mid
forearm.
CT left lower extremity [**6-11**]:
IMPRESSION:
1. Markedly comminuted, depressed, intra-articular fracture of
the tibial
plateau, with separation of the articular fragments from the
proximal tibia, consistent with a Schatzker type VI fracture.
2. Displacement of intercondylar eminence fragment with possible
associated
ACL injury.
3. Comminuted fracture of fibular head and neck, and associated
injury to the "posterolateral corner" structures should be
considered.
4. Rotated, displaced fracture fragment, in close proximity to
the popliteal artery. Although fat plane exists, possible injury
to the popliteal artery should be entertained.
Right upper extermity [**6-11**]:
IMPRESSION:
1. Right distal radius intraarticular and impacted acute
fracture.
2. Acute fracture of the right third metacarpal shaft.
3. Limited views of the left wrist with acute fracture (probably
intra-
articular) of the left distal radius.
4. Possible foreign bodies in the soft tissues of the mid
forearm.
Chest XR [**6-13**]:
Cardiomegaly, CHF, probable small bilateral effusions and
underlying collapse
and/or consolidation.
Brief Hospital Course:
Traumatic fall: Pt brought to ED after 25 foot fall from roof
without loss of consciousness. Primary and secondary surveys
were performed and multiple x-rays and CT scans were performed
to determine extent of injuries. Trauma surgery, plastic
surgery, orthopedic surgery, and ophthalmology evaluated the
patient. Injuries were identified: non-operative distal right
radius fracture, operative left distal radius fracture, left
tibial fracture, left facial bone fractures.
Ophthalmology evaluated the patient because of his periorbital
facial trauma and determined that his vision was within normal
limits and that no further evaluation or intervention was
required from them. Plastic surgery evaluated the patient and
felt that there was no functional need to operate on his facial
fractures, but that comesis would be improved through surgery.
He decided not to pursue plastic surgery for his facial bone
fractures, so plastic surgery signed off. Orthopedic surgery
evaluated him and took him to the OR on [**6-12**] with the following
preoperative diagnoses:
1. Open left proximal shaft tibia fracture.
2. Left distal radius multi-part fracture.
3. Right distal radius fracture.
They performed the following procedures:
1. Irrigation and debridement of open tibia fracture with
an inclusive of level of bone.
2. Open reduction and fixation right tibia proximal
fracture with 55 mm locking plate.
3. Open reduction internal fixation of left distal radius
fracture with locking plate.
4. Closed treatment of radius fracture without
manipulation.
Post-operatively, the patient was tranferred to the [**Month/Year (2) 13042**] while
still intubated. He had been a difficult intubation and there
was some concern that if reintubation was required, it would be
challenging. After several hours of good urine output and stable
vitals in the [**Last Name (LF) 13042**], [**First Name3 (LF) **] attempt at extubation was made. Pt
quickly became agitated and tachypneic so the decision was made
to keep him sedated and intubated. He was admitted to the trauma
ICU for further treatment.
In the TSICU, hematocrits were checked and had fallen
significantly from pre-operative levels, so 2 units PRBCs were
transfused and additional fluid resuscitation was provided.
Subsequent hematocrits were stable. On [**6-13**], patient was
successfully extubated and continued to be observed.
On [**6-14**], he was tranferred to the floor. He received an IVC
filter from interventional radiology in an effort to prevent
pulmonary embolisms. His diet was slowly advanced to soft
regular, his foley catheter was replaced with a condom catheter
because of his severely limited bilateral upper extremity
mobility. He was given a bowel regiment and had a bowel
movement. His IV fluids were discontinued when he was taking
good PO. Pain was controlled on oral medications. He received
physical and occupational therapy evaluation and treatment. He
was deemed ready for discharge to a rehabilitation facility on
[**6-17**].
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Traumatic fall from ladders with multiple face fractures, open
left tibial fracture, left radius fracture
Discharge Condition:
Stable, meets discharge criteria to rehab facility, eating soft
diet, voiding via condom catheter, pain well controlled on oral
medications.
Discharge Instructions:
Take your medications as prescribed. You will be discharged to a
recharge facility where physical and occupational therapists
will continue to work with you to improve your strength and
mobility.
Return to the Emergency Department or see your own doctor right
away if any problems develop, including the following:
* Swelling, pain or redness getting worse.
* Fingers or toes become pale (whiter) or become dark or
blue.
* Numbness, tingling or coldness of your fingers or toes.
* Loss of movement.
* Rubbing sensation, burning or soreness of your skin,
especially under a cast.
* Chest pain, shortness of breath or trouble breathing.
* Fever or shaking chills.
* Headache, confusion or any change in alertness.
* Anything else that worries you.
The Emergency Department is open 24 hours a day for any
problems.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 22750**] to
schedule an appointment.
Follow up with the orthopedic trauma clinic in 1 week to have
your staples removed. Call ([**Telephone/Fax (1) 2007**] to schedule an
appointment.
Follow up with your
Follow up with the plastic surgery clinic if you decide you want
to pursue reconstructive surgery for your facial bone fractures,
call Dr.[**Name (NI) 29526**] office at ([**Telephone/Fax (1) 29527**] to schedule an
appointment.
|
[
"2859"
] |
Admission Date: [**2162-12-17**] Discharge Date: [**2162-12-31**]
Date of Birth: [**2094-12-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABG X 3
Maze procedure
History of Present Illness:
68 y/o male adm. to outside hospital on [**12-16**] CP, r/i for NQWMI.
Cath: 3vCAD, EF 35%, he was transferred to [**Hospital1 18**] for CABG
Past Medical History:
HTN
hypercholesterolemia
GERD
Schizoaffective disorder
Social History:
married, lives w/wife
Physical Exam:
unremarkable upon admission
Pertinent Results:
[**2162-12-30**] 06:25AM BLOOD PT-16.5* PTT-75.8* INR(PT)-1.7
[**2162-12-30**] 06:25AM BLOOD WBC-9.2 RBC-3.69* Hgb-10.8* Hct-31.9*
MCV-86 MCH-29.4 MCHC-34.0 RDW-12.7 Plt Ct-557*
[**2162-12-30**] 06:25AM BLOOD Glucose-102 UreaN-18 Creat-1.3* Na-140
K-5.0 Cl-99 HCO3-30* AnGap-16
Brief Hospital Course:
Adm. on [**2162-12-17**], went in to atrial fibrillation
pre-operatively, started on amiodarone. Had pre-op echo, and
carotid studies
Taken to OR on [**2162-12-21**], for CABG X 3 (LIMA > LAD, SVG > OM, SVG
> RCA), and maze procedure.
Stable post-op, transferred to telemetry floor on post-op day #
1
Had some post-op atrial fibrillation, but has now remained in
sinus rhythm for the past few days.
Psychiatry consultation obtained, and meds adjusted per their
recommendation.
Started on IV heparin drip to anticoagulate for AFib. D/C'd on
[**12-30**] when INR was 1.7.
Had some mild confusion post-op which resolved spontaneously.
Medications on Admission:
heparin gtt, captopril 6.25 mg [**Hospital1 **], Zocor 20 mg QD, Klonepin 0.5
mg [**Hospital1 **], Lopressor 25 mg QD *from outside hospital), propranolol
80 mg [**Hospital1 **], aripiprozole 5mg QD, Protonix 40 mg QD, Sertraline
100 mg QD
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily) for 5 days.
Disp:*20 Capsule, Sustained Release(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. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Propranolol HCl 20 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
11. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 3 days: then check INR and dose for target INR
2.0-2.5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
CAD
atrial fibrillation
HTN
Discharge Condition:
good
Discharge Instructions:
no lifting > 10 # or driving for 1 month
no creams lotions or ointments to any incisions
may shower, no bathing for 1 month
Followup Instructions:
wiht Dr. [**Last Name (STitle) **] in [**2-2**] weeks
with Dr. [**Last Name (STitle) 70**] in [**5-6**] weeks
Completed by:[**2162-12-30**]
|
[
"41071",
"41401",
"42731",
"4019",
"2720",
"53081"
] |
Admission Date: [**2175-2-14**] Discharge Date: [**2175-2-16**]
Date of Birth: [**2126-9-26**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 48 year old
African-American female with nonsmall cell lung cancer who
has three brain metastases. Her oncological problems began
in [**2173-4-16**] when she developed nausea and a cough with
yellow sputum. X-rays showed three synchronous lesions in
the right upper lobe. She underwent right upper lobectomy by
Dr. [**Last Name (STitle) 175**] in [**2173-5-16**]. She was treated with three cycles
of carboplatin and Taxol.
In [**2174-4-16**] she developed left hip pain where she had
metastasis to her left hip. She was enrolled in the Aresa
trial from [**2174-9-16**] to [**2174-12-17**]. She developed
elevated liver functions and was taken off the Aresa at that
time. While being evaluated for another protocol, staging
and MRI showed that she had three enhancing lesions, one
measuring 2.5 cm in the right frontal brain, another 0.5 cm
lesion posterior right frontal brain and a third one
measuring 0.5 cm in the right insula.
She was completely asymptomatic. Did not have any headache,
nausea, vomiting or psychomotor slowing, personality change,
unsteady gait, seizures or falls.
PAST MEDICAL HISTORY: She has asthma. History of iron
deficiency anemia.
PAST SURGICAL HISTORY: She had right thyroidectomy which she
thinks was for thyroid cancer.
FAMILY HISTORY: There are members of her family who had or
has a brain tumor, thyroid cancer, CAD, hypertension and
asthma.
SOCIAL HISTORY: The patient smoked [**11-17**] pack of cigarettes
per day for 40 years. She drinks an occasional beer.
MEDICATIONS ON ADMISSION: Celexa 40 mg p.o. q.d., Decadron 4
mg p.o. q.six hours, oxycodone 10 mg p.o. q.four to six hours
p.r.n., fentanyl patch 75 mcg q.72 hours, Protonix 40 mg p.o.
q.day, Compazine p.o. p.r.n. q.day, albuterol inhaler,
Atrovent inhaler, stool softener.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Blood pressure was 130/88, heart rate
100, respiratory rate 20. HEENT was unremarkable. Neck was
supple, no cervical, axillary or supraclavicular
lymphadenopathy. Cardiac exam revealed regular rhythm and
rate. Lungs were clear. Abdomen soft. Extremities did not
show cyanosis, clubbing or edema. Neurological exam showed
that she was awake, alert and oriented times three. There
was no right to left confusion or finger agnosia.
Calculation was intact. Language was fluent with good
comprehension, naming and repetition. Visual fields were
full. Extraocular movements were full. Pupils were reactive
to light 4 mm to 2 mm. Face was symmetric. She had no
drift. Muscle strength was [**3-20**]. Reflexes were 3+
bilaterally.
HOSPITAL COURSE: The patient was brought to the operating
room on [**2-14**] where she underwent right frontal craniotomy
and resection of right frontal metastasis. Frozen section
was sent to the lab. Patient did very well overnight and was
monitored in the post anesthesia recovery unit where her
vital signs remained stable. She was awake, alert and showed
no deficits after surgery. On the second post-op day she was
ambulating in the hallway, tolerating a complete diet. Pain
was well controlled. No nausea, vomiting. She was cleared
by physical therapy to go home safely.
DISCHARGE MEDICATIONS: On [**2-16**] patient was discharged home
on the same medications except for the addition of Percocet
one to two p.o. q.four to six hours p.r.n. pain. She was to
continue on Protonix. She will be started on a Decadron
taper. She will take 4 mg b.i.d. on discharge day; on [**2-17**], 4 mg b.i.d.; on [**2-18**], 4 mg in the a.m., 2 mg in the
p.m.; same on the 6th; on the 7th she is to decrease to 2 mg
b.i.d. until further notice.
She has a followup appointment in the brain tumor clinic on
[**2-20**] at 3:00 p.m. She will be meeting with Dr. [**First Name (STitle) **] at that
time and she will have her staples removed at that time.
