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Unit No: [**Numeric Identifier 69107**]
Admission Date: [**2145-8-7**]
Discharge Date: [**2145-8-19**]
Date of Birth: [**2145-8-7**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] #1 is the
former 34 and [**2-9**] week gestational age twin. At the moment of
discharge, she is 12 days old, with a corrected gestational
age of 36 and 2/7 weeks. Maternal history: 36 year old, GEP
1 to 3 woman with past history notable for term delivery in
[**2141**]. Perinatal screen as follows: Blood type A positive,
antibody screen negative, HBS antigen negative, RPR
nonreactive, Rubella immune, GBS unknown. Estimated delivery
date of [**2145-9-15**]. Twins were born with gestational age of
34 and 3/7 weeks on [**2145-8-7**]. Pregnancy was
complicated by twin gestation and pregnancy induced
hypertension. Repeat Cesarean section for pre-eclampsia and
twin gestation. Epidural and spinal anesthesia was done.
There was no fever or other clinical evidence of
chorioamnionitis. Antepartum antibiotic prophylaxis was not
administered. Rupture of membranes occurred at delivery,
yielding clear amniotic fluid.
Infant emerged apneic, orally and nasally bulb suctioned,
dried, bag mask ventilated. At one minute, subsequently pink
with moderate grunting and retractions. Apgars 7 at 1 minute
and 8 at 5 minutes.
PHYSICAL EXAMINATION: On admission, birth weight is 2475
grams. Length 45.5 cm. Head circumference 32 cm. Heart
rate 154; respiratory rate 60 to 70; temperature 98.0; blood
pressure 60/31 with a mean of 40; saturating 93% on 29%
oxygen, C-Pap. Anterior fontanel soft and flat, non
dysmorphic female. Infant palate. Normal cephalic. Chest
with mild to moderate retractions, improved on C-Pap. Good
breath sounds bilaterally. Well perfused. Regular rate and
rhythm. Symmetrical femoral pulses, no murmurs. Abdomen
soft, nondistended, no organomegaly. No masses. Breath
sounds active with 3 vessel umbilical cord. Normal female
genitalia. Active, responsive to stimulation infant, with
tone appropriate for gestational age. Suck, root and gag
intact. Normal spine, limbs, hips and clavicles.
LABORATORY DATA: D-stick on admission 46. CBC with 9.6
white blood cells, 22 polys, 1 band, 71 lymphs. Hematocrit
50.2; platelets 306.
HOSPITAL COURSE BY SYSTEMS: Respiratory: On admission,
infant was placed on C-pap 6 with some oxygen
supplementation. Arterial gases were reassuring. She weaned
successfully to room air on day of life #1. She was
monitored for apnea of prematurity and one spell was noticed
on day of life 2. She remained spell free since then. Her
hospital course otherwise was unremarkable.
Cardiovascular: Reassuring exam through the hospital course.
Fluids, electrolytes and nutrition/GI: On admission, she was
made n.p.o. and IV fluids at 60 cc per kg of D-10-W were
started. Enteral feeds were introduced on day of life #2.
She advanced to full feeds by day of life 4. She is p.o. ad
lib since [**8-15**], day of life 8. She was followed for
hyperbilirubinemia. Her bili peaked on day of life #4 at 10.9
and no phototherapy was started. Follow-up daily on day of
life 6 was 9.6. She remained slightly jaundiced at the
moment of discharge. She is discharged home on full p.o.
feeds of breast milk/Similac 24 calories per ounce. Her weight on
discharge was 2480 grams.
Hematology: Initial CBC was reassuring. No blood products
were transfused through hospital stay.
Infectious disease: Initial cultures on admission were
negative. She was treated for 48 hours with Ampicillin and
Gentamycin for sepsis rule out. She was treated with nystatin
for a monilial rash.
Neurology: Reassuring exam through hospital course. No head
ultrasounds were done.
Audiology: Infant passed newborn hearing screen on both ears
prior to discharge.
Ophthalmology: No eye exam was indicated. Examination was
reassuring.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged home with parents.
Feeds at time of discharge: Breast milk 24 cal/oz made with
similac powder or similac 24 cal/oz.
Newborn screen sent on [**8-10**]. Results were within normal limits.
She passed a car seat test prior to discharge
PRIMARY CARE DOCTOR: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43888**] at [**Hospital **] Pediatrics.
Hepatitis B immunization was given on [**2145-8-11**].
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: Appointment scheduled with primary care doctor 2
days after discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks, resolved.
2. Respiratory distress syndrome, resolved.
3. Rule out sepsis, resolved.
4. Hypoglycemia, resolved.
5. Hyperbilirubinemia, resolved
6. Monolial rash, improved
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Doctor Last Name 69108**]
MEDQUIST36
D: [**2145-8-19**] 07:47:35
T: [**2145-8-19**] 08:22:57
Job#: [**Job Number 56689**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2129-7-8**] Discharge Date: [**2129-8-4**]
Date of Birth: [**2073-11-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
shortness of breath, fever, respiratory failure
Major Surgical or Invasive Procedure:
Intubation
aline placement
IJ line placement x 2
Bronchoscopy
Esophageal balloon placement
History of Present Illness:
This is a 55 yo M with h/o HTN who initially presented to an OSH
2 days ago complaining of fevers, SOB and now is being
transferred in the setting of respiratory failure. History is
obtained from OSH records and pt's family. Per OSH d/c summary,
pt was being conservatively treated for URI sxs 5 days prior to
presentation to OSH with ? unknown abx, cefclor, promethazine,
and codeine but did not feel better and thus was admitted to
[**Hospital3 **] on [**7-6**]. At the time, he was reportedly
complaining of subjective fevers, chills, rigros, sore throat,
shortness of breath, and cough without hemoptysis. No diarrhea,
abd pain, n/v, myalgias.
.
On presentation to OSH, febrile to 104.3, O2 sat 91% on RA -->
96% 4L NC, RR 18. WBC 4.7 with 86.3% neutrophils, plts 106K, Na
128, Cr 1.2, HCO3 29. CXR revealed multi-focal PNA (L>R). Flu
swab negative. Sputum cx, urine legionella, HIV still pending.
He was placed on respiratory isolation for r/o TB for unclear
reasons other than his history of being from [**Country 3587**]. He was
treated with IV vancomycin, ceftriaxone, azithromycin and
bactrim (added on [**7-8**]). However, on am of transfer, pt noted to
desat from 97% on 2-3L NC to 77%, requiring NRB. Pt also noted
to be tachypneic with RR in 30s, febrile to 101-102 in spite of
tylenol. ABG 7.44/35/71/24 on NRB. CXR revealed nearly complete
white out of left lung.
.
Upon arrival to the [**Hospital Unit Name 153**], the pt is intubated and not responsive
to sternal rub.
Past Medical History:
HTN
Hypercholesterolemia
Social History:
Works as school bus driver. Married and lives at home with wife.
[**Name (NI) **] EtOH, illicits, IVDA, tobacco per OSH d/c summary. Moved to
USA from [**Country 3587**] 20 years ago. No other known recent TB risk
factors.
Family History:
No family contacts with known tuberculosis. Otherwise
non-contributory
Physical Exam:
98.1 149/91 92 20 97RA Glucose 148
GEN: appears weak, but comfortable, non-toxic. NAD.
HEENT: clear OP, mmm
NECK: No LAD.
CV: RRR, no MRG, +2 pulses
CHEST: CTA B, good AE.
ABD: +BS, soft, NT/ND
EXT: No edema, well perfused
Neuro: CN2-12 grossly intact, no focal defecits.
MSK: profound generalized weakness, slowly improving daily.
Unable to feed self, able to sit forward in chair, but unable to
sit up in bed from lying position. Strength 3/5 diffusely.
Pertinent Results:
LABS ON ADMISSION:
[**2129-7-8**] 03:32PM BLOOD WBC-3.5* RBC-3.76* Hgb-11.5* Hct-32.8*
MCV-87 MCH-30.6 MCHC-35.1* RDW-13.3 Plt Ct-119*
[**2129-7-8**] 03:32PM BLOOD Neuts-79* Bands-10* Lymphs-9* Monos-1*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2129-7-8**] 03:32PM BLOOD PT-13.8* PTT-36.9* INR(PT)-1.2*
[**2129-7-8**] 03:32PM BLOOD WBC-3.5* Lymph-10* Abs [**Last Name (un) **]-350 CD3%-43
Abs CD3-150* CD4%-34 Abs CD4-120* CD8%-10 Abs CD8-33*
CD4/CD8-3.62*
[**2129-7-8**] 03:32PM BLOOD Glucose-204* UreaN-13 Creat-0.8 Na-131*
K-4.8 Cl-100 HCO3-25 AnGap-11
[**2129-7-8**] 03:32PM BLOOD ALT-76* AST-201* LD(LDH)-1794*
CK(CPK)-5948* AlkPhos-51 Amylase-74 TotBili-0.3
[**2129-7-8**] 03:32PM BLOOD Lipase-64*
[**2129-7-8**] 03:32PM BLOOD Albumin-2.8* Calcium-6.8* Phos-2.7 Mg-2.3
.
Micro:
[**7-22**] BAL: GNRs
PCP- [**Name10 (NameIs) 5963**]
HIV [**2-4**]- negative, HIV viral load negative
Cryptococcal Ag- negative
Toxo Ab- negative
C. Diff- negative
CMV Ab and viral load- negative
Legionella negative
Beta glucan and galactomannan- negative
Viral resp culture- negative
Echinococcus Antibody Igg- negative
Mycoplasma- negative
HSV [**2-4**]- IgG + for HSV1, IgM - neg
EHRLICHIA- negative
Histoplasmosis- pnd
Entamoeba- pnd
Hanta virus- neg
LEPTOSPIRA- pnd
LCM- pnd
Q-fever- negative
.
Reports-
.
echo-
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion
.
CT torso
IMPRESSION:
1. Extensive multifocal pulmonary consolidations with areas of
ground-glass opacity, together suggestive of extensive
infection.
2. Hepatic hypodensity as above, most likely a cyst.
3. Large amount of fluid seen throughout the colon, with further
characterization not possible on this non-contrast study
.
LENI
IMPRESSION: No DVT of either lower extremity
.
CXR [**8-1**]:
IMPRESSION:
1. NG tube tip in stomach.
2. Multifocal pneumonia with slight improvement in left upper
lobe aeration.
.
Abd US:
IMPRESSION:
1. Gallbladder sludge with no evidence of cholecystitis.
2. Left hepatic cyst unchanged from that described on CT done on
the same
day.
.
CT CAP:
IMPRESSION:
1. Extensive multifocal pulmonary consolidations with areas of
ground-glass opacity, together suggestive of extensive
infection.
2. Hepatic hypodensity as above, most likely a cyst.
3. Large amount of fluid seen throughout the colon, with further
characterization not possible on this non-contrast study.
.
Discharge labs:
[**2129-8-3**] 06:00AM BLOOD WBC-9.3 RBC-3.55* Hgb-10.8* Hct-32.9*
MCV-93 MCH-30.5 MCHC-32.9 RDW-15.5 Plt Ct-329
[**2129-8-3**] 06:00AM BLOOD Neuts-63.9 Lymphs-22.6 Monos-6.2 Eos-6.7*
Baso-0.6
[**2129-7-8**] 03:32PM BLOOD WBC-3.5* Lymph-10* Abs [**Last Name (un) **]-350 CD3%-43
Abs CD3-150* CD4%-34 Abs CD4-120* CD8%-10 Abs CD8-33*
CD4/CD8-3.62*
[**2129-8-3**] 06:00AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-136
K-3.8 Cl-101 HCO3-24 AnGap-15
[**2129-7-29**] 04:05AM BLOOD ALT-61* AST-30 AlkPhos-84 TotBili-0.6
[**2129-8-1**] 06:15AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
[**2129-7-18**] 10:45AM BLOOD ANCA-NEGATIVE B
[**2129-7-18**] 10:45AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2129-7-14**] 04:07AM BLOOD HIV Ab-NEGATIVE
Brief Hospital Course:
55 M w HTN, who originally presented to OSH w fever/SOB, and was
subsequently transferred to [**Hospital1 18**] in hypoxic respiratory failure
in the setting of multi-focal PNA.
.
# Acute Hypoxic Respiratory Failure: Pt required intubation
before transfer to [**Hospital Unit Name 153**]. He had prolonged fevers without
identifable cause. Required high PEEP requirement while on
Vanc/Zosyn/Levo. He had a multifocal PNA on CXR and required
proning to increase oxygenation. He had a low CD4 count despite
negative HIV test at [**Hospital1 **] and OSH. There was concern also for PCP
and he was also treated with steriods and bactrim. Bactrim was
later stopped and then later restarted. Steriods were stopped
and then restarted and later tapered. Differential included CAP
vs interstitial inflammatory process (acute interstial pna,
acute eosionphilic pna) vs vasculitis. Vasculitis less likely
with no hemorrhage on bronch on [**7-22**], and negative [**Doctor First Name **], ANCA,
and anti-GBM. Infectious work-up showed: HIV 1 and 2 negative,
PCP negative, [**Name9 (PRE) 20890**] and glucactomanna negative, Legionella
antigen negative, viral culture negative, blood cultures
negative, toxo negative, CMV negative, ehrlichia negative,
mycoplasma negative. Urine culture yeast only. Neg Hep C/B. Met
Hb normal. Had a dose of caspo on [**7-16**], was discontinued
following discussion with ID. Echinococcus, LCM, hanta virus,
and Entamoeba negative. Due to high levels of PEEP initally BAL
and bronch were not able to be completed until [**7-22**]. Cx from BAL
grew a small amount of yeast and was negative for PCP and virus;
AFB was negative as well. ID closely followed the patient. He
was treated with vancomycin, Zosyn, Levo. Also had Azithro,
flagyl (stopped with negative c. diff), Bactrim, Doxycycline,
and Micafungin. During [**Last Name (un) 10128**] also had ET complication of a
partial extuabation with cuff above vocal cords, then was
corrected. 2 days later had rupture of balloon and ET tube
exchanged. Xray with findings of pneumomediastinum, thoracics
evaluated pt, otherwise stable and though to be secondary to
high PEEP. Patient was gradually weaned off the vent over the
course of the next couple days and was extubated on [**7-26**] without
complication. On [**7-26**], antibiotics were discontinued. Pt
was transferred to the floor stable, on room air, and on tube
feeds due to failed swallow study on [**7-28**]. On the floor,
patient remained afebrile with stable pulmonary status. He was
continued on a slow prednisone taper, as it is unclear if
steroids in the ICU were responsible for some of his improvement
in the ICU. On [**8-4**] his prednisone was decreased from 10 mg to
7.5 mg, with plans to decrease dose by 2.5 mg every 5 days until
off.
# Hypertension: Has hx of htn at baseline. Intially BP meds
held. Later in course BP was elevated. He was give sedation as
needed and treated with PRN hydral and metoprolol. BP was
labile, and was increased as sedation was weaned. Pt required
propofol, versed, and fentanyl to prevent agitation.
.
Pt was started on metoprolol and later low dose lisinopril was
added for improved BP control. Please follow up on his blood
pressure and titrate medications as necessary. Please note that
his blood pressure may improve as his prednisone dose decreases.
Please check lytes, BUN/Cr in 5 days to ensure tolerating
lisinopril.
.
# ARF: Developed acute renal failure but had adequate UOP. FeNa
consistent with pre-renal, however was third spacing. Given
blood as neede. Renally dosed meds.
.
Renal failure improved, and normalized by the time of discharge.
.
# Hypernatremia: Developed hypovolemia hyponatremia. Improved
with free water boluses as needed.
.
# Constipation/Diarrhea: Initially had consiptiaon, then later
had diarrhea after PO contrast and bowel meds. C. diff negative
x 3. Diarrhea later improved. Had a
flexiseal placed. Abd CT without obstruction of evidence of
acute process. Diarrhea resolved.
.
# Diabetes: Had elevated blood sugars elevated, that were more
elevated with steriod treatments. Was placed on SSI intiailly
then changed to insulin gtt. On the floor, he was treated with
SQ insulin, but did not reliably require insulin. Please follow
glucose levels, and consider starting metformin if remains
elevated.
.
# Elevated LDH, CK: Had what appeared to be rhabomyolisis. CK to
[**Numeric Identifier 7923**]. Given IVF and monitored UO. CK improved.
.
# Hyperkalemia: With renal failure and rhabo had developed
elevated K to >6. No EKG changes. Was treated with kayexalate
and insulin. Improved once BMs started. Resolved by time of
discharge.
.
# Anemia: unclear cause, but likely marrow suppression due to
acute illness. Hemolysis labs negative.
.
# Pancytopenia: Initially thrombocytopenic at OSH but has
progressively developed leukopenia and anemia. Low CD4, but with
negative HIV testing. Unclear cause. Cell counts improved.
.
# Weakness: pt was noted to have profound generalized weakness,
initially unable to sit up in bed, feed self, or lift arm above
shoulder. Pt worked with PT with gradual but signif
improvement. The profound weakness is thought to be due to an
ICU myopathy from prolonged intubation/sedation. Pt will be
discharged to [**Hospital1 **] for inpatient rehab.
Medications on Admission:
HOME MEDICATIONS:
Atenolol 25 mg daily
Cefaclor 250 mg po tid
Promethazine [**2-4**] tsp qid
.
MEDICATIONS ON TRANSFER:
Vancomycin 1 gm IV q12h (last dose [**7-8**] 1200)
Ceftriaxone 1 gm IV q24h (last dose 6/4 1400)
Azithromycin 250 mg IV q24h (last dose 6/4 1800)
Bactrim 350 mg IV q6h (last dose [**7-8**] 1000)
Albuterol neb q1h prn
Albuterol neb q6h prn
Ipratropium neb q6h prn
Lidocaine
SL NTG 0.4 mg prn
Maalox 30 ml q2-4h prn
Milk of magnesia 10 ml daily prn
Docusate 100 mg [**Hospital1 **] prn
Atenolol 25 mg daily
Tylenol 1gm q6h prn
Benzonatate 100 mg tid prn
Pantopraozle 40 mg daily
Hydrocone syrup 5 ml q4h prn
Propofol 150 mg IV X 1, vecuronium 10 mg IV X 1, ativan 4 mg IV
X 1 and then 2 mg IV X 1 with intubation
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
3. Prednisone 5 mg Tablet Sig: as dir Tablet PO once a day: 7.5
mg po q day x 4 days, then 5 mg po q day x 5 days, then 2.5 mg
po q day x 5 days, then d/c.
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please check lytes, BUN/Cr in 5 days. Note: started on [**8-3**].
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
# Acute respiratory failure/Multifocal pneumonia; unclear
etiology (presumed infectious)
# ARDS
# ICU myopathy/profound weakness
# Hypertension
# Anemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted for an acute respiratory failure that required
prolonged intubation. Extensive laboratory workup was
performed, but no definative diagnosis was able to be made,
however we suspect that this was due to an infectious etiology.
You were treated with antibiotics, and are now only being
treated with a slow taper of prednisone. After your ICU stay,
you were profoundly weak, and will require inpatient rehab to
help you regain your strength.
Followup Instructions:
Recommend a slow prednisone taper for his respiratory failure of
unclear etiology. Pt's prednisone was decreased from 10mg to
7.5 on [**8-3**], and recommend decreasing by 2.5 mg every 5 days
until off.
.
Pt was started on Lisinopril on [**8-3**] for hypertension. Please
note that this may improve once off of prednisone. Please
follow up lytes/bun/cr in 5 days to ensure tolerating well.
Titrate prn.
.
Pt will need aggressive PT. Patient is highly motivated.
.
Recommend monitoring patient off of insulin, and if persistently
hyperglycemic, consider starting metformin.
.
He should follow up with his primary care physician in approx 2
weeks.
|
[
"486",
"51881",
"2761",
"5849",
"2762",
"4019",
"2720",
"2859"
] |
Admission Date: [**2190-5-7**] Discharge Date: [**2190-5-16**]
Date of Birth: [**2124-2-28**] Sex: M
Service: Cardiac surgery
HISTORY OF PRESENT ILLNESS: Patient is a 66 year-old
gentleman who started having angina in [**2187-4-26**]. He
underwent prior catheterization at the time and was found to
have a mid LAD stenosis which was stented. He presented to
he Emergency Room in [**2189-11-26**] and was found to have
electrocardiogram changes. He again underwent cardiac
catheterization and had stenting of his left main into the
circumflex. Patient did well and was discharged on Plavix
and Lopressor. He again underwent an elective cardiac
catheterization as follow up on [**2190-5-7**]. He has had some
progression of his symptoms of dyspnea. The cardiac
catheterization revealed diffuse 50 percent restenosis of his
LMCA. This extended into the ostial circumflex stent which
showed restenosis up to 60 percent. The LAD had a 90 percent
ostial stenosis. His ejection fraction preoperatively was 55
percent. Patient was referred to the cardiac surgery
service.
PAST MEDICAL HISTORY: Is significant for coronary artery
disease. Status post percutaneous interventions as above,
hypertension, pancreatitis, hypercholesterolemia, colon
surgery times two for diverticulitis and hernia repair.
MEDICATIONS: Aspirin 325 mg p.o. q.d., Lipitor 60 mg p.o.
q.d., Plavix 75 mg p.o. q.d., Lopressor 50 mg p.o. b.i.d.,
multivitamin and vitamin E. Patient has a questionable
allergy to morphine and Accupril.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2190-5-8**] and underwent coronary artery bypass graft times
two with LIMA to the LAD and saphenous vein graft to the
obtuse marginal. Patient's operative course was complicated
and he was transferred to the SCRU. He was extubated
postoperatively and did well and was transferred to the floor
on postoperative day number one. Patient was noted to have
copious sputum production. Although he did remain afebrile
with a normal white count his sputum was sent off for culture
and was positive for hemophilus influenza. Patient was
started on Levaquin. He was also started on Combivent and
albuterol MDI for his wheezing. Patient continued to improve
and was limited only by his respiratory status which improved
with MDI and diuresis. Patient also complained of dyspepsia
throughout his hospital course and was started on Protonix as
well as well as Reglan at the recommendation of Dr. [**Last Name (STitle) 1940**],
his gastroenterologist and primary care physician. [**Name10 (NameIs) **]
is being discharged on postoperative day number six. He is
doing well. On discharge he is afebrile. His heart is
regular at a rate of 82. His blood pressure was 130/70 and
he is breathing comfortably with O2 saturations of 91 o 94
percent on room air. On examination his heart is regular.
His sternum is stable. His wounds are clean, dry and intact.
His lungs are clear to auscultation bilaterally without
wheezes, rales or rhonchi. His abdomen is soft, nontender,
nondistended. His extremities are warm. He had a chest
x-ray on [**5-13**] showed bibasilar atelectasis and small
bilateral pleural effusions. On discharge his white count is
7.9 and his hematocrit is 30, his platelets are 210. His BUN
and creatinine are 19 and 1.2.
His medications on discharge include: 1) Lopressor 75 mg
p.o. b.i.d., 2) Lasix 20 mg p.o. b.i.d. time 14 days, 3)
KayCiel 20 mEq p.o. q.d. times 14 days, 4) Percocet 1 to 2
tablets p.o. q 4 to 6 hour p.r.n. eor pain, 5) Colace 100 mg
p.o. b.i.d., 6) multivitamin 1 p.o. q.d., 7) Combivent 2
puffs q.i.d., 8) ECASA 326 mg p.o. q.d., 8) Levaquin 500 p.o.
q.d. times 10 days, 9) Protonix 40 mg p.o. q.d., 10) Reglan
10 mg p.o. t.i.d. 1/.2 hour prior to meals, 11) Lipitor 60 mg
p.o. q.h.s. and 12) Plavix 75 mg p.o. q.d.
CONDITION ON DISCHARGE: Good.
[**Last Name (STitle) 25726**] follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1940**] within
two weeks and he will follow up with Dr. [**Last Name (Prefixes) **] in six
weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 25727**]
MEDQUIST36
D: [**2190-5-16**] 09:58
T: [**2190-5-16**] 10:35
JOB#: [**Job Number 25728**]
|
[
"41401",
"9971",
"4019"
] |
Admission Date: [**2201-5-25**] Discharge Date: [**2201-5-30**]
Date of Birth: [**2138-9-5**] Sex: M
Service: CSU
ADMISSION ILLNESS: The patient was admitted with mitral
valve regurgitation and atrial fibrillation. He is a 62-year-
old patient of Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] and Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] with mitral valve disease referred for outpatient
cardiac catheterization prior to valve surgery.
HISTORY OF PRESENT ILLNESS: This 62-year-old man has a
history of mitral valve disease and paroxysmal atrial
fibrillation. His most recent echocardiogram is from
[**2201-1-27**] where the EF was noted at greater than 60 percent
with mild LVH and a mildly dilated left ventricular cavity.
There was moderate dilation of the left atrium. The mitral
valve leaflets were myxomatous and mildly thickened with
moderate-to-severe mitral valve prolapse and 2 plus mitral
regurgitation. His most recent stress test was in [**2197**] and
did not reveal any objective evidence of ischemia.
He denies chest discomfort, shortness of breath, fatigue, or
dizziness. In terms of his atrial fibrillation, he reports
that he has not had any episodes in several months. He is
referred not to be anticoagulated with Coumadin and is on
daily aspirin therapy along with propafenone.
Denies claudication, edema, orthopnea, PND, or
lightheadedness.
PAST MEDICAL HISTORY: Mitral valve disease, PAF, history of
remote prior DCCP, and also BPH; also decreased bone density,
currently enrolled in a research trial at [**Hospital6 2121**]; and mild arthritis. His history is
negative for TIA and negative for CVA, negative for melena or
GI bleed.
PAST SURGICAL HISTORY: Tonsillectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission,
1. Aspirin 325 mg p.o. q.d.
2. Moexipril 5 mg p.o. q.d.
3. Proscar 15 mg p.o. q.d.
4. Propafenone 150 mg p.o. t.i.d.
5. Parathyroid hormone injection daily ([**Hospital1 2025**] study).
6. Tums.
7. Vitamins.
8. Glucosamine.
PHYSICAL EXAMINATION: On exam, he is a 62-year-old man, in
no acute distress. HEENT: Pupils equal, round, and reactive
to light; EOMI. Neck and throat, benign. Pulmonary: Lungs
are clear to auscultation bilaterally. Cardiovascular:
Regular rate and rhythm. Abdomen: Benign. Extremities:
Slight peripheral edema bilaterally. Neurological: Alert and
oriented x3.
LABORATORY DATA: His labs as of [**2201-4-14**], a CBC and a Chem-7
within normal limits and INR of 1.1.
HOSPITAL COURSE: The patient was admitted on [**2201-5-25**] and
went to the Operating Room on that day for a minimally
invasive mitral valve replacement/maze/repair of the right
femoral artery and placement of a 33 mm Mosaic Porcine mitral
valve. He underwent general anesthetic with endotracheal
tube and did well on the surgery with minimal blood loss. He
also had pacer wires placed at this time. The following day,
he was weaned off Levophed in the evening. He was alert and
oriented. His lungs were clear and his physical exam was
benign. He was transferred from the CSRU to the floor on
[**2201-5-27**]. While on the floor, he experienced atrial
fibrillation and was started on heparin. He was converted
with the assistance of his pacer wires, but remained on the
heparin and began Coumadin on [**2201-5-29**]. Pacer wires were
removed on that day and he was discharged home with
instructions for 2 days of Coumadin and an INR check on
Monday.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Status post mitral valve replacement, maze, femoral artery
repair on [**2201-5-25**].
2. Benign prostatic hypertrophy.
3. Arthritis.
4. Osteopenia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg tablet p.o. q.d.
2. Pantoprazole sodium 40 mg tablet p.o. q.d.
3. Finasteride 5 mg tablet 3 tablets p.o. q.d.
4. Propafenone HCl 150 mg tablet p.o. t.i.d.
5. Acetaminophen 325 mg tablet 2 tablets p.o. q.4 h. p.r.n.
pain.
6. Oxycodone/acetaminophen 5/325 mg tablet 1 to 2 tablets
p.o. q.4 h. p.r.n. pain.
7. Warfarin sodium 5 mg tablet p.o. q.d. for 2 doses. Note,
blood test for INR Monday, [**2201-6-2**].
8. Metoprolol tartrate 50 mg tablet p.o. b.i.d.
9. Furosemide 40 mg tablet p.o. b.i.d. for 1 week.
10. Potassium chloride 20 mEq packet p.o. b.i.d. for 1
week. Note, hold for potassium greater than 4.5.
RECOMMENDED FOLLOWUP: The patient is to follow up with Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] on [**2201-8-4**] at 04:15 p.m.; also to follow
up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], and that appointment should be
made in 1 month.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Doctor First Name 4772**]
MEDQUIST36
D: [**2201-5-31**] 05:56:54
T: [**2201-5-31**] 06:50:14
Job#: [**Job Number 4773**]
|
[
"4240",
"42731",
"4019"
] |
Unit No: [**Numeric Identifier 75753**]
Admission Date: [**2178-12-21**]
Discharge Date: [**2178-12-27**]
Date of Birth: [**2178-12-21**]
Sex: M
Service: NB
IDENTIFICATION: Baby [**Name (NI) **] [**Known lastname **] is a 1 week old former 34 week
twin (twin #2) who is being transferred from [**Hospital1 18**] NICU to
[**Hospital 1474**] Hospital SCN.
HISTORY OF PRESENT ILLNESS: [**Known lastname 67181**] [**Known lastname **], twin #2, was born
at 34 and 0/7 weeks gestation by vacuum assisted vaginal
delivery. The mother is a 29 year-old, G5, P2 now 4 woman.
Her prenatal screens are blood type 0 positive, antibody
negative, Rubella immune, RPR nonreactive, hepatitis surface
antigen positive and group beta strep unknown. The mother's
previous medical history is remarkable for gestational
diabetes and chronic hypertension. Her medications included
Aldomet and Pepcid. This was a spontaneous diamniotic,
dichorionic pregnancy. The mother was transferred from
[**Name (NI) 1474**] Hospital where she started on magnesium sulfate and
betamethasone was given for pre-eclampsia. The pre-eclampsia
was cause for induction of this labor. There were no other
sepsis risk factors. Rupture of membranes occurred 2 minutes
prior to delivery. Intrapartum antibiotics were given 5 hours
prior to delivery for the indication of prematurity. Under
epidural anesthesia, the infant emerged vigorous. Apgars were
7 at 1 minute and 9 at 5 minutes. The birth weight was 2,450
grams (50th percentile). Birth length was 48.5 cm (90th
percentile). Head circumference 32 cm (50th percentile).
PHYSICAL EXAMINATION: At the time of discharge, the weight
at discharge was 2,295 grams. The physical exam revealed a
vigorous, nondysmorphic preterm infant, swaddled in an open
crib. Anterior fontanel open and flat. Sutures approximated.
Positive bilateral red reflex. Palate intact. Oral mucosa
without lesions. Neck supple and without masses. Clavicles
intact. Comfortable respirations in room air. Lung sounds
clear and equal. Heart was regular rate and rhythm, no
murmur. Pink and well perfused. Quiet precordium and
present femoral pulses. Abdomen soft, nontender, nondistended
and with active bowel sounds. Cord on and dry and no
hepatosplenomegaly. Testes descended bilaterally. No sacral
anomalies. Stable hip examination. Normal digits and
creases. Mongolian spot over buttocks and age appropriate
toe and reflexes.
NICU COURSE BY SYSTEMS: Respiratory status: He initially
had some mild grunting, flaring and retracting but has always
remained in room air. Respiratory distress resolved by a few
hours of age. On examination, his respirations are
comfortable. Lung sounds are clear and equal. He has had no
apnea or bradycardia during his NICU stay.
Cardiovascular status: He has remained normotensive
throughout his NICU stay. There is no heart murmur and there
are no cardiovascular issues.
Fluids, electrolytes and nutrition: Enteral feeds were begun
on day of life 1 and advanced without difficulty to full
volume feeds by day of life 4. At the time of transfer, he
is on total fluids, 150 ml per kg per day of 20 calorie per
ounce premature enfamil, mostly by gavage with limited oral
intake. He has remained euglycemic throughout his NICU stay. His
last set of electrolytes on [**2178-12-24**] were sodium of 133,
potassium of 5.7, chloride 103, bicarbonate of 22.
Gastrointestinal status: Peak bilirubin was 9.2/0.3 on day of
life 4, with follow-up bili of 6.7 on day of life 6; no
phototherapy was needed.
Hematology: His hematocrit at the time of admission was
51.9, platelets 430,000. He has received no blood product
transfusions during his NICU stay.
Infectious disease status: Blood culture was done at the time
of admission and remains negative to date. He has not
received any antibiotic therapy during this NICU stay. Initial
WBC was 10.1 with 51%P/0%B.
Audiology: Hearing screening has not yet been performed and
is recommended prior to discharge.
Psychosocial: The mother has been visiting during the NICU
stay.
DISPOSITION: The infant is discharged in good condition. He
is transferred to [**Hospital 1474**] Hospital, level II nursery, for
continuing care.
PRIMARY PEDIATRIC CARE PROVIDER: [**Name10 (NameIs) **] yet identified.
RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feedings: 20 calories per ounce formula at 150 ml/kg per
day.
2. He is discharged on no medications.
3. Iron and vitamin D supplementation: Iron
supplementation can be considered 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.
4. He will need a car seat position screening just prior to
discharge.
5. His state newborn screen was sent on [**2178-12-23**].
6. He has received the following immunizations:
His hepatitis B vaccine on [**2178-12-21**] due to maternal
positive hepatitis B surface antigen and his HbIg (hepatitis
B immunoglobulin) on [**2178-12-21**].
1. Immunizations:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks gestation.
2. Twin #2.
3. Hepatitis surface antigen positive mother.
4. Status post transitional respiratory distress and sepsis
ruled out.
5. Mild hyperbilirubinemia of hematuria.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56741**]
Dictated By:[**Last Name (NamePattern1) 65342**]
MEDQUIST36
D: [**2178-12-27**] 02:10:57
T: [**2178-12-28**] 04:45:31
Job#: [**Job Number 75754**]
|
[
"7742",
"V053",
"V290"
] |
Admission Date: [**2106-3-1**] Discharge Date: [**2106-3-5**]
Date of Birth: [**2041-8-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypotension, unresponsive episode
Major Surgical or Invasive Procedure:
CT-guided lung biopsy
History of Present Illness:
64-year-old M with DM, HTN, and DM-associated neuropathy,
followed at [**Hospital1 18**] for probable sarcoidosis, transferred to MICU
after unresponsive episode, accompanied with hypotension s/p
lung biopsy.
.
Patient presented today for planned CT-guided lung biopsy.
During the procedure he got fentanyl 100mcg. On CT his stomach
was noted to be distended, adrenal nodules, RML mass. Post
procedure CXR w/o pneumothorax. After his biopsy, he was in the
PACU and was found to have an unresponsive episode. He was
thought to be questionably pulseless, CPR started, and patient
immediately woke up after 20sec of CPR. He was also hypotensive
to 70s and ivfs started. He was transferred to the ED.
.
In the ED, initial VS: 97.5 72 85/59 16 97%. His blood pressure
improved, but then patient triggered for hypotension and
bradycardia (SBP 50s, HR 50s). Throughout this time, he was
awake, responsive, but felt cool and clammy on exam. His labs
were notable for: Lactate:2.3, Trop-T: <0.01, Na 142, K 3.8, BUN
19, Cr 0.8, HCO2 33, ALT 20, AST 16, AP 44, Tbili 0.3, Alb 3.5,
Lip 23, INR 1.1, WBC 3.7, Hct 32.5->29.1, Plt 192, Ca 8, UA few
bact, neg leuks/wbc/nit, trace prot. Blood cx sent. CT head neg
for acute process. CTA chest showed small to moderate
pneumothorax, small hemoperitoneum and pneumoperitoneum, no
evidence of active extravasation, RML/RLL consolidative mass. CT
head no acute intracranial process. Surgery was consulted, and
given hct stable, exam unremarkable did not feel CT findings and
clinical exam correlated. They recommended MICU admission for
further work up. Pt received vanc, zosyn, hydrocort 100,
morphine 5, and 1unit pRBC.
.
Of note, pt initially developed progressive weakness (started in
legs), followed by hoarseness, EMG showing severe sensorimotor
polyneuropathy, sural nerve bx (endoneural and perineural
non-necrotic granulomatous inflammation c/w sarcoid vs leprosy)
and maculopapular rash (multiple skin biopsies at [**Hospital1 18**] path
notable for deep dermal lymphohistiocytic infiltrate with rare
giant cells). He has had previous CT chests that showed numerous
lung nodules, repeat chest CT on [**2106-1-6**] showed resolution of
nodules but new lesion in the right middle lobe. He underwent
bronchoscopy on [**12/2105**], that revealed alveolar tissue with
macrophages, culture negative. He has been evaluated by
rheumatology, pulmonology, neuromuscular, and dermatology. He
was started on prednisone 100 mg daily since
[**2105-11-5**] that has been titrated down slowly given lack of
improvement; last week he was titrated down from 30mg to 20mg
daily.
.
On arrival to the MICU, patient c/o abdominal discomfort along
upper quadrants. He denies lightheadedness, denies sob, cp,
palpitations, diaphoresis, n/v.
n MICU, pt was 3 liters +, remained normotensive. Vanc/zosyn was
d/ced and crit remained stable. Pt ate a meal prior to transfer
and tolerated PO. His vitals were 98.1, 79, 133/80, 97% RA. Pt
is alert and oriented. He has not gotten oob yet.
.
Past Medical History:
Diabetes, diagnosed 8 years ago complicated by small/large fiber
neuropathy ([**First Name8 (NamePattern2) **] [**Last Name (un) **] notes from [**2101**])
Hypertension
Cholecystectomy
Tonsillectomy
Bypass surgery right lower extremity
Vocal cord paralysis surgery
.
Diffuse Rash - underwent 2 biopsies and culture. Culture was
negative and biopsies were not specific. Per the patient,
dermatologist in [**Location (un) 3320**] suggested trial of removing
medications
one by one to see if rash improved although impression was
unlikely allergic rash. He notes the rash is sensitive to
touch.
Vocal cord paralysis - Hoarse voice in [**2104-12-20**] and
underwent
ENT evaluation. Diagnosed with right vocal cord paralysis of
unclear cause and had surgical repair at [**Hospital1 3278**] (Dr. [**First Name (STitle) **] this
past spring. Reported a CT neck that was negative and an MRI
brain did not show cause (states it took 2 hours but isn't sure
exactly what was imaged).
.
Ischemic digits - in [**2105-2-17**] two toes on right foot became
black, he was diagnosed with decreased circulation and had
peripheral artery bypass with improvement. He briefly required
a
walker after this but improved with 5 days of rehab. right leg
remains swollen, unclear if left leg has thinned. He is unable
to
put on compression stocking due to hand weakness.
.
Social History:
He completed 16 years of school and is a retired police officer.
He is a veteran and was exposed to [**Doctor Last Name 360**] [**Location (un) 2452**].
he notes having used Fixodent denture cream for 30+ years,
switched to non-zinc Polygrip 2 weeks ago. He is married and
lives with his wife. [**Name (NI) **] smoked cigarettes for 15 years but quit
35-40 years ago. He denies alcohol or illicit drug use.
Family History:
Mother passed away of CHF in her 60s, Father passed away of
"natural causes" in his 70s. No family history of cancer.
Physical Exam:
Admission physical 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, TTP along RU/LUQ, distended, +BS
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Vitals: 99.3, 158/75, 66, 20, 96%
General: Alert, oriented, no acute distress
HEENT: OP clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased breath sound at right base, otherwise clear
Abdomen: soft, nontender, nondistended, +BS
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact
Pertinent Results:
Admission labs:
[**2106-3-1**] 08:45AM WBC-3.9*# RBC-3.48*# HGB-11.2* HCT-32.5*#
MCV-94 MCH-32.1* MCHC-34.3 RDW-15.4
[**2106-3-1**] 08:45AM PLT COUNT-169
[**2106-3-1**] 08:45AM PT-10.8 INR(PT)-1.0
.
[**2106-3-1**] 01:00PM CORTISOL-6.9
[**2106-3-1**] 01:00PM TSH-6.7*
[**2106-3-1**] 08:56PM TSH-2.0
.
[**2106-3-1**] 01:00PM CK-MB-2
[**2106-3-1**] 01:00PM cTropnT-<0.01
[**2106-3-1**] 08:56PM CK-MB-2 cTropnT-<0.01
[**2106-3-1**] 08:56PM CK(CPK)-19*
.
[**2106-3-1**] 04:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]->1.050*
[**2106-3-1**] 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2106-3-1**] 04:50PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
[**2106-3-1**] 01:00PM GLUCOSE-183* UREA N-19 CREAT-0.8 SODIUM-142
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-33* ANION GAP-9
[**2106-3-1**] 01:00PM ALT(SGPT)-20 AST(SGOT)-16 CK(CPK)-20* ALK
PHOS-44 TOT BILI-0.3
[**2106-3-1**] 01:00PM ALBUMIN-3.5 CALCIUM-8.0* PHOSPHATE-3.4
MAGNESIUM-1.9
.
Imaging:
CT abdomen/pelvis with contrast:
IMPRESSION:
1. Bilateral adrenal nodules, which do not meet CT criteria for
adenoma on
current CT or previous non-contrast CT. These are likely to
statistically
represent adenomas. Followup on routine scans is recommended.
2. Distended fluid-filled stomach despite patient's fasting
state. Findings suggestive for gastroparesis due to diabetes.
3. No evidence of pathologically enlarged intra-abdominal
adenopathy.
.
bx:
DIAGNOSIS:
Lung mass, right middle lobe, biopsy (A):
1) Necrotizing granulomatous inflammation, see note.
2) Liver parenchyma and vascular wall within normal limits, see
note.
Note:
The specimen consists of three tissue fragments.
The first fragment consists of a necrotizing granuloma without
definite attached lung parenchyma. Special stains for fungal
and acid-fast organisms are negative. A cytokeratin stain
highlights residual normal epithelial elements whereas a CD68
stain is positive in the epithelioid histiocytes.
The second fragment consists of liver parenchyma with preserved
architecture. There is focal minimal portal mononuclear
inflammation, which is non-specific. In addition, there is
minimal steatosis without balloon degeneration. A trichrome
stain to assess fibrosis is in progress and will be reported as
an addendum.
The third fragment consists of vascular wall within normal
limits.
The differential diagnosis for the finding of a necrotizing
granuloma includes infectious causes (which are not ruled out by
negative special stains), as well as unusual causes such as
autoimmune disorders (such as Rheumatoid Arthritis),
Granulomatosis with Polyangiitis (formerly known as Wegener's
Granulomatosis), and, although non-necrotizing granulomas are
more common, sarcoidosis, amongst other rare disorders.
Correlation with clinical findings and laboratory values is
recommended.
.
Discharge:
[**2106-3-5**] 07:06AM BLOOD WBC-3.1* RBC-2.96* Hgb-9.5* Hct-28.0*
MCV-95 MCH-32.1* MCHC-33.9 RDW-15.5 Plt Ct-202
[**2106-3-5**] 07:06AM BLOOD Plt Ct-202
[**2106-3-4**] 06:34AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-145
K-4.9 Cl-109* HCO3-32 AnGap-9
Brief Hospital Course:
64-year-old M with DM, HTN, and DM-associated neuropathy,
followed at [**Hospital1 18**] for probable sarcoidosis, transferred to MICU
after unresponsive episode, accompanied with hypotension s/p
lung biopsy.
.
#. RML Mass, Weakness: Has had extensive w/o by multiple
specialists including - aspirgillosus/b-glucan neg, aldolase 8.2
(nl <8.1), ace wnl, FTA-ABS neg, RNP ANTIBODY negative, RO/LA
negative, SCL-70 ANTIBODY, [**Doctor First Name **] pos (1:40), dsDNA neg, CRP 1.8,
spep neg, tsh wnl, b12 wnl, cpk 23, BAL/tissue bx [**1-8**] - no org,
neg mycobacterium/fungal cx, neg afb. CT guided biopsy ended up
gathering tissue from liver, blood vessel and a third source
(likely lung parenchyma) that revealed a necrotizing granuloma.
At time of discharge, final stains were still pending, but the
ddx of granulomatous disease had still not changed, but now
included leprosy as a possibility. neoplastic process vs
sarcoid are still amongst the possibilities. Pt was discharged
without any further workup and will follow up next week for
repeat EBUS.
#. Unresponsive episode, syncope: Likely hypotension secondary
to acute blood loss. Have completed ROMI, and no arrhythmia
overnight. Neuro exam remains non-focal. CT scan notable for
pneumo/hemoperitoneum, which was caused by IR guided biopsy. CT
head wet read showed no acute intracranial process. Pt remained
conscious and responsive throughout remainder of
hospitalization.
.
# Pneumo/hemoperitoneum and pneumothorax: caused secondary to
IR guided biopsy, which accidentally took tissue from vascular
source and liver. The bleed and PTX likely contributed to pts
hypotension and unresponsive episode. He received one unit of
PRBC and 4L NS in ICU and pressures improved. AM cortisol was
normal, cardiac workup unremarkable and no signs of sepsis.
[**Name (NI) 1094**] PTX had resolved by the time he was transferred to the
floor and he was remained normotensive throughout remainder of
hospitalization. Hematocrits remained stable and did not have
any signs of re-bleed.
.
# DM II: Patient placed on insulin sliding scale. At time of
discharge he was transitioned back to home medication regimen.
.
Transitional:
- final path results
- will need another bx, likely via EBUS for definitive diagnosis
Medications on Admission:
ATENOLOL 25 mg daily.
DULOXETINE [CYMBALTA] 60 mg Capsule, Delayed Release(E.C.) daily
GABAPENTIN 300 mg Capsule - 3 Capsule(s) by mouth twice daily.
LOSARTAN 100 mg daily
METFORMIN 500 mg daily.
PANTOPRAZOLE 40 mg Tablet, Delayed Release (E.C.) daily
PRAVASTATIN 40 mg daily
PREDNISONE 10 mg Tablet - 3 Tablet(s) by mouth daily 30mg/day
for 2 weeks then 20mg/day
SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet every
Monday, Wednesday and Friday
ASPIRIN 81 mg daily.
CALCIUM CARBONATE-VITAMIN D3 - 500 mg calcium (1,250 mg)-125
unit twice daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO twice a
day.
8. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
10. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumo-hemoperitoneum
pneumothorax
hypovolemic shock secondary to IR-guided lung biopsy
Secondary:
DMII
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 2031**]
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted to the hospital for hypotension, pneumo-hemoperitoneum
(blood and air in abdomen) and a pneumothorax (collapsed lung)
after a CT-guided biopsy. You were stabilized in the ICU and
transferred to the floor. The biopsy results were insufficient
for diagnosis.
.
We have not changed any of your home medications
Followup Instructions:
You will be contact[**Name (NI) **] by Dr. [**Last Name (STitle) 3373**] or someone from his office to
schedule the time for your biopsy.
.
Department: NEUROLOGY
When: TUESDAY [**2106-3-16**] at 2:30 PM
With: EMG LABORATORY [**Telephone/Fax (1) 2846**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2106-3-31**] at 9:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2106-3-31**] at 10:00 AM
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"2851",
"4019",
"V5867",
"V1582"
] |
Admission Date: [**2170-9-26**] Discharge Date: [**2170-9-28**]
Date of Birth: [**2101-7-3**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
R SAH s/p MVC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69F unrestrained taxi passenger in MVA in downtown [**Location (un) 86**]. +LOC
<5 minutes, no spider-glass on the scene. Reportedly hit her R
periorbital region to the divider in the taxi. GCS 15 at the
scene, 15 in the trauma bay. Stellate 2cm laceration on
superio/medial aspect of R eye, on medial brow edge.
Past Medical History:
"late menopause"
hypothyroid
Social History:
currently single, denies smoking, lives alone
Family History:
non-contributory
Physical Exam:
ON ADMISSION
[**2170-9-26**]
p78 bp 152/72 rr16 spo2 97% on RA
Gen: AOx3, NAD
HEENT: extensive R periorbital edema and ecchymosis, 2cm
stellate lac on the medial margin of R eyebrow. PERRL 4-->2mm.
No oral trauma. C-collar intact
Pulm: CTA bilaterally, non-tender, no deformities
Cards: RRR c s1s2
Abd: Soft, NTTP, no masses, rectal with normal tone, brown,
guaic negative stool
Ext: No deformities, 2+ pulses x 4, 5/5 strength, full sensation
Neuro: intact. CN II-XII, no cerebellar signs, no pronator drift
Pertinent Results:
[**2170-9-26**] 11:46AM GLUCOSE-122* LACTATE-1.1 NA+-142 K+-4.2
CL--97* TCO2-29
[**2170-9-26**] 11:35AM UREA N-17 CREAT-0.7
[**2170-9-26**] 11:35AM estGFR-Using this
[**2170-9-26**] 11:35AM AMYLASE-60
[**2170-9-26**] 11:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-9-26**] 11:35AM WBC-9.4 RBC-4.82 HGB-13.7 HCT-41.2 MCV-85
MCH-28.3 MCHC-33.2 RDW-14.6
[**2170-9-26**] 11:35AM PLT COUNT-356
[**2170-9-26**] 11:35AM PT-11.5 PTT-23.4 INR(PT)-1.0
[**2170-9-26**] 11:35AM FIBRINOGE-588*
CT SINUS/MANDIBLE/MAXILLOFACIA
Reason: ? frx
[**Hospital 93**] MEDICAL CONDITION:
69 year old woman with R periorbital swelling, ecchymosis, s/p
MVC with R facial trauma
REASON FOR THIS EXAMINATION:
? frx
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 69-year-old female with right periorbital swelling,
ecchymosis, status post MVC with right facial trauma. Please
evaluate for fracture.
COMPARISON: CT head performed concurrently.
TECHNIQUE: Contiguous axial images were obtained through the
paranasal sinuses. Coronal reformatted images were prepared.
SINUS CT: There is extensive swelling and hemorrhage in the
right frontal scalp and periorbital soft tissues. No orbital or
facial fracture is identified. The globe is intact and the lens
is in normal position. The intraconal fat is normal in
appearance. There is no orbital emphysema or fluid in the right
maxillary sinus. The included mastoid air cells and middle ear
cavity are clear. There is moderate multifocal subarachnoid
hemorrhage as described in the separate dictation of the
concurrent CT head.
IMPRESSION:
1. Marked right frontal scalp and periorbital soft tissue
hematoma with intact right globe, lens and orbital cone; no
orbital fracture.
2. Moderate bifrontal subarachnoid hemorrhage (please see
separately dictated CT head report).
CT ABDOMEN W/CONTRAST; CT CHEST W/CONTRAST
Reason: ? injury
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman with mva, hit face, +LoC,
REASON FOR THIS EXAMINATION:
? injury
CONTRAINDICATIONS for IV CONTRAST: None.
CT OF THE TORSO WITH CONTRAST.
HISTORY: 68-year-old woman, status post MVA, hit face with loss
of consciousness; ? injury.
TECHNIQUE: Helical 5-mm MDCT axial images were obtained from the
thoracic inlet through the pubic symphysis during dynamic
intravenous but without oral contrast administration, sagittal
and coronal reformations were prepared, and all images were
viewed in soft tissue, lung and bone window on the workstation.
FINDINGS: There are no comparison studies on record. There is no
induration or focal hematoma in the subcutaneous soft tissues to
suggest acute injury, and no fracture is identified. The lungs
are well-inflated and clear, without focal airspace abnormality,
and there is no pleural effusion or pneumothorax. The central
airways are patent. There is evidence of left ventricular
enlargement, but there is no pericardial effusion and the great
vessels are normal in appearance; specifically, there is no
evidence of acute traumatic aortic injury, with no mediastinal
hematoma seen. Incidentally noted is a 4.2 (AP) x 2.3 (TRV) x
4.0 cm (CC) well-defined and cystic-appearing (22-26 [**Doctor Last Name **]) lesion
in the left posterior mediastinum. This lies immediately
adjacent to and slightly indents the left lateral aspect of the
esophagus and appears quite pliable, conforming to the dorsal
contour of the normal-appearing descending thoracic aorta. There
is no inflammatory response in the immediately adjacent lung or
remodeling or other abnormality of adjacent vertebral bodies.
There is no ascites, and the liver, spleen, pancreas (which is
slightly fatty- replaced), stomach, and adrenal glands enhance
normally, without evidence of focal injury. The gallbladder is
not separately identified and may be surgically absent. Both
kidneys enhance and excrete contrast normally. The major
retroperitoneal vessels enhance normally with atherosclerotic
mural calcification involving the abdominal aorta and its
branches, without focal aneurysmal dilatation. Evaluation of
bowel loops is rather limited, due to the lack of oral contrast,
but these are unremarkable and there is no mesenteric
fat-stranding to suggest either bowel or primary mesenteric
injury. The uterus is bulky and lobulated with numerous
rim-enhancing and centrally low-attenuation structures, likely
representing several leiomyomata. There is no free
intraperitoneal fluid, blood, or gas. No acute fracture is
identified. There are degenerative changes involving the
thoracolumbar spine; these are most marked at the L4-5 level
where there is disc degeneration with vacuum phenomenon and
Grade I anterolisthesis, likely related to disc disease and
facet arthropathy.
IMPRESSION:
1. No evidence of acute traumatic injury in the chest, abdomen
or pelvis.
2. No free intraperitoneal fluid, blood or gas.
3. Incidentally noted cystic lesion in the left posterior
mediastinum, which may be intimately related to the dorsal
aspect of the esophagus. The overall appearance suggests a
non-aggressive entity, such as esophageal duplication or
neurenteric cyst, with bronchogenic cyst less likely and
cystic-type neurogenic tumor, a more remote consideration.
4. Mild-moderate lumbar levoscoliosis with degenerative changes,
including degenerative anterolisthesis at the L4-5 level.
5. Transitional anatomy lumbosacral junction with partial
sacralization of the lowest segment, as well as pseudoarthrosis
(with vacuum phenomenon).
6. Fibroid uterus.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 3900**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
CT C-SPINE W/O CONTRAST
Reason: ? frx
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman with mva, hit face, +LoC
REASON FOR THIS EXAMINATION:
? frx
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 58-year-old female with motor vehicle collision and
facial trauma. Right frontal scalp and periorbital soft tissue
hematoma identified on CT sinus. Please evaluate for C-spine
injury.
COMPARISON: None available.
TECHNIQUE: Contiguous axial images of the cervical spine were
obtained without IV contrast. Sagittal and coronal images were
reconstructed.
FINDINGS: There is maintenance of the normal cervical lordosis,
with
no fracture or malalignment. There are degenerative changes of
the cervical spine most pronounced at C6-C7, where anterior and
posterior osteophyte formation is associated with bilateral
(L>R) neuroforaminal narrowing. Incidental note is made of a
small ossific density at the tip of the dens (401:22) which is
well corticated and likely represents an accessory ossicle (e.g.
os odontoideum).
The right internal carotid artery displaces the trachea
medially, which is a normal variant. The imaged portion of the
lung apices is clear.
IMPRESSION: No acute fracture or soft tissue injury of the
cervical spine.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 3900**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
CT HEAD W/O CONTRAST [**2170-9-26**] 11:46 AM
CT HEAD W/O CONTRAST
Reason: ?intracranial injury
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman with mva, hit face, +LoC
REASON FOR THIS EXAMINATION:
?intracranial injury
CONTRAINDICATIONS for IV CONTRAST: None.
CT OF THE HEAD WITHOUT CONTRAST
HISTORY: 68-year-old woman, status post MVA hitting face with
loss of consciousness; ?intracranial injury.
TECHNIQUE: 5-mm axial tomographic sections were obtained from
the skull base through the vertex and viewed in brain and bone
window on workstation.
FINDINGS: There are no comparisons on record. There is extensive
swelling and hemorrhage in the right frontal scalp and
periorbital soft tissues; however, no underlying skull or
orbital fracture is identified and the right ethmoid air cells
and included portion of that maxillary antrum are clear. There
is no intraorbital emphysema. No other focal soft tissue
abnormality is seen and there is no skull fracture elsewhere.
There is moderate amount of acute subarachnoid hemorrhage,
multifocal. There is blood filling the right sylvian and left
interhemispheric fissures, with blood in several sulci of both
frontal convexities, including at the left paramedian vertex.
However, there is no other extra- and no intra-axial or
intraventricular hemorrhage. There is no evidence of cerebral
edema or shift of the midline structures, and the posterior
fossa structures are unremarkable.
IMPRESSION:
1. Moderate, multifocal subarachnoid hemorrhage as described, in
a somewhat random and non-aneurysmal distribution. Given the
soft tissue injury, this is likely post-traumatic.
2. No traumatic hemorrhage in any other brain compartment.
3. Marked right frontal scalp and periorbital soft tissue
hematoma, with intact right globe and orbital cone and no
definite orbital fracture (please see separately dictated report
of dedicated CT of the orbits and facial bones).
COMMENT: Findings discussed with Trauma Surgery houseofficer,
and posted to the ED dashboard.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
CT HEAD W/O CONTRAST
Reason: ? change in bleeding. please have HEAD CT done at 7:00
am 10
[**Hospital 93**] MEDICAL CONDITION:
69 year old woman with SAH, R frontal lobe contusion, s/p mvc
REASON FOR THIS EXAMINATION:
? change in bleeding. please have HEAD CT done at 7:00 am
[**2170-9-27**]
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 69-year-old woman with subarachnoid hemorrhage with
right frontal lobe contusion status post motor vehicle accident.
Question change in bleeding.
COMPARISON: The CT of the head on [**2170-9-26**] was used as a
comparison.
TECHNIQUE: CT of the head without contrast.
FINDINGS: The extensive swelling and hemorrhage in the right
frontal scalp and periorbital soft tissues has shown an interval
decrease since the previous examination. There is no underlying
skull or orbital fracture is identified and the right ethmoid
and remainder of the paranasal sinuses remain clear. There has
been relatively no change in the acute multifocal subarachnoid
hemorrhage identified in the previous examination. There is
blood filling the right sylvian and left interhemispheric
fissures with hemorrhage and several sulci of the left frontal
convexity. There is no evidence of cerebral edema or new shift
of the normally appearing midline structures.
IMPRESSION:
1. Unchanged moderate multifocal subarachnoid hemorrhage as
described above. Given the severity of the soft tissue injury
previously described. This is likely posttraumatic.
2. Interval improvement in right frontal scalp and periorbital
soft tissue hematoma with intact right globe and no definite
fracture.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 75127**]
Brief Hospital Course:
Pt was assessed and stabalized in the trauma bay. Her vitals
were within normal limits and she was AOx3. Due to the nature
of the impact and the severity of her facial edema she recieved
a Ct-Head, Ct-face, and CT-c-spine, results of which are shown
above.
#SAH--> Neurosurgery was emergently consulted and the patient
was loaded with Dilantin. She was admitted to the TSICU with
q1h neuro checks. At all times she had a normal neurologic
exam. She was treated with dilantin and had a repeat CT on the
morning of HD#2, which showed no worsening of her SAH. As her
exam remained stable, she was discharged with neurosurg
follow-up and orders to complete a 10day course of PO dilantin.
#Laceration--> Repaired with 6-0 nylon; will need removal in [**1-14**]
days
#Optho--> Evaluated the patient secondary to the mechanism of
trauma and the degree of edema. The recommended serial exams to
ensure against compartment syndrome; the patient's swelling went
down serially, and she was able to open her R eye without
problems.
#PT/OT--> Pt. was evaluated and cleared for home
#FEN--> Pt. tolerated a full diet
#Dispo---> Pt. to home with PT
Medications on Admission:
Levothyroxine 100mg
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 8 days.
Disp:*24 Capsule(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home with Service
Discharge Diagnosis:
R SAH s/p MVC
Discharge Condition:
stable, tolerating a regular diet, pain well controlled
Discharge Instructions:
[**Name8 (MD) **] MD if you develop fever >101F, increased pain, shortness of
breath, acute visual changes, or any other symptoms that concern
you or your family.
Followup Instructions:
Follow up with your PCP.
Follow up with Dr. [**Last Name (STitle) 548**] of Neurosurgery in 4 weeks. Call
[**Telephone/Fax (1) 1669**] to schedule this appointment. You will require a
head CT without contrast prior to this appointment.
Follow up with your regular Ophthalmologist within 4 weeks.
|
[
"2449"
] |
Admission Date: [**2164-4-3**] Discharge Date: [**2164-4-5**]
Date of Birth: [**2164-4-3**] Sex: F
Service: NB
This is a premature infant admitted to the NICU for
management of prematurity.
The infant was born at 35 2/7 weeks to a 28 year old G1 P0-2
mother with prenatal screens notable for: A positive,
antibody negative, GBS unknown, RPR nonreactive, Hep-B
surface antigen negative. OB history was remarkable for
infertility. This was an FSH and IUI pregnancy. Triplets were
reduced to twins. Mother had a prenatal history also notable
for gestational diabetes. She was admitted on [**2-1**] due
to a short cervix and preterm contractions. Briefly, she was
treated with magnesium sulfate. She did receive betamethasone
on [**2-1**] and [**2-2**]. She was discharged and then
readmitted on [**3-27**] for glucose control with insulin
management. Decision to deliver today was because of growth
restriction in twin B. Delivery was via cesarean section
under spinal anesthesia. Apgars were 8 and 9.
EXAM ON ADMISSION: Birth weight was [**2133**] g, length of 44 cm
and head circumference of 31 cm. Exam was remarkable for a
small, well-appearing near term infant in no respiratory
distress. Color was pink. Anterior fontanelle was soft with
an intact palate, normal facies, no grunting, flaring or
retracting. There were clear breath sounds with no murmur.
Femoral pulses were present. Abdomen was soft and nontender
without hepatosplenomegaly. There was normal external
genitalia with stable hips, normal perfusion and normal tone
and activity.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: The patient has remained stable in room air.
2. Cardiovascular: The patient has remained hemodynamically
stable.
3. FEN: The patient initially was started on minimum feeds of
60 cc/kg/day. She required about half of her feeds via
gavage tube for the first day of life, but since has
improved on her oral feeding and over the last 24 hours,
is taking over 100 cc/kg/day.
4. GI: The patient had a bilirubin at 24 hours of life of
5.7/0.2. She is currently on no phototherapy.
5. Infectious Disease: She is currently on no antibiotics.
CONDITION AT TRANSFER: [**Hospital **] transfer to Newborn Nursery.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) 62111**] in [**Hospital1 1559**],
[**State 350**].
CARE RECOMMENDATIONS:
1. Feeds at discharge are breast milk or Similac, ad lib on
demand.
2. Medications: None.
3. Immunizations: The patient has not yet received any
immunizations.
DISCHARGE DIAGNOSIS: Prematurity at 35 2/7 weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 58729**]
MEDQUIST36
D: [**2164-4-5**] 13:21:11
T: [**2164-4-5**] 13:52:15
Job#: [**Job Number 62112**]
|
[
"V053"
] |
Admission Date: [**2152-2-27**] Discharge Date: [**2152-3-3**]
Service: NEUROSURGERY
Allergies:
Penicillins / Tetracycline / Clarithromycin / Bactrim /
Ofloxacin / Cefaclor / Levofloxacin / Iodixanol / Simvastatin /
Atorvastatin / Solifenacin / Amlodipine / Cortisone
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Called by Emergency Department to evaluate left cerebellar ICH
Major Surgical or Invasive Procedure:
SUBOCCIPITAL CRANIECTOMY FOR LEFT CEREBELLAR HEMORRHAGE
History of Present Illness:
HPI: Ms. [**Known lastname **] is an 87-year-old woman with a history of HTN
who presents with nausea and dizziness and was found to have a
left cerebellar ICH. She awoke this morning and did not remember
that her husband was planning to go grocery shopping early, and
so became anxious when she could not find him. She called her
daughter, who lives upstairs. Her daughter came around 8 AM and
found her to be anxious but otherwise at her baseline. Shortly
afterwards, though, she began to feel nauseated. She said her
legs felt "weak." She said she needed to get to the bathroom but
could not get there because her legs were too "weak." Shortly
after, she began dry-heaving. Her daughter called 911, and she
was taken to [**Doctor Last Name 38554**] Hospital. Head CT AT AGH revealed a
3cm x 3cm x 2cm intraparenchymal hemorrhage in the left
cerebellar hemisphere. Repeat head CT is without much change.
Past Medical History:
PMH:
HTN
Hyponatremia
CAD s/p MI [**1-/2142**]
TIA [**1-/2147**]
Hypothyroid
Diverticulosis
Hiatal hernia
Osteoporosis
Irritable Bowel Syndrome
s/p Appy
s/p Tonsillectomy
s/p TAH
Melanoma on back s/p removal [**2123**]
s/p CCY [**2126**]
Right ovary tumor removed [**2112**]
Rectocele [**2132**]
Bilateral cataracts s/p IOL
Bilateral total knee replacements [**2142**]
Cystocele [**2149**]
s/p thyroidectomy [**2150**]
Social History:
Social Hx: Lives at home with husband, previously independent.
No
smoking history.
Family History:
nc
Physical Exam:
Physical Exam:
Vitals: T: P: 54 R: 14 BP: 148/77 -> 54/31 after propofol bolus,
improved to 91/50s after propofol stopped SaO2: 100% on CMV
General: Intubated, off sedation moving all over the bed with
purposeful movements, attempting to reach for the ET Tube.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,2 to 1
mm bilaterally.
VIII: Hearing intact to voice.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Appears to be moving all four extremities equally,
localizes bilaterally with uppers to noxious stimuli, withdraws
to noxious stimuli bilateral lower extremities.
Toes upgoing left, down going right
ON DISCHARGE: Unchanged from above.
Wound: C/D/I
Pertinent Results:
[**Known lastname **],[**Known firstname **] [**Medical Record Number 81054**] F 87 [**2064-11-22**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2152-2-27**] 1:20
PM
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2152-2-27**] 1:20 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 81055**]
Reason: eval ETT placement
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman intubated for ICH
REASON FOR THIS EXAMINATION:
eval ETT placement
Final Report
INDICATION: 87-year-old woman intubated for intracranial
hemorrhage. Evaluate
ET tube placement.
COMPARISON: None available.
SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: Heart size is normal
given
technique. An endotracheal tube tip is seen with its tip located
4.4 cm from the carina. A tubular structure extends from the
right paramedian neck to the left abdomen with an unusual course
for an OG tube. The side hole port projects above the diaphragm
(if this is an OG tube). Mediastinal and hilar contours are
normal. The aorta is calcified and tortuous.
There is mild left basal atelectasis. There is no focal
parenchymal
opacification. There is no large pleural effusion or
pneumothorax. Pulmonary vasculature is grossly normal. Osseous
structures are within normal limits.
IMPRESSION:
1. ET tube 4.4 cm from carina.
2. Tubular structure from right paramedian neck to overlap left
of expected gastro-esophageal junction is unusual in course. If
an oro- or nasogastric tube then side hole is at or above
diaphragm; recommend advancement.
COMMENT: These updated findings were transmitted telephonically
to Dr [**Name (NI) 81056**]
[**Name (STitle) **] by Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 805**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: SUN [**2152-2-27**] 9:22 PM
[**Known lastname **],[**Known firstname **] [**Medical Record Number 81054**] F 87 [**2064-11-22**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2152-2-27**]
1:34 PM
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2152-2-27**] 1:34 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 81057**]
Reason: eval for interval progression
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman with ICH, intubated
REASON FOR THIS EXAMINATION:
eval for interval progression
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: DXAe SUN [**2152-2-27**] 2:39 PM
3.4 x 2.6 cm midline left cerebellar parenchymal without other
definite
hemorrhage seen, although exam is somewhat limited by motion.
Moderate
associated vasogenic edema causes effacement of the lateral
cerebromedullary cistern without gross mass effect or
ventricular dialtion.
Final Report
INDICATION: Intracranial hemorrhage. Evaluate for interval
progression.
COMPARISON: No previous studies here.
TECHNIQUE: Non-contrast head CT.
FINDINGS: Two scans were performed due to patient motion on the
first scan.
There is a large acute hematoma centered in the left superior
cerebellar
vermis, which measures 4.3 x 2.8 cm in maximal axial cross
section. There is mild surrounding edema. The fourth ventricle
appears essentially obliterated. However, the third and lateral
ventricles are not dilated. The left aspect of the quadrigeminal
plate cistern is nearly completely effaced. There is mass effect
on the left inferior colliculus.
There is no evidence of acute hemorrhage, edema, or acute
infarction in the supratentorial portion of the brain.
Hypodensities in the periventricular white matter adjacent to
the lateral ventricles, likely related to chronic small vessel
ischemic disease in the patient of this age. Extensive
calcifications are seen in the internal carotid and vertebral
arteries.
The imaged bones appear unremarkable. There is mild mucosal
thickening in the right maxillary sinus.
IMPRESSION: Large hematoma centered in the left superior
cerebellar vermis, with near-complete obliteration of the fourth
ventricle. No dilatation of the third and lateral ventricles at
this time. Neurosurgical consultation is recommended.
Head MRI with and without contrast, as well as head MRA or CTA,
are suggested to exclude an underlying mass or vascular
abnormality.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94**]
DR. [**First Name11 (Name Pattern1) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**]
Approved: SUN [**2152-2-27**] 5:07 PM
Imaging Lab
[**Known lastname **],[**Known firstname **] [**Medical Record Number 81054**] F 87 [**2064-11-22**]
Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2152-2-27**]
7:44 PM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG TSICU [**2152-2-27**] 7:44 PM
MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 81058**]
Reason: 87 year old woman with cerebellar hemorrhage,?
underlying le
Contrast: MAGNEVIST Amt: 10
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman with cerebellar hemorrhage,? underlying
lesion.
REASON FOR THIS EXAMINATION:
87 year old woman with cerebellar hemorrhage,? underlying
lesion.
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
HISTORY: 87-year-old woman with cerebellar hemorrhage seen on
previous study.
COMPARISON: Comparison is made to CT studies of the head both
done on [**2-27**], [**2151**].
TECHNIQUE: Sagittal and axial T1-weighted images as well as
axial T2 STAR,
FLAIR and T2 images were obtained of the brain. Following
administration of gadolinium contrast axial T1-weighted images
were obtained. Diffusion-weighted images were also obtained.
FINDINGS:
Again visualized is a large hematoma centered at the left
superior cerebellar hemisphere and vermis, which appears similar
in size to the previous CT studies. T2 images show blood-fluid
levels within it, suggesting internal evolution of this
hematoma. The surrounding edema, is more prominent than that on
the previous CT particularly the extension anteriorly into the
middle cerebellar peduncle. Associated with this edema is
effacement of the left aspect of the quadrigeminal plate and the
left ambient cistern, consistent with upward transtentorial
herniation. The fourth ventricle is effaced and displaced to the
right. The third and lateral ventricles are normal in size and
configuration. Periventricular hyperintensity on FLAIR images is
more likely chronic small vessel infarction, given the rim of
normal tissue immediately adjacent to the ventricles making
transependymal migration of CSF less likely. There is no intra-
or perilesional enhancement on post- contrast images. There is
no abnormal enhancement of the parenchyma, leptomeninges or
dura. There are no feeding vessels seen at the level of the
hematoma. MPRAGE images show no evidence of venous sinus
thrombosis or active extravasation.