CONDITION AT DISCHARGE: Patient was discharged
neurologically stable.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**First Name3 (LF) 100593**]
D: [**2175-2-16**] 09:17
T: [**2175-2-17**] 11:51
JOB#: [**Job Number 100594**]
|
[
"49390"
] |
Admission Date: [**2132-5-20**] Discharge Date: [**2132-5-25**]
Date of Birth: [**2068-8-6**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 64-year-old male
with known right coronary artery disease, status post
inferior myocardial infarction in [**2122**], who has demonstrated
recurrent angina over the past month treated with TPA
beginning on [**2132-4-3**]. The patient underwent a direct
stenting of the left circumflex artery on [**2132-4-7**], and
was subsequently recommended for repeat cardiac
catheterization on [**2132-5-20**]. Repeat catheterization
demonstrated left main and right coronary artery disease with
50% stenosis at the bifurcation of the LAD and the left
circumflex artery and total occlusion of the right coronary
artery immediately distal to the RV marginal branch. The
patient's calculated left ventricular ejection fraction was
56%. The patient was subsequently admitted to the [**Hospital Unit Name 196**]
Service on [**2132-5-20**] for further evaluation and
management.
PAST MEDICAL HISTORY: Inferior myocardial infarction in
[**2122**], status post cataract surgery.
ADMISSION MEDICATIONS:
1. Enteric coated aspirin.
2. Zocor 40 mg p.o. q.d.
3. Toprol XL 50 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Altace 5 mg p.o. q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives in [**Location 29789**] and is retired,
the patient is married. The patient denied any history of
tobacco or alcohol use. The patient reportedly golfs and
exercises four times a week for at least an hour a day.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**]
Service on [**2132-5-20**] for further evaluation of his cardiac
pathology. Following a discussion with the patient regarding
the relative risks and benefits of cardiac surgery, the
patient consented to undergo a coronary artery bypass graft
procedure to be scheduled on [**2132-5-21**].
On [**2132-5-21**], the patient, therefore, underwent a
quadruple coronary artery bypass graft procedure.
Anastomosis included from the LIMA to the LAD, saphenous vein
graft to the distal RCA and saphenous vein graft to the OM1,
OM3. The patient had a bypass time of 78 minutes and a cross
clamp time of 51 minutes. The patient's pericardium was left
open; lines placed included an arterial line and CVP; both
ventricular and atrial wires were placed; both mediastinal
and bilateral pleural tubes were placed intraoperatively.
The patient was subsequently transferred to the Cardiac
Surgery Recovery Unit, intubated, for further evaluation and
management. Shortly upon arrival in the CSRU, the patient
was successfully weaned and extubated without complication
and was noted, thereafter, to be tolerant of oral intake.
On postoperative day number one, the patient was successfully
weaned from all pressors and was noted to have his pain well
controlled via oral pain medications.
On postoperative day number two, the patient was cleared for
transfer to the regular floor and was subsequently admitted
to the Cardiothoracic Service under the direction of Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**]. On the floor, the patient progressed well
clinically through the time of his discharge.
The patient was evaluated by Physical Therapy, who cleared
him for discharge to home following resolution of his acute
medical issues.
On postoperative day number three, the patient's chest tubes
and pacing wires were removed without complication. The
patient's Foley catheter was subsequently removed without
complication. The patient was thereafter noted to be
independently productive of adequate amounts of urine for the
duration of his stay. The patient subsequently cleared level
V PT certification on postoperative day number four, [**2132-5-25**], and was subsequently cleared for discharge to home with
instructions for follow-up.
CONDITION ON DISCHARGE: The patient is to be discharged to
home with instructions for follow-up.
STATUS AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Lopressor 12.5 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. times ten days.
3. Colace 100 mg p.o. b.i.d.
4. Potassium chloride 20 mg p.o. b.i.d. times ten days.
5. Enteric coated aspirin 325 mg p.o. q.d.
6. Percocet one to two tablets p.o. q. four to six hours
p.r.n. pain.
7. Lipitor 40 mg p.o. q.d.
DISCHARGE INSTRUCTIONS: The patient is to maintain his
incisions clean and dry at all times. The patient may shower
but should pat dry incisions afterwards; no bathing or
swimming until further notice. The patient may resume a
regular diet. The patient has been advised to limit physical
activity; no heavy exertion, no driving while taking
prescription pain medications. The patient is to follow-up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1275**] in one to two weeks; the patient is to
call [**Telephone/Fax (1) 3658**] to schedule an appointment. The patient is
to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in six weeks; the
patient is to call [**Telephone/Fax (1) 170**] to schedule an appointment.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 49788**]
MEDQUIST36
D: [**2132-5-24**] 05:16
T: [**2132-5-24**] 17:44
JOB#: [**Job Number 49789**]
|
[
"41401",
"412",
"2720",
"V4582"
] |
Admission Date: [**2110-8-23**] Discharge Date: [**2110-8-29**]
Service: NEUROLOGY
Allergies:
Codeine
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Sudden onset right hemiplegia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 83 year old woman without significant prior
medical history who presents with sudden onset right hemiplegia
in the context of a left frontal intraparenchymal hemorrhage.
She
was admitted to the SICU on [**8-23**]. The patient was intubated
for airway protection.
Past Medical History:
Diverticulitis
Social History:
lives with her husband in the [**Location (un) **], she raised her two
daughters (one lives in the area), both daughters are here in
town at present, she does the bills in the house, she never
smoked, she does not drink, no illicit drug use.
Family History:
no history of stroke or bleeding diathesis.
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: T 98.3, HR 68, BP 154/78, R 18, on O2 2l NC
Gen: lethargic.
HEENT: NCAT, MMM, anicteric sclera, OP clear
Neck- no carotid bruits
Pulm- CTA B
Abd- Soft, nt, nd, BS+
Extrem- no CCE
Neurologic Examination:
MS: unresponsive. Mobilizes the left hemibody with noxious
stimuli.
Left gaze conjugated deviation.
PERRL 4-->2mm on the left, sluggish on the right, no facial
asymmetry.
Motor- R leg externally rotated, no adventitious movements,
normal bulk, increased tone in R hemibody with hemiparesis.
Coordination: npt possible to examine.
Sensory: unresponsive not examined.
Toes- bilaterally upgoing.
Gait- unable to test.
Pertinent Results:
[**2110-8-23**] 02:30PM GLUCOSE-141* UREA N-20 CREAT-0.7 SODIUM-144
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-19
[**2110-8-23**] 02:30PM estGFR-Using this
[**2110-8-23**] 02:30PM CK(CPK)-107
[**2110-8-23**] 02:30PM cTropnT-<0.01
[**2110-8-23**] 02:30PM CK-MB-4
[**2110-8-23**] 02:30PM WBC-13.7* RBC-4.63 HGB-14.8 HCT-41.7 MCV-90
MCH-32.0 MCHC-35.6* RDW-12.9
[**2110-8-23**] 02:30PM NEUTS-91.1* BANDS-0 LYMPHS-5.9* MONOS-2.4
EOS-0.3 BASOS-0.2
[**2110-8-23**] 02:30PM PLT COUNT-166
[**2110-8-23**] 02:30PM PT-12.0 PTT-20.5* INR(PT)-1.0
CT CNS w/o Contrast: 08/ 02/ 08
Large left frontoparietal intraparenchymal hemorrhage with no
significant mass effect, and grossly unchanged compared to the
outside
hospital CT performed three hours prior. Given the lobar
distribution, the
differential diagnosis includes amyloid angiopathy, underlying
mass of AVM, or
aneurysm. Comparison with concurrent CTA demonstrates no
evidence of these
entities at this time. An MRI and repeat CTA could be obtained
when the
hemorrhage has resolved to evaluate for amyloid angiopathy,
underlying mass or vascular malformation.
CT CNS w/ wo contrast: 08/ 02/ 08: No AVM aneurysm underlying
the left frontoparietal
intraparenchymal hematoma.
There is, however, suggestion of an incidental 4.6 mm aneurysm
probably
arising from the left cavernous carotid artery extending to the
suprasellar
cistern. Evaluation of this area on CT is limited due to
artifact from bone.
MRI CNS: 08 / [**3-29**]:
Stable left frontoparietal hemorrhage with enhancement of the
hematoma wall and hyperemia. No underlying AVM or mass seen on
the current
study but cannot be excluded due to the large amount of
hemorrhage.
CT CNS w/o contrast: 08 / 05/ 08:
here is new blood within the lateral ventricles bilaterally.
However, there is no evidence of increased bleeding associated
with the large
hematoma previously noted. It is possible this represents
rupture of the
existing hematoma into the ventricles. There is slight
dilatation of the
ventricles since the study of [**2110-8-25**]. Edema surrounding the
hematoma appears
stable.
Brief Hospital Course:
The patient had an episode of twitching her left arm and
hemiface. She was
loaded on fosphenytoin 1000 mg iv.
The prognosis was discussed with the family in a meeting on 08 /
06/ 08 at 11:00 am. They agreed with a change to DNR status. By
the time she had been on hypertonic saline that was stopped
given the Na and osmolality levels. She did not improve
clinically. A new family meeting was held. The palliative are
team was involved and the family decided to make her CMO on 08/
07/ 08.
Once the therapeutic measures were removed and she just received
comfort measures only she passed away.
Medications on Admission:
None
Discharge Medications:
Ms [**Known lastname **] [**Last Name (Titles) **].
Discharge Disposition:
[**Last Name (Titles) **]
Discharge Diagnosis:
Left frontal intraparenchimal hemorrhage
Discharge Condition:
[**Last Name (Titles) **]
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"2760",
"53081"
] |
Admission Date: [**2150-1-20**] [**Month/Day/Year **] Date: [**2150-1-27**]
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
Past Medical History:
Hypertension
Hypothyroidism
Osteoarthritis
Depression
Obesity
Urinary Incontinence
GERD
s/p Total TAH
Social History:
Independent at home with ADL's/IADL's prior to her fall.
Family History:
Noncontributory
Pertinent Results:
[**2150-1-20**] 02:55AM GLUCOSE-139* UREA N-20 CREAT-0.9 SODIUM-135
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-25 ANION GAP-12
[**2150-1-20**] 02:55AM CALCIUM-8.3* PHOSPHATE-3.8 MAGNESIUM-2.2
[**2150-1-20**] 02:55AM TSH-0.30
[**2150-1-20**] 02:55AM WBC-10.3 RBC-3.77* HGB-10.7* HCT-32.3* MCV-86
MCH-28.5 MCHC-33.2 RDW-14.7
[**2150-1-20**] 02:55AM PLT COUNT-265
[**2150-1-19**] 10:59PM HGB-12.1 calcHCT-36
[**2150-1-19**] 10:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-1-19**] 10:45PM FIBRINOGE-465*
MR CERVICAL SPINE W/O CONTRAST; MRA NECK W&W/O CONTRAST
Reason: - please MRA w/ fat saturation supression sepqence- to
eval
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with C1 burst fx and anterior hematoma
w/minimal cord compression
REASON FOR THIS EXAMINATION:
- please MRA w/ fat saturation supression sepqence- to eval for
expansion of hematoma / ligimentous injury / vascular injury
INDICATION: Patient with C1 burst fracture and anterior hematoma
with minimal cord compression. Please evaluate for extension of
hematoma, ligamentous injury and vascular injury.
COMPARISON: CT of the cervical spine and CTA of the neck of
[**2150-1-19**].
TECHNIQUE: Sagittal T1, T2 and STIR sequences of the cervical
spine were obtained, with axial gradient-echo and T2-weighted
scans through the entire cervical spine. Axial T1-weighted
fat-saturated images were attempted, but are of poor quality due
to patient motion. 2D time-of-flight imaging as well as
gadolinium MRA of the carotid and vertebral arteries were also
performed, with multiplanar reconstructions.
MRI OF THE CERVICAL SPINE: The C1 burst fracture is better
appreciated on the CT images of one day previous. Other cervical
vertebral body heights are maintained. Mild anterolisthesis of
C4 on C5 is better appreciated on the recent CT evaluation.
There is a large retropharyngeal hematoma spanning the entire
anterior aspect of the cervical spine. It is difficult to
evaluate for a mild interval change in the size of this hematoma
given differences in technique.
There is no definite epidural hematoma component. There is no
evidence of cord edema or hematoma.
Axial T1-weighted fat-saturated images are nondiagnostic due to
gross patient motion.
MRA OF THE CAROTID AND VERTEBRAL ARTERIES: As delineated on the
CTA of the neck obtained one day ago, the gadolinium-enhanced
MRA demonstrates occlusion of the horizontal portion of the left
vertebral artery, at the level of the foramen magnum. The
nonenhancing portion appears unchanged compared to the recent
CTA. The left vertebral artery appears reconstituted
approximately 2 cm inferior to the vertebrobasilar junction. The
findings are in agreement with the recent CT angiogram.
IMPRESSION:
1. Occlusion of the horizontal portion of the left vertebral
artery, with reconstitution intracranially as described on the
prior CTA. While axial T1- weighted fat-saturated images are
nondiagnostic, the most likely cause for the vascular occulsion
is a dissection. The occluded portion appears not significantly
changed compared with the recent CTA exam.
2. Large retropharyngeal hematoma as previously described.
3. Mild anterolisthesis of C4 on C5, without evidence of edema
at this level.
4. C1 fracture is better delineated on CT.
CHEST (PORTABLE AP)
Reason: TRAUMA
INDICATION: Trauma.
PORTABLE AP CHEST: The patient is significantly rotated which
precludes proper assessment of the mediastinal width. Cannot
exclude aortic injury. The lungs are clear. No rib fractures are
apparent. There is no large pneumothorax. Trauma board is
obscuring fine detail.
SHOULDER (AP, NEUTRAL & AXILLA; ELBOW (AP, LAT & OBLIQUE) LEFT
Reason: please eval for bony injury
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman s/p fall w/reported c1 fx and shoulder pain
REASON FOR THIS EXAMINATION:
please eval for bony injury
INDICATION: [**Age over 90 **]-year-old woman status post fall with reported C1
fracture and shoulder pain. Evaluate for bony injury.
AP AND LATERAL VIEWS OF THE LEFT SHOULDER AND ELBOW: There are
degenerative changes in the AC joint. Bony alignment is
anatomic. No acute fractures or dislocations are seen.
CT HEAD W/O CONTRAST
Reason: S/P FALL WITH CI FX
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman s/p fall w/reported c1 fx
REASON FOR THIS EXAMINATION:
please eval for iph / fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: [**Age over 90 **]-year-old woman status post fall with reported C1
fracture. Please evaluate for intracranial hemorrhage and
fracture.
CT HEAD WITHOUT CONTRAST: There is a C1 [**Location (un) 5621**] burst
fracture, which is better assessed on the accompanying CT of the
C-spine. There is a prominent circumferential epidural space at
the C1/2 level, which may simply be a result of the fracture
causing malalignment of C1 v. C2, as opposed to prominent but
otherwise normal epidural veins. A focal epidural hematoma seems
less likely. There is ample residual subarachnoid space between
the dura and the cord at this level. Please see further details
within the cervical spine CT report. No skull fractures are
apparent. There is no evidence of acute intracranial hemorrhage.
There is no CT evidence of acute major vascular territorial
infarct. There are mild cerebral periventricular white matter
hypodensities consistent with small vessel infarction.
Ventricles, sulci, and basal cisterns are prominent, appropriate
for the patient's age. Visualized paranasal sinuses and mastoid
air cells are clear. There is moderate-sized right
frontotemporal and smaller left posterior parietal scalp soft
tissue swelling, likely subgaleal hematomas.
The patient appears to be status post bilateral cataract
surgery.
IMPRESSION:
1. C1 burst fracture.
2. No acute intracranial hemorrhage.
3. Moderate-sized right frontotemporal and smaller left
posterior parietal subgaleal hematomas.
4. Mild cerebral periventricular white matter hypodensities
consistent with chronic small vessel infarction.
ADDENDUM: There is a subcm. osteoma arising from the outer table
of the frontal bone.
Brief Hospital Course:
She was admitted to the Trauma service. Neurosurgery was
immediately consulted because of her cervical spine fracture.
The injury was nonoperative; she is to remain in a hard cervical
collar for a total of 12 weeks from the injury date ([**2150-1-20**]).
Follow up with Dr. [**Last Name (STitle) **], Neurosurgery in 12 weeks for repeat
cervical spine imaging.
Neurology was consulted because of a ?vertebral artery
dissection. An MRI of the neck was recommended; the results
revealed an occlusion of the horizontal portion of the left
vertebral artery, with reconstitution intracranially. She was
started on ASA 325 daily per recommendation of Neurology.
Geriatrics was also consulted given her age and mechanism of
injury. Several recommendations were made concerning pain
management; bone prophylaxis with Vitamin D and Calcium was also
initiated. Her TSH was checked; it was 0.30. It was also
recommended that her Celexa be held because of low sodium and so
this was stopped. She will need to have her chemistries followed
at least weekly and prn while at rehab to ensure resolution of
her hyponatremia.
She was transfused with 2 units of packed red cells on [**1-26**] for a
hematocrit of 21.9. Lasix was given following the transfusions.
Her hematocrit on day of [**Month/Day (1) **] is 29.4. She is also on iron
daily.
Her appetite has been fair to poor since her fall. Nutrition
services was consulted; she was placed on calorie counts and
ordered for tid Ensure. Per her son report patient has
suboptimal nutrition at baseline; likes to eat chocolate. She
will need further nutritional consultation once at rehab.
Medications on Admission:
Synthroid 125'
Enalapril 20'
Citalopram 20
[**Month/Day (1) **] Medications:
1. Insulin Regular Human 100 unit/mL Solution [**Month/Day (1) **]: One (1) dose
Injection four times a day as needed for per sliding scale.
2. Aspirin 325 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO DAILY (Daily).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ML
Injection TID (3 times a day).
5. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day): hold for loose stools.
9. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every
6 hours).
10. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day): hold fro SBP <110; HR <60.
11. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO BID (2 times a day).
13. Levothyroxine 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Ferrous Sulfate 325 (65) mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
[**Last Name (STitle) **] Disposition:
Extended Care
Facility:
[**Street Address(1) 23157**]
[**Street Address(1) **] Diagnosis:
s/p Fall
C2 ring fracture
Secondary Diagnosis:
Urinary Tract Infection
Anemia
[**Street Address(1) **] Condition:
Stable
[**Street Address(1) **] Instructions:
You must continue to wear the cervical collar for the next 12
weeks because of the fracture in your spine.
Followup Instructions:
Follow up in 3 months with Dr. [**Last Name (STitle) **], Neurosurgery. Call
[**Telephone/Fax (1) 2731**] for an appointment. Inform the office that you will
need a repeat cervical spine CT scan with reconstruction for
this appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] form
rehab.
Completed by:[**2150-2-4**]
|
[
"5990",
"4019",
"2449",
"311",
"53081"
] |
Unit No: [**Numeric Identifier 68624**]
Admission Date: [**2189-10-3**]
Discharge Date: [**2189-10-29**]
Date of Birth: [**2189-10-3**]
Sex: F
Service: NB
REASON FOR ADMISSION: Prematurity (33 and 6/7 weeks
gestation).
MATERNAL HISTORY: Baby Girl [**Known lastname 68625**] was born to a 23 year-
old, Gravida I, Para 0 Mom with BNS blood type 0 positive,
antibody negative, RPR nonreactive, Rubella immune, hep-B
negative, GBS unknown. Her EDC was [**2189-11-15**]. Her pregnancy
was complicated by premature rupture of membranes at 33 6/7
weeks and preterm labor. She was treated with antibiotics,
multiple doses, prior to delivery.
BIRTH HISTORY: Baby Girl [**Known lastname 68625**] was born by Cesarean
section for non reassuring fetal heart rate. She was a
difficult extraction. She had Apgar scores of 7 at 1 minute
and 7 at 5 minutes. She was given positive pressure bag andmask
ventilationa and facial C-Pap in the delivery room. This infant
was taken to the NICU for further management.
PHYSICAL EXAMINATION: General: Infant pale, lethargic.
Weight 2175 grams. Head circumference 32.5 cm. Length 44.5
cm.
Vital signs: Temperature 99; respiratory rate 40; heart rate
152; blood pressure 45/15 (mean 22). Repeat 55/22 (mean 33).
Intubated. SIMV 25/5; FI02 25%; sats 99%. D-sticks 97.
HEENT: Molding of the head significant. Scalp bruising. 2 to
2.5 cm oval-shaped bruise over her left eye and ocular
region. Left moderate side caput. Anterior fontanel open and
flat. Palate intact.
Respiratory: Lungs coarse breath sounds but very shallow
spontaneous respirations.
CVS: Regular rate and rhythm, no murmur. Femoral pulses 2+
bilaterally.
Abdomen: Soft with active bowel sounds, no masses or
distention.
Extremities: Warm, well perfused, brisk capillary refill.
Spine: Midline, no dimple. Clavicles intact.
Hips: Lax but no dislocation, held in former breech
position.
Genitourinary: Swollen labial folds. Anus patent.
Neuro: Decreased tone globally but moved all extremities
equally.
HOSPITAL COURSE:
1. Respiratory: The initial respiratory course and chest x-
ray were consistent with respiratory distress syndrome.
She received 2 doses of Surfactant and was ventilated for
the first day of life. She was successfully extubated to
nasal cannula oxygen on day 2. By day 3 of life, she was
comfortably breathing in room air with no oxygen
requirements. She has had no problems with apnea of
prematurity. At the time of discharge, she is comfortably
breathing in room air with no apnea.
2. Cardiovascular: No cardiovascular issues.
3. Fluids, electrolytes and nutrition: She was n.p.o. for
the first 2 days of life and feeds were gradually
introduced on day 3 in the form of breast milk, special
care formula. Feeds were gradually advanced to full
volume po/pg feeds at 150 mg/kg per day by day of life 7.
The calories were increased to 24 cals per ounce for
better weight gain. At the time of discharge, she is on
Similac 24, ad lib p.o. feeds, taking approximately 165
ml/kg per day. Weight at discharge is 2640 grams.
4. Gastrointestinal: She had no gastrointestinal
complications. She received phototherapy for exaggerated
physiologic jaundice due to prematurity with a maximum
bilirubin of 11.5/0.4 mg/dl on day of life 3.
5. Hematology: No complications of prematurity and she did
not need any blood transfusions.
6. Infectious disease: Baby [**Known lastname 68625**] had sepsis ruled out at
the time of admission and received intravenous
antibiotics for 48 hours. She had no episodes of proven
infection.
7. Neurology: She did not qualify for routine head
ultrasound scan.
8. Sensory:
Audiology: She passed her newborn hearing test.
Ophthalmology: She does not qualify for routine ROP exam.
9. Psychosocial: [**Hospital1 69**]
social work was involved with the family. No social
concerns.
CONDITION ON DISCHARGE: Well.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 2398**] [**Last Name (NamePattern1) 68626**], MD, [**Telephone/Fax (1) 68627**]. Fax #[**Telephone/Fax (1) 68628**].
FEEDS AT DISCHARGE: Similac 24.
MEDICATIONS: None.
CAR SEAT POSITION SCREENING: Passed.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine, first dose on
[**2189-10-12**].
SCREENING: Newborn state screen was sent on [**10-16**] and [**10-27**].
Results are pending.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: (1) Born at less than
32 weeks; (2) Born between 32 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.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP: Appointments scheduled/recommended:
Pediatrician 2 to 3 days following discharge.
DISCHARGE DIAGNOSES:
1. Prematurity (33 and 6/7 weeks gestation).
2. Respiratory distress syndrome.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Doctor Last Name 68342**]
MEDQUIST36
D: [**2189-10-30**] 08:32:08
T: [**2189-10-30**] 09:02:16
Job#: [**Job Number 68629**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2154-1-2**] Discharge Date: [**2154-1-4**]
Date of Birth: [**2091-1-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Sepsis, DIC
Major Surgical or Invasive Procedure:
Endotracheal intubation (at OSH)
History of Present Illness:
62y/o F with h/o COPD, CVA, + PPD [**12-27**] exposure to husband s/p
INH course x9 months, dementia, EtOH, hypertension presented to
OSH with increasing dyspnea. Was recently d/c'ed with COPD
exacerbation - treated with steroids and gatifloxacin. One week
later, c/o worsening dyspnea on [**12-29**]. She was confused, producing
thick yellow sputum, with chills.
Pt admitted to the floor. Desatted, with episode of a fib with
RVR - transferred to unit, treated with dig, lopressor, and dilt
- converted to normal sinus. Was hemodynamically stable.