Otherwise, the supratentorial brain shows no hemorrhage, edema
or vascular
territory infarct. There is no lateral shift of normal midline
anatomy.
IMPRESSION:
1. Left cerebellar hemispheric hematoma, characterized as above.
No evidence of underlying mass or vascular abnormality.
Surrounding edema is noted as was described on the previous CT
scans with mass effect and upward transtentorial herniation, but
no evidence of obstructive hydrocephalus.
2. No enhancing abnormality underlying the hemorrhage or
elsewhere.
3. No focal extravasation to specifically suggest risk of
expansion.
4. Chronic small-vessel ischemic change.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
Approved: MON [**2152-2-28**] 7:55 PM
Brief Hospital Course:
Pt was admitted to the hospital through the emergency department
after transfer from addison - [**Doctor Last Name **] hospital for CT with
cerebellar hemorrhage. She was combative in this emergency
department and intubated. Her exam remained stabilized
throughout the night and she was extubated the next am. MRI of
the brain was obtained.
Later that day [**2152-2-28**] she c/o dizziness and headache associated
with visual changes. A repeat scan revealed no significant
changes however her worsening mental status it was decided that
she would benefit from sub-occipital decompression. She was
brought to the operating room on an urgent basis.
She underwent the procedure without difficulty. Her post
operative images were stable and she was extubated the following
am ([**2152-2-29**]).
She was evaluated by Speech Therapy, initially she had some
difficulty swallowing, but passed on a subsequent trial passed
and was cleared for thin liquids and ground solids.
She is being discharged to a rehab facility for ongoing rehab.
Medications on Admission:
Medications:
ASA EC 81 mg po bid
Cozaar 50 mg po daily
Zantac 150 mg po daily
Levothyroxine 125 mcg po daily
Xanax 0.25 mg po daily
Levsin 125 mcg po daily prn
Prednisone 1 mg po daily
Vicodin 5/500 po tid
Cranmax 500 mg po daily
Citrucel 2 tabs po bid
Vitamin C
Vitamin E
Folate
Caltrate + D 600 mg po bid
Calcium carbonate 600 mg po bid
Refresh tears OU qid
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
3. Losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Vitamin E 50 unit/mL Drops Sig: Four (4) PO DAILY (Daily).
7. Calcium Carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension Sig:
One (1) PO BID (2 times a day).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
12. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
Thirty (30) ML PO QHS (once a day (at bedtime)).
13. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): Hold for HR <60 and SBP < 110.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Left Cerebellar Hemorrhage
Discharge Condition:
NEUROLOGICALLY IMPROVED
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 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:[**2152-3-3**]
|
[
"4019",
"41401",
"412",
"2449"
] |
Admission Date: [**2134-4-11**] Discharge Date: [**2134-4-13**]
Date of Birth: [**2050-7-3**] Sex: M
Service: MEDICINE
Allergies:
Horse/Equine Product Derivatives / Calcium Channel Blocking
Agents-Benzothiazepines / Metoprolol
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Attempted LP
History of Present Illness:
83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and
dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR) transferred
from nursing home, w/ MS change. His son who accompanies him
says that he has noticed an increase in his RR over the past few
days and a decrease in his energy level. When he went to visit
him this morning, he was very sleepy and not coherent which is a
change so they called the ambulance. BP and O2 sats there noted
to be low. He did not eat breakfast this morning which is very
unusual for him.
.
In the emergency department, initial vitals: 19:00 U 97.1 74
98/63 22. 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3
here (but per son, not at baseline), BP unresponsive to 2L NS so
left femoral central line placed under U/S guidance (as INR 13)
and levo started. Moving arms but legs weaker. 2 U FFP, 10 vit K
IV. Cxr w/ increased CHF. Head CT NEG. Could not pass foley X 2,
now w/ small amt of blood. Given vanco 1g IV, levo 750 mg IV,
flagyl 500 mg IV. Cool hands/feet, dopplerable PT but not DP,
vasc called and will see on the floor. Guaiac + brown stool.
.
On arrival to the ICU, his son states he is more alert now but
not back to baseline.
.
Review of systems: Pt. states he feels short of breath but
cannot clarify further.
Past Medical History:
On 2-3L O2 at NH for unclear reason
- PVD (Followed by [**Name (NI) 3407**]) w/ chronic LUE and bilateral LE
ischemis
- Chronic renal failure on HD x 4 years (thought to be due to
obstructive uropathy, kidney stones, BPH)
- Systolic heart failure w/ EF 25% on ECHO [**6-26**]
- Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate
(2+) aortic regurgitation is seen. Moderate to severe (3+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. ([**6-26**])
- Hx atrial fibrillation and paroxysmal atrial tachycardia
- s/p AV nodal ablation and implantation of a dual chamber
pacemaker
- Baseline AV conduction delay
- Hypertension
- Coronary artery disease with old posterior MI on EKG and pMIBI
in [**6-/2130**] with EF44%, global hypokinesis, no reversible defects.
- Hx Left 4-9th rib fx, Left hemothorax
- R kidney stone s/p Lithotripsy
([**6-23**], complicated by ESBL Klebsiella UTI)
- s/p stroke (cerebellar), found on MRI, sxs of gait instability
- hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal
cord compression [**12-21**] cerival spondylosis, L median nerve injury
- Anemia
- Benign prostatic hypertrophy
- [**Month/Day (2) 98041**] headaches
- Hx of positive PPD, never treated
- Hx squamous cell and basal cell ca
- HSV keratouveitis
- ventral hernia
- s/p open cholecystectomy [**2130-4-21**]
- s/p small bowel resection (80-90%) for mesenteric ischemia
- s/p umbilical hernia repair
- s/p cystocele repair
- s/p laminectomy - c/b osteomyelitis
- s/p TURP [**9-24**]
Social History:
Patient has been at a NH and has not gotten home since
hospitalization in [**Month (only) 958**]. His wife lives in [**Name (NI) 8**]. He is a
retired psychiatrist. Social history is significant for the
remote tobacco use, 3ppd x 40 years, quit 20 years ago. He
drinks alcohol occasionally, denies illicit drug use.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VITAL SIGNS: T 95.9 BP 96/61 HR... RR... O2
GENERAL: Awake but confused, NAD. Answers do not make sense.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck
Supple.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**] but very distant heart sounds.
LUNGS: Occasional crackles anteriorly and posteriorly w/ poor
inspiratory effort.
ABDOMEN: NABS. Soft, midline scar. No HSM
EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP
bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.
SKIN: Xerosis.
NEURO: Alert but not oriented. Speaking nonsensical sentences.
Able to show 2 fingers on the R but not L. Able to wiggle toes.
Could not follow other commands.
Pertinent Results:
[**2134-4-11**] 07:20PM BLOOD WBC-8.6 RBC-4.09*# Hgb-14.5# Hct-48.4#
MCV-118*# MCH-35.6* MCHC-30.1* RDW-21.7* Plt Ct-200
[**2134-4-13**] 03:15AM BLOOD WBC-14.9* RBC-3.37* Hgb-12.0* Hct-38.1*
MCV-113* MCH-35.6* MCHC-31.4 RDW-21.3* Plt Ct-172
[**2134-4-11**] 07:20PM BLOOD Neuts-91* Bands-1 Lymphs-4* Monos-3 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-2*
[**2134-4-11**] 07:20PM BLOOD PT-99.7* PTT-60.9* INR(PT)-13.2*
[**2134-4-12**] 03:04AM BLOOD PT-21.9* PTT-43.0* INR(PT)-2.1*
[**2134-4-12**] 09:55AM BLOOD PT-17.8* PTT-39.7* INR(PT)-1.6*
[**2134-4-13**] 03:15AM BLOOD PT-17.0* PTT-38.0* INR(PT)-1.5*
[**2134-4-11**] 07:20PM BLOOD Glucose-98 UreaN-45* Creat-4.3* Na-137
K-4.6 Cl-92* HCO3-26 AnGap-24*
[**2134-4-13**] 03:15AM BLOOD Glucose-76 UreaN-54* Creat-4.5* Na-138
K-4.7 Cl-94* HCO3-18* AnGap-31*
[**2134-4-11**] 07:20PM BLOOD ALT-13 AST-18 CK(CPK)-31* AlkPhos-128*
TotBili-0.3
[**2134-4-11**] 07:20PM BLOOD cTropnT-0.41*
[**2134-4-12**] 03:04AM BLOOD CK-MB-NotDone cTropnT-0.34*
[**2134-4-11**] 07:20PM BLOOD Albumin-4.1 Calcium-8.3* Phos-6.9*
Mg-1.5*
[**2134-4-13**] 03:15AM BLOOD Calcium-7.8* Phos-5.5* Mg-1.9
[**2134-4-13**] 03:15AM BLOOD Vanco-9.2*
[**2134-4-11**] 10:30PM BLOOD Type-[**Last Name (un) **] pO2-70* pCO2-79* pH-7.13*
calTCO2-28 Base XS--4
[**2134-4-12**] 12:54AM BLOOD Type-CENTRAL VE pO2-42* pCO2-79* pH-7.17*
calTCO2-30 Base XS--1
[**2134-4-12**] 07:18AM BLOOD Type-[**Last Name (un) **] pO2-32* pCO2-56* pH-7.28*
calTCO2-27 Base XS--2 Intubat-NOT INTUBA
[**2134-4-12**] 03:09AM BLOOD Lactate-2.6*
[**2134-4-12**] 07:18AM BLOOD Lactate-1.2
[**2134-4-12**] 03:09AM BLOOD O2 Sat-56
.
[**4-11**] CXR
FINDINGS: Comparison is made to [**2134-1-25**]. Right pacemaker and
two
intracardiac leads remain in place. Since prior exam, left IJ
hemodialysis
catheter has been placed, with tip low in position, possibly
within the IVC.
[**Year (4 digits) **] stens are noted in the left subclavian and
brachiocephalic vein.
Cardiomegaly again noted with central congestion, bilateral
pleural
effusions. Lung bases are suboptimally assessed given low lung
volumes though
compared with prior, effusion and CHF is increased.
IMPRESSION:
1. Dialysis catheter tip low, likely in IVC.
2. CHF, worse.
.
[**4-11**] CT Head
NON-CONTRAST HEAD CT: No edema, masses, mass effect, hemorrhage
or infarction
is detected. The ventricles and sulci are slightly prominent
consistent with
involutional changes. Periventricular white matter hypodensities
are
compatible with small vessel ischemic changes. Mild mucosal
thickening of the
right ethmoid sinus is unchanged. The remainder of the
visualized part of the
paranasal sinuses and mastoid air cells is clear. Calcification
of cavernous
carotid arteries is noted bilaterally. There has been interval
placement of a
hearing aid device on the left side. Incidental note is made of
posterior non-
fusion of c1.
IMPRESSION: No acute intracranial pathology.
.
[**4-13**] CXR
IMPRESSION: AP chest compared to [**4-11**]:
Moderate right and small left pleural effusions have increased,
mild-to-moderate pulmonary edema stable or worsened. Moderate
cardiomegaly
longstanding. Left basal atelectasis severe and unchanged. No
pneumothorax.
Dual-channel left central venous line ends in the right atrium,
transvenous
right atrioventricular pacer leads in standard placements.
Brief Hospital Course:
ASSESSMENT AND PLAN: 83 M w/ pmh of ESRD on HD, Afib s/p AVN
ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)
transferred from nursing home, w/ MS change and hypotension.
Etiology of hypotension and hypercarbia were never clarified
during his hospital course. The hypotension was concerning for
sepsis given l-shift, indwelling HD line and h/o line infection
(STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line.
Also has a pacemaker. Could not get a urine specimen. CXR w/
loss of diaphragm on R but w/o obvious infiltrate. Could also be
from cardiogenic shock given baseline depressed EF. Given his
presentation w/ altered mental status, he was covered with Vanc,
ceftriaxone, ampicillin and acyclovir for possible meningitis.
An LP was attempted but not successful given prior lumbar
laminectomy surgery and an IR-guided LP was planned. He was
initially on NE for blood pressure support but this was weaned
off the day after admission. The following morning, when the
resident went in to round on Mr. [**Known lastname **], she noted that he was
apneic and without a pulse. A code was called and he was given
epi/atropine, insulin, dextrose, bicarb for PEA. He was
intubated by anesthesia. His wife was called and she asked that
agressive recussitation be stopped (it had not been successful
to that point) and he expired.
.
Hospital course also complicated by the following problems:
.
#. Acute respiratory acidosis: Unclear precipitant. DDX from
percocets vs infection vs hypophosphatemia vs respiratory muscle
fatigue. He tolerated bipap the night of admssion with a small
decrease in CO2. His mental status improved slightly over the
next day.
.
#. Altered mental status: DDX from hypercarbia vs from percocets
vs from infection. CT head w/o acute process. Could possibly be
from meningitis but no nucal rigidity or headache.
- treatment w/ bipap and antibiotics for meningitis as above
.
#. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from
worsening valvular disease. Could also be an infiltrate that is
hidden by edema. Apparently has been on [**12-22**] L NC at rehab w/
unclear diagnosis but getting spiriva and albuterol. No formal
dx of COPD.
- albuterol and atrovent nebs
.
#. ESRD on HD: Dialysis MWF at [**Location (un) **] Dialysis.
- renal followed him and was planning for dialysis the day he
expired
.
#. Systolic heart failure: Unclear if ischemic in etiology or
from valvular disease (mod AS, severe MR).
- appeared total body volume overloaded despite hypotension.
.
#. Afib: INR supratherapeutic at 13.2 on admission but quickly
resolved s/p 2 U FFP and 10 mg vit K IV X 1 in the ED. No
obvious signs of bleeding. HCT w/ hemoconcentration given
baseline of 32. S/p AVN ablation and dual-chamber pacemaker.
- held coumadin
- trended coags
.
#. PVD: Known LUE and bilateral LE PVD followed by Dr. [**Last Name (STitle) 3407**].
- per [**Last Name (STitle) 1106**], nothing to do for now
.
#. Macrocytic Anemia: Current hct likely hemoconcentration. No
signs of bleeding. B12/folate wnl in [**1-25**].
.
EMERGENCY CONTACT: [**First Name8 (NamePattern2) 13291**] [**Known lastname **] ([**Telephone/Fax (1) 98048**], [**Telephone/Fax (1) 98049**], wife
[**Name (NI) 382**]
Medications on Admission:
(per med sheets)
Coumadin 3 mg daily
Dialysis at [**Location (un) **] dialysis MWF
Acetaminophen
ASA 325 mg daily
calcium acetate 667 mg 2 tabs tid
dextroamphetamine 2.5 mg daily
docusate
folate 1 mg daily
lotemax 0.5% eye drops
mucinex 600 mg [**Hospital1 **]
mucomyst nebs [**Hospital1 **]
nephrocaps
pantoprazole 40 mg daily
sensipar 30 mg [**Hospital1 **]
spiriva daily
tobramycin 0.3% eye drops
Valtrex 500 mg daily
lactulose
lorazepam 0.5 mg [**Hospital1 **]
percocet 5/325 [**Hospital1 **]
dexadrine 5 mg daily
Albuterol
vit B12 1000 mg daily
nepro 235 daily
albumin w/ dialysis
darbapoetin w/ dialysis
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypercarbic respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"0389",
"78552",
"51881",
"40391",
"2762",
"99592",
"4280",
"2859",
"42731",
"V1582",
"41401"
] |
Admission Date: [**2121-3-11**] Discharge Date: [**2121-3-14**]
Date of Birth: [**2059-9-1**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 61-year-old female,
who underwent a gastric bypass surgery for the treatment and
management of morbid obesity. The patient underwent
laparoscopic gastric bypass on [**2121-3-11**]. The procedure
was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and there were no
complications during the surgery. Patient tolerated the
procedure without any difficulty.
Following the procedure, the patient was unable to be
intubated secondary to low tidal volumes and weakness. The
patient was brought to the PACU intubated. Patient initially
failed her spontaneous ventilation trial. The patient
remained intubated overnight and was extubated approximately
eight hours after returning to the recovery room. Following
extubation, the patient had no further pulmonary issues and
was stable enough to go to the floor.
Postoperatively, the patient had no complications during her
postoperative period. Was able to tolerate Stage II diet
without any difficulty. Her Foley was D/C'd on postoperative
day number two, and the pain was well controlled on Roxicet.
By postoperative day number three, the patient continued to
have an uneventful postoperative course. Was passing bowel
movements and flatus, and was tolerating her Stage III diet
without difficulty. Her [**Location (un) 1661**]-[**Location (un) 1662**] drain was removed, and
the patient was discharged to home.
DISCHARGE DISPOSITION: Patient was discharged to home, and
asked to followup with Dr. [**Last Name (STitle) **] within two weeks. The patient
was instructed to please call Dr.[**Name (NI) 20848**] office for this
appointment.
DISCHARGE DIAGNOSES:
1. Status post laparoscopic gastric bypass.
2. Morbid obesity.
3. Hypertension.
4. Diabetes mellitus.
5. Coronary artery disease.
6. Status post coronary artery bypass graft times three.
7. Gastroesophageal reflux disease.
8. Rheumatoid arthritis.
9. Depression.
DISCHARGE MEDICATIONS:
1. Avandia 4 mg p.o. q.d.
2. Aspirin 81 mg p.o. q.d.
3. Diovan 80 mg p.o. b.i.d.
4. Lipitor 10 mg p.o. q.d.
5. Lasix 20 mg p.o. q.d.
6. Zantac 150 mg p.o. b.i.d.
7. Paxil 30 mg p.o. q.d.
8. Naprosyn 500 mg p.o. b.i.d.
9. Actigall 300 mg p.o. b.i.d. for six months.
10. Roxicet [**5-12**] mL p.o. q.4-6h. prn pain.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-331
Dictated By:[**Last Name (NamePattern1) 19938**]
MEDQUIST36
D: [**2121-5-15**] 10:37:01
T: [**2121-5-16**] 11:08:55
Job#: [**Job Number 51057**]
cc:[**Last Name (NamePattern4) 39276**]
|
[
"25000",
"4019",
"2720",
"V4581",
"311"
] |
Admission Date: [**2113-12-3**] Discharge Date: [**2113-12-6**]
Service: MICU/Green
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: This is an 85-year-old woman
with a history of coronary artery disease; status post
coronary artery bypass graft times four in [**2113-10-20**],
with a long hospital course complicated by difficulty
weaning, status post tracheostomy and percutaneous endoscopic
gastrostomy tube placement, as well as an upper
gastrointestinal bleed who was discharged to [**Hospital **]
Rehabilitation on [**11-28**]; now presenting with bloody
stools.
The patient had been doing well until one day prior to
admission when she had a large bowel movement with dark
clotted blood, approximately 300 cc, from the rectum. Upper
gastrointestinal lavage was negative. Continued with
"brick-colored" stools all night. Hematocrit was 41.6 on
[**11-28**], which decreased to a hematocrit of 25 on
[**12-2**]. She received one unit with an increase in her
hematocrit to 28. Received a second unit prior to transfer
back to [**Hospital1 69**]. Blood pressure
was slightly lower than normal at 96/50 (usually runs
110/60). A slight bump in her creatinine from 1.2 to 1.5.
She was also noted to have a decrease in mental status. At
baseline, she follows simple commands and mouths words.
In the Emergency Department, she was placed on synchronized
intermittent mandatory ventilation 500 X 12, 60% FIO2, with 5
of pressure support and 5 of positive end-expiratory
pressure. Her ventilation settings at [**Hospital1 **] were a
synchronized intermittent mandatory ventilation of 40 X 4,
with 5 of pressure support, 15 of positive end-expiratory
pressure, and 40% FIO2. She received 1 mg of Haldol
intravenously for agitation and remained hemodynamically
stable.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease; status post myocardial
infarction in [**2113-10-20**] with a catheterization in
[**2113-10-20**] showing a left main 30% occlusion, left
anterior descending artery 100%, left circumflex 90%
occlusion, right coronary artery 90% occlusion with a
pulmonary capillary wedge pressure of 25. She underwent a
coronary artery bypass graft times four in [**2113-10-20**]
with a left internal mammary artery to diagonal, saphenous
vein graft to left anterior descending artery, saphenous vein
graft to posterior descending artery, and saphenous vein
graft to obtuse marginal. The course was complicated by
postoperative atrial fibrillation. An echocardiogram done on
[**2113-11-4**] showed a left ventricular ejection fraction
of 40% to 50%, right ventricular hypertrophy, 2+ mitral
regurgitation, and 1+ tricuspid regurgitation. It was of
suboptimal quality.
3. Hypercholesterolemia.
4. Right total knee replacement.
5. A colonoscopy with polypectomy in [**2113-7-20**] at
[**Hospital **] [**Hospital 1459**] Hospital that revealed a cecal polyp
approximately 6 mm X 8 mm which was removed (and was negative
by biopsy per her niece). It also showed diverticulosis as
well as internal hemorrhoids.
6. The patient had an upper gastrointestinal bleed
secondary to grade I esophagitis erosion in the
gastroesophageal junction as well as gastritis, and a
diverticulum in the third part of the duodenum with no active
bleeding. This was done on her prior admission.
7. Status post tracheostomy placement on [**11-14**].
8. Status post percutaneous endoscopic gastrostomy tube
placement on [**11-14**].
9. Chronic obstructive pulmonary disease.
10. Congestive heart failure.
11. Anxiety.
12. History of ventricular tachycardia; on amiodarone.
MEDICATIONS ON TRANSFER: (Medications on transfer included)
1. Prevacid 30 mg p.o. b.i.d.
2. Lopressor 12 mg p.o. b.i.d.
3. Amiodarone 200 mg p.o. q.d.
4. Aspirin 81 mg p.o. q.d.
5. Doxycycline 100 mg p.o. b.i.d.
6. Colace 100 mg p.o. b.i.d.
7. Lasix 40 mg p.o. b.i.d.
8. BuSpar 10 mg p.o. b.i.d.
9. Haldol 1 mg p.o. as needed.
10. Tylenol.
11. Benadryl.
ALLERGIES:
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 100, heart rate was 86 to 91, blood
pressure was 117/69 (ranging from 98 to 117/52 to 69), oxygen
saturation was 100% on a synchronized intermittent mandatory
ventilation 500 X 12 with 5 pressure support, 5 of positive
end-expiratory pressure, and 60% FIO2. In general, this was
an elderly with a tracheostomy who appeared uncomfortable.
Head, eyes, ears, nose, and throat examination revealed
pupils were equal, round, and reactive to light. Sclerae
were anicteric. Extraocular movements were intact. Mucous
membranes were dry and crusted. The neck was supple. Lungs
revealed coarse breath sounds throughout. Cardiovascular
examination revealed a regular rate and rhythm. The abdomen
was soft, nontender, and nondistended. Normal active bowel
sounds. Extremities revealed no edema. Dorsalis pedis
pulses were 2+ on the left, trace right with heel splints on
bilaterally. Neurologically, awake, followed simple
commands. She moved all four extremities.
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratory data revealed white blood cell count was 7.4,
hematocrit was 34, and platelets were 206. Mean cell volume
was 86. Differential with 74% neutrophils, 19% lymphocytes,
4% monocytes, and 3% eosinophils. PT was 13.5, INR was 1.2,
PTT was 24.8. Sodium was 146, potassium was 4.3, chloride
was 110, bicarbonate was 26, blood urea nitrogen was 39,
creatinine was 1, and blood glucose was 129. Arterial blood
gas revealed pH was 7.51, PCO2 was 33, and a PO2 was 212.
Lactate level was negative.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 10038**]
Dictated By:[**Name8 (MD) 210**]
MEDQUIST36
D: [**2113-12-5**] 17:21
T: [**2113-12-5**] 18:14
JOB#: [**Job Number **]
|
[
"4280",
"42731",
"496",
"4019"
] |
Admission Date: [**2141-7-18**] Discharge Date: [**2141-7-23**]
Date of Birth: [**2074-12-31**] Sex: M
Service: CSU
ADMISSION DIAGNOSES: Coronary artery disease.
Hypercholesterolemia.
History of nephrolithiasis.
History of polio.
History of peptic ulcer disease.
Status post appendectomy.
Status post foot surgery.
DISCHARGE DIAGNOSES: Coronary artery diseases, status post
coronary artery bypass grafting times three.
Hypercholesterolemia.
History of nephrolithiasis.
History of polio.
History of peptic ulcer disease.
Status post appendectomy.
Status post foot surgery.
HISTORY OF PRESENT ILLNESS: The patient is a 66 year old
male who was referred by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for outpatient
cardiac catheterization secondary to having some symptoms of
progressive chest discomfort. He developed some new onset
exertional chest discomfort in [**2141-3-30**], which was
progressive and worsening and occurred after only climbing
one flight of stairs. On [**2141-7-13**], he underwent an exercise
treadmill test where he was found to have a large size severe
inferolateral reversible defect for which he was sent for
cardiac catheterization.
HOSPITAL COURSE: He underwent cardiac catheterization on
[**2141-7-18**], and was found to have complex very proximal 95
percent stenosis of the left anterior descending coronary
artery involving D1 and a 50 percent mid left anterior
descending coronary artery lesion. The left circumflex had
mild disease and the right coronary artery had 100 percent
proximal disease. Otherwise, the left main coronary artery
was normal. Given his significant disease, it was
recommended that he be referred to Cardiac Surgery for
evaluation. He was seen on [**2141-7-18**], for this and it was
felt that he would benefit from coronary revascularization.
On [**2141-7-18**], the patient underwent a coronary artery bypass
grafting times three of the left internal mammary artery to
left anterior descending coronary artery, saphenous vein
graft to diagonal, saphenous vein graft to posterior
descending coronary artery. His cardiopulmonary bypass time
was 55 minutes and his cross clamp time was 39 minutes. The
patient tolerated the procedure well and was taken to the
Post Anesthesia Care Unit on a Propofol drip. He was
extubated on postoperative day zero and on postoperative day
number one, he continued to do quite well and was started on
beta blockade and weaned off any vasopressor medications.
Physical therapy was initiated for the patient and, by
postoperative day number two, he was transferred to the floor
in good condition and his chest tubes and pacing wires were
removed. Otherwise, postoperative days three and four were
essentially focused on physical therapy and gentle diuresis
with Lasix. He was seen by physical therapy and they felt it
was safe for him to go home with assistance. It was felt on
postoperative day number four, as the patient was afebrile
and otherwise hemodynamically stable and saturating 97
percent in room air and otherwise making good urine and good
pain control with oral medications, that he could be
discharged to home.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. once daily for five days.
2. Potassium Chloride 20 mEq p.o. once daily for five days.
3. Colace 100 mg p.o. twice a day p.r.n.
4. Zantac 150 mg p.o. twice a day for two weeks.
5. Aspirin 325 mg p.o. once daily.
6. Tylenol p.r.n.
7. Percocet one to two tablets every four to six hours as
needed for pain.
8. Lipitor 10 mg p.o. once daily.
9. Lopressor 25 mg p.o. twice a day.
FOLLOW UP: He was told to follow-up with Dr. [**Last Name (STitle) **] in four
weeks and otherwise he should follow-up with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) **] in seven to ten days.
LABORATORY DATA: Prior to discharge, his hematocrit was
29.0, platelet count 236,000. Blood urea nitrogen was 17 and
creatinine was 0.7.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2141-7-23**] 12:29:53
T: [**2141-7-23**] 13:31:06
Job#: [**Job Number 58478**]
|
[
"41401",
"2720"
] |
Unit No: [**Numeric Identifier 78769**]
Admission Date: [**2152-4-20**]
Discharge Date: [**2152-4-26**]
Date of Birth: [**2095-8-26**]
Sex: M
Service: VSU
CHIEF COMPLAINT: Symptomatic abdominal aortic aneurysm with
hypertensive crisis.
HISTORY OF PRESENT ILLNESS: This is a patient that was
initially evaluated at [**Hospital **] Hospital at [**Hospital1 **] for
acute onset of abdominal back pain and hypertension. The
patient underwent an abdominal CT which showed a large
abdominal aortic aneurysm. His hypertension was treated with
IV Lopressor and patient was life-flighted here for further
vascular care.
PAST MEDICAL HISTORY: Post-traumatic syndrome and depression
which is treated.
MEDICATIONS ON ADMISSION: Include buspirone 15 mg b.i.d. and
paroxetine 60 mg daily.
SOCIAL AND HABIT HISTORY: Not obtainable at the time of
admission.
PHYSICAL EXAM: The patient was alert and oriented x3 in no
acute distress. Blood pressure was 220/110. The patient had
diminished pedal pulses. Abdomen was mildly tender to
palpation with an abdominal mass of 5 cm.
HOSPITAL COURSE: The patient was evaluated in our emergency
room. Patient's white count was 10.6 with hematocrit of 42.8,
BUN 16, creatinine 1. Coags were normal. A CT of the abdomen
and pelvis with contrast was done which showed a 6.7 cm
infrarenal aortic aneurysm with no intramural hematoma or
obvious leak or periaortic stranding. The patient was
administered 100 mg labetalol IV and hydralazine 20 mg IV and
morphine sulfate IV x2 doses at 2 mg each.
The patient was transferred emergently to surgery and
underwent an open abdominal aortic resection with a right
aortofem limb anastomosis. The patient tolerated the
procedure well. He was transfused 1 unit of packed red blood
cells intraoperatively. The patient was transferred to the
ICU intubated. He did require Neo for blood pressure
hypotension. This was weaned in the immediate perioperative
period. His exam showed him to have a regular rate, rhythm on
cardiac. Lungs were clear. Incisions were clean, dry and
intact, and pulse exam was palpable popliteals with a
dopplerable left PT with absent left DP, right DP and PT. The
patient remained in the ICU. Postoperative hematocrit was 32,
BUN 14, creatinine 0.9. Incisions were clean, dry and intact.
Abdomen was unremarkable. Extremity pulses showed DP on the
left with no pulses on the right. The right leg was cooler
than the left.
Patient required fluid resuscitation for systolic hypotension
with an improvement. The patient was weaned from vent and
extubated on postoperative day #2. His Lopressor was
increased for rate control and hypertension. His NG tube was
discontinued and he was allowed sips for medicines. His
Dilaudid PCA was instituted. The patient was transferred to
the VICU for continued monitoring and care.
Postoperative day #3, there were no overnight events. He did
require Lasix x1 dose for diuresis. His count was 25.7 but
they felt this was related to mobilization of fluid and not
blood loss. He was not transfused. He remained n.p.o. until
he passed flatus. Postoperative day #3, diuresis was
continued for a goal of fluid diuresis of [**12-8**] liters. The
patient did well otherwise. On postoperative day 4, the
patient passed flatus, his diet was advanced to clears and
his home meds were reinstituted. He ran a low-grade
temperature of 100.4-98.1. Incentive spirometry was
encouraged. There was mild abdominal distention but the
abdomen was soft. His pulse exam showed improvement with
palpable pedal pulses bilaterally. Later that day, his diet
was advanced to regular and a bowel regimen was instituted.
PT was consulted. They evaluated the patient on [**4-23**]. They
felt that he would benefit from daily physical therapy in
preparation for discharge to home to improve his gait pattern
and mobility.
On postoperative day 4, the patient was delined and
transferred to the regular nursing floor. He did have a bowel
movement and his diet was advanced as tolerated on
postoperative day #5 and he continued to ambulate with
physical therapy. By postoperative day 6, he was reevaluated
by physical therapy and felt he would be safe to be
discharged to home.
The patient was discharged to home on postoperative day 6,
afebrile. Wounds were clean, dry and intact. He had
dopplerable pedal pulses bilaterally. His wounds were clean,
dry and intact. The abdominal skin clips were removed and
Steri-Strips were placed along the incisional line. The
patient will follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks for
postoperative visit and groin clip removal.
DISCHARGE INSTRUCTIONS: The patient may shower but no tub
baths. He should call if his abdominal groin incisions
develop redness, swelling or drainage. He should also call if
he develops a fever greater than 101.5. He should not lift
anything greater than 2 pounds for the next 4 weeks. He may
ambulate essential distances. No driving until seen in follow-
up with Dr. [**Last Name (STitle) 1391**]. Patient has been started on aspirin. He
should continue this lifelong. He has also been started on
Lopressor for his hypertension. He should follow-up with his
primary care physician for blood pressure management and
medication adjustment. The patient should continue a stool
softener while on pain medications to prevent constipation
and straining with bowel movements.
DISCHARGE DIAGNOSIS:
1. Abdominal aortic aneurysm, inflammatory, symptomatic.
2. Acute hypertensive crisis.
3. History of post-traumatic syndrome.
4. History of depression.
5. Postoperative blood loss anemia, transfused.
MAJOR SURGICAL PROCEDURE: Open abdominal aortic aneurysm
repair with a right aortofemoral limb anastomosis on
[**2152-4-20**].
DISCHARGE MEDICATIONS: Aspirin 81 mg daily, buspirone 15 mg
b.i.d., paroxetine 60 mg daily, metoprolol 37.5 mg b.i.d.,
Percocet 5/325 tablets [**12-8**] q.4h. p.r.n. for pain, Colace 100
mg daily.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2152-4-26**] 11:52:33
T: [**2152-4-27**] 14:56:35
Job#: [**Job Number 78770**]
|
[
"2851",
"311",
"4019"
] |
Admission Date: [**2185-11-29**] Discharge Date: [**2185-12-7**]
Date of Birth: [**2123-4-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
transfer from OSH for STEMI
Major Surgical or Invasive Procedure:
cardiac catheterization with stent to left circumflex artery and
ballon angioplasty to OM1
History of Present Illness:
62 year old gentleman was is transferred from an outside
hosptial for urgent catheterization. He presented to Caritas
[**Hospital3 **] with 7/10 SSCP, STE of inf leads and depression of
ant and lat leads. He was given ASA, originally started on NTG
gtt and integrillin gtt. In their ED he had VT/VF for which he
was DC cardioverted 10 times and placed on Amio and lido gtts.
He was intubated and sent via [**Location (un) **] for cardiac cath.
Briefly recieved CPR for pulseless VT while being transported
via med flight. His PMH is sig for type II DM, HTN,
Hypercholestrolemia, ? CVA s/p L CEA. Of note hx of L leg Art
thrombosis s/p toe amputations on coumadin. In the cath lab he
was found to have a L dom system with total prox occlusion of
his Lcx and had successful PCI of the lesion with a stent and
subsequnt ballooning of his OM1. He required Dopamine Gtt and
IABP Amio and Lido gtt throughout the course of his cath. His HD
showed CI 4.75 with PCWP 24. He was sent to the CCU intubated,
on integrillin gtt with IABP, dopa, amio gtt. He was given 600
mg plavix through NGT.
Past Medical History:
HTN
DM II (diet controlled)
L foot Art thrombosis s/p L 4&5th Toe amputations
s/p L CEA
Social History:
Hx of tobacco use, quit smoking
Family History:
Father died of MI at age 49
Physical Exam:
gen- sedated, intubated lying in bed in NAD
vs- 94.9 83 124/60 20 93% on 100 % FIO2
heent- nc/at, eomi, perrl, mmm
neck- supple, unable to assess jvp, no lad, no thyromegaly, no
bruits
cv- normal s1, s2, no m/r/g
Abd- mildly obese, soft, nt
Ext- trace b/l le edema, no cyanosis, 2+ dp/Pt pulses b/l, s/p l
[**4-27**] toe amputations. L groin site minimal oozing, R sheath/
Aline without bleeding or hematoma
Rectal- Heme - per OSH ED note
Pertinent Results:
[**12-5**] Echo- LVEF 40%
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild to moderate regional
left ventricular systolic dysfunction with basal to mid inferior
and infero-lateral hypokinesis. No masses or thrombi are seen in
the left ventricle. Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2185-11-30**], no
major change.
.
[**11-30**] Echo- LVEF 40%
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild to moderate regional
left ventricular systolic dysfunction with inferior and
infero-lateral hypokinesis. No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size is normal. Right
ventricular systolic function is borderline normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2185-11-29**],
overall LVEF appears lower.
.
[**11-29**] Echo- LVEF 50-55%, Mild inf/inferolat hypokinesis, 1+ MR,
no AI. Normal RV function.
.
[**12-4**] CXR (2-view)- There is no significant interval change.
There is again seen small bilateral pleural effusions. There is
mild prominence of the pulmonary vascular markings without overt
pulmonary edema. Vascular pedicle is not widened and the
cardiac silhouette is normal.
.
[**11-30**] CXR- Bilateral edema/infiltrates, normal size heart
.
[**11-29**] EKG- Sinus brady, > 50% resolution of Inf ST elevations.
V1-V5 ST depressions persistent. Q waves in inf leads
.
[**11-29**] Cath-
COMMENTS:
1. Selective coronary angiography in this left dominant system
revealed
one vessel coronary artery disease. The LMCA, LAD and RCA had
no
significant disease. The LCx was totally occluded proximally.
THere
was a large thrombus burden that extended into OM1.
2. Left ventriculography was deferred.
3. Hemodynamics demonstrated a mean RA pressure of 12 mmHg.
Pulmonary
artery systolic hypertension was noted. The PA pressure was
59/24 mmHg.
Central aortic pressure was 87/60 with a mean of 74 (all mmHg).
Pulmonary capillary wedge pressure was 24 mmHg. Cardiac output
was
elevated at 10.1 L/min (index of 4.75 l/min/m2).
4. An intra aortic balloon pump was placed in the left femoral
artery.
5. Successful thrombectomy and PCI of a dominant circumflex
system with
placement of a 3.0x33mm bare metal stent in the proximal to mid
AV
groove circumflex coronary artery.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Intra aortic ballon pump placement.
3. Successful PCI of a dominant circumflex coronary artery using
a
3.0x33mm bare metal stent. (see ptca comments for further
details)
.
Hematology:
[**2185-11-29**] 06:19PM HGB-14.8 calcHCT-44 O2 SAT-93
[**2185-11-29**] 06:19PM GLUCOSE-252* LACTATE-1.5 NA+-133* K+-3.8
[**2185-11-29**] 06:19PM PO2-76* PCO2-50* PH-7.19* TOTAL CO2-20* BASE
XS--9
[**2185-11-29**] 08:41PM PLT COUNT-327
[**2185-11-29**] 08:41PM WBC-24.6* RBC-4.97 HGB-14.6 HCT-42.9 MCV-86
MCH-29.5 MCHC-34.1 RDW-13.8
.
Chemistry:
[**2185-11-29**] 08:41PM CORTISOL-45.4*
[**2185-11-29**] 08:41PM CALCIUM-8.2* PHOSPHATE-3.9 MAGNESIUM-2.5
[**2185-11-29**] 08:41PM ALT(SGPT)-170* AST(SGOT)-486* LD(LDH)-1406*
ALK PHOS-94 TOT BILI-0.6
[**2185-11-29**] 08:41PM GLUCOSE-304* UREA N-32* CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-17* ANION GAP-18
[**2185-11-29**] 08:46PM O2 SAT-89
[**2185-11-29**] 08:46PM GLUCOSE-285*
[**2185-11-29**] 08:46PM TYPE-ART TEMP-34.4 RATES-12/ TIDAL VOL-600
PEEP-5 O2-100 PO2-53* PCO2-41 PH-7.27* TOTAL CO2-20* BASE XS--7
AADO2-648 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED
[**2185-11-29**] 08:51PM O2 SAT-71
[**2185-11-29**] 08:51PM TYPE-MIX
[**2185-11-29**] 09:53PM TYPE-MIX
[**2185-11-29**] 11:30PM CK-MB-GREATER TH
[**2185-11-29**] 11:30PM CK(CPK)-7871*
[**2185-11-29**] 11:30PM POTASSIUM-3.8
Brief Hospital Course:
62M h/o DM II, HTN, Hyperlipidemia, who presented to an OSH with
SSCP with inferolateral STEMI who had subsequent episodes of
monomorphic and polymorphic VT s/p DCCV x 10 OSH.
.
# CAD- The patient was taken directly to the cath lab where he
received a BMS to LCx (3.0 x 33) with eventual TIMI III flow. He
also had a POBA to the OM 1. He presented in cardiogenic shock
and an IABP was placed and the patient was on a dopamine drip
for two days. By day 2 post intervention, the dopamine had been
weaned off, the IABP was removed and the patient was extubated.
He was maintained on ASA 325, Plavix 75 and started on a low
dose BB. Statin was initially held due to mildly elevated LFTs
in setting of MI, but was started on 10mg lipitor prior to
discharge. Recommend follow-up LFTs as an outpatient.
.
# Rhythm- The patient had sustained mono and polymorphic VT/VFib
and was DCCV x 10 prior to arrival at [**Hospital1 18**]. He was started on
an amio gtt for supression of ventricular ectopy. On day 2 post
intervention, the patient had two episodes of stable sustained
monomorphic VT at a rate of 120-130 and converted with an amio
bolus both times. As these episodes were monomorphic with a slow
rate, it was not likely to be attributed to ischemia but rather
idioventricular arrythmia secondary to reperfusion. This raised
questions about further episodes of VT and therefore the need
for possible ICD placement. The amio drip was increased and EP
was consulted. His electrolytes were aggressively monitored and
repleted. He had one episode of 4 beat NSVT but otherwise no
further arrythmias during stay. Outpatient f/u evaluation with
EP was arranged prior to discharge.
.
# Pump- The patient was in cardiogenic shock with BP maintained
on a dopamine drip and IABP x 2 days. An echo done the day after
his intervention on dopamine showed LVEF 40% with mild
inf-inferolat hypokinesis. Dopamine was eventually weaned off
and the IABP was pulled on day 2. Repeat echo off dopa revealed
LVEF 40%. As his wedge pressure was high coming out of the cath
lab, he was diuresed with IV lasix. Once his BP had stabilized
off of the balloon pump and dopamine, a low dose BB was started
which he tolerated well.
.
# Pulm- The patient was intubated for cardiogenic shock. A CXR
done on the day of admission showed diffuse bilateral
infiltrates/edema. He was extubated on day two s/p intervention.
He was weaned off supplemental oxygen with subsequent diuresis.
However, cont to have productive cough and low-grade fevers.
Concern for PNA. Started on ceftriaxone IV with resolution of
fevers. Transitioned to cefpodoxime prior to discharge to
complete 10 day course for CAP.
.
# DM II- Blood sugars in 300's at presentation and started on
insulin gtt for tight blood sugar control. Had anion Gap of 14 x
2 and was acidotic. DKA was ruled out. FS eventually
well-controlled and transitioned to ISS which was discontinued
prior to discharge. He is diet-controlled at baseline and will
f/u with PCP for further management.
.
# Transaminitis- Likely [**2-24**] MI. No evidence for shock liver as
Cr stable and BP stable. LFTs improved but cont to have AST and
ALT in 50's. Started on low-dose atorvastatin. Will need
oupatient LFT monitoring.
.
# AG metabolic acidosis: Pt presented with mild lactic acidosis
(lactate 2.4) from low CI/perfusion during cardiogenic shock. AG
resolved, glucose WNL.
.
# h/o arterial thrombosis: coumadin initially held given
multiple lines, IABP. restarted on heparin gtt bridge to
coumadin prior to discharge. goal INR [**2-25**]. coumadin increased
compared to home dose. INR level to be checked Friday [**2185-12-9**]
at usual outpatient lab and followed by PCP.
Medications on Admission:
Tricor 145 qd
Vytorin 10/40
Atenolol 25 qd
Coumadin 5 qd
nifedipine XR 60 qd
ASA 81 qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO once a day.
[**Month/Day/Year **]:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
6. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 days.
[**Month/Day/Year **]:*16 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
8. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain: call your doctor.
[**Last Name (Titles) **]:*30 tablets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
ST elevation Myocardial infarction
Discharge Condition:
Good
Discharge Instructions:
2gm sodium diet
call your doctor if your weight increases by > 3 pounds
please take all medications as prescribed
.
Please call your PCP or return to the hospital if you experience
any shortness of breath, chest pain, nausea, vomiting, or any
other symptoms that concern you.
.
You have had a heart attack with stents placed in you coronary
arteries. You must take aspirin and plavix every day to prevent
stent thrombosis. Failure to do this could be life threatening.
Followup Instructions:
Contact the appropriate provider with any questions or if you
need to reschedule
.
Please call to schedule a follow up appointment with your PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 12593**], 1-2 weeks after discharge. You must have your INR
level checked on Friday [**2185-12-9**].
.
Please schedule an appointment with your cardiologist, Dr.
[**First Name (STitle) 3646**], in [**4-28**] weeks.
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2186-1-20**] 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"41401",
"4280",
"2762",
"25000",
"4019"
] |
Admission Date: [**2112-3-29**] Discharge Date: [**2112-4-18**]
Date of Birth: [**2058-4-29**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 53-year-old
female with a past medical history significant for diabetes
mellitus type 1 complicated by triopathy, hypothyroidism,
hypertension, peripheral vascular disease, status post left
fem-[**Doctor Last Name **] bypass in [**2109**] which was complicated by an anterior
MI (status post stent to LAD complicated by cardiogenic shock
and oliguria). Of note, the patient's catheterization in
[**2110-11-4**] was performed secondary to jaw pain and
showed 50% LAD stenosis after D1, 40-50% in-stent restenosis
of LAD, 70% ostial diagonal, 80-90% mid diagonal. Previous
catheterization in [**2111-8-4**] was performed for a positive
stress test and showed distal and proximal LAD and mid
diagonal disease. She received a cipher stent to the distal
and proximal LAD and to her mid diagonal.
In [**2112-3-6**], a follow-up Adenosine MIBI showed a
partial reversible defect in the mid and basilar focal apical
region. The patient was scheduled for elective
catheterization by her primary cardiologist, Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**],
which was scheduled for [**2112-3-29**]. She was initially
admitted to the Medicine service for pre catheterization
hydration and Mucomyst.
In the Catheterization Laboratory, stent was deployed in the
distal LAD. The patient subsequently became hypotensive and
asystolic and was in cardiac arrest. She received
Vasopressin, epi, Atropine, and a temporary pacer.
Catheterization showed large thrombosis throughout the left
main/LAD/diagonal. Angiojet was performed of the distal
circumflex and LAD. There were unsuccessful attempt at PTCA
of the diagonal. A second stent was deployed in the distal
LAD. The patient had a left groin intra-aortic balloon pump
placed as well as a right groin pacing wire. She was in
normal sinus rhythm and off pressors when she arrived into
the CCU. She arrived to the CCU intubated.
PAST MEDICAL HISTORY:
1. Full cardiac history includes: 1. Perioperative
anterior MI in [**2109-9-4**], status post LAD stent
complicated by cardiogenic shock. A catheterization in [**11-5**]
for jaw pain showed 50% LAD stenosis after D1, 40-50%
in-stent restenosis of LAD, 70% ostial diagonal, 80-90% mid
diagonal. Catheterization in [**8-6**] for positive stress test
showed distal and proximal LAD and mid diagonal disease. At
that time, the patient received a cipher stent to the distal
and proximal LAD into her mid diagonal. Follow-up Adenosine
MIBI as described above in the HPI in [**2112-3-6**] showed
a partial reversible defect in the mid and basilar focal
apical regions.
2. Diabetes mellitus type 1 complicated by triopathy.
3. History of MI, as above.
4. Hypothyroidism.
5. Pernicious anemia.
6. Hypertension.
7. Legally blind.
8. Nonhealing left heel ulcer.
PAST SURGICAL HISTORY:
1. Left fem-[**Doctor Last Name **] bypass on [**2109-9-2**].
2. Status post appendectomy.
3. Status post cesarean section.
4. Status post tonsillectomy.
5. Status post wrist surgery.
ADMISSION MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Atenolol 50 mg p.o. q.d.
3. Vitamin B12 250 micrograms p.o. q.d.
4. Colace 100 mg p.o. q.p.m.
5. Diovan 320 mg p.o. q.d.
6. Epogen 10,000 units q. nine days.
7. Tylenol 500 mg p.o. q.p.m.
8. Lopid 600 mg p.o. b.i.d.
9. Humalog insulin sliding scale at breakfast and dinner.
10. Lantus insulin 8 units in the a.m.
11. Humulin N insulin 6 units in the p.m.
12. Lasix 40 mg p.o. q.a.m.
13. Lescol 80 mg p.o. q.p.m.
14. Neurontin 300 mg p.o. q.a.m., 600 mg p.o. q.p.m.
15. Niferex 150 grams p.o. t.i.d.
16. Nitroglycerin patch 0.1 mg p.o. q.d.
17. Norvasc 5 mg p.o. q.d.
18. Plavix 75 mg p.o. q.d.
19. Protonix 40 mg p.o. q.d.
20. Prozac 40 mg p.o. q.d.
21. Synthroid 0.1 mg p.o. q.d.
22. Xanax 0.5 mg p.o. q.p.m.
FAMILY HISTORY: Mother who died from an MI at age 50.
SOCIAL HISTORY: Married, lives in [**Location 17566**] with her
husband. She uses a wheelchair.
PHYSICAL EXAMINATION ON ADMISSION TO THE CCU: Vital signs:
Temperature recorded BP 120/48, pulse 60, respirations 18.
The patient was sedated and intubated. Her ventilator
settings were AC 18 (rate), tidal volume 600, PEEP of 5, FI02
100%. Pulmonary: Coarse breath sounds, ventilated.
Cardiovascular: Regular rhythm with normal S1 and S2. No
murmurs, rubs, or gallops. Neck: Supple, nontender, no JVD.
No carotid bruits. Extremities: Moves all four extremities
spontaneously, withdrawals to pain. No lower extremity
edema. There was 1+ DP pulses bilaterally.
LABORATORY/RADIOLOGIC DATA: On admission, white blood cell
count 19.0, hematocrit 32.2, platelets 248,000, INR 1.8.
Lactate 1.7. Sodium 135, potassium 3.5, chloride 108,
bicarbonate 17, BUN 34, creatinine 1.2. On arrival to the
medicine floor, her creatinine was 1.4. Glucose 343. ABGs
during the catheterization was 7.4/34/508. First CK was 79
with a troponin of 0.14.
The latest echocardiogram was on [**2112-3-30**] which
showed an EF of 55%.
Most recent cardiac catheterization results were mentioned in
the HPI, on [**2112-3-29**] with 70% stenosis of the mid
LAD, 70% stenosis of the LAD, 95% stenosis of diagonal I.
EKG, post catheterization, on [**2112-3-30**] showed a
normal sinus rhythm at 62 beats per minute, normal axis,
normal intervals, low-voltage T wave inversions in aVL, poor
R wave progression.
Hemodynamic data at catheterization: Right atrial pressure
of 18, right ventricular pressure of 40/19, pulmonary artery
pressure of 40/20, wedge pressure 22, SVR of 1112, cardiac
output 5.9, cardiac index 3.1.
HOSPITAL COURSE: 1. CARDIOVASCULAR: A) Ischemia/CAD: The
patient had thrombosis in her left main. The etiology of
this initially was diverse including dissection/trauma,
versus question of a prior nidus and thrombus propagation
versus HIT2 antibody. Initially, the patient received no
heparin for worry of the HIT antibody. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] test for the
HIT antibody was negative and a special send out serotonin
releasing assay was sent which at the time of this dictation
is still pending. The patient required anticoagulation for
CVVH secondary to ATN (see below in section regarding renal
issues) and citrate was initially started for anticoagulation
which was subsequently discontinued when the patient's
calcium levels continued to decline. The decision was made
after consulting Hematology regarding the HIT antibody that
the patient should be started on Argatroban which the patient
was put on for several days for CVVH anticoagulation but
since the patient had increased oozing from her line sites as
well as difficult to manage PTTs. The decision was made
after discussing with Hematology whether heparin could be
started with close monitoring of the patient's platelet
count. Considering a negative HIT [**Doctor First Name **] antibody test this
was felt to be relatively safe since the serotonin assay
would not be back for several weeks and the Argatroban was
difficult to manage. The patient was started on heparin for
CVVH therapy and tolerated this well with no decrease in her
platelet count.
The patient now can tolerate heparin in her dialysate as well
as heparin subcutaneously and has had no evidence of platelet
dysfunction regarding this. It is still unclear what the
patient's large left main thrombosis may have been secondary
to.
In relation to ischemia, the patient's enzymes were cycled
and her CK appeared to peak on the 27th at 1,853 with an MB
fraction of 6.1 and then appeared to trend downward until
[**2112-4-3**].
On the evening of [**2112-4-2**], the patient's heart rate
and blood pressure decreased with heart rate in the 50s and
blood pressure 90/60 down from low 100s. The patient
initially was given a fluid bolus with no improvement. The
nurse gave one amp of Atropine with no response. The heart
rate remained in the 40s and systolic blood pressure in the
50s. The nurse then gave 1 amp of epinephrine without prior
consultation of the house officer and blood pressure increase
to 200/100 with a heart rate in the 180s. The house officer
was then called after the amp of epinephrine was delivered.
EKG showed new left axis deviation, peaked T waves in V2 and
V3, ST depressions in V5 and V6, II, III, and aVF. Blood
pressure decreased to the 70s and heart rate decreased to the
60s and the patient was started on dopamine.
The patient's next set of CKs were elevated on [**2112-4-4**]
at 3,354 and her CK MB was 28. Afterwards, her CKs and CK
MBs continued to trend downward and were last 169 on [**2112-4-15**] with a negative MB. The patient's troponins
continued to increase to a peak of 0.87 on [**2112-4-15**] but
this was thought likely secondary to question of demand
ischemia versus continual leak of troponins from previous
ischemia. The patient's CKs and troponin were no longer
cycle after [**2112-4-15**] since the patient had no signs of
active ischemia. She was continued on her aspirin and Plavix
for coronary artery disease. Her EKG remained unchanged.
HEMODYNAMICS: The patient's blood pressure on admission to
the CCU was high and the patient was placed temporarily on a
nitroglycerin drip. Her blood pressure continued to decline
and was normotensive until [**2112-4-3**] when she became
acutely hypotensive. She was placed on a dopamine drip and
her blood pressure continued to remain low. She was
initially increased on the dopamine drip but did not tolerate
this very well and thus her dopamine drip was titrated to off
and she was started on Levophed. She was kept off of her
beta blocker and calcium channel blocker secondary to
hypotension.
It is unclear why the patient continued to be hypotensive but
it was thought that maybe this was secondary to possible
sepsis. The patient was placed on broad spectrum antibiotics
as well as on steroids for a question of polyglandular
syndrome recommended by her outpatient cardiologist, Dr.
[**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]. She was slowly titrated off pressors and
remained hemodynamically stable.
Since then, the patient had one episode of hypotension
secondary to the hemodialysis where she was briefly placed on
Levophed, but her blood pressure has now remained stable
ranging in the low 100s to as high as the 130s without
pressors for over a week now. She has been hemodynamically
stable. Four to five days prior to discharge, the patient had
a low-dose metoprolol added at 12.5 b.i.d. for cardiac
benefit and she has tolerated this well. Since the renal
team wishes to keep her mean arterial pressure above 70 and
her systolic blood pressure above 110, this dose of beta
blocker has now been increased but can be done as an
outpatient if her blood pressure tolerates this.
PUMP: At the outside hospital where the patient had her
stress MIBI performed, the patient's EF was reportedly 67%.
An echocardiogram performed on [**2112-3-30**] showed an EF
of 70%. Repeat echocardiogram on [**2112-4-1**] showed a
worsening acute ejection fraction of 20-30% with multiple
wall motion abnormalities. A follow-up echocardiogram on
[**2112-4-4**] showed even worsening systolic function with an
EF of 20-25% with inferior akinesis. She had an intra-aortic
balloon pump placed in the catheterization laboratory which
subsequently was removed after arrival to the CCU. The
patient showed signs of increased pulmonary edema and
congestion and attempts were made at diuresis with Lasix 200
IV and Natrecor. The patient did not diurese to either of
these regimens and her creatinine continued to increase to
2.4. Given her new acute on chronic renal failure as well as
increased pulmonary edema and cardiogenic shock, the renal
team was consulted who recommended CVVH for volume removal.
The patient tolerated CVVH and continued on this regimen for
volume removal until [**2112-4-11**]. The patient's urine
output continued to improve as mentioned in the renal section
and hemodialysis was started on [**2112-4-12**].
The patient diuresed well and was able to remove a
significant amount of fluid and showed decreased pulmonary
edema on chest x-ray as well as on examination. Upon
discharge, the patient continues to have very good pulmonary
status and occasionally needed hemodialysis for volume
removal as an outpatient but has continued to increase her
urine output. Of note, the patient was started on digoxin
for her pump on [**2112-4-4**] which is now being dosed every
other day for renal dosing and the patient should likely have
a digoxin level checked every three to four days to ensure
that her levels remain within normal limits. The goal I&Os
for this patient would be even to slightly negative.
Of note, the patient also had a Swan-Ganz catheter placed in
her right IJ for monitoring of her filling pressures and her
Swan-Ganz catheter was discontinued on [**2112-4-7**] with
CVPs ranging in [**12-16**] systolic PA pressures in the 30 range,
cardiac index 3.5, cardiac output 7.1, mean PA pressures in
the 20s.
PULMONARY: The patient arrived to the CCU intubated and was
attempted to wean off the ventilator. She was weaned off the
ventilator on [**2112-5-1**] to face mask but, however, was
reintubated on [**2112-5-2**] for hypoxia and increased work
of breathing. On [**2112-4-5**], it was noted that the
patient had worsening ABGs at 7.33/41/51/with an increased
FI02 requirement of 90%. Chest x-ray on [**2112-4-4**] showed
a right apical pneumothorax 25%, most likely thought to be
related to right IJ placement. Interventional pulmonary was
called and a chest tube was placed. Subsequent repeated
chest x-rays daily showed resolution of the pneumothorax.
The patient's chest tube was subsequently discontinued on
[**2112-4-13**] after she was extubated. The patient was
successfully extubated on [**2112-4-12**] after her RISBI was
in the 70s. The patient has continued to oxygenate well,
status post extubation with now currently saturating on room
air at 95-97%. Her last chest x-ray was improved with
clearing of the question of a left lower lobe infiltrate and
she remained from a pulmonary standpoint stable. She has
also diuresed well after CVVH and hemodialysis therapy and
shows no signs of pulmonary edema.
GASTROINTESTINAL: The patient had an episode of melenic
blood from the NG tube on [**2112-3-31**] which cleared
after NG lavage after 500 cc and had no further GI bleeding
until [**2112-4-12**] when she began to have a few episodes of
melenic stool. These subsequently cleared after two days.
The patient's hematocrit remained relatively stable from 28
to 31 and she had no further episodes of OB positive stool.
The patient has had frequent stools with no bright red blood.
She will likely need a colonoscopy as an outpatient when her
other acute issues resolve to further workup this history of
a GI bleed. The patient was placed initially on Protonix
b.i.d. IV during her episode of melena but this was
subsequently changed to daily Protonix for GI prophylaxis
after her recent stools have been heme-negative.
The patient also had a NG tube placed initially for nutrition
for tube feeds. Although the Speech and Swallow Team
initially evaluated the patient status post extubation and
determined that the patient was aspirating and that she
should avoid clear liquid, the patient has been tolerating
thickened pudding and thickened liquids quite well and is
able to swallow her pills without too much difficulty. The
patient also is able to tolerate thickened liquids, pudding,
and soft diet such as mashed potatoes and soft substances as
long as she is monitored carefully. At the time of this
dictation, a Dobbhoff tube was not felt to be necessary since
the patient was able to swallow her pills and maintain
adequate nutrition without the discomfort of a tube
placement.
Of note, the patient was intermittently placed on TPN for
additional nutrition throughout her hospital course but this
has been discontinued several days prior to discharge.
RENAL: The Renal team was consulted when the patient's
creatinine acutely increased to 2.4 with minimal urine
output. They recommended CVVH for volume removal and
suggested that the patient was most likely suffering from
oliguric acute tubular necrosis, likely multifactorial from
shock/contrast/hypotension. The patient diuresed well with
CVVH and gradually as her hemodynamic and cardiovascular
issues resolved was able to make urine. Just prior to
discharge, the patient has been continually increasing her
urine output daily to as much as 700-800 cc per day. It his
thought that the patient most likely will need intermittent
hemodialysis as an outpatient for additional volume removal
but this may also not be necessary if the patient's urine
output continues to improve. The patient's creatinine has
stabilized now in the low 2s. A Lasix trial was attempted
just prior to discharge but was not successful and it was
thought that the patient would most likely benefit from
hemodialysis if volume removal was necessary.
The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] was held secondary to increased creatinine
but if the patient's creatinine continues to improve after
discharge, this could likely be added back as an outpatient.
In terms of maintaining renal perfusion, the renal team
recommends that the patient maintain her blood pressures with
a systolic of 110 and a MAP greater than 70 until her urine
output turns back to baseline. ACE inhibitors and NSAIDs
should also be avoided secondary to her renal failure.
HEME: The patient's hematocrit remained stable at around 28
to 32 and she occasionally required transfusions. The
patient has had episodes of GI bleed with melena which seem
to have resolved prior to discharge. She should likely be
scheduled for an outpatient colonoscopy when her other issues
resolve. Otherwise, she should resume her vitamin B12, iron,
and Epogen as she was on as an outpatient. Her blood
transfusions have been timed according to hemodialysis
adequate volume removal. The patient is currently
hemodynamically stable, as mentioned above.
INFECTIOUS DISEASE: The patient's white count continued to
trend upward throughout her hospital stay to a peak of
20,000. It is still unclear why the patient had an
increasing leukocytosis but in the setting of hypotension
requiring pressors it was thought that most likely the
patient had an underlying infection. Blood cultures revealed
no growth. The patient had a sputum culture from [**2112-4-9**] with 4+ gram-negative rods but no growth on respiratory
culture. A urine culture from [**2112-4-6**] yielded a pan
sensitive Enterococcus. The patient was treated with a full
course of levofloxacin for ten days for a pan sensitive
enterococcal UTI and then a question of a left lower lobe
pneumonia. In the face of her increasing leukocytosis,
vancomycin was also added for additional coverage empirically
for her multiple lines and this antibiotic was subsequently
discontinued.
On [**2112-4-15**], since the patient's leukocytosis was
improving, she received a full nine day course of vancomycin
dosed by levels and there was no clear indication for its
use. The patient was also put on empiric Flagyl for question
of C. difficile therapy as well as empiric Ceftazidime for
question of a ventilator associated pneumonia. The patient
received a full seven days of cephalosporin which was
subsequently discontinued on [**2112-4-17**] when the
patient's white count returned back to normal and she
remained without signs or symptoms of infection. The patient
should continue with an additional seven days of Flagyl for
Clostridium difficile therapy, although she has had two C.
difficile antigens which have tested negative but there is a
strong clinical suspicion that she did indeed have a C.
difficile infection with her melena and a question of
colitis. On discharge, the patient's white count has
returned to 9,000. She remains afebrile and has had no new
culture data.
DIABETES: The patient's blood sugars were tightly controlled
with an insulin drip throughout her hospital course. The
patient has now been transitioned to a Humalog insulin
sliding scale and at the time of this dictation is currently
on Glargine 15 units q.a.m. for management of her blood
sugars. At the time of this dictation, her blood sugars
still remain elevated ranging from as low as 149 to as high
as 458. It is likely that her diabetes regimen will be
modified prior to discharge and may need further adjustment
as an outpatient as she resumes a normal diet and additional
supplementation is discontinued.
OTHER ENDOCRINE ISSUES: The patient was maintained on
levothyroxine 100 mg p.o. q.d. The patient was also started
on a short seven day course of IV steroids, hydrocortisone
100 IV q. eight hours for a question of a polyglandular
failure that was theorized by her outpatient cardiologist.
In her last admission, the patient was apparently placed on a
seven day course of steroids and improved dramatically.
After placement of steroids on this admission, it is unclear
if the patient's clinical improvement was secondary to
steroids versus broad spectrum antibiotic therapy. The
patient did improve after her seven day course of steroids.
The patient did not undergo a taper since it was felt that
the seven day course was short enough.
FLUIDS, ELECTROLYTES, AND NUTRITION: The patient has had
daily Chem-7s and her electrolytes have been monitored
closely in conjunction with CVVH and hemodialysis. Nutrition
wise, she was initially placed on TPN and was transitioned to
tube feeds. A speech and swallow assessment was performed
and it was felt that the patient aspirates with thin liquids
but is able to tolerate thickened liquids while sitting
upright and with assistance and monitoring. The patient
should only swallow pills with thickened pudding or thickened
liquids and only with monitoring and sitting upright and
thickened substances as well. A Dobbhoff tube was thought
not to be appropriate since the patient has been tolerating
her pills and thickened substances adequately and is
uncomfortable with tube placement. If necessary, this may
have to be done at the rehabilitation facility if she is not
maintaining adequate nutritional needs.
CODE STATUS: Full code.
PROPHYLAXIS: The patient should be maintained on her
Protonix, subcutaneous heparin dose t.i.d. For pain, she has
often required Percocet p.r.n. for lower back pain.
ACCESS: The patient currently has a left non-tunneled IJ
catheter that can be used for dialysis as necessary as an
outpatient. The patient also has a right PICC line for
additional access as necessary.
COMMUNICATION: The patient has a very supportive husband who
is very involved in her care. Phone number is [**Telephone/Fax (1) 35048**].
DISPOSITION: The patient has been working with physical
therapy for increased strength building and mobility and is
able to sit in a chair and has gradually improved over the
course of the last week. She will likely continue to benefit
from continued physical therapy and acute rehabilitation.
DISCHARGE CONDITION: Stable, saturating well on room air,
95-97%.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Reglan 10 mg p.o. q.i.d. and at each meal and q.h.s.
3. Flagyl 500 mg p.o. t.i.d. times seven more days.
4. Atrovent nebulizers q. six hours p.r.n. shortness of
breath, wheezing.
5. Metoprolol 12.5 mg p.o. b.i.d., hold for SBP less than 85
and heart rate less than 60.
6. Digoxin 0.125 mg p.o. q.o.d.
7. Ferrous sulfate 325 mg p.o. b.i.d.
8. Cyanocobalamin 250 micrograms p.o. q.d.
9. Gabapentin 300 mg p.o. q.d.
10. Fluoxetine 30 mg p.o. q.d.
11. Heparin 5,000 units subcutaneously q. eight hours.
12. Percocet one tablet p.o. q. four to six hours p.r.n. back
pain.
13. Plavix 75 mg p.o. q.d.
14. Aspirin 325 mg p.o. q.d.
15. Nystatin swish and swallow 5 milliliters p.o. q.i.d.
16. Epogen 10,000 units subcutaneously two times per week on
Mondays and Thursdays.
17. Levothyroxine 100 micrograms p.o. q.d.
18. Glargine 15 unit q.a.m. with a Humalog insulin sliding
scale.
19. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n.
FOLLOW-UP PLANS: The patient should follow-up with her
outpatient cardiologist, Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**], in one to two
weeks. The patient should also be followed by a nephrologist
as an outpatient for hemodialysis. The patient should
follow-up with her PCP within one to two weeks after
discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2112-4-17**] 05:47
T: [**2112-4-17**] 18:46
JOB#: [**Job Number 35049**]
|
[
"41401",
"5845",
"4280",
"0389"
] |
Admission Date: [**2157-4-23**] Discharge Date: [**2157-5-14**]
Date of Birth: [**2157-4-23**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 56084**] is a former
[**2097**]-gram product of a 33 and [**4-29**] gestation infant born to a
38-year-old primiparous woman whose pregnancy was apparently
uncomplicated until the morning of admission to [**Hospital1 346**] on [**4-21**] with spontaneous rupture
of membranes. She did receive antibiotics. No sepsis risk
factors except for prematurity and spontaneous rupture of
membranes and unknown group B strep status.
Prenatal screens revealed O positive, antibody negative,
hepatitis B surface antigen negative, and rapid plasma reagin
nonreactive.
Labor progressed to a spontaneous vaginal delivery on [**4-24**].
Newborn Intensive Care team attended delivery. Vigorous at
delivery with Apgar scores of 8 at one minute and 9 at five
minutes. The baby received blow-by oxygen and stimulation
and was transferred to the Neonatal Intensive Care Unit after
visiting with parents.
PHYSICAL EXAMINATION ON PRESENTATION: A pink, active,
nondysmorphic infant. The skin was without lesions. Head,
eyes, ears, nose, and throat examination was within normal
limits. Cardiovascular examination revealed normal first and
second heart sounds. There were no murmurs. The abdomen was
benign/nontender. Mild-to-moderate retractions noted on
arrival to the Neonatal Intensive Care Unit. Well saturated
on room air. Lungs with crackly breath sounds bilaterally.
The abdomen revealed there was no hepatosplenomegaly. Normal
premature female genitalia. The hips were normal. The anus
was patent. The spine was intact. Neurologic examination
was nonfocal and age appropriate. Birth weight was [**2097**]
grams (50th percentile). Discharge weight was 2320 grams
(10th to 25th percentile). Admission length was 43 cm
(greater than 25th percentile). Discharge length was 48 cm
(greater than 50th percentile). The admission head
circumference was 31.5 cm (greater than 50th percentile).
Discharge head circumference was 32 cm (greater than 25th
percentile).
SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS:
1. RESPIRATORY ISSUES: The infant's respiratory distress was
progressively worse even on continuous positive airway
pressure. An endotracheal tube was placed. The infant
received one dose of surfactant. Initial cord blood gas
was 7.23/61. She weaned on her ventilator settings, and
on day of life was extubated. She then transitioned
nicely to room air. A follow-up gas on low ventilator
settings was 7.48/33.
The infant continues to be respiratorily stable. Her
baseline respiratory rate was in the 40s to 50s. She has no
further distress. The infant has not exhibited any apnea or
bradycardia of prematurity. She did not require any
methylxanthine treatment.
1. CARDIOVASCULAR ISSUES: The infant has been
cardiovascularly stable. Her baseline heart rate is 140s
to 160s. Blood pressures were 60s/30s to 40s, with mean
in the 40s to 50s. She initially had a soft intermittent
murmur that is no longer audible. She did not require any
pressor support during this admission.
1. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: Weight as described
above. Initially, the infant had a peripheral intravenous
line placed and was started on intravenous fluids of D-10-
W at 80 cc per kilogram. Her initial Dextrostix was 81.
She did not exhibit any hypoglycemia. Enteral feedings
were introduced on day of life two as her respiratory
status stabilized. She advanced to full enteral feedings
of breast milk or Premature Enfamil without incident. The
infant did require some gavage feedings. Her caloric
density was increased to 24 calories per ounce, and she
has shown adequate growth.
At the time of discharge, the infant was feeding breast milk
24 with 4 calories per ounce of Enfamil powder and going to
breast when mother is available. She was voiding and
stooling and has had no further issues. Initial electrolytes
on intravenous fluids were sodium was 131, potassium was 5.1,
chloride was 95, bicarbonate was 25.
1. GASTROINTESTINAL ISSUES: The infant did demonstrate
physiologic jaundice. She had a peak bilirubin on day of
life four of 13.7/0.4/13.3. She responded nicely to
double phototherapy. The infant had a rebound bilirubin
of 3.6/0.2.
1. HEMATOLOGIC ISSUES: The infant did not require any blood
products during this admission. Her admission hematocrit
was 50.2.
1. INFECTIOUS DISEASE ISSUES: The infant initially had a
sepsis evaluation on admission with a white blood cell
count of 20.9 (34 polys, 2 bands, and 57 lymphocytes), her
platelet count was 280,000, and her hematocrit was 50.2.
A blood culture was sent. The infant received 48 hours of
ampicillin and gentamicin. At 48 hours, her blood
cultures were negative, and she was clinically well. The
antibiotics were discontinued, and she had no further
issues with infection.
1. INTEGUMENTARY ISSUES: Of note, the infant has had a
diaper rash and has received Corticaid topically for
protection, and it is improving. The Corticaid is removed
with mineral oil topically.
1. NEUROLOGIC ISSUES: The infant has been clinically
appropriate for gestational age. She did not require any
imaging based on gestational age of greater than 32 weeks.
1. OPHTHALMIC ISSUES: Not examined based on a gestational
age of greater than 32 weeks.
1. PSYCHOSOCIAL ISSUES: The parents are looking forward to
[**Known lastname 56085**]'s transition home. They have been visiting daily
and were pleased with her progress.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with family.
PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) 32729**], [**Location (un) 13588**],
[**State 350**] (telephone number [**Telephone/Fax (1) 56086**]); with a follow-
up appointment on [**5-16**] at 10:30 a.m.
CARE RECOMMENDATIONS:
1. Continue ad lib breast feeding with several bottles per
day of 24-calorie breast milk.
2. Medications: None at the time of discharge.
3. Car seat position screen passed.
4. State newborn screen: Initial screen was within the
normal range. Repeat on [**5-7**] was pending.
5. Immunizations received: Hepatitis B vaccine on [**2157-5-7**].
IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) born at less than 32 weeks gestation; (2) born
between 32 and 35 weeks gestation with 2/3 of the following:
Plans for day care during respiratory syncytial virus season,
a smoker in the household, neuromuscular disease, airway
abnormalities, or with school-age siblings; and/or (3) with
chronic lung disease.
Influenza immunization should be considered annually in the
Fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, and for the first
24 months of the child's life, immunization against influenza
is recommended for household contacts and out of home
caregivers to protect the infant.
DISCHARGE INSTRUCTIONS-FOLLOWUP:
1. Follow-up appointments with primary care pediatrician (Dr.
[**First Name (STitle) **] [**Name (STitle) 32729**]) on [**5-16**] at 10:30 a.m.
2. [**Location (un) 932**] Visiting Nurses Association to visit on Sunday,
[**5-15**] (telephone number [**Telephone/Fax (1) 56087**]; fax number [**Telephone/Fax (1) 56088**]).
DISCHARGE DIAGNOSES:
1. Former 33 and [**4-29**] week premature female.
2. Status post respiratory distress syndrome.
3.
Status post rule out sepsis with antibiotics.
4. Status post physiologic jaundice.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Last Name (NamePattern4) 55464**]
MEDQUIST36
D: [**2157-5-13**] 22:20:45
T: [**2157-5-14**] 08:12:36
Job#: [**Job Number 56089**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2184-10-6**] Discharge Date: [**2184-10-8**]
Date of Birth: [**2119-2-4**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Left leg and arm weakness
Major Surgical or Invasive Procedure:
Intubation/Extubation
History of Present Illness:
65yo M with HTN, hyperlipidemia, CAD s/p CABG, ? h/o PAF
oncoumadin presents with intracerebral hemorrhage. Pt was
welluntil this evening while taking a shower he called out to
hiswife. When wife entered the bathroom she noticed he was
sittingin the bathtub and stated, "My left leg and arm just went
out."EMS noted left facial droop and L hemiparesis. OSH CT
scanrevealed large left intraparenchymal hemorrhage with
extension tolateral ventricles 3rd and 4th ventricles. He was
given VitaminK, FFP at the OSH and transferred to [**Hospital1 18**].
His wife and daughter state that the patient lived an active
lifeand would not want to live his life with a hemiparesis or
worse.They have decided to defer offer by neurosurgery
forintraventricular drain. Repeat CT scan on arrival to
BIDMCreveals hydrocephalus and enlarged area of hemorrhage.
CTAreveals ruptured PCOM aneurysm.
Past Medical History:
Diabetes Mellitus
MI and CABG x3 ([**2169**])
Chest Melanoma
Social History:
Married, lives with his wife, daughter in the area, son in
[**Name (NI) 108**], works as a firefighter.
Family History:
not elicited
Physical Exam:
Vitals: T: 97 BP: 153/54 HR:81 R 14 O2Sats-100% intubated on
CMV
Gen- critically ill, intubated off sedation.
HEENT: NCAT, blood at ET tube tip, anicteric..
Neck- no carotid bruits
CV- RRR
Pulm- CTA B
Abd- obese, soft, ND, BS+
Extrem- 1+ pitting LE edema bilat
Neurologic Exam:
MS- no response to noxious stimulation.
CN- absent corneals, absent oculocephalic reflex, pupils 2mm and
unreactive to light. Unable to visualize optic discs. Intact gag
reflex.
Motor/Sensory- no response to nailbed pressure in all
extremities.
Reflexes: unable to elicit any DTR's.
Toes upgoing bilaterally.
Brief Hospital Course:
65yo M with HTN, Hyperlipid, CAD, Paroximal AF on coumadin
presents with large intracerebral hemorrhage with
intraventricular spread. His exam is limited due to likely
resdual effect of midazolam gtt (off x 1hr prior to exam).
However remarkable only for intact gag and otherwise absent
other brainstem reflexes. Family wishes to make pt [**Name (NI) 3225**] in
accordance with the patient's expressed wishes prior to the
event. The team informed the family about the prognosis.
The patient was transferred out the critical care unit to the
regular neurology floors. He was DNR/DNI and [**Name (NI) 3225**]. Hence, he was
kept on a Morphine gtt and a scopalamine patch for secretions
once extubated. He also received ativan PRN agitation.
He was pronounced on 09 12 08 at 15:35.
Medications on Admission:
Coumadin 5mg QDay
Amiodarone 200mg QOD
Lopressor 50mg Qday
Vasotec 20mg QDay
Zocor 80mg QDay
ASA 81mg QDay
Zetia 10mg QHS
Novalog (rapid acting) implanted insulin pump.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraventricular brain bleed
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"4019",
"2724",
"25000",
"42731",
"V4581",
"V5861"
] |
Admission Date: [**2187-9-8**] Discharge Date: [**2187-9-16**]
Date of Birth: [**2112-11-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
chlorhexidine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain/SOB
Major Surgical or Invasive Procedure:
[**2187-9-11**] 1. Coronary artery bypass grafting x4. Left internal
mammary artery to the left anterior descending artery.
2. Bypass from ascending aorta to diagonal artery branch of the
left anterior descending artery using reverse autologous
saphenous vein graft.
3. Bypass from ascending aorta to the ramus artery using reverse
autologous vein graft.
4. Bypass from ascending aorta to the posterior descending
artery using reverse autologous saphenous vein graft.
History of Present Illness:
74 year-old gentleman transferred from [**Hospital6 204**]
for coronary artery revascularization. He presented [**2187-9-6**] with
Chest pain and shortness of breath. Cardiac enzymes were
positive for non-ST-elevation MI. Prior to transfer here today
he had an episode of flash pulmonary edema responded to IV lasix
and MSO4. During this evaluation he denies chest pain, SOB,
palpitations,
or orthopnea. He walks 3 miles a day and recently has had
increased chest pain relieved with rest and SL TNG.
He was seen by his cardiologist at [**Hospital 1268**] [**Hospital3 112169**] and his stress test showed evidence of ischemia in the
anterior wall with a fixed defect. He was started on nitrates
for medical management. Cardiac surgery was consulted for
Coronary revascularization.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction s/p
angioplasty [**2171**] at [**Hospital3 2358**]
Diabetes Mellitus Type 2 on insulin
Hypertension
Hyperlipidemia
Gout
Social History:
Race: Caucasian
Last Dental Exam:
Lives with: self
Contact:Daughter [**First Name8 (NamePattern2) 1785**] [**Last Name (NamePattern1) 2251**] Phone #[**Telephone/Fax (1) 112170**]
Occupation:retired truck driver
Cigarettes: Smoked no [] yes [x] last cigarette 20 yrs ago Hx:
80
pack-year
Other Tobacco use:
ETOH: < 1 drink/week [] [**2-20**] drinks/week [] >8 drinks/week []
quit 22 years ago
Illicit drug use: none
Family History:
Family History:Premature coronary artery disease
Father MI < 55 [x] Mother < 65 []
Physical Exam:
Pulse: 71 SR Resp:22 O2 sat: 92 6L NC
B/P Right:131/77 Left: 133/78
Height: Weight:82 Kg
General:
Skin: Dry [x] intact [x] rash on face and right forearm
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: bilaterally late crackles right lower lobe otherwise
clear
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen:Soft [x] non-distended [x] non-tender [x] bowel sounds +
Extremities: Warm []x, well-perfused [x] Edema [] _none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2187-9-11**] Echo: Prebypass: The left atrium is moderately dilated.
No thrombus is seen in the left atrial appendage. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction with septal and inferioseptal hypokinesis.
There is mild global left ventricular hypokinesis (LVEF = 45-50
%). The right ventricular cavity is moderately dilated with
normal free wall contractility. There are simple atheroma in the
ascending aorta. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2187-9-11**]
at 0930.
Postbypass: There is preserved left ventricular function that is
unchanged from prebypass. There is no evidence of aortic
dissection.
.
[**2187-9-13**] CXR: A left-sided chest tube, mediastinal drains,
endotracheal tube, and enteric catheter have been removed.
There is no pneumothorax status post chest tube removal. The
left-sided pleural effusion has decreased. Moderate left-sided
basal atelectasis is similar. Postoperative irregularity of the
mediastinal contour is similar to prior. Central pulmonary
vascular congestion has improved. Left-sided internal jugular
catheter tip terminates in the low SVC.
[**2187-9-16**] 08:10AM BLOOD WBC-8.8 RBC-3.35* Hgb-10.5* Hct-32.1*
MCV-96 MCH-31.4 MCHC-32.8 RDW-14.1 Plt Ct-349
[**2187-9-8**] 05:35PM BLOOD WBC-14.1* RBC-4.68 Hgb-14.9 Hct-44.2
MCV-94 MCH-31.9 MCHC-33.8 RDW-14.3 Plt Ct-279
[**2187-9-13**] 03:40AM BLOOD PT-15.0* INR(PT)-1.4*
[**2187-9-8**] 05:35PM BLOOD PT-11.6 PTT-25.8 INR(PT)-1.1
[**2187-9-16**] 08:10AM BLOOD Glucose-125* UreaN-21* Creat-1.0 Na-136
K-4.4 Cl-99
[**2187-9-8**] 05:35PM BLOOD Glucose-105* UreaN-24* Creat-1.2 Na-142
K-3.5 Cl-100 HCO3-34* AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 28989**] was transferred from outside hospital following a
cardiac cath which showed severe three vessel coronary artery
disease. Upon admission he was medically managed and underwent
work-up for surgery. On [**9-11**] he was brought to the operating
room where he underwent a coronary artery bypass graft x 4.
Please see operative note for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later this day he was weaned from sedation,
awoke neurologically intact and extubated. A dermatology consult
was called regarding a bilateral rash in his axillary and
brachial areas. He was placed on Hydrocortisone cream for a
contact [**Name (NI) **] believed to be caused by Chlorhexadine wash.
On post-op day one he was started in beta-blockers and diuretics
and diuresed towards his pre-op weight. Later this day he was
transferred to the floor for further care. Chest tubes were
removed on post-op day two and his epicardial pacing wires
removed on post-op day three. He continued to make good recovery
while working with physical therapy for mobility. He failed to
void on the first attempt with a post void residual>800cc. The
foley was replaced, Flomax was initiated, and narcotics were
discontinued. POD# 5 his 2nd void trial was successful with
minimal post void residual. He was discharged home with VNA
services on POD#5 with appropriate follow up appointments
advised.
Medications on Admission:
Amlodipine 10 mg daily
Atenolol 100 mg twice daily
Aspirin 325 mg daily
Allopurinol 300 mg daily
Doxazosin 2 mg HS
Lisinopril 20 mg daily
Hydrochlorothiazide 25 mg daily
Lasix 20 mg daily
Glipizide 20 mg twice daily
Metformin 500 mg twice daily
Januvia daily
Gemfibrozil 600 mg twice daily
Ambiem 10 mg HS
Imdur ? dose
Prednisone 60 mg taper for poison [**Female First Name (un) **] started [**9-5**] but was
stopped during his recent hospitalization
Discharge Medications:
1. Allopurinol 150 mg PO DAILY
RX *allopurinol 300 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*1
2. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once daily Disp #*30 Tablet Refills:*1
4. Doxazosin 2 mg PO HS
RX *doxazosin 2 mg 1 tablet(s) by mouth HS Disp #*30 Tablet
Refills:*1
5. Gemfibrozil 600 mg PO BID
RX *gemfibrozil 600 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
6. GlipiZIDE 20 mg PO BID
RX *glipizide 10 mg 2 tablet(s) by mouth twice a day Disp #*120
Tablet Refills:*1
7. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
RX *sitagliptin [Januvia] 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
8. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
10. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
11. Rosuvastatin Calcium 20 mg PO DAILY
RX *rosuvastatin [Crestor] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
12. Furosemide 20 mg PO Q12H
RX *furosemide 20 mg 1 tablet(s) by mouth [**Hospital1 **] x 10 days then
decrease to once daily Disp #*40 Tablet Refills:*1
13. Potassium Chloride 20 mEq PO Q12H
Hold for K+ > 4.5
RX *potassium chloride 20 mEq 1 tablet by mouth [**Hospital1 **] x 10 days,
then decrease to once daily Disp #*40 Tablet Refills:*1
14. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once daily Disp
#*30 Tablet Refills:*1
15. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once daily Disp #*30
Capsule Refills:*1
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q4-6h Disp #*45 Tablet
Refills:*0
17. Atenolol 100 mg PO BID
RX *atenolol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
18. Hydrocortisone Cream 2.5% 1 Appl TP QID
to bilateral hand rash/poison [**Female First Name (un) **]
RX *hydrocortisone 2.5 % apply to affected areas four times a
day Disp #*1 Tube Refills:*0
19. Zolpidem Tartrate 10 mg PO HS
RX *zolpidem 10 mg 1 tablet(s) by mouth HS Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary artery bypass graft x 4
Past medical history
Myocardial Infarction s/p angioplasty [**2171**] at [**Hospital3 2358**]
Diabetes Mellitus Type 2 on insulin
Hypertension
Hyperlipidemia
Gout
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check on [**2187-9-25**] at 10:45AM in [**Hospital Unit Name **]
Surgeon: Dr. [**First Name (STitle) **] on [**10-9**] at 2:45PM
Cardiologist: Please obtain cardiology referral from PCP
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 68588**] in [**3-18**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2187-9-16**]
|
[
"41071",
"41401",
"2851",
"412",
"V4582",
"25000",
"4019",
"2724",
"V1582"
] |
Admission Date: [**2196-6-26**] Discharge Date: [**2196-7-1**]
Date of Birth: [**2127-11-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 year old male with history of Asthma, OSA, DM type 2,
hypercholesterolemia, Parkinson's, mental retardation, s/p
stroke with residual lt sided weakness began having malaise,
tiredness/weakness and trouble walking which began on [**6-21**]. The
patient was taken to see his PCP who diagnosed him with a UTI by
UA and started him on Cipro. On [**6-23**] the patient began to have a
cough, non-productive, which was treated with albuterol. From
[**Date range (1) 135**] the patient had increasing difficulty breathing, nasal
congestion and chest congestion. He had increased cough but
non-productive, he was given Mucinex. On [**6-26**] he began having
persistent cough until he became SOB, temp to 102. Albuterol
relieved SOB but group home concerned re: fever, persistent
weakness and SOB so he was transfered to [**Hospital1 18**] ED.
In the ED he was placed on CPAP with great improvement in
sats, got ceftriaxone and levofloxacin for PNA. A CTA was
performed which showed bilateral PEs. He was started on Heparin
drip.
Past Medical History:
1. OSA - CPAP at night
2. Diabetes type 2
3. Asthma
4. Rt carotid artery obstruction
5. h/o stroke with Lt sided weakness
6. hypercholesterolemia
7. Parkinson's
8. Cataracts
9. Mood disorder
10. OA- knees s/p ACL and meniscus repair
11. s/p rt lobectomy
12. Mental Retardation
Social History:
Lives in group home, brother : [**Name (NI) **], no tobacco, no EtOH
Family History:
Family history of Parkinson's, SL, RA, heart attacks
Physical Exam:
Vitals
T 102.8, Pulse 101, BP 157/98, RR 38, 84%, 100% NRB
Gen: comfortable with CPAP
HEENT: NC/AT, EOMI, PERRL, MMM, OP clear
chest: suprasternal notch scar (old trach)
Neck: unable to assess JVD due to thick neck
CV: tachycardic, no S1S2, no murmers/rubs/gallops
Lungs: Rhonchi bilaterally, minor wheezes
Abd: large, obese, NT/ND, positive BS
Ext: Mild edema
Neuro: CN II-XII grossly intact
Pertinent Results:
Admission labs:
[**2196-6-26**] 07:47PM LACTATE-0.9
[**2196-6-26**] 09:58AM LACTATE-3.2*
[**2196-6-26**] 09:55AM GLUCOSE-254* UREA N-18 CREAT-1.0 SODIUM-137
POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-32* ANION GAP-16
[**2196-6-26**] 09:55AM CK(CPK)-71
[**2196-6-26**] 09:55AM CK-MB-NotDone cTropnT-0.01
[**2196-6-26**] 09:55AM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-1.9
[**2196-6-26**] 09:55AM WBC-13.4*# RBC-4.25* HGB-12.5* HCT-38.3*
MCV-90 MCH-29.4 MCHC-32.7 RDW-14.0
[**2196-6-26**] 09:55AM NEUTS-81.9* LYMPHS-11.1* MONOS-6.3 EOS-0.2
BASOS-0.5
[**2196-6-26**] 09:55AM PLT COUNT-296
[**2196-6-26**] 09:55AM PT-14.0* PTT-22.7 INR(PT)-1.3
CXR:
IMPRESSION:
1) Mild congestive heart failure.
2) Interval increase in right lower lobe opacity, consistent
with effusion. Underlying pneumonia cannot be excluded.
3) Left lower lobe opacity, atelectasis versus early pneumonia.
CTA:
bilateral pulmonary emboli
right base atelectasis, also left but smaller
lymphadenopathy in mediastinum
pneumobilia as seen on previous studies
Brief Hospital Course:
68 year old male with Parkinson's s/p stroke with lt sided
weakness, asthma, OSA, SM2, hypercholesterolemia, presents with
two days of acute SOB and fever to 102.
Brief hospital course, by problem:
1. Hypoxia: He was started on Heparin drip and transferred to
[**Hospital Unit Name 153**] for further moniotring, where he remained hemodynamically
stable and was started on coumadin. He was transferred to the
floor on HD 2. His hypoxia was thought secondary to new
bilateral PE, in combination with hx of R. partial lobectomy,
bronchitis, OSA on cpap, and a new layering effusion on the R.
side. Had micu reevaluation on [**6-28**] secondary to worsening
hypoxia (ABG was 7.38/61/60 on 80% FM) and CXR with evidence of
worsening effusion on right with ?mucus plug/collapse. We added
flagyl for coverage of possible aspiration and gave 20 IV lasix
(with resultant 1L out). Repeat CXR the next day showed
improving effusions after diuresis with lasix 20 IV x 1. He was
diuresed further with standing lasix 20 po x 2 days. This was
discontinued once euvolemia was acheived and as he had improving
lung exam and a normal EF (60%). He was on vancomycin for one
day for coag positive cocci in [**1-19**] bxcx bottle, but as he was
without leukocytosis or fever, we suspect that the positive
blood culture bottle was a contaminant and the vanco was d/c'd.
A speech and swallow eval was done [**6-29**], which showed no
evidence of aspiration, so flagyl was also d/c'd. He was
titrated back to 3 liters NC oxygen although he does continue to
have occasional bouts of desaturation to mid 80's if not sitting
properly, or if nebs or chest PT are missed.
We maintained q4 nebs, aggressive chest PT, levofloxacin.
Heparin was discontinued after coumadin was therapeutic x 24h.
He appears slowly improving.
.
2. Bronchitis - continue 10d course of levofloxacin. Recently
treated for UTI also.
.
3. OSA
- CPAP at night--> must continue to get scheduled nebs
throughout this.
.
4. DM type 2 -
- resume metformin as tolerating diet, cont RISS, diabetic diet
.
5. Asthma
- Atrovent, albuterol nebs
- Continue with Asthmacort
6. Hypercholesterolemia
- Continue with Lipitor
7. Mood disorder
- Continue with Benztropine, clonazepam, Risperdal, Paxil
8. FEN
- cleared by S&S for regular ([**Doctor First Name **]) diet.
9. PPx
- coumadin, eating
10. Access
- PIVs
11. Mediastinal lymphadenopathy on CT
- F/U CT as outpatient
12. FULL code - readdressed with family on [**6-28**].
13. DISPO - short term rehab then back to group home.
Medications on Admission:
Paxil 30, Risperdal 1mg, Clonazepam 1mg, Metformin 500mg [**Hospital1 **],
ASA 325, Azmacort 2 puffs [**Hospital1 **], Lipitor 10, Benztropine 0.5,
Nystatin, Tylenol, Albuterol 2puffs, Keopectate prn, Ibuprofen
prn, Mucinex prn
Discharge Medications:
1. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
7. Benztropine Mesylate 0.5 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Insulin Regular Human 100 unit/mL Solution Sig: qs
Injection ASDIR (AS DIRECTED): see attached sliding scale.
12. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
14. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location **] manor
Discharge Diagnosis:
Primary diagnoses:
Bilateral pulmonary emboli
Bronchitis
Secondary diagnoses:
Obstructive sleep apnea requiring nightly CPAP
Diabetes mellitus Type 2
Asthma
Right carotid artery obstruction
History of CVA with residual Left sided weakness
Hypercholesterolemia
Parkinson's disease
Cataracts
Mood disorder
Osteoarthritis of knees s/p ACL and meniscal repair
status post Right lobectomy
Mental retardation
Discharge Condition:
stable and improved, with continuing oxygen requirement
Discharge Instructions:
Please seek immediate medical attention if pt develops fever
>101, shaking chills, worsening shortness of breath, has blue
fingers or toes, has chest pain, or any other concerning
symptoms.
Please take all medications as directed. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]
of nebulizers, even overnight.
Followup Instructions:
Please have your INR checked in three days.
Please follow up with Dr. [**Last Name (STitle) 5762**] in one week.
|
[
"49390",
"2720",
"25000"
] |
Admission Date: [**2135-5-2**] Discharge Date: [**2135-5-10**]
Service: CARDIOTHORACIC
Allergies:
Levaquin / Penicillins / Flagyl
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion/Syncope
Major Surgical or Invasive Procedure:
Aortic Valve Replacement (21mm CE Pericardial Tissue Valve)
[**2135-5-2**]
History of Present Illness:
83 y/o female with dyspnea on exertion and syncope who was found
to have severe Aortic Stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.6 cm2. Referred
for elective cardiac surgery.
Past Medical History:
Hypertension, Hypercholesterolemia, Asthma, Hypothyroidism,
Gastroesophageal Reflux Disease, Patent Foramen Ovale, h/o C.
Diff colitis, Heart Block s/p Pacemaker insertion [**5-2**], s/p ERCP
w/ Bile Duct Stent, s/p Cholecystectomy, s/p Hernia Repair
Social History:
lives alone, independent in all ADL/IADLs; 8 children involved
in her care
no tob, EtOH
Family History:
Father died of MI in 60's
Physical Exam:
VS: 74 16 136/76 140/82 5'3" 150
General: WD/WN female in NAD
Skin: Erythema inferior to breasts
HEENT: EOMI, PERRL, Edentulous
Neck: Supple, FROM, -JVD, -Carotid Bruits
Chest: CTAB -w/r/r
Heart: RRR +S1S2, [**1-3**] murmur
Abd: Soft, NT/ND +BS,
Ext: Warm, Well-perfused, Trace Edema, few varicosities
Neuro: Grossly intact, A&O x 3, MAE, non-focal
Pertinent Results:
Echo [**5-2**]: Prebypass: There is a bidirectional shunt across the
interatrial septum at rest. A small secundum atrial septal
defect is present. There is mild symmetric left ventricular
hypertrophy. Resting regional wall motion abnormalities include
mild hypokinesia of the mid and apical portions of the inferior
wall. The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**11-29**]+) mitral regurgitation is seen.
Post Bypass: Biventricular systolic function is unchanged.
Bioprosthetic valve seen in the aortic position. Valve is well
seated and the leaflets move well. No Aortic insufficiency
present. Peak gradient across the aortic valve post replacement
is 17 mm Hg. The mitral regurgitation is more on the mild side
post aortic valve replacement. Small secundum ASD present- not
repaired by surgeons.
[**2135-5-2**] 02:47PM BLOOD WBC-6.9 RBC-3.35* Hgb-9.7* Hct-28.3*
MCV-85 MCH-29.0 MCHC-34.4 RDW-14.0 Plt Ct-107*
[**2135-5-2**] 02:47PM BLOOD PT-15.1* PTT-39.8* INR(PT)-1.4*
[**2135-5-2**] 04:03PM BLOOD UreaN-15 Creat-0.7 Cl-111* HCO3-23
[**2135-5-6**] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2135-5-8**]): FECES
NEGATIVE FOR C. DIFFICILE TOXIN BY EIA: Negative.
[**2135-5-9**] 07:50AM BLOOD WBC-10.5 RBC-3.87* Hgb-11.4* Hct-33.3*
MCV-86 MCH-29.5 MCHC-34.3 RDW-14.5 Plt Ct-324#
[**2135-5-4**] 02:00AM BLOOD PT-12.8 PTT-28.3 INR(PT)-1.1
[**2135-5-9**] 07:50AM BLOOD Glucose-95 UreaN-13 Creat-1.0 Na-140
K-4.3 Cl-100 HCO3-31 AnGap-13
[**2135-5-6**] 07:55AM BLOOD Calcium-8.2* Phos-2.0* Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname **] was electively admitted after pre-operative work-up
was done as an outpatient. She was brought directly to the
operating room where she underwent an Aortic Valve Replacement
(tissue). Please see operative report for surgical details. She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition. She remained intubated
until post-op day one secondary to decline in SpO2. She was
extubated following awaking neurologically intact. Chest tubes
were removed on post-op day two. Beta blockers and diuretics
were started and she was gently diuresed towards her pre-op
weight. EP interrogated pacemaker before and after surgery.
Later on post-op day two she was transferred to the cardiac
surgery step down floor. Epicardial pacing wires were removed on
post-op day three. Physical therapy worked with patient during
entire post-op course for strength and mobility. C. Diff assay
was negative all 3 times. Over the next several days she
continued to make good progress and was discharged to rehab on
post-op day eight with the appropriate follow-up appointments.
Medications on Admission:
Lipitor 20mg qd, Levoxyl 75mcg qd, Omeprazole 20mg qd, Atenolol
25mg qd, Celexa 10mg qd, Aspirin 325mg qd, MVI, Vancomycin 250mg
[**Hospital1 **]
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:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 1474**] TCU
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Hypertension, Hypercholesterolemia, Asthma, Hypothyroidism,
Gastroesophageal Reflux Disease, Patent Foramen Ovale, h/o C.
Diff Colitis, s/p Pacemaker insertion [**5-2**], s/p ERCP w/ Bile
Duct Stent, s/p Cholecystectomy, s/p Hernia Repair
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Gently pat incision dry. Do not take bath.
Do not apply lotions, creams, ointment or powders to incision.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 10 weeks.
If you develop a fever or notice redness or drainage from
incision, please contact office immediately.
Please call to make all follow-up appointments.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**12-31**] weeks
Dr. [**Last Name (STitle) **] in [**11-29**] weeks
Completed by:[**2135-5-10**]
|
[
"4241",
"4019",
"2724",
"2449"
] |
Admission Date: [**2112-5-6**] Discharge Date: [**2112-5-12**]
Date of Birth: [**2052-12-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Respiratory distress.
Major Surgical or Invasive Procedure:
1. Inubation
2. Placement of central venous access via the right internal
jugular
History of Present Illness:
Mr. [**Known lastname 4509**] is a 59yo M with history of severe COPD and pulmonary
hypertension who was brought in by ambulance for respiratory
distress. Per report, when EMS arrived all of his inhalers were
empty.
.
In the ED, initial vs were: T 98.8 P 121 BP 100/67 R 17 O2 sat
100%. He was immediately intubated for respiratory distress as
he wasn't able to speak few words. He was on propofol for
sedation. His pressures were in the 90s and dipped to the 80s
so R IJ was placed and levophed was started. CXR showed fluffy
bilateral infiltrates and ABG was significant for hypcarbia to
106. He received 125mg IV solumedrol, albuterol, magnesium,
levaquin, ceftriaxone and was started on versed/fent drips.
.
In the ICU, patient is intubated and sedated.
Past Medical History:
# COPD - was seen frequently at [**Hospital6 **]. Has
smoked 3 packs /day x 45 years, quit on last admission to [**Hospital1 18**].
No PFTs in our system.
# Congential Bicuspid Aortic Valve; s/p porcicine repair [**2102**].
Echo in [**2110**] on recent admission within normal limits
# Hypertension
# Lower Extremity Edema
# Hypertension
Social History:
Smoked 3pks ppd x 45 years. Former head of maintence at [**Hospital1 756**]
and women's hospital, also a car mechanic. No exposure to
asbestos. Now on disability due to dyspnea. Lives wtih
girlfriend. Minimal etoh now though former heavy alcohol user
Family History:
Parents with heart disease - MIs. Sister with arrhythmia that
went away.
No fhx of cancers.
Physical Exam:
Upon admission:
T: 99.5 BP: 91/55 P: 94 100% on AC 550x18, 50% Fi02, PEEP 5
General: Sedated, intubated, not following commands
HEENT: Pinpoint pupils bilaterally slightly responsive to light,
sclera anicteric, MMM, oropharynx clear, tongue with abnormal
fasciculations
Neck: supple, JVP unable to be assessed, no LAD
Lungs: Bilateral coarse wheezing
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: Foley
Ext: warm, well perfused, 1+ DP pulses bilaterally, bilateral
lower extremities with chronic venous stasis changes, no
clubbing, cyanosis or edema
.
At discharge:
VS: 97.3 129/78 (149/86) 94 (88) 20 92-97 on 3L NC
I/O not well recorded yesterday
General: NAD, sitting up in bed, pleasant, funny and interactive
HEENT: MMM tongue with no abnormal fasciculations
Lungs: Bilateral coarse sounds, very tight, scattered wheezes
throughout lung fields.
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 1+ DP pulses bilaterally, bilateral
lower extremities with chronic venous stasis changes, no
clubbing, cyanosis or edema
Pertinent Results:
ADMISSION
[**2112-5-6**] 06:25AM FIBRINOGE-651*
[**2112-5-6**] 06:25AM PLT COUNT-146*
[**2112-5-6**] 06:25AM WBC-10.0 RBC-5.08 HGB-15.6 HCT-47.2 MCV-93
MCH-30.7 MCHC-33.0 RDW-12.6
[**2112-5-6**] 06:25AM WBC-10.0 RBC-5.08 HGB-15.6 HCT-47.2 MCV-93
MCH-30.7 MCHC-33.0 RDW-12.6
[**2112-5-6**] 06:25AM LIPASE-11
[**2112-5-6**] 10:58AM LACTATE-0.9
[**2112-5-6**] 11:51AM PT-12.6 PTT-27.6 INR(PT)-1.1
[**2112-5-6**] 11:51AM GLUCOSE-165* UREA N-20 CREAT-0.5 SODIUM-140
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-40* ANION GAP-8
.
DISCHARGE
[**2112-5-12**] 06:25AM BLOOD WBC-7.4 RBC-4.65 Hgb-13.7* Hct-42.5
MCV-92 MCH-29.6 MCHC-32.3 RDW-13.1 Plt Ct-185
[**2112-5-8**] 02:46AM BLOOD Neuts-80.0* Lymphs-14.2* Monos-5.5
Eos-0.2 Baso-0.1
[**2112-5-12**] 06:25AM BLOOD Glucose-121* UreaN-15 Creat-0.5 Na-143
K-3.5 Cl-97 HCO3-37* AnGap-13
[**2112-5-12**] 06:25AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0
[**2112-5-8**] 02:56AM BLOOD Type-[**Last Name (un) **] Temp-36.7 Rates-16/ Tidal V-550
PEEP-5 FiO2-40 pO2-46* pCO2-64* pH-7.39 calTCO2-40* Base XS-10
-ASSIST/CON Intubat-INTUBATED
.
IMAGING STUDIES
CHEST XRAY ADMISSION [**5-6**]
PORTABLE AP CHEST RADIOGRAPH: Sternotomy wires are midline and
intact.
Surgical clips are noted in the midline. The ET tube is above
the thoracic
inlet, approximately 7.5 cm above the expected location of the
carina.
Nasogastric tube is traced best up to the level of the mid
esophagus,
uncle[**Name (NI) 4510**] traced thereafter. A tube-like structure within the
expected region of the stomach may represent the continuation of
the nasogastric tube, however uncertain. Bilateral low lung
volumes are noted with appearance suggestive of pulmonary
fibrosis.
.
CHEST XRAY [**5-9**]
Frontal view of the chest is compared to multiple prior
examinations. Right IJ catheter terminates in superior vena
cava. Remainder of lines and tubes are unchanged. There is
moderate congestive failure, small bilateral pleural effusions
and atelectasis at the right lung base. Heart and mediastinum
are stable.
.
CT SCAN [**5-6**] FINAL REPORT
IMPRESSION:
1. Diffuse ground glass and nodular opacities with an appearance
most consistent with mycoplasma pneumonia. Extensive mediastinal
and hilar lymphadenopathy, likely reactive. Trace bilateral
pleural effusions.
2. Endotracheal tube ends approximately 1 cm above the carina.
.
CT SCAN WITH AND WIHTOUT CONTRAST [**5-6**]
1. No acute intracranial process.
2. Intubation, with retained sinonasal secretions.
Brief Hospital Course:
HOSPITAL COURSE
Mr. [**Known lastname 4509**] is a 59yo M with history of severe COPD and pulmonary
hypertension who presented with hypercarbic respiratory distress
requiring intubation. He did well after extubation and was
discharged to pulmonary rehabilitation for further care.
.
ACTIVE ISSUES
# Hypercarbic respiratory failure: His respiratory distress was
likely related to extreme hypercarbia due to his underlying
COPD. His COPD flare was likely due to medication noncompliance
in setting of running out of inhalers. Chest CT showed diffuse
bronchopulmonary pneumonia concerning for a mycoplasma/atypical
process. He was started levofloxacin and will complete a 7 day
course on the night of discharge. He was started on solumedrol
and then switched to prednisone. Extubated [**5-9**] without
complication. He was continued on 60mg prednisone on transfer to
the floor. A slow prednisone taper was initiated on discharge
to pulmonary rehab where additional titration of nebulizer
therapy will be continued and initation of home inhaler regimen
of advair and spiriva will be started. His Bipap was continued
but at lower settings of 18/16, and his supplemental oxygen was
3L at discharge. He was encouraged to stop smoking. He will
have pulmonary follow up after discharge from pulmonary rehab.
.
# Hypotension: He is likely hypertensive at baseline given
lisinopril on med list but recent baseline is unknown.
Hypotension in MICU was possibly related to sedation surrounding
intubation or from decrease in right heart filling pressure with
positive pressure ventilation. Normal lactate and lack of
leukocytosis are reassuring. He was started on levophed in the
ED and this was weaned off as fluid boluses given.
# Tongue movement: His abnormal tongue movement in MICU was
concerning for possible fasciculation or seizure activity. He
does not have a history of seizures and recent events leading to
hospitalization. These events did not continue and no further
work up pursued.
.
# Hypertension with Diastolic Dysfunction: Previously on
lisinopril and lasix - has not refilled Rx in two years. He was
restarted on lisinopril and aspirin with a lower dose of lasix.
His blood pressure was well controlled and renal function
stable. His peripheral edema slowly improved. It is likely
that his lasix will need to be uptitrated in the outpatient
setting.
.
TRANSITIONAL ISSUES
# Disposition: Pulmonary Rehabilitation with close Pulmonary and
Cardiology follow-up
Mr. [**Known lastname 4509**] has not had medical follow-up in over 2 years and
medication compliance a significant issue in future management.
# Code: Full
Medications on Admission:
Medications: Per list from [**2110**], unknown if patient taking these
now:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 vial via nebulizer Every 6-8 hours as needed
for shortness of breath/wheezing
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2 puffs(s) by mouth every four (4) to six (6) hours as needed
for cough/wheezing
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk with Device - 1 puff(s) inhaled Twice daily Rinse mouth
after use
FUROSEMIDE - 80 mg Tablet - 1 Tablet(s) by mouth daily
LIDOCAINE - (Prescribed by Other Provider) - 5 % (700 mg/patch)
Adhesive Patch, Medicated -
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
daily
NAPROXEN - 500 mg Tablet - 1 Tablet(s) by mouth Twiec a day
([**Hospital1 **]) For 2 week course
OXYGEN - (Prescribed by Other Provider) - - 2L at rest via
NC; 3L with activity
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled Once daily
ACETAMINOPHEN [TYLENOL ARTHRITIS] - (OTC) - 650 mg Tablet
Extended Release - Tablet(s) by mouth
ASPIRIN [ASPIR-81] - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth daily
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
7. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
8. prednisone 10 mg Tablet Sig: 6 pills x 3 days, 5 pills x 3
days, 4 pills x 3 days, 3 pills x 3 days, 2 pills x 3 days, 1
pill x three days then STOP Tablets PO once a day: Prednisone
taper.
9. Bipap
BiPap 18/16 when sleeping or napping.
10. Oxygen therapy
Oxygen 3L. Titrate to keep sats >90%, unknown home flow rate.
11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO at bedtime
for 1 doses: Please give on [**5-12**].
12. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis: Acute Exacerbation of Chronic Obtructive
Pulmonary Disease, Community Acquired Pneumonia, Tobacco Abuse
Secondary Diagnosis: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for managment of respiratory distress likely
caused by pneumonia and a COPD exacerbation. You were intubated
for three days to assist with your breathing. You were treated
with antibiotics for a pneumonia, and bronchodilator and steroid
therapy for management of your COPD. You continued to improve.
While you were here, we restarted many of the medications that
were prescribed to you in the past. It is very important that
you continue these medications and follow-up with your primary
care physician, [**Name10 (NameIs) 2085**] and pulmonologist as your
underyling pulmonary and cardiac issues have not been evaluated
in some time. It is likely that some of these medications will
need to be changed or adjusted.
You are being discharged to a pulmonary rehabilitation center
prior to going home given the severity of your symptoms. They
will prepare you for discharge to home.
We strongly encourage you to quit smoking as this is one of the
few things that will increase your life expectancy related to
your lung disease.
The following changes were made to your medication list:
1. START lisinopril 10mg daily
2. START lasix 20mg daily
3. START albuterol Nebulyzer therapy
4. START ipratropium Nebulyzer therapy
5. START Nicotine Patch
6. START Monteleukast
7. COMPLETE Prednisone taper as prescribed
8. CONTINUE aspirin and protonix as you have been taking
9. CONTINUE supplemental oxygen
10. CONTINUE BIPAP at night and while napping
Please talk to your PCP if you are having any problems with
obtaining these medications.
These medications may change upon discharge from Pulmonary
Rehab.
Followup Instructions:
PULMONOLOGY
The office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] will call you to set up an
appointment on discharge. If you have not heard from his office
when you leave Pulmonary Rehab: Please call ([**Telephone/Fax (1) 513**] to
schedule an appointment.
CARDIOLOGY
Department: CARDIAC SERVICES
When: FRIDAY [**2112-6-3**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"51881",
"V4581",
"4168",
"4019",
"3051",
"4280"
] |
Admission Date: [**2196-8-5**] Discharge Date: [**2196-8-14**]
Date of Birth: [**2122-1-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Fosamax / Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Shortness of breath on exertion, cough, tracheobronchomalacia
Major Surgical or Invasive Procedure:
Right thoracotomy, thoracic tracheoplasty with mesh, right
main-stem bronchus and bronchus intermedius bronchoplasty with
mesh, left main-stem bronchus bronchoplasty with mesh,
bronchoscopy with lavage.
History of Present Illness:
A 74 y.o. female with restrictive lung disease due to scoliosis,
reports prog worsening DOE and cough. She was diagnosed with TBM
by CT and bronch. On [**2196-3-10**] she had a Y stent placed and noted
significant improvement in her symptoms but not resolution. She
presents for surgical treatment of TBM.
Past Medical History:
DVT/PE '[**67**], '[**85**]
Scoliosis
Restrictive lung disease
severe TBM
hiatal hernia
fibromyalgia
s/p right foot [**Doctor First Name **]
OA
evac hematoma right LE [**2192**]
Social History:
Does not smoke, occasional alcohol use. Acid exposure (worked in
factory).
Family History:
non-contributory
Physical Exam:
VS: T 97.6, HR 70, BP 141/60, RR 18, O2-sat 96%
General: Appears well, in NAD
HEENT: MMM, no scleral icterus, trachea and tongue midline, no
palpable lymphadenopathy
Cardiac: RRR
Pulmonary: CTAB
Abdomen: Soft, non-tender, nondistended, positive bowel sounds,
no palpable masses
Extremities: no edema
Skin: Right arm chemical irritation improving
Brief Hospital Course:
[**8-5**]: OR for R thoracotomy, tracheobrochoplasty,
tracheobronchoplasty, thoracic epidural placed, extubated in
SICU. Epidural split d/t referred shoulder pain unresponsive and
mild hotn.
[**8-6**]: better w/epidural/dil PCA, OOB, pulm toilet better, CK
trending down, UO low overnight 10, 10, 500cc NS x 1, improved
to 30-40/hr
[**8-7**]: Chest tube, dc'ed CXR: right chest tube removed no ptx
gross effusion; Continued chest pt, Lasix 10mg x2, Gauifenisen.
Hep locked IV. Started clear liquids. AM Heparin [**8-8**] being held
for epidural removal.
[**8-8**]: CXR worsened this AM, SpO2 92-95 Lasix 20mg given. epidural
d/c'd
[**8-9**]: CXR displaced rib fracture noted. Desaturation, tachypnea,
respiratory distress this AM, bronch stenosis noted to be
improved no significan intervention. Respiratory status
improved, Lasix 20mg IV x1.
[**8-10**] afib with rvr, replete lytes lopressor 5mg x 2, dilt load
dilt gtt started minimal response to max dilt for 30mins dilt
gtt dc'ed. Pt started on amio load, amio gtt. Hold diuresis.
metop 12.5'' increased to 25'' per thoracic, clears, oob/amb
w/PT
[**8-11**]: DC amio gtt at 1800. Restart coumadin.
[**8-12**]: phlebitis in RUE, ? edema in LUE, stat UE u/s, transfer
orders in, f/u daily INR level
[**8-13**]: Tolerating PO, respiratory status improving, no pain
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Gabapentin 800 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Warfarin 2.5 mg PO MONDAYS AND WEDNESDAYS
4. Warfarin 5 mg PO TUE, THURS, FRI, SAT, SUN
5. Guaifenesin 600 mg PO BID
6. Simvastatin 10 mg PO Frequency is Unknown
7. Montelukast Sodium 10 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
9. Metoclopramide 10 mg PO DAILY:PRN nausea
10. Omeprazole 20 mg PO DAILY
11. Calcium Carbonate 500 mg PO Frequency is Unknown
12. Sertraline 100 mg PO DAILY
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
2. Gabapentin 800 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*40 Tablet Refills:*0
4. Guaifenesin 600 mg PO BID
5. Montelukast Sodium 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Sertraline 100 mg PO DAILY
8. Warfarin 2.5 mg PO MONDAYS AND WEDNESDAYS
RX *Coumadin 2.5 mg 1 tablet(s) by mouth Mondays and Wednesdays
Disp #*2 Tablet Refills:*0
9. Warfarin 5 mg PO TUE, THURS, FRI, SAT, SUN
RX *Coumadin 5 mg 1 tablet(s) by mouth Tuesday, Thursday,
Friday, Saturday, and Sunday Disp #*2 Tablet Refills:*0
10. Acetaminophen 1000 mg PO Q6H
11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
13. Calcium Carbonate 500 mg PO HS:PRN unknown
14. Metoclopramide 10 mg PO DAILY:PRN nausea
15. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Tracheobronchomalacia
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 tracheobronchoplasty and
you've recovered well. You are now ready for discharge.
* Please keep your arm splint on for another 24 hours. Please
follow-up with plastic surgery as needed.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 650 mg every 6 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 5067**]/Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you
experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Please call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 2348**] to schedule
an appointment in 2 weeks.
Please follow up on Tuesday morning ([**2196-8-16**]) at your primary
care physician's office to have an INR drawn. You have an
appointment to follow up with Dr. [**First Name8 (NamePattern2) 4468**] [**Last Name (NamePattern1) **] at 2:45PM,
[**2196-8-17**] for management of your coumadin.
Location: [**Hospital **] CLINIC, INC.
Address: [**Street Address(2) 71573**], [**Hospital1 **],[**Numeric Identifier 71574**]
Phone: [**Telephone/Fax (1) **]
Fax: [**Telephone/Fax (1) 92344**]
|
[
"42731",
"32723",
"4019"
] |
Admission Date: [**2137-6-4**] Discharge Date: [**2137-6-18**]
Date of Birth: [**2085-7-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Right PICC line placement [**6-5**]
History of Present Illness:
51 yo M with history of dCHF (EF 75%), cryptogenic organizing
pneumonia (on high dose prednisone), h/o PE in [**6-/2136**] (not on
anticoagulation), lymphedema, and multiple admissions for CHF
exacerbation presents with complaints of worsening dyspnea and
bilateral leg edema for one week. In the ED, had BNP newly
elevated to 279 and had CXR showing increased interstitial
markings, read by radiology as pulmonary vascular congestion
without focal consolidation. Labs in the ED were notable for K
2.4, Cl 74, HCO3 45, and glucose 336.
.
Was transferred to the floor and given acetazolamide 500 mg IV x
1 with minimal net diuresis given that patient's oral intake
matched his diuresis. Despite this, he was doing well with
stable oxygen sats in the low 90s on 4L NC. ABG initially on
floor 7.49/65/54. He was then placed on home BiPAP settings and
had desats to 70s which improved with discontinuation of BiPAP
and increased suplemental oxygen. Patient reporting that he is
most comfortable when sitting upright with his legs hanging over
edge of bed. Of note, his admission weight was 371 lbs and he
was noted to have actually decreased his weight by 13 lbs since
his last hospital discharge. Floor resident's primary concern
was patient's somnolence as he would fall asleep in mid
sentence. Patient himself denied confusion or altered sensorium.
Later in the morning, ABG was essentially unchanged from earlier
in evening (7.45/68/57, which is close to his baseline). Despite
no new hypercarbia, given increased somnolence and worsening
hypoxemia, transfer to the MICU was deemed appropriate.
.
Upon arrival to the MICU, patient was given 60 po potassium and
oxygenation improved to 90-92% on 6.5 Liters.
Past Medical History:
- BOOP/COP, dx via RML wedge resection [**2-/2136**], on chronic
prednisone.
- One vessel coronary artery disease
- Chronic lymphedema.
- PE's; subsegmental, d/x [**2136-6-7**].
- Fracture of L2 and multiple ribs after mechanical fall.
- Crush injury to his legs after being involved in a [**Doctor Last Name 9808**]
collapse in [**2116**], leading to right knee replacement and
bilateral femoral pins.
- Multiple gunshot wounds to legs/back/buttocks, complicated by
osteomyelitis, in [**2106**] after being involved in an altercation
with a neighbor.
- Obesity
- Tracheobronchomalacia with difficult intubation
- Severe obstructive sleep apnea -- restarted biPAP [**5-/2136**]
- Hypertension
- Hyperlipidemia
- Diastolic CHF, EF>55% in [**8-11**]
- Diabetes mellitus -- developed secondary to steroids
- Depression and PTSD
- Tobacco abuse
- Alcohol abuse
- Squamous cell carcinoma on dorsum of right hand s/p Mohs
- Back pain s/p multiple surgeries in cervical through lumbar
spine on narcotics contract
- Questionable h/o pericarditis with pericarial effusion
requiring drainage at [**Hospital1 **] (patient report)
- Obesity hypoventilation syndrome
- Suicidal ideation (passive and contracting for safety)
Social History:
Divorced from wife but continues to have good relationship with
her. Lives alone. Lives alone with VNA. Son died last year in
[**Hospital1 8751**]; daughter is living age 19. He notes previous asbestos
exposure when doing demolition work. He quit smoking three
months ago, previously a 20 pack year smoker. He drinks 3-6
alcoholic beverages (typically vodka, sometimes beer) per day,
last drink Monday. He reports history of occasionally drinking
more than 20 beers at a sitting but not recently. Denies IVDU.
Family History:
- Mother and father with emphysema
- Brother with heart transplant for pericarditis
- Mother had melanoma and died of perforated peptic ulcer at 71
Physical Exam:
On Admission to MICU:
Vitals: T: BP:134/78 P:77 R: 17 O2: 94% on 6.5L
General: Alert, but sleepy, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated,
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 3+ edema in BLE edema and
diffuse erythema to knee bilaterally.
Pertinent Results:
Admission labs:
[**2137-6-4**] 02:15PM BLOOD WBC-12.5* RBC-4.45* Hgb-11.6* Hct-35.6*
MCV-80* MCH-26.0* MCHC-32.5 RDW-19.8* Plt Ct-240
[**2137-6-4**] 02:15PM BLOOD Neuts-90.5* Lymphs-5.9* Monos-3.1 Eos-0.2
Baso-0.3
[**2137-6-3**] 02:28PM BLOOD PT-12.7 INR(PT)-1.1
[**2137-6-3**] 02:28PM BLOOD UreaN-16 Creat-1.3* Na-131* K-3.0* Cl-75*
HCO3-42* AnGap-17
[**2137-6-4**] 02:15PM BLOOD CK(CPK)-59
[**2137-6-4**] 02:15PM BLOOD proBNP-279*
[**2137-6-4**] 02:15PM BLOOD Calcium-9.0 Phos-2.4*# Mg-2.0
[**2137-6-4**] 10:47PM BLOOD Type-ART pO2-54* pCO2-65* pH-7.49*
calTCO2-51* Base XS-21
[**2137-6-4**] 10:47PM BLOOD Lactate-2.1*
EKG:
Sinus rhythm. Non-specific ST-T wave changes. Intraventricular
conduction
delay. Compared to the previous tracing of [**2137-5-8**] no diagnostic
change.
[**2137-6-4**] CXR PA/Lateral:
FINDINGS: PA and lateral views of the chest were obtained.
Technically limited study given patient's body habitus. Low lung
volumes result in bronchovascular crowding. Indistinct and
engorged pulmonary vasculature is new from [**2137-5-8**], due to
mild pulmonary edema. The cardiac silhouette is enlarged. The
mediastinal silhouette is stable. No pneumothorax.
IMPRESSION: Findings consistent with cardiogenic pulmonary
edema.
Blood cultures: ([**2137-6-4**]) no growth to date
Discharge Labs:
[**2137-6-16**] 06:09AM BLOOD WBC-10.3 RBC-4.35* Hgb-11.4* Hct-36.2*
MCV-83 MCH-26.1* MCHC-31.4 RDW-17.6* Plt Ct-325
[**2137-6-16**] 06:09AM BLOOD Plt Ct-325
[**2137-6-18**] 03:20PM BLOOD UreaN-25* Creat-0.9 Na-135 K-4.2 Cl-94*
[**2137-6-4**] 11:10PM BLOOD cTropnT-<0.01
[**2137-6-5**] 06:36AM BLOOD CK-MB-1 cTropnT-<0.01
[**2137-6-5**] 02:10PM BLOOD CK-MB-2 cTropnT-<0.01
[**2137-6-18**] 05:18AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
[**2137-6-5**] 05:44AM BLOOD Type-ART pO2-57* pCO2-68* pH-7.45
calTCO2-49* Base XS-18 Intubat-NOT INTUBA
[**2137-6-5**] 05:44AM BLOOD freeCa-1.12
Brief Hospital Course:
51 M with h/o cryptogenic organizing PNA, PE ([**6-11**] not on
anticoag), chronic lymphedema, chronic pain on narcotic
contract, OSA, DM, hypertension, dCHF, and depression
transferred from floor on the day of admission to the Medical
ICU with worsening hypoxia, not initially improving with BiPap.
# Acute on Chronic Hypoxia: Patient with chronic hypoxia and
hypercapnia and presented with acute hypoxia to 70% on RA not
improving with BiPaP. Chronic etiologies include obesity
hypoventilation, OSA, COP, and possibly diastolic CHF. CXR
notable for increase vascular congestion likely secondary to
chronic hypoxia and hypercapnia as this has been shown to cause
sodium retention due to aldosterone imbalance. Since patient
does not use supplemental oxygen at home to improve his hypoxia,
and ?using BiPAP consistently, he was likely retaining more salt
and water causing him to become more volume overloaded causing
worsening hypoxia. (Eur Respir J Suppl. [**2129**] [**Month (only) **];46:33s-40s.
Fluid homeostasis in chronic obstructive lung disease.)
On day of transfer to ICU, patient received 60 mg IV lasix x1
and was 5L negative. On ICU day 2 patient continued to have
oxygen requirement and received an additional 60 mg IV lasix.
On transfer to medicine floor, total cumulative fluid balance
was almost negative 6 L. Patient also had hypokalemia and was
started on spironolactone 12.5 mg daily. He was fluid
restricted to 1200 cc/day.
On the floor, he was started on torsemide as he may not be
adequately absorbing lasix at home. Dose was uptitrated to 100mg
daily with approx 3L UOP per day. For additional diuresis, he
was given lasix 60-100mg IV in the afternoon/evening and was
negative approximately 4L per day with 6L UOP and 2L fluid
restriction. Daily weights were inaccurate as they indicated pt
lost and gained 20-30 pounds per day. Spironolactone was also
increased to 25mg daily and he only required potassium repletion
approximately once every 3 days. He was discharged on torsemide
120 mg PO daily and IV lasix 100 mg daily at 4 PM. His
electrolytes were stable on this diuretic regimen with minimal
potassium and magnesium repletion. He reports his dry weight is
340 to 350 pounds, and he was 361 lbs on discharge. He was also
started on home oxygen which should be continued upon discharge
from rehabilitation.
# Hypokalemia: On IV lasix plus aldosterone/renin imbalance in
setting of chronic hyercapnia (see citation above and paper in
chart). Patient was repleted with IV and PO potassium. Patient
had PICC line placed to administer concentrated IV potassium.
Electrolytes were carefully monitored in ICU. Spironolactone
was added to medication regimen and uptitrated to 25mg daily
with good effect.
# Metabolic Alkalosis: Chronic, secondary to OSA/obesity
hypoventilation. Patient continued on bipap at night.
# LE Edema: Secondary to fluid retention from above process plus
chronic lymphedema. He was diuresed as above. Pain was
controlled with home oxycontin and oxycodone and IV dilaudid prn
breakthrough. He was also given triamconolone cream for venous
stasis changes and legs were wrapped with ACE bandages as much
as possible.
# COPD: Patient on high doses of steroids on admission for
presumed COP flare in last admission. His steroids were tapered
from 40 to 30mg daily for 1 week then 20mg daily until he is
seen by outpatient pulmonary. He was continued on mycophenolate
as patient is on several month trial as per outpatient pulm.
Continued bactrim prophylaxis and calcium and vitamin D
# Diabetes: Patient was started on sliding scale and glargine.
Blood sugar was not well controlled, so glargine dose was
increased to 50 units qam and 80 units qhs with a humalog
insulin sliding scale. Prednisone also tapered as above.
# Chronic anemia - Continued iron and B12.
# Depression - History of passive SI. Contracted for safety.
Continued citalopram.
# Hyperlipidemia - Continued simvastatin.
# BPH Continued finasteride and tamsulosin.
# Chronic Pain: on pain contract at [**Company 191**]. Continued home regimen
of oxycontin and oxycodone (see discharge medications). Patient
also received IV dilaudid for lower extremity pain as needed to
relieve pain from his lymphedema while he is being diuresed.
Medications on Admission:
citalopram 20 mg daily
omeprazole 40 mg daily
prednisone 40 mg daily
simvastatin 40 mg daily
finasteride 5 mg daily
Vitamin D 800 unit daily
oxycontin 60 mg q8h
oxycodone 30 mg q4h
tamsulosin 0.4 mg qhs
aspirin 81 mg daily
calcium carbonate 200 mg (500 mg) Tablet [**Hospital1 **]
trazodone 50 mg qhs
ipratropium neb q6h prn SOB, wheezing
albuterol sulfate neb q4h prn SOB, wheezing
gabapentin 100 mg q8h
sulfamethoxazole-trimethoprim 800-160 mg qMWF
multivitamin 1 tab daily
docusate sodium 100 mg [**Hospital1 **]
senna 8.6 mg [**Hospital1 **] prn constipation
ferrous sulfate 300 mg daily
cyanocobalamin (vitamin B-12) 1000 mcg daily
mycophenolate mofetil 500 mg [**Hospital1 **]
insulin glargine 80 units qhs while on high dose prednisone
furosemide 100 mg [**Hospital1 **]
humalog sliding scale
Discharge Medications:
1. Supplemental Oxygen
Diagnosis: Obesity Hypoventilation, CHF, Cryptogenic organizing
pneumonia. 1-3L continuous pulsed dose for portability
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Three (3)
Tablet Extended Release 12 hr PO Q8H (every 8 hours): hold for
rr < 9, confusion, sedation.
8. oxycodone 15 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain: immediate release
hold for sedation, rr < 9.
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
13. ipratropium bromide 0.02 % Solution Sig: [**2-3**] puff Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**2-3**] puff Inhalation every 4-6 hours as needed
for SOB/wheezing.
15. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
22. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
23. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
25. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): in addition to 20 mg tablet for total of 120 mg PO
daily.
27. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day: in
addition to 100 mg tablet for a total of 120 mg daily.
28. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Until patient has pulmonary follow-up appointment.
29. triamcinolone acetonide 0.025 % Cream Sig: One (1) Appl
Topical DAILY (Daily): apply to legs.
30. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q6H:PRN pain
please hold for sedation, RR<12
31. Furosemide 100 mg IV DAILY
Please give at 4 PM daily
32. Lantus 100 unit/mL Solution Sig: One (1) injection
Subcutaneous twice a day: 50 U with breakfast
80 U at bedtime.
33. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: Per insulin sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary Diagnosis:
Secondary Diagnosis:
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with swelling in your legs and
low oxygen levels as well as very low potassium levels. We gave
you potassium and medications to remove fluid from your legs and
your lungs and your symptoms improved. We also started a
medication that increases your potassium levels.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
We made the following changes to your medications
1. Please START spironolactone as directed.
2. We changed your lasix to torsemide as directed.
3. We added oxygen which you should continue at home when you
are discharged from rehabilitation.
4. We increased your insulin dosing (Lantus 50 U qAM and 80 U
qPM) along with an insulin sliding scale
5. We decreased your prednisone to 20 mg daily
Followup Instructions:
Department: [**Hospital3 249**]
With: [**Known firstname **] [**Last Name (NamePattern1) 24385**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call this number after discharge to make an appointment
Name: [**Last Name (LF) **], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD
Location: [**Hospital1 18**] - DIVISION OF PULMONARY AND CRITICAL CARE
Address: [**Location (un) **], KSB-23, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 612**]
Appt: We are working on a follow up appt for you. THe office
will call you with an appt. Please call them directly to book
at discharge.
If you are interested in learning more about our Bariatric
Surgery program and wish to receive the packet of screening
questionnaires to start the process, please call [**Telephone/Fax (1) **].
Department: CARDIAC SERVICES
When: TUESDAY [**2137-7-9**] at 1:30 PM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NOTE: [**Hospital1 **] [**Location (un) 1110**] was called and informed the day after
discharge that PCP appointment and Pulmonary Appointments needed
to be called and [**Location (un) 1988**] after discharge. PCP appt on [**2137-6-24**]
was cancelled.
Completed by:[**2137-6-19**]
|
[
"4280",
"2724",
"311",
"2859",
"496"
] |
Admission Date: [**2152-10-2**] Discharge Date: [**2152-10-8**]
Date of Birth: [**2090-3-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
ProAir HFA
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Aymptomatic Aortic Insufficency
Major Surgical or Invasive Procedure:
[**2152-10-4**]: Resection of the ascending aortic aneurysm and aortic
valve replacement with a Bentall procedure with a [**Street Address(2) 11688**]. [**Hospital 923**]
Medical mechanical valve conduit.
History of Present Illness:
62M was treated for bronchitis in [**Month (only) 205**] and found to have
moderate
to severe AI on echo as well as ascending aortic aneurysm of
5.3cm. He is asymptomatic, able to climb stairs and walk
distances without difficulty. Cardiac cath revealed clean
coronary arteries. The patient presents today for PAT. He had
dental extractions last week and will see his dentist in
follow-up for letter of clearance.
Past Medical History:
Aortic insufficiency
Ascending Aortic Aneurysm
History of hyponatremia
Hypertension
High Cholesterol
Cataract
Glaucoma
Depression
Anxiety
Tobacco use 1ppd x 40 years
Vitamin D deficiency
S/P skin tag removal
Mild varicose veins
S/P left patellar fracture [**2147**]
Left foot crush injury [**2147**]
Past Surgical History
S/P left knee surgery [**2147**] with titanium wires in place
Tonsillectomy
Social History:
Lives with: Lives alone. High stress due to laid off [**12-23**] from
job at [**Location (un) 6692**] in cargo.
Cigarettes: Tob: 1 ppd x 40+ yrs-- **quit [**2152-9-19**]
ETOH: Daily [**4-18**] 12 oz beers most days. **quit [**2152-9-19**]
Substance abuse: Past marijuana
Contact upon discharge: [**Name (NI) 449**] [**Name (NI) 90689**], brother-in-law
Family History:
Premature coronary artery disease - none
Physical Exam:
Pulse:71 Resp:15 O2 sat:100% RA
B/P Right: 149/82 Left: 148/96
Height: 5'[**51**]" Weight:203#
General: AAO x 3 in NAD
Skin: Dry [x] intact [x] left knee well healed scar
HEENT: PERRLA [x] EOMI [x] Several missing teeth with remaining
teeth in poor repair
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade I/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] None
Varicosities: + right lower extremity
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
Admission Labs:
[**2152-10-2**] 07:15AM HGB-13.4* calcHCT-40
[**2152-10-2**] 07:15AM GLUCOSE-108* LACTATE-0.9 NA+-137 K+-4.0
CL--102
[**2152-10-2**] 12:32PM FIBRINOGE-188
[**2152-10-2**] 12:32PM PT-17.5* PTT-43.9* INR(PT)-1.6*
[**2152-10-2**] 12:32PM PLT COUNT-242
[**2152-10-2**] 12:32PM WBC-6.5 RBC-2.58*# HGB-7.7*# HCT-22.6*#
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.7
[**2152-10-2**] 02:03PM UREA N-15 CREAT-0.8 SODIUM-137 POTASSIUM-4.7
CHLORIDE-110* TOTAL CO2-23 ANION GAP-9
Echo [**10-4**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2152-10-3**] 8:10
AM
Final Report: The patient is status post cardiac surgery.
sternal wires are intact. The cardiomediastinal silhouette,
small left pleural effusion, and minimal pneumopericardium are
all stable. There is no pneumothorax. The right internal jugular
line ends in the upper SVC. Minimal left lung base atelectasis
is unchanged. There are no new lung opacities of concern.
[**2152-10-7**] 07:15AM BLOOD WBC-6.9 RBC-3.03* Hgb-8.8* Hct-27.3*
MCV-90 MCH-29.1 MCHC-32.3 RDW-13.7 Plt Ct-387
[**2152-10-7**] 07:15AM BLOOD UreaN-12 Creat-0.9 Na-133 K-4.5 Cl-99
[**2152-10-7**] 07:15AM BLOOD PT-24.9* INR(PT)-2.4*
Brief Hospital Course:
Mr. [**Known lastname 90690**] was brought to the operating room on [**2152-10-2**] where
the he underwent a Bentall procedure with a 23mm mechanical
valved conduit and ascending aorta/hemiarch replacement with Dr.
[**Last Name (STitle) **]. Cardiopulmonary bypass time was 174 minutes, cross
clamp time 126 minutes and circulatory arrest 19 minutes.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Post operative
day one found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Coumadin was initiated for the mechanical valve. He did develop
acute kidney injury with a rise in creatinine from 0.8 to 1.6.
Lasix and Lisinopril were discontinued and urine output was
monitored very closely. By the end of his stay his renal
function returned to baseline. Chest tubes and pacing wires
were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on
post-operative day five the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged in good condition with appropriate
follow up instructions.
Medications on Admission:
BRINZOLAMIDE [AZOPT] - (Prescribed by Other Provider) - 1 %
Drops, Suspension - 1 drop each eye two times daily
LATANOPROST - (Prescribed by Other Provider) - 0.005 % Drops -
1
drop each eye at bedtime
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
Capsule(s) by mouth once a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] ().
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*2*
7. potassium chloride 10 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*2*
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day: take
2mg nightly or as directed by the office of Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
INR to be drawn on [**10-9**] with results called to the office of Dr.
[**Last Name (STitle) **]. INR goal for mechanical aortic valve is 2.5-3
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p Bental,AVR(23mm St. [**Male First Name (un) 923**] mechanical valved conduit)
PMH: Aortic insufficiency, Ascending Aortic Aneurysm, History of
hyponatremia, Hypertension, High Cholesterol, Cataract,
Glaucoma, Depression, Anxiety, Tobacco use 1ppd x 40 years,
Vitamin D deficiency, S/P skin tag removal, Mild varicose veins,
S/P left patellar fracture [**2147**], Left foot crush injury [**2147**],
S/P left knee surgery [**2147**] with titanium wires in place,
Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD :[**Telephone/Fax (1) 170**] :[**2152-11-8**] @1:00P
[**Hospital 409**] Clinic: [**Telephone/Fax (1) 170**] :[**2152-10-17**] @10:30A
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5686**], MD on [**10-26**] at 10:45A
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 11006**],[**First Name3 (LF) 640**] W [**Telephone/Fax (1) 23874**] in [**4-18**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication -Mechanical aortic valve
Goal INR 2.5-3
First draw [**10-9**] with results to the office of Dr. [**Last Name (STitle) **]
Results to phone ([**Telephone/Fax (1) 1504**]
Completed by:[**2152-10-7**]
|
[
"4241",
"5849",
"4019",
"2720",
"3051"
] |
Admission Date: [**2118-2-5**] Discharge Date: [**2118-2-8**]
Date of Birth: [**2063-2-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
chest pain/STEMI.
Major Surgical or Invasive Procedure:
cath- s/p bare metal stent to LAD
History of Present Illness:
54 yo M with h/o [**Hospital **] transfered from OSH after SSCP x 1 hour.
Patient's pain woke him up from sleep @ 4 am, he never had this
pain before. It was L sided pain radiating to the L arm, no
radiation to the back. NO sob/palpitations, no n/v, no
diaphoresis or lightheadedness. Called EMS. Received 8mg
morphine, 4 baby asa, 4 [**Name2 (NI) **] with pain lasting until
catherizatoin. At [**Hospital 8125**] hospital he was found to be hypotensive
at BP 59/28, with HR 40's. Given 600ml NS. EKG showed STE in
V1-3, I, aVL. Given 600mg plavix, heparin gtt, nitro gtt,
integrillin. WBC 18, Cr 2.4, CK, troponin negative. He was
medfligthed to [**Hospital1 18**] where he underwent urgent catherization. It
showed nl RCA, Lcx comming off the R cusp, LAD with fresh
thrombus at proximal to bifurcation with D1 that was
thrombectomized with clot visualization, and BMS was placed. D1
showed 60% of lesion that was not intervened. Patient was
assymptomatic and post-PCI EKG showed AIVR at 80 bpm.
Past Medical History:
HTN
"Congenital kidney disease"
Physical Exam:
VS: afebrile, HR 62 BP 122/68 RR 12 98% on 2L
Gen: obese large male, NAD, not diaphoretic, asleep
HEENT: NC, AT, anicteric, no JVD, no carotid bruits
CV: RRR, nl s1, s2, no m/r/g
Chest: CTAB/L
Abd: + BS, snt/nd, no hsm
Ext: no edema, no cyanosis, + 1 DP b/l
Pertinent Results:
[**2118-2-5**] Cath: FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Elevated left and right sided filling pressures.
3. Preserved cardiac index.
4. Acute anterolateral myocardial infarction.
5. Successful thrombectomy, PTCA, and stenting of the proximal
LAD with
a bare metal stent.
.
[**2118-2-5**] Renal U/S: IMPRESSION:
1. Large anechoic cyst along the right renal hilum. This may
represent a large parapelvic cyst or exophytic renal cyst.
Although there are no solid components, its etiology is unclear.
If clinically indicated, CT or MR with contrast could be helpful
to evaluate further when clinically feasible.
2. 16-mm indeterminate left renal lesion. When clinically
feasible, CT or MR could be employed to exclude a small solid
left renal lesion.
3. No hydronephrosis.
.
[**2118-2-5**] ECHO: LVEF 45% Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with mid to distal anteroseptal and apical akinesis.
No LV thrombus seen. Overall left ventricular systolic function
is mildly depressed. Right ventricular chamber size is normal.
Right ventricular free wall motion may be normal but views are
suboptimal. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of tricuspid regurgitation may be significantly UNDERestimated.]
There is no pericardial effusion.
.
[**2118-2-6**] EKG: Sinus bradycardia
Long QTc interval
Possible left atrial abnormality
Left axis deviation - anterior fascicular block
Extensive infarction - age undetermined
.