At OSH, oriented to person and place, but not time. Sat 94% on
2L. WBC on arrival was 25.4, Hct 27.5, plt 35. She was found to
have a RLL infiltrate on CXR. Was on BiPAP initially, eventually
intubated [**12-27**] worsening respiratory failure. Had a chest CT with
loculated R effusion, 2.2 cm RML spiculated mass and R axillary
and supraclavicular LAD. Head CT performed [**12-27**] MS changes -
acute infarct in L frontal lobe. Head CT 4 days later showed no
change. Due to findings on chest CT, had a bronch on the AM of
admission - thick purulent secretions in RML, had cytology
brushings and quantitative cytology brushings sent. On the day
of admission, fibrinogen < 70, FDP > 20, plts 47, INR 1.9. Pt
rec'd 4 units of cryo, then 10 units cryo on [**1-1**], ? FFP, ?
platelets, vitamin K. Acute rise in LFTs - AST 275, ALT 260, alk
phos 82. Were normal on admission [**12-28**] - AST 31, ALT 15, alk phos
82, t bili 1.0.
Was treated with vanco and imipenem. Was transferred here for
expedited workup of RML mass.
Past Medical History:
h/o TB exposure - INH x9 months
lupus anticoagulant positive
hypertension
hyperlipidemia
h/o CVA
EtOH
tobacco use
Social History:
lives with one of her daughters. [**Name (NI) 4906**] died about 1 year ago
[**12-27**] TB. In the past, pt drank EtoH daily, was a heavy smoker -
quit [**10-29**].
Family History:
NC
Physical Exam:
VS: 98.0 151/44 77 16 95% AC 450x16/7/0.5
Gen: not responsive to commands, intubated
HEENT: PERRL
CV: RRR, nl S1/S2, no m/r/g
Pulm: clear bilaterally
Abd: mildly distended, hypoactive bowel sounds
Ext: dusky R foot with non-dopplerable pulses, purple R 3rd
finger
Neuro: does not open eyes on command
Pertinent Results:
OSH Radiology Studies:
CT head without contrast [**12-31**] (OSH): c/w acute infarct, left
frontal; atrophy with additional small areas of decreased
attenuation c/w previous ischemic changes; R parietal temporal,
L posterior parietal, deep central R parietal - c/w areas of
previous infarct - no change from [**12-28**]
.
CT chest with contrast [**12-31**] (OSH): anteriorly at R base, 2.2cm
area of increased attenuation, possible rounded atelectasis but
cannot exclude lung mass in RML; soft tissue prominence in R
axilla, enhancing; soft tissue fullness in supraclavicular
region on R c/w adenopathy
.
CXR [**1-2**] (not official read): R sided diffuse infiltrate, could
not visualize discrete mass
[**Hospital1 18**] Radiology Studies:
[**1-3**] CXR:
1. Moderate loculated right pleural effusion.
2. Right paratracheal/suprahilar density, which may represent a
mass or
lymphadenopathy.
3. Patchy opacities in the right lung.
4. Further evaluation by chest CT is recommended.
[**1-3**] RLE U/S:
The right common femoral vein is patent and compressible, with
normal waveforms. The right common femoral artery is patent as
well, with a normal waveform, and without evidence of
pseudoaneurysm. Small amount of calcification is noted within
the right common femoral artery.
[**1-3**] Abdominal U/S:
1. Patent hepatic vasculature. No evidence of portal venous
thrombosis.
2. The gallbladder is fairly distended with sludge and possible
small amount shadowing stones within it. There is no gallbladder
wall thickening or edema, but there is a small amount of free
fluid in the gallbladder fossa. The appearance is not diagnostic
of cholecystitis, but the appearance is not entirely normal. If
there is clinical concern for cholecystitis, HIDA scan or
follow-up ultrasound may be helpful.
3. Right pleural effusion.
[**1-3**] Head CT:
There are multiple moderate size areas of hypodensity in the
cortex
and subajcent white matter of both cerebral hemispheres. These
are associated with loss of the [**Doctor Last Name 352**]-white matter
differentiation and are suggestive of subacute-chronic infarcts.
The abnormal areas are in the frontal and parietal lobes
bilaterally. The distribution is consistent with embolic
phenomenona but could be compatible with a watershed
distribution as well. There is no evidence of hemorrhagic
transformation. There is no hydrocephalus or shift of normally
midline structures. Note is made of septum cavum pellucidum et
vergae.
OSH Labs and Results:
Labs from AM of admission:
WBC 20.2 (90% PMNs), Hct 27.9, MCV 87, plt 47
Na 146 113 52 111
4.1 20 1.4
Ca 8.8 Mg 1.8
AST 275, ALT 260, alk phos 82, t bili 0.7, alb 2.9
dig 1.2
vanco 13.9
PT 22 PTT 37 INR 1.9
fibrinogen <70, FDP >20
Other labs - [**12-29**]:
AT III 78%
lupus anticoagulant positive
protein C 54%
homocysteine 10.4
anticardiolipin <7
protein S 71%
TSH 1.1
[**12-31**]: B12 326, folate 5.6
AFB neg x 1
[**Hospital1 18**] Labs:
BCx: Pending at time of death
UCx: Yeast
Urine Legionella negative
[**2154-1-2**] 11:30PM BLOOD WBC-17.7* RBC-3.82* Hgb-10.7* Hct-32.8*
MCV-86 MCH-28.1 MCHC-32.7 RDW-16.7* Plt Ct-95*
[**2154-1-3**] 04:29AM BLOOD WBC-22.9* RBC-3.69* Hgb-10.4* Hct-31.6*
MCV-86 MCH-28.2 MCHC-32.9 RDW-16.3* Plt Ct-76*
[**2154-1-3**] 06:05PM BLOOD WBC-16.1* RBC-2.79* Hgb-7.9* Hct-24.0*
MCV-86 MCH-28.4 MCHC-33.0 RDW-17.6* Plt Ct-70*
[**2154-1-2**] 11:30PM BLOOD Neuts-89* Bands-0 Lymphs-4* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-24*
[**2154-1-3**] 06:05PM BLOOD PT-15.8* PTT-24.1 INR(PT)-1.4*
[**2154-1-3**] 04:29AM BLOOD PT-18.1* PTT-25.8 INR(PT)-1.7*
[**2154-1-2**] 11:30PM BLOOD PT-17.6* PTT-25.1 INR(PT)-1.6*
[**2154-1-2**] 11:30PM BLOOD Fibrino-179
[**2154-1-2**] 11:30PM BLOOD FDP->1280*
[**2154-1-3**] 06:05PM BLOOD Fibrino-71*#
[**2154-1-2**] 11:30PM BLOOD Glucose-152* UreaN-55* Creat-1.5* Na-148*
K-3.8 Cl-110* HCO3-24 AnGap-18
[**2154-1-3**] 04:29AM BLOOD Glucose-139* UreaN-55* Creat-1.7* Na-146*
K-3.7 Cl-109* HCO3-21* AnGap-20
[**2154-1-3**] 06:05PM BLOOD Glucose-104 UreaN-49* Creat-1.1 Na-149*
K-3.2* Cl-117* HCO3-23 AnGap-12
[**2154-1-2**] 11:30PM BLOOD ALT-170* AST-108* LD(LDH)-686*
AlkPhos-110 Amylase-37 TotBili-0.9
[**2154-1-3**] 04:29AM BLOOD CK(CPK)-157*
[**2154-1-2**] 11:30PM BLOOD Lipase-20
[**2154-1-2**] 11:30PM BLOOD CK-MB-3 cTropnT-0.13*
[**2154-1-2**] 11:30PM BLOOD Albumin-3.5 Calcium-9.1 Phos-4.8* Mg-2.0
[**2154-1-3**] 06:05PM BLOOD Calcium-7.8* Phos-3.9 Mg-1.7
[**2154-1-2**] 11:30PM BLOOD Hapto-175
[**2154-1-3**] 06:05PM BLOOD Cortsol-2.7
[**2154-1-2**] 10:36PM BLOOD Type-ART pO2-91 pCO2-47* pH-7.34*
calHCO3-26 Base XS-0
[**2154-1-2**] 10:36PM BLOOD Lactate-1.8
[**2154-1-2**] 10:12PM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.015
[**2154-1-2**] 10:12PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-15 Bilirub-SM Urobiln-4* pH-5.0 Leuks-SM
[**2154-1-2**] 10:12PM URINE RBC-3* WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
[**2154-1-3**] 04:41PM URINE Hours-RANDOM UreaN-634 Creat-83 Na-41
Brief Hospital Course:
Ms. [**Known lastname 65506**] arrived to the ICU intubated. Initial labs
confirmed likelihood of DIC, probably [**12-27**] sepsis. There was no
evidence of acute bleeding, so FFP, platelets, and cryo were not
given. She was started on empiric vancomycin and meropenem for
PNA coverage, with the intention of d/c'ing vanc if no GPC on
blood or sputum cultures in 48h. She was also placed on steroid
taper since pt received decadron treatment at OSH. She was kept
on respiratory precautions due to h/o TB exposure, and sputum
cultures were ordered to r/o active pulmonary TB, given history.
On initial exam, a dusky blue right foot was seen, and pulses
were non-palpable in that foot. Vascular surgery was called
emergently, who saw the patient that night. It was thought that
the patient's DIC and lupus anticoagulant, in addition to
possibly being hypercoagulable [**12-27**] likely lung malignancy,
placed Ms. [**Known lastname 65506**] at very high risk for arterial thrombosis,
and vascular surgery recommended heparinization if possible. In
the context of recent stroke, it was decided to avoid heparin
until imaging of the brain could be done, and the neurology
service consulted.
Ms. [**Known lastname 65506**] was stable overnight until 6AM, when she became
hypertensive and tachycardic to 160s, with ECG demonstrating
afib with RVR. She was given diltiazem and metoprolol, which
slowed her HR somewhat. She also appeared agitated, and was
started on fentanyl and versed, after which she appeared more
comfortable, and more hemodynamically stable.
In the morning, a repeat head CT was done, which revealed
several large areas of hypoattenuation consistent with subacute
stroke. From the OSH head CT reports, which described small
areas of old CVAs, this was thought to possible represent a
progression with possible new or evolving infarcts. Neurology
was consulted, who recommended obtaining an MRI/MRA/MRV, given
hypercoagulable status, maintaining SBP>140, and holding heparin
in the context of possible ongoing stroke. She had q1h neuro
checks, and the head of her bed was elevated to 30 degrees. An
echocardiogram and carotid ultrasounds were also ordered, given
thromboembolic possibilities, and she was kept on ASA 325mg qD.
That evening, code status was discussed again with pt's daughter
and HCP. [**Name (NI) **] had previously been known to be DNR/DNI, but
had been intubated due to what was initially thought to be a
quickly reversible cause. Once Ms. [**Known lastname 65506**]' evolving and
deteriorating clinical course was discussed with her HCP, it was
decided to change the goals of care to comfort measures only.
Her other medications were d/c'ed, blood draws and radiology
tests were d/c'ed, and Ms. [**Known lastname 65506**] was placed on a morphine
drip. At midnight, her endotracheal tube was pulled. An hour
later, hosuestaff was called to the bedside to pronounce her
death. On auscultation, she had no respirations or heart sounds
for two minutes, and had no palpable pulse over this time
period. She had no corneal reflex. She was pronounced dead, and
an autopsy requested by the family.
Medications on Admission:
Meds on transfer:
decadron 8mg IV daily (rec'd 12mg IV [**12-30**])
vancomycin 1g x1 (10AM on am of transfer)
imipenem 500mg IV q8 (day 1)
colace 100mg daily
combivent q4h
diltiazem ? dose
albuterol nebs prn
lansoprazole 30mg [**Hospital1 **]
simvastatin 20mg qHS
haldol prn
ativan prn
milk of magnesia
SL ntg prn
morphine prn
phenergan prn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
DIC
Acute Stroke
Ischemic limb
Sepsis secondary to pneumonia
Lung mass
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"0389",
"51881",
"496",
"99592",
"486",
"4019"
] |
Admission Date: [**2165-10-10**] Discharge Date: [**2165-10-19**]
Date of Birth: [**2119-8-21**] Sex: F
Service: CSU
CHIEF COMPLAINT: Mitral valve thrombus.