Pertinent labs:
CBC: WBC-11.7* RBC-3.80* Hgb-11.9* Hct-33.9* MCV-89 MCH-31.3
MCHC-35.1* RDW-13.7 Plt Ct-187
Chem 10: Glucose-123* UreaN-26* Creat-1.1 Na-142 K-4.3 Cl-105
HCO3-27 Calcium-9.4 Phos-2.5* Mg-2.5
LFTS: ALT-41* AST-104* CK(CPK)-992* AlkPhos-106 Amylase-29
TotBili-0.3
CK [**Month/Day/Year **]: 4872, 4297, 2412
CK-MB [**Month/Day/Year **]: 73*, 500, 322, 125
MD [**First Name (Titles) **] [**Last Name (Titles) **]: 7.4*, 7.5, 5.2
%HbA1c-5.8
Cholesterol panel: Triglyc-62 HDL-63 CHOL/HD-2.5 LDLcalc-81
Brief Hospital Course:
Mr. [**Known lastname 71491**] is a 54 year old male with h/o hypertension who
presented with anterior STEMI. Pt rushed to cath lab and had
thrombectomy of fresh thrombus from prox LAD then BMS placement.
He still has a 60% D1 lesion that was considered non-culprit.
He will need dual asprin/plavix X 30 days then asprin
monotherapy thereafter. His ECHO revealed EF ~40% w/ severe
apical akinesis, so coumadin was initiated and his goal INR is
2.0-3.0. He should be theraputically anticoagulated X 6 months.
He was discharged w/ lisinopril 5mg and toprol XL 25 mg both
daily. He has been chest-pain free since his intervention; he
was cleared to go home by physical therapy. His creatinine was
2.2 on admission, likely related to NSAID usage as outpt, and
now NSAIDs are contraindicated for him. He has a 16-mm
indeterminate left renal lesion. When clinically feasible, CT
or MR could be employed to exclude a small solid left renal
lesion.
Medications on Admission:
hctz
lisinopril
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
5. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*75 Tablet(s)* Refills:*2*
6. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
anterior STEMI
apical akinesis requiring anticoagulation
Discharge Condition:
stable. assymptomatic.
Discharge Instructions:
You were admitted to the hospital with a heart attack. You had
a stent placed in one of your coronary arteries and should be on
plavix for at least 30 days. Also you must have your INR
checked and coumadin dose adjusted to a goal INR of 2.0-3.0.
Dr[**Last Name (STitle) **] office should be able to do this for you.
NO FURTHER IBUPROFEN, ALEVE, MOTRIN. You can take tylenol only
for pain.
Followup Instructions:
Please follow up with -
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1511**] ([**2118**] on Thursday [**2118-2-10**] at 10:30AM
Dr. [**Last Name (STitle) 5310**] ([**Telephone/Fax (1) 5319**]. His office will call you with
appointment.
|
[
"5849",
"41401",
"4019"
] |
Admission Date: [**2137-6-4**] Discharge Date: [**2137-6-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Bradycardia
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y.o. Polish speaking male with h/o paroxysmal afib, Diastolic
HF, several falls and recent [**Hospital1 18**] admissions [**Date range (1) 77733**] after
fall with left humerus fx and on [**4-4**] for decreased
appetite and increased fatigue thought to be due to diastolic
heart failure. During his most recent admission cardiology was
consulted and the recommended event montor to eval for arhythmia
as a possible cause of falls, but pt refused. They also
recommended holding off on coumadin for treatement of Afib, and
using only aspirin given multiple falls. Per report, patient was
more lethargic at his NH today and was responsive only to
painful stimuli, he was found to by bradycardic to the 40s and
hypotensive with SBPs in the 80s. He received atropine 1 mg in
the field with increase in his HR to 60s and was brought to the
ED.
.
In the ED, initial vitals were T: 96.8 HR:55 BP:90/38 RR:18
O2Sat:100% on NRB. Patient received 9 L of NS with UOP of about
100 cc and no response in his BP. He then developed abdominal
distention and underwent a CT abdomen, which revealed evidence
of volume overload. CXR showed a resolving right-sided pleural
effusion. He had 1 episode of bradycardia to the 30s and
received atropine 0.5 mg. He was admitted for further
management of bradycardia and hypotension.
Past Medical History:
Diastolic heart failure
2+ MR, 3+ TR
Afib
Left humerus fracture [**2137-3-15**]
Recurrent falls
Social History:
Origially from Poland. Worked as a chemistry teacher. Came to US
after the war. was living independently prior to last admission.
Ambulated with cane. Has supportive son [**Name (NI) **] who is HCP. [**Name (NI) **]
would visit with him 5 days/week but had increasing concern for
his safety at home. Wife lives in a NH secondary to stroke. Also
has a daughter who is not really involved. Has remote h/o
tobacco >40 yrs and denies etoh. He deferred to his son
regarding code status who confirms that his father does not want
life-prolonging measures and prefers to focus on quality.
Confirms DNR status.
Previously wore hearing aids, but has not worn for years. Also
has old broken glasses that he no longer wears.
Family History:
NC
Physical Exam:
Skin warm and dry, NAD. Frail, cachetic male. Alert, engaging,
but unable to communicate as he cannot hear the interpretor on
the phone
HEENT: MMM dry, no teeth
Pulm: decreased breath sounds at bases bilaterally R>L
CV: distant heart sounds, [**Last Name (un) 3526**], [**Last Name (un) 3526**], no murmur
Abd: distended but soft, +BS, non-tender
EXT: 1+ DP pulses, no edema
Neuro: awake, movinf all 4 extremiti
Pertinent Results:
[**2137-6-4**] 05:31PM WBC-7.6 RBC-3.77* HGB-11.3* HCT-34.7* MCV-92
MCH-30.0 MCHC-32.6 RDW-14.1
[**2137-6-4**] 05:31PM NEUTS-80.1* LYMPHS-15.1* MONOS-3.8 EOS-0.9
BASOS-0.2
[**2137-6-4**] 05:31PM PLT COUNT-227
[**2137-6-4**] 05:27PM GLUCOSE-120* UREA N-29* CREAT-1.6* SODIUM-136
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-13
[**2137-6-4**] 05:27PM CK(CPK)-20*
[**2137-6-4**] 05:27PM cTropnT-<0.01
[**2137-6-4**] 05:27PM CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-2.2
[**2137-6-4**] 05:27PM PT-13.0 PTT-29.6 INR(PT)-1.1
[**2137-6-4**] 11:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR
[**2137-6-4**] 11:15PM URINE RBC-21-50* WBC-[**2-20**] BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2137-6-4**] 11:15PM URINE HYALINE-0-2
[**2137-6-4**] 11:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2137-6-5**] 03:22AM BLOOD PT-13.5* PTT-29.1 INR(PT)-1.2*
[**2137-6-5**] 03:22AM BLOOD CK(CPK)-33*
[**2137-6-5**] 03:22AM BLOOD CK-MB-3 cTropnT-0.01
.
[**6-4**] CT ABD and Pelvis - prelim read Stranding in the mesentery
is likley related to fluid overload, without
evidence of large abscess or hemorrhage.
Brief Hospital Course:
Assessment/Plan: [**Age over 90 **] y.o. male with h/o syncope with falls, afib,
recent humerus fx is s/p pna with known large right pleural
effusion,
presents with lethargy and weakness found to be bradycardic and
hypotensive
.
# Bradycardia: Unclear etiology as not on BB, CCB or digoxin.
Unclear if patient's bradycardia and hypotension were trully
related. Was in slow atrial fibrillation on admission.. Likely
age-related sclerotic conduction system disease. Evaluated by EP
per family wishes, no role for ICD.
# Hypotension: No focal infectious etiology. Perhaps volume
depletion secondary to diarrhea.
# ARF: Likely pre-renal in etiology given recent diarrhea versus
ATN given hypotension.
Resolved.
# Diarrhea: Unclear etiology. He had loose stools on his last
admission as well that were attributed to narcotic withdrawl and
antibiotics and chronic stool softner use. Of note, he was also
on amoxicillin at the nursing home for unclear reasons.
.
# Diastolic CHF: Patient has received 9 L IVF. No LE edema, but
does have pleural effusion and abdominal edema.
Patient restarted on home lasix day prior to d/c, satting well
on RA on d/c.
.
# Pleural effusion: He has had a loculated pleural effusion in
setting of recent pna, possible parapneuomnic effusion vs
transudate from right heart failure. No fevers, no elevtaed WBC
to suggest active infection.
-Patient continued on home diuresis.
.
# Afib: actually in slow afib. not anticoagulated secondary to
patients wishes.
- continue ASA
.
# h/o Humerus fx: tylenol PRN
.
# FEN: regular heart healthy diet, nectar thickened liquids
.
# ACCESS: PIVs
.
# PPX: SC heparin, fall precautions, aspiration precautions
.
# Code Status: DNR/DNI, no CVL, no invasive procedures, however
patient's son did want evaluation by EP for question of
pacemaker placement.
# Contact: HCP [**Name (NI) **] [**Name (NI) 77734**] [**Telephone/Fax (1) 77735**]
.
Medications on Admission:
.
CURRENT MEDICATIONS: (per nursing home list)
1. Aspirin 325 mg Po Qday
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
3. Docusate Sodium 100 mg PO BID
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Lasix 20 mg PO once a day.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID
7. MOM PRN
8. [**Name2 (NI) 77736**] 875 mg PO BID ([**Date range (1) 77737**])
9. Dulcolax PRN
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO daily
(): mix with 8 ounces of water.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
5. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a
day.
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
On [**Location (un) **] - [**Location (un) **]
Discharge Diagnosis:
Bradycardia
Hypotension
Acute Renal Failure
Diastolic Heart Failure Acute
Delirium
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return if having difficulty breathing, fevers, chills (pending
final CMO decision by family).
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2137-6-11**] 8:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2137-6-11**] 8:40
Pt's family to schedule f/u appt with PCP.
|
[
"5849",
"42789",
"4280",
"42731",
"4240",
"V1582"
] |
Admission Date: [**2127-12-6**] Discharge Date: [**2127-12-16**]
Date of Birth: [**2054-7-11**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin / Augmentin / Benadryl
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73F w/ stage IV colon CA (s/p r hemicolectomy and diverting
colostomy), who presented to the ED with hematemesis that began
at Friday at midnight. The patient reports that she had some
cranberry juice. Thereafter she started having multiple episodes
of dry heaves, periumbilical cramping pain and subsequent
hematemesis. Her ostomy bag was also noted to be bloody.
.
In the ED her vitals were as follows T98 HR 72 BP 157/72 R17
O2sat 96%RA.An NGL was done and cleared after 600cc. The patient
was typed and crossed for 4u. She was never transfused. She
received 2L of IVF. Her Hct on presentation was noted to 37.2,
repeated 32.6. Her INR was 1.1 and PTT 24.1.
.
Of note the patient was recently on Augmentin for a stomal
cellulitis. She developed a diffuse body rash. She never had
compromised of her respiratory function.
.
Pt refused EGD. Admitted to [**Hospital Unit Name 153**] for further monitoring.
Past Medical History:
Stage IV colon CA ( s/p right hemicolectomy and diverting
colostomy)
GERD
Iron Deficiency Anemia
Hypothyroidism
Depression
Stomal Cellulitis
Asthma
h/o DVT
Social History:
Patient lives with her son in [**Name (NI) **]. Her husband died last
year from ESRD. She has three sons two are in prison.
Family History:
noncontributory
Physical Exam:
T98.9 HR70 BP135/65 RR20 O2sat 95%RA
Gen: NAD, speaking in full sentences
HEENT: no conjunctival pallor, MMM dry, OP clear
HEART: nl rate, S1S2, no gmr
LUNGS: poor insp effort
ABD: ostomy bag L mid quadrant surrounded by profound
erythematous, eczematous skin changes, mild tenderness to the R
of the umbilical region and hypoactive bowel sounds
EXT: non-blanching macular-papular rash lower extremities,
2+pitting edema, lanced blister on the plantar surface of the
left foot,
Pertinent Results:
[**2127-12-6**] 02:30PM BLOOD Lipase-33
[**2127-12-6**] 02:30PM BLOOD ALT-14 AST-20 AlkPhos-51 Amylase-72
TotBili-0.4
[**2127-12-6**] 02:30PM BLOOD Glucose-146* UreaN-13 Creat-1.0 Na-140
K-3.7 Cl-104 HCO3-22 AnGap-18
[**2127-12-16**] 05:50AM BLOOD Glucose-104 UreaN-7 Creat-1.0 Na-137
K-3.7 Cl-102 HCO3-27 AnGap-12
[**2127-12-6**] 08:50PM BLOOD WBC-12.4* RBC-3.76* Hgb-11.4* Hct-32.6*
MCV-87 MCH-30.3 MCHC-34.8 RDW-14.4 Plt Ct-452*
[**2127-12-16**] 05:50AM BLOOD WBC-5.6 RBC-3.60* Hgb-10.7* Hct-31.3*
MCV-87 MCH-29.7 MCHC-34.2 RDW-14.4 Plt Ct-410
.
CT Abdomen:
FINDINGS: The lung bases demonstrate no nodular densities or
focal opacities. The liver is mildly low in attenuation
diffusely consistent with fatty liver. The gallbladder is
colapsed with at least 2 gallstones. No pericholecystic fluid or
stranding noted. The pancreas and spleen are unremarkable. The
adrenal glands are within normal limits. Again demonstrated is a
right-sided hydronephrosis with a soft tissue density
surrounding the right mid ureter just cephalad to the sacral
promontory. Delayed excretion is again identified as on prior
study.
.
Soft tissue thickening is again demonstrated within the
duodenum, however given lack of oral contrast, specific
comparison is difficult. There are multiple fluid filled and
mildly dilated loops of small bowel. The terminal ileum is
collapsed. Grouped small bowel loops make identification of a
discrete transition point difficult. The colon contains air and
stool extending all the way to the colostomy site within the
left lower quadrant. There is wide-mouth parastomal hernia with
no evidence of incarceration as on prior study. There are
multiple omental metastatic lesions as demonstrated on prior
study similar in size.
.
CT PELVIS WITH IV CONTRAST: The urinary bladder is unremarkable.
The prostate is normal size. The sigmoid colon contains multiple
diverticula with no evidence of diverticulitis. There are no
soft tissue foci within the perirectal space.
.
BONE WINDOWS: There are no suspicious lytic or sclerotic bony
lesions.
.
IMPRESSION:
1. Multiple moderately distended loops of small bowel with air
fluid levels with no transition point identified. There is a
small portion of terminal ileum that is collapsed. These
findings are consistent with either ileus or early small-bowel
obstruction. Close interval followup recommended. A small bowel
series under fluoroscopy may be of benefit.
2. Stable-appearing right hydronephrosis and hydroureter. Mass
lesion abutting mid right ureter as above suspicious for
metastatic disease.
3. Stable-appearing parastomal hernia. No evidence of
incarceration
Brief Hospital Course:
Hospital Course by Problem:
.
#UGIB: DDX included peptic ulcer disease (given ?duodenal
inflammation on CT), AVMs, worsening of metastatic disease, or
viral gastroenteritis causing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**]-[**Doctor Last Name **] tear (esp given hx
of prolongued dry heaves). She was lavaged in ED, and then
transferred to [**Hospital Unit Name 153**]. IN the ICU, she remained hemodynamically
stable with serial HCT checks. She was started on PPI IV bid,
she required no blood transfusions. GI was consulted and
intially recommended EGD, however, given her clinical stability
for >24hrs, EGD was deferred. While on the floor she had no
further episodes of hematemesis or blood ostomy output. HCT
remained stable.
.
R sided Hydronephrosis: noted to be stable from prior CT scan.
Conferring with her oncologist, this was thought to represent
metastatic disease encasing the ureter. She will follow up with
her oncologist for systemic chemotherapy.
.
?SBO: several days into the hosptialization, she developed
worsening abdominal pain and distention. KUB showed a few
moderately dilated loops of small bowel thought to represent
early obstruction. Surgery team was consulted, who recommended
bowel rest, NGT, IVF, NPO. Her SBO resolved with conservative
treatments and she was tolerating a full diet on the day of
discharge.
Medications on Admission:
(per [**Company 4916**] Pharmacy, [**Location (un) 3146**])
Advair diskus 500-50
ASA 81
Calcium 600/D one by mouth twice a day
Iron 325mg
Levoxyl 200mcg
Omeprazole 20mg daily
Zoloft 50mg daily
Ketoconazole topical cream
Nystatin
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Omeprazole 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*
9. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Allcare VNA
Discharge Diagnosis:
Primary Diagnoses:
Small Bowel Obstruction, resolved
Hematemesis, resolved (?[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear)
R sided hydronephrosis; stable from prior CT scan
Secondary Diagnoses:
Stage IV colon CA ( s/p right hemicolectomy and diverting
colostomy)
GERD
Iron Deficiency Anemia
Hypothyroidism
Depression
h/o Stomal Cellulitis
Asthma
Discharge Condition:
stable, tolerating full POs
Discharge Instructions:
Please contact your primary care doctor should you develop any
fevers, chills, sweats, abdominal pain, blood in your vomit or
stool, black stools, or any other serious complaints.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2127-12-30**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name11 (NameIs) **]/ONCOLOGY-CC9
Date/Time:[**2127-12-30**] 9:30
Provider: [**Name Initial (NameIs) 4426**] 18 Date/Time:[**2127-12-30**] 10:00
[**Last Name (LF) 1576**],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**]-[**Doctor Last Name 1576**] APG (SB)
Date/Time:[**2128-1-7**] 11:10
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Date/Time:[**2128-4-13**] 10:10
|
[
"53081",
"2449"
] |
Admission Date: [**2185-5-7**] Discharge Date: [**2185-5-24**]
Date of Birth: [**2104-3-13**] Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / Percocet / Percocet
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Right thoracentesis (diagnostic and therapeutic)
History of Present Illness:
81 y/o female with a hx of metastatic squamous cell carcinoma of
the L leg; she presented to her oncologists office 2 days ago
with L hip and left leg thought to be from her radiation
therapy; she had a CT scan from a week prior which revealed L
sided hydronephrosis in the presence of a urinary tract
infection. The urology consult noted this hydro was from
external compression from L iliac chain LAD.
She initially presented to the emergency department upon urging
from her oncologist where she received antibiotics, and was seen
by urology who requested additional imaging. She was admitted
for a complicated urinary tract infection and seen by urology
following a reapeat CT Scan on [**5-4**]; On [**5-5**] the patient
underwent a cystoscopy, L retrograde pyelogram, and a left
double-J stent placement.
The patient tolerated the procedure well - but on [**5-7**], a rapid
response was called and the patient presented with shortness of
breath, tachycardia to 120 and SBPs in the 100's. The patient
was found to have an INR of 6.2, and transferred to the [**Hospital1 **]
ICU. She was noted to have progressively worsening
leukocystosis to 21,000. Her creatinine bumped to 1.7 and began
trending down to 1.3 prior to transfer.
On arrival to the MICU, the patient was in no apparent distress,
saturating 95% on 15L via nonrebreather mask. She was alert and
oriented to person, place, time and denies any discomfort or
subjective feelings of dyspnea.
Past Medical History:
-Squamous Cell Carcinoma to L leg x1 year s/p radiation and
chemo
-A.fib (on warfarin, on dilt)
-HTN
-Recurrent UTI
Social History:
Lives in [**Hospital1 **] Village retirement facility with husband.
Retired from work in jewelry sales. 3 grown children. Lifelong
nonsmoker. Drinks red wine.
Family History:
-Father died at 97
-Mother died at 87; palpitations, DMII
-Brother died at 74; prostate CA
-Son 57, alive; DMII
-Daughter 56, alive and well
-Daughter 54, alive and well
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.7 BP: 101/59 P: 103 R: 25 O2: 95% NRB
General: Alert, oriented, no acute distress, thin
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops; Peripheral IV lines in both hands and the L AC
Lungs: Clear to auscultation bilaterally, diminished bases
bilaterally, no retractions, mild tachypnea, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE PHYSICAL EXAM:
VS: 99 94/57-111/58 75-90 18 94%RA
GENERAL - elderly female in NAD
HEENT - sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTAB, slightly decreased at bases. respirations
unlabored, no accessory muscle use. no wheezing or rales. able
to speak in full sentences
HEART - irregularly irregular, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses, 2+ LLE pitting edema up
to ankle
SKIN - no rashes or lesions
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
WBC-18.9* RBC-2.67* Hgb-9.6* Hct-29.5* MCV-110* MCH-36.1*
MCHC-32.7 RDW-14.0 Plt Ct-383
Neuts-92.7* Lymphs-2.8* Monos-3.9 Eos-0.5 Baso-0.1
PT-59.8* PTT-40.9* INR(PT)-6.0*
Glucose-98 UreaN-32* Creat-1.0 Na-136 K-3.9 Cl-103 HCO3-19*
AnGap-18
ALT-5 AST-14 LD(LDH)-197 CK(CPK)-59 AlkPhos-95 TotBili-0.4
CK-MB-3 cTropnT-<0.01 proBNP-4015*
Albumin-3.2* Calcium-8.2* Phos-3.2 Mg-1.9
Type-[**Last Name (un) **] pO2-43* pCO2-31* pH-7.46* calTCO2-23 Base XS-0
Intubat-NOT INTUBA
Lactate-1.1
freeCa-1.11*
URINALYSIS: Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.019 Blood-LG
Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-MOD
RBC->182* WBC->182* Bacteri-MOD Yeast-FEW Epi-0 AmorphX-OCC
URINE WBC Clm-MANY Mucous-RARE
.
DISCHARGE LABS
[**2185-5-24**] 07:05AM BLOOD WBC-29.9* RBC-2.52* Hgb-8.4* Hct-28.0*
MCV-111* MCH-33.2* MCHC-29.9* RDW-14.8 Plt Ct-257
[**2185-5-24**] 07:05AM BLOOD Neuts-90* Bands-3 Lymphs-0 Monos-5 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2185-5-24**] 07:05AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Bite-OCCASIONAL
[**2185-5-24**] 07:05AM BLOOD PT-28.1* PTT-30.1 INR(PT)-2.7*
[**2185-5-24**] 07:05AM BLOOD Glucose-71 UreaN-13 Creat-0.4 Na-138
K-3.0* Cl-100 HCO3-26 AnGap-15
[**2185-5-24**] 07:05AM BLOOD Calcium-7.7* Phos-3.1 Mg-1.7
.
PLEURAL FLUID LABS:
-PLEURAL TotProt-1.5 Glucose-121 LD(LDH)-186 Albumin-1.1
-PLEURAL WBC-363* RBC-448* Polys-4* Lymphs-4* Monos-0 Meso-2*
Macro-90*
-CYTOLOGY: negative
-CULTURES: no growth
.
Other micro
- blood culture [**5-8**] - no growth
- blood culture [**5-17**] - no growth
- urine [**5-15**] - >100,000 yeast
- stool [**5-12**] - C. diff positive
.
CXRFINDINGS [**5-8**] : There are no old films available for
comparison. The heart is mildly enlarged. Both hemidiaphragms
are obscured likely due to a combination of volume loss and
effusions. An underlying infectious infiltrate cannot be
excluded. There is mild pulmonary vascular re-distribution and
some alveolar opacities. The overall impression is that of CHF.
An underlying infectious infiltrate cannot be excluded.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2185-5-8**]
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bilateral moderate-to-large simple pleural effusions.
3. Bilateral consolidations associated with the pleural
effusions. These
most likely represent atelectasis, although in the proper
clinical setting, pneumonia cannot be excluded.
4. 7-mm ground-glass nodular opacity and two sub-4-mm pulmonary
nodules in the left upper lobe. Given the patient's history of
cancer, per the
[**Last Name (un) 8773**] guidelines, a followup CT of the chest is recommended
at 3 to 6
months.
5. Moderate-to-severe cardiomegaly.
.
ECHO [**5-9**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. No premature appearance of agitated saline is
seen at rest. The estimated right atrial pressure is 5-10 mmHg.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened with mild posterior leaflet elongation, but no
frank systolic prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension.There is an
anterior space which most likely represents a prominent fat pad.
There is a left sided pleural effusion.
IMPRESSION: Mild mitral regurgitation without discrete
vegetation or definite systolic prolapse. No vegitations seen.
No transpulmonary shunt identified. Normal regional and global
biventricular systolic function. Mild pulmonary arterial
hypertension. .
.
CT torso [**2185-5-18**]
1. Proctitis. No evidence of [**Last Name (un) 2432**]-colon.
2. Volume overload as evidenced by moderate-sized bilateral
pleural
effusions, cardiomegaly and anasarca.
3. Mediastinal and supraclavicular lymphadenopathy with
pulmonary nodules is
concerning for metastatic disease. Followup CT of the chest
could be
performed in three to six months to document stability of the
pulmonary
nodules.
4. Dysmorphic liver. In the setting of a large heart and
dilated hepatic
veins, a cardiac etiology should be considered.
.
CXR [**5-19**]
IMPRESSION: Unchanged small left and trace right pleural
effusions since
[**2185-5-15**].
Brief Hospital Course:
81 yo F with hx of SCC, Afib, HTN who presents with UTI and L
hydronephrosis s/p stent placement found to by hypoxic with
large bilateral pleural effusions now improved after R.
thoracentesis and course complicated by [**Female First Name (un) **] cystitis and
severe C. diff infection.
.
1. Respiratory Failure/hypoxia due to pleural effusions -
Patient found to have large bilateral pleural effusions after
aggressive fluid administration during urology procedure. She
was initially admitted to the intensive care unit for hypoxia.
She underwent a thoracentesis (removed 1L of fluid) with
subsequent improvement in oxygenation. Pleural effusions were
thought to be due to volume overload related to aggressive
volume given during urology procedure combined with low albumin
state. She has no renal failure or evidence of CHF on echo to
explain volume overload. Alternatively, pleural fluid was
exudative by LDH criteria and given history of malignancy there
was also concern for possible malignant effusion. However,
cytology and micro from sample were negative. Patient responded
well to IV diuresis (20 mg IV Lasix) and was able to wean to
low-mid 90s on room air without evidence of respiratory
distress. Her discharge weight was 116.4 lbs. She was not
discharged on oral Lasix given that she was orthostatic on exam.
If she gains more than 5 pounds, develops worsening lower
extremity edema, or respiratory distress, would restart Lasix at
either 20 mg IV or 40 mg oral.
2. Severe C. difficile colitis with leukocytosis - Patient found
to have sudden increase in her white blood cell count to 30,000
with diarrhea. She was found to have positive C. diff toxin and
initiated on IV Flagyl. Her WBC continued to
increase and she was broadened to PO and PR Vancomycin. Given
abdominal distention, she underwent a CT Torso which showed
proctitis likely related to C. diff infection but otherwise no
evidence of occult infection or megacolon. The imaging did
however show concern for metastatic disease. Her WBC stabilized
but did not improve with her improving symptoms. Infectious
disease was therefore consulted who felt her WBC was consistent
with C. diff plus a leukemoid reaction, possibly related to her
malignancy. We continued her PO Vancomycin at 500 mg, then back
to 125 mg QID. She remained stable with soft bowel movements
with mild abdominal distention, but no pain, fever, or ileus.
We recommend continuing PO vancomycin to complete a full course
and monitoring her WBC for resolution. Her course may need to
be extended or tapered should she not respond. Heme/Onc eval of
her leukocytosis may also be considered.
--she was discharged on oral vancomycin every 6 hours for at
least a 14 day course (day 1 was [**5-22**]). She was discharged on
500 mg QID. However, if patient has no worsening symptoms in the
2 days following discharge, she can change the vancomycin dose
to 125 mg QID to complete her course.
2. Bacterial/Fungal UTI - Patient was admitted on antibiotics to
treat complicated urine infection. Initially she was placed on
Zosyn. Urine culture showed E. coli sensitive to cephalosporins.
She was subsequently changed to ceftriaxone. She completed a 14
day course. On repeat urine study, patient was noted to have
greater than 100,000 yeast. Given continued dysuria she was
started on fluconazole and completed a 7 day course. She will
need to follow up with urology for management of her ureteral
stents
3. AFib: Presented with supra therapeutic INR which was
subsequently reversed for thoracentesis. Coumadin dose was
titrated to maintain therapeutic INR between [**1-7**]. She will need
to have her INR checked daily after discharge. When it
falls below 2.5, would give Coumadin 0.5 mg. She will need to
have INR checked at least twice weekly until on stable dosing.
Patient was given her home diltiazem dosing. She was also
restarted on her home metoprolol however she became bradycardic
and this was discontinued. She maintained adequate rate control
between 60-80 with diltiazem alone.
4. hypertension - Patient continued on diltiazem. Her metoprolol
and nifedepine were held and blood pressures maintained in low
100s.
- Monitor for resolution of her orthostasis
5. [**Last Name (un) **]: Patient had peak creatinine of 1.7 at OSH which
subsequently resolved.
6. squamous cell carcinoma - s/p chemo and radiation with
evidence of metastatic disease on imaging, with LAD and
pulmonary nodules. Patient was started on long acting pain
control with OxyContin and continued on oxycodone prn for
breakthrough. She was also given standing Tylenol. She should
follow up with her oncologist to discuss further treatment and
goals of care.
7. Poor Nutritional Status: Patient with poor appetite and
albumin notably was 3.2. She was encouraged to drink ensure TID
with her meals. This should be encouraged further in rehab.
transitional issues:
- C diff infection - She was discharged on 500 mg QID. However,
if patient has no worsening symptoms in the 2 days after
discharge, can change the dose of vancomycin to 125 mg QID to
complete her course.
- Goals of care: patient with clear end of life wishes,
discussed with daughter; no code/compressions, but OK to
intubate if respiratory failure
- patient will need INR checked daily. When INR less than 2.5
would start 0.5 mg of Coumadin. She will need to have her INR
checked at least twice weekly after restarting Coumadin until on
stable regimen.
- Patient's discharge weight was 116.4 lbs. If she gains more
than 5 pounds, develops worsening lower extremity edema or
respiratory distress, would restart Lasix at either 20 mg IV or
40 mg oral. Notably patient had episodes of orthostasis while
being diuresed.
- patient will need to follow up with her oncologist regarding
her leukocytosis and metastatic disease to address further
treatment and goals of care.
- Patient will need to follow up with urology for management of
her ureteral stents.
Medications on Admission:
-Warfarin 2mg PO daily
-Nifedipine XL 120mg PO daily
-Fluticasone Propionate 0.05%
-Toprol XL 50mg PO daily
-Nitrofurantoin 50mg PO daily
-Diltiazem 240mg PO daily
-Alprazolam 0.25mg PO qhs
-APAP/Codeine 300/30mg PO q4h PRN pain
-Famotidine 20mg PO daily
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Diltiazem Extended-Release 240 mg PO DAILY
hold for SBP<100, HR<60
3. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Senna 1 TAB PO BID:PRN Constipation
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
hold for oversedation, RR<12
9. Oxycodone SR (OxyconTIN) 10 mg PO Q8H
hold for oversedation, RR<12
10. Vancomycin Oral Liquid 500 mg PO Q6H Duration: 12 Days (can
decrease dose to 125 mg QID to complete course if patients
symptoms do not worsenen in the next 2 days)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4470**] HealthCare Center at [**Location (un) 38**]
Discharge Diagnosis:
primary diagnosis: urinary tract infection, clostridium
difficile colitis. dyspnea
secondary diagnosis: squamous cell carcinoma of the skin, atrial
fibrillation
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 112065**],
It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted to the hospital with
difficulty breathing after a recent urologic procedure. You were
found to have fluid around your lungs (pleural effusions),
likely caused by getting fluids during your operation. The fluid
was removed from your right lung via thoracentesis, and your
oxygenation improved. You were also give intravenous medications
to help remove the fluid. In addition to this you were treated
for both a bacterial and yeast urine infection with medications.
You were also found to have an infection called Clostridium
difficile colitis which you started treatment for. You were
evaluated by the physical therapy team who felt that you would
benefit from rehab.
.
The following changes have been made to your medication regimen.
Please START taking
- oral vancomycin 500 mg every 6 hours for total 14 days (day 1
[**5-22**])
- lasix 40 mg as needed if weight increases by more than five
pounds
- oxycontin 10 mg three times a day
- oxycodone 5 mg every six hours as needed for pain
.
Please STOP taking
- metoprolol
- nifedipine
- tylenol #3
.
You were not discharged on a [**Month/Year (2) 1988**] coumadin dose. You will
need to have your INR checked at your facility and your dose
will be adjusted appropriately.
.
Please take the rest of your medications as prescribed and
follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
Followup Instructions:
Department: Hematology/ Oncology
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Tuesday [**2185-6-7**] at 11:15 AM
Location: [**Location (un) **] HEMATOLOGY ONCOLOGY
Address: [**Location (un) 10726**], [**Hospital1 **],[**Numeric Identifier 10727**]
Phone: [**Telephone/Fax (1) 10728**]
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital 1263**] Hospital
Address: [**Apartment Address(1) 112066**] [**Location (un) 686**], MA
Phone: [**Telephone/Fax (1) 64585**]
Appointment: Friday [**2185-6-10**] 10:45am
Completed by:[**2185-5-24**]
|
[
"51881",
"5849",
"42731",
"V5861",
"4019",
"2859"
] |
Admission Date: [**2132-6-12**] Discharge Date: [**2132-6-23**]
Date of Birth: [**2055-12-9**] Sex: M
Service: SURGERY
Allergies:
Demerol / Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Scooter collision vs auto
Major Surgical or Invasive Procedure:
PEG placement [**2132-6-18**]
Extrernal fixation and debridement left ankle [**2132-6-12**]
History of Present Illness:
74 yo male who while crossing street in his motorized scooter
was struck by an auto at an unknown rate of speed. No LOC. He
was taken to an area hospital, found to have an open tib/fib
fracture. He was later transferred to [**Hospital1 18**] for continued trauma
care.
Past Medical History:
Multiple sclerosis
Family History:
Noncontributory
Physical Exam:
VS upon admission to truam bay: T 100.8 BP 180/palp HR 88 RR
20 O2 Sat 99% on NRB mask GCS 15
HEENT: forhead laceration; raised area on occipital region
Neck: cervical collar
Chest: CTA bilat with symmetrical expansion
Cor: RRR
Abd: soft, tender RLQ
Back: non tender
Pelvis: stable; abrasion left hip
Rectum: good tone, guaiac negative
Extr: LLE with open fracture
Pertinent Results:
[**2132-6-12**] 04:42PM LACTATE-2.2*
[**2132-6-12**] 04:40PM GLUCOSE-119* UREA N-21* CREAT-1.1 SODIUM-139
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-19* ANION GAP-18
[**2132-6-12**] 04:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2132-6-12**] 04:40PM WBC-19.8* RBC-4.65 HGB-14.3 HCT-41.5 MCV-89
MCH-30.7 MCHC-34.5 RDW-13.6
[**2132-6-12**] 04:40PM PLT COUNT-203
[**2132-6-12**] 04:40PM PT-13.1 PTT-24.4 INR(PT)-1.1
Sinus rhythm. Poor R wave progression. Non-specific T wave
changes in
leads I and aVL. Compared to the previous tracing of [**2132-6-17**] the
QRS changes in
lead V3 could be due to lead placement. T waves are now inverted
in lead aVL
and atrial fibrillation is absent.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 162 74 [**Telephone/Fax (2) 67107**] 85
PATIENT/TEST INFORMATION:
Indication: New AF in setting of leg fracture.
Height: (in) 70
Weight (lb): 175
BSA (m2): 1.97 m2
BP (mm Hg): 150/43
HR (bpm): 69
Status: Inpatient
Date/Time: [**2132-6-16**] at 12:14
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W020-0:23
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.1 cm
Left Ventricle - Fractional Shortening: 0.35 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 60% (nl >=55%)
Aorta - Valve Level: *3.8 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.50
Mitral Valve - E Wave Deceleration Time: 195 msec
TR Gradient (+ RA = PASP): *36 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Normal regional LV systolic function. No
resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic root. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild to
moderate ([**2-11**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. No PS.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with
normal cavity size and systolic function (LVEF>55%). Regional
left ventricular
wall motion is normal. Right ventricular chamber size and free
wall motion are
normal. The aortic root is mildly dilated. The ascending aorta
is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic
stenosis is not present. Mild to moderate ([**2-11**]+) aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary
artery systolic hypertension. There is no pericardial effusion.
C-SPINE NON-TRAUMA [**3-14**] VIEWS PORT [**2132-6-14**] 5:07 AM
C-SPINE NON-TRAUMA [**3-14**] VIEWS P
Reason: ap/lat to assess fusion
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with c-spine fx
REASON FOR THIS EXAMINATION:
ap/lat to assess fusion
HISTORY: C-spine fracture, assess fusion.
CERVICAL SPINE, TWO VIEWS.
C1 through the C7/T1 disc space is demonstrated. The patient is
status post osteometallic fusion at C6/C7, with anterior plate
and screws and intervening fusion plug. There is limited
purchase of the lower screws into the C7 vertebral body. The
plate lies approximately 7.5 mm anterior to the anterior cortex
of C7, with only approximately 3.6 mm of screw within the
vertebral body. The fusion plug is seen in the disc space, which
is wider anteriorly. There is approximately 2 mm gap between the
anterior cortex of the plug and the inferior endplate of C6,
though the deeper portion of the plug abuts both adjoining
endplates. There is approximately 3.4 mm distance between the
superior portion of the anterior plate and the anterior cortex
of C6. There is mild kyphotic angulation centered at C6/C7. Mild
prevertebral soft tissue swelling is present. Background
osteopenia and degenerative change are noted. The patient is
status post laminectomy at C3 through C7. The T1 level is not
evaluated optimally on this film. Overlying skin staples are
noted. The patient is edentulous.
IMPRESSION:
1) S/p C6/7 fusion and C3/7 laminectomy.
2) Anterior fusion plate not directly abutting vertebral bodies,
with limited purchase of screws in C7. C6/7 disc space and
graft, as described. Clinical correlation requested.
CT HEAD W/O CONTRAST [**2132-6-12**] 4:46 PM
CT HEAD W/O CONTRAST
Reason: eval for bleed/fx
[**Hospital 93**] MEDICAL CONDITION:
74 year old man s/p ped struck
REASON FOR THIS EXAMINATION:
eval for bleed/fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Pedestrian struck by motor vehicle.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT scan.
FINDINGS: There is no evidence of acute intracranial hemorrhage,
or shift of normally midline structures. There is moderate
asymmetric dilatation of the lateral ventricular bodies and
atria, right more than left, with more symmetric sulcal and
fissural prominence. This likely reflects atrophy superimposed
on congenital/developmental ventricular asymmetry, as there is
no defnite focal volume loss on the right. [**Doctor Last Name **]- white
differentiation appears preserved, with moderate bihemispheric
periventricular white matter micro- ischemic change. Surrounding
osseous and soft tissue structures are unremarkable.
IMPRESSION: No evidence of acute intracranial hemorrhage.
Asymmetrically prominent ventricles, likely representing
involutional changes superimposed on developmental asymmetry.
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedic surgery and
Neurosurgery were consulted because of his injuries. He was
taken to the operating room for repair of his left open tib
fracture. He will be discharged on Clindamycin and will need to
follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics in 1 week. He will
also need to continue with Lovenox for a total of 4 weeks.
Neurosurgery was consulted because of his cervical spine
fractures; he is being treated conservatively with a hard collar
to be worn for a total of 3 months. He will then need to follow
up with Neurosurgery for repeat imaging.
Cardiology was consulted because atrial fibrillation; it was
recommended that he start on a beta blocker, ACEI, Amiodarone
which is being tapered and ASA 81 daily.
These were implemented.
Geriatrics was consulted as well and have made several
recommendations regarding his medications.
Speech Language Pathology was consulted, a bedside swallow
evaluation was performed; patient exhibited aspiration; he
should therefore remain NPO. A repeat swallow study will need to
be performed.
Patient underwent PEG placement in the operating room on
[**2132-6-18**]; postoperatively he had decreased urine output and has
been pre-renal; most recent labs today [**6-23**] BUN 50(47) and Cr
1.5 (1.7) He has been hydrated with IVF and has received IVF
boluses intermittently. His Foley catheter remains in place
primarily due to increased scrotal edema and decreased urinary
output. He was also treated for a UTI early during his hospital
stay; a repeat U/A was sent today; results pending at time of
this dictation.
Physical and Occupational therapy were also consulted and have
recommended rehab for patient.
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 weeks.
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): See attached sliding scale.
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day): hold for HR <60 and/or SBP <110.
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
6. Oxycodone 5 mg/5 mL Solution Sig: [**2-11**] PO Q6H (every 6 hours)
as needed for pain.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash: Apply to groin region.
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) for 2 days: Continue 400 mg tid until [**6-25**]; then 400 mg
[**Hospital1 **] x 1 week; then 400 mg qd x 1 week; then 200 mg qd
thereafter.
12. Clindamycin Phosphate 150 mg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours): Continue until follow up with
Orthopedic surgery in 1 week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
s/p Scooter collision vs. auto
Left open tib/fib fracture
Right C5-C6 facet fracture
Left C6 lamina fracture
Discharge Condition:
Stable
Discharge Instructions:
* You must continue to wear your cervical collar until you
follow up with Neurosurgery.
* Follow up with Dr. [**Last Name (STitle) 1005**] (Orthopedics) in 2 weeks, call
for appointment: ([**Telephone/Fax (1) 2007**]. You will need to continue with
the Clindamycin until follow up with Dr. [**Last Name (STitle) 1005**].
*Follow up with Neurosurgery in 10 weeks.
*Follow up with your primary care doctor after your dicharge
from rehab.
Followup Instructions:
Call [**Telephone/Fax (1) 1228**] for an appointment with Dr.[**Last Name (STitle) 1005**],
Orthopeidcs in 2 weeks.
Call [**Telephone/Fax (1) 2731**] for an appointment with Dr. [**Last Name (STitle) 65817**],
Neruosurgery in 10 weeks. Inform the office that you will need
repeat CT scan of your cervical spine for this appointment.
Completed by:[**2132-6-23**]
|
[
"5990",
"42731",
"5849",
"4019"
] |
Admission Date: [**2189-1-20**] Discharge Date: [**2189-2-16**]
Date of Birth: [**2121-4-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
Hemodialysis initiation
Paracentesis
Thoracentesis
History of Present Illness:
HPI: Mr. [**Known lastname **] is a 67 y.o. male with cryptogenic cirrhosis
and hepatorenal syndrome presented to outside hospital with
incrasing abdominal girth. He has also experienced increasing
shortness of breath and right flank pain similar to his prior
symptoms due to increased ascities. He was [**Hospital 82065**]
[**Hospital3 8834**] and had his ascities tapped today,
approx 5000 ml (turbid serosanguineous) taken out. His CXR was
suspicious for Multifocal PNA.
His lab tests there were HCT 30.3, plt 193, wbc 12.1, PT 17, INR
1.7, glu 136, BUN 61, CR 3.8, Na 134, K 5.7, Cl 102, bicarb 17,
Ca 9.3, prot 6.1, alb 3.6, bili 1.8, alk phos 353, alt 20, ast
60, amylase 58, lipase 112. His creatine trended upto 4.7 today
per discharge summary.
He was treated with zosyn 2.25 grams IV q8h, cipro 250 mg daily,
midodrine 5 mg tid, prilosec 20 mg daily, carafate 1 gram qid,
sodium bicarb 650 mg [**Hospital1 **], lactulose 10 grams [**Hospital1 **], dilaudid 1 mg
q3h, vitamin K 5 mg oral.
He was afebrile at OSH with stable vital signs per verbal
report. On arrival to MICU his vitals were HR 106 BP 112/50
RR 22 96% on 4LNC. Temp was not measured. Patient states that
his symptoms improved after the paracentesis.
Past Medical History:
- cryptogenic cirrhosis; heterozygous for HFE gene mutation and
liver biopsy with marked iron deposition; grade I varices s/p
banding [**10/2188**]; listed for transplant (currently inactive given
his pneumonia)
- recent hepatorenal syndrome with rising creatinine
- left carotid endarterectomy on [**2189-1-13**] with Dr. [**Last Name (STitle) **]
- known left-sided chylothorax per thoracentesis [**12/2188**]
- nephrolithiasis s/p surgical stone extraction
Social History:
Patient denies current alcohol, tobacco or illicit drug use. He
reports prior, social alcohol use and infrequent tobacco use. He
has no tattoos or piercings and also denies a history of blood
transfusions. He is self-employed, working in sales.
Family History:
Nephew with hemachromatosis, otherwise no family history of
liver disease. Father died from prostate CA and mother died from
CAD. Two sisters died from CAD. Two brothers alive with cardiac
problems. 3 daughters alive and well.
Physical Exam:
Admission Exam
Vitals: HR 106 BP 112/50 RR 22 96% on 4LNC
General: pleasant gentleman in no acute distress, following
commands
HEENT: MMM, EOM-I, sclerae anicteric
Neck: supple, JVP 8-9 cm
Cor: S1S2, regular tachycardic
Lungs: Left base > right base crackles, no wheezing
Abd: distended but soft, nontender, hypoactive bowel sounds
Ext: 3+ pitting edema bilaterally, feet warm, cellulitis in left
lower extremity, right elbow abrasion.
Neuro: AOx3, strength 5/5, sensation is intact. No asterixis
Skin: no jaundice, multiple skin tears
Discharge Exam:
Patient deceased
Pertinent Results:
[**2189-1-20**] 09:35PM PT-28.5* PTT-46.0* INR(PT)-2.9*
[**2189-1-20**] 09:35PM PLT COUNT-228
[**2189-1-20**] 09:35PM NEUTS-82* BANDS-3 LYMPHS-7* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2189-1-20**] 09:35PM WBC-17.5* RBC-2.86* HGB-10.2* HCT-31.5*
MCV-110* MCH-35.5* MCHC-32.2 RDW-18.8*
[**2189-1-20**] 09:35PM ALBUMIN-3.6 CALCIUM-10.2 PHOSPHATE-6.0*#
MAGNESIUM-2.3
[**2189-1-20**] 09:35PM ALT(SGPT)-221* AST(SGOT)-1452* LD(LDH)-1412*
ALK PHOS-337* TOT BILI-2.5*
[**2189-1-20**] 09:35PM estGFR-Using this
[**2189-1-20**] 09:35PM GLUCOSE-57* UREA N-72* CREAT-5.2*# SODIUM-138
POTASSIUM-6.9* CHLORIDE-102 TOTAL CO2-19* ANION GAP-24*
[**2189-1-22**] 02:07AM BLOOD WBC-14.0* RBC-2.50* Hgb-8.9* Hct-26.8*
MCV-107* MCH-35.7* MCHC-33.3 RDW-19.0* Plt Ct-139*
[**2189-1-22**] 02:07AM BLOOD PT-33.6* PTT-56.8* INR(PT)-3.5*
[**2189-1-22**] 02:07AM BLOOD Plt Smr-LOW Plt Ct-139*
[**2189-1-22**] 02:07AM BLOOD Glucose-128* UreaN-82* Creat-5.8* Na-141
K-4.2 Cl-103 HCO3-21* AnGap-21*
[**2189-1-20**] 09:35PM BLOOD ALT-221* AST-1452* LD(LDH)-1412*
AlkPhos-337* TotBili-2.5*
[**2189-1-21**] 06:58AM BLOOD ALT-177* AST-1137* LD(LDH)-827*
AlkPhos-230* TotBili-1.9*
[**2189-1-22**] 02:07AM BLOOD ALT-107* AST-358* LD(LDH)-270* CK(CPK)-38
AlkPhos-222* TotBili-1.7*
[**2189-1-22**] 02:07AM BLOOD Albumin-3.8 Calcium-9.7 Phos-5.6* Mg-2.2
.
[**2189-1-21**] 3:41 pm PERITONEAL FLUID
GRAM STAIN (Final [**2189-1-21**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
.
[**2189-1-21**] 4:29 pm URINE Source: CVS.
**FINAL REPORT [**2189-1-22**]**
URINE CULTURE (Final [**2189-1-22**]):
YEAST. >100,000 ORGANISMS/ML..
.
[**2189-1-21**] 4:29 pm URINE Source: CVS.
**FINAL REPORT [**2189-1-22**]**
Legionella Urinary Antigen (Final [**2189-1-22**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
.
[**1-20**] CXR: PORTABLE AP CHEST RADIOGRAPH: New right mid lung
perihilar consolidation. Oblique sharp margin seen in the left
lower chest is frequently assigned to collapse of left lower
lobe. However, no heart border can be identified, the appearance
is similar in prior studies, and there is no displacement of the
heart. Therefore, we would like to think that this sharp margin
probably does not represent lung collapse.
.
[**1-21**] Liver US
FINDINGS: As before, the liver is diffusely nodular and
heterogeneous in
architecture, in keeping with cirrhosis. There is a large amount
of ascites. Incidental note is also made of a left pleural
effusion. The spleen measures 10.6 cm in length. There is no
intra- or extrahepatic biliary dilatation. The common bile duct
measures 4 mm, unchanged.
Main portal vein, left portal vein, and right portal vein are
all patent, and demonstrate normal waveform and flow direction.
Left, middle, and right
hepatic veins are patent and demonstrate normal flow direction.
IVC is
unremarkable. Hepatic arteries are patent and demonstrate normal
waveforms. Splenic vein is patent.
IMPRESSION:
1. Patent and normal-appearing hepatic vessels.
2. Cirrhosis with large amount of ascites.
3. Left pleural effusion
.
[**1-21**] Renal US:
FINDINGS: Comparison made to [**2189-1-8**]. Right kidney measures
11.3 cm, left kidney measures 10.5 cm. Cyst in the upper pole of
the left kidney measuring 2.1 x 1.5 x 1.4 cm is not
significantly changed. There is no solid mass, stone, or
hydronephrosis in either kidney. There is a large amount of
ascites throughout the abdomen.
Color Doppler evaluation of both kidneys shows normal color flow
and arterial waveforms.
IMPRESSION:
1. No hydronephrosis. No evidence of renal artery stenosis.
2. Large volume ascites.
.
[**1-22**] CXR: In comparison with study of [**1-20**], the moderate left
pleural
effusion persists. Right upper lobe consolidation is similar in
appearance to the previous study. Left basilar atelectasis is
unchanged.
.
[**1-26**] CT Abd, Chest: 1. Multiple tiny hepatic non-enhancing
hypodensities are consistent with cirrhosis although small
hepatic abscesses can not be excluded (in the absence of prior
studies to suggest stability).
2. Right upper lobe opacification with consolidation worse
posteriorly
suggests pneumonitis from aspiration or infection.
3. Persistent multifocal ground-glass opacification in the right
lower lobe; the etiology can be infectious or inflammatory.
4. Large left pleural effusion with associated relaxation
atelectasis.
5. Persistent significant ascites, cirrhosis.
6. Engorgement of mesenteric vessels.
.
[**1-30**] CXR: Overall unchanged compared to prior study, with
moderate-sized
left pleural effusion associated with left basilar atelectasis.
Brief Hospital Course:
67 y.o. male with cryptogenic cirrhosis, likely due to
alpha-1-antitrypsin deficiency (per biopsy) and hemochromatosis,
complicated by hepatorenal syndrome was admitted to OSH with PNA
and transfered here for further evaluation.
# Fungemia (ICU Course): The patient was transferred to the ICU
for sepsis and hemodynamic instability. He was intubated and
ventilated with Central access obtained. He was found to be
fungemic. Treatment was initated, however the family was
consulted and directed our team to withdraw care.
# Pneumonia: Transfered from OSH for CXR with multifocal PNA.
HAP given recent admission. Hemodynamically stable on arrival,
sating in mid 90s on 4 L NC. CXR with R upper/middle lobe
infiltrate. By day of transfer patient had O2 sat 99% on 2L,
significantly better than on admission. He has CP with coughing
localized to R ribs, Had significant fall at OSH when getting
Out of bed and landed on right side. It is possible that the CXR
finding reflect a contusion from fall and not pneumonia. Sputum
culture with yeast. urine legionella negative. Treated with
vanc, zosyn, and fluconazole for two weeks. The pt's symptoms
resolved, as did the consolidation on CXR. However, Mr. [**Known lastname **]
had a persistant, left-sided pleural effusion. Due to
persistent episodes of SOB, pt. underwent thoracentesis w/ 1.8L
removal. Fluid showed chylous transudative materarial,
consistent w/ hepatic hydrothorax.
# L. Effusion. Pt. w/o overt signs of infection, but continued
to have episodes or respiratory distress including dyspnea, felt
to be [**3-9**] hepatic hydrothorax. As pt. continued to experience
respiratory distress episodes of tachypnea, and SOB, he
underwent a therpaeutic and diagnostic thoracentesis on [**2189-2-8**].
Fluid was transudative, w/ 58 WBCs, 7 Polys, 23 Meso, 43 Macro
and > 14K RBCs, chylous, cytology was pending at time of
discharge. Pt. developed small L PNTx, persistent on CXR on
post thoracentesis day 1, on discharge this had resolved.
Patient will require a repeat CT of chest in 4wks to assess for
resolution of RUL PNA and L effusion.
# Tachycardia. Pt had persistently elevated HR in 100-110
during floor stay. He was ruled out for PE w/ CTA, which showed
slightly worsened RUL opacification (see below). There was no
chest pain, no changes in ECG. He completed ABx course as above
and there were no signs of infection, w/ [**Female First Name (un) 576**]/para results
negative for infection after initial PNA was treated. Pain was
adequately controlled. Despite tachycardia, patient was he
denied palpitations.
# Respiratory distress episodes. Pt. w/ dyspnea, tachypnea,
wheezing and tachycardia on occasions and during HD. These
episodes ceased temporarily after thoracentesis on [**2189-2-8**],
however recurred by [**2189-2-10**]. They were felt to be related to the
RUL lesion, L effusion and massive ascites. Pt. had
emphysematous changes on CXRs. Due to continued SOB, patient
underwent another therapeutic paracentesis on [**2189-2-11**] with
improvement in symptoms. Mr. [**Known lastname **] was started on
ipratropium nebulizers while treated for PNA and Xopenex was
added on [**2189-2-7**]. Echo w/ bubble study was performed to assess
for intrapulmonary shunting and reassessment of pulmonary
hypertension as possible causes of dyspnea episodes.
# Hepatorenal syndrome: Patient currently on both the liver and
kidney transplant lists. Serum Creatinine on recent discharge
from [**Hospital1 18**] was 3.8 with BUN of 60. He was treated with midodrine
as outpatient. On admission Cr was over 5, it was unclear if
this was purely HRS or if this represented intrinsic kidney
insult. UOP steadily declined during admission and Cr peaked at
6.7. Renal US [**1-21**] was normal. Pt did not respond to fluid
challenge and HRS was diagnosed. Pt was treated for HRS with
midodrine 10mg tid, octreotide (200mg Q8h), and albumin until
dialysis. A R tunneled line was placed on [**1-23**] followed by HD
as transition to transplant. BPs improved, thus midodrine and
ocreotide were discontinued. Mr. [**Known lastname **] had two episodes of
hypotension to SBP in 70s during dialysis and was thus restarted
on Midodrine in AM prior to dialisis. The first, on [**1-26**], was
associated with dyspnea and diaphoresis. His infectious work-up
was negative. He received a diagnostic and therapeutic
paracenteses that afternoon, while led to complete relief of his
symptoms and increase in his BP. On [**1-31**], the pt had
hypotension to SBP 70s while attempting to take fluid off - he
was given albumin and his BP recovered. Pt. continued to
receive midodrine and albumin prior to each dialysis session.
His MELD ranged 27-30 through most of his hospitalization. SBPs
were in 90-110 range. Pt. was arranged for HD on T/T/Saturday
as OP (please see discharge plan). For hyperphosphatemia
patient was started on Ca Acetate. In addition he was started
on nephrocaps. Pt. is on SBP prophylaxis.
# Abdominal Pain/Cirrhosis: Secondary to
cryptogenic/alpha-1-antitrypsin/hemochromatosis cirrhosis. Pt
was accepted to liver and kidney transplant lists. Paracentesis
[**1-27**] showed no SBP; 7.5L taken off. Para [**2-4**] no SBP; 5.5L
taken off, while paracentesis on [**2-11**] was performed w/ 5L
removal. These procedure also led to resolution of the pt's
abdominal pain, indicating that the distension was his trigger.
Pt's cirrhosis confirmed on CT and continued to have elevated
LFTs throughout his stay. His Tbili ranged from 1.5 to 3.0; his
INR ranged from 1.9 to 3.7. PPD was negative and HBsAg, HBcAb
were also negative. HBsAb intermediate. HCV neg. His MELD
ranged 27-30 through most of his hospitalization. Pt. is to
follow up with Liver clinic within 1wk of discharge from [**Hospital1 18**].
# Anemia. Macrocytic. On admission, Hct decreased from 31.5 ->
23.6. Likely a dilutional effect in addition to rectal bleeding.
The pt has confirmed internal hemorrhoids, small AV
malformations [**10-13**] on c-scope, and had several episodes of BRBPR
prior to admission and early in the admission. His Hct stayed in
the 25-30% throughout his admission. He did not require
transfusions. The stool guaiacs during the second half of his
stay were negative for blood. Folate, B12 were nl. TSH was
mildly high, 6.6 and free T4 was marginally low 0.91 (lower
limit of nl 0.93). This decrease was felt not significant
enough to account for anemia.
# Nurtition. Patient w/ poor nutritional status and irregular
intake of caloric requirement. Albumin was 3.1 on admission.
Due to this, he required placement of post pyloric tube placed
on [**2189-2-9**] with required tube feeds, Nutren Renal Full strength
at 40 ml/hr, w/ 50 ml water flushes q4h.
# Peripheral arterial disease: s/p recent left carotid
endarterectomy [**2189-1-13**]; no active issues; outpatient follow-up.
Medications on Admission:
Medications on Transfer:
Zosyn 2.25 grams IV q8h
Ciprofloxacin 250 mg daily
Midodrine 5 mg tid
Prilosec 20 mg daily
Carafate 1 gram qid
Sodium bicarb 650 mg [**Hospital1 **]
Lactulose 10 grams [**Hospital1 **]
Dilaudid 1 mg q3h
Vitamin K 5 mg oral.
.
Allergies/Adverse Reactions: NKDA
Discharge Medications:
1. 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*
2. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO 7AM ON DAYS OF
DIALYSIS ().
Disp:*30 Tablet(s)* Refills:*2*
3. Lactulose 10 gram/15 mL Syrup Sig: 15-45 MLs PO TID (3 times
a day): Titrate to [**4-8**] bowel movements daily.
Disp:*5 bottles* Refills:*10*
4. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO QFriday.
Disp:*12 Tablet(s)* Refills:*2*
5. 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.
6. Albumin, Human 25 % 25 % Parenteral Solution Sig: 12.5 mg
Intravenous Q Dialisis.
7. Epogen 4,000 unit/mL Solution Sig: One (1) ml Injection Q
Dialisis.
8. Outpatient Lab Work
CBC with differential, Chem 10, AST, ALT, Total Bilirubin,
Albumin, PT/PTT/INR, to be drawn at EOD or at discretion of
rehabilitation physician.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itchyness.
12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses:
- Cirrhosis, likely from alpha-1-antitrypsin deficiency and
hemochromatosis
- Hepatorenal syndrome
- L-sided pleural effusion
- Hospital-acquired pneumonia
.
Secondary diagnoses:
- peripheral vascular disease
Discharge Condition:
Deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"486",
"5119",
"2762",
"0389",
"99592",
"2767",
"4019",
"2859"
] |
Admission Date: [**2198-5-22**] Discharge Date: [**2198-6-13**]
Date of Birth: [**2135-9-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Codeine
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Group B Strep Endocarditis with OD Endophthalmitis
Major Surgical or Invasive Procedure:
TEE
PICC line placement
EGD
History of Present Illness:
This is a 62yo female with history of autoimmune hepatitis on
chronic immunosuppression, liver cirrhosis, diabetes, COPD,
chronic leg swelling from previous fracture, on imuran and
prednisone, transferred from OSH with Strep B bacteremia and
endopthalmitis. The patient was initially admitted to OSH on
[**2198-5-17**] for diarreha, nausea, and vomiting, with fever of 102 on
the day of admission. She was initially felt to have an acute
gastroenteritis, mild CHF, and LLE cellulitis. On admission she
was started on IV Vanc for presumed LLE cellulitis, and her
other meds (including imuran and prednisone) were held. She
developed acute loss of vision in her R eye on the night of
admission, and MRI/MRA was obtained. MRI showed multiple
punctate bilateral embolism c/w septic emboli. She was started
on heparin. Neurology recommended echo and MRA of the aortic
arch, concluding her symptoms were c/w embolic stroke. Her
gastroenterologist, Dr. [**Last Name (STitle) 62005**], recommended continuing the
pts Imuran and prednisone. She was also started on stress dose
solu-cortef for unclear reasons (not clear if pt was
hypotensive). On [**5-19**] she was started on IV Gent in addition to
her IV Vanc. Prior to transfer she was seen by opthamology who
felt her sxs were consistent with endopthalmitis and needs
urgent eval for vitreous tap and possible vitrectomy. Of note,
the pt is growing 4/4 bottles from [**5-17**] with strep agalactiae
group B. CXR on [**5-17**] was c/w mild CHF. ESR on [**5-18**] was 75. Urine
cx on [**5-17**] is growing strep agalactiea. Echo on [**5-21**] was
suspicious for mitral valve vegetation.
.
Past Medical History:
A-utoimmune hepatitis with liver cirrhosis and splenomegaly--on
imuran and prednisone
-Grade I esophageal varices
-anemia in setting of imuran
-COPD
-depression
-osteopenia
-chronic sinusitus
-endometrial metaplasia
-L ankle arthritis
Social History:
Employed as conservation [**Doctor Last Name 360**]. Husband. Two children. Non
smoker
Family History:
Non contributory
Physical Exam:
PE: 96.9, 130/62, 71, 18, 94%RA
Gen: ill appearing female laying in bed with eyes closed.
HEENT: Right eye with cloudy purulence coating [**Doctor First Name 2281**], pupil.
Scleral injection. No proptosis. Able to visualize light through
right eye, no movement. No papilledema left eye. Vision intact
on left. JVP to ear lobe.
CV: III/VI SEM LUSB radiating to carotids. Holosystolic murmur
to apex.
LUNGS: Sparse crackles at bases bilaterally
AB: Distended, non tender, + BS. Liver not palpable.
EXTREM: 2+ edema on right, 3+ on left. Erythema over posterior
aspect of calf, anteriorly to knee. Non tender to palpation.
Chronic venous stasis changes. 2+ DP right, 1+left given edema
difficult to palpate.
NEURO: Alert and oriented x 3. EOMI. Cranial nerves not
Skin- no lesions on palms or soles, echymoses throughout body.
Pertinent Results:
[**2198-5-22**] 09:21PM GLUCOSE-175* UREA N-28* CREAT-1.0 SODIUM-138
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2198-5-22**] 09:21PM estGFR-Using this
[**2198-5-22**] 09:21PM ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-79 TOT
BILI-3.7*
[**2198-5-22**] 09:21PM CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-2.3
[**2198-5-22**] 09:21PM WBC-15.9*# RBC-3.41* HGB-12.5 HCT-36.3
MCV-106* MCH-36.8* MCHC-34.5 RDW-16.5*
[**2198-5-22**] 09:21PM NEUTS-86.9* LYMPHS-5.9* MONOS-6.0 EOS-0.1
BASOS-1.1
[**2198-5-22**] 09:21PM ANISOCYT-1+ POIKILOCY-1+ MACROCYT-3+
[**2198-5-22**] 09:21PM PLT COUNT-130*#
[**2198-5-22**] 09:21PM PT-18.9* PTT-35.4* INR(PT)-1.8*
BLOOD WORK [**2198-6-2**]
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2198-6-2**] 07:00AM 13.8* 2.58* 9.6* 28.0* 109* 37.4* 34.5
21.7* 59*
Source: Line-PICC
INR 1.5
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2198-6-2**] 07:00AM 139* 34* 0.7 128* 4.2 94* 31 7*
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili [**2198-6-2**] 07:00AM 34 41* 79
6.5*
.
[**5-24**] CT HEAD
IMPRESSION: No evidence of acute intracranial hemorrhage.
Multiple hypodensities could be consistent with history of
septic emboli. However, for specific evaluation, a
contrast-enhanced CT of the brain or MRI is recommended.
.
[**2198-5-25**] ECHO
Conclusions:
No thrombus is seen in the left atrial appendage. The
interatrial septum is aneurysmal, but no atrial septal defect or
patent foramen ovale is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular systolic function is normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque. The aortic valve leaflets
(3) are mildly thickened. No masses or vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen. There is a
large (1.6 x 1.5 cm) vegetation on the posterior mitral leaflet,
with leaflet perforation. An associated jet of severe (4+)
mitral regurgitation is seen. The anterior mitral leaflet is
normal in appearance, and there is no associated mitral annular
abscess. No vegetation/mass is seen on the pulmonic valve and
tricuspid valve.
IMPRESSION: Mitral valve endocarditis with posterior leaflet
perforation. Severe mitral regurgitation.
.
[**2198-5-28**] PELVIS ULTRASOUND
This is a technically difficult examination. The transabdominal
study is very limited due to the patient's body habitus.
Endovaginal examination was also technically difficult. The
uterus measures 4 cm in transverse x 4.7 cm in AP x 6.5 cm in
sagittal dimensions. The endometrial stripe measures 5 mm in
maximum dimension. Multiple heterogenous areas are identified
within the uterus in the mid body which may represent fibroids.
The largest of these measures less than 2 cm. The ovaries are
not visualized.
IMPRESSION: Technically difficult abdominal and transvaginal
examinations in patient with normal endometrial stripe thickness
and heterogenous appearance of uterus which may represent
fibroids. Ovaries not imaged.
.
[**2198-5-28**] DOPPLER LIVER
COLOR & PULSED DOPPLER SON[**Name (NI) **] LIVER: Normal flow and
waveforms are demonstrated within the hepatic arteries. No
portal venous flow is identified within the main portal vein and
the main portal vein is not well delineated.
IMPRESSION: 1) Heterogeneous echotexture of the liver consistent
with cirrhosis. No focal mass lesion identified.
2) The portal vein is not well delineated on this study. No
color flow or Doppler pulse is present within the expected
region of the portal vein. Chronic portal vein thrombus cannot
be excluded.
3) Cholelithiasis without evidence of cholecystitis.
.
REPEAT ECHO [**2198-6-7**]
No significant changes from prior.
.
Brief Hospital Course:
This is a 62 yo pt with autoimmune hepatitis on chronic
immunosuppression transferred from OSH, with Group B strep
bacteremia, septic brain emboli, endopthalmitis, endocarditis
with large mitral valve vegetation and small perforation.
# Endocarditis/bacteremia: The patient was initially on
vancomycin and gentamycin when transferred, and placed on the
sepsis protocol. AS per ID, gentamycin was discontinued and then
was switched to penicillin 3 million units q 4 hours IV after
desensitization in the MICU without adverse reaction. Pt was
afebrile while in house, with no growth from blood cultures in
house. Vitreous fluid grew group B strep sensitive to vancomycin
and Penicillin. ID followed the patient and she must remain on
antibiotics for a minimum of six weeks. On ID follow up on the
[**6-19**], they will determine the total treatment length. A PICC
line was placed on [**2198-6-1**].
.
# Mitral valve damage: Given bacteremia and probable septic
emboli, as well as likely mitral vegetation on outside hospital
TTE, TEE was performed [**5-25**]. This revealed large mitral valve
vegetation with perforation and severe mitral regurgitation.
Cardiac surgery was immediately consulted. They followed the
patient and determined she was not a surgery candidate given her
multiple risk factors, including her Childs B/C classification.
The patient was started on lasix 20 mg PO daily, and a low dose
of lisinopril. Her beta blocker was increased, and she tolerated
these changes well until an episode of low BP(see below). Prior
to discharge, her nadolol was again reduced to 10 mg [**Hospital1 **] and
tapered off due to decreased low pressure in the setting of
steroid taper.
She developed hypotension 70s/doppler on [**6-6**], which did not
respond appropriately to 1.5 L fluid bolus plus one unit PRBCs.
She was put back on stress dose steroids, all BP meds were d/c
and new blood cultures were sent, with no growth. The next day,
a new echo was ordered out of concern for cardiogenic shock. The
results were similar to the previous one. She never became
febrile or tachycardic. On [**6-7**], BP was 100s/doppler and the
patient continued to be asymptomatic. She compalined of
intermittent atypical chest pain, and several EKG revealed no
ischemic changes.
She needs to be on afterload reduction ideally, consisting of
BB, ACE-I and lasix, however due to her blood pressure running
in the 100's systolic without any symptoms, these medications
were stopped and should slowly be added back as blood pressure
tolerates. Patient is clinically hypervolemic with LE edema and
JVD, however no evidence of pulmonary fluid overload on exam.
.
# Embolic stroke: MRI/MRA outside hospital with evidence of
punctate lesions likely septic emboli. Pt was on Heparin at
outside hospital, but given risk of hemorrhagic bleed into
emboli, it was discontinued upon presentation to the [**Hospital1 18**].
Neurology followed the patient in house. She was disoriented at
times but this was more consistent with hepatic encephalopathy
and depression. She did not develop any neuro deficits. CT head
repeated with no evidence of acute bleed.
.
#Endophtalmitis: the patient presented with hypopyon and
complete vision loss. She underwent tap and aspiration, but not
vitrectomy, liquid growing Strep B, and had antibiotics injected
directly into the chamber: vancomycin and cefepime. Ophto
followed closely and they deem the R eye not salvageable.
Evisceration versus enucleation was planned, however the patient
wished to wait. In the meantime, she was continued on eye drops
recommended by ophto (see medication list). She must protect her
remaining eye at all times. She has been arranged for follow up
with ophto.
.
#Hyperkalemia and hyponatremia- No evidence of adrenal failure.
With hyponatremia and hyperkalemia, there was concern for
adrenal insufficiency, though patient was on stress dose
steroids, which were subsequently tapered to 10 mg daily IV,
then started PO on 80 mg, tapered down to 20 mg PO daily, final
goal 5 mg every other day. Pharmacy was consulted about
penicillin with ~30 MEQ daily potassium, but they did not feel
that this could cause persistent hyperkalemia. The patient was
previously on K sparing diuretic Spironolactone which was held.
The patient required [**Hospital1 **] lyte checks for a few days and several
doses of kayexelate. The hyperkalemia resolved 8 days prior to
discharge, also in the setting of increased insulin.
Hyponatremia persists, and is consistent with ADH derangements
with concentrated urine osmolality. The patient was placed on
free water restriction 1.5 liter daily.
.
#Thrombocytopenia- Platelets decreased during admission, but
remained above 50 except for a value in the 40s on [**6-12**]. Low
platelets are in the setting of cirrhosis with compromised
synthetic function (albumin 1.5). She received vitamin K SQ x 3
doses. HIT was positive, but Serotonin Release Antibody was
negative, therefore the patient was continued on SQ heparin with
no evidence of decreased platelet count or thrombosis. Small
amount of vaginal bleeding during admission, which resolved.
.
#Cirrhosis: EGD demonstarted grade I varices. The hepatology
service followed the patient. Imuran was held. Nadolol was
re-started at 10 [**Hospital1 **], then increased to 20 [**Hospital1 **]. The BB was
subsequently decreased again to 10 mg in the setting of low
blood pressures. Aldactone was held with the development of
hyperkalemia. The patient developed hepatic encephalopathy with
asterixis and lactulose was begun and titrated to 3 BM daily,
with the patient's mental status improving. The patient
developed worsening unconjugated bilirubinemia with some
evidence of hemolysis. Bilirubin then trended down (although it
remains elevated). Transaminases remained normal with a mild
elevation the last few days. Hepatology started rifaximin on
[**6-7**]. Per hepatology, Imuran can be restarted if LFTs double.
Taper of prednisone can continue while watching her LFTs. She
should continue on 20 mg prednisone daily for [**6-13**] and [**6-14**] and
then be decreased to 10 mg daily to be continued indefinitely.
.
#Hemodynamics: The patient blood pressure became low on [**6-5**] and
[**6-6**]. On [**6-6**], she triggered for BP 78/doppler. She was clammy on
exam but not lightheaded or diaphoretic. That same day, her
HCT<25 with no significant bleeding (she had persistent
hematuria throughout admission, insufficient to explain her Hct
drop). She was treated with 1500 cc NS and transfused one unit,
without adequate response. She was started on stress dose
hydrocortisone. After transfusion, the HCT was appropriately 2
points higher. Blood cultures were sent, which were negative.
The next day, an echo showed no changes from prior. BP was
100s/doppler and an EKG was obtained as described above, with no
ischemic changes. The patient's blood pressure stabilized and
she was again placed on steroid taper 2 days later. Discharge BP
was 100/50, which is consistent with patient's baseline BP.
.
#Hyperglycemia: Initially the patient's sugars were 200-300s.
Lantus dose was increased to 32 units, then 34 and 36, and
humalog as well as sliding scale was successively tightened. At
discharge, the finger sticks were significantly improved, and
the lantus dose is again decreased in setting of steroid taper.
.
#Depression: initially, all psychotropic medications were held
due to the patient's poor mentation in the setting of bacteremia
and possibly hepatic encephalopathy. The patient's sensorium
cleared significantly with treatment, however her mood became
increasingly depressed. The patient endorsed feelings of
hopelesness, helplessness, and deep depression. Celexa was
restarted on [**6-11**].
.
#Vaginal bleeding: The patient developed mild vaginal bleeding
with stable crit. She had had a normal Gyn exam and Pap 4 months
prior to admission. Gyn was consulted and examination revealed
dark blood at the cervical os. They recommend that the patient
have an endometrial biopsy as an outpatient.
.
#Funguria: Two successive urine cultures revealed yeast. A
decision was made to institute a short course of fluconazole
(last day [**2198-6-6**]) given the patient's immunosppression. An
attempt was made to d/c Foley, but the patient became unable to
void, and the Foley was reinstituted. A spontaneous voiding
trial on 5/ 5/ 07 again resulted in the patient being unable to
void, therefore the Foley remains in place at discharge. The
patient had at all times a normal neuro exam and specifically,
she did not have saddle anesthesia.
.
#ADL: PT and OT evaluated the patient and the consensus is that
she is significantly below baseline and has excellent rehab
potential. The patient is severely deconditioned and has
difficulty ambulating at discharge.
.
#FEN: diabetic, cardiac diet
.
#PPX: SSI while on steroids, PPI, heparin SQ.
.
#Code: full
.
#[**Name (NI) **] husband at [**Telephone/Fax (1) 62006**]
.
#Dispo- to rehab.
Medications on Admission:
-imuran 75 mg daily
-aldactone 100 mg daily
-lasix 40 mg daily
-prednisone 20 mg daily
-solu-cortef 100 mg IV bid
-Vanc 1 g IV bid
-Garamycin 80 mg IV q 8hr since [**5-19**]
-heparin gtt
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
2. Ciprofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic Q3H
(every 3 hours): Right eye.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): Right eye.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Penicillin G Potassium 5,000,000 unit Recon Soln Sig: One
(1) Recon Soln Injection Q4H (every 4 hours).
12. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic Q3H (every 3 hours): Right eye.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed.
14. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day): Right eye.
15. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO TID (3
times a day).
18. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
19. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 days: Please continue for [**6-13**] and [**2198-6-14**]. .
20. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
Please start on [**2198-6-15**] and continue indefinitely. .
21. Insulin
Please continue glargine and humalog per sliding scale insulin
sheet attached to discharge paperwork.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Endocarditis with mitral valve rupture
Endophtalmitis with irreversible loss of vision OD
Septic Emboli brain
Autoimmune hepatitis with cirrhosis and bilirubinemia
Secondary:
Diabetes Mellitus
Anemia
Thrombocytopenia
Funguria
Vaginal bleeding
Urinary retention
Hepatic encephalopathy
Discharge Condition:
Fair to good.
Discharge Instructions:
You were admitted with an infection in your heart
(endocarditis), which has damaged one of your heart valves, the
mitral valve. In addition, your right eye was severely infected
with endophtalmitis and you also had some septic emboli to your
brain. Other problems with which you presented were uncontrolled
blood sugars, anemia (low blood), and yeast infection to your
urine.
You were desensitized to penicillin and have been receiving
penicillin intravenously. This antibiotic needs to be continued
for at least 6 weeks, and can be administered through the PICC
line that was placed in your right arm. You need to follow the
recommendations of your Infectious Disease doctor (with whom you
have an appointment) as to the exact number of days you must
take antibiotics. Please continue the antibiotics until you see
the ID physician.
[**Name10 (NameIs) 62007**] medical consults were ordered while you were in the
hospital:
- The liver service recommended you stop taking imuran. Your
steroid dose was also slowly reduced to 20 mg daily, which is
your current dose and will be further tapered to 10 mg daily.
- The eye doctors recommend surgery on your right eye, and you
need to follow up with them. YOU MUST PROTECT YOUR LEFT EYE AT
ALL TIMES.
- You were also seen by a gynecologist for vaginal bleeding, and
you need to arrange for an endometrial biopsy as an outpatient.
- The GI doctors examined your [**Name5 (PTitle) 62008**], stomach and duodenum
and found enlarged veins.
You were started on a medication to control your fluid status,
lasix, once a day. You were also started on a new blood pressure
medication, lisinopril. Your nadolol dose was increased to help
your heart. However due to lower blood pressures, these
medications were stopped and can be restarted slowly.
Followup Instructions:
DR [**Last Name (STitle) **] (Eye, [**Last Name (un) **] Center) [**2198-6-22**], 2:30 pm
With your gynecologist as soon as feasible.
With provider (Infectious Disease): [**First Name8 (NamePattern2) 7618**] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2198-6-19**] 9:00
With provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2198-9-6**] 10:45
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"496",
"4280",
"2761",
"2875",
"4240",
"25000",
"2859",
"311"
] |
Admission Date: [**2167-7-31**] Discharge Date: [**2167-8-7**]
Date of Birth: [**2105-6-24**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 62 -year-old
male with known history of coronary artery disease status
post myocardial infarction with angioplasty in [**2155**]. He has
a history of increased cholesterol, family history of heart
disease, and states he has had angina symptoms for many
years. He said within the last year his symptoms have
increased with concomitant shortness of breath. The patient
stated that he was golfing roughly four days prior to
admission and had episodes of left sided chest pains which
radiated to the shoulder and arm.
The patient, on [**2167-7-29**], presented to an Emergency Room for
rule out myocardial infarction and the myocardial infarction
was ruled out with enzymes and electrocardiogram. On
[**2167-7-30**], the patient started exercising, had increased chest
pains for roughly seven minutes, which resolved. The patient
was then worked up for a myocardial infarction once again and
was transferred to a Catheterization Lab for possible
angioplasty.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction in [**2155**].
2. Status post angioplasty of the left circumflex in [**2155**].
3. Gastroesophageal reflux disease.
4. Hypertension.
5. Hypercholesterolemia.
6. Benign prostatic hypertrophy.
7. Dupuytren contractures.
ADMITTING MEDICATIONS: Include Lipitor 40 mg, Cardizem 120
mg q day, aspirin 325 mg q day, Flomax 0.4 mg q day, Ambien
5.0 mg HS, and Ativan 0.5 mg tid prn.
ALLERGIES: Include contrast dye.
PHYSICAL EXAMINATION: On initial examination, vital signs:
blood pressure 150/90, heart rate 50. Neck: negative jugular
venous distention. Chest is clear to auscultation. Heart:
regular rate and rhythm. Abdomen: soft, nontender, positive
bowel sounds. Extremities: +1 dorsalis pedis and posterior
tibial.
LABORATORY DATA: Sodium 143, potassium 3.6, chloride 101,
CO2 27, BUN 13, creatinine 1.0. White blood cell count 5.3,
hemoglobin 13, hematocrit 40, platelets 235,000.
Electrocardiogram showed normal sinus rhythm at 60 and
abnormal.
HOSPITAL COURSE: The patient was admitted on [**2167-7-31**] and
was worked up for coronary artery disease. On [**2167-7-31**] the
patient also had a cardiac catheterization which showed left
main coronary artery normal, left anterior descending long
50% to 60% after S1, LCM occluded, major marginal and
collaterals to distal vessels, right coronary artery distal
occlusion with left coronary collaterals. On [**2167-7-31**]
Cardiothoracic Surgery was consulted and was assessed to have
significant three vessel disease and a coronary artery bypass
graft was planned for the following Monday.
The patient's course between that time and the surgery was
uneventful. On [**2167-8-3**] the patient was brought to the
Operating Room with an initial diagnosis of coronary artery
disease. The patient had a coronary artery bypass graft
times four with an left internal mammary artery to the left
anterior descending, saphenous vein graft to the obtuse
marginal artery and diagonal, and saphenous vein graft to the
AM. The patient tolerated the procedure well and was
transferred to the Post Anesthesia Care Unit in stable
condition.
On postoperative day one, the patient was extubated and was
doing well. The patient was transferred to the floor. On
postoperative day two the patient continued to do well,
increased his physical therapy level and was tolerating a
regular diet. The patient stated that he lived with his wife
and most likely would like to return home after the hospital
stay.
On postoperative day three, the patient continued to do well
and increased his physical therapy level to a III. On
postoperative day four, the patient's physical therapy level
was a V, his hematocrit was stable, and he was discharged
home.
His discharge physical examination: maximum temperature 98.7
F, heart rate 100, respirations 22, blood pressure 105/70, O2
saturation 93% on room air, plus 5.5 kg. Physical therapy
was level V. Cardiovascular was regular rate and rhythm.
Respiratory: clear to auscultation bilaterally. Abdomen was
soft nontender, nondistended. Extremities was negative
peripheral edema. The incisions were clean, dry, and intact.
COMPLICATIONS / SIGNIFICANT EVENTS: None.
DISCHARGE MEDICATIONS: Lasix 20 mg po q twelve hours,
potassium chloride supplements 20 mEq po q twelve hours,
aspirin 81 mg po q day, Lipitor 40 mg po q HS, Flomax 0.4 mg
po q day, Lopressor 50 mg po bid, Niferex 150 mg po q day,
Percocet 5.0 mg one to two tablets po q four to six hours
prn.
DISCHARGE CONDITION: Good and stable to home.
DISCHARGE STATUS: To home.
FOLLOW-UP: Follow-up with Dr. [**Last Name (STitle) 1537**] in three to four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2167-8-7**] 18:01
T: [**2167-8-7**] 19:51
JOB#: [**Job Number 3644**]
|
[
"41401",
"4019",
"2720",
"53081"
] |
Admission Date: [**2101-11-1**] Discharge Date: [**2101-11-8**]
Date of Birth: [**2022-7-3**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 79-year-old gentleman
with known aortic stenosis who has a four-month history of
worsening lightheadedness, fatigue and shortness of breath.
Echocardiogram showed aortic valve area of 1.1 cm squared
with a transvalvular gradient of 29 mm mercury, ejection
fraction of 77 percent. Cardiac catheterization showed a
left ventricular and diastolic pressure of 19, a capillary
wedge pressure of 15, 30 percent proximal LAD stenosis and 50
percent osteal PDA stenosis. The patient was referred to Dr.
[**First Name (STitle) **] [**Last Name (Prefixes) **] for aortic valve replacement.
PAST MEDICAL HISTORY:
1. Status post retinal hemorrhage of the left eye [**2100**].
2. Status post transient ischemic attack of the left eye
[**2099**].
3. Rheumatic heart disease.
4. Status post bilateral knee replacement.
5. Status post appendectomy.
6. Status post bilateral cataract surgery.
7. Hypercholesterolemia.
8. Hard of hearing.
PREOPERATIVE MEDICATIONS:
1. Allopurinol 300 mg once a day.
2. Welchol 625 mg tablets, 3 tablets twice a day.
3. Aspirin 325 mg p.o. once a day.
ALLERGIES: No known drug allergies.
PREOPERATIVE PHYSICAL EXAMINATION: Significant for pupils
that were unequal with his right pupil greater than his left.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2101-11-1**] for aortic valve
replacement with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], with a 23 mm
pericardial aortic valve. The patient tolerated the
procedure well and was transferred to the Intensive Care Unit
in stable condition on Neo-Synephrine and amiodarone infusion
which was started in the Operating Room for irritable rhythm
post bypass. The patient was weaned and extubated from
mechanical ventilation on his first postoperative evening.
The patient's chest tubes were removed on postoperative day
no. 1. He was transferred from the Intensive Care Unit to
the regular part of the hospital. He was started on Lasix
and low dose Lopressor. His pacing wires were removed
without incident. He began working with physical therapy.
The evening of postoperative day no. 2, the patient developed
atrial fibrillation. He was rebolused with amiodarone. On
postoperative day no. 3, the patient was started on heparin
infusion for anticoagulation as well as Coumadin therapy. On
postoperative day no. 3, the patient was noted to have an
elevated creatinine. Lasix was held and the creatinine
drifted back down to approximately 1.4 and 1.5 by
postoperative day no. 6. The patient's allopurinol was also
discontinued. By postoperative no. 7, his creatinine
stabilized and was restarted on Lasix. The patient continued
to be anticoagulated reaching an INR of 2.0. The patient
converted to sinus rhythm on the evening of postoperative day
no. 6 and he was able to ambulate 500 feet and climb one
flight of stairs without requiring oxygen and remaining
hemodynamically stable. By postoperative day no. 7 he was
cleared for discharge to home.
CONDITION ON DISCHARGE: TMAX 98.9 degrees, pulse 59 and
sinus rhythm, blood pressure 123/58, respiratory rate 16,
room air oxygen saturation 98 percent. Neurologically, he is
awake, alert, oriented times three. Heart: Regular rate and
rhythm without rub or murmur. Respiratory: Breath sounds
are clear bilaterally. Abdomen soft, nontender and
nondistended. Positive bowel sounds, tolerating a regular
diet. The sternal incision is clean, dry and intact. The
sternum is stable. There is no erythema or drainage.
LABORATORY DATA: White blood cell count 10.8, hematocrit
28.6, platelet count 255, sodium 136, potassium 4.6, chloride
102, bicarbonate 26, BUN 28, creatinine 1.6, glucose 101.
DISCHARGE DIAGNOSIS:
1. Aortic stenosis.
2. Aortic valve replacement.
3. Postoperative atrial fibrillation.
4. Postoperative elevated creatinine.
DISPOSITION: To be discharged to home in stable condition.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Zantac 150 mg p.o. twice a day.
3. Tylenol with codeine 1-2 tablets p.o. q.4h. p.r.n.
4. Lopressor 25 mg p.o. twice a day.
5. Amiodarone 200 mg p.o. once a day.
6. Aspirin 81 mg p.o. once a day.
7. Coumadin. The patient is to take 2 1/2 mg on [**11-8**]
and [**11-9**], and he is to have a PT and INR checked and
the results called to Dr.[**Name (NI) 39613**] office and further
Coumadin dosing and INR checks per Dr.[**Name (NI) 39613**] office.
8. Lasix 20 mg p.o. once a day times 7 days.
9. Welchol 625 mg tablets, 3 tablets p.o. twice a day.
The patient is to follow-up with his primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 656**], in one to two weeks, and to follow-up with Dr.[**Name (NI) 39614**] office by phone on Thursday, [**2101-11-10**] for
INR results and Coumadin dosing, and to follow-up with Dr.
[**Last Name (STitle) 1295**] in the office in one to two weeks and he is to
follow-up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in three to four weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2101-11-9**] 18:26:10
T: [**2101-11-9**] 22:33:34
Job#: [**Job Number **]
|
[
"9971",
"42731",
"41401",
"4019"
] |
Admission Date: [**2120-8-24**] Discharge Date: [**2120-8-31**]
Date of Birth: [**2050-2-16**] Sex: F
Service: MED
Allergies:
Dilantin / Aspirin
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Hyponatremia/UTI/mental status changes
Major Surgical or Invasive Procedure:
Head CT
CXR
EEG
History of Present Illness:
70 cambian speaking F with repeated admissions for
hyponatremia/uti, h/o cva, h/o meningioma s/p vp shunt, h/o sz
d/o admitted to [**Hospital1 18**] for alterned mental status from nursing
home. Found to be hyponatremic at 117 and u/a c/w uti. In [**Name (NI) **]
pt developed ?sz and given ativan. Pt snowed and hypotensive.
Taken to [**Hospital Unit Name 153**] for monitoring. Treated with prednisone/normal
saline for hyponatremia and amp/ctx for uti (h/o multi-resistant
bugs). Mental status improved, hyponatremia improved and now
transfered to floor.
Past Medical History:
CVA, multiple UTI's, meningioma with optic nerve involvement and
blindness in right, cranial radiation, VP shunt, spinal
stimulator for headache, two thalamic hemorrhages on the left,
possible (?) sz d/o, panhypopituitarism, DM, HTN,hypothyroidism,
hyponatremia, hypercholesterolemia, asthma, osteoporosis
Social History:
cambodian speaking only, lived with daughter and son-in-law in
the past, then due to recent frequent admissions, was in and out
of hospitals and nursing homes. very involved family
Family History:
non contributory
Physical Exam:
In ED ([**8-24**]), 99.0, 85, 105/61, 17 97% RA
Thin female NAD, lying in bed
Left pupil reactive to light, right eye blind without response
to light.
Neck supple
CTAB
RRR, no m/r/g
Abd soft, no masses
Moves L arm and leg spontaneously, moves right arm and leg with
stimulation
No rashes
Neuro: turns head to daughter's voice in Cambodian, mouths words
to daughter.
Once pt was transferred to the general medical floor [**8-25**]), PE
as follow:
97.2, 115-130/50-70, 15, 100% RA
General: lethargic, but follows commands
dry mm
CTAB
RRR, no m/r/g
abd soft, NT, ND, right VP shunt in place
Ext: +2 pedal pulses bilaterally, no c/c/e
Neuro: unable to get patient to move all 4 extremeties.
Pertinent Results:
[**2120-8-24**] 08:00PM GLUCOSE-231* UREA N-11 CREAT-0.6 SODIUM-121*
POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-17* ANION GAP-17
[**2120-8-24**] 08:00PM OSMOLAL-267*
[**2120-8-24**] 03:50PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2120-8-24**] 03:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2120-8-24**] 03:50PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2120-8-24**] 03:50PM URINE WBCCLUMP-OCC
[**2120-8-24**] 03:00PM GLUCOSE-214* UREA N-13 CREAT-0.7 SODIUM-117*
POTASSIUM-5.6* CHLORIDE-84* TOTAL CO2-22 ANION GAP-17
[**2120-8-24**] 03:00PM WBC-9.0 RBC-4.32 HGB-11.7* HCT-34.6* MCV-80*
MCH-27.1 MCHC-33.8 RDW-13.9
[**2120-8-24**] 03:00PM NEUTS-86.4* LYMPHS-11.1* MONOS-2.2 EOS-0.2
BASOS-0.2
[**2120-8-24**] 03:00PM HYPOCHROM-1+ MICROCYT-1+
[**2120-8-24**] 03:00PM PT-11.7 PTT-48.5* INR(PT)-0.9
Brief Hospital Course:
overall, this is a 70 year old Cambodian speaking woman with
multiple neurological issues (suprasellar meningioma s/p
resection and vp shunt placement, multiple CVA's, h/o complex
seizure disorder, chronic HA s/p spinal stimulator placement)
and multiple endocrine abnormalities including but not limited
to: panhypopit thought to be [**3-11**] to her meningioma and related
surgery, DMII, hypothyroidism, once treated for central DI with
ddAVP, which then led to hyponatremia, and the drug was
subsequently d/c-ed--this probably also led to the impression
that she has SIADH, which has never been worked up and
diagnosed. She presented with 3-4 days of increased somnelence
and poor PO intake. Her Na was found to be 124 two days prior to
admission, and because of her ? diagnosis of SIADH, she was
further fluid restricted to 500cc fluids per day. Of note, she
had three recent admissions: in [**Month (only) 547**] for MS changes, in [**Month (only) **]
with mental status changes and Ecoli UTI, in [**Month (only) 205**] with mental
status changes and found to have hyponatremia responsive to
steriod and IVF as well as Enterococci UTI. Her hospital course
by system is as follows:
1. hyponatremia - At presentation, her Na was 117, she was
corrected slowly. Within 5 hours, her Na was 121, at which time
she had one ? seizure episode with grimacing and clenching her
hands--this quickly resolved with IV ativan and Decadron. She
subsequently developed hypotension with SBP to the 90's and
became unresponsive. She received fluid rescucitation of 3L NS
and transferred to ICU for further monitoring. In ICU, her Na
corrected slowly by NS infusion at a rate calculated for optimal
correction. Na returned to 142 at 18 hours after presentation.
She received a total of 1.5 L of NS while in ICU. She was
transferred to medicine floor on HD#2 ([**8-25**]). Her serum sodium
was maintained within normal limit while patient was NPO for
poor MS. She was also started on IV hydrocortisone 50 mg [**Hospital1 **],
which was later switched to PO prednisone 10mg for possible
adrenal insufficiency. Her antihypertensive med lisinopril was
discontinued becuase it was thought of as possibly causing
SIADH. Her sodium only dropped on one occassion to 129 on HD#4
([**8-27**]) while pt on [**2-9**] NS. With improved mental status, she was
started on a high protein, high salt diet, with the thought that
her severe hyponatremia was likely at least partially due to
severe dehydration and poor PO intake of electrolytes. Her Na
has remained in the normal range two days off IVF at discharge.
In terms of work up of the causes of her hyponatremia, it is
really unclear whether she has SIADH or not, she certainly has
all the reasons to have it: brain tumor/XRT/surgery/meds,
however, because she presented with such severe hyponatremai and
MS changes, NS infusion was started before serum osm/urine osm
were obtained. We did obtain on [**8-27**] a set of serum osm/urine
osm, however, the urine and blood specimens were obtained 13
hours apart and by the time the urine sample was collected, the
serum Na was already normalized. Because of her recent 2
admissions both with hyponatremia, it is unlikely
dehydration/poor po is the only cause. This is probably a
multifactorial process, with SIADH, dehydration/nutrition
deficit and possiblly adrenal insufficiency all contributing to
the extremely low Na. It is thought by the team that patient
will need endocrine and renal workup as an outpatient once acute
issues are solved. Appropriate followup are arranged as such.
She is to be discharged to nursing home with weekly Na checks.
2. Altered mental status - at presentation, it was likely
secondary to hyponatremia, but she got head CT which ruled out
acute CNS process.Then when her MS worsened with Na correction,
ativan sedation, acute response to high dose steroid or central
pontine myelinosis were suspected as the cause. However, CPM is
a pathological process without effective treatment. Her mental
status slowly improved with correction of Na, increased pO
intake and IVF. At discharge, she returned to her baseline
mentation.
3. h/o sz - In addition to the seizure occured in ED, she had
two more seizure episodes witnessed by family on [**8-25**], both of
which resolved spontaneously within seconds. She was restarted
on keppra, which was discontinued 2 weeks ago because of
sedative effect. Then her antiseizure meds were adjusted by
neuro. At discharge, she was taking only 100mg qhs, this dose is
to continue until [**9-10**] (2wk course0. Then she is to take
Zonisamide 100mg [**Hospital1 **] for two more weeks and to be followed up
with Dr .[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] to adjust the dose if needed. An EED was done
while in hospital, which was non-focal.
4. uti - initially covered empirically with ctx/ampi Urine
culture grew out 10k to 100k E coli, resistant to amp and
sensitive to Ceftriaxone. AMP d/c-ed [**8-28**]. Continued Ceftriaxone
for a total of 7 days. Will go home on five days of Keflex.
Given that the patient has had three admissions at least
partially attributable to UTI's in the past two months and her
declined functional status (bedridden, wearing pads), she is to
start Oral 50 mg dose qhs continuous Nitrofurantoin prophylaxis
once the five day course of Keflex is completed. She is also
given topical intravaginal estriol cream, which has been
convincingly shown to decrease the risk of UTI recurrences in
postmenopausal women. [**8-25**] Blood culturex2 negative.
5. Nutrition - Patient tolerated high protein diet with booster
and salt tablet supplementation,with normalization of her
electrolytes. This is the diet that the patient should follow
once discharged.
6. HTN: normotensive while in hospital. should continue to be
off lisinopril for concern of its SIADH effect
7. Hypothyroidism: stable on syntroid
8. DMII: stable on RISS. Metformin at discharge
9. Panhypopit: 15mg po hydrocortisone in the AM and 10mg po
hydrocortisone preferably after lunch but anytime in the
afternoon is ok. Hydrocortisone has better mineralocorticoid
coverage.
10. GI: chronic constipation, patient given aggresive bowel
regimen at discharge.
Medications on Admission:
synthroid
lisinopril
lipitor
VitD
Neurontin
Insulin
Fosamax
Dulcolox
Pepcid
Predinisone
Glucophage
Senekot
Discharge Medications:
1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
Disp:*50 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day) as needed.
Disp:*2 inhalers* Refills:*0*
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic QD
(once a day).
Disp:*QS * Refills:*2*
10. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QMON
(every Monday).
Disp:*30 Tablet(s)* Refills:*2*
11. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*QS * Refills:*0*
12. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
13. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Mineral Oil Oil Sig: Thirty (30) ML PO ONCE (once) for 1
doses.
Disp:*QS ML(s)* Refills:*0*
15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
16. Hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)).
Disp:*90 Tablet(s)* Refills:*2*
17. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO QHS (once a day (at bedtime)): please start this
medicine on [**2120-9-5**] after completion of Keflex. .
Disp:*30 Capsule(s)* Refills:*2*
18. Conjugated Estrogens 0.625 mg/g Cream Sig: One (1) Vaginal
QD (once a day) for 3 weeks.
Disp:*QS * Refills:*2*
19. Hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO LUNCH
(Lunch).
Disp:*30 Tablet(s)* Refills:*2*
20. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO QHS (once
a day (at bedtime)) for 11 days.
Disp:*11 Capsule(s)* Refills:*0*
21. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO twice a
day for start from [**2120-9-11**] after completion of once daily regimen
days.
Disp:*60 Capsule(s)* Refills:*1*
22. Lactulose 20 g Packet Sig: One (1) packet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 21957**] Home - [**Location (un) **]
Discharge Diagnosis:
Hyponatremia due to dehydration
Dehydration
Acute mental status changes
Seizure disorder
E. coli UTI
Panhypopituitism
Adrenal insufficiency
Hypothyroidism
Iron deficiency Anemia/Anemia of chronic disease
Diabetes mellitus type II
Discharge Condition:
Good
Discharge Instructions:
Please take medication as instructed
Please check weekly Na levels, if lower than 130, please page
Dr. [**Last Name (STitle) **] immediately at [**Telephone/Fax (1) 2756**] pager number: [**Numeric Identifier 43442**]
Please get patient out of bed at least once a day to chair, if
tolerates.
Keep good hydration and nutrition. Really encourage PO intake
because patient takes better PO with prompting, this may
decrease the chance of her developing hypovolemic hyponatremia
due to dehydration and decreased nutritional status.
Please take the anti-seizure medication Zonisamide at 100mg 1
tablet per day before bedtime by mouth until [**9-10**], then on
[**9-11**], please take Zonisamide 100mg 1 tablet twice a day by
mouth until the next time the patient is seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
(preferrably after [**9-24**]) who may adjust the dosing as
needed.
Please return to the nearest emergency room or call your doctors
if [**Name5 (PTitle) **] develop any of the following symptoms: increased
lethargy, somnelence, fever/chills, constipation or any other
worrisome symptoms
Followup Instructions:
1. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**9-4**] and
[**9-11**].
2. Please follow up with your renal doctor: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.,
PH.D.[**MD Number(3) **]: [**Hospital6 29**] MEDICAL SPECIALTIES
Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2120-10-7**] 3:30
3. Please follow up with your endocrine doctor: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
MD Where: [**Hospital6 29**] MEDICAL SPECIALTIES
Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2120-10-10**] 3:00
4. Please follow up with your neurologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at the
[**Hospital1 18**] to after [**9-24**] to adjust Zonisamide dose, please
call his office at [**Telephone/Fax (1) 6574**] to make an appointment or if the
patient needs to be seen for other issues earlier than the time
recommended.
|
[
"5990",
"2761",
"2720",
"4019",
"49390"
] |
Admission Date: [**2160-10-9**] Discharge Date: [**2160-10-26**]
Date of Birth: [**2120-4-8**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 40 year old
woman with a history of hypoparathyroidism secondary to a
parathyroid adenoma and papillary thyroid cancer, status post
total thyroidectomy and right superior parathyroidectomy on
[**2160-9-30**], who recovered well but whose course was
complicated by parathyroid studding with hypocalcemia. She
was admitted to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] shortly
after her surgery, with symptomatic hypocalcemia. Her
calcium was repleted and she was discharged home on Rocaltrol
and Tums E-X calcium supplementation every day.
The patient presented to the Emergency Room the night prior
to admission with nausea, vomiting, dizziness, inability to
tolerate oral intake and a calcium level of 18.2. Her
electrocardiogram showed sinus bradycardia but was otherwise
normal. She was given fluids, calcitonin and pamidronate,
with a resultant decrease in her calcium level to 11.9. She
was admitted for close monitoring of her calcium level and
monitoring by telemetry. She now feels much better, with
some residual nausea, dizziness and fatigue. She also
complained of abdominal soreness from frequent emesis. Her
review of systems was otherwise negative.
PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus for the
past five years, well controlled on oral hypoglycemics with
no complications. 2. Depression for the past four years,
controlled on Celexa. 3. Anxiety for the past four years,
controlled on Klonopin as needed. 4. Right knee
osteoarthritis, status post arthroscopy times two. 5.
Status post breast biopsy that was negative. 6. Status post
polypectomy during colonoscopy with a repeat colonoscopy that
was negative. 7. Hypoparathyroidism due to parathyroid
adenoma, status post right superior parathyroidectomy. 8.
Papillary thyroid cancer, status post total thyroidectomy,
now on Cytomel.
MEDICATIONS ON ADMISSION: Glucophage 1,000 mg p.o.b.i.d.,
Celexa 20 mg p.o.q.d., Avandia 4 mg p.o.b.i.d., Klonopin 0.5
mg p.o.q.h.s.p.r.n., Cytomel 25 mcg p.o.q.d., Tums E-X 4 gm
six times per day, magnesium oxide 400 mg p.o.q.d., Rocaltrol
0.25 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives with her husband. She
does not use tobacco, alcohol or drugs.
FAMILY HISTORY: The patient's family history is negative for
thyroid cancer or hypoparathyroidism, positive for diabetes
mellitus and hypertension.
REVIEW OF SYSTEMS: Negative.
PHYSICAL EXAMINATION: On physical examination, the patient
was a mildly anxious, relatively fatigued woman who was
afebrile with a blood pressure of 100/60, pulse 76,
respiratory rate 20 and oxygen saturation 93% in room air.
Head, eyes, ears, nose and throat: Mucous membranes dry,
otherwise unremarkable. Neck: Well healed incision, clean,
dry and intact without erythema. Lungs: Clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm, no murmur, rub or gallop. Abdomen: Diffusely tender
but otherwise soft and nondistended with no rebound or
guarding, positive bowel sounds. Extremities: Without
edema, 2+ peripheral pulses. Neurologic: Nonfocal, 5/5
strength, normal sensation to light touch, intact cranial
nerves, negative Chvostek's and negative Trousseau's signs.
LABORATORY DATA: Admission white blood cell count was 10.6
with normal differential, hematocrit 33.8, platelet count
383,000, sodium 143, potassium 4.2, chloride 107, bicarbonate
25, BUN 12, creatinine 0.8, glucose 164, albumin 4, TSH 2.5
and parathyroid hormone 6.8 (low). Initial calcium was 18.2,
which dropped to 11.9 with fluids in the Emergency Room.
Initial ionized calcium was 2.36, which was high. Initial
magnesium was 1.4.
HOSPITAL COURSE: The patient came to the floor after
receiving fluids, calcitonin and pamidronate in the Emergency
Room. Her calcium levels were initially followed three times
a day. She was initially hypocalcemic and required frequent
intravenous infusions of calcium gluconate. Given her
frequent need for intravenous electrolyte replacement and
three times a day blood draws, a left subclavian line was
placed. Her magnesium was also followed three times a day
and she often required intravenous magnesium repletion. She
was started on higher doses of oral Tums and magnesium oxide
than she had been on at home.
In the middle of her hospital course, the patient required
such frequent infusions of intravenous electrolytes that she
was transferred to the Medical Intensive Care Unit for
monitoring. Once she was on a better oral regimen with a
decreased need for intravenous infusions, she was transferred
back to the floor. She eventually achieved a dose of
calcium, magnesium oxide and Rocaltrol that maintained her at
stable blood levels of these electrolytes.
Hypophosphatemia secondary to the intravenous calcium
infusions was a complication that was treated initially with
phosphorous repletion and then by having her take her Tums
not at meals in order to prevent it from acting as a
phosphorous binder. She briefly had hypokalemia during her
first few days in the hospital, that resolved quickly with
only a few days of repletion.
The cause of the patient's hypomagnesemia was unclear,
although her urinary fraction excretion of magnesium was
high. A renal consult was obtained and they suggested that
she should be followed over time, mainly weeks to months, for
improvement in her magnesium levels, and continue oral
supplementation in the meantime. Her magnesium doses that
she received did induce diarrhea but it was not significantly
uncomfortable for the patient.
During her hospital stay, the patient was changed from
Cytomel to Synthroid. The initial plan after her thyroid
resection had been to keep her on Cytomel in preparation for
discontinuation of hormone to look for any remaining thyroid
tissue that might require removal. However, given her more
pressing problem of electrolyte imbalances, she was changed
to Synthroid for better control of her hypothyroidism. At
some point in the future, she will be switched back to
Cytomel and a search for residual thyroid tissue will be
done.
Cardiovascular: The patient was kept on telemetry. She
initially had a long QT but, as her hypocalcemia resolved,
her QT shortened. Once her calcium levels were stable, she
was taken off telemetry as she had no further signs of
electrocardiographic abnormalities.
From a hematologic standpoint, the patient had a baseline
hematocrit of 33 on admission, which was post surgical. She
developed a dilutional anemia, after receiving the fluids in
the Emergency Room, that was slowly resolving, although her
hematocrit did not completely correct due to frequent, namely
three times a day, laboratory draws. She was guaiac negative
throughout her stay and was started on iron tablets to
support her during the time of blood loss from phlebotomy.
Infectious disease: The patient tolerated her left
subclavian line well but spiked a temperature to 100.6 on day
13 after the line was placed. The line was removed and she
had no further fever spikes. At that point, she was no
longer requiring intravenous electrolyte infusions and was
down to blood draws twice a day, so removing the line was an
acceptable course of action.
CONDITION AT DISCHARGE: Improved.
DISCHARGE DIAGNOSES:
Hypocalcemia secondary to parathyroid studding.
Hypothyroidism.
Diabetes mellitus.
Depression.
Anxiety.
Right knee osteoarthritis.
DISCHARGE MEDICATIONS:
Glucophage 1,000 mg p.o.b.i.d.
Celexa 20 mg p.o.q.d.
Avandia 4 mg p.o.b.i.d.
Klonopin 0.5 mg p.o.q.h.s.p.r.n.
Synthroid 175 mcg p.o.q.d.
Iron sulfate 325 mg p.o.b.i.d.
Tums E-X 4 tablets p.o.t.i.d., not with meals; this would
give the patient a total of 800 mg of elemental calcium three
times a day or 2.4 grams of elemental calcium every day.
Magnesium oxide 1 gm p.o.t.i.d.
Rocaltrol 0.25 mg p.o.q.d.
DISCHARGE STATUS: To home to follow up with primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5361**], for daily blood draws beginning the
day after discharged. As the patient's levels stabilize
further, she will be able to have fewer blood draws. The
patient will also follow up with Dr. [**Last Name (STitle) 9287**], her
endocrinologist, in four days after discharge. On discharge,
her calcium level was 8.4 and stable. Her magnesium was 1.7
and stable. Her phosphorous level was 2.2. Her parathyroid
hormone was 9.3, which was still low.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 22132**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2160-11-9**] 20:33
T: [**2160-11-11**] 12:24
JOB#: [**Job Number 22133**]
|
[
"25000",
"311",
"42789"
] |
Admission Date: [**2104-1-11**] Discharge Date: [**2104-1-15**]
Date of Birth: [**2052-9-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Melena, hematemsis
Major Surgical or Invasive Procedure:
1. Esophagogastroduodenoscopy with banding of one of the
esophageal varices
2. Blood transfusion
History of Present Illness:
Mr. [**Known lastname **] is a 51 year old male with history of hepatitis C,
alcoholic cirrhosis, and low platelets. He presented to the
[**Hospital1 18**] ED on [**2104-1-11**] after episodes of hematemsis. He endorsed
recent alcohol intake, on [**12-17**], and [**1-10**], after a month of
being sober. He reports recent usage of ibuprofen, two pills a
day of unknown dose, for worsening lower back pain. For the last
several days, he reports dark, black colored stools. This
morning, he had two episodes of dark red blood emesis. He
reports this was alarming and large in amount. This had never
happened before. He called 911.
.
Upon arrival to [**Hospital1 18**] ED, initial vital signs were temperature
of 98.5, blood pressure 127/70, heart rate 93, respiratory rate
of 18, and oxygen saturation of 99% on room air. Nasogastric
lavage was completed, per report with specks of bright red blood
that cleared with 500 cc of normal saline. He received 1000 cc
of NS, pantoprazole drip at 8 mg/hr after 40 mg IV bolus,
ceftriaxone 2 grams, octreotide 25 mg bolus and drip. He also
received 4 mg of zofran. Rectal examination was notable for
guaiac positive stool, melenatic.
.
Upon arrival to the ICU, he reports some mild abdominal pain and
lower back pain. He has had no additional episodes since this
morning.
Past Medical History:
- Alcoholic cirrohsis: prior EGD from [**11/2103**] demonstrated
gastropathy and small varices
- Hepatitis C: followed by Dr. [**Last Name (STitle) 7033**], interferon has been
discussed by deferred due to relapses of alcohol use
- Alcohol abuse
- Lower back pain
- History of pancreatitis noted in chart, per patient
- Depression
Social History:
Lives with wife and grandson. [**Name (NI) **] two grown children. On
disability due to back pain and depression, previously worked as
groundskeeper. Smoked [**2-3**] PPD since age 16. History of
significant alcohol abuse, with periods of abstenance.
Family History:
Notable for diabetes and cirrhosis in mother. Father has
diabetes and hypetension. Sister has heart disease.
Physical Exam:
Admission Physical Exam
VS: Temp: BP: 149/76 HR: 82 RR: 12 O2sat: 98% on room air
GEN: pleasant, comfortable, NAD, slightly anxious.
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, no
rebound tenderness
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters, + spider angiomas on
shoulders/arm/back
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No asterixis.
RECTAL: Completed by GI and in ED, melena, guaiac +
.
Discharge Physical Exam
8.7 111-121/69-71 65-70 18 97-98%RA
BM x 3; guiaic positive
GENERAL: Male in no acute distress
HEENT: Anicteric. PERRLA. EOMI. Supple neck without
lymphadenopathy
LUNGS: Clear to auscultation bilaterally. No crackles or
wheezing noted.
CARDIO: Regular rate and rhythm. No mumurs or gallops
appreciated.
ABD: Soft, nontender and nondistended. NABS.
EXTREMITIES: No edema
SKIN: No rash
PSYCH: Appropriate affect and mood.
NEURO: CN 2-12 intact.
Pertinent Results:
EGD [**2104-1-11**]
Esophagus: Protruding Lesions 1 cord of grade II varice and 2
cords of grade II varices were seen in the lower third of the
esophagus. The grade II varix at 6' o'clock with ulceration and
clot indicating recent bleed was banded; 2 other varices
compressed following banding. 1 band was successfully placed.
Stomach: Mucosa: Mosaic appearance of the mucosa was noted in
the whole stomach. These findings are compatible with moderate
portal hypertensive gastropathy.
Duodenum: Normal duodenum.
Impression: Varices at the lower third of the esophagus
(ligation)
Mosaic appearance in the whole stomach compatible with moderate
portal hypertensive gastropathy Otherwise normal EGD to third
part of the duodenum
[**2104-1-11**] 01:15PM BLOOD WBC-7.5# RBC-3.50* Hgb-12.1* Hct-35.8*
MCV-102* MCH-34.7* MCHC-33.9 RDW-14.8 Plt Ct-113*#
[**2104-1-13**] 05:40AM BLOOD WBC-3.7* RBC-2.64* Hgb-9.2* Hct-27.1*
MCV-102* MCH-34.7* MCHC-33.9 RDW-14.8 Plt Ct-63*
[**2104-1-15**] 05:30AM BLOOD WBC-3.4* RBC-3.10* Hgb-10.7* Hct-31.2*
MCV-101* MCH-34.5* MCHC-34.3 RDW-16.3* Plt Ct-74*
[**2104-1-11**] 01:15PM BLOOD PT-16.1* PTT-27.5 INR(PT)-1.4*
[**2104-1-15**] 05:30AM BLOOD PT-14.4* PTT-29.8 INR(PT)-1.2*
[**2104-1-11**] 01:15PM BLOOD Glucose-159* UreaN-24* Creat-0.6 Na-142
K-4.4 Cl-104 HCO3-27 AnGap-15
[**2104-1-15**] 05:30AM BLOOD Glucose-121* UreaN-12 Creat-0.7 Na-140
K-3.9 Cl-104 HCO3-28 AnGap-12
[**2104-1-11**] 01:15PM BLOOD ALT-104* AST-122* AlkPhos-95 TotBili-1.2
[**2104-1-15**] 05:30AM BLOOD ALT-110* AST-128* AlkPhos-105 TotBili-0.8
[**2104-1-13**] 05:40AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.0 Mg-1.8
[**2104-1-15**] 05:30AM BLOOD Albumin-3.2* Calcium-8.3* Phos-4.2 Mg-1.6
[**2104-1-11**] 01:15PM BLOOD ASA-NEG Ethanol-59* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2104-1-11**] 04:41PM BLOOD Lactate-2.5*
Brief Hospital Course:
Mr. [**Known lastname **] is a 51 year old male with history of alcoholic
cirrhosis, hepatitis C, and lower back pain admitted with
hematemsis and melena.
.
1. Upper GI bleed: He was admitted to the MICU where EGD was
performed that showed three varices at the distal esophagus.
One of his varices was banded. His Hematocrit stayed stable
over next few days even though he continued to have guiaic
positive stools. He tolerated the advance of his diet well. He
was continued to pantoprazole 40 mg po BID. He received five
days of Ceftriaxone 1 grams IV qdaily for prophylaxis and
carfate 1 gram QID x 5 days. He was given one unit of PRBCs
prior to discharge. He was started on nadolol 20 mg po qdaily
for secondary prophylaxis of his varices. He will follow up with
Dr. [**Last Name (STitle) **] on Friday [**2104-1-18**] for further banding of his
varices.
2. Alcoholic cirrhosis, HCV: Patient reports recent alcohol use.
Serum alcohol levels were positive. His liver enyzmes were
elevated though at baseline. Most recent HCV viral load from
[**10/2103**] was 841,000 IU/mL. He was started on folate,
multivitamin and folate for nutrition and social work was
consulted for help with alcohol abuse. Patient reported he will
stay abstinent in front of his family.
3. Thrombocytopenia: At baseline. Due to ESLD.
.
4. Depression: Fluoxetine was held in the ICU but restarted on
the floor.
.
5. Epigastric pain: CXR and enzymes x 1 were negative. Thought
to be due to banding.
Medications on Admission:
(per discharge summary from [**12/2103**])
- Fluoxetine 20 mg Capsule
- Gabapentin 300 mg Capsule PO BID
- Omeprazole 20 mg Capsule
- Thiamine HCl 100 mg Tablet
- Folic acid 1 mg Tablet
- Multivitamin 1 Tablet PO DAILY (Daily).
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 5 days: Only if you get banding on [**2104-1-18**] by Dr.
[**Last Name (STitle) **].
Disp:*20 Tablet(s)* Refills:*0*
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: Only if you get banding on [**2104-1-18**] by Dr. [**Last Name (STitle) **].
Disp:*5 Tablet(s)* Refills:*0*
9. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. Upper gastrointestinal bleed from esophageal varices
2. Alcoholic/Hepatitis C cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you were noted to have
gastrointestinal bleeding. It was thought to be due to varices
in your esophagus. You underwent esophagogastroduodenoscopy
with banding of one of the three varices. You received one unit
of blood. Your blood volume remained stable over next two days
and you tolerated your diet well.
.
You were discharged home with follow up with Dr. [**Last Name (STitle) **] on
Friday, [**2104-1-18**] for another esophagogastroduodenoscopy
with possibility of further banding of your varices.
.
It is extremely important that you do not drink alcohol.
.
Following medication changes were made to your regimen:
START NADOLOL 20 mg by mouth once a day
INCREASE OMPREZOLE to 40 mg by mouth twice a day until you see
Dr. [**Last Name (STitle) **] on [**2104-1-18**]
Followup Instructions:
Department: ENDO SUITES
When: FRIDAY [**2104-1-18**] at 11:00 AM
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2104-1-18**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: LIVER CENTER
When: WEDNESDAY [**2104-2-20**] at 12:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"2875"
] |
Admission Date: [**2205-11-25**] Discharge Date: [**2205-12-12**]
Date of Birth: [**2143-12-3**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Roxicet / Sirolimus
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
initiation of dialysis
Major Surgical or Invasive Procedure:
Tunneled line catheter placement
Dialysis
History of Present Illness:
Mr. [**Known lastname 2809**] is a 61 year old male with past medication history
significant for HBV/HCV cirrhosis s/p liver [**Known lastname **] in [**2194**],
CKD with proteinuria, medication induced polymyositis in [**2204**].
.
He was admitted to [**Hospital1 18**] from [**2205-11-6**] to [**2205-11-15**] for
peripheral neuropathy and worsening kidney function which was
thought to be related to tacrolimus toxicity. His
immunosuppression was switched from tacrolimus to Cellcept and
prednisone. Kidney biopsy did not show any etiology and he
continued to have worsening of his kidney function. He was
discharged to [**Hospital1 100**] house for neuro rehabilitation with close
renal follow.
.
He is admitted today for inititiation of dialysis.
Past Medical History:
Status post liver [**Hospital1 **] in [**2194**] secondary to hepatitis B &
C and alcohol abuse
Hepatic artery replacement [**2195**]
Asymptomatic strokes ([**2195**]: left corona radiata and posterior
putaminal infarct, periventricular white matter disease; [**8-12**]
MRI with evidence of chronic cerebellar infarcts)
Frontal gait disorder of unclear etiology
Stage IV chronic kidney disease
Central and obstructive sleep apnea (sleep study [**2203**])- not on
CPAP
Polymyositis of unclear etiology though possibly from tacrolimus
Seizure disorder
Paraproteinemia
Cataract removal
Retinal detachment
Inguinal hernia repair
Social History:
Patient lives with wife and pets (3 cats, 2 dogs). They have no
children. He denies current use of tobacco or EtOH. Says he has
smoked 2ppd for 40 years and quit 7 years ago. Also endorses
heavy drinking history (~30 years) and says he drank 6pack/day
at his worst. He quit EtOH use several years prior to
[**Year (4 digits) **]. H/o IVDU as per previous records. Walks w/ walker at
baseline.
Family History:
The patient is adopted. No known family history of stroke or
neurological disease.
Physical Exam:
Admission Physical Exam
Vital Signs: 97.3 119/77 68 18 95%RA
General: Thin male in no acute distess. He appears chronically
ill and has poor hygeine.
HEENT: PERRLA. EOMI. Anicteric. Supple neck without
lymphadenopathy
Chest: Normal respirations and breathing comfortably on room
air. He has rales at the bases bilaterally.
Heart: Regular rhythm. Normal S1, S2. III/VI HSM best heard at
base with radiation to the carotids.
Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
Extremities: No edema. No rash
MSK: Joints with no redness, swelling, warmth, tenderness.
Normal ROM in all major joints.
Skin: No lesions, bruises, rashes.
Neuro: Alert, oriented x3. Speech and language are normal. CN
intact other than old left ptosis. No involuntary movements or
muscle atrophy. Normal tone in all extremities. Motor [**4-10**] in
upper and lower extremities bilaterally though his RLE is
somewhat weaker than left. His proximal muscles are not weaker
than his distal muscles. He is
too weak to stand without full assistance. Finger-to-nose
normal. No pronator drift. Gross sensation to light touch intact
in upper and lower extremities bilaterally.
Pertinent Results:
Admission Labs
[**2205-11-26**] 04:40AM BLOOD WBC-13.1* RBC-3.43* Hgb-10.9* Hct-32.1*
MCV-94 MCH-31.6 MCHC-33.8 RDW-14.1 Plt Ct-173
[**2205-11-26**] 04:40AM BLOOD Neuts-79.5* Lymphs-14.2* Monos-4.6
Eos-1.3 Baso-0.4
[**2205-11-25**] 07:20PM BLOOD Glucose-190* UreaN-113* Creat-7.5*#
Na-137 K-6.2* Cl-105 HCO3-19* AnGap-19
[**2205-11-26**] 04:40AM BLOOD ALT-57* AST-52* LD(LDH)-555* AlkPhos-70
TotBili-0.3
[**2205-11-26**] 04:40AM BLOOD Albumin-2.4* Calcium-8.0* Phos-4.7*
Mg-2.3
.
Cardiac Enzymes:
[**2205-12-5**] 01:55PM BLOOD CK-MB-11* MB Indx-10.5* cTropnT-0.38*
[**2205-12-5**] 08:44PM BLOOD CK-MB-25* MB Indx-17.9* cTropnT-0.45*
[**2205-12-6**] 05:25AM BLOOD CK-MB-49* MB Indx-21.9* cTropnT-0.66*
[**2205-12-7**] 04:45AM BLOOD CK-MB-23* MB Indx-19.7*
[**2205-12-8**] 06:30AM BLOOD CK-MB-12* cTropnT-0.63*
.
Discharge labs
.
([**2205-11-26**]): Successful placement of a right internal jugular
approach
tunneled hemodialysis catheter with its tip in the right atrium.
The catheter
is ready for use.
[**2205-12-11**] 05:31AM BLOOD WBC-10.0 RBC-3.74* Hgb-11.5* Hct-33.0*
MCV-88 MCH-30.7 MCHC-34.9 RDW-16.4* Plt Ct-118*
[**2205-12-8**] 06:30AM BLOOD Neuts-79.3* Lymphs-13.6* Monos-6.1
Eos-0.8 Baso-0.2
[**2205-12-11**] 05:31AM BLOOD PT-12.4 INR(PT)-1.0
[**2205-12-11**] 05:31AM BLOOD Glucose-75 UreaN-22* Creat-3.0* Na-138
K-3.8 Cl-104 HCO3-27 AnGap-11
[**2205-12-11**] 05:31AM BLOOD ALT-50* AST-48* AlkPhos-46 TotBili-0.4
[**2205-12-11**] 05:31AM BLOOD Calcium-7.2* Phos-2.4* Mg-1.7
[**2205-12-5**] 01:55PM BLOOD Triglyc-292* HDL-71 CHOL/HD-3.8
LDLcalc-142*
[**2205-12-8**] 06:30AM BLOOD Hapto-<5*
[**2205-12-4**] 01:10PM BLOOD Ammonia-3*
[**2205-11-29**] 06:00AM BLOOD PTH-523*
[**2205-11-26**] 11:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2205-12-11**] 05:31AM BLOOD tacroFK-2.1*
[**2205-11-26**] 11:25AM BLOOD HCV Ab-POSITIVE*
.
Imaging:
Cardiac ECHO [**2205-12-7**]: LEFT ATRIUM: Normal LA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Low normal LVEF. Beat-to-beat
variability on LVEF due to irregular rhythm/premature beats.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Focal calcifications in aortic root. No 2D or Doppler
evidence of distal arch coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
AS (area 1.2-1.9cm2). Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - body habitus.
Suboptimal image quality - patient unable to cooperate.
Cardiac Cath [**2205-12-5**]: 1. Coronary angiography in this left
dominant system demonstrated two vessel coronary artery disease.
The LMCA had no
angiographically apparent disease. The proximal LAD had a 60%
stenosis
and a calcific, thrombotic 90% mid stenosis. There were mild
irregularities throughout the LAD. The LCx had a seperate ostia
with
diffuse noncritical disease of up to 40%. The origin of the Cx
had a
60% stenosis on non-selective injection. The RCA was small,
non-dominant with mild, diffuse disease.
2. Resting hemodynamics revealed systemic arterial systolic and
diastolic hypertension with an aortic pressure of 189/130 mmHg.
3. Successful primary PCI of proximal LAD lesion with bare metal
stent.
4. Aspirin 81 mg daily.
5. Plavix 75mg daily for a minimum of 1 month.
6. Secondary prevention of coronary artery disease.
[**2205-11-29**]: CXR: FINDINGS: As compared to the previous radiograph,
the patient has received a double-lumen right-sided central
venous access line. The line is in correct position. There is no
evidence of complications and no evidence of infection. No
pleural effusions. Normal size of the cardiac silhouette.
[**2205-11-27**]: Upper extremity vein mapping: IMPRESSION: Patent right
upper arm cephalic vein with small diameters. Patent right
basilic vein with small diameters in the forearm and reasonable
diameters in the upper arm. Left cephalic vein thrombosis in the
upper arm. Left basilic vein with small diameters in the
forearm and moderate-to-large diameters in the upper arm.
[**2205-12-5**]: ECG: Sinus rhythm. One to two millimeter ST segment
elevation in leads V1-V4 concerning for acute myocardial
infarction. Q waves inferiorly with one half millimeter ST
segment elevation concerning for myocardial injury. ST segment
changes in high lateral and lateral leads concerning for
myocardial ischemia. Compared to the previous tracing earlier
the same day, the severity of the ST segment elevation in leads
V1-V2 is similar and there may be mild decrease in the extent of
elevations in leads V3-V4 with new T wave inversions consistent
with an evolving anteroseptal myocardial infarction. The
inferior ST segment elevations and ST segment changes are
consistent with ongoing myocardial ischemia. Clinical
correlation is suggested.
Microbiology:
H.Pylori [**2205-12-3**]: negative
Blood cultures [**2205-12-3**], [**2205-12-1**], [**2205-11-29**]: negative
Urine culture [**2205-11-30**]: negative
MRSA screen [**2205-12-5**]: negative
VRE screen [**2205-12-7**]: negative
Brief Hospital Course:
61 year old year old male with past medication history
significant for HBV/HCV cirrhosis s/p liver [**Month/Day/Year **] in [**2194**],
CKD with proteinuria, medication (tacrolimus vs interferon)
induced polymyositis in [**2204**] and Acute kidney injury on Chronic
kidney disease stage 3 thought be due to tacrolimus toxicity
admitted for initiation of dialysis. HD was tolerated well
however course was complicated by GI bleed and STEMI while on
HD.
#. ACUTE ON CHRONIC RENAL FAILURE leading to End Stage Renal
Disease: Likely progression of his underlying chronic kidney
disease. Switched off tacrolimus to Cellcept last admission,
although restarted tacrolimus and Cellcept dose reduced due to
elevation in liver enzymes . Tunneled line catheter was placed
with subsequent dialysis three days weekly. He tolerated HD
well aside from one episode of orthostasis (resolved with
temporarily holding his BP meds) and a STEMI (see below). He
will need to have care established with a renal/dialysis
physcian when he leaves the rehabilitation facility, preferably
near his home location. He previously saw Dr. [**Last Name (STitle) **]
(nephrology) at [**Hospital1 18**], however Dr. [**Last Name (STitle) 17253**] does not manage
outpatient dialysis patients.
.
# GI BLEED: On [**12-2**] he had a large melenatic stool. He was
started on IV pantoprazole, made NPO, and transfused 1u pRBCs
given slightly altered mental status. On [**12-3**] he had an EGD
which showed a duodenal ulcer (clipped and injected) as well as
[**Female First Name (un) **] esophagitis. He was last transfused [**2205-12-8**], but has
maintained a stable Hct >30 since then, without melena, and
remains hemodynamically stable. He was transitioned to PPI PO
BID which should be continued. Nystatin swish and swallow was
started for his esophagitis (note fluconazole not used due to
risk of hepatotoxicity and patient did not endorse dysphagia).
# STEMI: On [**2205-12-5**] during dialysis, he developed tachycardia
HR 150bpm but was completely asymptomatic. EKG revealed ST
elevations V3 and V4. CODE STEMI was called and the patient was
taken to the catheterization lab where a 90% LAD lesion was
found and a BMS was placed successfully. He was started on
aspirin, plavix, atorvastatin and restarted on his labetolol.
Note his aspirin dose was 81mg not 325mg due to his ongoing GI
bleed. He was not started on an ACE-I because his EF>50%. He
does not smoke. His cardiac enzymes peaked and downtrended. He
did not have any further chest pain.
#. HISTORY OF LIVER [**Date Range **] in [**2194**] due to alcohol/hepatitis
B & C: Tacrolimus restarted at low dose 0.5mg [**Hospital1 **], Cellcept
decreased to 500 mg po BID and he is now on prednisone 30/40
every other day for polymyositis. He should continue on Bactrim
SS daily while on prednisone. His liver enzymes improved while
on tacrolimus.
.
#. Polymyositis: Continued on prednisone 30 mg / 40 mg every
other day (as per neurology recommendation two weeks ago) for
his polymyositis which is clinically controlled per EMG. He
will follow up with Dr. [**Last Name (STitle) **] at which point his prednisone
should be tapered.
.
#. Seizure disorder/Epilepsy. Continued on oxcarbazepine at 150
mg [**Hospital1 **]
.
#. Hypertension: Well controlled on labetalol 200 mg po BID.
#. Depression: He initially expressed suicidal ideation to
housestaff and nursing staff. Psychiatry was consulted and
venlafaxine was increased to goal 150mg daily. Ritalin was also
added and titrated to goal 5mg qam and 5mg qnoon with
improvement in his mood.
.
# OSTEOPOROSIS: His alendronate will be restarted on discharge.
.
He was FULL CODE for this admission.
Medications on Admission:
1. folic acid 1 mg po qdaily
2. alendronate 35 mg po qweek
3. amlodipine 10 mg po qdaily
4. oxcarbazepine 150 mg po BID
5. prednisone 40 mg/30 mg po every other day
6. sulfamethoxazole-trimethoprim 800-160 mg po 3x week
(Tu/Th/Sa)
7. venlafaxine 75 mg Capsule, Sust. Release 24 hr po qdaily
8. labetalol 200 mg po BID
9. calcium acetate 667 mg Capsule po TID with meals
10. sodium bicarbonate 650 mg po BID
11. aspirin 81 mg po qdaily
12. calcium carbonate 200 mg (500 mg) po TID
13. mycophenolate mofetil 1000 mg po BID
14. multivitamin po qdaily
15. oxybutynin chloride 5 mg Tablet po qhs
16. Vitamin C 100 mg po qdaily
17. Toprol XL 5 mg po qhs
18. Bisacodyl 10 mg po qhs
19. lasix 40 mg po BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis
1. End state renal disease
2. Hepatitis B/hepatitis C/alcohol cirrhosis s/p liver
[**Hospital6 **] [**2194**]
3. Polymyositis
4. Upper GI bleed
5. STEMI
6. Esophageal candidasis
7. Seizure disorder
8. Hypertension
9. Depression
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 Mr. [**Known lastname 2809**],
You were admitted for initiation of dialysis. A tunneled
catheter line was placed with help of intervention radiology.
You tolerated dialysis well.
During your hospital stay you developed an ulcer in your small
intestines requiring several blood transfusions. You had an
endoscopy and the ulcer was clipped. You stopped bleeding and
your anemia improved.
During a hemodialysis session, your heart rate increased and you
had a heart attack. You were taken to the catheterization lab
immediately and a bare metal stent was placed in an artery in
your heart. You were started on Plavix and Aspirin. You MUST
continue to take your plavix to prevent a future heart attack.
Please do not stop this medication unless told to do so by your
cardiologist.
Please follow up with your physicians.
We made the following changes to your medications:
- STOP amlodipine
- INCREASE venlafaxine to 150mg daily
- STOP calcium acetate
- STOP sodium bicarbonate
- DECREASE mycophenylate mofetil to 500mg twice daily
- STOP Toprol XL
- STOP Lasix
- START Ritalin 5mg every morning and at noon
- START Tacrolimus 0.5mg twice daily
- START Sucralafate 1gm three times daily - wait 4 hours after
taking tacrolimus for the first dose
- START pantoprazole 40mg twice daily
- START atorvastatin 80mg daily
- START nephrocaps 1 tab daily
- START plavix 75mg daily
- START nystatin swish and swallow: 5mL four times daily
- START Insulin Sliding Scale as needed
- START Thiamine 100mg daily
- START B-complex vitamin with vit C: 1 tab daily
- STOP vitamin C
We wish you a speedy recovery.
Followup Instructions:
Department: [**Known lastname **]
When: MONDAY [**2205-12-16**] at 10:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2205-12-31**] at 2:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) 10828**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: THURSDAY [**2206-1-2**] at 1:30 PM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD [**Telephone/Fax (1) 541**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
Completed by:[**2205-12-12**]
|
[
"41071",
"40391",
"32723",
"41401"
] |
Admission Date: [**2168-6-12**] Discharge Date: [**2168-6-12**]
Date of Birth: Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 6884**] is a 27 -year-old man
with a history of substance abuse, attention deficit disorder
with hyperactivity, and depression, who was transported to
the Emergency [**Hospital1 **] after being found slumped against a car
outside of a nightclub. Bystanders mentioned that he may
have been using drugs and/or alcohol in the course of that
evening. The patient was brought to the Emergency [**Hospital1 **] and
intubated for airway protection. He was given 15 mg of
Versed for sedation for agitation. Electrocardiogram in the
Emergency [**Hospital1 **] showed tall T-waves and possible J-point
elevations in the anterior precordial leads. Toxicology
screen in the Emergency [**Hospital1 **] was positive for alcohol at a
level of 148, as well as for amphetamines.
PAST MEDICAL HISTORY:
1. Substance abuse with cocaine and GHB.
2. Gonococcal urethritis.
ALLERGIES: No known drug allergies.
ADMITTING MEDICATIONS: Effexor and Adderall.
Social history: Cocaine use and GBH use, documented in the
past. The patient also came in with a prison identification
card and a temporary alcohol license. Cigarettes were found
in his pockets.
FAMILY HISTORY: Unknown.
PHYSICAL EXAMINATION: The patient's temperature was 96.2 F,
pulse of 80, blood pressure was 134/70. The patient was
mechanically ventilated with oxygen saturation of 96%. In
general, he was a sedated, non-responsive male, intubated and
on a ventilator. Head, eyes, ears, nose and throat
examination was normocephalic with a cut on the lower lip.
Pupils were equal, round, and reactive to light, size was 4.0
mm baseline and 3.0 mm and reactive to light. oral mucosa
were moist and an endotracheal tube was in place. Chest
examination significant for a few inspiratory wheezes;
otherwise clear to auscultation bilaterally. Cardiovascular
examination: the patient had a regular rhythm, normal S1, S2,
no murmurs, rubs, or gallops.
Abdominal examination was soft, nontender, nondistended,
there were normoactive bowel sounds and no
hepatosplenomegaly. The patient's extremities were warm,
peripheral pulses were 2+. There was no cyanosis, clubbing
or edema. Neurologic examination: the patient was sedated,
cranial nerves examination demonstrated a positive
oculocephalic and gag reflexes. Strength: the patient was
moving all four extremities in the Emergency [**Hospital1 **]. Reflexes
are 1+ throughout.
NOTABLE LABORATORY DATA: Arterial blood gas with pH of 7.33,
PaCO2 is 48, PO2 is 206. The patient had a white blood cell
count of 12.1, hematocrit of 45.6, and platelets of 278,000.
The differential was 83 neutrophils, 14 lymphocytes, 2
monocytes, and 1 eosinophils. His Chem 7 included a sodium
of 143, potassium of 3.5, chloride 103, bicarbonate of 20,
BUN of 8.0, creatinine of 1.0, glucose of 99, and an anion
gap of 20. The patient also had osmotic gap of 4.0.
The patient's urinalysis indicated a few amorphic crystals,
otherwise within normal limits. Serum toxicology screen:
alcohol was 148, A.S.A., Tylenol, barbiturates,
benzodiazepine, and Tri-Cyclen antidepressants were negative.
Urine toxicology screen: amphetamine was positive and
benzodiazepine, opiates, cocaine, and methadone were
negative.
Chest x-ray indicated an endotracheal tube and orogastric
tube were in place. There was no pneumothorax or infiltrate.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit and given charcoal. Serial
electrocardiograms were concerning for the possible J-point
elevations in the anterior precordial leads, versus
repolarization abnormalities. The Cardiology Fellow was
called and a nitroglycerin was started. Cardiac enzymes were
drawn which were negative.
The patient became increasingly agitated in the Intensive
Care Unit and it was decided to wean the patient's sedation
and extubate the patient, which was done without any
difficulty. As the patient became more alert, he provided
additional history, stating that he had taken Ecstasy and GHB
prior to losing consciousness. He described his reaction as
an accident and denied suicidal ideation.
After further consultation with Cardiology, it was decided
that the electrocardiogram changes were probably benign in
nature and reflected repolarization abnormality. A Substance
Abuse consult was ordered. Psychiatry came to evaluate the
patient and found that he did not have active suicidal
ideation. Further, the patient has been enrolled in
intensive rehabilitation and day hospital program for his
drug abuse and psychiatric issues. According to Psychiatry,
the patient has excellent follow-up in these areas.
After the patient was cleared to go home, both by Psychiatry
and by the Intensive Care Unit team, his mental status having
cleared and cardiac issues resolved, he was discharged to
home.
DISCHARGE DIAGNOSIS:
Ecstasy and GHB intoxication.
FOLLOW-UP: The patient is to follow-up with his primary care
provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8310**], within one to two weeks. He will also
report back to his psychiatric day hospital program the day
following discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2168-6-13**] 14:18
T: [**2168-6-13**] 22:02
JOB#: [**Job Number 28371**]
|
[
"51881",
"311"
] |
Admission Date: [**2130-1-27**] Discharge Date: [**2130-1-31**]
Date of Birth: [**2069-5-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
ACA aneurysm
Major Surgical or Invasive Procedure:
Cerebral Angiogram for ACA aneurysm coiling
History of Present Illness:
60-year-old right-handed female who has been referred here with
a
history of an anterior communicating artery aneurysm. She has a
history of headaches and had an MRI scan. She has a strong
family history of brain aneurysm with her mother having died at
age 51 from a ruptured aneurysm. She has not had any major
headaches suggestive of an aneurysm rupture. A year ago, she
did
have one episode of a significant headache while she was
shopping in the mall. This was probably about a [**5-26**] headache
and did not persist for very long. She has not had any
seizures
or double vision. She has been known to have high blood
pressure
sometime in the past.
Past Medical History:
PMH: HTN
Past surgical history is significant for D&C and benign tumor
removed and from the left neck area more than 30 years ago,
tonsillectomy as a child.
Social History:
She works as a teacher's aide. She does not smoke and takes
alcohol sparingly.
Physical Exam:
Pre-angio:
Examination, blood pressure was 150/90. Pupils were equal and
reactive to light. Extraocular movements are intact. Face is
symmetric. Tongue is in the midline. Motor strength is [**4-20**] in
all four extremities. Gait and coordination normal.
On discharge:
AOx3, [**Last Name (LF) 2994**], [**First Name3 (LF) 2995**] with full motor, angio site C/D/I.
Brief Hospital Course:
60F elective admission for ACA aneurysm coiling. She was
admitted to the Neuro ICU for overnight observation for
continued neuro checks and strict blood pressure control. She
was kept flat for 4 hours after groin closure. On post op exam
she was AOx3, MAE with fulls strength. Her groin site was dry
with no signs of hematoma and she had good distal pulses. On
[**1-28**] she remained stable and was transferred to the floor, as
she did not feel ready for discharge. She was seen by PT and
cleared for home without services. She will be DC'd home in
stable condition on [**1-29**], however, patient felt unsteady and had
some orthostatic hypotension with physical therapy and was kept
inpatient. On [**1-30**] physical therapy cleared her for home with no
services but patient was anxious to go home as her husband was
away for the night. She was discharged home on [**1-31**].
Medications on Admission:
atenolol 25 mg once daily,
amitriptyline one tablet at bedtime
lorazepam 0.5 mg twice daily
Flonase one to two sprays in each nostril once a day
fluoxetine one and half tabs daily, lisinopril 10 mg daily,
simvastatin one tablet daily.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
2. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-18**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*90 Tablet(s)* Refills:*0*
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety: Please see PCP for refills.
Disp:*20 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
9. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
ACA Aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Coiling
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 4 weeks, no imaging is
needed at that time. Please call [**Telephone/Fax (1) 4296**] to make this
appointment.
Completed by:[**2130-1-31**]
|
[
"4019"
] |
Admission Date: [**2148-1-20**] Discharge Date: [**2148-1-26**]
Date of Birth: [**2076-7-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Acetaminophen / Percocet
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Altered mental status, melena
Major Surgical or Invasive Procedure:
LP unsuccessful attempt x 2
RIJ central venous line
Intubation for procedure for airway protection
EGD
VP shunt tap
Colonoscopy
History of Present Illness:
History obtained from patient's family, outside ED/Hospital
records, our ED records, & OMR as the patient is minimally
responsive and not communicative on interview.
The patient has been admitted from and OSH ED from her nursing
home for nausea/vomiting, abdominal pain and leukocytosis for
the past 24 hours. She has become increasingly altered over that
time.
Since [**2147-7-14**] she has been in declining health. At that
time she was living at home and was admitted to an OSH for chest
pain found to be coronary artery disease medically managed
presumedly with anti-platelet therapy. She developed black tarry
stools and was found to have a bleeding ulcer at that time. In
[**2147-10-14**] she had a dyspnea admission ruled anxiety. In
[**2147-12-14**] she was admitted again for vomiting and found to
have a VRE UTI, L sided pneumonia with LLE cellulitis. Per her
daughter, during this admission the patient had an "upper GI
obstruction," likely volvulus warranting surgery. However no
surgery was performed. She was transferred to Country [**Hospital 731**]
Rehab for several hours and returned with an acute MI. She was
transferred to [**Hospital 12017**] Hospital for cath and had bare metal
stent placed in the "front artery." Upon return to rehab she was
again readmitted for Pulmonary edema. This most recent stay
ended [**2148-1-17**] with discharge to [**Hospital 32944**] Rehab.