HISTORY OF PRESENT ILLNESS: Mrs. [**Last Name (STitle) 10123**] is a 46-year-old
woman with a history of congestive heart failure, mitral
valve repair, complete heart block and asthma who was
admitted to the hospital for heparinization prior to a
planned redo mitral valve replacement with Dr. [**Last Name (STitle) **]. The
patient originally had a mechanical valve placed about 10
years ago, she developed complete heart block and had a
pacemaker placed after the mitral valve surgery. While she
was having her pacemaker replaced in [**2165-6-6**], she
developed a mitral valve thrombus, followed by a successful
thrombolysis, however, a TEE (transesophageal echocardiogram)
done at that time, revealed the mitral valve failure, and she
was scheduled for surgery. Mrs. [**Last Name (STitle) 10123**] says her goal INR
since then has been 3 to 4. She was recently admitted for
surgery but it was delayed because she had an INR that was
greater than 5. She was discharged with daily INR checks and
told to return to [**Hospital1 **] MC when her INR was less than 3.5. On
the day of admission, her INR is 2 and she comes to [**Hospital1 **] MC
for heparinization prior to her catheterization and mitral
valve surgery.
PAST MEDICAL HISTORY: Congestive heart failure, complete
heart block, depression, allergic rhinitis, asthma, anxiety
and status post mitral valve replacement.
SOCIAL HISTORY: Remote tobacco use. Denies alcohol use.
FAMILY HISTORY: CAD (coronary artery disease), her father
had a CABG (coronary artery bypass graft) in his early 60s.
PHYSICAL EXAM: Temperature 98.4, blood pressure 120/80,
respiratory rate 20, O2 sat 96 percent on room air. GENERAL:
Anxious young woman in no acute distress. HEENT: Pupils
equally round and reactive to light. Extraocular movements
intact. Sclera anicteric. Oropharynx pink. NECK: Supple
with no lymphadenopathy. LUNGS: Clear to auscultation
bilaterally. CARDIAC: Regular rate rhythm with a late
systolic ejection murmur. ABDOMEN: Soft, nontender,
nondistended with normal active bowel sounds. No
hepatosplenomegaly. EXTREMITIES: With no clubbing, cyanosis
or edema. NEURO: Alert and oriented x4, responds
appropriately, follows commands. Cranial nerves intact.
Strength was [**4-10**] throughout. Sensation to light touch is
intact throughout.
LABORATORY DATA: PT is 18.4, INR is 2.1. TEE on [**10-9**]:
Prostatic mitral valve leaflet is normal with only one disk
appearing to open. The gradients are higher than expected for
this type of prosthesis.
MEDICATIONS ON ADMISSION: Zoloft 100 mg q. Nightly.
The patient states no known drug allergies.
The patient went for cardiac catheterization on [**10-11**]
that showed moderate to severe mitral stenosis with no
pulmonary hypertension, 1+ MR (mitral regurgitation) an EF
(ejection fraction) of 50 percent, and no angiographically
apparent CAD (coronary artery disease)>
The patient was followed by the Medicine Service over the
next several days while awaiting for her INR to come down and
on [**10-14**], she was brought to the operating room where
she underwent mitral valve replacement. Please see the OR
report for full details. In summary, the patient had a
mitral valve replacement with a No. 27 St. Jude valve. Her
bypass time was 117 minutes with a crossclamp time of 84
minutes. She tolerated the operation well and was
transferred from the operating room to the cardiothoracic
intensive care unit. At the time of transfer, the patient
was sent A-sensed and V-paced at a rate of 96 beats per
minute with a mean arterial pressure of 74 and a CVP of 4
with epinephrine at 0.03 mics/kilogram/minute, Neo-Synephrine
at 0.5 mics/kilogram/ minute and propofol at 10
mics/kilogram/minute. The patient did well in the immediate
postoperative period, her anesthesia was reversed. She was
weaned from the ventilator and successfully extubated on
postoperative day 1. The patient remained hemodynamically
stable, although she was noted to have periods of ventricular
bigeminy, and the electrophysiology service was consulted at
that time. She continued on an amiodarone drip, as well as a
Neo-Synephrine drip and she was kept in the Intensive Care
Unit for hemodynamic monitoring. By postoperative day 2, the
patient had weaned off her Neo-Synephrine drip. She was
transitioned to oral amiodarone. Her chest tubes, as well as
temporary pacing wires, were removed. She was begun on
heparin, as well as warfarin, and transferred to the floor
for continuing postoperative care and cardiac rehabilitation.
Once on the floor, the patient had an uneventful
postoperative course. Her activity level was increased with
the assistance of the nursing staff as well as the physical
therapy staff. Her warfarin doses were adjusted to attain a
goal INR of 3 to 3.5, and ultimately on postoperative day 5,
it was decided that the patient would be stable and ready to
be discharged home.
At the time of this dictation, the patient's physical exam is
as follows: Temperature 98.9, heart rate 80 A-sensed, V-
paced, blood pressure 108/60, respiratory rate 16, O2 sat 95
percent on room air. Weight on day of discharge 54.5,
preoperatively 53.
LABORATORY DATA: White count 12.4, hematocrit 34, platelets
547, sodium 141, potassium 4.0, chloride 99, CO2 29, BUN 17,
creatinine 1.2, glucose 96, PT 22.8, PTT 38, INR 3.3.
PHYSICAL EXAM: NEURO: Alert and oriented x3. Moves all
extremities. Follows commands. Nonfocal exam. PULMONARY:
Clear to auscultation bilaterally. CARDIAC: Regular rate
and rhythm, S1-S2 with a sharp click. Sternum is stable.
Incision with Steri-Strips, open to air, clean and dry.
ABDOMEN: Soft, nontender, nondistended with normal active
bowel sounds. EXTREMITIES: Warm with trace edema.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Status post redo mitral valve replacement with a No. 27
St. [**Male First Name (un) 923**] mechanical valve.
2. Complete heart block, status post permanent pacemaker
placement.
3. Depression.
4. Asthma.
DISCHARGE MEDICATIONS: Include potassium chloride 20 mEq
q.daily x2 weeks, oxycodone 5/325 1-2 tablets PO q.4-6 hours
p.r.n., Sertraline 100 mg q.daily, albuterol 1-2 puffs q.6
hours p.r.n., warfarin as directed to maintain a goal INR of
3 to 3.5. The patient is to take 4 mg on [**10-19**] and [**10-20**],
then have an INR check on [**10-21**]. Further dosages to be
prescribed by further dosage is to be prescribed by Dr.
[**First Name (STitle) **]. Amiodarone 400 mg t.i.d. x1 week, then 400 mg b.i.d.,
x1 week, then 400 mg q.daily x1 week, and ultimately 200 mg
q.daily. The patient is to take Lasix 20 mg q.daily x2
weeks.
She is to be discharged to home with visiting nurses. She is
to have an INR check on Monday the 15th, with results called
to Dr. [**Last Name (STitle) 1683**]. She is to have follow-up in the wound clinic
in 2 weeks. Follow-up with Dr. [**Last Name (STitle) 1683**] in [**1-8**] weeks. Follow-
up with Dr. [**Last Name (STitle) **] in 4 weeks. Follow-up in the device
clinic on [**10-23**] at 10:30 a.m. and then follow-up with
Dr. [**Last Name (STitle) **] in 1 month.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2165-10-19**] 14:01:31
T: [**2165-10-20**] 08:11:03
Job#: [**Job Number 10124**]
|
[
"4280",
"311"
] |
Admission Date: [**2182-8-30**] Discharge Date: [**2182-9-7**]
Date of Birth: [**2126-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
metformin / Shellfish
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Grafting x2 (left internal mammary artery
grafted to left anterior descending artery/Saphenous vein
grafted to Obtuse Marginal) [**2182-8-30**]
History of Present Illness:
56 year old man who recently developed new onset chest pain.
Went to outside hospital this AM and underwent cardiac
catheterization which revealed complex left circumflex lesion at
OM branch and 90% RCA. Transferred to [**Hospital1 18**] for further care and
evaluation of revascularization.
Past Medical History:
insulin-dependent diabetes mellitus
Hypertension
Hyperlipidemia
s/p nerve stimulator placed in back
s/p C7 2 bones remov
Social History:
Lives with:alone
Occupation:part-time works at [**Company 17115**] in the meat department
Cigarettes: Smoked no [] yes [x] Hx: <1ppd x a few months quit
when he was 28
ETOH: < 1 drink/week [x]
Family History:
Uncle with CABG
Physical Exam:
Physical Exam
Pulse:52 Resp:20 O2 sat:100/RA
B/P Right:147/74 Left:141/78
Height: 5'8" Weight: 229 lbs
General: NAD, alert, cooperative
distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [X] Irregular [] no Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right:+2 Left: +2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2182-8-30**] Echo:
Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.4 cm
Left Ventricle - Fractional Shortening: *0.23 >= 0.29
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Left Ventricle - Stroke Volume: 59 ml/beat
Left Ventricle - Cardiac Output: 3.45 L/min
Left Ventricle - Cardiac Index: *1.68 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aortic Valve - LVOT VTI: 23
Aortic Valve - LVOT diam: 1.8 cm
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 4.9 m/sec
Mitral Valve - E/A ratio: 0.20
Mitral Valve - E Wave deceleration time: 165 ms 140-250 ms
PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. The mitral valve appears
structurally normal with trivial mitral regurgitation.
POST-CPB: Preserved LV function post cpb. Aortic contour is
normal post decannulation.
CXR [**9-6**]
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Colonic distention.
Comparison is made with prior study performed a day earlier.
Cardiomegaly is stable. There are low lung volumes. Bibasilar
atelectases
have increased. There is no pneumothorax. Left pleural effusion
is small.
Nerve stimulators and sternal wires are unchanged.
[**2182-9-7**] 07:50AM BLOOD WBC-10.9 RBC-3.42* Hgb-10.2* Hct-28.7*
MCV-84 MCH-29.8 MCHC-35.6* RDW-13.3 Plt Ct-433
[**2182-9-7**] 07:50AM BLOOD Glucose-151* UreaN-15 Creat-1.0 Na-133
K-4.5 Cl-96 HCO3-31 AnGap-11
[**2182-9-6**] 06:10AM BLOOD ALT-31 AST-34 LD(LDH)-269* AlkPhos-81
[**2182-9-6**] 06:10AM BLOOD Lipase-41
[**2182-9-7**] 07:50AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.1
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for coronary artery bypass graft surgery. Please see operative
report for further surgical details. He tolerated the procedure
well and was transferred to CVICU. In the first twenty four
hours he was weaned from sedation, awoke neurologically intact
and was extubated without complications. He was started on
betablockers and diuretics, and later on post operative day one
was transferred to the floor. Physical Therapy was consulted
for evaluation of strength and mobility. He continued to
progress slowly and had issues with abdominal distention but
normal liver function tests. CT scan unremarkable with general
surgery consult. He was given an aggressive bowel regimen with
good results. Chest tubes and pacing wires removed per protocol.
On post operative day 8 he was ambulating with assistance,
tolerating a full diet and his incisions were healing well. He
continued to progress and was cleared for discharge to rehab at
[**Location (un) **] House on POD #8.All f/u appts were advised.
Medications on Admission:
Lantus 70 units HS
Atenolol 25mg Daily
Lipitor 80mg Daily
Acots 45mg Daily
Zestoretec 20/2.5mg [**Hospital1 **]
Lisopril 20 mg [**Hospital1 **]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 2 weeks.
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
10. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day for 10
days.
11. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day.
12. Lantus 100 unit/mL Solution Sig: Seventy Five (75) units
units Subcutaneous once a day.
13. insulin Sliding scale (see attached)
Humalog sliding scale
Breakfast Lunch Dinner Bedtime
120-159 mg/dL 2 Units 2 Units 2 Units 0 Units
160-199 mg/dL 4 Units 4 Units 4 Units 2 Units
200-239 mg/dL 6 Units 6 Units 6 Units 4 Units
240-280 mg/dL 8 Units 8 Units 8 Units 6 Units
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
insulin-dependent Diabetes mellitus
Hypertension
Hyperlipidemia
mild postop ileus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with dilaudid and tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage
1+ Edema bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 170**] - [**2182-10-2**] at 1:30pm
Cardiologist: Dr. [**Last Name (STitle) 42394**] [**9-16**] at 8:45am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**12-23**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2182-9-7**]
|
[
"41401",
"4019",
"2724",
"25000",
"V5867",
"V1582"
] |
Admission Date: [**2175-7-14**] Discharge Date: [**2175-7-17**]
Date of Birth: [**2095-12-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Rectal bleeding [**1-25**] prostate biopsy.
Major Surgical or Invasive Procedure:
Colonoscopy.
Tagged RBC scan.
History of Present Illness:
79 yo AAM w/PMH sx for CAD s/p CABGx2 and PCI, ventricular
pacer, DM2, and BPH s/p recent biopsy for elevated PSA who was
at home sitting at his computer when he felt the urge to
defecate. He notes that he delayed going to the bathroom for a
while, then noted increasing urgency to move his bowels, and on
the way to the bathroom, he passed a large amount of bright red
blood per rectum, with associated lighthesadness. No SOB, chest
pain, nausea or vomiting, or SOB. At the time, he called EMS and
was transported to the ED, where he continued to pass multiple
clots of BRB. He was transferred emergently to the MICU for
stabilization.
Past Medical History:
CAD s/p CABG X 2 and PCI, Pacer
DM-2 on insulin
PVD.
BPH
Chronic anemia
Chronic thrombocytopenia
Prostate Cancer - diagnosed today - had biopsy one week ago
today, but did not have any bleeding afterwards at that time.
Social History:
Retired [**University/College **] Biochemistry Professor. Quit tobacco in [**2154**]
Occasional ETOH - one glass of wine per day. Lives at home with
his wife. Children in the area.
Family History:
DM-2
Physical Exam:
Tm 98.8 BP 140/57 HR 64 O2 sat: 93% 2L
Gen: well appearing. alert and oriented. hard of hearing.
conversing comfortably.
HEENT: PERRL. EOMI. MMM. JVD to 12 cm.
Lungs: Inspiratory bibasilar crackles. Poor inspiratory effort.
No rales or rhonchi.
Hrt: Irreg irreg. No MRG.
Abd: S/NT. Mildly distended. +BS. Fem art sheath in place. No
bleeding or tenderness at site.
Ext: 2+ pitting edema in BLE. 2+carotid, radial, DP pulses.
Purplish discoloration of BLE. No rash or tenderness.
Neuro: 5/5 mm strength bilaterally. Intention tremor. Negative
FTN.
Pertinent Results:
[**2175-7-14**]
Hct 27.7 --> 33.8
CEx3 negative.
[**2175-7-14**]
PT: 13.5 PTT: 27.1 INR: 1.2
137 101 65 / 246 AGap=16
-------------
4.6 25 1.9
7.4 \ 9.6 / 127
------
27.7
N:69.5 L:20.4 M:6.4 E:3.3 Bas:0.4
PT: 13.9 PTT: 27.5 INR: 1.3
UA Lg nitrites. >50 WBC. 0-2 bact. Neg LE.
EKG: V-paced. Unchanged from prior.
GI Bleeding study:
INTERPRETATION: Following intravenous injection of autologous
red blood cells
label with technetium-[**Age over 90 **]m, blood flow and delayed images of the
abdomen were
obtained for 90 minutes.
Blood-flow images do not show any abnormal trace of activity.
Delayed blood-flow images show increased trace of activity in
the area behind
the urinary bladder. This area is somewhat obscured by the
activity in the
urinary bladder and the penile contamination. Increased trace of
activity is
also seen in the sheets adjacent to the patient's buttock, who
was having bright
red blood per rectum during the time of this study.
IMPRESSION: Findings are consistent with active bleeding in the
rectosigmoid
area.
IR Embolization:
No active extravasation of contrast. No evidence of
angiodysplasia,
arteriovenous malformation or aneurysm involving the bowel
vascular tree. No
finding is present for which intervention could be directed.
Local anesthesia in the right inguinal region with 5 cc of 1%
lidocaine.
A total of 44 cc of Optiray radiograph contrast was utilized.
No immediate complications.
IMPRESSION: No angiographic finding that could warrant
intervention.
Follow-up with endoscopy may be of use, if indicated.
On discussion with the intensive care unit the right common
femoral 5-French
vascular sheath was left in situ postprocedure. All other
equipment was
removed. The sheath was fixed in place with a single 0 silk
suture and a
Tegaderm dressing.
Sigmoidoscopy:
A single diverticulum was seen in the splenic, however, the
presence of more diverticula can not be excluded due to the poor
prep.
Colonoscopy:
Impression: 1. An adherent clot at 8 cm from the anal verge and
localized to the left lobe of prostate gland by simultaneous
palpation and endoscopy. Source of GI bleeding is due to
post-prostate biopsy bleed. Two endoclips placed for hemostasis.
2. Angioectasia in the mid-ascending colon
3. Polyp in the sigmoid colon
4. Diverticulosis of the sigmoid colon
Brief Hospital Course:
IMPRESSION: 79 year old man with hx CAD and MI s/p PTCA on
Plavix and ASA, ventricular pacer, DM2, and prostate cancer
presents with BRBPR [**1-25**] prostate biopsy performed several days
prior.
1. BRBPR: On admission to the MICU, patient was initially
stable, and in the early morning, he became tachycardic, and
dropped his blood pressure into the 60s/30s, and received 4u
pRBCs and 2L NS for resuscitation. On evaluation by GI, patient
was felt to need a tagged RBC scan by IR, which showed bleeding
at the rectal sigmoid junction, with continued BRBPR. An
embolization was attempted in IR, but it was felt that they were
unable to localize the bleeding and the embolization was
unsuccessful. A femoral sheath was left in place at the time. A
sigmoidoscopy was attempted as well, but also did not localize
site of bleeding due to incomplete bowel prep. Patient was then
prepped for colonscopy in AM to attempt to further localize the
site of bleeding. Colonoscopy was performed, and showed an
adherent clot at left lobe of the prostate gland, with endoclips
applied for hemostatis, as well as angioectasia, polyps, and
diverticuli. It was felt that the source of GI bleeding was due
to post-prostate biopsy bleeding.
After hemostasis was achieved during colonoscopy, patient
remained stable with no further decrease in hematocrit. His
platelet count decreased to 75 throughout admission; a HIT panel
was sent and pending at the time of discharge. Patient was
placed on IV protonix, and his plavix and aspirin were held. Two
large bore peripheral IVs were placed, and patient was
transitioned to po Protonix. Patient's hematocrit was monitored
closely. On admission, hematocrit was originally 27.7, which
dropped to 23, and after transfusion of 7u pRBC, his hematocrit
stabilized at 35. On discharge, his hematocrit was
He had trace OB+ stools on discharge, felt to be residual from
his large volume LGIB two days prior.
2. CAD. Patient had three sets of negative cardiac enzymes and
no changes on EKG, as well as no complaints of chest pain. He
was restarted on his blood pressure medications when he was
transferred out of the MICU; however, he had an asymptomatic
hypotensive episode of SBP in the 90s, and patient's lisinopril
and Imdur were both discontinued, and he was discharged only on
metoprolol 50 mg po qd. He was also restarted on his
atorvastatin 10 mg po qd.
3. DM2, on insulin. Patient was placed on a diabetic diet, with
FSQID and SSI per his [**Last Name (un) **] sliding scale with NPH 18 qam and
17 qpm.
4. Prostate cancer. Patient's prostate cancer was diagnosed on
the day of the prostate biopsy. Stage is unknown.
5. FEN. His electrolytes were stable throughout admission. He
was able to take full diet. His I/Os and daily weights were
monitored.
6. Rehabilitation. Patient was seen by physical therapy during
his admission.
7. Access - Patient had two large-bore peripheral IV's placed.
8. Code - DNR/DNI.
9. Disposition - Patient was discharged to home.
Medications on Admission:
Isosorbide
Lasix
Flomax
Toprol
Lipitor
Plavix
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO HS (at bedtime).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
take 40 mg 5 days a week and 20 mg 2 days per week.
4. Insulin 70/30 70-30 unit/mL Suspension Sig: 18 u Qam, 17 u
QPM as directed Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Rectal Bleed
Discharge Condition:
good
Discharge Instructions:
Please do not take your Aspirin, Plavix, Toprol, Lisinopril and
Isosorbide until you follow up with Dr. [**First Name (STitle) **] in the [**Hospital 191**]
clinic.
Return to the ED or call your doctor if you have any episodes of
rectal bleeding, lightheadedness, dizziness, shortness of
breath, chest pain or if your symptoms worsen.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] or one of his colleagues at the [**Hospital 191**]
clinic in 1 week. Call [**Telephone/Fax (1) 1247**] to make an appointment. He
will take your blood pressure and talk to you about restarting
your blood pressure medications as well as your aspirin and
plavix.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"2875",
"2851",
"5849",
"V4581",
"25000",
"V5867"
] |
Admission Date: [**2107-7-29**] Discharge Date: [**2107-8-17**]
Date of Birth: [**2049-10-7**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
cough, dyspnea
Major Surgical or Invasive Procedure:
1. Bronchoscopy
2. G tube placement
3. Vocal cord injection
History of Present Illness:
Mr. [**Known lastname 13014**] is a 57-year-old man with a history of metastatic
EGFR positive NSCLC with mets to brain, kidney, liver, on
Erlotinib, with recent discharge for pneumonia, who presents
with worsening SOB, cough productive of greenish sputum,
low-grade fever, and fatigue. Per report, he has also had poor
po intake for the past 2 days. He completed course of meropenem
yesterday ([**7-28**]) for PNA. No F/C/sweats/CP/N/V. Sent from rehab
for WBC 24 today. He has had normal bowel movements, no
diarrhea. He is unable to cough up any sputum.
In ED, initial vitals were: pain 5 T 97.7 HR 89 BP 98/67 RR 18
98%.
Exam was significant for cachectic appearing male, with lungs
clear with good air entry and dry cough. Labs were significant
for WBC to 24 with 90% PMN's. CXR showed LUL consolidation
largely unchanged. Lactate reassuring at 1.5. Increasing
parenchymal opacification with volume loss on left, cavitation,
which may be associated with increased extent of infection.
Blood cultures were sent. He was given 1g IV Vancomycin x1 in
addition to nebs. Pt given tylenol as well for chronic back
pain.
Final vitals prior to transfer were 99.1 ??????F (37.3 ??????C), Pulse:
94, RR: 14, BP: 100/56, O2Sat: 97.
Review of Systems:
(+) Per HPI + wt loss,
(-) Denies fever, chills, night sweats. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations, lower extremity edema. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, melena,
hematemesis, hematochezia. Denies dysuria, stool or urine
incontinence. Denies arthralgias or myalgias. Denies rashes or
skin breakdown. No numbness/tingling in extremities. All other
systems negative.
Past Medical History:
NSCLC, s/p LUL resection and chemo/XRT, with metastatic disease
to brain diagnosed in [**3-21**] s/p XRT and steroid treatment stg
radiation-esophagitis
Malnutrition previously receiving TPN at home via PICC stopped
[**4-21**]
h/o pilonidal cyst
.
PAST ONCOLOGIC HISTORY:
- [**9-/2106**]: developed a cough, progressed to voice hoarseness
11/[**2106**].
- [**11-20**]: CT showed left upper lung mass and left-sided
lymphadenopathy
- [**2106-12-24**]: PET scan showed a large left upper lung spiculated
mass measuring 4.2 x 3 cm with an SUV of 24.2 and a left hilar
conglomerate of lymph nodes with an SUV of 9.3
- [**2106-12-30**]: flexible bronchoscopy with EBUS. Brushings from
this bronchoscopy were positive for adenocarcinoma lesion.
Lymph
node stations 4L, 7 and 11L were positive. The tumor stained
positive for CK7 and TTF-1 and negative for P63 and
CK5/6.
- [**2106-12-31**]: Head MRI negative
- [**2107-1-17**]: started Cisplatin 50 mg/m2 days 1, 8, 29, 35 with
Etoposide 50 mg/m2 given on days 1 through 5 and 29 through 33,
with concomitant XRT.