Per the patient's daughter, the patient was vomiting and
complaining of abdominal pain the night prior to presentation.
The patient is alert and oriented at [**Hospital 5348**] but does become
combative when irritated.
At the OSH ED she was somnolent but arousable and oriented.
There she received Dilaudid & a benzodiazepine with IV Fluids.
She was monitored on telemetry. Concern for Small Bowel
Obstruction warranted Abdominal CT with PO contrast only (no
sufficient IV access). That scan was reviewed by our
radiologists and showed only a ventral hernia and poor
penetration of contrast into her colon, not suggestive of
obstruction or acute abdominal process. She was noted to have a
WBC of 21 with 91% neutrophils, HCT 34.3, Cr 1.1. CK 29 with
CKMB 8.6 which is elevated and tropinin I of 0.12 which is
within the normal range. They treated her with 1g vancomycin for
concern of shunt infection and sent her to [**Hospital1 18**] for further
evaluation. Of note, she has recently been on doxycycline,
vanomycin and levafloxacin for M. Catarrhalis from her sputum,
resistant E coli from urine and also with linezolid for VRE in
the urine (per records from [**Hospital 12017**] Hospital).
In our ED, VS: 96.5 BP 125/79 P 118 RR 14 98% on room air. The
patient received Flagyl/Zosyn for putative abdominal infection.
Surgery was consulted and based on exam and review of the films,
did not feel she had an acute problem nor did she warrant
surgical intervention. Stable ventral hernia, easily reducible
with bowel in hernia. She was admitted to medicine for elevated
WBC count and evaluation of her mental status.
On arrival to the floor the patient is tachycardia and minimally
responsive. She awakes to vigorous stimulation and multiple
sternal rubs. She is unable to give any history or status.
Past Medical History:
Obtained from family and OSH records and OMR:
- CAD s/p recent MI and cardiac stenting on [**2148-1-9**] (likely BMS
to LAD given family history, but waiting for OSH records)
- Bilateral fem-[**Doctor Last Name **] bypass
- Right AKA
- Pseudoaneurysm repair to left fem artery
- [**2142**] massive hydrocephalus with brain stem compression s/p
craniectomy complicated by cerebellar hemorrhage and non
communicating hydroceph and need for VP shunt
- COPD
- Gout
- HTN
- Recent pneumonia
- Recent VRE UTI
- MRSA history
- s/p CCy and appy
- AAA (reported per OSH records)
Social History:
Lives in nursing home technically, however in and out of
hospitals as above for the past 6-8 months per daughter. Smoking
history of strong tobacco use until very recently (1ppd for 55
years), denies EtOH.
Family History:
Non-contributory
Physical Exam:
Vitals: 98.8 110/52 86 20 98% RA
General: Awake and pleasant
HEENT: No JVD, MM dry, oropharynx clear
CV: S1&S2 regular without murmur
Lungs: Scant crackles at bases, otherwise clear
Abdomen: Prominent reducible ventral hernia, BS present, no
tenderness elicited.
Ext: R AKA, Left palpable DP pulse
Neuro: AAOx3, Cranial nerves grossly intact to confrontation
Pertinent Results:
[**2148-1-20**] 04:07AM BLOOD WBC-34.2*# RBC-4.60 Hgb-10.6* Hct-34.1*
MCV-74* MCH-23.0*# MCHC-31.0 RDW-17.0* Plt Ct-428#
[**2148-1-20**] 07:51PM BLOOD Hct-26.0*
[**2148-1-21**] 09:54AM BLOOD Hct-32.6*
[**2148-1-22**] 04:24AM BLOOD WBC-10.3 RBC-3.56* Hgb-9.1* Hct-28.4*
MCV-80* MCH-25.5* MCHC-31.9 RDW-17.2* Plt Ct-200
[**2148-1-22**] 01:35PM BLOOD Hct-30.4*
[**2148-1-20**] 04:07AM BLOOD Glucose-95 UreaN-45* Creat-0.9 Na-138
K-3.9 Cl-101 HCO3-24 AnGap-17
[**2148-1-22**] 04:24AM BLOOD Glucose-73 UreaN-10 Creat-0.5 Na-140
K-4.6 Cl-111* HCO3-21* AnGap-13
[**2148-1-20**] 04:17AM BLOOD Lactate-1.6
[**2148-1-20**] 09:52AM BLOOD Lactate-1.1
Discharge Labs:
140 105 7
--------------<97
3.5 29 0.5
Ca: 7.8 Mg: 1.5 P: 3.8 D
Wbc 8.6 Hgb 8.6 Hct 26.4 Plt 319
PT: 14.6 PTT: 27.1 INR: 1.3
CT head [**1-20**] AM:
IMPRESSION: Stable position of ventricular shunt with slightly
increased
ventricular size and transependymal edema. No evidence of acute
hemorrhage.
CT head [**1-20**] PM:
IMPRESSION: No short interval change in ventricular caliber. No
new
intracranial hemorrhage or shift of normally midline structures.
Endoscopy [**2148-1-20**]:
Normal EGD to third part of the duodenum
Recommendations: Monitor HCT q6hrs
Continue PPI
Additional notes: There was absolutely no blood seen in the
upper GI tract as far as the scope could be passed. Source of
melena likely right sided colonic versus small bowel lesion.
Colonoscopy [**2148-1-24**]
Multiple diverticula were seen in the whole colon.
Melena was seen in the ascending colon, transverse colon,
descending colon and sigmoid colon.
No active bleeding seen from the diverticula.
No large polyps or masses identified; however the presence of
small polyps or lesions cannot be completely excluded due to the
presence of melena.
Consider capsule endoscopy to r/o small bowel source of bleeding
[**2148-1-23**]: UE U/S
Small partial filling defect in the right subclavian vein
suggesting chronic nonocclusive thrombus.
Microbiology:
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2148-1-22**]):
EQUIVOCAL BY EIA.
GRAM STAIN (Final [**2148-1-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
FLUID CULTURE (Final [**2148-1-24**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take 3-8 weeks to grow..
VIRAL CULTURE (Preliminary): No Virus isolated so far.
CRYPTOCOCCAL ANTIGEN (Final [**2148-1-21**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2148-1-22**]):
Feces negative for C.difficile toxin A & B by EIA.
Blood Culture, Routine (Final [**2148-1-26**]): NO GROWTH.
URINE CULTURE (Final [**2148-1-21**]):
GRAM NEGATIVE ROD(S). ~[**2138**]/ML.
Brief Hospital Course:
71 year old lady with recent stented NSTEMI, multiple medical
problems admitted to the hospital for leukocytosis and altered
mental status found to have a GI bleed.
1) GI Bleed: The patient developed melena during a lumbar
puncture attempt to evaluate her altered mental status. Her
hematocrit dropped signficantly over the next 6 hours and she
was transported to the ICU with central venous line and 1 unit
of packed reb blood cells already in place. During her bleed
she was maintained on Aspirin & Plavix & carvedilol for her
coronary disease despite the risks given her recent stent. She
remained in the ICU for 2 days where she was intubated for
airway protection during an endoscopy. Endoscopy did not find
any bleeding and the patient was successfully extubated,
transfused a second unit of blood and returned to the medical
floor. She continued to experience melena and was prepared for
a MAC anesthesia colonoscopy which showed melena but no source
of bleeding. After the colonoscopy the patient's melena slowed
and stopped. She was transfused a third (final) unit of blood
for a hct < 28 prior to discharge. To further investigate the
source of bleeding, she has a capsule endoscopy [**Year (4 digits) 1988**] on
[**2148-2-7**]. She has no melena on discharge.
2) Coronary artery diseas/CHF: Record review indicated the
patient had a Bare Metal Stent placed late [**2147-12-14**]. She
was continued on aspirin, clopidogrel, carvedilol (increased to
12.5 once bleeding subsided) and a statin despite the inherent
risks of these medications. She will be discharged on these
medicines and on her home lasix/potassium regimen. We have
stopped her HCTZ.
3) Leukocytosis: The patient had a significant leukocytosis not
clearly explained during this admission. She was started on
Flagyl for possible C. diff colitis and stopped after several
days when her assay and colonoscopy returned negative. Her
white count resolved. Her VP shunt was tapped and found to be
functioning and not infected.
4) Altered mental status: The patient was admitted altered,
likely from narcotic and sedative medication administered prior
to transfer/admission. Her status cleared and returned to a
pleasant [**Year (4 digits) 5348**]. During her admission she occasionally became
agitated and 0.5mg of Haldol PO was used successfully.
5) COPD: The patient was continued on home inhaled medications.
6) GERD: The patient was continued on protonix for Gi bleed,
switched back to omeprazole on discharge.
Full code
Medications on Admission:
Lasix 20 mg PO qday
Carvedilol 6.25 mg PO BID
Hydrochlorothiazide 12.5 mg PO qday
ASA 325 mg PO qday
Clopidogrel 75 mg PO qday
Omeprazole 40 mg PO daily
Isosorbide 60mg PO daily
Lisinopril 10 mg PO QAM
K+ 20 mEq PO QAM
Simvastatin 40 mg PO QAM
Advair diskus 1 puff [**Hospital1 **]
Spiriva 18 mg QAM
Albuterol inhaler 2.5% 2 puffs q4hr PRN
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for wheezing.
10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
12. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Health of [**Hospital3 **] - [**Location (un) 32944**]
Discharge Diagnosis:
Lower gastrointestinal bleeding
Acute blood loss anemia
Altered mental status
Coronary artery disease
Discharge Condition:
Vital signs stable, tolerating regular diet, no melena observed
Discharge Instructions:
You were admitted to the hospital because of abdominal pain and
because of bleeding from below. You have been given 3 units of
blood and your bleeding has stopped. You had a colonoscopy and
upper endoscopy and no source of your bleeding was found.
You are still [**Location (un) 1988**] for a "Capsule Endoscopy" to evaluate
the part of your bowels that could not be seen from either
endoscopy or colonoscopy to keep looking for a cause of
bleeding.
Despite your bleeding, we have continued your Aspirin and Plavix
to protect your heart. This puts you at high risk of bleeding,
but you must continue these medications uninterrupted given your
recent stent. Do not stop these medications without discussing
this with your cardiologist.
Your blood pressure medications have been changed.
1. Coreg (carvedilol) was increased to 12.5mg by mouth twice
daily.
2. Stop taking HCTZ (no need for it after increasing your other
medication.
3. Continue lisinopril 10mg, lasix 20mg daily
Your VP shunt was investigated by neurosurgery and found to be
functioning well and was without infection.
Should you experience chest pain, shortness of breath, notice
bright red blood from below, please call your doctor or 911.
You may notice small amounts of very dark stools, but if it
increases, please call your doctor or 911.
Followup Instructions:
1. Capsule Endoscopy:
You have been [**Location (un) 1988**] for a Capsule Endoscopy on [**2148-2-7**] at 8am. This requires some preparation, so please review
the attached paperwork. Please call [**First Name8 (NamePattern2) 13544**] [**Last Name (NamePattern1) 39685**] at
[**Telephone/Fax (1) 13545**] should you need to reschedule.
To Prepare:
You must eat a low residue diet three days prior to study.
Please have only a clear liquid diet for the day before the
study and take the prescribed prep; and do not eat anything from
midnight before your study.
For the capsule study: Go to [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 1950**] building
[**Location (un) **]: ERCP 2 (ST-4) GI ROOMS Date/Time:[**2148-2-7**] 8:00
(please arrive at 7:45am). The study will be done by [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2148-2-7**] 8:00
Please call to make an appointment with Dr. [**First Name (STitle) **] within 2 weeks of
discharge. He can be reached at [**Telephone/Fax (1) 59868**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
|
[
"2851",
"496",
"4019",
"53081",
"41401",
"V4582"
] |
Admission Date: [**2206-5-14**] Discharge Date: [**2206-6-6**]
Date of Birth: [**2146-4-3**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Lisinopril
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Dyspnea, hypotension
Major Surgical or Invasive Procedure:
1) Bronchoscopy
2) Transfusion with packed red blood cells
3) Intubation/extubation
4) Central Line placement (L and R)
History of Present Illness:
Ms. [**Known lastname 97713**] is a 60 year old female with past medical
history of CAD status-post CABG, status-post AVR and MVR, and
COPD who presented with dyspnea. History is obtained from ED
sign-out and chart review, per discussion much is from the
daughter.
.
Per report, she has had worsening dyspnea for about one week,
along with dizziness. Reportedly she has not been taking her
medications, and her daughter has found them hidden around the
house. The night before admission, she was more short of breath,
and either coughed or vomited up a small amount of blood. This
morning, she attempted to walk to the bathroom and fell twice,
at which point EMS was called.
.
Upon arrival to the BIMDC ED, her initial vitals were a
temperature of 101, blood pressure of 129/78, heart rate of 136,
respiratory rate of 32, and oxygen saturation of 92% on
non-rebreather. Due to respiratory distress and respiratory rate
of 40, she was intubated with etomade and succ. Prior to
intubation, systolic blood pressure recorded as 160-170.
Post-intubation, on propofol, systolic blood pressure dropped to
70-80. She received 300 cc of IVF with improved to 80's, however
at that point a right IJ central line was placed and neo was
started peripherally. Levophed was initiated after central line
placement.
.
While in the ED, she also received 1 gram of ceftriaxone, 500 mg
of azithromycin, 650 mg of acetaminophen, and 10 mg of IV
decadron.
.
Cardiology was consulted regarding elevated troponin, and given
the bloody ETT secretions, it was recommended that heparin drip
be held for now.
.
Upon arrival to the ICU, she is intubated and sedated,
occasional moving.
Past Medical History:
- CAD s/p CABG '[**95**] and stents in [**2199**].
[**2195**]: non-Q MI s/p CABG in [**2195**] (by Dr. [**Last Name (STitle) 1537**]. LIMA>>LAD,
SVG>>PDA and OM1. [**9-1**] Cardiac cath: 2VD
- Aortic valve replacement in [**2195**]; Mitral valve
ring-annuloplasty [**2204**]
- Diastolic CHF, EF 55%, followed by Dr. [**First Name (STitle) 437**] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
- HTN
- Hyperlipidemia
- Hypothyroidism [**12-31**] iodine treatment for [**Doctor Last Name 933**] disease- [**2180**]
- Depression with psychosis, bipolar disorder
- Discoid lupus
- PTSD
- H/o carcinoid s/p resection in [**2173**]
- COPD, prior admissions for acute exacerbations [[**8-1**] PFTs FEV1
51%pred, FVC 51%pred, DSB(Hb) 56%pred]
- TAH bilateral SBO
- Hemolytic anemia secondary to AVR
- Migraine
- T9-T10 disk herniation
- Temporal arteritis, followed by Dr. [**Last Name (STitle) **]
- Obstructive sleep apnea, not on CPAP
- Chronic renal disease, baseline creatinine 1.3-1.4
# Coronary artery disease, sp CABG and AVR, with MV
annuloplasty, [**2204**], also s/o cath [**2199**] with multiple stents.
# Diastolic CHF, EF [**2204**] 55%
# Hypertension
# Hyperlipidemia
# Hypothyroidism secondary to RAI for [**Doctor Last Name 933**] Disease
# Depression with psychosis/ bipolar disorder
# Discoid Lupus
# PTSD
# Carcinoid s/p resection in [**2173**]
# COPD w/ admissions for acute exacerbations ([**8-1**] PFTs FEV1
51%pred, FVC 51%pred, DSB(Hb) 56%pred)
# s/p TAH and b/l BOS
# Hemolytic Anemia
# Migraine
# T9/T10 Disc Herniation
# Right hip arthritis
# obstructive sleep apnea (not on CPAP)
Social History:
Per notes, smokes a pack per day, no alcohol or ilicit drug use.
Significant social stressors, including possible pending
eviction. On disability.
Family History:
Per prior notes:
Mother with MI. Hypertension, migraines, breast cancer in other
relatives.
Sister with MI, "enlarged heart" at 42, fatal.
Father still alive at 90.
Physical Exam:
Temperature 101, Heart rate 99, Blood pressure 114/66
Ventilator settings: AC, TV 450, RR 14, FiO2 100%
General: Sedated, though awakens intermittently and responds to
commands
HEENT: NC/AT, MMM, clear oropharynx with ETT and OG in place. No
scleral icterus or pallor.
Neck: Supple, no thyroid tissue palpable. Right IJ in place,
appears c/d/i. Very difficult to assess JVP, but appears
slightly elevated.
Lungs: Diffuse rhonchi, left greater than right,
Cardiac: Regular, tachycardic, possible soft systolic murmur, no
clear rubs or gallops
Abd: Soft, no clear tenderness, +BS but soft
GU: Foley in place with dark amber urine
Extr: Trace bilateral peripheral edema bilaterally to ankles,
cool hands, feet warmer, though still cool. No clubbing or
cyanosis.
Neuro: Awake intermittently, appropriately following commands.
PERRL
Psych: Unable to fully assess
Physical Exam on Discharge:
Lungs: CTAB
MSK: [**3-3**] muscle strength throughout, still weak
GU: No foley or rectal tube in place
Neuro: A&Ox3, responds appropriately, back to baseline
Pertinent Results:
[**2206-5-14**] 10:00AM PT-13.3 PTT-28.0 INR(PT)-1.1
[**2206-5-14**] 10:00AM PLT COUNT-173
[**2206-5-14**] 10:00AM NEUTS-91.0* LYMPHS-5.2* MONOS-3.1 EOS-0.6
BASOS-0.2
[**2206-5-14**] 10:00AM WBC-12.9* RBC-4.06* HGB-11.5* HCT-35.9*
MCV-89 MCH-28.3 MCHC-31.9 RDW-19.0*
[**2206-5-14**] 10:00AM CORTISOL-86.7*
[**2206-5-14**] 10:00AM CK-MB-19* MB INDX-0.2
[**2206-5-14**] 10:00AM cTropnT-0.34*
[**2206-5-14**] 10:00AM CK(CPK)-[**Numeric Identifier 97722**]*
[**2206-5-14**] 10:00AM estGFR-Using this
[**2206-5-14**] 10:00AM GLUCOSE-197* UREA N-18 CREAT-1.7* SODIUM-136
POTASSIUM-2.5* CHLORIDE-96 TOTAL CO2-24 ANION GAP-19
[**2206-5-14**] 11:02AM URINE EOS-NEGATIVE
[**2206-5-14**] 11:02AM URINE MUCOUS-FEW
[**2206-5-14**] 11:02AM URINE GRANULAR-0-2 HYALINE-0-2 WBCCAST-<1
[**2206-5-14**] 11:02AM URINE RBC-[**1-31**]* WBC-[**1-31**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2206-5-14**] 11:02AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2206-5-14**] 11:02AM URINE COLOR-[**Location (un) **] APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2206-5-14**] 11:02AM URINE GR HOLD-HOLD
[**2206-5-14**] 11:02AM URINE HOURS-RANDOM
Labs at Discharge:
[**2206-6-6**] 06:31AM BLOOD WBC-7.9 RBC-3.13* Hgb-9.4* Hct-28.9*
MCV-92 MCH-30.0 MCHC-32.5 RDW-23.0* Plt Ct-240
[**2206-6-6**] 06:31AM BLOOD PT-35.7* PTT-33.5 INR(PT)-3.7*
[**2206-6-6**] 06:31AM BLOOD Glucose-91 UreaN-22* Creat-1.2* Na-139
K-3.9 Cl-104 HCO3-28 AnGap-11
[**2206-6-4**] 06:27AM BLOOD ALT-61* AST-72* LD(LDH)-423* CK(CPK)-56
AlkPhos-111* TotBili-0.6
[**2206-6-6**] 06:31AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.2
Cardiac Enzymes:
[**2206-6-3**] 11:17PM BLOOD CK-MB-5 cTropnT-0.30*
[**2206-6-4**] 06:27AM BLOOD CK-MB-5 cTropnT-0.39*
[**2206-6-4**] 04:10PM BLOOD CK-MB-8 cTropnT-0.29*
Imaging:
[**6-5**] CXR- IMPRESSION: Minimal decrease in left upper lobe
pneumonia from the most recent study but considerable
improvement since [**2206-4-29**]; small left pleural effusion.
Echo [**5-17**] The left atrium is mildly dilated. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). Diastolic function could not be assessed. The
right ventricular cavity is dilated with depressed free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. A
mechanical aortic valve prosthesis is present. The aortic valve
prosthesis leaflets appear to move normally. The transaortic
gradient is normal for this prosthesis. The mitral valve
leaflets are mildly thickened. A mitral valve annuloplasty ring
is present. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. Compared with the prior study (images
reviewed) of [**2206-5-14**], the findings are similar.
Brief Hospital Course:
Ms. [**Known lastname 97713**] is a 60 year old female with complicated past
medical history including coronary artery disease, status-post
aortic and mitral valve replacement, COPD, temporal arteritis,
and chronic renal insufficiency who presented with hypoxemic
respiratory failure and hypotension.
#) Hypoxemic respiratory failure: Ms. [**Known lastname 97713**] presented with
significant respiratory distress and was intubated in the
emergency room. Initially the etiology of her respiratory
failure was unclear. She was treated broadly with antibiotics
for hospital-acquired pneumonia, and heparin drip was initiated
for her mechanical heart valves, which also empirically covered
for PE. Upon arrival to the MICU, she was noted to have some
blood-tinged secretions, and underwent bronchoscopy for airway
inspection and broncho-alveolar lavage (BAL). There was no
active bleeding identified, so anti-coagulation for her AVR and
MVR was pursued.
The morning after admission, her urine legionella antigen
returned positive. Her BAL did not grow out any organisms. She
remained on the ventilator until [**2206-5-25**]. During the first
week, there were times when she was difficult to oxygen and
ventilate, and she required paralytics in order to fully be
ventilated. Eventually her respiratory support was able to be
decreased as she was diuresed prior to extubation. She continued
on atrovent and albuterol for her history of COPD.
Broad antibiotic coverage was continued for a two week course,
however eventually narrowed to levofloxacin for the legionella.
Her pneumonia improved and now has no oxygen requirement, O2 Sat
99% on RA and has completed her course of Levofloxacin on
[**2206-6-5**].
#) Shock: Initially Ms. [**Known lastname 97713**] was hypotensive and placed
on pressors. Given that she had cool extremities, her cardiac
history, and a sub-therapeutic INR, cardiogenic etiology was
considered. An echocardiogram completed within hours of MICU
admission did not reveal any significant change, aside from
increased right-sided pressures, which were eventually felt to
be secondary to her very large left-sided pneumonia. Her shock
was felt to be septic in nature, supported by her imaging
findings of pneumonia. She was bolused with intravenous fluids
until her CVP was at goal and she was no longer fluid
responsive. She was on supported with pressors until these were
able to be weaned.
#) Supraventricular tachycardia: During her ICU stay, she
developed a narrow-complex tachycardia intermittently, most
commonly in setting of febrile state, with rates to the 160's.
Intravenous beta-blockers and calcium-channel blockers were
used, and eventually an amiodarone drip was required to control
her heart rate. Cardiology was consulted and followed along.
Eventually she was able to be weaned off the amiodarone drip,
and continued on an oral amiodarone load. Her loading dose of
amiodarone was initiated on [**5-22**] and is 400mg tid.
At follow up with her cardiologist, Dr. [**First Name (STitle) 437**], decision may be
made regarding whether she needs to continue on the amiodarone
and at what dose. Her amiodarone was d/c'd and her metoprolol
was decreased to 25mg. She will follow up with Dr. [**First Name (STitle) 437**] 2 weeks
after discharge.
#) Acute on chronic kidney injury: Patient initially was
olioguric during the initial part of her MICU stay. Her acute
kidney injury was felt to be secondary to hypotension and likely
ATN. Her creatinine peaked at 2.4. Her renal function recovered
and was better than baseline(1.3-1.4) at time of discharge.
#) Leukocytosis and Fevers: Patient had significant leukocytosis
during her admission, with peak WBC of 38.2. Additional work-up
for her fever was undertaken, including urine, blood, and sputum
cultures. CT of her chest/abdomen/pelvis did not reveal any
other pathology to account for her fever. She was not found to
have a large enough pleural effusion to tap. Her central line
was re-sited and cultured. She was covered with broad
antibiotics, including metronidazole for c. difficile, however
these were narrowed to only levofloxacin for her legionella
pneumonia. She had one positive blood culture with coagulase
negative staph, which was likely a contaminant, however she
completed a course of vancomycin.
During her admission, she initially spiked high fevers to
103-104 nearly daily. This was felt to be secondary to her
legionella pneumonia, however search for other potential
etiologies (including drug fever) was completed as noted above.
Prior to discharge, her fever curve had greatly improved and she
was afebrile for 24 hours, though had had some low grade
temperatures (99-100.5) in the preceding days.
At time of discharge, her white blood cell count was 7.9
#) Status-post AVR and MVR: At time of admission, patient's INR
was 1.1. It was unclear if she had been taking her warfarin, as
further history was not able to be obtained from patient. Per
report from family, there were concerns regarding whether she
had been taking her medications recently. After bronchoscopy
which did not reveal any active bleeding source, she was
initiated on a heparin drip. Prior to discharge, her warfarin
was resumed on [**2206-5-27**] and she was bridged on a heparin drip.
Her INR at time of discharge was 3.7. She will need to be
followed by the [**Hospital 191**] [**Hospital **] clinic ([**Telephone/Fax (1) 10844**].
Warfarin was held on the day of discharge due to
supratherapeutic INR of 3.7. Goal is 2.5 to 3.5. INRs will need
to be checked daily at rehab. Would recommend restarting
Coumadin at dose of 2 mg daily on [**2206-6-7**] if INR is not
supratherapeutic.
#) Elevated LFT's: Patient was noted to have rising LFT's during
her admission. It was felt that this was possibly due to
right-sided congestion after fluid rescusitation, medication
effect, or possibly from shock liver. Hepatology consult was
obtained, and a number of test were completed, including iron
studies (Ferritin 1724, TIBC 174, Iron 106), Hepatitis A, B, and
C (all negative), AMA/[**Doctor First Name **] (negative) and HSV 1& 2(IgG positive).
Liver ultrasound was unremarkable. Anti-smooth muscle antibody
was positive.
At time of discharge, her numbers were trending downward, with
ALT 44, AST 72, Alk Phos 189, and Total bilirubin of 1.1.
She should follow up with her PCP, [**Name10 (NameIs) **] which time referral to
hepatology may be considered should her liver function tests
remain elevated.
#) Anemia: Patient had anemia during her admission, which was
felt to be secondary to both serial phebletomy, anemia of
chronic disease, and possibly low level hemolysis secondary to
her AVR. Her HCT remained stable and was at 28 at tiem of
discharge. During her stay, she received a total of four units
of packed red blood cells.
#) COPD: She was treated with albuterol and ipratropium while
intubated, and resumed on her home regimen of albuterol, advair,
and spirvia at time of discharge.
#) Temporal arteritis: Patient was continued on her home dose of
prednisone (7 mg). She required 20mg of stress dose steroids as
her cortisol was low. Her methotrexate was held given liver
abnormalities, and may be re-started after discharge per
instructions from her rheumatologist. She will need to follow up
with rheumatology within 2-3 weeks of discharge.
#) Psychosis: Patient's seroquel was held after extubation due
to her mild somnolence but was resumed before discharge.
#) Depression: Citalopram was continued. Clonazepam was held
given her mental status, and was resumed before discharge.
Lamotrigine was continued.
#) Hypertension: Prior to discharge, an [**First Name9 (NamePattern2) 97723**] [**Last Name (un) **]
(losartan) was resumed. The patients Lasix was d/c'd due to an
episode of hypotension most likely from dehydration. Her
metoprolol was decreased to 25mg.
#) CAD: Patient's clopidogrel was held due to bloody secretions
from her ETT tube and need for anti-coagulation given her
mechanical valves. This was resumed at discharge. Her isosorbide
was also resumed. Her statin was held given her elevated liver
function tests, but resumed prior to discharge as they were
trending downward. She initially had a set of cardiac enzymes
checked that remained flat.
#) Elevated troponin: Troponin was checked on [**2206-6-4**] in the
setting of hypotension. This was elevated to peak 0.39 but
remained flat with negative CK and unchanged EKG. The patient
was evaluated by cardiology, who recommended outpatient
cardiology follow-up.
#) Hypernatremia: The patient developed hypernatremia during her
MICU stay likely secondary to the furosemide drip and tube
feeds. She was repleted with free water throughout her stay.
On the day of transfer from the MICU, her sodium level was 147.
She received 1L of D5W prior to transfer. On day of discharge,
her Na=139.
#) Hypothyroidism: TSH was checked during her admission and
found to be 0.71. Her home dose of levothyroxine was continued.
#) Code status: FULL CODE
Medications on Admission:
- Albuterol nebulizer q4 hours PRN wheezing
- Albuterol inhaler 90 mcg: 2 puffs every 6 hours PRN shortness
of breath
- Atorvastatin 10 mg
- Chlorhexidine mouth wash
- Citalopram 30 mg daily
- Clonazepam 2 mg QAM, 1 mg QHS
- Clopidogrel 75 mg
- Cyclobenzaprine 10 mg [**Hospital1 **]
- Ergocalciferol 50,000 units weekly for 3 months
- Fluticasone-salmeterol 100 mcg/50 mcg [**Hospital1 **]
- Folic acid 1 mg daily
- Furosemide 160 mg
- Isosorbide SR 60 mg daily
- Lamotrigine 75 mg daily
- Levothyroxine 112 mcg daily
- Methotrexate 10 mg weekly
- Metoprolol Succinate 100 mg daily
- Nitroglyercin SL PRN
- Nystatin cream PRN
- Olmesartan 5 mg
- Omeprazole 20 mg
- Oxycodone 5-10 mg [**Hospital1 **]
- Prednisone 7 mg daily
- Quetiapine 100 mg QHS
- Tiotropium 18 mcg daily
- Warfarin 2-4 mg daily as directed by [**Hospital 191**] [**Hospital 197**] Clinic
- Aspirin 81 mg
- Bisacodyl 10 mg PRN constipation
- Docusate 200 mg daily
Discharge Medications:
1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-30**] Inhalation Q6H (every 6 hours).
7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day: Check
LFTs.
8. [**Month/Day (2) **] 75 mg Tablet Sig: One (1) Tablet PO once a day.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Was
held on [**6-6**], please start on [**6-7**] and check INR daily. Goal INR
2.5 to 3.5.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
15. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
17. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day:
Give 3 tablets (15mg) for 3 days, then give 2 tablets (10mg)
daily as her standing dose for her history of temporal arteritis
.
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
19. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center
Discharge Diagnosis:
Primary: Legionella Pneumonia
Secondary:
-Acute renal failure
-Anemia
-Hypernatremia
-COPD
-Hypertension
-Status-post AVR, MVR on Warfarin
-CAD status-post stent now on [**Hospital **]
-Supraventricular tachycardia
-Hypothyroidism
-Constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with difficulty breathing, and found to have a
pneumonia and treated with the antibiotic Levofloxacin. You
were placed on a ventilator, and cared for by the medical ICU
team. You were then transferred to the general medicine floor.
Your pneumonia improved and your antibiotic was stopped while
you were still in the hospital. You were delerious and
hallucinated in the beginning but improved and returned to your
normal state of mental health by the time of discharge.
It is IMPERATIVE that you stop smoking.
The following changes have been made to your medications:
1) Metoprolol tartrate is now 25mg twice daily
2) STOP taking your Methotrexate Sodium 10 mg Tablet once a week
until you see your rheumatologist DR. [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**] and he
says that it is okay to re-start it.
3) INCREASE your dose of Prednisone to 15mg once a day for only
3 days, then take 10mg daily. This will be your new Prednisone
dose that you will take for your history of having temporal
arteritis.
.
The following medications were stopped:
-Cyclobenzaprine 10mg [**Hospital1 **]
-Oxycodone 500mg 1-2tab [**Hospital1 **]
-Isosorbide Mononitrate
-Olmesartan
-Lasix
.
Please follow up with your appointments as stated below.
Followup Instructions:
Please go to your appointment with your Primary Care Physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**], on WEDNESDAY [**2206-6-11**] at 12:00 PM.
Please go to your appointment with Dr. [**First Name (STitle) 437**] (Cardiology) on
TUESDAY [**2206-7-1**] at 2:00 PM.
Please go to your appointment with your Rheumatologist, Dr.
[**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**] on WEDNESDAY [**2206-6-18**] at 11:30 AM.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2206-6-11**] at 12:00 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2206-7-1**] at 2:00 PM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RHEUMATOLOGY
When: WEDNESDAY [**2206-6-18**] at 11:30 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2206-7-21**] at 10:20 AM
With: [**Name6 (MD) 10160**] [**Name8 (MD) 10161**], NP [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2206-12-3**] at 11:40 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"V4582",
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] |
Admission Date: [**2124-12-15**] Discharge Date: [**2124-12-16**]
Date of Birth: [**2068-7-22**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 56 year old man with
a history of lung cancer status post radiation therapy and
chemotherapy and chronic obstructive pulmonary disease, who
presents with acute dyspnea and oropharynx swelling. The
patient states that he was in his usual state of health when
three hours after eating a dinner of shrimp and scallops,
began to develop burning and warmth of his posterior cervical
neck and forehead. He went to CVS to get some Benadryl and
on the way became progressively short of breath and
complained of upper and lower lip swelling. The Emergency
Medical Services was activated. He was found to be
stridorous with a blood pressure of 60/palpation complaining
of his throat closing up.
The patient received epinephrine 0.3 subcutaneously and
Benadryl 50 mg intravenous en route to the hospital and his
blood pressure normalized. The patient was saturating at 98%
on room air. He received intravenous Solu-Medrol and
intravenous Cimetidine.
The patient reported a history of swelling after a bee sting
30 years ago for which he went to the Emergency Room and
received intravenous Benadryl. He consumes shellfish
regularly and has had no adverse events in the past. The
patient is currently on chemotherapy, the cycle beginning in
[**Month (only) 359**]. His last dosage of medication being approximately
two weeks prior to presentation.
PAST MEDICAL HISTORY:
1. Nonsmall cell lung cancer status post chemotherapy and
radiation therapy found to be non-surgical on thoracotomy.
Evidence of metastases to the left adrenal gland.
2. Emphysema.
3. Depression.
4. Status post tonsillectomy.
MEDICATIONS:
1. Chemotherapy.
2. Combivent two puffs four times a day p.r.n.
3. Wellbutrin 150 mg twice a day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs were afebrile. Blood
pressure 94/48; pulse 109; respirations 20; saturation of 98%
on room air. In general, in no apparent distress, alert and
oriented times three. The patient is speaking in full
sentences. No respiratory distress. HEENT: Normocephalic,
atraumatic. Pupils are equal, round and reactive to light.
Extraocular movements intact. Sclerae anicteric. There is
swelling of the upper and lower lips and question of swelling
of the tongue; no airway compromise, no lymphadenopathy.
Chest is clear to auscultation bilaterally. Cor:
Tachycardia, normal S1, S2, no murmurs, rubs or gallops.
Abdomen is soft, nontender, nondistended. No
hepatosplenomegaly or masses. Positive bowel sounds.
Extremities are warm and well perfused. Positive for
clubbing. No cyanosis of edema. Neurological: Cranial
nerves II through XII are intact. He moves all extremities.
Strength is five out of five.
LABORATORY: White blood cell count 3.9, hematocrit 30.4,
platelets 494. Sodium 143, potassium 4.4, chloride 107,
bicarbonate 29, BUN 13, creatinine 0.7, glucose 130. Serum
toxicology screen negative.
EKG with sinus tachycardia at the rate of 114.
Chest x-ray with ill defined density overlying the right
superior hilum suggestive of a mass. Right lateral pleural
thickening, rib fractures and atelectatic changes consistent
with post surgical change.
HOSPITAL COURSE:
1. ANAPHYLAXIS: The patient was started on intravenous
hydrocortisone, intravenous famotidine and intravenous
diphenhydramine,. He was admitted and observed in the
Medical Intensive Care Unit given his history for previous
anaphylaxis in the setting of p.o. allergen.
The patient remained hemodynamically stable and his
angioedema resolved. It seemed unusual that the patient
would develop an allergy to shellfish at the age of 56. It
was suspected that the patient's history of chemotherapy may
have put him at risk for this allergic reaction.
The patient will be discharged with the plan to follow-up
with his primary care physician on [**Name9 (PRE) 766**], [**12-18**]. He
will be referred to an allergist and is instructed in the use
of an epinephrine pen which he will carry with him at all
times, keeping one in the glove compartment of his car and
one in his house.
The patient will complete a rapid steroid taper.
2. LUNG CANCER: This is followed by the patient's
oncologist at the [**Hospital3 328**].
3. TACHYCARDIA: The patient remained in sinus tachycardia
in the low 100s throughout his hospital course. This was
felt to represent the physiologic response to the patient's
anemia. This will be followed up at the patient's primary
care physician.
4. The patient's anemia was felt to be secondary to
chemotherapy. Further evaluation is deferred to the
patient's primary care physician.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Anaphylaxis to shellfish.
2. Nonsmall cell lung cancer.
3. Resting tachycardia.
DISCHARGE MEDICATIONS:
1. Prednisone taper, 40 mg times one day, then 20 mg times
one day.
2. Albuterol ipratropium MDI one to two puffs q. six hours
p.r.n.
3. Bupropion 150 mg p.o. twice a day.
4. Benadryl 50 mg p.o. q. six hours p.r.n.
5. Epinephrine pen 1/[**Numeric Identifier 4856**] syringe, one injection
intramuscular p.r.n. anaphylaxis.
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6512**], at the Southern [**Hospital 12162**] Health Center on
[**12-18**], at 11:30 a.m.
2. The patient will be referred to an allergist for further
evaluation.
Dictated By:[**Name8 (MD) 96586**]
MEDQUIST36
D: [**2124-12-16**] 12:15
T: [**2124-12-16**] 19:17
JOB#: [**Job Number 96587**]
|
[
"2859",
"311"
] |
Admission Date: [**2115-3-9**] Discharge Date: [**2115-3-29**]
Date of Birth: [**2037-12-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
slurred speech, mental status changes
Major Surgical or Invasive Procedure:
[**2115-3-14**] - EGD
[**2115-3-20**] - Endovascular repair of thoracic aneurysm with 34
x 15 TAG endograft, aortogram and right proximal external
iliac to common femoral artery bypass with 8-mm Dacron graft.
History of Present Illness:
Ms. [**Known lastname 8320**] is a 77 year old female admitted on [**2115-3-9**] with an
approximately 2 day history of mental status changes and slurred
speech. The neurology service was consulted, and and MRI showed
likely old small lacunar strokes, but no acute changes. It was
felt that the mental status changes were due to hypertension.
Ms. [**Known lastname 8320**] had run out of Hydrochlorothiazide and had not taken
it for likely 1 week. Blood pressure in the emergency
department was 226/87. Chest x-ray was suspicious for a dilated
thoracic aorta. Chest CTA revealed a 6.6 cm aortic aneurysm of
the descending aorta at the level of T10, and a smaller 4.6 cm
focal aneurysmal dilation just below this area. She was
admitted for further evaluation and management.
Past Medical History:
Cerebrovascular accident times three
Transient ischemic attack
Hypertension
Social History:
6 pack year history of tobacco use. 2 rum and cokes a day.
Lives in [**State 2748**] with her nephew.
Family History:
Mother with heart problems. [**Name (NI) **] other family history of stroke
or blood clots.
Physical Exam:
Temperature: 96.8 BP: 140/60 HR: 72 RR: 18 O2sat;98% RA
General: appears her stated age, pleasant in no acute distress
HEENT: atraumatic, anicteric, pupils 2 mm, equal and reactive.
Clear oropharynx, dentures
Neck: no jugular venous distention, no carotid bruits, no
lymphadenopathy
CV: S1S2, regular rate and rhythm, no murmurs
Lungs: distant breath sounds, otherwise clear, no wheeze, no
accessory muscle use
Abd: soft, non-tender, non-distended, normoactive bowel sounds,
no masses; no flank tenderness
Ext: trace edema bilaterally, warm. DP pulses palpable
bilaterally. No asterixis. No tenderness over vertbrae.
Neuro: cranial nerves [**1-27**] intact, no facial droop, no
dysarthria; alert and oriented, no focal deficits. Strength 5/5
in all extremities, equal without pain with passive or active
movement on lower extremities bilaterally
Pertinent Results:
Head CT [**2115-3-9**] No intracranial hemorrhage or mass effect is
identified. Left basal ganglia chronic lacunar infarct and
cerebellar atrophy.
CTA Chest [**2115-3-11**] 6.6 cm focal lesion in the azygoesophageal
recess abutting the aorta. Quite possibly a thrombosed saccular
aneurysm of the descending aorta at the T10 level.
CTA chest [**2115-3-12**] 4.9 cm fusiform aneurysm of the infrarenal
aorta. 3.0 x 3.5 cm mass adjacent to the thoracic aorta at the
T10 level which could represent a lung or neurogenic tumor or
much less likely a duplication cyst or aortic aneurysm. 8 mm
nodule at the right lung apex. Followup CT of the chest in three
months should be performed to ensure stability.
Carotid Ultrasound [**2115-3-12**] Non-hemodynamically significant
stenosis of less than 40% was demonstrated in the right internal
carotid artery. Hemodynamically significant stenosis of 40-59%
was demonstrated in the left internal carotid artery.
Video Oropharyngeal Swallow [**2115-3-13**] No evidence of aspiration.
For further details, please see the dedicated speech and
language pathology report of [**2115-3-13**].
MRI [**2115-3-14**] 2.8 x 3.3 x 3.9 cm right paraaortic mass with
features most likely represents a thrombosed pseudoaneurysm or
thrombosed saccular aneurysm. The differential diagnosis also
includes duplication cyst or pericardial cyst containing
proteinaceous material, although these entities are considered
much less likely. TEE could be performed for further evaluation
to determine whether duplication cyst may be present.
2. Mild ectasia of the descending aorta and multifocal areas of
mural plaque consistent with atheromatous disease.
[**2115-3-9**] 03:40PM BLOOD WBC-5.1 RBC-4.13* Hgb-12.8 Hct-37.4
MCV-91 MCH-31.1 MCHC-34.4 RDW-13.6 Plt Ct-199
[**2115-3-11**] 06:15AM BLOOD WBC-5.9 RBC-3.98* Hgb-11.7* Hct-35.9*
MCV-90 MCH-29.5 MCHC-32.6 RDW-13.7 Plt Ct-223
[**2115-3-20**] 07:41PM BLOOD WBC-12.3*# RBC-3.51* Hgb-10.7* Hct-30.9*
MCV-88 MCH-30.5 MCHC-34.7 RDW-13.7 Plt Ct-190
[**2115-3-25**] 03:08AM BLOOD WBC-12.9* RBC-3.58* Hgb-11.1* Hct-30.9*
MCV-86 MCH-30.9 MCHC-35.8* RDW-14.7 Plt Ct-199
[**2115-3-26**] 04:30AM BLOOD WBC-10.2 RBC-3.20* Hgb-9.9* Hct-27.9*
MCV-87 MCH-30.9 MCHC-35.4* RDW-14.6 Plt Ct-211
[**2115-3-27**] 01:57AM BLOOD WBC-10.5 RBC-3.39* Hgb-10.3* Hct-29.8*
MCV-88 MCH-30.4 MCHC-34.6 RDW-14.6 Plt Ct-260
[**2115-3-28**] 05:32AM BLOOD WBC-12.1* RBC-3.83* Hgb-11.6* Hct-34.2*
MCV-89 MCH-30.4 MCHC-34.1 RDW-14.5 Plt Ct-330
[**2115-3-9**] 03:40PM BLOOD Neuts-54.7 Bands-0 Lymphs-36.4 Monos-6.7
Eos-1.5 Baso-0.7
[**2115-3-9**] 03:40PM BLOOD PT-11.6 PTT-23.0 INR(PT)-1.0
[**2115-3-27**] 01:57AM BLOOD PT-13.3* PTT-22.0 INR(PT)-1.2*
[**2115-3-9**] 03:40PM BLOOD Glucose-94 UreaN-11 Creat-0.9 Na-142
K-4.2 Cl-104 HCO3-28 AnGap-14
[**2115-3-11**] 06:15AM BLOOD Glucose-87 UreaN-13 Creat-1.0 Na-142
K-4.0 Cl-106 HCO3-28 AnGap-12
[**2115-3-25**] 03:08AM BLOOD Glucose-177* UreaN-15 Creat-0.8 Na-141
K-3.8 Cl-100 HCO3-31 AnGap-14
[**2115-3-27**] 01:57AM BLOOD Glucose-94 UreaN-14 Creat-0.8 Na-138
K-3.9 Cl-99 HCO3-29 AnGap-14
[**2115-3-28**] 05:32AM BLOOD Glucose-122* UreaN-20 Creat-1.2* Na-142
K-3.7 Cl-97 HCO3-31 AnGap-18
[**2115-3-22**] 02:51AM BLOOD Lipase-16
[**2115-3-25**] 03:08AM BLOOD Lipase-24
[**2115-3-10**] 07:00AM BLOOD Mg-1.9 Cholest-199
[**2115-3-28**] 05:32AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.4
[**2115-3-22**] 02:51AM BLOOD Albumin-2.9* Calcium-8.4 Phos-4.3 Mg-1.8
MICROBIOLOGY:
[**2115-3-10**] Urine Cx: negative
[**2115-3-20**] TEE: There is severe symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%) There are
simple atheroma in the aortic root and ascending aorta. The
aortic arch is mildly dilated. There are complex (>4mm) atheroma
in the aortic arch. The descending thoracic aorta is moderately
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. At the distal visible extent of the thoracic
aorta, a large aneurysmal pouch is identified. There is some
flow seen, but a predominant large clot collection. In the sac.
The full dimenisons cannot be identified by TEE, but the sac is
greater than 4 cm across. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are moderately
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is a small
pericardial effusion. The pulmonic valve is normal without
regurgitation. In the proximal pulmonary artery, an echogenic
structure is seen as a luminal irregularity which could
represent clot, intimal hyperplasia, or artifact from fluid in
the transverse coronary sinus. Suggest clinical correlation.
Post Endostenting, the stent is poorly seen. Flow can be seen in
branch vessels, possibly intercostals, but no definite flow is
seen in the aneurysm. LVEF remains normal. Aortic contours
otherwise unchanged. Remaining exam unchanged. Results discussed
with surgical team at time of the exam.
[**2115-3-14**] Endoscopy Results: Erosive gastritis
Duodenitis in the bulb
Extrinsic compression in the esophagus
Brief Hospital Course:
Ms. [**Known lastname 8320**] was admitted for further evaluation and management for
mental status changes and hypertension and was found to have a
large thoracic/descending aortic aneurysm. On admission, oral
blood pressure medications were adjusted for optimal blood
pressure control. She was evaluated by the cardiac surgical
service. The vascular surgery service was also consulted. She
underwent multiple chest CT scans as well as an MRI to
characterize her thoracic/descending aortic aneurysm (please see
results section for reports). These were compared with MMS
reconstruction images of MRI images from an outside institution.
Carotid ultrasound was done on [**2115-3-12**] and showed
non-hemodynamically significant stenosis of less than 40% was
demonstrated in the right internal carotid artery with
hemodynamically significant stenosis of 40-59% demonstrated in
the left internal carotid artery. As part of her pre-operative
work-up, the GI service was consulted for long-standing
dysphagia. Oropharyngeal swallowing evaluation showed no
evidence of aspiration. Her esophagram was normal. EGD showed
erosive gastritis, duodenitis in the bulb with extrinsic
compression in the esophagus. It was recommended that she
undergo an outpatient esophageal motility study.
After pre-operative workup was completed, the patient was taken
to the operating room for endovascular repair of her thoracic
aortic aneurysm on [**2115-3-20**] (please see the detailed operative
note of Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]). She was
extubated on post-operative day 1 in the cardiac intensive care
unit. She required a nitroglycerin drip for 2 days for blood
pressure control and this was eventually weaned off. She
received 1 unit of blood on post-op day 2 and her lumbar drain
was removed. She was able to tolerate a regular diet and was
able to get out of bed to chair. On postoperative day three, Ms.
[**Known lastname 8320**] was transferred to the cardiac floor for further recovery.
Of note, she had an episode of left lower extremity weakness
with concurrent hypotension on the evening of post-op day 2. She
had a drop in her hematocrit from 29 to 23 and required 2 units
of blood. Repeat imaging revealed a stable (not actively
bleeding) left lower quadrant retroperitoneal hematoma. She was
transferred back to the intensive care unit for closer
monitoring. MRI imaging revealed some lumbar cord edema but no
epidural hematoma. Neurology was consulted and recommended
conservative management. Her left lower extremity weakness
spontaneously resolved. She had some nausea and a KUB revealed a
mild ileus and she was placed NPO for a day. Her diet then
resumed without complication. She required a nitroglycerin drip
for blood pressure control which was weaned off and she was
transferred back to the floor on post-operative day 7. She then
worked with physical therapy daily to increase her strength and
mobility. Oral antihypertensives were optimized for blood
pressure control. Ms. [**Known lastname 8320**] continued to make steady progress
and was discharged on [**2115-3-28**]. She will follow-up with Dr. [**Last Name (Prefixes) **], Dr. [**Last Name (STitle) **], her cardiologist and her primary care
physician as an outpatient.
Medications on Admission:
Pravachol 40 mg qd
ASA 81 mg qd
Wellbutrin SR 300 qd
Plavix 75 mg qd
Norvasc 5 mg qd
Hydrochlorothiazide 25 mg Qd
MVI 1 tablet qd
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*1*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 * Refills:*0*
5. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
8. 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*
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
caregroup
Discharge Diagnosis:
Thoracic/Abdominal Aortic Aneurysm/Thrombosed pseudoaneurysm or
saccular aneurysm
Transient encephalopathy NOS
Poorly controlled hypertension
Discharge Condition:
Good
Discharge Instructions:
Please continue to take all of your medications as instructed.
We have started you on a new medication to help control your
blood pressure.
Please make an appointment with your primary care physician
within one week of discharge to follow-up on further testing and
establishing a neurologist.
Also make appointment with Vascular surgery for follow-up tests.
[**Last Name (NamePattern4) 2138**]p Instructions:
PCP 2 weeks
Cardiologist 2 weeks
Dr. [**Last Name (Prefixes) **] 3 weeks
Dr. [**Last Name (STitle) **] for follow up of abdominal aneurysm.
Completed by:[**2115-5-9**]
|
[
"4019",
"3051"
] |
Admission Date: [**2130-3-17**] Discharge Date: [**2130-3-19**]
Date of Birth: [**2069-6-15**] Sex: M
Service: NEUROLOGY
Allergies:
Diphenhydramine / Bee Pollen / phenytoin
Attending:[**First Name3 (LF) 35628**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
intubated/extubated
History of Present Illness:
Mr. [**Known lastname 23686**] is intubated and sedated. History obtained from
transfer records, review of OMR and speaking with family.
Mr. [**Known lastname 23686**] is a 61 year-old man with PMH notable for right
parietal lesion (initially thought to be stroke vs. low grade
glioma; has been stable on multiple repeat MRIs with the most
recent being [**2130-3-6**]), followed by Dr. [**Last Name (STitle) 6570**] in [**Hospital **]
clinic and seizures (unclear if post-traumatic s/p motorcycle
accident or if seizure precipitated the accident; he was
previously on AEDs, but this was recently stopped) who was
transferred from OSH with IPH and seizure. Per transfer report,
he was having headaches beginning last night. This morning, at
work, around 9:30 AM, his co-workers thought he had a "deer in
headlights" look and was confused. He was also reportedly
complaining of left arm numbness. He was taken to LGH, where in
triage, he had a GTC lasting 2-3 minutes and breaking with 6 mg
Ativan. He received Dilantin 1 gram. He was intubated for airway
protection. He underwent NCHCT which showed right
temporoparietal
hypodensity, likely edema, with hemorrhagic component. He was
then transferred to [**Hospital1 18**] for further care.
Regarding his seizure history, his only witnessed seizure was
after a motorcycle accident in [**2129-4-27**]. It is possible a
seizure was the inciting reason for the accident, though this is
not confirmed. He has been on AEDs in the past, some of which
were stopped due to side effects; keppra resulted in
short-temperedness, topiramate in diarrhea and weight loss and
phenytoin caused fatigue. He was most recently on Zonisamide,
but
this had been stopped earlier this month as he had remained
seizure free.
ROS: unable to obtain from patient. Per family, he has been
increasingly fatigued recently. Also possible weight loss as he
has dropped 2 pant sizes; unsure over how much time this
occurred.
Past Medical History:
-right parietal lesion
-motorcycle accident
-seizure
-hypertension
-dyslipidemia
-coronary artery disease
Social History:
Unable to obtain from patient. Per OMR- He is married
and lives with his wife. [**Name (NI) **] works as a diesel mechanic for the
local fire department. He was a heavy smoker for 22 years, but
quit ten years ago.
Family History:
Unable to obtain from patient. Per OMR- He had ten
siblings, one died in a motorcycle accident, and one died at age
62 with heart problems. The other siblings are healthy. His
mother died at 88 and his father died at 77
Physical Exam:
Physical Exam:
Vitals: P: 74 BP: 105/65 intubated R 16 O2 100 % (vent)
General: intubated, sedated
HEENT: ET tube in place
Neck: Supple,
Pulmonary: anterior lung fields cta b/l
Cardiac: RRR, S1S2
Abdomen: soft, nondistended, +BS
Extremities: warm, well perfused
Neurologic: eyes open to voice. Not following any commands.
Pupils in midline, 1 mm and sluggishly reactive to light.
+Dolls.
+ corneals. + cough/gag. Moves all extremities spontaneously and
purposefully. Was moving all extremities spontaneously so
difficult to assess any reaction to noxious stimulation; there
was no clear grimmace noted. Upper extremity reflexes 2+ and
symmetric. Unable to elicit patellar or Achilles reflexes.
Extensor plantar response b/l.
--------
on discharge
Awake, alert interactive
language intact
CN intact
Motor: normal tone, full strength throughout
Sensory, pin/ JPS intact in toes
Gait: able to tandem with mild difficulty, negative romberg, can
walk on heels and walk on toes.
Pertinent Results:
ADMISSION LABS:
[**2130-3-17**] 05:45PM ALT(SGPT)-24 AST(SGOT)-24 ALK PHOS-71 TOT
BILI-0.8
[**2130-3-17**] 05:45PM ALBUMIN-4.2
[**2130-3-17**] 05:45PM PHENYTOIN-6.1*
[**2130-3-17**] 03:48PM TYPE-ART PO2-88 PCO2-39 PH-7.37 TOTAL CO2-23
BASE XS--2
[**2130-3-17**] 12:20PM freeCa-1.11*
[**2130-3-17**] 12:05PM LIPASE-37
[**2130-3-17**] 12:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2130-3-17**] 12:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
DISCHARGE LABS:
[**2130-3-19**] 06:10AM BLOOD WBC-10.0 RBC-4.97 Hgb-14.4 Hct-43.4
MCV-87 MCH-29.0 MCHC-33.2 RDW-13.2 Plt Ct-245
[**2130-3-19**] 06:10AM BLOOD Glucose-83 UreaN-8 Creat-0.9 Na-142 K-3.7
Cl-108 HCO3-23 AnGap-15
[**2130-3-19**] 06:10AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.2
CT from OSH shows edema and question of small amount of
calcification/blood in the area of the left parietal lesion
Brief Hospital Course:
After he was admitted the patient already intubated and was
taken to the neuro ICU. There he had been loaded on Dilantin.
He had been taken off of his Zonisamide as it was unclear if he
had a seizure and he had been doing well since his previous
motor vehicle accident. In the ICU he was hooked up to LTM EEG
and he did not have any further seizures. His CT head from the
OSH showed the area of edema around his known lesion with a
question of small area of blood. He conitnued to do well in the
ICU and the next day was extubated. He was transferred to the
floor on [**3-18**].
He conitnued to do well. He had no more seizures, his exam
returned to baseline. He was restarted on Zonegran 50mg [**Hospital1 **].
The plan was to keep him on PHT for about 5 days then slowly
taper it off, leaving him on Zonegran. We discussed the plan
with Dr. [**Last Name (STitle) **] as well. He was discharged home with plan for
follow up in the [**Hospital **] clinic.
Medications on Admission:
-Amlodipine-Atorvastatin 10 mg-80 mg daily
-Carvedilol 6.25 mg daily
-Coenzyme Q10
-cyanocobalamin 250 mcg daily
Discharge Medications:
1. zonisamide 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO three times a day: take TID for 5 days, then [**Hospital1 **] for 3 days,
then once a day for 3 days then stop.
Disp:*25 Capsule(s)* Refills:*0*
6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
seizure secondary to brain lesion - low grade glioma vs stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Cranial nerves intact, normal motor/sensory, gait normal, able
to tandem with mild difficulty
Discharge Instructions:
You were admitted with an episode of confusion which evolved
into a seizure. We think this occured because of the lesion in
your brain which can cause seizures. You were recently taken
off your seizure medication Zonegran to see if you no longer
needed it, as it was not clear if you having seizures. It
appears that you now need seizure medication and we have
restarted the Zonegran. While you were here we started another
seiuzre medicaitn initially, Phenytoin, while the Zonegran gets
to steady state we want you to stay on this and can titrate
after a week. We will provide you with a schedule.
Your medications were changed as follows:
restarted Zonegran 50mg [**Hospital1 **]
started Phenytoin (Dilantin)300mg daily, with plan to taper
after 5 days.
Followup Instructions:
Dr. [**Last Name (STitle) **] will call you with a follow up appointment - if you
don't hear from him be sure to call his office at ([**Telephone/Fax (1) 6574**]
also call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 9587**] for a follow
up appopintment
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 35629**]
|
[
"4019",
"2724",
"41401"
] |
Admission Date: [**2138-12-11**] Discharge Date: [**2138-12-17**]
Date of Birth: [**2079-6-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2138-12-11**] Two Vessel Coronary Artery Bypass Grafting utilizing
left internal mammary to left anterior descending, and vein
graft to diagonal
History of Present Illness:
Ms. [**Known lastname 64711**] is a 59 year old female who presented with acute
coronary syndrome back in [**2138-10-3**]. She ruled in for a
NSTEMI at that time and was found to have severe obstructive
coronary artery disease. An echocardiogram was notable for
normal LV function with only mild mitral regurgitation. Based on
the above, she was referred for cardiac surgical intervention.
Prior to her operation, she lost approximately 20 pounds.
Past Medical History:
Coronary Artery Disease, Hypertension, Hyperlipidemia, Type II
Diabetes Mellitus, Obesity, Sleep Apnea, Osteoarthritis, Asthma,
Peripheral Neuropathy
Social History:
Quit tobacco back in [**2122**]. Denies ETOH. She lives alone.
Family History:
Father expired from MI at age 34. Mother expired at age 72
stroke. History of diabetes and HTN in family.
Physical Exam:
Vitals: BP 140/80, HR 70, RR 20
General: very pleasant, morbidly obese female in no acute
distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: obese, soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 1+ distally
Neuro: alert and oriented, nonfocal
Pertinent Results:
[**2138-12-17**] 06:20AM BLOOD WBC-7.8 RBC-2.97* Hgb-9.2* Hct-26.8*#
MCV-90 MCH-31.0 MCHC-34.3 RDW-14.5 Plt Ct-239
[**2138-12-17**] 06:20AM BLOOD Plt Ct-239
[**2138-12-17**] 06:20AM BLOOD Glucose-143* UreaN-16 Creat-1.0 Na-140
K-3.9 Cl-98 HCO3-35* AnGap-11
[**2138-12-11**] ECHO
PRE CPB: No spontaneous echo contrast is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Focal calcification is present on the left coronary
cusp of the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POST CPB: Hyperdynamic left ventricular function. There is no
aortic
regurgitation. Trace mitral regurgitation is present.
[**2138-12-15**] CXR
PA and lateral chest radiographs. Patient is status post CABG
with median sternotomy wires and multiple surgical clips
identified. The cardiomediastinal silhouette is stable. The
pulmonary vascularity is unremarkable. The left apical
pneumothorax is again seen and appears slightly smaller compared
to the study from a day prior. Atelectasis is identified at the
left lung base. The remainder of the lungs are clear and there
is no evidence of pleural effusion. Soft tissue and osseous
structures are unremarkable.
Brief Hospital Course:
Ms. [**Known lastname 64711**] was admitted on [**12-11**] and underwent coronary artery
bypass grafting by Dr. [**Last Name (STitle) **]. The operation was uneventful and
she was transferred to the CSRU for invasive monitoring. For
further surgical details, please see separate dictated operative
note. That same evening, she awoke neurologically intact and was
extubated without incident. Her CSRU course was uncomplicated
and she transferred to the SDU on postoperative day one. She
remained in a normal sinus rhythm. Pacing wires were removed
without complication. Over several days, she made clinical
improvement with diuresis. She was transfused on POD #5 with 2
units of red blood cells for postoperative anemia. Ms. [**Known lastname 64711**]
worked with physical therapy daily. She continued to make steady
progress and was cleared for discharge on postoperative day 6.
She is to make all follow-up appts. as per discharge
instructions.
Medications on Admission:
Aspirin 325 qd, Lipitor 40 qd, Neurontin 300 qhs, Metformin 500
qid, Lasix 40 qd, Metoprolol, Plavix(last dose [**12-4**]), MVI,
Calcium, Omega 3, Inhaler prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*0*
6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours):
twice a week for 2 weeks then decrease to once a day with lasix.
Disp:*120 Capsule, Sustained Release(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks: twice a day for 2 weeks, then once a day ongoing.
Disp:*60 Tablet(s)* Refills:*0*
12. Metformin 500 mg Tablet Sustained Release 24HR Sig: Two (2)
Tablet Sustained Release 24HR PO at bedtime.
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*0*
13. Nateglinide 120 mg Tablet Sig: One (1) Tablet PO three times
a day: with meals .
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG, Hypertension,
Hyperlipidemia, Type II Diabetes Mellitus, Obesity, Sleep Apnea,
Osteoarthritis, Asthma
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**5-7**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**3-7**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**3-7**] weeks, call for appt
Completed by:[**2139-1-9**]
|
[
"41401",
"32723",
"412",
"4019",
"49390",
"2724"
] |
Admission Date: [**2157-11-5**] Discharge Date: [**2157-11-11**]
Service:
CHIEF COMPLAINT: Middle scapular pain for one day.
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
woman with a history of arthritis, chronic renal
insufficiency, and no known cardiovascular risk factors who
presented after onset of middle scapular pain. She felt like
she was unable to get comfortable. She had some associated
nausea and vomiting but no shortness of breath. The pain
radiated to her shoulders bilaterally. She took an aspirin
and Maalox without significant relief. She denies
hematemesis or diaphoresis. She has never experienced
anything like this in the past.
On arrival to the Emergency Room, her initial
electrocardiogram showed ST elevations of 2 mm to 3 mm in V1
through V5 with poor R wave progression anteriorly consistent
with anterior wave myocardial infarction. Symptoms resolved
completely with sublingual nitroglycerin. Because she was
symptom free, the decision was made not to proceed with acute
intervention and she was treated with heparin, and
Integrilin, and aspirin. A follow-up electrocardiogram was
consistent with completion of anterior wave myocardial
infarction, and she had creatine kinase elevation to 304,
with a MB of 29, and troponin of 33, MB index of 10%.
A bedside echocardiogram in the Emergency Room showed
anterior wall motion deficit. Of note, her glucose in the
Emergency Room was 462 without a prior history of diabetes.
PAST MEDICAL HISTORY:
1. Osteoporosis.
2. Arthritis, left foot valgus with use of a brace.
3. Status post hysterectomy 20 years ago.
4. No diabetes, no history of hypertension.
MEDICATIONS ON ADMISSION: Medications at home include Aleve
and Os-Cal.
ALLERGIES: CODEINE causes nausea and vomiting.
FAMILY HISTORY: No cardiovascular disease. No diabetes
mellitus.
SOCIAL HISTORY: No smoking, rare alcohol use.
REVIEW OF SYSTEMS: The patient denied fever, chills, weight
loss, blurry vision, polyuria, diarrhea, constipation, bright
red blood per rectum, melena, dysuria, hematuria, paroxysmal
nocturnal dyspnea or lower extremity edema. She sleeps on
one pillow and did report some recent polydipsia.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were pulse
of 97, blood pressure 142/60, respiratory rate 18, afebrile,
oxygen saturation 96% on 3 liters nasal cannula. In general,
an elderly pleasant woman in no apparent distress. HEENT
revealed pupils were equal, round, and reactive to light.
Extraocular muscles were intact. The oropharynx with
bleeding left upper palate. Positive arcus. Cardiovascular
revealed jugular venous pressure 7 cm. No carotid bruits
heard. Neck was supple with full range of motion. A regular
rate and rhythm. No murmurs, gallops or rubs. Pulmonary had
crackles at the left lower base; otherwise clear to
auscultation bilaterally. The abdomen was soft,
nondistended, normal active bowel sounds, and nontender.
Extremities were positive for degenerative joint disease,
trace bilateral edema, faint but palpable pulses bilaterally.
Neurologically, cranial nerves were intact. No focal
findings. Normal sensory examination. Rectal examination
was guaiac-negative per Emergency Room.
PERTINENT LABORATORY DATA ON ADMISSION: Complete blood count
with a white blood cell count 9.7, hematocrit 45,
platelets 146. Sodium 134, potassium 4, chloride 98,
bicarbonate 21, BUN 12, creatinine 0.7, glucose 462. Normal
differential. Normal PT, PTT, and INR; INR 1.1, PTT 23.
Creatine kinase #1 was 304, creatine kinase #2 was 779,
creatine kinase #3 was 552. MB #1 was 29, MB #2 was 98, MB
#3 was 62. MB index #1 was 10, MB index #2 was 12.7, MB
index #3 was 11.2. Albumin 3.4, calcium 9.2. Troponin 33.
Triglycerides 85, HDL 77, LDL 100. Phosphorous 2.8,
magnesium 1.8. Acetone negative. Urinalysis had small
blood,, greater than 1000 glucose, 15 ketones, pH of 6, 1 red
blood cell, 2 white blood cells, occasional bacteria,
specific gravity of 1.03.
RADIOLOGY/IMAGING: Initial electrocardiogram revealed sinus
rate 100, normal axis, intervals 0.129/0.76/0.408. ST
elevations of 2 mm to 3 mm in V1 through V5. No comparison
electrocardiogram.
Electrocardiogram #[**Street Address(2) 27317**] elevations but not at
baseline, T wave inversions anteriorly, and Q waves
anteriorly.
Electrocardiogram #3 with sinus rate of 80, normal axis,
0.14/0.8/0.47, Q wave in V1 through V4, 0.5-mm ST elevations
in V2 with resolution of other ST elevations. T wave
inversions in V1 through V5.
Chest x-ray on admission revealed no infiltrates, no
pneumothorax, widened mediastinum.
IMPRESSION: An 80-year-old woman with no known cardiac risk
factors but newly found diabetes mellitus and anterior ST
elevations likely anterior myocardial infarction in evolution
with positive creatine kinases and troponin. By the time the
Cardiology team admitted the patient she was pain free and
repeat electrocardiogram showed improvement in her ST
elevations.
HOSPITAL COURSE:
1. CARDIOVASCULAR: The patient's creatine kinases and
troponin levels were followed until they peaked and then
decreased. She was placed on aspirin, heparin drip, and
Integrilin drip. She was started on a beta blocker to
control her moderately elevated blood pressure on admission.
She was also started on an ACE inhibitor. The patient was
not taken for an urgent catheterization immediately.
On hospital day two, the patient's Integrilin drip was
discontinued as her creatine kinases decreased and she was
asymptomatic. She was continued on the heparin drip for a
total of 48 hours. Her beta blocker, Lopressor, and ACE
inhibitor were increased to control her heart rate and blood
pressure, and Lipitor was also started.
On hospital day two, the patient was also transferred from
the Coronary Care Unit to the floor because she was stable
and asymptomatic. Her anterior wave myocardial infarction
was completed at this point without any complications such as
congestive heart failure. The patient's official
echocardiogram [**Location (un) 1131**] was an ejection fraction of 35% to 40%
with basal anterior, middle anterior, and middle anterior
septal, anterior apex, septal apex, akinetic, and basal
anterior septal hypokinesis.
On the morning of [**11-8**] the patient underwent a
Persantine MIBI given the difficulty of exercising with her
severe arthritis. Her stress electrocardiogram showed no ST
changes and she experienced no anginal symptoms. The nuclear
report reported an ejection fraction of 49% and a partial
reversible defect in lateral wall. After discussion with the
family it was decided that the patient would undergo cardiac
catheterization on [**11-9**].
On catheterization the following pressures were found: Left
ventricle 143/12, aortic 143/70, with a mean of 100, left
ventricular end-diastolic pressure of 9, ejection fraction
of 47%, akinetic anterolateral hypokinesis, hypokinetic
apical, hypokinetic inferior, and normal mitral valve. The
middle right coronary artery showed discrete 50% lesion,
middle left anterior descending artery with diffuse disease
of 80%, distal left anterior descending artery with diffuse
disease of 80% after second diagonal. Right-dominant
coronaries, 1-vessel disease, mild systolic ventricular
dysfunction, and a percutaneous transluminal coronary
angioplasty and stent were done of the middle left anterior
descending artery stenosis.
Post catheterization, the patient did well. She was
continued on aspirin and Lipitor, and she was placed on
Integrilin overnight. She was also continued on her
metoprolol and captopril.
2. ENDOCRINE: The patient had a high blood glucose on
admission with no prior history of diabetes. A hemoglobin
A1c was checked, and she was placed on a sliding-scale
regular insulin for blood glucose control, q.i.d.
fingersticks were checked. The goal was to keep her blood
sugars less than 150 ideally in this post infarction time
period. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultation was called on the patient
given her new diagnosis of diabetes. The [**Last Name (un) **] team
recommended starting Glucotrol 2.5 mg p.o. b.i.d. after her
catheterization which was done.
A diabetes teaching nurse also came to teach the patient how
to use the glucometer, and it was determined that she would
follow up with Dr. [**Last Name (STitle) 27318**] in the [**Hospital **] Clinic two weeks
after discharge. While starting the oral hypoglycemics she
was continued on the regular insulin sliding-scale. Prior to
discharge, her Glucotrol was increased to 5 mg p.o. q.a.m.
and 2.5 mg p.o. q.p.m. The patient's hemoglobin A1c came
back at 11.8.
3. GASTROINTESTINAL: The patient was placed on Protonix and
Colace for prophylaxis.
4. RENAL: The patient's renal function was at baseline and
remained stable.
5. RHEUMATOLOGY: The patient has a history of arthritis.
She was placed on p.r.n. Tylenol.