- [**2107-2-14**]: Cycle 2 Cisplatin/Etoposide
- [**2107-3-7**]: Completed XRT
- [**Date range (1) 92150**]: Admitted with twitching, loss of control of
left
arm, found to have seizures; MRI showed multiple supratentorial
sites of metastatic disease as well as 2 cerebellar lesions.
- [**2107-3-17**]: started whole brain radiation
- [**2107-3-28**]: PET scan with multiple sites of metastatic disease in
[**Month/Day/Year 500**] and muscle.
- EGFR positive.
- [**2107-4-28**]: Started Erlotinib
Social History:
Currently residing at rehab, Windgate in [**Location (un) 620**]. He has a
sister nearby who is very involved in his care. Non smoker, no
alcohol.
Lived in the home of a physician with MS, whom he has helped
with daily activities up until recently. He recently stopped
working doing home repair. Non smoker, no alcohol.
Family History:
His mother had breast cancer at the age of 54,
which was treated and then recurred and died at age 60. His
father had [**Name2 (NI) 500**] cancer in his 70s and also had several types of
skin cancer, possibly melanoma. He has two sisters who are with
him today and one brother without any history of malignancy. He
is not married and lives alone. He has no children.
Physical Exam:
Admission:
Vitals - T: 98.5 BP: 98/65 HR: 93 RR: 24 02 sat: 96% RA
GENERAL: cachectic, mildly tachypnic, speaks slowly
HEENT: + facial wasting, EOMI, PERRLA, anicteric sclera, pink
conjunctiva, patent nares, dry MM, nontender supple neck, no
LAD, no JVD
CARDIAC: Reg, S1/S2, no murmurs, gallops, or rubs
LUNG: decreased BS diffusely, particular on left
ABDOMEN: thin, nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities , no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, slow speech but oriented and
appropriate
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge:
Vitals - Tc-98.1, Tm- 98.9, HR 60-90s, BP 90-110s/60-70s, RR
16-21, 95-97% RA
I/O: 1664 (PO) +1006 (TF)/ 800
GENERAL: cachectic, slow speech with hoarse voice, in NAD
HEENT: + facial wasting, dry mucous membranes without evidence
of mucositis or thrush
CARDIAC: Reg, S1/S2, no murmurs, gallops, or rubs
LUNG: L sided rales heard best at base, clear on the right
ABDOMEN: thin, nondistended, +BS, nontender, G tube in place
with overlying dressing, pink macular rash around dressing
EXTREMITIES: moving all extremities, no edema
NEURO: 5/5 strength in UE with exception of decreased L grip
strength, which is improving
SKIN: macular acneiform rash on face, neck, and shoulders
Pertinent Results:
Admission:
[**2107-7-29**] 03:25PM WBC-24.4*# RBC-3.49* HGB-9.7* HCT-29.4*
MCV-84 MCH-27.9 MCHC-33.1 RDW-15.1
[**2107-7-29**] 03:25PM NEUTS-90.7* LYMPHS-2.3* MONOS-3.5 EOS-3.5
BASOS-0.1
[**2107-7-29**] 03:25PM PLT COUNT-455*
[**2107-7-29**] 03:25PM GLUCOSE-78 UREA N-33* CREAT-0.7 SODIUM-136
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13
[**2107-7-29**] 03:39PM LACTATE-1.5
[**2107-7-29**] 03:25PM cTropnT-<0.01
Imaging:
CXR [**2107-7-29**]:
Persistent extensive left upper lobe consolidation including a
large cavitary component. Although a left-sided pleural
effusion is probably
reduced, there is increasing parenchymal opacification with
volume loss at the
left base, which may be associated with increased extent of
infection.
Clinical correlation is suggested.
CT Chest [**2107-7-30**]:
While there has been improvement in left-sided moderate pleural
effusion, there are now confluent opacities at the left lower
lobe suggestive of progression of multifocal pneumonia in this
region. Otherwise, there is stable appearance of consolidation
involving the left upper lobe, left lower lobe, and lingula with
little change in the appearance of left upper lobe cavitary
lesion.
CT Abdomen/Pelvis [**2107-8-3**]:
1. Advancement of disease, marked by increased size of a
hepatic lesion and an increase in the lytic components of known
osseous disease. No new
metastatic foci identified.
2. Significant fecal load.
3. Likely unchanged metastatic disease to the kidneys,
comparison is
difficult given contrast timing.
4. Left lower lobe consolidation with volume loss consistent
with known
pneumonia.
Microbiology:
ASPERGILLUS GALACTOMANNAN ANTIGEN (Bronchoalveolar Lavage)
Test Result Reference
Range/Units
ASPERGILLUS ANTIGEN 1.2 H <0.5
Blood cultures [**2107-7-29**]: Negative
CXR [**2107-8-11**]: worsening LLL PNA
Discharge Labs:
[**2107-8-17**] 04:03AM BLOOD WBC-17.4* RBC-3.14* Hgb-8.6* Hct-26.3*
MCV-84 MCH-27.5 MCHC-32.8 RDW-16.9* Plt Ct-352
[**2107-8-17**] 04:03AM BLOOD Glucose-121* UreaN-19 Creat-0.7 Na-136
K-4.3 Cl-103 HCO3-27 AnGap-10
[**2107-8-17**] 04:03AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 13014**] is a 57-year-old man with a history of metastatic EGFR
positive NSCLC with mets to brain, kidney, liver, on Erlotinib,
with recent discharge for pneumonia, who presents with worsening
SOB, cough productive of greenish sputum, and significant
leukocytosis secondary to complicated LLL PNA.
# Complicated PNA: Pt had complicated course during last
admission with continued LUL cavity. Patient presented with a
new LLL consolidation on CT despite recently completing
treatment course of meropenem. CT read as LLL PNA and continued
LUL cavity. Aspiration event was likely given his vocal cord
dysfunction. He was started on vancomycin and meropenem per ID
recs. He was evaluated by pulmonary and a bronchoscopy was
performed on [**8-1**] which showed a large amount of secretions but
no obstruction. BAL was aspergillus ag positive and grew yeast,
but serum aspergillus ag and beta glucan were negative. Pt
started on voriconazole on [**8-4**]. Vanc d/c'ed and pt maintained
on [**Last Name (un) **]/Vori. Pt with supplemental O2 requirements [**8-11**] and CXR
noted to have increase in LLL PNA. [**Last Name (un) **] and Vanc restarted. Vori
continued. [**Last Name (un) **] changed to Zosyn [**8-12**]. Will stop IV antibiotics
on discharge.
# [**Month/Day (4) 9036**] care: Pall care consult initiated at request of pt's
sister, [**Name (NI) 66110**]. Pt expressed wishes to focuse on [**Name (NI) **] and
stop IV antibiotics. Family meeting with Dr. [**Last Name (STitle) 3274**] [**8-16**]. Pt to
be discharged to residential hospice. Pt desires to continue
tube feeds. Spoke with him regarding voriconazole by G tube and
he wanted to continue for time being.
# Cachexia/malnutrition: Patient continued to have poor PO
intake for multiple reasons. He has difficulty and pain with
swallowing with known vocal cord dysfunction, pain in his back
that makes it uncomfortable for him to sit up and eat, and
overall poor appetite. CT abdomen showed possible progression of
cancer which may indicated decreased response to tarceva.
Attempted dobhoff placement but pt did not tolerate well.
Patient underwent G-tube placement and vocal cord injection on
[**8-9**] after being cleared and consented by anesthesia. Tube feeds
were started [**8-10**], pt tolerated tube feeds well at goal and
wishes to continue tube feeds in hospice center.
# Anemia: Hct remained chronically low in low 20s. He was
transfused 2 units PRBCs on [**2107-8-9**] prior to going to OR for Hct
of 20. There were no signs of frank bleeding and Hct remained
stable. Pt received 3u pRBCs [**8-9**]. H/H remained stable after
transfusion.
# Left vocal cord paralysis: Noted on last admission. He
underwent vocal cord injection with Dr. [**Last Name (STitle) 85784**] [**Name (STitle) **] on [**8-9**].
The patient was transferred to the ICU overnight s/p L vocal
cord injection with poor abduction of R cord and concern for
possible airway obstruction secondary to b/l medialization of
the cords. The patient did well overnight and was given 10 mg
IV decadron. He was then transferred to the oncology team. Pt
unable to get repeat L sided vocal cord injection for 4-6wks per
ENT team. With hospice in place, will not f/u with ENT as OP
unless he chooses to set it up with goal of quality of life.
Chronic issues:
# Dysphagia/Odynophagia: Likely secondary to radiation therapy
and tumor. He was able to tolerate soft solids; po medications
were changed to IV whenever possible. However, given
long-standing dysphagia that pt reported was worsening, GI was
curbsided regarding possibility of upper endoscopy. Pt ended up
getting G tube as opposed to PEG so endoscopy was not pursued to
evaluate esophagus for cause of odynophagia. We will not pursue
further workup in setting of hospice care.
# NSCLC, EGFR positive: mets to brain, kidney, liver, on
Erlotinib. Repeat CT abdomen/pelvis showed advancement of
disease in liver and lytic components. He was continued on
erlotinib for his lung cancer and keppra for seizure
prophylaxis. Palliative care was consulted per request from pt's
sister, [**Name (NI) 66110**]. Pt opted for [**Name (NI) **] measures with residential
hospice. Will go off erlotinib at time of discharge since
progression while on med and focus on [**Name (NI) **].
# Back Pain: Chronic. Likely due to axial metastatic lesions.
He was continued on liquid oxycodone and a fentanyl patch was
added.
# Coccyx ulcer: Wound consult was initiated and recommendations
for wound care were followed by nursing.
# GERD: He was continued on ranitidine.
Transitions of Care:
1. Code Status: DNR/DNI
2. Contact: Sister [**Name (NI) 66110**]
3. Discharge to residential hospice.
Medications on Admission:
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): at 1700.
2. clindamycin phosphate 1 % Gel Sig: as directed Topical once
a day: apply to infected area once daily.
3. erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. levetiracetam 500 mg/5 mL (5 mL) Solution Sig: Ten (10) ml PO
twice a day.
5. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO four times a
day as needed for pain.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q6H (every 6 hours) for 8 days: last day = [**2107-7-27**].
8. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Four
Hundred (400) mg PO DAILY (Daily).
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain, fever
please contact HO if giving for fever
RX *acetaminophen 650 mg/20.3 mL 650 mg by G tube every 6 hours
Disp #*1 Liter Refills:*0
2. Ranitidine (Liquid) 150 mg PO DAILY
RX *ranitidine HCl 15 mg/mL 150 mg by G tube daily Disp #*1
Liter Refills:*0
3. LeVETiracetam Oral Solution 1000 mg PO BID
RX *Keppra 1,000 mg 1 tablet by G tube twice daily Disp #*60
Tablet Refills:*0
4. Megestrol Acetate 400 mg PO DAILY:PRN low appetite
RX *Megace Oral 400 mg/10 mL (40 mg/mL) 400mg Suspension(s) by G
tube daily Disp #*1 Liter Refills:*0
5. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily
Disp #*90 Capsule Refills:*0
6. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
RX *Diocto 50 mg/5 mL 100 mg by G tube twice daily Disp #*1
Liter Refills:*0
7. Fentanyl Patch 25 mcg/hr TP Q72H
RX *fentanyl 25 mcg/hour 25mcg/hr patch every 72 hours Disp #*10
Transdermal Patch Refills:*0
8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
RX *nystatin 100,000 unit/mL 5 mL by mouth four times daily Disp
#*100 Milliliter Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
hold for loose stools
RX *ClearLax 17 gram/dose 17 g(s) by G tube daily Disp #*30
Packet Refills:*0
10. Senna 1 TAB PO BID
hold for diarrhea
RX *senna 8.8 mg/5 mL 5 mL by G tube twice daily Disp #*100
Milliliter Refills:*0
11. Voriconazole 200 mg PO Q12H
RX *Vfend 200 mg 1 tablet(s) by G tube every 12 hours Disp #*60
Tablet Refills:*0
12. Hospice eval
Please screen and admit to hospice.