6. HEMATOLOGY: The patient's coagulations were followed on
the heparin drip and Integrilin drip and remained stable.
7. PROPHYLAXIS: The patient was on Protonix and heparin.
She was also eating a regular diabetic diet when she was not
undergoing tests. She was also seen by Physical Therapy
while she was in the hospital.
8. CODE STATUS: Full.
9. DISCHARGE DISPOSITION: On hospital day two the patient
was hemodynamically stable without recurrent anginal symptoms
or chest pain, and she was transferred to the regular floor
but continued to be followed by the Coronary Care Unit team.
The patient was seen by Physical Therapy on [**11-8**], who
noted some balance impairments; although the patient denied
this. They determined that she was unsafe to go home and
that she may require some [**Hospital 3058**] rehabilitation.
However, the patient lives with her daughter and refused any
rehabilitation placement. She was seen once more by Physical
Therapy prior to discharge, and this time did better
ambulating.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Home with daughter.
MEDICATIONS ON DISCHARGE:
1. Lipitor 20 mg p.o. q.p.m.
2. Zestril 10 mg p.o. q.d.
3. Atenolol 25 mg 3 tablets p.o. q.d.
4. Aspirin 325 mg p.o. q.d.
5. Plavix 75 mg p.o. q.d. for 30 days.
6. Glucotrol 5 mg 1 tablet p.o. every morning and half
tablet p.o. every afternoon.
DISCHARGE INSTRUCTIONS:
1. The patient was instructed to call the [**Hospital **] Clinic to
make an appointment with Dr. [**Last Name (STitle) 27318**] in two weeks after
discharge and to make an appointment with Healthy You and
Food For Thought for diabetic counseling.
2. The patient was asked to see her primary care physician
within one to two weeks after discharge and to have her
cholesterol rechecked three weeks after discharge.
DISCHARGE DIAGNOSES:
1. Status post acute anterior myocardial infarction with a
percutaneous transluminal coronary angioplasty and stent of
left anterior descending artery.
2. Diabetes mellitus, newly diagnosed.
3. Arthritis.
4. Osteoporosis.
[**Name6 (MD) 9272**] [**Name8 (MD) 9273**], M.D. [**MD Number(1) 9274**]
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2157-12-28**] 15:28
T: [**2157-12-30**] 06:33
JOB#: [**Job Number 27319**]
(cclist)
|
[
"41401",
"42731",
"25000",
"4019"
] |
Admission Date: [**2150-11-30**] Discharge Date: [**2150-12-3**]
Date of Birth: [**2095-6-8**] Sex: M
Service: MEDICINE
Allergies:
Dicloxacillin
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
-Cardiac catheterization with stenting of Left circumflex.
History of Present Illness:
Pt is 55 yo M with CAD (s/p several MI's, s/p 3V CABG in [**2132**]),
DM2, who presented to [**Hospital3 59514**] Hospital last PM with chest
tightness, diaphoresis, and nausea. At around 11:30 pm on [**11-29**],
pt experienced chest tightness, diaphoresis, nausea, and
bilateral elbow pain after returning home from a holiday party.
Had not had recent CP, SOB, DOE prior to this episode; was able
to climb 5 flights of stairs in parking lot without CP in recent
days. Pt went to OSH ED and EKG showed up to 2-mm STD in V1-3, Q
and TWI in III. Enzymes were flat at OSH, but were drawn about
2-3h after onset of CP. He receieved ASA, heparin, and
integrilin. Chest pain went from [**5-16**] to [**12-16**] with 3 SL NTG. He
then received morphine and NTG gtt 30mcg in ambulance on the way
to [**Hospital1 18**], and then he fell asleep.
.
In the [**Hospital1 18**] ED, his vitals were stable and he had [**12-16**] chest
pain. He was given plavix 300mg, atorvastatin 80mg, Metoprolol
5mg IV, Atenolol 50mg, Morphine 4mg IV, and was continued on
integriling gtt, heparin gtt, and nitro gtt. ECG improved when
compared OSH.
.
Pt currently c/o continued chest discomfort, which he desribes
as a [**1-16**] "pressure." He denies SOB, N/V.
Past Medical History:
- CAD: s/p several MI's (s/p cardiac arrest after auto accident
in [**2126**] and was "brought back by CPR"), s/p 3V CABG in [**2126**]. Last seen at [**Hospital 2940**] in [**2132**] and records are paper only,
in warehouse and unavailable over holiday. PCP/Cardiologist-
[**First Name8 (NamePattern2) 29069**] [**Doctor Last Name 29070**] ([**Hospital1 3597**], NH) [**Telephone/Fax (1) 37284**] has done stress and
cath within the last several years. Reportedly pt had patent
LIMA-LAD, thrombosed SVG-OM graft, unknown 3rd graft (cath
approx [**2-7**] yrs ago for NSTEMI, no stents placed). Stress 1.5-2
years ago with reported inferior hypokinesis, but complete
results unavailable.
- DM2: on metformin at home
- Recurrent cellulitis of R leg
- hyperlipidemia
Social History:
Married. Lives at home with wife. Smoked 3ppd x 25 yrs (quit in
[**2123**]'s). Drinks 1 glass wine per day. No IVDU. Works as a
corporate manager for [**Company 71334**].
Family History:
Father died of heart disease at age 72. Sister with CAD (s/p
CABG) and hyperlipidemia.
Physical Exam:
On admission:
Vitals: T 98.6 BP 136/84 HR 72 RR 18 O2 96% 3L NC
Gen: NAD, comfortable, pleasant
HEENT: PERRL. OP clear.
Neck: Supple. No JVD.
Cardio: RRR, nl S1S2, no m/r/g
Resp: crackles at L base
Abd: soft, nt, nd, +BS. No rebound/guarding
Ext: 1+ BL LE edema, healed scars BL from vein harvesting. No
signs of infection. 2+ DP/PT pulses BL. 2+ fem pulses, no fem
bruits.
Neuro: A&Ox3.
Pertinent Results:
REPORTS:
.
Cardiac Cath [**11-30**]:
Initial angiiogram demonstrateda 50% stenosis of the
proximal LCx and a subsequent 90% stenosis. The SVG to the diag
was full
of thrombus and had very poor flow and considered too high risk
to
intervene. It was planned to treat the native LCx lesion with
PTCA and
stenting. Integrelin was the anticoagulant used during the
procedure. A
7FXB 3.5 guide catheter provided optimal support. The lesion was
crossed
with an Asahi prowater wire into the distal vessel.
The lesion was pre-dilated with a 2.25 x 15 Quantum Maverick
balloon at
10 ATM, a 2.5 x 20 Taxus DES was deployed across the lesion at
14 ATM
and post dilated with a 2.75 Quantum Maverick at 20 ATM distally
and
proximally. Final angiography demonstrated no residual stenosis
and no
angiographic evidence of dissection, thrombus or perforation
with TIMI
III flow in the distal vessel. The patient left the lab in
stable
condition and pain free.
.
[**12-2**] TTE:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with basal
inferior akinesis and mid to distal inferolateral hypokinesis
and apical hypokinesis (apex not fully
visualized). Overall left ventricular systolic function is
mildly depressed. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2150-11-30**], there is no definite change.
.
[**12-2**] CXR:
PA and lateral chest compared to [**2150-12-1**]: Patient has
had median sternotomy and coronary bypass grafting.
Cardiomediastinal silhouette is normal and unchanged. Lungs are
clear and there is no pleural effusion.
.
LABS:
.
[**2150-12-3**]: Na 139, K 4.2, Cl 103, HCO3 27, BUN 19, Cr 1.3, Glu
126
[**2150-12-3**]: Ca 8.9, Mg 2.1, PO4 2.6
[**2150-12-3**]: WBC 8.0, Hct 41.4, Plt 226
[**2150-12-2**] 06:11AM BLOOD WBC-9.0 RBC-4.59* Hgb-15.2 Hct-42.3
MCV-92 MCH-33.1* MCHC-35.9* RDW-13.4 Plt Ct-216
[**2150-12-1**] 04:50AM BLOOD WBC-11.1* RBC-4.84 Hgb-15.8 Hct-44.9
MCV-93 MCH-32.6* MCHC-35.1* RDW-13.1 Plt Ct-184
[**2150-11-30**] 11:30PM BLOOD Hct-44.1
[**2150-11-30**] 06:13PM BLOOD WBC-11.2* RBC-4.74 Hgb-15.7 Hct-43.3
MCV-91 MCH-33.2* MCHC-36.4* RDW-13.4 Plt Ct-208
[**2150-11-30**] 06:45AM BLOOD WBC-12.2* RBC-4.72 Hgb-15.5 Hct-43.4
MCV-92 MCH-32.9* MCHC-35.8* RDW-13.6 Plt Ct-238
[**2150-11-30**] 06:45AM BLOOD Neuts-78.7* Lymphs-16.6* Monos-4.4
Eos-0.1 Baso-0.2
[**2150-12-2**] 06:11AM BLOOD Plt Ct-216
[**2150-12-1**] 04:50AM BLOOD Plt Ct-184
[**2150-12-1**] 04:50AM BLOOD PT-11.1 PTT-23.9 INR(PT)-0.9
[**2150-11-30**] 06:15PM BLOOD PTT-38.1*
[**2150-11-30**] 06:13PM BLOOD Plt Ct-208
[**2150-11-30**] 12:40PM BLOOD PTT-54.2*
[**2150-11-30**] 06:45AM BLOOD Plt Ct-238
[**2150-11-30**] 06:45AM BLOOD PT-12.7 PTT-75.4* INR(PT)-1.1
[**2150-12-2**] 06:11AM BLOOD Glucose-140* UreaN-15 Creat-1.2 Na-140
K-4.2 Cl-104 HCO3-28 AnGap-12
[**2150-12-1**] 04:50AM BLOOD Glucose-185* UreaN-14 Creat-1.1 Na-136
K-3.9 Cl-99 HCO3-26 AnGap-15
[**2150-11-30**] 11:30PM BLOOD Glucose-142* K-4.3
[**2150-11-30**] 06:20PM BLOOD Glucose-158* K-3.9
[**2150-11-30**] 06:45AM BLOOD Glucose-179* UreaN-13 Creat-0.9 Na-138
K-3.9 Cl-104 HCO3-23 AnGap-15
[**2150-12-1**] 04:50AM BLOOD CK(CPK)-1094*
[**2150-11-30**] 11:30PM BLOOD CK(CPK)-1398*
[**2150-11-30**] 06:20PM BLOOD CK(CPK)-1567*
[**2150-11-30**] 10:39AM BLOOD CK(CPK)-1325*
[**2150-11-30**] 06:45AM BLOOD CK(CPK)-324*
[**2150-12-1**] 04:50AM BLOOD CK-MB-78* MB Indx-7.1* cTropnT-1.68*
[**2150-11-30**] 11:30PM BLOOD CK-MB-135* MB Indx-9.7*
[**2150-11-30**] 06:20PM BLOOD CK-MB-186* MB Indx-11.9* cTropnT-2.27*
[**2150-11-30**] 10:39AM BLOOD CK-MB-178* MB Indx-13.4* cTropnT-1.70*
[**2150-11-30**] 06:45AM BLOOD cTropnT-0.34*
[**2150-11-30**] 06:45AM BLOOD CK-MB-36* MB Indx-11.1*
[**2150-12-2**] 06:11AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.2
[**2150-12-1**] 04:50AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.1
[**2150-11-30**] 06:20PM BLOOD Cholest-143
[**2150-11-30**] 06:45AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9
[**2150-11-30**] 06:20PM BLOOD %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE
[**2150-11-30**] 06:20PM BLOOD Triglyc-149 HDL-37 CHOL/HD-3.9 LDLcalc-76
.
MICRO:
.
URINE CULTURE (Final [**2150-12-2**]): NO GROWTH.
.
[**2150-12-1**] 4:50 am BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
Brief Hospital Course:
Assessment/Plan: 55 year old man with CAD status post 3 vessel
CABG in [**2132**] who presented on [**11-29**] with NSTEMI. In past
several years, per cardiologist patent LIMA-LAD, with thrombosed
SVG-OM graft. Cardiac stress test one year ago revealed
inferior hypokinesis.
Repeat cardiac catheterization on [**11-30**] revealed 3 vessel
disease. Taxus DES placed in mid L circumflex.
.
1) CP/NSTEMI:
Patient with known CAD, status post multiple MI's and status
post 3-vessel CABG in [**2150**]. PCP/cardiologist
has done stress and caths within the last several years
(reported patent LIMA-LAD). Patient ruled in for NSTEMI and was
taken to cardiac catheterization on [**11-30**]. Found to have 90%
LCx, which was stented. Pt also with SVG to diagonal with
occlusion. The chronicity was unclear, and this lesion was not
stented. Elevated LVEDP status post procedure.
- Continue ASA 325, plavix 75 qd. Received plavix load.
- Integrillin was continued for 18hrs and then off after
procedure.
- Increased metoprolol to 125mg [**Hospital1 **] on night of [**12-2**]. As
outpatient, can consider uptitrating for HR<70.
- Started lisinopril 5mg qd.
- Increased atorvastatin to 80mg qd
- CK peaked at 1567 ,but has trended down.
- Repeat echo on [**12-2**] revealed an EF of 50%. Normal PCPW.
Basal inferior akinesis and apical hypokinesis. Mild MR.
- Patient will need Echo and/or cardiac MRI in 6 weeks for
prognosis. Patient's cardiologist to schedule.
- Sent TSH level on [**12-3**], so results will need to be assessed
by PCP [**Name Initial (PRE) **]/or cardiologist.
.
2) Fever:
-Patient with fever to 101.5 after procedure. Blood cx's
pending. UA negative. UCx negative. CXR shows opacity which
represents atalectasis vs. aspiration.
- Repeat PA and lateral CXR on [**12-2**] was improved and no
evidence of PNA. Patient has remained afebrile in past several
days.
.
3) DM2:
On metformin at home, but holding in hospital.
- Will continue q6hr FS with RISS
- A1c 6.3 %.
- Will restart metformin as outpatient.
.
4) Hyperlipidemia:
- Given NSTEMI, increased lipitor to 80mg qd.
- Cholesterol panel: chol 143, TG:149, HDL 37, LDL 76.
.
5) FEN:
Placed on cardiac diet.
.
6) Prophylaxis:
Placed on heparin SC, PPI, bowel regimen.
.
7) Dispo:
Pending discharge for [**2150-12-3**].
.
8) Code:
Full Code
Medications on Admission:
MEDS (at home):
Atenolol 50mg qd
Lipitor 20mg qd
Metformin 1000mg qam, 500mg qpm
Niacin 2000mg qd
Fish oil
.
MEDS (on transfer):
heparin gtt
nitro gtt
integrilin gtt
ASA
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO qAM.
Disp:*30 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO qPM: Take one
tablet at night.
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
Five (5) Tablet Sustained Release 24HR PO BID (2 times a day).
Disp:*300 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
CAD/NSTEMI
Secondary diagnoses:
DM2
Hyperlipidemia
Discharge Condition:
Vitals stable. Afebrile. Ambulating. Taking good PO.
Discharge Instructions:
-Please seek medical attention immediately if you experience
chest pain, shortness of breath, nausea, vomiting, palpitations,
excessive sweating, or any other concerning symptoms.
-Please take all medications as prescribed. You should take
Aspirin and Plavix every day. Your cholesterol medication,
atorvastatin, was increased to 80mg every day. You will no
longer take atenolol, but have changed to metoprolol 125 [**Hospital1 **].
-You should schedule a cardiac MRI or echocardiogram in
approximately 6 weeks. Please have your cardiologist schedule
this test for you. Your cardiac ECHO and catheterization
results have been included.
Followup Instructions:
-Please follow up with your PCP [**Last Name (NamePattern4) **] 1 week.
-Please follow up with your cardiologist in [**12-8**] weeks. You
should schedule a cardiac MRI or echocardiogram in approximately
6 weeks. Please have your cardiologist schedule this test for
you.
|
[
"41071",
"41401",
"25000",
"2724"
] |
Admission Date: [**2126-9-17**] Discharge Date: [**2126-9-19**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
abdominal pain, DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
21 yo female with h/o type I DM and multiple admissions for DKA
the last of which was 78/19-8/22 who presents with DKA. The
patient reports that on the evening prior to admission she
devoloped constipation which she describes as sensation of
having to move her bowels but being unable. She checked her
finger stick glucose last night and it was in mid 200's. Her
urine ketones were small. She otherwise was feeling well but did
not sleep well because of constipation and getting to the
bathroom. The next morning her bg was about 130's and she
developed some lower abdominal cramps. Later in the day, she
checked her urine ketones and results were "large" so the
patient decided to come to the ED. She denies nausea or
vomiting. No melena or hematochezia, no mucous in stool. Her
last BM was the day prior to admission and was normal. No recent
change in diet. No new medicaitons. ROS is otherwise negative
for fever, chills, chest pain, SOB, upper respiratory symptoms,
urinary urgency or frequency, dysuria or vaginal discharge. She
is on Depo-Provera. One sexual partner. Urine HCG was negative
in the ED.
.
On admission, the patient's glucose 647, AG=29, pH=7.24 and
positive urine ketones. In the ED, the patient was given 10
units of regular insulin IV and received 4L of NS. She was
started on insulin gtt at 7 units per hour and was changed to 3
units per hour with D51/2 NS when her blood glucose came down to
<250.
.
At the time of arrival to the MICU, the patient's AG was down to
19 and she denied any abdominal pain or cramping.
Past Medical History:
1. Diabetes Type I diagnosed in [**2120**] after her first pregnancy.
Most recent Hgb A1C 10.4 % ([**7-/2125**])
2. Hyperlipidemia
3. S/P MVA [**5-4**] - lower back pain since then. + back muscle
spasm treated with tylenol.
4. Goiter
5. Depression
6. DKA admissions
7. G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p
C-section in [**2122**], not menstruating secondary to being on
Depo-Provera shots
8. Genital Herpes
Social History:
The patient was born and raised in [**Location (un) 669**], where she lived in
house with siblings, mother, grandmother, and [**Name2 (NI) 12232**] when
growing up. Currently lives in her own apartment. Attended job
corp training following h.s., but presently unemployed feeling
too overwhelmed between diabetes care and caring for three year
old her son. She has a boyfriend. She is close to mother,
sister, and [**Name2 (NI) 12232**] who live nearby. Denies abuse in childhood
or adulthood. She denies tobacco, alcohol or illicit drug use.
Family History:
Family History:
GM with Type I diabetes. Otherwise non-contributory. Relatives
with "acid in blood" not related to diabetes.
Physical Exam:
Physical Exam:
VS: 98.7 HR 100 BP 121/85 RR 18 100 % on RA
GENERAL: pleasant young woman, lying on a stretcher comfortably,
NAD, cooperative with the examination
HEENT: NC, AT, PERRL, sclera non-icteric, OP clear
NECK: supple, no LAD, thyroid palpable but no nodules
CV: regular, nl S1, S2, no mrg
PULM: CTA bilaterally
ABD: NABS, soft, NT, ND, no organomegaly
EXT: warm and dry, no edema
RECTAL (per ED note): stool guaiac +
Pertinent Results:
EKG: NSR at 97; nl axis; nl intervals; no chnages from prior
EKG; no ST or Twave changes.
.
CXR [**2126-9-17**]: no PNA
[**2126-9-17**] 08:30PM GLUCOSE-249* UREA N-7 CREAT-0.7 SODIUM-135
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-11* ANION GAP-20
[**2126-9-17**] 06:52PM TYPE-ART PO2-112* PCO2-21* PH-7.24* TOTAL
CO2-9* BASE XS--16
[**2126-9-17**] 03:58PM LACTATE-1.5 K+-6.2*
[**2126-9-17**] 03:40PM ALT(SGPT)-9 AST(SGOT)-13 ALK PHOS-99
AMYLASE-63 TOT BILI-0.5
[**2126-9-17**] 03:40PM LIPASE-23
[**2126-9-17**] 03:40PM CALCIUM-10.1 PHOSPHATE-3.7 MAGNESIUM-1.8
[**2126-9-17**] 03:40PM WBC-7.2 RBC-4.73 HGB-13.9 HCT-44.0 MCV-93
MCH-29.3 MCHC-31.5 RDW-12.8
[**2126-9-17**] 03:40PM NEUTS-72.0* LYMPHS-25.3 MONOS-1.7* EOS-0.5
BASOS-0.5
Brief Hospital Course:
1. DKA ?????? type I DM status post multiple admissions for DKA
without clear precipitating causes. CXR and urine w/o evidence
of infection. WBC is normal. Pregnancy test negative in the ED.
Denies any missed medication doses. Anion gap was initially
elevated at 29. She was started on IVF, insulin drip, and
potassium supplementation. When she arrived in the MICU, gap
had improved to 19, and insulin drip was initially continued.
This was discontinued on the evening of hospital day 2, and she
was continued thereafter on her standing lantus with a
humalog/carbohydrate counting scale. Anion gap remained within
normal limits, and she was taking in adequate POs. Abdominal
cramping and constipation was improved. There was some question
that she may not have been accurately carbohydrate counting at
home. She was seen by [**Last Name (un) **] in-house and will follow up with
her outpatient diabetologist. Upon transfer to the floor on
hospital day 3, pt refused to stay in-house for observation
(grandfather recently passed away;she wished to attend his
funeral). She understood the possible risks of leaving (given
she had just been restarted on her lantus). She signed the AMA
form prior to discharge, and blood sugar was 124. She will
follow up with [**Last Name (un) **] as an oupatient after she returns she
returns from her grandfather's funeral.
2. CAD risk. Lipitor, lisinopril, and ASA were continued
in-house.
3. Constipation. Symptoms improved after judicious use of colace
and senna.
4. Disposition: as above, she signed out AMA and will follow up
with her diabetologist for further management and education (to
avoid further episodes of DKA). Dr. [**Last Name (STitle) **], the medical
attending physician, [**Name10 (NameIs) **] not have an opportunity to meet,
interview, or examin the patient as she left AMA within an hour
of arrival to the medical floor. Apparently, the patient had
mentioned that she was leaving AMA while in the ICU, however
this information was not appreciated until she arrived to the
floor.
Medications on Admission:
Medications on Admission:
1. Aspirin 81 mg po qd
2. Atorvastatin 40 mg po qd
3. Lantus 29 units qhs
4. Novolog 15gm carbs:1 unit with each meal tid
5. Lisinopril 10 mg po qd
All: Morphine (rash).
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. insulin
Please take 29 units of insulin glargine (Lantus) in the
evening. Please follow your usual insulin regimen for sliding
scale and carbohydrate doses.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Discharge Condition:
Leaving against medical advice. competent.
off insulin drip, tolerating PO without nausea or vomiting.
Hemodynamically stable.
Discharge Instructions:
Please check your fingerstick frequently (definitely before
meals and before bedtime) and be sure to take your evening
lantus, your sliding scale to cover your sugars, and the usual
insulin with meals.
Please drinks a great lots of water in the next few days to stay
hydrated.
If you feel nauseated, vomiting, or ill, please check your blood
sugar, check your urine ketones, and call or go to the doctor if
you have ketones.
Followup Instructions:
Please call [**Last Name (un) **] to make a follow up appointment with Dr.
[**Last Name (STitle) 3617**] within 2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
"4019"
] |
Admission Date: [**2147-9-9**] Discharge Date: [**2147-9-21**]
Date of Birth: [**2147-9-9**] Sex: F
Service: Neonatology
ADMISSION HISTORY AND PHYSICAL EXAMINATION: Baby Girl
[**Known lastname 62250**] is a 34-5/7 week gestational age girl, birth weight
2110 gram infant who was born by cesarean section due to
mother's spontaneous rupture of membranes at 7:30 A.M. on [**9-9**]
and history of previous cesarean section. No betamethasone was
given.
MATERNAL HISTORY: Mother is a 28 year-old gravida II, para I,
now II mother. Prenatal screens O positive, antibody negative,
RPR nonreactive, hepatitis B surface antigen negative, Rubella
immune, GBS unknown. She did have a history of frequent
urinary tract infections and a history of postpartum
depression after her last delivery.
In the delivery room the Apgars were 9 and 9. No
resuscitation was needed. She was born at approximately 12
noon on [**2147-9-9**].
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 2100 grams,
length 24.5 cm, head circumference 31.25 cm. Temperature
within normal limits. Pulse 140s, blood pressure 63/34 with a
50. O2 saturation 100% on room air.
General: She was a well developed, appropriate for
gestational age 34-5/7 week infant, pink and well perfused,
active, in no apparent distress. Head, eyes, ears, nose and
throat examination revealed mild caput with an anterior
fontanel that was soft and flat. Eyes within normal limits
to examination with red reflex noted bilaterally. Ears within
normal limits and mouth within normal limits with an intact
palate. Chest examination revealed breath sounds that were
equal. Cardiovascular examination revealed normal heart
sounds with no murmurs. Auscultation and percussion within
normal limits. Abdominal examination was within normal limits
with no masses and no hepatosplenomegaly. Soft and
nondistended. GU revealed a normal female with patent anus.
Back was within normal limits and skin was normal.
Neurologic: Baby was appropriate activity, tone and posture
as well as reflex and movements for 34 to 35 gestational age
infant with a vigorous cry.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Patient remained stable and normal
throughout her hospital course. She did have some apnea
of prematurity and has been 5 days since her last apneic
spell. Infant had one choking episode associated with spell
3 days prior to discharge--none before or since.
2. CARDIOVASCULAR: Patient was hemodynamically stable
throughout her admission. No murmur noted on examination.
3. FLUID, ELECTROLYTES AND NUTRITION: Patient initially was
started on Enfamil 20 or breast milk on day of life 0.
She was advanced to 24 calories on day of life 3. Most
recent weight on day of discharge was 2310g. Recent Length
on [**9-18**]=45.5cm, HC=31.25cm.
4. GASTROINTESTINAL: Patient was started on phototherapy on
day of life #3 for an elevated bilirubin. Phototherapy
was discontinued on day of life #3 and rebound bilirubin
was within normal limits.
5. INFECTIOUS DISEASE: CBC and blood culture were drawn on
admission. Patient was not started on antibiotics. Blood
culture was negative at 48 hours and CBC was benign.
6. NEUROLOGIC: Head ultrasound was not indicated.
7. AUDIOLOGY: Patient passed the hearing screen.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) 56963**] in
[**Location (un) 701**].
CARE RECOMMENDATIONS AT DISCHARGE:
1. FEEDS: Similac 24 calories per ounce or breast feeding.
2. MEDICATIONS: Patient is going home on no medications.
3. STATE NEWBORN SCREEN: Was performed on [**2147-9-12**].
4. Patient received hepatitis B vaccine on [**2147-9-10**].
5. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for all infants who meet any of
the following three criteria: Born 32 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 or with chronic lung disease.
6. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age and
before this age and for the 24 months of the child's life
immunization against influenza is recommended for
household contact and out of home care givers.
FOLLOW UP APPOINTMENTS SCHEDULED/RECOMMENDED:
1. Primary care pediatrician 2 to 3 days after discharge.
2. [**Hospital6 407**].
DISCHARGE DIAGNOSES:
1. Prematurity at 34-5/7 weeks.
2. Hyperbilirubinemia, resolved
3. s/p apnea of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) 58671**]
MEDQUIST36
D: [**2147-9-20**] 17:02:41
T: [**2147-9-20**] 17:45:09
Job#: [**Job Number 62251**]
|
[
"7742"
] |
Admission Date: [**2144-8-31**] Discharge Date: [**2144-9-4**]
Date of Birth: [**2069-6-6**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
Fever and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75M w/ hx arthritis, HTN, gout s/p hernia repair [**8-21**], presented
with 4 day history of intermittent dyspnea and one day of fever
and chills. The patient underwent a right direct inguinal,
epigastric, and umbilical hernia repair, w/o immediate
complication. Post-op course was complicated by urinary
retention for which a foley catheter was placed requiring
overnight obs. he was discharged with foley catheter in place,
which was removed [**8-26**] at his PCPs office. At discharge on [**8-22**]
pt's vitals were 98.7, 83, 140/83, 16, 92% RA.
[**Name (NI) **] pt presented to rheumatologist [**8-28**] with 3 days of left
knee pain. An arthrocentesis was attempted by OP
rheumatologist, but there was no fluid to aspirate. He was
referred to the ED for r/o DVT. In the ED, LLE doppler was
negative for DVT. At this time, his leukocytosis had improved
to 18K and his cr was 1.8. He was discharged home from the ED.
He returned on [**8-31**] with fever and shortness of breath. As per
daughter (documented in [**Name (NI) **] signout) pt was c/o vague dysuria,
and occsional difficulty voiding. He denied cough, DOE, PND,
pleuritic CP. No N/V, diarrhea, constipation, dysuria, urinary
retention, night sweats, sore throat, headache, vision changes,
increased redness or drainage from surgical site.
Past Medical History:
Past medical history is significant for:
1. Arthritis.
2. Hypertension.
3. Gout.
Past Surgical History: R inguinal hernia, epigastric and
umbilical hernia repair ([**2144-8-21**])
Social History:
From central america. Lives at home with wife/ family and 6
daughters + rest of family.
- Tobacco: 14 pack years - quit 40 years ago
- Alcohol: used to drink 4 beers/day, stopped 40 years ago
- Illicits: no
Family History:
Family history significant for breast cancer.
Physical Exam:
UPON ADMISSION:
Vitals: 103 90 110/67 30 92% ra
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, slightly distended. Well healing
surgical incisions.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly intact aox3
UPON DISCHARGE:
Vitals: 99.1 98.0 63 136/76 20 98%RA
Gen: AAOx3, NAD
HEENT: anicteric sclera, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD, no JVD
CV: RRR, +S1/S2, no m/r/g
Resp: CTAB, no w/c/r
Abd: soft, NT, ND, well-healing surgical incisions, +BS, no
r/r/g
Inc: c/d/i, no erythema/drainage/induration
Ext: warm, well-perfused, no c/c/e
Neuro: CN2-12 grossly intact, [**5-2**] motor exam throughout, normal
sensory exam throughout
Pertinent Results:
ADMISSION LABS:
[**2144-8-31**] 02:40PM WBC-40.0*# RBC-4.25* HGB-13.3* HCT-39.2*
MCV-92 MCH-31.3 MCHC-33.9 RDW-14.2
[**2144-8-31**] 02:40PM NEUTS-94.7* LYMPHS-2.8* MONOS-2.3 EOS-0
BASOS-0.2
[**2144-8-31**] 02:40PM PT-13.9* PTT-33.3 INR(PT)-1.3*
[**2144-8-31**] 10:30AM TYPE-[**Last Name (un) **] TEMP-38.9 PO2-41* PCO2-37 PH-7.35
TOTAL CO2-21 BASE XS--4 INTUBATED-NOT INTUBA
[**2144-8-31**] 10:30AM LACTATE-2.4*
[**2144-8-31**] 07:56AM ALT(SGPT)-76* AST(SGOT)-65* LD(LDH)-248
CK(CPK)-56 ALK PHOS-101 TOT BILI-1.6*
[**2144-8-31**] 02:55AM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5 LEUK-LG
[**2144-8-31**] 02:55AM URINE RBC-8* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0 TRANS EPI-<1
[**2144-8-31**] 02:55AM URINE WBCCLUMP-FEW MUCOUS-RARE
[**2144-8-31**] 02:30AM cTropnT-<0.01
CXR ([**8-31**]): Basilar atelectasis, although in the appropriate
clinical
setting, an underlying pneumonia cannot be excluded.
CT ABDOMEN PELVIS ([**8-31**]):
1. Heterogeneous enhancement of the right kidney with right
periureteric
stranding, compatible with right pyelonephritis and ureteritis,
given history of known UTI.
2. Status post right inguinal and umbilical hernia repairs. No
intra-abdominal fluid collection or pneumoperitoneum.
3. Small bilateral pleural effusions.
ECHOCARDIOGRAM ([**9-1**]):
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is probable mild regional left ventricular
systolic dysfunction with mid to distal inferior hypokinesis
(see clip [**Clip Number (Radiology) **]) although views of regional wall motion are
technically suboptimal. Right ventricular chamber size and free
wall motion are probably normal (not fully visualized). The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
DISCHARGE LABS:
[**2144-9-4**] 03:49AM BLOOD WBC-13.3* RBC-4.83 Hgb-14.8 Hct-44.0
MCV-91 MCH-30.7 MCHC-33.7 RDW-14.5 Plt Ct-338
[**2144-9-2**] 05:17AM BLOOD Glucose-96 UreaN-21* Creat-1.4* Na-138
K-3.6 Cl-107 HCO3-23 AnGap-12
Brief Hospital Course:
The patient was admitted to the hospital for evaluation and
treatment of his fever and shortness of breath.
In the ED, initial vital signs were 103 90 110/67 30 92% ra.
Labs were notable for WBC 15.9, lactate 2.3, Cr. 1.9, trop
negative x1, ddimer was 1014 and urinalysis with many bacteria,
nitrite positive and >185WBC. CXR showed low lung volumes/
bibasilar atelectasis. Blood cultures were sent x 2. Patient
received 3L NS, 1g tylenol, vancomycin 1g and
ampicillin/sulbactam 3g, albuterol and ipratropium nebs. He was
initially admitted to medicine floor, but around 6am he began
rigoring and became tachycardic to 130s in the setting of
receiving nebulizers. Due to persistent tachycardia he was
admitted to MICU.
Shortly after arrival to the ICU, his care was transferred to
the Surgical ICU (SICU) team. His workup was continued with a CT
abdomen/pelvis, serial laboratory studies, and followup of the
microbiology sent earlier (reader referred to 'Pertinent
Results' section for details). He was aggressively hydrated,
kept NPO for diet, and given IV antibiotics. He transiently
required pressor support for his blood pressure, and was
successfully weaned off pressor support on [**8-31**] itself. His urine
output was closely monitored.
On [**9-1**], his care was continued in this manner. His diet was
slowly advanced to clear liquids and then a regular diet. His
antibiotics were continued, and catered to his blood and urine
cultures (GNRs, ultimately growing out zosyn-susceptible and
ciprofloxacin-susceptible E.coli). IVF rehydration was
continued. On the evening of this day, given his significantly
improved clinical presentation, he was transferred to the
general surgical floor.
On [**8-14**], and [**9-4**], his IV fluids were discontinued upn
achievement of sufficient oral intake of food and liquids.
Antibiotic treatment was continued. He was encouraged to
ambulate. His WBC count was noted to improve every day, and he
remained afebrile since and including the day of [**9-1**]. He
expressed feeling significantly improved and prepared to
continue his recovery at home. He was explained the neccessity
of completing a full course of his prescribed antibiotics
(ciprofloxacin 500 mg Q12H for 11 days after discharge, to make
for a complete 2 week course of antibiotics). He was also
explained the importance of eating a healthy diet, and
ambulating regularly. Finally, he was clearly explained the link
between his urinary health and his recent illness; he was
scheduled for a 1-week appointment with Urology to discuss and
evaluate this further.
Throuhgout his hospital stay, vital signs were routinely
monitored. Good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
Electrolytes were routinely followed, and repleted when
necessary. The patient's white blood count and fever curves were
closely watched for signs of infection. Wound care was performed
regularly and thoroughly. The patient's blood sugar was
monitored throughout his stay; insulin dosing was adjusted
accordingly. The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Discharge medications: ([**8-22**])
1. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*40
Capsule Refills:*0
2. Oxycodone-Acetaminophen (5mg-325mg) [**12-30**] TAB PO Q4H pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**12-30**] tablet(s) by mouth
every four (4) hours Disp #*45 Tablet Refills:*0
3. Allopurinol 300 mg PO DAILY
4. Colchicine 0.6 mg PO EVERY OTHER DAY
5. Losartan Potassium 25 mg PO DAILY
- of note, was on ASA 81 on admission, but this was held at
discharge
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*22 Tablet Refills:*0
2. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 tablet(s) by mouth once a day Disp #*40
Tablet Refills:*1
3. Tamsulosin 0.4 mg PO HS
4. Allopurinol 300 mg PO DAILY
5. Colchicine 0.6 mg PO EVERY OTHER DAY
6. Losartan Potassium 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Fever, tachypnea and tachycardia in the setting of a
post-operative Foley cathether, most concerning for urosepsis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for evaluation
and treatment of your fever and shortness of breath. You have
done well in the hospital and are now safe to return home to
complete your recovery with the following instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-7**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
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.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD
Phone:[**Telephone/Fax (1) 5727**]
Date/Time:[**2144-9-10**] 4:20 PM
Location: [**Hospital Ward Name **] 3, [**Hospital1 18**]
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 13365**], MD
Phone:[**Telephone/Fax (1) 3201**]
Date/Time:[**2144-9-16**] 9:45 AM
Location: [**Hospital1 18**], [**Hospital Ward Name **] 3 - SURGICAL SPECIALTIES OFFICE
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD
Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2145-1-7**] 9:30 AM
Completed by:[**2144-9-4**]
|
[
"5849",
"2761",
"40390",
"99592",
"78552",
"5859",
"V1582"
] |
Admission Date: [**2153-8-26**] Discharge Date: [**2153-8-31**]
Date of Birth: [**2096-9-11**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Transfer from [**Hospital3 417**] Hospital with pericardial effusion
Major Surgical or Invasive Procedure:
Pericardiocentesis with placement of drain.
History of Present Illness:
This is a 56 year-old man with a recent history of pericarditis
who presented to [**Hospital3 417**] on [**2153-8-26**] with shortness of
breath. Patient's most relevant history dates to [**8-8**] when he
presented to [**Hospital3 **] with chest pain, had negative stress
test/myoview and was noted to ahave small pericardial effuision
on CT, EKG consistent with pericarditis. Treated with NSAIDs. He
was cathed here on [**8-17**] and had clean coronaries. EF of 60-70%.
.
Over the past 2 weeks he has had shortness of breath and some
pleuritic chest pain. Denies fevers. Generally not feeling
himself. Also reports GERD. SOB described as inability to take
full breaths.
.
At [**Hospital3 417**] EKG consistent with pericarditis, no
alternans, ?decreased voltage and CXRAY demonstrating
cardiomegaly consistent effusion. Blood pressure in 120-130's
by documentation. Transferred to [**Hospital1 **] for further management.
Past Medical History:
hyperlipidemia
GERD
Lyme disease-remote, 20 years ago-knee effusion
kidney stones requiring lithotripsy and ureteral stent
Social History:
Civil judge. No smoking, occasional alcohol, no drug use.
Family History:
father and siblings with prostate cancer
Physical Exam:
Temp:tmax 101.3 at OSH, 99 here BP: 140/90 HR:80 RR:18
96%rm airO2sat Weight: 190lbs. pulsus:5
general: pleasant, comfortable, NAD
HEENT: PERLLA, EOMI, ano scleral icterus, MMM, op without
lesions, no supraclavicular or cervical lymphadenopathy, jvp
10-12cm, no carotid bruits
lungs: CTA b/l with good air movement throughout although no
deep breath secondary to pain
heart: RR, S1 and S2 wnl, +friction rub
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no edema
skin/nails: no rashes/no jaundice/no splinters
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout.
Pertinent Results:
[**2153-8-27**] 05:02AM WBC 9.2 HCT 32.4* Plt 268
[**2153-8-29**] 05:39AM ESR 23*
.
ECHO Study Date of [**2153-8-26**]
Conclusions: The left atrium is normal in size. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Right ventricular chamber size is
relatively small with preserved free wall motion. There is a
large circumferential pericardial effusion with sustained right
atrial and right ventricular diastolic collapse, consistent with
impaired fillling/tamponade physiology.
IMPRESSION: Large circumferential pericardial effusion with
evidence for
increased pericardial pressure/tamponade physiology.
.
ECHO Study Date of [**2153-8-30**] (follow-up post-drain placement)
GENERAL COMMENTS: Left pleural effusion.
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
functionare
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
3. Compared with the prior study (images reviewed) of [**8-29**]/200,
the
pericardial effusion is smaller.
.
ECHO Study Date of [**2153-8-31**]: The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size is normal. Right
ventricular systolic function is normal. There is a small
partially echo dense/organized pericardial effusion. There are
no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2153-8-30**],
findings are similar.
Brief Hospital Course:
This is a 56 year-old man with recent dx of pericarditis [**8-8**],
subsequent negative ischemic work-up, d/ced NSAIDs secondary to
GERD symptoms with shortness of breath over the past 2-3 weeks,
transferred from [**Hospital3 417**] for further management of
pericardial effusion.
.
1)CV:
-Ischemia: No CAD by recent cath. Continue statin.
-pump: large, primarily posterior, pericardial effusion with
slight impingement of rv filling. JVP to 10-12 cm, bp's in
130's to 140, heart sound not distant, positive rub, slightly
decr voltage by ekg, small pulsus parodoxus. [**Doctor First Name **] to lab for
drainage. Revealed tamponade physiology. 860 cc drained in lab.
Transferred back to CCU with drain in place. 400 more drained
that day. Echo revealed question of loculated posterior portion,
but continued to drain for 2 more days with aggressive flushing.
Cardiac surgery followed for possible pericardial window. Window
uneccessary. Drain eventually pulled without event. Follow-up
echocardiogram revealed stable pericardial effusion.
-valves: no valcular dz
-rhythm: normal sinus
Medications on Admission:
Atorvastatin 20
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
Idiopathic pericarditis w/ pericardial and pleural effusions
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital if you have symptoms of shortness
of breath, chest pain or fever.
Followup Instructions:
Please follow up with your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within one week of
discharge.
.
Please follow up with your primary cardiologist, Dr. [**Last Name (STitle) **],
one week after discharge.
|
[
"5119",
"2724"
] |
Admission Date: [**2181-2-23**] Discharge Date: [**2181-2-27**]
Date of Birth: [**2106-4-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Ischemic left foot
Major Surgical or Invasive Procedure:
OPERATION PERFORMED:
1. Cutdown of left femoral to anterior tibial artery vein
graft.
2. Arteriogram of the left lower extremity.
3. Angioplasty of left dorsalis pedis artery.
4. Angioplasty of left distal anterior tibial artery.
5. Vein graft angioplasty.
6. Closure of left vein graft arteriotomy.
History of Present Illness:
Mr. [**Known lastname **] presented for followup of his lower extremity
ischemia sooner than scheduled visit. Over the last two days,
his left foot and calf has been hurting. This is the site of an
old left fem-DP bypass that acutely occluded post CABG in
[**Month (only) **] and treated with angioplasty and cutting balloon and
partial thrombectomy.
Past Medical History:
coronary artery disease
aortic stenosis
peripheral [**Month (only) 1106**] disease
gastroesophageal reflux disease
hypertension
hyperlipidemia
h/o prostate disease
s/p coronary artery stenting
Social History:
Spanish speaking. He is married and lives with his wife. [**Name (NI) **]
continues to smoke [**4-30**] cigs/day, h/o 1ppd since age 15. Denies
EtOH for years, but history of heavy drinking. Denies drug use.
Family History:
Brother died of colon CA at age 70. No sudden cardiac death.
Physical Exam:
Physical Exam: AFB VITAL SIGN STABLE
PE: AOX3 NAD
PERRL / EOMI
Neur: CN grossly intact
Lungs: no respiratory distress, CTAB antior
CARDIAC: RRR
ABDOMEN: Soft, ND, NT
EXT:
rle - pt, doppler dp doppler foot warm no erythema
lle - DP palpable graft palpable, otherwise dopplerable
Pertinent Results:
[**2181-2-27**] 06:05AM BLOOD
WBC-6.9 RBC-4.55* Hgb-11.5* Hct-37.4* MCV-82 MCH-25.2*
MCHC-30.7* RDW-17.1* Plt Ct-316
[**2181-2-27**] 06:05AM BLOOD
PT-27.1* PTT-39.3* INR(PT)-2.6*
[**2181-2-26**] 02:11AM BLOOD
Glucose-99 UreaN-14 Creat-1.2 Na-138 K-4.0 Cl-102 HCO3-27
AnGap-13
[**2181-2-23**] 7:25 pm MRSA SCREEN NASAL SWAB.
MRSA SCREEN (Final [**2181-2-26**]): No MRSA isolated.
Brief Hospital Course:
The patient had a 4 day history of left leg, Pt seen in office:
Taken emergently to the OR:
1. Cutdown of left femoral to anterior tibial artery vein
graft.
2. Arteriogram of the left lower extremity.
3. Angioplasty of left dorsalis pedis artery.
4. Angioplasty of left distal anterior tibial artery.
5. Vein graft angioplasty.
6. Closure of left vein graft arteriotomy.
Prior to the procedure, it was noted that there was a small
amount of bright red blood exiting the patient's rectum. The
patient's hematocrit was checked and
found to be 23.6, previously his baseline was noted to be ~30.
He was also found to be supra therapeutic on his Coumadin, INR
was 6.1. Of note, his INR was 1.4 on [**2181-2-8**].
Given emergent nature of procedure, decision was made to proceed
while giving blood products during the procedure. The patient
was given heparin for the procedure, and then intra op re-check
of hematocrit was found to be 16.2, with INR of 9.0. The
patient received 5 units of PRBCs, 3 units of FFP and 1 unit of
cryo, with improvement of the patient's hematocrit to 21.1.
The procedure was completed, and the patient received
resuscitation for a total of 3.8 liters of blood products and
lactated ringers. He was then brought to the PACU still
intubated and under sedation. Vital signs were stable on
transfer to PACU.
Post-operatively, then was extubated and transferred to the VICU
for further stabilization and monitoring.
While in the VICU he received monitored care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabilized from the acute setting of post operative care,
he was transferred to floor status
On the floor, remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home in stable
condition.
To note his Coumadin has been DC'ed, PCP is [**Name Initial (PRE) 12309**]. No need for
Coumadin from cardiac surgery standpoint.
Medications on Admission:
Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1)
Inhalation twice a day.
Hydrochlorothiazide 12.5 mg Tablet Sig: 0.5 Tablet PO once a
day.
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Start after your
plavix is completed.
Coumadin
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): stop prilosec and take zantac when on plavix. After
plavix is complete. can take prilosec.
Disp:*30 Tablet(s)* Refills:*0*
9. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1)
Inhalation twice a day.
10. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day: can
stop and take prilosec after plavix is discontinued.
Disp:*30 Tablet(s)* Refills:*0*
11. Hydrochlorothiazide 12.5 mg Tablet Sig: 0.5 Tablet PO once a
day.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Start after your
plavix is completed.
14. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO four times a
day for 30 days: pen.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Failing graft left lower extremity.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery
Lower Extremity Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-28**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and 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 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
YOUR COUMADIN HAS BEEN STOPPED. NO NEED TO HAVE YOUR INR
FOLLOWED.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2181-3-6**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2181-3-6**] 3:45
Completed by:[**2181-2-27**]
|
[
"41401",
"4241",
"53081",
"4019",
"V4582",
"3051"
] |
Admission Date: [**2178-4-13**] Discharge Date: [**2178-5-7**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
cough, tachycardia
Major Surgical or Invasive Procedure:
[**2178-4-20**] Aortic Valve Replacement (21mm porcine)
.
[**2178-4-18**] Extraction of teeth numbers 13, 14, 22,
24 and 25 prior to cardiac surgery
History of Present Illness:
87 year old male presented to PCP for
cough, and found to have rate in 150s. He was sent to NEBH
ambulatory hospital where EKG was suspicious for aflutter and
troponin was 3.6. He was transferred to [**Hospital1 18**]. Here, he received
lopressor 2.5 mg IV and Cardizem 10 mg IV without improvement.
He
then received 60 mg PO diltiazem, and converted to aflutter with
ventricular rate of 87. He was admitted and sent for cardiac
catheterization and found to have critical aortic stenosis. He
is
now being referred to cardiac surgery for an aortic valve
replacement.
Past Medical History:
Aortic Stenosis
Hypertension
BPH
Past Surgical History:
appendectomy
choleysectomty
?hernia repair (patient does not remember)
Social History:
no current tobacco, never smoker, 1 EtOH drink per day, no drug
use. Wife passed away several years ago leading to mild
depression.
Family History:
non-contributory
Physical Exam:
ADMIT:
VS: 97.9, 122/67, 96, 22, 96% RA
GENERAL: Well-appearing in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: tachycardic, nl S1-S2, appears to have grade II
holosystolic murmur heard best at LSB.
LUNGS: rhonchi bilaterally, no wheezing or crackles appreciated,
good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, strength and
gait not assessed.
Pertinent Results:
Cardiovascular Report Cardiac Cath Study Date of [**2178-4-14**]
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate pulmonary hypertension.
3. Biventricular diastolic dysfunction.
4. Critical aortic stenosis.
5. Reduced ejection fraction with anterior wall hypokinesis
CT CHEST W/O CONTRAST Study Date of [**2178-4-16**] 8:29 AM
IMPRESSION:
1. Non-calcified, dilated, fusiform ascending aorta.
2. Diffuse bibasilar ground-glass peribronchial opacity could
represent a
nonspecific interstial pneumonitis or mild CHF.
3. Probable tracheobronchmalacia involving the trachea and
bilateral mainstem
bronchi.
4. Dilated right main pulmonary artery. Consider pulmonary
hypertension.
The study and the report were reviewed by the staff radiologist.
.
[**2178-4-20**] Intra-op TEE:
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is significant
aortic valve stenosis with fixed left and non-crornary cusps.
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen.
POSTBYPASS
Biventricular systolic function remains preserved. There is a
well seated, well functioning bioprosthesis in the aortic
position. No aortic regurgitation is seen. The MR remains mild.
.
[**2178-5-7**] 06:08AM BLOOD WBC-9.2 RBC-3.72*# Hgb-8.3*# Hct-26.7*#
MCV-72* MCH-22.4* MCHC-31.1 RDW-21.9* Plt Ct-394
[**2178-5-7**] 08:23AM BLOOD Hct-28.1*
[**2178-5-7**] 06:08AM BLOOD UreaN-25* Creat-1.0 Na-139 K-4.2 Cl-108
[**2178-4-28**] 01:21AM BLOOD ALT-98* AST-147* AlkPhos-132* Amylase-45
TotBili-1.4
[**2178-5-7**] 06:08AM BLOOD Mg-1.8
[**5-6**] PA&Lat:
IMPRESSION: AP chest compared to [**5-2**]:
Previous mild pulmonary edema has cleared, and moderate left
lower lobe
atelectasis and small left pleural effusion have decreased.
There is,
however, a new cluster of nodular opacities in the right mid
lung laterally
(projected over the right first and second ribs), which could be
residual or
organized infection. Findings are consistent with patient's
clinical picture,
CT scanning would be helpful in comparison to the scan on [**4-24**]. It is
useful to note that there were no lung nodules at that time
concerning for
malignancy.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Brief Hospital Course:
87 y/o healthy male with HTN and BPH who initially presented to
PCP for cough, found to have rate in 150s, with EKG suspicious
for atrial flutter, and elevated cardiac enzymes suggestive of
NSTEMI. The patient was brought to the Operating Room on [**2178-4-20**]
where the patient underwent Aortic Valve Replacement with Dr.
[**Last Name (STitle) **]. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Initially out
of OR he was hypoxic and extubation was delayed until the
following morning. POD 1 the patient eventually extubated and
was neurologically intact. He developed rapid atrial
fibrillation. Amiodarone was initiated and the patient converted
to SR. Beta blocker was initiated and the patient was diuresed
toward the preoperative weight. He developed respiratory
distress and was re-intubated on POD 2. Bronchoscopy was
performed and large mucus plug removed from RLL. Vancomycin and
Cefepime were started empirically for pneumonia. Dob Hoff was
placed for tube feeds. He remained intubated 2nd to hypoxia
continued agitation and confusion. He eventually extubated on
[**4-26**] but was reintubed 6 hours later due to respiratory distress
and agitation. He was stated on coumadin for a-fib but he became
supratherapeuitic and due to the fact that he remained in SR
coumdain was dc'd. Chest tubes and pacing wires were
discontinued without complications. He eventually extubated
again on [**4-29**] and required aggressive pulmonary toileting. He
completed a course of antibiotics despite negative cultures, his
WBC were elevated during his post-op course but have since
returned to [**Location 39511**]. His current CXR still shows RML density but
clinically he has improved. He will need to be followed closely
while at rehab. Due to his confusion he was started on Seroquel
but this was discontinued due to over sedation, he responded
well to low dose haldol but this was discontinued prior to
discharge. He remains pleasently confused but cooperative. He
was evaluated by speech and swallow and diet was advanced as
indicated. The patient continued to make slow progress and was
transferred to the telemetry floor for further recovery. While
on the floor continued to progress. He has been incontinuent at
times and needs assistance with walking and care. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. He was deemed safe for discharge on
POD#17 to [**Hospital 100**] Rehab.
Medications on Admission:
- nifedipine 30 mg daily
- sertraline 100 mg daily
- flomax 0.4 mg daily
Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezes.
Disp:*1 * Refills:*0*
2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
5. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 1 weeks.
Disp:*7 Tablet Extended Release(s)* Refills:*0*
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Ext Release 24 hr(s)* Refills:*2*
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*1 ML(s)* Refills:*0*
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
Disp:*1 * Refills:*2*
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain, fever.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Aortic Stenosis
Hypertension
BPH
Past Surgical History:
appendectomy
choleysectomty
?hernia repair (patient does not remember)
Discharge Condition:
Alert and appropriate
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema-minimal
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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) **] [**2178-6-10**] 1:45 pma[**Telephone/Fax (1) 170**]
Cardiologist Dr. [**Last Name (STitle) **] [**2178-5-20**] 1:45pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 11144**] in [**3-5**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2178-5-7**]
|
[
"486",
"41401",
"42731",
"4168",
"4019",
"311"
] |
Admission Date: [**2106-4-6**] Discharge Date: [**2106-4-9**]
Date of Birth: [**2021-11-28**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2106-4-7**]
Cardiac catheterization with placement of drug-eluting stent
[**2106-4-8**]
History of Present Illness:
Mr. [**Known lastname 89277**] is an 84yo male with history of CAD s/p CABG in [**2098**]
(LIMA-LAD and SVG-Ramus), hypertension, hyperlipidemia, CRI,
unilateral vocal cord paralysis after CABG in [**2098**], and
sarcoidosis who presents now with exertional dyspnea and chest
pain concerning for unstable angina.
Mr. [**Known lastname 89277**] did well s/p CABG in [**2098**], though had recurrent chest
pain four years later. Exercise thallium test [**2103-6-21**] showed
mild anteroapical ischemia, but given patient did not want to
procede with repeat cath, he was continued on medical management
of CAD. However, over the past several months he has had
increasing exertional dyspnea, prompting repeat exercise
thallium stess test on [**2105-12-4**]. This study showed no ischemia,
but did show evidence of a borderline increase in LV filling
pressure during exercise. Had echo [**2106-3-26**], which showed mild
concentric LVH, decreased LV diastolic compliance, and
borderline pulmonary hypertension. LVEF was preserved.
Patient had been started on furosemide 20mg daily by his
cardiologist in late [**Month (only) 958**], given concern that exertional
dyspnea may be secondary to dCHF. Patient's symptoms did not
improve, and he also began to develop exertional chest pain. He
describes the pain as a pressure-like sensation across his chest
which is non-radiating and comes on after walking a short
distance. The pressure is associated with mild dyspnea, but no
dizziness, nausea, or diaphoresis. The pain resolves within one
minute if he stops to rest. Over the past 2-3 days, he has also
had similar chest pressure with minimal activity such as washing
dishes. He saw his cardiologist for follow-up in clinic
yesterday, who was concerned that his symptoms are due to
recurrent ischemia. Cardiologist recommended right and left
heart cath for further evaluation, and patient is admitted now
for pre-cath hydration given CRI, with plans for cath early
tomorrow morning.
On arrival to the floor, patient is comfortable and denies any
dyspnea or chest pain. Denies any HA, dizziness/lightheadedness.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. Does report chronic
non-productive cough, chronic right-sided leg cramps at night.
All of the other review of systems were negative.
Cardiac review of systems is notable for absence of PND,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Patient does report [**2-26**] pound weight gain over past several
months.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: [**2098**], LIMA-LAD and SVG-Ramus
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
CAD s/p CABG [**2099-6-4**] at [**Hospital1 112**]
Diastolic CHF
Hypertension
Hyperlipidemia
CRI, recent baseline Cr 1.9
DJD
Unilateral vocal cord paralysis after CABG in [**2098**]
Sarcoidosis
s/p cholecyctectomy [**2094**]
s/p left inguinal hernia repair [**2088**]
s/p hydrocolectomy [**2073**]
s/p TURP [**2094**]
s/p left total knee [**2100**]
Social History:
Widowed. Lives alone, but son is 2 miles away. Retired plumber.
Rare smoking history in past ~ 60 years ago, but no recent use.
Rare EtOH use. No illicit drug us.
Family History:
Father deceased from MI, brother deceased from MI in his 40s,
uncle with MI in his 50s.
Physical Exam:
ADMISSION EXAM:
VS: T= 98.8 BP= 193/88 HR= 62 RR= 16 O2 sat= 96% RA
Weight: 83.5 kg
GENERAL: elderly male, comfortable appearing, pleasant, alert,
oriented, NAD
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva mildly injected
bilaterally. MMM.
NECK: Supple, JVP of 10cm
CARDIAC: RRR, normal S1/S2, no r/m/g, S4 present
LUNGS: Respirations unlabored, no accessory muscle use.
Bibasilar rales, no wheezing or rhonchi
ABDOMEN: Bowel sounds present, soft, NTND. No
hepatosplenomegaly.
EXTREMITIES: Warm, well-perfused, 1+ edema to mid-shins
bilaterally, no clubbing or cyanosis
SKIN: No stasis dermatitis, rashes or lesions
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
PSYCH: Calm, appropriate
DISCHARGE EXAM:
VS: 97.9 168/75 59 16 94% RA
GENERAL: elderly male, alert, oriented, NAD
HEENT: sclera anicteric, MMM
NECK: supple, no appreciable JVD
CARDIAC: RRR, normal S1/S2, S4, no r/m/g
LUNGS: bibasilar rales, no wheezing or rhonchi
ABDOMEN: soft, NTND
EXTREMITIES: warm, well-perfused, 1+ edema to mid-shins
bilaterally
GROIN: bilateral faint femoral bruits, no evidence of hematoma
bilaterally at cardiac cath sites
PULSES: femoral/DP/PT 2+ bilaterally
Pertinent Results:
ADMISSION LABS:
[**2106-4-6**] 05:34PM BLOOD WBC-5.8 RBC-4.13* Hgb-14.4 Hct-40.1
MCV-97 MCH-34.8* MCHC-35.8* RDW-13.1 Plt Ct-124*
[**2106-4-6**] 05:34PM BLOOD PT-12.4 PTT-31.6 INR(PT)-1.0
[**2106-4-6**] 05:34PM BLOOD Glucose-86 UreaN-53* Creat-2.2* Na-135
K-4.9 Cl-101 HCO3-27 AnGap-12
[**2106-4-6**] 05:34PM BLOOD proBNP-449
[**2106-4-6**] 05:34PM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1
OTHER PERTINENT LABS:
[**2106-4-8**] 05:44AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.1 Mg-2.0
[**2106-4-7**] 01:57PM BLOOD CK-MB-4 cTropnT-<0.01
[**2106-4-7**] 10:20PM BLOOD CK-MB-4 cTropnT-0.11*
[**2106-4-8**] 05:44AM BLOOD CK-MB-3 cTropnT-0.08*
[**2106-4-7**] 01:57PM BLOOD CK(CPK)-55
[**2106-4-7**] 10:20PM BLOOD CK(CPK)-60
[**2106-4-8**] 05:44AM BLOOD ALT-57* AST-50* LD(LDH)-215 CK(CPK)-58
AlkPhos-90 TotBili-1.2
DISCHARGE LABS:
[**2106-4-9**] 07:25AM BLOOD Glucose-89 UreaN-37* Creat-2.2* Na-139
K-4.2 Cl-104 HCO3-25 AnGap-14
[**2106-4-9**] 07:25AM BLOOD WBC-7.8 RBC-3.79* Hgb-13.2* Hct-36.6*
MCV-97 MCH-34.8* MCHC-36.0* RDW-13.1 Plt Ct-114*
IMAGING:
ECG [**2106-4-6**]: Normal sinus rhythm. Left atrial abnormality.
Otherwise, tracing is within normal limits. No previous tracing
available for comparison.
CXR [**2106-4-6**]:
1. Scattered interstitial and alveolar opacities. Differential
diagnosis
includes pulmonary sarcoidois, however, basilar changes suggest
an additional interstial lung disease or superimposed pulmonary
edema.
2. Pleural irregularity, possible asbestos exposure.
TTE [**2106-4-7**]: Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
No thoracic aortic dissection is seen. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
CTA Chest [**2106-4-7**]:
1. No aortic dissection.
2. Extensive moderately severe atherosclerosis of the aorta and
its branches, including thoracic aortic arch ulcers as
described, and ulcerated mixed plaque in the proximal left
subclavian artery, of undetermined age. There is no periaortic
bleeding.
3. Occlusion of the left vertebral artery from its origin, of
undetermined
age.
4. Extensive scarring in both apices and lung bases consistent
with the given history of sarcoidosis, comparison with prior
imaging is suggested to determine disease activity.
5. Very mild pulmonary edema.
6. Solid left renal lesion, possible renal cell carcinoma.
7. Chronic mild scarring and traction bronchiectasis, right
lower lobe.
CARDIAC CATH [**2106-4-7**] (Prelim):
Right dominant
LMCA 30% tapering distally
LAD 90% ostial stenosis
LCX 70% ostial stenosis
RCA 95% proximal stenosis
SVG-OM1 patent
LIMA-LAD unable to engage for selective injection because of
tortuosity of left subclavian
Ascending aorta and arch - no obvious dissection
CARDIAC CATH [**2106-4-8**]: report pending
Brief Hospital Course:
84yo male with history of CAD s/p CABG, HTN, HL, CRI and
sarcoidosis who presented for cardiac catheterization in setting
of progressive dyspnea on exertion and new onset exertional
chest pain, concerning for unstable angina.
# Exertional Dyspnea/Chest Pain/CAD: Exertional dyspnea and
chest pain prior to admission were concerning for unstable
angina. Patient underwent right and left heart cath on [**2106-4-7**],
which revealed patent SVG-OM1 graft, presumed patent LIMA-LAD
graft, and new proximal 95% RCA stenosis. Patient developed
severe, non-pleuritic pain across his chest during the procedure
and had vagal response, requiring administration of atropine and
increased IVF. He did not have any acute ST changes on ECG, and
CTA chest was negative for dissection or PE. Had slight
troponin bump, which was felt to be secondary to demand ischemia
in setting of hypotension from vagal response. Patient was
transferred to CCU for close BP monitoring, and later became
hypertensive requiring nitro gtt. Went back to cath lab on
[**2106-4-8**] for repeat cath with DES placed to RCA. Patient
tolerated procedure well and did not have further CP during the
admission. He remained hemodynamically stable, and was weaned
off nitro gtt. Was discharged on regimen of aspirin 325mg
daily, plavix 75mg daily, simvastatin, and metoprolol. ACE
inhibitor was not started given Cr slightly elevated above
baseline, though patient would likely benefit from addition of
ACEi if Cr remains stable in outpatient setting. Patient will
follow-up with his cardiologist within 1 week of discharge.
# Acute dCHF: Recent echo [**2106-3-26**] showed preserved LVEF but
evidence of diastolic dysfunction, and diastolic dysfunction
also present on recent exercise thallium test. TTE [**2106-4-7**]
showed EF >55%. Cardiac cath revealed mildly increased right
and left heart filling pressures, again consistent with
diastolic dysfunction. Patient's exam was suggestive of volume
overload, and HTN was likely contributing to acute exacerbation
of dCHF. Patient's home furosemide dose increased from 20mg
daily to 40mg daily on discharge. He was continued on a beta
blocker, though atenolol changed to metoprolol given underlying
CKD. Patient will likely benefit from an ACE inhibitor, though
this was deferred to outpatient setting given Cr slightly above
baseline during this admission.
# Hypertension: Patient hypertensive on admission, and of note
briefly required nitro gtt during his hospital course for
management of hypertension. His nifedipine dose was increased
from 30mg daily to 60mg daily, and atenolol was changed to
metoprolol given underlying CKD. Patient will need BP monitored
in follow-up, and may need further adjustment to
anti-hypertensive regimen. [**Month (only) 116**] benefit from ACE inhibitor,
though this was deferred to outpatient provider given Cr
elevated above baseline this admission.
# CKD: Baseline Cr 1.9, and Cr ranged 1.9-2.2 this admission.
Patient received pre-cath hydration, as he is at higher risk for
contrast-induced nephropathy given low GFR. His Cr was stable
during the admission, but should be rechecked in follow-up the
week of [**2106-4-12**]. As above, if Cr stable, patient will likely
benefit from ACE inhibitor.
# Hyperlipidemia: Continued simvastatin 20mg daily.
# Sarcoidosis: CXR this admission revealed scattered
interstitial and alveolar opacities, which could represent
pulmonary sarcoidosis. Patient will follow-up with his PCP.
# Left renal mass: CTA chest revealed incidental finding of 38 x
37mm peripherally enhancing solid left renal lesion, concerning
for a renal cell carcinoma. Patient will follow-up with PCP
within one week of discharge, and will likely need MRI for
further evaluation based on radiology recommendations. Pending
MRI results, patient may require biopsy or resection, as well as
referral to heme/onc if mass determined to be malignant.
PENDING AT TIME OF DISCHARGE:
-final cardiac catheterization report from [**2106-4-7**], [**2106-4-8**]
TRANSITIONAL CARE ISSUES:
-Patient's code status was DNR/DNI this admission
-Patient will likely need outpatient MRI for further evaluation
of left renal mass, and may eventually need biopsy or resection
of mass as well as referral to hematology/oncology if mass
determined to be malignant
-Patient will need renal function checked at follow-up
appointment week of [**2106-4-12**]
-Patient will need to be on aspirin 325mg daily, plavix 75mg
daily x12 months
Medications on Admission:
Furosemide 20 mg daily (stopped yesterday)
Atenolol 50 mg daily
Simvastatin 20 mg daily
Nifedipine 30 mg ER tablet daily
Aspirin 325mg daily (dose increased [**2106-4-5**])
MVI daily
Discharge Medications:
1. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
Disp:*30 Tablet Extended Release(s)* Refills:*2*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for CAD: RCA DES.
Disp:*30 Tablet(s)* Refills:*2*
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Coronary artery disease
Hypertension
Acute on chronic diastolic heart failure
Seconary Diagnoses:
Dyslipidemia
Chronic kidney disease
Sarcoidosis
Renal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 89277**],
You were admitted to the hospital for a cardiac catheterization,
for further evaluation of your shortness of breath and chest
pressure. During your catheterization on [**2106-4-7**], you developed
the sudden onset of chest pain. This was likely caused by
having decreased blood flow to the heart because your blood
pressure was low.
You were briefly admitted to the ICU for close monitoring of
your blood pressure, which improved. You had a repeat cardiac
catheterization on [**2106-4-8**], and had a stent placed into one of
the coronary arteries. You will need to continue taking
aspirin, and will also need to take a new medication called
clopidogrel (plavix) daily for the next 12 months. It is very
important that you take this medication daily, and that you
speak with Dr. [**First Name (STitle) **] before stopping it for any reason.
Your CT scan revealed that there is a mass on your left kidney,
which could represent a cancer. We will let Dr. [**First Name (STitle) **] know about
this lesion. You may need to have an MRI to look more closely
at the kidney, and ultimately they may decide to either biopsy
the lesion or remove it.
We made the following changes to your medications while you were
here:
1. STARTED clopidogrel (plavix) 75mg daily
2. STOPPED atenolol
3. STARTED metoprolol tartrate 25mg twice daily
4. INCREASED furosemide to 40mg daily
5. INCREASED nifedipine to 60mg daily
Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]-[**Doctor Last Name **]
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: ONE [**Location (un) 542**] ST, [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 8506**]
When: Thursday, [**4-15**], 1:45PM
|
[
"41401",
"4280",
"40390",
"5859",
"2724",
"V4581"
] |
Admission Date: [**2143-7-9**] Discharge Date: [**2143-7-18**]
Date of Birth: [**2078-2-13**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Tetracycline / Penicillins / Cephalosporins
/ Vinorelbine / Peanut / Oxycodone Hcl / Hydrocodone / Atrovent
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
- Two bronchoscopies (one with Y-tube removal)
- Mechanical Intubation/extubation
History of Present Illness:
65yo F PMHx NSCLC s/p RUL VATS lobectomy [**5-/2143**] c/b LUL
subsegmental PE now s/p bronchoscopy and Y stent placement with
short portion in trachea placed yesterday , p/w acute dyspnea x
2hrs hours. Pt reports that since bronching "has not felt
right". Overnight, patient resp status worsened, called EMS.
On EMS arrival, O2 sat 90%, respiratory rate 40. Denies fevers,
chills, nightsweats, chest pain. Notes that was not taking
Mucinex because pills were too large to swallow.
.
In ED, initially VS HR106 134/94 40 97%FM, patient w loud ronchi
bilaterally, reports some relief from mucomyst, but remaining
very uncomfortable. CXR w/o focal opacities. Admitted
emergently to ICU for further management.
Past Medical History:
Past Medical History:
- NSCLC s/p LLLobectomy '[**39**] c/b recurrences/p L lingulectomy '[**40**]
- Right upper lobe nodule s/p Right VATS lobectomy/superior
segmentectomy [**2143-5-1**], exploratory R VATS/RML detorsion [**2143-5-3**]
- OA
- Chronic Lower back pain
- hypothyroidism
- benign Right parotid mass
- HTN
- HLD
.
PAST SURGICAL HISTORY:
C-section, Hemorrhoidectomy, Tonsillectomy, RUL VATS
lobectomy/superior segmentectomy [**2143-5-1**], exploratory R VATS/RML
detorsion [**2143-5-3**]
Social History:
She lives with her husband. She does not have any pets. She is
a lifetime nonsmoker. Sales clerk. Occasional etoh.
Family History:
Her son has allergies. Her brother has thyroid disease,
otherwise no pulmonary history.