13. Morphine Sulfate (Concentrated Oral Soln) 5-10 mg PO Q2H:PRN
pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5-10 mg(s) by G
tube every 2 hours Disp #*30 Milliliter Refills:*0
14. Lorazepam 0.5 mg SL Q2H:PRN anxiety
RX *Ativan 0.5 mg 1 tablet(s) by G tube every 2 hours Disp #*100
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital 13054**] Hospice
Discharge Diagnosis:
Primary:
-Pneumonia
-Severe Malnutrition
-Vocal cord paralysis
Secondary:
-Metastatic EGFR positive NSCLC
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 13014**],
It was a pleasure taking care of you during this admission. You
were hospitalized for a recurrent pneumonia and treated with
antibiotics. You were also not eating well, so a tube was placed
in you stomach to help supplement you with nutrition. You also
received a vocal cord injection for your vocal cord paralysis.
Some changes have been made to your medications. Please see the
attached list.
You have decided to focus on [**Last Name (LF) **], [**First Name3 (LF) **] you will be transferred
to a residential hospice center. We will stop your IV
antibiotics.
Followup Instructions:
You will follow-up with the hospice physicians.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2107-8-17**]
|
[
"5070",
"2760",
"2859",
"53081"
] |
Admission Date: [**2122-4-14**] Discharge Date: [**2122-4-23**]
Date of Birth: [**2055-12-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
acid reflux, anemia
Major Surgical or Invasive Procedure:
s/p transhiatal esophagectomy for adenocarcinoma of distal
esophagus [**4-14**].
History of Present Illness:
66-year-old gentleman with
longstanding gastroesophageal reflux disease, Barrett's
esophagus who recently presented with anemia and was found to
have a lesion in the esophagus which was biopsy proven to be
adenocarcinoma. Endoscopic ultrasound suggested a T2, N0
lesion supported by a PET scan and a CT scan. I recommended
transhiatal esophagectomy for definitive therapy and to
establish pathologic staging. We reserved the decision
regarding adjuvant chemoradiotherapy to pathologic
examination of the resected specimen.
Past Medical History:
Cornary artery disease, Hypertension, Hypercholesterolemia,
Superficial bladder cancer, gout, adenocarcinoma of distal
esophogas, esophogeal reflux, Barrett's esophogas
Social History:
lives w/ girlfriend in [**Location (un) **].
+ smoker- 4 pack years [**2066**]'s, occassional etoh
Family History:
ovarian cancer in mother
brother w/ prostate cancer
Physical Exam:
General
HEENT
RESP
COR
ABD
EXT
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2122-4-19**] 05:30AM 10.0 4.31* 12.8* 36.8* 85 29.8 34.9 13.9
230
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2122-4-19**] 05:30AM 230
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2122-4-22**] 06:15AM 128* 24* 1.2 146* 4.5 107 30 14
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2122-4-22**] 06:15AM 8.9 3.1 2.2
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2122-4-18**] 11:38 AM
Reason: r/u PTX
[**Hospital 93**] MEDICAL CONDITION:
66 year old man s/p transhiatal esophagectomy and left chest
tube placement, chest tube to water seal, now desatting and
fever to 101
REASON FOR THIS EXAMINATION:
r/u PTX
HISTORY: Fever.
A single portable chest radiograph again demonstrates a right
internal jugular central venous catheter. Catheter tip is likely
in the distal SVC and unchanged. A nasogastric tube is again
noted with tip in the stomach. Surgical skin staples project
over the soft tissues of the left neck. No pneumothorax.
Bibasilar atelectasis and small bilateral pleural effusions are
unchanged. Trachea remains midline.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2122-4-17**] 3:35 PM
Reason: please eval interval change, ptx, s/p CT d/c
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with s/p esophagectomy, s/p Left CT d/c
REASON FOR THIS EXAMINATION:
please eval interval change, ptx, s/p CT d/c
INDICATION: Esophagectomy, status post chest tube removal,
question pneumothorax.
Comparison is made to [**2122-4-15**]. There is interval removal
of the left chest tube. Again seen is a small left apical
pneumothorax which appears unchanged in size (approximately 5%).
A right IJ line is in unchanged position. An NG tube is seen
with the tip in the stomach. A retrocardiac air- fluid level is
attributed to fluid within the gastric pull-up. There is
atelectasis at both lung bases and likely small pleural
effusions.
RADIOLOGY Final Report
FOOT 2 VIEWS LEFT [**2122-4-19**] 8:20 AM
Reason: fx?
[**Hospital 93**] MEDICAL CONDITION:
66 year old man s/p esophagectomy with L foot trauma
REASON FOR THIS EXAMINATION:
fx?
HISTORY: Foot trauma.
Two radiographs of the left foot demonstrate mild, diffuse,
demineralization. Joint spaces are maintained without
periarticular erosion. No fracture. Assessment is limited by
overlying dressing material. Dense vascular calcifications are
noted.
IMPRESSION:
No fracture.
********************
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 64800**],[**Known firstname 177**] [**2055-12-12**] 66 Male [**Numeric Identifier 64801**] [**Numeric Identifier 64802**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: ESOPHAGUS + PROXIMAL STOMACH,LT GASTRIC LN.
Procedure date Tissue received Report Date Diagnosed
by
[**2122-4-14**] [**2122-4-14**] [**2122-4-21**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/nbh
DIAGNOSIS:
I. Esophagogastrectomy (A-AA, AG-AH):
Adenocarcinoma of the distal esophagus, see synoptic report.
Barrett's esophagus with high grade glandular dysplasia.
Segment of stomach, within normal limits.
Esophageal squamous epithelium at proximal margin and gastric
corpus mucosa at distal margin.
II. Lymph nodes, left gastric (AB-AF):
Eight lymph nodes, with metastatic adenocarcinoma in one.
Esophagus: Resection Synopsis
MACROSCOPIC
Specimen Type: Esophagogastrectomy.
Tumor site: Distal esophagus.
Tumor Size
Greatest dimension: 3.0 cm. Additional dimensions: 1.9
cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: G2: Moderately differentiated.
EXTENT OF INVASION
Primary Tumor: pT1b: Tumor invades superficial submucosa.
Regional Lymph Nodes: pN1a: (1 to 3 nodes involved).
Lymph Nodes
Number examined: 15 (includes left gastric).
Number involved: 1.
Distant metastasis: pMX: Cannot be assessed.
Margins
Proximal margin: Uninvolved by invasive carcinoma.
Distal margin: Uninvolved by invasive carcinoma.
Circumferential (adventitial) margin: Uninvolved by
invasive carcinoma.
Distance of invasive carcinoma from closest margin: 4 mm.
Specified margin: Adventitial.
Lymphatic (Small Vessel) Invasion: Absent.
Venous (Large vessel) invasion: Absent.
Clinical: Esophageal carcinoma.
Gross:
The specimen is received fresh in two parts, both labeled with
"[**Known lastname **], [**Known firstname **]" and the medical record number.
Part 1 is additionally labeled "esophagus and proximal stomach"
and consists of an esophagogastrectomy specimen. The esophagus
measures 7.0 cm in length x 3.0 cm in diameter. The stomach
measures 14.0 cm x 7.0 and has an 11 cm stapled distal margin.
The specimen is opened to reveal tan-pink glandular mucosa
extending above the GE junction approximately 4 cm. There is a
3.0 x 1.9 cm ulcerated lesion within this area of glandular
extension into the esophagus, that abuts the GE junction and is
located approximately 2.9 cm from the esophageal margin and 7.0
cm from the stomach margin. The gastric mucosa is tan, pink and
grossly unremarkable with normal rugal folding. The external
surface of the esophagus is inked in blue and the proximal
esophageal resection margin is submitted for frozen section.
Frozen section diagnosis by Dr. [**Last Name (STitle) 7108**] is "esophageal margin; no
malignancy identified. The attached yellow fibrofatty soft
tissue is stripped and searched for lymph nodes. The specimen is
represented as follows: A-M = completely submitted ulcerated
lesion extending distally, N = representative sections of
unremarkable esophageal squamous mucosa, O-P = GE junction, Q =
esophagus with glandular mucosa, R-S = grossly unremarkable
gastric mucosa, T-X = gastric resection margin, Y-AA = possible
lymph nodes. AG-AH = frozen section remnant of esophageal
resection margin.
Part 2 is additionally labeled "left gastric lymph nodes" and
consists of a fragment of yellow fibrofatty tissue measuring 6.9
x 4.4 x 2.8 cm. The specimen is searched for lymph nodes.
Representative sections of possible lymph nodes are submitted in
AB-AF.
Brief Hospital Course:
Patient admitted SDA for transhiatal esophagectomy for
adenocarcinoma of distal esophogas [**2122-4-14**]. Patient tolerated
procedure well, pain control w/ dil/bup epidural, transfer to
ICU extubated on cool aerosol mist .40.
[**4-15**] CT to water seal CxR okay; NPO; afebrile 97SR, 123/63; IS/
pul toilet.
[**4-16**] to floor, wt 118 kg, cr 1.6, wbc 16, TF at 30cc/hr,
maintenance IVF, epidural split, CXR no ptx ? LLL atelectasis,
fever to 101, u/a neg
[**4-17**] wbc 15, abx off, Epidural dc'd, CT dc'd, DC Abx, CXR stable
L atelectasis, small apical ptx
[**4-18**] Awaiting Bowel function. CxR no PTX. Inc TF. L foot trauma
([**4-17**]) while transfer, Ankle X-ray no fx, Ortho consulted, Foot
x-ray requested.
[**4-19**] Stable, OOB, awaiting flatus
[**4-20**] NGT DC
[**4-21**] Passed grape juice swallow- clear liqs tolerated well.
[**4-22**] JP, neck staples, [**2-9**] abd staples d/c'd; full liquids
tolerated well
[**4-23**] REmainder of stables removed w/o complication. Pt
discharged to home instable condition in company of family
member to Western Mass. Discharge instructions given and
reviewed by NP and RN. Services provided by [**Hospital1 5065**]--[**Telephone/Fax (1) 39931**],
[**Doctor Last Name 64803**] [**Hospital 45902**] Hospital-fax [**Telephone/Fax (1) 64804**].
Medications on Admission:
lopressor 25", colchicine 0.6', lipitor 20', protonix 40',
allopurinol 300', MVTs
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
5. Acetaminophen 160 mg/5 mL Solution Sig: [**2-9**] PO Q4-6H (every
4 to 6 hours) as needed for fever.
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
7. tube feeding
Probalance
75cc/hr x24 hours
Cycle as per tolerance:
90cc/hr x20hr; 110cc/hr x16hr; 130cc/hrx14hr; 150cc/hr x12hr
Flushe w/ 120cc H2O every 6hours if no intake
8. tube feeding supplies
kangaroo pump, IV pole, feeding bags, 60 cc catheter tip
syringes, J- tube
Discharge Disposition:
Home With Service
Facility:
[**Doctor Last Name **] [**Last Name (un) **] fax[**Telephone/Fax (1) 64804**]
Discharge Diagnosis:
Cornary artery disease, Hypertension, Hypercholesterolemia,
Superficial bladder cancer, gout, adenocarcinoma of distal
esophogas
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name **]/ Thoracic Surgery office [**Telephone/Fax (1) 170**] for:
Fever, shortness of breath, chest pain, nausea/ vommiting,
difficulty swallowing.
Intake- Full liquids only by mouth. [**Month (only) 116**] crush pills in full
liquids. tube feeding as below.
[**Hospital1 5065**] for Tube feeding issues-[**Telephone/Fax (1) 64805**] or [**Telephone/Fax (1) 43291**]-
Probalance tube feeding; 75cc/hr x24 hours.
Cycle as per tolerance:
90cc/hr x20hr; 110cc/hr x16hr; 130cc/hrx14hr; 150cc/hr x12hr
Flushes w/ 120cc H2O every 6hours if no intake;
Needs 700 additional fluid, then flush H2O 120cc q6h
VNA services w/ [**Doctor Last Name **] [**Hospital 45902**] Hospital-- [**Telephone/Fax (1) 64804**].
Followup Instructions:
Call Dr.[**Doctor Last Name **]/ Thoracic Surgery office for an appointment in
[**11-21**] days. [**Telephone/Fax (1) 170**].
Completed by:[**2122-4-23**]
|
[
"53081",
"412",
"2720",
"4019"
] |
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