Physical Exam:
On admission:
VS: 96.9 104 154/91 32 99%on Bipap
GEN: tachypnic, mild distress
HEENT: PERRL, EOMI, MMM
NECK: no JVD, no LAD, supple
LUNGS: loud rhonchi throughout, very junky, moving air well
bilaterally
HEART: tachy, regular,
ABD: Soft, NT/ND, no rebound/guarding
EXT: warm, sweaty, 2+radial pulses, no cyanosis/edema
Pertinent Results:
ADMISSION LABS:
[**2143-7-9**] 04:30AM BLOOD WBC-9.8# RBC-3.93* Hgb-12.6 Hct-36.9
MCV-94 MCH-32.0 MCHC-34.1 RDW-12.9 Plt Ct-172
[**2143-7-9**] 04:30AM BLOOD Neuts-75.3* Lymphs-18.7 Monos-5.6 Eos-0.1
Baso-0.3
[**2143-7-9**] 04:30AM BLOOD PT-13.9* PTT-31.3 INR(PT)-1.2*
[**2143-7-9**] 04:30AM BLOOD Glucose-120* UreaN-17 Creat-0.9 Na-140
K-4.1 Cl-102 HCO3-22 AnGap-20
[**2143-7-10**] 04:01AM BLOOD Calcium-9.1 Phos-2.5* Mg-1.7
[**2143-7-9**] 08:13AM BLOOD Type-ART pO2-154* pCO2-43 pH-7.37
calTCO2-26 Base XS-0
[**2143-7-9**] 08:13AM BLOOD Lactate-3.1*
OTHER LABS:
[**2143-7-10**] 04:01AM BLOOD WBC-13.1* RBC-3.26* Hgb-10.3* Hct-30.1*
MCV-92 MCH-31.7 MCHC-34.3 RDW-12.9 Plt Ct-111*
[**2143-7-10**] 04:01AM BLOOD Neuts-93.8* Lymphs-3.6* Monos-2.3 Eos-0.2
Baso-0.2
[**2143-7-18**] 05:15AM BLOOD WBC-7.8 RBC-3.63* Hgb-11.6* Hct-33.1*
MCV-91 MCH-31.9 MCHC-35.1* RDW-12.9 Plt Ct-189
[**2143-7-15**] 06:00AM BLOOD PT-13.1 PTT-30.9 INR(PT)-1.1
[**2143-7-18**] 05:15AM BLOOD PT-19.1* PTT-40.8* INR(PT)-1.7*
[**2143-7-18**] 05:15AM BLOOD Glucose-85 UreaN-20 Creat-0.8 Na-138
K-3.9 Cl-104 HCO3-28 AnGap-10
[**2143-7-18**] 05:15AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.9
[**2143-7-15**] 06:05AM BLOOD Vanco-16.6
[**2143-7-9**] 08:13AM BLOOD Type-ART pO2-154* pCO2-43 pH-7.37
calTCO2-26 Base XS-0
[**2143-7-10**] 01:42AM BLOOD Type-ART pO2-152* pCO2-50* pH-7.28*
calTCO2-24 Base XS--3
[**2143-7-10**] 03:12AM BLOOD Type-ART pO2-100 pCO2-36 pH-7.41
calTCO2-24 Base XS-0
[**2143-7-11**] 11:38AM BLOOD Type-ART PEEP-5 pO2-199* pCO2-37 pH-7.43
calTCO2-25 Base XS-1 Intubat-INTUBATED
[**2143-7-9**] 02:11PM BLOOD Lactate-4.2*
[**2143-7-10**] 03:12AM BLOOD Lactate-2.8*
[**2143-7-12**] 03:39AM BLOOD Lactate-1.0
MICROBIOLOGY
[**2143-7-9**] 9:24 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2143-7-12**]**
GRAM STAIN (Final [**2143-7-9**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CHAINS.
RESPIRATORY CULTURE (Final [**2143-7-12**]):
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2143-7-9**] 9:30 am BLOOD CULTURE (x2)Final [**2143-7-15**]: NO GROWTH.
RADIOLOGY
CHEST (PORTABLE AP); [**2143-7-9**] 4:28 AM
Again seen are changes of right upper lobe wedge resection with
chain sutures, staples, and superior retraction of the inferior
pulmonary ligament. Discoid atelectasis in the left upper lobe
has improved. There is no focal consolidation. Heart size is
normal. There are no pleural effusions or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
CHEST (PORTABLE AP); [**2143-7-11**] 9:25 AM
IMPRESSION: Increasing left lower lung consolidation consistent
with edema
Study Date of
CHEST (PORTABLE AP); [**2143-7-11**] 10:49 AM
FINDINGS: Single portable view of the chest shows an ET tube to
be in proper position. There is an oropharyngeal tube whose port
is seen within the region of the stomach. The previously seen
consolidation of the left lower lung has resolved. Again,
consistent with resolving edema. Post-surgical changes as
described previously.
IMPRESSION: Appropriate ET tube placement
CT TRACHEA W/O C W/3D REND [**2143-7-15**] 9:12 AM
Reason: Evaluate for tracheobronchomalacia
IMPRESSION:
1. No dynamic changes of the tracheobronchial tree on dynamic
expiration
versus inspiratory series.
2. Interval development of multifocal ground-glass
opacification, compatible with multifocal pneumonia.
3. Interval improvement though with small residual fluid
collection in the
right lateral chest wall.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 52354**] is a 65 year old woman with recurrent lung CA s/p
multiple lobectomies (LLL, lingula, RUL, R superior seg)
admitted to the MICU with respiratory distress 5 days s/p
Y-stent placement.
# Y-stent occlusion/respiratory distress - The patient presented
with respiratory distress in the setting of recent bronchial
Y-stent placement. Bronchoscopy demonstrated partial occlusion
of branching bronchi and the stent was removed; however, the
patient remained tachypneic and continued to have non-productive
cough. At this point, the patient was afebrile and without
leukocytosis and had a CXR without clear focal opacities. For 24
hours following bronchoscopy, the patient had intermittent
episodes of acute dyspnea and tachypnea with loud expiratory
upper airway sounds requiring intubation. Given high suspicion
for upper airway process, bronchoscopy and direct vocal cord
visualization was performed, which demonstrated infraglottic
edema/ulceration. The patient was treated with IV dexamethasone
TID, nebulizers, racemic epinephrine, and heliox. She improved
and was extubated and then remained stable >24hrs in the MICU
prior to transfer to the medicine service. After 5 days of
dexamethasone 10mg TID, steroids were tapered over two days. The
patient sometimes required albuterol nebulizers and O2 by NC
while on the medicine service. With extensive walking including
stairs, the patient's oxygen saturation did not drop below 96%
and thus did not meet requirements for home oxygen. PT evaluated
and recommended outpatient pulmonary rehab, which was arranged
for after discharge. She was walking and sleeping comfortably
without supplemental oxygen on the day of discharge.
.
The patient had evidence of intermittent airway closure with
respiration seen during bronchoscopy and was started on bi-pap
at night. A dynamic airway CT to evaluate for
tracheobronchomalacia did not show dynamic changes of the
tracheobronchial tree on dynamic expiration versus inspiratory
series. Continuing bi-pap was recommended by interventional
pulmonology due to closure seen during bronchoscopy; however,
the patient would not tolerate bi-pap while sleeping and it was
discontinued. An outpatient evaluation for OSA was recommended
after discharge, as outpatient positive pressure ventilation
would not be covered by insurance without this study.
.
# MRSA positive sputum cultures
The patient developed a leukocytosis to 13.7 on the day after
admission and sputum cultures obtained during bronchoscopy grew
out MRSA. A course of 8 days Vancomycin IV was completed prior
to discharge and leukocytosis resolved. On discharge, the
patient was started on a 6 day course of bactrim to continue
treating positive MRSA cultures per thoracic surgery
recommendations.
.
# History of pulmonary embolism
The patient is on home warfarin for history of PE. She was
transitioned to lovenox prior to bronchoscopy. Lovenox was held
for the bronchoscopies and restarted following the procedures.
She was bridged to warfarin for DVT prophylaxis after transfer
to the medicine service. On discharge, PT was 1.7. She was
instructed to have her PT/INR checked the day after discharge
and to continue SQ lovenox until instructed that INR was
therapeutic by primary care clinic. The patient was discharged
on her normal home warfarin dosing with possible changes
implemented by her primary care clinic pending results of PT/INR
the day after discharge.
.
# Anemia/thrombocytopenia
The patient developed both anemia and thrombocytopenia after ICU
admission. HCT fell from 37 on admission to 28; Plts fell from
172 to 111. Thrombocytopenia resolved with plts of 189 on the
day of discharge. Anemia improved to HCT of 33 on the day of
discharge.
.
# Tongue swelling/throat itching
Patient reported symptoms possibly associated with restarted
warfarin dose, though she had taken warfarin chronically prior
to admission. The symptoms never caused respiratory distress or
changes appreciable on physical exam. Symptoms may have been due
to anxiety and improved on subsequent days prior to discharge.
.
# Bradycardia ?????? The patient had an episode of bradycardia in the
ICU in the setting of propofol. This did not reoccur in the ICU
or after transfer to the medicine service.
.
# GERD
The patient was treated with IV PPI for GERD and switched to PO
PPI prior to discharge. She sometimes required additional PRN
maalox for GERD.
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 3 ml inhaled via nebulizaiton every six (6) hours
as needed for shortness of breath or wheezing
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs inhaled a4h prn for SOB or wheezing
LEVOTHYROXINE [SYNTHROID] - 75 mcg Tablet - 1 Tablet(s) by mouth
once a day
WARFARIN - 1 mg Tablet - 2 to 3 Tablet(s) by mouth daily or as
directed based on INR
Medications - OTC
SENNOSIDES-DOCUSATE SODIUM - 8.6 mg-50 mg Tablet - 1 (One)
Tablet(s) by mouth twice a day as needed for constipation
ACETAMINOPHEN PRN pain
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
Disp:*QS * Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO Twice
daily as needed as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. warfarin 1 mg Tablet Sig: 2-3 Tablets PO once a day: 2
tablets M,W,F; 3 tablets TU,TH,[**Last Name (LF) **],[**First Name3 (LF) **].
9. guaifenesin 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1)
Tablet, ER Multiphase 12 hr PO BID (twice a day) as needed as
needed for cough, sputum.
10. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
11. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous every twelve (12) hours: Take this medication until
your INR is [**1-3**]. .
12. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY DIAGNOSES
# Airway obstruction
# MRSA Pneumonia
SECONDARY DIAGNOSES
# Anemia
# Thrombocytopenia
# History of DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent; with pulmonary
limitations
Discharge Instructions:
Dear Ms. [**Known lastname 52354**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
because you had difficulty breathing which was likely due to
problems with the [**Name (NI) 7935**] that had recently been placed to keep
your airway open. The stent was removed and you were treated
with antibiotics for a pneumonia, steroids for airway
inflammation, and an acid blocking medication for ulcers in your
airway. You will be discharged home today with outpatient
pulmonary rehabilitation and follow-up with multiple providers.
MEDICATION CHANGES
START Bactrim DS 1 tab twice per day for 6 more days
START Pantoprazole 40mg twice per day for your airway
ulcerations
START Guaifenesin 1200mg twice per day as needed for cough or
sputum
START Enoxaparin 60mg subcutaneous injection every 12 hours
until your INR is therapeutic
CONTINUE Warfarin: You will need to get your INR checked
tomorrow. You should take your usual home schedule of 2mg on
M,W,F; 3mg on T,TH,[**Last Name (LF) **],[**First Name3 (LF) **] unless you get different directions
from your primary care clinic after your INR is checked.
Followup Instructions:
Please follow-up with all of your outpatient appointments
scheduled below:
1. Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2143-7-23**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
2. Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2143-7-23**] at 11:00 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: EAST Best Parking: [**Street Address(1) 592**] Garage
3. Provider: [**Name (NI) 2482**] [**Name (NI) 2483**], PT, CCS Phone:[**Telephone/Fax (1) 2484**]
WEDNESDAY [**7-24**] 2:45
4. Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED
When: MONDAY [**2143-7-29**] at 10:50 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, MPH [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
5. Department: OTOLARYNGOLOGY-AUDIOLOGY
When: MONDAY [**2143-7-29**] at 2:30 PM
With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
*There is a shuttle that goes to this location from the [**Location (un) **]
office. Check with your PCP if you are interested in using this.
6. Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2143-8-22**] at 10:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
7. Department: MEDICAL SPECIALTIES
When: THURSDAY [**2143-8-22**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"42789",
"53081",
"4019",
"2724",
"51881",
"2859",
"2875"
] |
Admission Date: [**2119-12-14**] Discharge Date: [**2119-12-19**]
Date of Birth: [**2055-5-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tetanus Toxoid,Adsorbed
Attending:[**Known firstname 922**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2119-12-14**] Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending coronary artery;
reversed saphenous vein single graft from the aorta to the first
obtuse marginal coronary artery; reverse saphenous vein single
graft from the aorta to the distal right coronary artery.
Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
64 year old male with failed kidney allograft referred for
cardiac catheterization as part of evaluation for kidney
transplant. His cardiac catheterization revealed severe three
vessel disease.
Past Medical History:
Hypertension
Polycystic kidney disease/End-stage renal disease with Kidney
Allograft failure and Hemodialysis MWF -> Right Subclavian
tunneled catheter and a non-matured left arm AV fistula
Gout
Anemia
Incarcerated Hernia as an infant (Surgically repaired)
Skin cancer s/p excision on back
Social History:
He is married to [**Doctor First Name 2013**], with 2 adult children who live locally.
He works in a sales position in own company. He denies any
alcohol, drug use or smoking.
Family History:
Mother and son with PKD.
Physical Exam:
Pulse:77 Resp:16 O2 sat: 95%RA
B/P Right: 119/72 Left: NO BP
Height: 5'7" Weight:200 lbs
General: WDWN in NAD
Skin: Dry, warm and intact. Right forearm is warm to palpation
with mild erythema. It is tender to touch. Right radial
ecchymosis at puncture site from cath. Left wrist AV fistula
with
minimal thrill.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, No M/R/G
Abdomen: Obese, Soft [X] non-distended [X] non-tender [X] bowel
sounds + [X] RLQ renal transplant incision well healed. No
hepatosplenomegaly.
Extremities: Warm [X], well-perfused [X] Trace->1+ Edema (B)
Varicosities: None noted on standing. Some minor superficial
varicosities noted which don't seem to be related to GSV system.
Neuro: Grossly intact, MAE, Strength 5/5
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 1+ Left: +Thrill
Carotid Bruit: Right: + Bruit Left: Question very faint bruit
Pertinent Results:
[**2119-12-18**] 05:05AM BLOOD Hct-29.0*
[**2119-12-17**] 08:00AM BLOOD WBC-4.8 RBC-3.06* Hgb-8.8* Hct-27.8*
MCV-91 MCH-28.6 MCHC-31.5 RDW-16.6* Plt Ct-174
[**2119-12-14**] 11:55AM BLOOD WBC-5.6 RBC-3.39*# Hgb-9.8*# Hct-31.1*
MCV-92 MCH-29.1 MCHC-31.7 RDW-16.1* Plt Ct-125*
[**2119-12-18**] 05:05AM BLOOD PT-17.3* INR(PT)-1.6*
[**2119-12-17**] 08:00AM BLOOD Plt Ct-174
[**2119-12-14**] 11:55AM BLOOD Plt Ct-125*
[**2119-12-14**] 11:55AM BLOOD PT-16.0* PTT-29.7 INR(PT)-1.4*
[**2119-12-14**] 11:55AM BLOOD Fibrino-501*
[**2119-12-18**] 05:05AM BLOOD UreaN-37* Creat-6.3*# K-4.5
[**2119-12-17**] 05:22AM BLOOD Glucose-112* UreaN-41* Creat-7.4*# Na-141
K-4.7 Cl-102 HCO3-27 AnGap-17
[**2119-12-14**] 01:32PM BLOOD UreaN-34* Creat-6.8*# Cl-110* HCO3-24
[**2119-12-17**] 05:22AM BLOOD Calcium-8.8 Phos-5.5*# Mg-2.6
[**Known lastname 26413**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 26414**] (Complete)
Done [**2119-12-14**] at 11:54:38 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**Known firstname 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2055-5-5**]
Age (years): 64 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Coronary artery disease. Left
ventricular function. Mitral valve disease. Right ventricular
function. Valvular heart disease.
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2119-12-14**] at 11:54 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Normal LV
cavity size. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). No AS. Mild (1+) AR. Eccentric AR
jet.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
thickening of mitral valve chordae. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
PRE-BYPASS: 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 is seen by 2D
or color Doppler. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric. The mitral valve leaflets are moderately thickened.
Trivial mitral regurgitation is seen. There is no pericardial
effusion.
POST CPB:
1. Preserved [**Hospital1 **]-ventricular systolic function.
2. No change in vemvular structure or function
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2119-12-14**] 12:26
Brief Hospital Course:
He was admitted same day surgery and underwent coronary artery
bypass graft surgery. Please see operative report for further
details. He was transferred to the intensive care unit for post
operative management. In the first twenty four hours he was
weaned from sedation, awoke neurologically intact and was
extubated without complications. On post operative day one he
was transferred to the floor for the remainder of his care.
Renal was consulted for renal disease and dialysis. Physical
therapy worked with him on strength and mobility. He was ready
for discharge home on post operative day five with plan for
dialysis [**2119-12-21**] at outpatient dialysis.
Medications on Admission:
Amlodipine 5mg po BID
Calcium Acetate 667mg cap 4 capsules po TID
Cincalcet 30mg po daily (Tx secondary hyperparathyroidism in
CKD)
Colchicine 0.6mg po daily
Furosemide 80mg po BID
Leflunomide 20mg po BID
Metoprolol Tartrate 75mg po BID
**Warfarin 5mg po daily - stopped last week for cath (This was
to
maintain patency of HD Catheter)
Phoslo 463mg tab, 3 tablets po TID
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 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:*0*
4. Leflunomide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*360 Capsule(s)* Refills:*0*
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a week
: monday and thrusday .
Disp:*10 Tablet(s)* Refills:*0*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose
changes based on INR - please have checked at HD [**12-21**] for
further dosing .
Disp:*60 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*0*
13. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6011**] Care
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
Hypertension
Polycystic kidney disease
Kidney Allograft failure
Hemodialysis MWF -> Right Subclavian tunneled catheter and a
non-matured left arm AV fistula - on coumadin for tunnel line
Gout
Anemia
Incarcerated Hernia as an infant (Surgically repaired)
Skin cancer s/p excision on back
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol prn
Discharge Instructions:
Please wash daily (no shower due to tunnel line per renal)
including washing incisions gently with mild soap, no baths or
swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr.[**Last Name (STitle) 914**] - tuesday [**1-23**] at 1:30pm [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) **] in [**12-30**] weeks
Cardiologist Dr. [**Last Name (STitle) **] in [**12-30**] weeks
Nephrology Dr [**Last Name (STitle) 17315**] ([**Telephone/Fax (1) 26415**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
PT/INR for coumadin dosing to be done with dialysis and further
lab draws and dosing done at dialysis (Dr [**Last Name (STitle) 17315**] nephrologist)
Completed by:[**2119-12-19**]
|
[
"41401",
"40391",
"2767",
"2859",
"V5861"
] |
Admission Date: [**2196-10-26**] Discharge Date: [**2196-11-4**]
Date of Birth: [**2122-3-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
BenGay
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
Ascending aorta and hemiarch replacement [**2196-10-28**]
History of Present Illness:
Mr. [**Known lastname 32296**] is a 74 year old male who was seen by Dr. [**Last Name (STitle) **] for
an aortic aneurysm that was incidently found 1 year ago. A
recent CT scan of his aorta showed his aneurysm to measure 5cm
where it was 4.8cm in [**2195-8-6**]. Given the progression of his
disease, he was referred to Dr. [**Last Name (STitle) 914**] for consultation. His
review determined aorta to be 5.2 cm. he will need will need his
aneurysm repair prior to hip surgery.
Past Medical History:
Aortic aneurysm
AV block Mobitz 1
Remote pericarditis
Jaundice as a teenager
Osteoarthritis
BLE varicosities
Dyslipidemia
Hypertension
Migraines
Chronic back pain
Depression
Sleep apnea ( has not been able to use CPAP in past)
Atrial fibrillation
Vitamin D Defficiency
One kidney from a remote injury playing football
Occasional testicular pain ( Rx neurontin)
Ventral hernia
Left Nephrectomy at age 15
Appendectomy
Back surgery for ruptured disc
Hand surgeries
Partial Left knee replacement [**6-14**]
Social History:
Mr. [**Known lastname 32296**] lives with his wife and is a retired banker. He
smoked his last cigarette 40 yrs ago and has a 40-45 pack-year
history. He drinks 2-7 alcoholic beverages per week.
Family History:
non-contributory
Physical Exam:
Pulse: 54 Resp: 18 O2 sat: 98%
B/P Right:121/80 Left: 124/79
Height: 5'[**96**]" Weight: 215 lbs
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera, OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD appreciated
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [] grade _-none_____
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]; no HSM
Extremities: Warm [x], well-perfused [x] Edema [] _none____
Varicosities: severe BLE
Neuro: Grossly intact [x]; MAE 5./5 strengths; nonfocal exam
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: Left:
Carotid Bruit Right: none Left:none
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 87122**] (Complete)
Done [**2196-10-28**] at 9:24:12 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2122-3-30**]
Age (years): 74 M Hgt (in): 61
BP (mm Hg): 124/79 Wgt (lb): 215
HR (bpm): 63 BSA (m2): 1.95 m2
Indication: Aortic valve disease. Atrial fibrillation. Left
ventricular function.
ICD-9 Codes: 427.31, 424.1, 441.2
Test Information
Date/Time: [**2196-10-28**] at 09:24 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW3-: Machine: us3
Echocardiographic Measurements
Results Measurements Normal Range
Right Atrium - Four Chamber Length: *6.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Lateral Peak E': 0.80 m/s > 0.08 m/s
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.8 cm <= 3.0 cm
Aorta - Ascending: *4.8 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Pressure Half Time: 887 ms
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No
spontaneous echo contrast in the body of the RA. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild regional LV systolic dysfunction. Low
normal LVEF.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Mildy dilated aortic root. Moderately dilated ascending
aorta Normal aortic arch diameter. Simple atheroma in aortic
arch. Mildly dilated descending aorta. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Mild to
moderate ([**2-7**]+) AR. Eccentric AR jet directed toward the
anterior mitral leaflet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**2-7**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: Pericardial calcifications.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient. See Conclusions for post-bypass
data
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The right atrium is moderately dilated. No
spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the mid inferior septal wall. The remaining
segments contract normally (LVEF =55X %). Overall left
ventricular systolic function is low normal (LVEF 50-55%). with
normal free wall contractility.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is moderately dilated. There are simple atheroma
in the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. There is no aortic
valve stenosis. Mild to moderate ([**2-7**]+) aortic regurgitation is
seen. The aortic regurgitation jet is eccentric, directed toward
the anterior mitral leaflet.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There are pericardial calcifications.
Dr. [**Last Name (STitle) 914**] was notified in person of the results before
surgical incision
POST-BYPASS:
Preserved biventricular sytolic function.
Intact thoracic aortic graft.
No new valvular findings.
Mild AI.
LVEF 55%
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2196-10-28**] 19:16
[**2196-11-2**] 06:23AM BLOOD WBC-8.2 RBC-3.41* Hgb-10.2* Hct-30.4*
MCV-89 MCH-29.9 MCHC-33.5 RDW-15.0 Plt Ct-191
[**2196-11-2**] 06:23AM BLOOD PT-14.0* INR(PT)-1.2*
[**2196-11-2**] 06:23AM BLOOD UreaN-34* Creat-1.1 Na-138 K-3.8 Cl-97
[**2196-11-3**] 04:58AM BLOOD WBC-8.1 RBC-3.60* Hgb-11.1* Hct-31.9*
MCV-89 MCH-30.9 MCHC-34.9 RDW-15.2 Plt Ct-218
[**2196-11-3**] 04:58AM BLOOD PT-14.6* INR(PT)-1.3*
[**2196-11-3**] 04:58AM BLOOD UreaN-30* Creat-1.2 Na-141 K-4.3 Cl-100
Brief Hospital Course:
On [**10-26**] Mr. [**Known lastname 32296**] was admitted for cardiac catheterization in
preparation for an ascending aneurysm repair scheduled for the
following day. This study revealed no significant coronary
artery disease. On [**10-28**] he underwent an ascending aorta and
hemiarch replacement, performed by Dr. [**Last Name (STitle) 914**]. Please see the
operative note for details. He tolerated this procedure well
and was transferred in critical but stable condition to the
surgical intensive care unit. He extubated on the following day
but woke agitated and therefore received haldol. Over the next
couple of days his mental status started to clear and hid QTc
prolonged, so haldol was discontinued. Coumadin was restarted
for atrial fibrillation. His epicardial wires and chest tubes
were removed. He was transferred to the step down floor and
seen in consultation by the physical therapy service. By
post-operative day six he was ready for discharge to [**Location (un) 582**] at
[**Hospital 7658**] Rehab. The patient's expected length of stay is less
than 30 days. All appropriate follow-up appointments were
advised.
Medications on Admission:
Fiorcet 50-325mg prn
Percocet 5/325mg Three times daily
Aspirin 81mg daily
Cyclobenzaprine10mg daily
Coumadin 5mg daily for afib
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. ezetimibe 10 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. atorvastatin 40 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. gabapentin 300 mg Capsule [**Hospital **]: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
5. furosemide 20 mg Tablet [**Hospital **]: Two (2) Tablet PO once a day for
10 days.
Disp:*20 Tablet(s)* Refills:*2*
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals [**Hospital **]:
Two (2) Tablet, ER Particles/Crystals PO once a day for 10 days.
Disp:*20 Tablet, ER Particles/Crystals(s)* Refills:*2*
7. Coumadin 2.5 mg Tablet [**Hospital **]: Two (2) Tablet PO once a day: or
as directed by the office of Dr. [**Last Name (STitle) 82226**] [**Name (STitle) **] [**Telephone/Fax (1) 87123**],
ask for [**Doctor First Name **] or [**Doctor First Name **].
Disp:*60 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
INR check on [**11-4**] with results to the office of Dr. [**Last Name (STitle) 82226**]
[**Name (STitle) **] [**Telephone/Fax (1) 87123**], ask for [**Doctor First Name **] or [**Doctor First Name **]. INR goal for
afib is 2-2.5
9. tramadol 50 mg Tablet [**Doctor First Name **]: One (1) Tablet PO every four (4)
hours as needed for pain.
10. docusate sodium 100 mg Capsule [**Doctor First Name **]: One (1) Capsule PO BID
(2 times a day).
11. magnesium hydroxide 400 mg/5 mL Suspension [**Doctor First Name **]: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. acetaminophen 325 mg Tablet [**Doctor First Name **]: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
13. bisacodyl 10 mg Suppository [**Doctor First Name **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Doctor First Name **]: One (1) Inhalation Q6H (every 6 hours).
15. ipratropium bromide 0.02 % Solution [**Doctor First Name **]: One (1) Inhalation
Q6H (every 6 hours).
16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
18. lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) 7658**]
Discharge Diagnosis:
Aortic aneurysm, AV block Mobitz 1, remote pericarditis,
jaundice(teenager), osteoarthritis, BLE varicosities,
Dyslipidemia, Hypertension, Migraines, Chronic back pain,
Depression, Sleep apnea, Atrial fibrillation, Vitamin D
Deficiency, One kidney(remote injury playing football), occ.
testicular pain(Rx neurontin), ventral hernia
PSH: Left Nephrectomy(15yo), Appendectomy, Back surgery-ruptured
disc,
Hand surgeries, Partial Left knee replacement([**6-14**])
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
No Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] on [**12-13**] at 2:00pm
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] ([**Location (un) **])on [**11-25**] at 11:30am
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**Last Name (STitle) **] [**Telephone/Fax (1) 82227**] in [**5-10**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin for afib
Goal INR 2-2.5
First draw [**11-4**]
Results to phone [**Telephone/Fax (1) 87123**], ask for [**Doctor First Name **] or [**Doctor First Name **] [**First Name8 (NamePattern2) **]
[**Doctor First Name **]
Completed by:[**2196-11-3**]
|
[
"5119",
"4168",
"4019",
"2724",
"42731",
"V5861",
"496"
] |
Admission Date: [**2143-7-22**] Discharge Date: [**2143-8-2**]
Service: MEDICINE
Allergies:
Coreg Cr
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
Drop in HCT and generalized weakness
Major Surgical or Invasive Procedure:
Selective coronary artery angiography with right and left heart
catheterization and percutaneous coronary intervention
History of Present Illness:
Ms. [**Known lastname 48684**] was admitted to the medical floor after presenting
with a drop in her Hct and generalized weakness x 1 week. In the
ED her initial vitals were T 98 BP 134/73 AR 82 RR 18 O2 sat 98%
RA. Denies bloody or black tarry stools. Upon transfer to the
medical floor, she became acutely SOB. Her BP was 170/90 with
oxygen saturation of 84-85% on RA. Cxray at the time consistent
with pulmonary edema. She was given Lasix 20mg IV x2 and
Morphine with mild improvement in her symptoms. She was
transferred to the MICU for non-invasive ventilation and closer
monitoring. ABG at this time was 7.34/44/56. She was immediately
placed on non-invasive ventilation.
.
Upon further questioning the patient denies any fevers, chills,
chest pain, SOB, PND, or orthopnea. She does admit to increasing
LE edema over the past several days. She has been compliant with
all her medications.
Past Medical History:
1)CAD s/p MI ([**2115**], [**2120**])
2)Monomorphic VT s/p ablation
3)Hypertension
4)Hyperlipidemia
5)OSA on BiPap
6)Diabetes mellitus, type 2
7)Osteoporosis
8)Recent shingles
10)Vertigo
Social History:
No history of alcohol use. Smoked 3pks/day for 30yrs, quit 25yrs
ago.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Physical Exam:
vitals T 93 BP 153/85 AR 101 RR 26 O2 sat 87% NRB
Gen: Patient in severe respiratory distress, breathing rapidly
HEENT: MMM
Heart: Distant heart sounds
Lungs: Course breath sounds throughout
Abdomen: soft, NT/ND, +BS
Extremities: [**11-27**]+ pitting edema bilaterally
Rectal: Guiac positive
Pertinent Results:
[**2143-7-23**] 10:15AM BLOOD WBC-6.4 RBC-3.59* Hgb-10.5* Hct-31.2*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.3 Plt Ct-190
[**2143-7-24**] 05:00AM BLOOD PT-15.5* PTT-35.7* INR(PT)-1.4*
[**2143-7-23**] 04:41PM BLOOD Glucose-165* UreaN-15 Creat-0.8 Na-128*
K-3.4 Cl-90* HCO3-29 AnGap-12
[**2143-7-23**] 12:40AM BLOOD CK(CPK)-48
[**2143-7-23**] 10:15AM BLOOD CK(CPK)-57
[**2143-7-23**] 04:41PM BLOOD CK(CPK)-54
[**2143-7-22**] 02:40PM BLOOD Calcium-8.8 Phos-4.0 Mg-1.9
[**2143-7-23**] 12:40AM BLOOD VitB12-839
[**2143-7-23**] 01:19AM BLOOD Type-ART pO2-56* pCO2-44 pH-7.34*
calTCO2-25 Base XS--2
.
[**2143-7-22**] EKG:
Technically difficult study
Probable sinus arrhythmia
First degree A-V block - intraventricular conduction delay
Late R wave progression - consider anterior myocardial
infarction
QT interval prolonged for rate
ST-T wave changes are nonspecific
Since previous tracing of [**2143-5-13**], QTc interval may be
miscalulated on last tracing
.
[**7-23**] CXR:
FINDINGS: Comparison to the previous study from [**2143-7-23**] at
8:16 a.m. Interstitial densities in the lungs bilaterally are
essentially unchanged or slightly worse compared to the previous
exam, possibly reflecting mild worsening in pulmonary edema. The
cardiomediastinal silhouette is unchanged. Retrocardiac opacity
is compatible with consolidation and/or atelectasis. There is a
left-sided pleural effusion. No pneumothorax is seen. Hilar
contours are stable. Osseous structures are within normal
limits.
IMPRESSION:
Slight increase in interstitial markings is compatible with
slightly worsened pulmonary edema. Retrocardiac opacity
compatible with consolidation and/or atelectasis. Left-sided
pleural effusion, stable.
.
[**2143-7-24**] Cardiac cath:
COMMENTS:
1. Coronary angiography in this right-dominant system revealed
two-vessel disease.
--The LMCA had no angiographically apparent disease.
--The mid-LAD had a 60% tubular lesion with a small aneurysm.
--The LCx had no angiographically apparent disease.
--The RCA was a large dominant vessel with a complex 90%
stenosis in the
mid-RCA.
2. Resting hemodynamics revealed mildly elevated RVEDP of 9
mmHg.
Elevated left-sided filling pressures were observed, with a PCWP
mean of
20 mmHg. There was mild pulmonary arterial systolic
hypertension with
PASP of 39 mmHg. The PVR was mildly elevated at 168
dynes-sec/cm5. The
SVR was within normal limits at 1053 dynes-sec/cm5. Systemic
arterial
pressures were normal. The cardiac index was preserved at 2.6
L/min/m2.
3. Successful PTCA and stenting of the mid RCA with a Driver
(3.5x24mm)
bare metal stent which was postdilated to 3.75 mm. Final
angiography
revealed a focal 10% residual stenosis, no angiographically
apparent
dissection and TIMI III flow (See PTCA comments).
FINAL DIAGNOSIS:
1. Two-vessel coronary artery disease.
2. Elevated left-sided filling pressures
3. Mild pulmonary arterial systolic hypertension.
4. Successful PTCA and stenting of the mid RCA vessel with a
bare metal
stent.
5. Patient should be maintained on aspirin 325mg daily.
Patient should
also remain on plavix 75mg po daily for a minimum of 1 month,
preferably
3-6 months.
.
[**2143-7-25**] ECHO:
The left atrium is mildly dilated. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 25 %). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2143-5-2**],
left ventricular function appears similar.
.
[**7-29**] CXR:
There is continued mild congestive failure, although this
appears to be slightly improved since the prior study. There is
continued moderate opacification of the right upper lobe, which
could represent focal pneumonia. The heart is mildly enlarged.
Small right pleural effusion, improved with residual minimal
blunting of the right costophrenic angle.
IMPRESSION:
1. Improved congestive failure.
2. Right upper lobe infiltrate concerning for pneumonia.
.
Labs on discharge:
WBC 3.8
HCT 30.2
PLTs 205
INR 2.1
Glucose UreaN Creat Na K Cl HCO3 AnGap
119* 18 0.8 130* 3.4 91* 30 12
HgA1c 6.7
TSH 28
Ft4 0.78
Brief Hospital Course:
Ms. [**Known lastname 48684**] is an 84yo female with PMH significant for CAD, DM
2, and HTN who originally presented for work up for low Hct and
weakness. She subsequently became acutely SOB on the floor and
was found to have flash pulmonary edema. Pt was transferred to
the MICU. An EKG showed new ST depressions in the inferior leads
suggestive of underlying ischemia. Pt was started on heparin
gtt, and her asa, BB were continued. At that time, pt refused
any interventional measures such as a cath. Subsequently, pt
had a recurrent episode of SOB and tachypnea and found to have a
recurrent episode of pulmonary edema. The EKG showed new T wave
inversions in teh anterior/septal leads. Pt was treated with
Lasix, morphine, nitro and asa and the heparin gtt continued. Pt
evaluated by cardiology and an echo was performed she went to
cath were a BMS was placed in her RCA.
.
NSTEMI: BMS to RCA. Peak CK 57, peak trop 0.07. Initially on
ASA/plavix/heparin but was crossed over from heparin to coumadin
(given h/o PE) and ASA stopped as her hct was trending down and
she was found to have guiac + stool (has not had a colonoscopy).
Never had chest pain during her hospital course. Continued on
Atorvastatin 40 mg daily.
.
Blood-loss and iron-deficiency anemia: Patient was initially
admitted to [**Hospital1 **] given drop in Hct from low 30's to 28. In
addition, she has been feeling more weak and tired. Per OMR and
patient, she has not had a colonscopy. Vitamin B12 levels
suboptimal in the past (<200) but currently not on any
supplements. Guiac positive on admission. She was transfused 2
U PRBC w/ appropriate bump in hct. Iron supplementation was
started. MMA level pending on discharge. Hematocrit should be
followed as an outpatient and consideration for colonscopy
should be discussed.
.
Leukopenia: she was noted to be leukopenic with WBC count as low
as 2.4 during hospital course (ANC 1650). Hematology was
consulted and no cause for her leukopenia could be identified
except for possibly captopril use.
- Her WBC could should continue to be followed as an outpatient
w/ hematology follow-up.
.
Hypothyroidism: she was found to have TSH of 20 with a FT4 of
0.78. Endocrine was consulted and she was started on
Levothyroxine 25 mcg daily, to be increased to 50 mcg daily in 2
weeks. Likely from amiodarone. Will follow-up with Dr.
[**Last Name (STitle) **] in clinic in 8 weeks. Anti TPO and anti TG antibodies
were neg. Antiparietal cell AB neg.
.
Hyponatremia: Patient presented with Na of 123. Per OMR, this is
a chronic problem for the patient and likely [**12-28**] CHF. Her Na
has decreased to as low as 122 on a prior admission. Her level
improves once she is appropriately free water restricted.
- Free water restriction~1-1.5L/day
.
DM2: Oral agents held until 2 days after cath at which point
metformin/glyburide was re-started. SSI was continued prn.
Last HgA1c 6.7.
.
Chronic pulmonary emboli: Patient was found to have incident
pulmonary embolus prior to admission and was subsequently
started on anticoagulation with Coumadin. Concerned whether
acute respiratory decline is due to extension of her PE given
subtherapeutic INR, but less likely now given setting of acute
ischemia that may account for decline in respiratory status.
Therapeutic on coumadin on D/C. O2 sats 98% on RA on discharge.
.
Hypertension: Patient on beta-blocker as outpatient.
Uncontrolled SBPs may have resulted in her acute respiratory
distress.
-switched from metoprolol [**Hospital1 **] to XL, valsartan added with
excellent BP control by discharge.
.
OSA: BiPAP at night with home mask.
.
Anxiety: low dose ativan prn w/ buspirone
Medications on Admission:
Atorvastatin 40 mg
Aspirin 81 mg QD
Metoprolol Tartrate 25 [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Lorazepam 0.5 mg QHS
Amiodarone 400 mg QD
Rosiglitazone 2mg PO daily
Warfarin 2.5mg PO HS
Glyburide-Metformin 5-500mg PO daily
Lasix 3x/week
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Buspirone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): It is very important that you take this every day.
Disp:*30 Tablet(s)* Refills:*2*
4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Glyburide-Metformin 5-500 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
7. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO once a day.
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)): as prescribed for goal INR [**12-29**].
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Oxycodone 5 mg Tablet Sig: [**11-27**] - 1 Tablet PO Q6H (every 6
hours) as needed for pain.
13. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): until [**8-11**], then increase to 50 mcg daily.
Disp:*60 Tablet(s)* Refills:*2*
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. Outpatient Lab Work
Please check TSH, Free T4 one week prior to appointment with Dr.
[**Last Name (STitle) **] and fax result to ([**Telephone/Fax (1) 86540**].
18. Outpatient Lab Work
INR on [**2143-8-5**]
Please fax to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 107964**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1)CAD s/p MI ([**2115**], [**2120**]), now s/p PCI with BMS to RCA
2)Monomorphic VT s/p ablation
3)Hypertension
4)Hyperlipidemia
5)OSA on BiPap
6)Diabetes mellitus, type 2
7)Osteoporosis
8)Recent shingles
10)Vertigo
11)Hypothyroidism
12) Leukopenia
13) Blood-loss Anemia
14) Chronic Pulmonary Emboli
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted with heart failure, which was treated by both
revascularizing your right coronary artery and by diuretics to
improve your breathing.
Please check your weight daily and call your doctor if your
weight increases by more than 3 pounds.
You had a bare metal stent placed in your coronary artery. You
must take Plavix every day for at least the next month to
prevent a clot from forming and causing a severe heart attack or
even death because of this stent. Continue taking the Plavix
until your cardiologist recommends stopping it.
Please seek medical attention immediately if you develop fever,
chills, shortness of breath, chest pain or any other concerning
symptoms.
Followup Instructions:
Call Dr [**Last Name (STitle) **] when you get home for an appointment within the
next week. [**0-0-**].
Please make a follow-up appointment with Dr. [**Last Name (STitle) **]
(Endocrinologist) in 8 weeks to manage your hypothyroidism. Tel
([**Telephone/Fax (1) 9072**]. Please have thyroid function labs drawn 1 week
prior and faxed to ([**Telephone/Fax (1) 86540**].
|
[
"41071",
"2761",
"4280",
"42731",
"41401",
"4019",
"32723",
"25000",
"2449"
] |
Admission Date: [**2181-6-17**] Discharge Date: [**2181-6-21**]
Date of Birth: [**2118-3-10**] Sex: F
Service: MEDICINE
Allergies:
Bactrim DS
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
Chief Complaint: acute SOB
Reason for MICU transfer: suspected PE, sepsis [**3-8**] UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63F w/ recurrent stage IIIC papillary serous ovarian CA on cycle
8 day 14 of carboplatin, gemcitabine, bevacizumab (avastin),
complicated by ureter obstruction requiring left ureteral stent
and right nephrostomy tube. She had a week of SOB PTA but on
[**6-16**] had acute onset of SOB when at home, with fever, without
cough, and no abd pain, no dysuria. Oncologic course has been
complicated by b/l hydronephrosis thought to be [**3-8**] malignancy,
as well as utereral obstructions requiring right nephrostomy
tube.
In the ED, initial VS were: 101 108 158/67 24 100% 2L (highest
temp was 102.3). EKG showed ST 106 incomplete RB on previous,
incomplete L bundle. CTA was deferred due to elevated Cr.
Non-con belly scan was ordered and bedside u/s showed normal
fast, no pericardial effusion, no right heart strain, mild left
hydronephrosis, normal right kidney. She was started on
Vanc/Cefepime and given APAP. Urine from nephrostomy was cloudy;
Foley'd urine was the second drawn. Heparin gtt was commenced
for suspected PE. She had an elevated pro-BNP but normal trop,
and no right axis deviation on ECG or on u/s: was not a
candidate for TPA.
On arrival to the MICU, she does not c/o any pain, but is still
feeling SOB, better when supine as opposed to sitting up. She
denies CP, HA, abdom pain, pain upon deep inspiration, pain in
calves/thighs. Adds that on day of admission, she felt more SOB
fairly abruptly while sitting outside; at baseline, has no h/o
heart problems or SOB when walking. She still urinates and also
has UOP through the nephrostomy tube; is maintaining PO intake
and says she still made urine at home today.
Review of systems:
Per HPI
Past Medical History:
ONCOLOGIC HISTORY:
-- [**2180-2-7**] diagnosed with epithelial ovarian cancer at the time
of
exploratory laparotomy performed by Dr [**Last Name (STitle) 2028**]. Pathology
revealed
stage IIIC poorly differentiated (G3) papillary serous
carcinoma.
Two pelvic lymph nodes and one groin node were involved. There
was no visible disease at the end of the operation.
-- [**2180-2-28**] C1D1 IP Cis/Taxol as per GOG 172
-- [**2180-3-20**] C2D1 IP Cis/Taxol as per GOG 172
-- [**2180-4-10**] C3D1 IP Cis/Taxol as per GOG 172
-- [**2180-5-1**] C4D1 IP Cis/Taxol as per GOG 172
-- [**2180-5-23**] C5D1 IP Cis/Taxol as per GOG 172
-- [**2180-6-12**] C6D1 IP Cis/Taxol as per GOG 172
.
Past Medical History:
HTN.
orthostatic hypotension.
Right femoral hernia repair [**2153**].
Cesarean section.
.
OB/GYN History: G3P3. 2 spontaneous vaginal deliveries and one
cesarean section.
No h/o pelvic infections.
No h/o abnormal pap smears.
Menopause five years ago without complication and no
postmenopausal bleeding.
Social History:
Tobacco: Denies.
Alcohol: Occasional.
Drugs: Denies.
She lives with her husband in [**Name (NI) 5176**], who is an optometrist at
the [**Hospital **] Clinic.
Family History:
Father: colon cancer in his 50s.
Son: testicular cancer at 19, with no evidence of recurrence.
No other family history of cancer.
Physical Exam:
Admission Physical Exam:
Vitals: T: 100 HR: 94 BP: 118/39 100% 2L NC
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 7-8cm, 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, no tenderness to palpation, no rebound or
guarding. Right nephrostomy tube draining yellow urine with some
white clots; entry site is w/o erythema or drainage.
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; no erythema or swelling or tenderness in calves
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
Discharge Physical Exam:
Vitals: 98.8, 136/82, 73, 20, 100% RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 7-8cm, 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, no tenderness to palpation, no rebound or
guarding. Right nephrostomy tube draining clear yellow urine;
entry site is w/o erythema or drainage.
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; no erythema or swelling or tenderness in calves
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2181-6-16**] 09:50PM BLOOD WBC-7.9 RBC-2.45* Hgb-7.8* Hct-24.9*
MCV-102* MCH-31.9 MCHC-31.3 RDW-18.6* Plt Ct-65*#
[**2181-6-16**] 09:50PM BLOOD Neuts-90.8* Lymphs-6.5* Monos-2.6 Eos-0.1
Baso-0.1
[**2181-6-16**] 09:50PM BLOOD PT-11.7 PTT-28.1 INR(PT)-1.1
[**2181-6-17**] 06:41AM BLOOD Ret Aut-0.2*
[**2181-6-16**] 09:50PM BLOOD Glucose-150* UreaN-23* Creat-1.9* Na-140
K-4.3 Cl-104 HCO3-22 AnGap-18
[**2181-6-16**] 09:50PM BLOOD ALT-15 AST-16 LD(LDH)-184 CK(CPK)-34
AlkPhos-94 TotBili-0.3
[**2181-6-16**] 09:50PM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-788*
[**2181-6-17**] 04:18AM BLOOD CK-MB-1 cTropnT-<0.01
[**2181-6-16**] 09:50PM BLOOD Albumin-4.3 Calcium-9.8 Phos-0.7*# Mg-2.0
UricAcd-6.6*
[**2181-6-16**] 09:50PM BLOOD D-Dimer-2249*
[**2181-6-17**] 04:18AM BLOOD Hapto-225*
[**2181-6-16**] 09:50PM BLOOD Lactate-3.0*
[**2181-6-17**] 07:05AM BLOOD Lactate-1.0
[**2181-6-16**] 11:20PM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.009
[**2181-6-16**] 11:20PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
[**2181-6-16**] 11:20PM URINE RBC-27* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
[**2181-6-17**] 12:15AM URINE Hours-RANDOM Creat-67 Na-44 K-36 Cl-40
.
DISCHARGE LABS:
[**2181-6-21**] 06:00AM BLOOD WBC-10.2 RBC-2.51* Hgb-8.1* Hct-24.5*
MCV-98 MCH-32.5* MCHC-33.3 RDW-18.2* Plt Ct-54*
[**2181-6-21**] 06:00AM BLOOD Neuts-80.9* Lymphs-12.2* Monos-6.0
Eos-0.7 Baso-0.1
[**2181-6-21**] 06:00AM BLOOD Plt Ct-54*
[**2181-6-20**] 05:51AM BLOOD Fibrino-470*
[**2181-6-20**] 05:51AM BLOOD Ret Aut-1.6
[**2181-6-21**] 06:00AM BLOOD Glucose-95 UreaN-14 Creat-1.2* Na-143
K-3.9 Cl-108 HCO3-28 AnGap-11
[**2181-6-21**] 06:00AM BLOOD ALT-26 AST-19 LD(LDH)-182 AlkPhos-115*
TotBili-0.2
[**2181-6-21**] 06:00AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
MICROBIOLOGY:
[**2181-6-16**] 10:30 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2181-6-17**]):
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2181-6-17**]):
GRAM NEGATIVE ROD(S).
[**2181-6-16**] URINE CULTURE (Preliminary):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.
.
IMAGING:
[**2181-6-16**] CXR:IMPRESSION: No acute cardiopulmonary abnormality.
[**2181-6-17**] CT abd/pelvis:
IMPRESSION:
1. Worsened left sided hydronephrosis with ureteral stent in
unchanged
position. New stranding around the left kidney is noted which
may represent new inflammation versus forniceal rupture.
Contiued stranding is noted along the course of the left ureter.
3. Urothelial thickening is noted on the right, with increase in
renal pelvis dilation but no gross hydronephrosis.
4. Right groin mass (series 2, image 78) previously identified
as local
recurrence is unchanged in size compared to the prior
examination.
.
-[**6-17**] b/l LENIs:
IMPRESSION: No evidence of deep vein thrombosis either the
right or left
lower extremity.
.
-[**6-17**] VQ scan: Very low likelihood ratio for recent pulmonary
embolism.
MICROBIOLOGY
[**2181-6-16**] 10:30 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT [**2181-6-19**]**
Blood Culture, Routine (Final [**2181-6-19**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final [**2181-6-17**]):
Reported to and read back by NIDHI SUKUL,5/13/12,10:40AM.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2181-6-17**]):
Reported to and read back by NIDHI SUKUL,5/13/12,10:40AM.
GRAM NEGATIVE ROD(S).
[**2181-6-16**] 11:20 pm URINE
**FINAL REPORT [**2181-6-19**]**
URINE CULTURE (Final [**2181-6-19**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- 32 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Brief Hospital Course:
Ms. [**Known lastname 18573**] is a 63F w/ recurrent stage IIIC papillary
serous ovarian CA on cycle 8 day 14 of carboplatin, gemcitabine,
bevacizumab (avastin), and b/l hydronephrosis [**3-8**] ureter
obstruction requiring left ureteral stent and right nephrostomy
tube. She p/w acute onset SOB in the setting of one week of
dyspnea and fatigue, which was initially concerning for PE.
Further w/u ended up ruling out PE, and her SOB was likely in
the context of her fever and GNR bacteremia, which were likely
[**3-8**] urinary source.
.
ACTIVE ISSUES:
.
# Dyspnea: Pt p/w acute onset SOB, and was found to be in sinus
tach with elevated d-dimer and BNP in setting of malignancy,
although bedside u/s showed no e/o R heart strain. She did not
undergo CTA due to elevated Cr, but was started on a heparin gtt
in the ED. Upon admission to [**Hospital Unit Name 153**], she had no Si/Sx of
hemodynamic or respiratory collapse. ACS, PNA or pulmonary edema
were r/o. LENIs were obtained, which were negative. A VQ scan
was subsequently performed, and it was low probability for PE
and the heparin was d/c'd. In the [**Hospital Unit Name 153**] her SOB vastly improved
without further intervention. Her dyspnea was most likely due to
her anemia as she significantly improved after transfusion of 2
units pRBCs for a HCT of 18.
.
# Fevers and UTI: UTI was likely cause for her fevers to 102.3
and diff with 91% PMNs. Pt has a h/o b/l hydronephrosis [**3-8**]
ureter obstruction requiring left ureteral stent and right
nephrostomy tube, and all UA's have been positive with pyuria
and hematuria since [**2-15**]. Upon admission, she again had positive
UA's from both foley and nephrostomy tube. She received
vanc/cefepime in the ED; her past urine Cx's have grown E coli
sensitive to cefepime. Per past urology notes, her R kidney is
not functioning as well as the left, and no other urological
interventions were necessary; she is scheduled for a left stent
change in [**7-17**].
While in the [**Hospital Unit Name 153**], GNRs grew out of her blood Cx from [**6-16**], and
she was continued on cefepime (d1=[**6-16**]), and continued on vanc
(d1=[**6-16**]) given that she has a port. Her urine culture grew coag
+ staph and per Urology, it was recommended to continue treating
the UTI w/o indication for stent removal at this time. Her urine
culture eventually speciated as pansensitive staphylococcus
aureus, and she was transitioned to oral augmentin to compelte a
total 14 day course following discharge. Her blood cultures
speciated as pansensitive E. coli and she was transitined to
oral ciprofloxacin, also to complete a 14 day course, priro to
dishcarge. She remained afebrile and stable on oral antibiotics
for 24 hours prior to discharge.
.
# [**Last Name (un) **]: Baseline Cr is about 1.2-1.3; pt initially p/w Cr 1.9.
Likely prerenal etiology given fever and UTI and FeNa of 0.9%.
She has a h/o obstruction, but had been maintaining good UOP
from urethra and nephrostomy. Her Cr improved in the [**Hospital Unit Name 153**] to 1.4
after 2 units pRBCs, and subsequently improved further to 1.2 by
the time of discharge.
.
# Anemia: Macrocytic anemia with Hct 24.9 and MCV 102 on
admission; baseline Hct is in high 20's. She had no Si/Sx of
active bleeding upon admission, although the pt endorses small
amts of blood in stool while on avastin, known to heme-onc. She
had a 6-point Hct drop after admission to the [**Hospital Unit Name 153**] with no
identified source; her Hct bumped appropriately after 2U PRBC's.
Her stool was guaiac negative.
.
CHRONIC OR INACTIVE ISSUES:
.
# Thrombocytopenia: Most likely [**3-8**] chemo per her primary
oncologist, as per hx of similar s/p chemo and is unlikely HIT
as her platelets were decreased upon admission and before the
initiation of the heparin gtt.
.
# Recurrent stage IIIC papillary serous ovarian CA on cycle 8
day 14 of carboplatin, gemcitabine, bevacizumab (avastin).
.
# HTN: initially held home lisinopril 5mg daily given fevers,
UTI, and [**Last Name (un) **]. Once her creatinine decreased to 1.4, her home
lisinopril was re-started.
Medications on Admission:
Home Medications:
Lisinopril 5mg PO daily
Vitamin D
Colace
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Vitamin D3 Oral
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days: last day [**2181-7-1**].
Disp:*22 Tablet(s)* Refills:*0*
5. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 11 days: last day [**2181-7-1**].
Disp:*22 Tablet(s)* Refills:*0*
6. 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*
7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Disp:*30 Powder in Packet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Eschirichia coli bactermeia
Methicillin sensitive staphylococcus aureus urinary tract
infection
Anemia
Thrombocytopenia
Secondary:
Stage IIIC papillary serous ovarian carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 18573**],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted with shortness of
breath and fevers. You were initially admitted to our intensive
care unit, where you were treated with antibiotics. Your blood
counts were found to be low, and you were given blood
transfusions. You were initally started on a blood thinner to
treat you for a potential blood clot in your lungs, but
subsequent studies showed that you were unlikely to have
developed a blood clot, and the blood thinner was stopped. Your
breathing improved after blood transfusion.
We found that you have an infection in your blood and urine.
You were treated initially with intravenous antibiotics, and
eventually switched to oral antibiotics. You will need to
compelte a course of oral antibiotics as an outpatient. Please
followup with Dr. [**Last Name (STitle) **] in clinic.
We made the following changes to your medications:
STARTED
-Augmentin until [**2181-7-1**]
-Ciprofloxacin until [**2181-7-1**]
-Senna and Polyethylene glycol to help you move your bowels
Please continue taking your other medications as usual.
Please followup with your doctors, see below.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2181-6-25**] at 9:30 AM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2181-6-25**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY CARE UNIT
When: WEDNESDAY [**2181-7-11**] at 9:00 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
Completed by:[**2181-6-23**]
|
[
"5990",
"2859"
] |
Admission Date: [**2118-9-9**] Discharge Date: [**2118-9-16**]
Date of Birth: [**2083-1-26**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Traumatic brain injury
Major Surgical or Invasive Procedure:
Right sided hemicraniectomy
History of Present Illness:
25 y/o man transferred from OSH intubated and sedated, however
not paralyzed. The patient walked into [**Hospital 27217**] hospital at ~
0300 on [**9-9**]/6 after being assaulted in the head with a pipe. At
0330 he started to decompensate, the patient was intubated and a
stat CT head was performed, which showed a
significant amount of SAH, multiple contusions, fx of the left
and right parietal lobes. The patient was subsequently
transferred to [**Hospital1 18**] where he was reassessed and a repeat head
CT was performed.
Past Medical History:
unknown
Social History:
unknown
Family History:
unknown
Physical Exam:
O: BP: 140/P HR: 94
Gen: WD/WN, intubated, sedated with propofol
HEENT: Pupils: equal bilaterally, sluggish 3-2mm
Neck: in C-collar
Lungs: CTA bilaterally.
Cardiac: RRR. .
Abd: Soft, non-distended
Extrem: Warm and well-perfused. No C/C/E.
.
Neuro:
Mental status: intubated, sedated
Orientation: unable to assess
Recall: unable to assess
Language: unable to assess
Naming unable to assess
.
Cranial Nerves:
II: Pupils 3-2mm bilaterally, sluggish.
VII: face with no grossly apparent droop.
.
Motor: not moving any of his extremities
.
Babinski: downgoing toes
Pertinent Results:
Admission Labs:
[**2118-9-9**] 05:05AM WBC-22.9* RBC-5.02 HGB-14.8 HCT-43.2 MCV-86
MCH-29.5 MCHC-34.2 RDW-13.9 PLT COUNT-258
[**2118-9-9**] 05:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2118-9-9**] 05:05AM AMYLASE-65
[**2118-9-9**] 05:05AM GLUCOSE-178* UREA N-15 CREAT-1.1 SODIUM-140
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-18* ANION GAP-21*
[**2118-9-9**] 05:45AM freeCa-1.16
[**2118-9-9**] 06:51AM TYPE-ART TEMP-37 PO2-354* PCO2-43 PH-7.31*
TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED
[**2118-9-9**] 10:51AM PT-14.6* PTT-26.9 INR(PT)-1.3*
.
Admission CT Head:
FINDINGS: There are bilateral extra-axial hemorrhages along the
parietal
convexities, right greater than left. These have mixed density.
The
thickness is up to 2 cm on the right and 1 cm on the left.
There are also
multiple small punctate hemorrhages in the adjacent brain
parenchyma in the parietal lobes. There is a fairly balanced
mass effect with minimal leftward shift of the midline
structures. The basal cisterns are not effaced, and there is no
hydrocephalus. There is fluid in the posterior ethmoid sinuses.
The mastoid air cells are clear. There are comminuted depressed
bilateral fractures of the parietal bones. Degree of depression
is approximately 1 cm on the right and 0.5 cm on the left.
There are large associated subgaleal hematomas. There is also
pneumocephalus with air within the extra-axial hemorrhage on the
right.
.
IMPRESSION:
Bilateral extra-axial hemorrhages. These are probably epidural
hemorrhages, but they may be mixed subdural and epidural
hemorrhages. There are multiple punctate foci of hemorrhage in
the adjacent brain parenchyma as well and associated depressed
bilateral parietal fractures.
.
NOTE ADDED AT ATTENDING REVIEW: I agree with the above, but note
that the
calvarial fragments on the right are depressed at least 1.5cm.
The posterior portion of the skull is not included in the study,
and the possibility of more fractures, perhaps with involvement
of the superior sagittal sinus, cannot be excluded on this study
.
CT C Spine: No evidence of fracture or dislocation
.
CT Chest, Abd, and Pelvis:
1. No evidence of traumatic injury of the torso.
2. 4-mm right middle lobe nodule and 7-mm nodular density of
the right major fissure are nonspecific but no prior study is
available for comparison. CT followup at one year is suggested.
3. Small hepatic cyst.
4. Incidental note of tortuosity of the left anterior
descending coronary
artery. No evidence of atherosclerotic change and the coronary
arteries
appear widely patent. Finding may indicate hypertension and
clinical
correlation is suggested.
5. Well corticated defect of the right transverse process of
the most
superior non-rib-bearing vertebra is likely congenital nonfusion
or a remote fracture.
.
Post Op Head CT:
FINDINGS: The study is compared with non-contrast CT
examination obtained
approximately 4.5 hours earlier. The patient has undergone
interval extensive right frontoparietal craniectomy, with
surgical skin staples and large subcutaneous emphysema and
pneumocephalus, as expected. The moderately large right
parietovertex epidural hematoma has been evacuated, with
resolution of the mass effect on subjacent brain. The left
parietal convexity extra-axial hematoma, which may represent a
combination of vertex epidural and more caudal subdural
hematoma, is unchanged, with similar degree of flattening of the
subjacent gyri, associated with depressed comminuted fractures
of the left parietal bone. There is no overall shift of the
midline structures. There are numerous punctate and ovoid
hemorrhagic foci with small adjacent zones of edema involving
the bilateral parietal convexities likely representing
contusions, though an element of diffuse axonal injury is also
possible. There is also likely a small amount of overlying
subarachnoid blood, at the vertex. No other parenchymal,
extra-axial, or intraventricular hemorrhage is identified. The
basilar cisterns are preserved, with no evidence of downward
transtentorial or uncal herniation. The left sphenoid sinus is
completely
opacified and fluid and air bubbles layer dependently within the
posterior
nasopharynx. No temporal bone or more caudal skull fracture and
no facial
fracture is seen.
.
IMPRESSION: Status post extensive right frontoparietal
craniectomy, with
evacuation of extra-axial, likely epidural, hematoma and relief
of mass
effect. The left parietovertex and convexity extra-axial
hematoma remains,
associated with depressed, comminuted parietal bone fractures,
with similar degree of mass effect and no overall midline shift.
Extensive bilateral parietovertex contusions with possible
element of diffuse axonal injury.
.
CT Head 12 hours post-op
Again seen are post-surgical changes from the patient's right
craniotomy and epidural hematoma evacuation. Foci of
intraparenchymal hemorrhage in the occipital lobes bilaterally
and the left extra-axial hematoma are unchanged. No new areas
of intracranial hemorrhage are identified.
.
[**9-10**] Head CT:
Stable post-surgical changes from epidural hematoma evacuation
and
right parietal craniotomy. Stable appearance of multiple foci
of
intraparenchymal hemorrhage and left extra-axial hematoma. No
new evidence of interval change or areas of new intracranial
hemorrhage.
Brief Hospital Course:
Pt. was taken to the OR emergently on [**9-9**] for right-sided
hemicraniectomy for decompression ,evacuation of epidural
hematoma, and exploration of subdural space. Procedure was
performed without complications and pt. was transferred to the
trauma SICU. Pt. was observed for 24 hours and repeat imaging
of the head and serial neurologic exams were stable. Over the
next 24 hours sedation was weaned and pt. was extubated without
incident. CT C spine was negative for fracture or dislocation
and flexion extension X-rays were negative for subluxation so C
collar was d/ced. 24 hours after extubation pt. was transferred
to the floor. He was continued on Dilantin for seizure
prophylaxis. On the floor he was evaluated by speech therapy,
who felt he could be advanced to a PO diet, and PT and OT, who
recommended acute rehab for further management. On discharge
his Neurologic exam showed full strength in all 4 extremitites,
awake and alert and following commands, with some question of a
left field cut.
Medications on Admission:
unknown
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Traumatic brain injury
Discharge Condition:
Neurologically stable
Discharge Instructions:
Watch incision for redness, drainage, bleeding, swelling, fever
greater than 101.5, neurological changes call Dr[**Name (NI) 9034**] office
Wear helmet at all times when out of bed
Followup Instructions:
Have staples removed at rehab on [**2118-9-19**]
Follow up with Dr [**Last Name (STitle) **] in 4 weeks with a head CT
Completed by:[**2118-9-16**]
|
[
"3051"
] |
Admission Date: [**2188-3-21**] Discharge Date: [**2188-3-27**]
Date of Birth: [**2125-1-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Aztreonam / Latex
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
foot ulcer
Major Surgical or Invasive Procedure:
I&D
I&D with toe amputation
RIJ placed and removal
PICC
History of Present Illness:
Story per record as patient is intubated
63 M with IDDM 2, hx of L foot ulcer, who presents with
worsening L foot pain and swelling, and three days of chills.
He saw his podiatrist who recommended he go to the ED for
admission.
Denies N/V, diarrhea, CP, SOB, Abd pain.
In the ED patient was initially stable, but near midnight was
noted to be more confused, spiked a fever to 101, and became
diaphoretic. He was seen by podiatry who found gas in the
tissues of his foot and decided to take him for emergent
surgery. While he was getting his pre-op CXR, his oxygen
saturations dropped, he started agonal breathing, became blue,
and may have been transiently apneic, and possibly pulseless. A
Code Blue was called. The timing is unclear but he soon began
breathing again on his own, with good femoral pulses. He was
intubated for airway protection and since he was due to go to
the OR. He went to the OR for an I & D and debridement of his L
foot.
.
Patient received 3 liters of NS, Vanco, Clinda, Flagyl, levo.
His lactate was 4.5 so patient was transferred from the OR to
MICU for sepsis.
Past Medical History:
diabetes-with peripheral neuorpathy-on insulin
obstructive sleep apnea,
elevated cholesterol,
depression.
He had a broken neck at age 13 with C1-C2 repair.
He also has some cognitive decline for which she is seeing a
behavioral neurology, Dr. [**First Name (STitle) 6817**].
L index finger pain-s/p steroid injections by Dr.[**First Name (STitle) **]
Social History:
(+) tobacco use x40 years, quit, patient denies past etoh abuse,
although OMR notes indicate past chronic alcohol use. Denies
illicit drug use. Married.
Family History:
non-contributory
Physical Exam:
VS: 97.4 80/53 75 19 100%
HEENT: intubated
Gen: intubated, sedated
CV: RRR, heart sounds distant
Resp: CTA on ant exam
Abd: soft, NT/ND, (+)BS, soft mobile mass in LRQ
Ext: + 2 pulse in R, L with c/d/i dressings, large area of
erythema and warmth from edge of dressings to knee on ant
surface of leg
NEURO: intubated, sedated
Pertinent Results:
Labs:
[**2188-3-20**] 10:20PM BLOOD WBC-10.4 RBC-3.00* Hgb-10.3* Hct-29.4*
MCV-98 MCH-34.2* MCHC-34.9 RDW-13.2 Plt Ct-272
[**2188-3-20**] 10:20PM BLOOD Neuts-80.0* Lymphs-9.5* Monos-8.0 Eos-1.9
Baso-0.5
[**2188-3-27**] 05:39AM BLOOD ESR-84*
[**2188-3-20**] 10:20PM BLOOD Glucose-82 UreaN-17 Creat-0.9 Na-137
K-4.6 Cl-98 HCO3-26 AnGap-18
[**2188-3-21**] 01:00AM BLOOD CK(CPK)-204*
[**2188-3-21**] 01:00AM BLOOD CK-MB-5 cTropnT-<0.01
[**2188-3-27**] 05:39AM BLOOD CRP-52.8*
[**2188-3-21**] 01:05AM BLOOD Lactate-4.5*
.
Foot x-ray [**2188-3-20**]
Large ulcer with extensive subcutaneous gas. Findings are highly
concerning for a gas-forming organism infection. No definite
radiographic evidence of osteomyelitis at this time.
.
CT LOW EXT W/O C LEFT [**2188-3-20**] 11:38 PM
Markedly abnormal appearance to the plantar soft tissues, with
deep ulcer reaching bone in the region of the fourth metatarsal
head. There is extensive subcutaneous emphysema, which may
relate to the reported recent probing and irrigation (noted in
the preliminary report). However, the extensive gas bubbles at
its dorsal aspect, removed from the ulcer, as well as the
intramedullary gas within the fourth metatarsal head are highly
suspicious for osteomyelitis, perhaps with gas-forming organism.
No focal fluid collection is identified.
.
Pathology submittede [**2188-3-21**], report [**2188-3-25**]
SPECIMEN SUBMITTED: LEFT INFECTED 4 METATARSAL AND INFECTED 4
PHRALNAN SPACE 4.
DIAGNOSIS:
Fourth metatarsal: Acute osteomyelitis.
.
Foot x-ray [**2188-3-22**]
There has been an interval osteotomy involving the fourth tarsal
metatarsal joint with soft tissue removal in that region.
Post-surgical changes are again evident in the second and third
metatarsals. The third metatarsal proximal phalanx cortical
margin is not well defined and infection cannot be excluded in
this region.
IMPRESSION: Postoperative changes. Acute osteomyelitis of the
surrounding bones cannot be totally excluded due to osteopenia
in these regions. Recommend followup.
.
Pathology:
Tissue: 4TH TOE (1) PENDING
Brief Hospital Course:
A/P: 63 M with IDDM 2, hx of L foot ulcer, who presents with
worsening L foot pain and swelling, chills, now with elevated
lactate and s/p Code Blue in ED, s/p I & D in OR, MICU admission
for sepsis, repeat I&D with toe amputation on long course of
antibiotics.
.
# Sepsis/foot infection: Most obvious source is his L foot
abscess. Patient off pressors since [**3-21**] in am. Lactate improved
from 4.5 to 1.2 SvO2 77%. Per surgeon, the infection was quite
severe, requiring deep debridement and removal of infected bone.
Pathology of first I&D was consistent with acute osteomyelitis.
A second I&D was performed this time with toe amputation and
pathology is still pending at the time of discharge. The
patient has a history of MRSA and has grown out organisms
resistant to clinda in the past. Blood cx (-) so far. Bone
biopsies were not sent for culture so the patient was treated
with broad coverage antibiotics. ID receommended vanco,
levofloxacin, flagyl for 4-6 weeks. Swab cultures growing out
MSSA, however given allergy to PCN, treated with vancomycin.
Physical therapy recommended home with PT vs rehab and based on
the patient's desire to go home plus good support at home,
patient was discharge with follow up and VNA services.
.
# Resp Failure: Patient intubated after being agonal prior to
arriving in OR. It is unclear whether this was sepsis induced
respiratory failure, fatigue or new PNA. CXR report with
evolving right lower lung field airspace consolidation,
worrisome for pneumonia versus aspiration and also with volume
overload. The patient's antibiotic regimen included vancomycin,
levoquin and flagyl as above. Good response to diuresis. The
patient was extubated without complication, insentive spirometry
was encouraged. O2 was gradually weaned.
.
#Anemia: Low HCT after surgical procedure but stable and vital
signs stable. No need for transfusion. Guaiac negative. Iron
studies consistent with ACD. Patient given iron supplement.
.
#T2 DM: Patient on Lantus and HISS.
.
#CAD: MIBI in [**2184**] no ischemia.
-ASA, statin
.
# Access: PIVs, RIJ. RIJ removed. PICC line in place at time of
discharge.
Medications on Admission:
Ibuprofen PRN
amlodipine 5 mg PO BID
buproprion 150 mg PO TID
Rosuvastin calcium 40 PO QD
Gabapentin 800 mg PO BID
Gabapentin 1200 PO QHS
venlafaxine 150 mg PO BID
insulin SS and glargine 48 U qhs
trazadone 50-150 po QHS
lisinopril 40 PO QD
.
Discharge Medications:
1. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
4. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
5. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed.
6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Insulin Glargine 100 unit/mL Solution Sig: As directed As
directed Subcutaneous at bedtime.
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: As directed
As directed Subcutaneous As directed.
9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 5 weeks: Please draw
trough once weekly.
Disp:*70 gram* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 weeks.
Disp:*105 Tablet(s)* Refills:*0*
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24 () for
5 weeks.
Disp:*840 Tablet(s)* Refills:*0*
13. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): Do not drive or operate heavy
machinery while taking this medication. .
Disp:*10 Patch 72 hr(s)* Refills:*0*
14. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**3-28**]
hours as needed for pain: Do not drive or operate heavy
machinery while taking this medicaiton.
Disp:*45 Tablet(s)* Refills:*0*
15. Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection
once a day as needed for for line flushes as needed: Saline
flushes .
Disp:*60 units* Refills:*0*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Outpatient Lab Work
Vancomycin trough once weekly. Fax results to Dr. [**First Name (STitle) **] at
[**Telephone/Fax (1) 432**]
20. Outpatient Lab Work
First week of [**2188-4-22**], check CBC, BUN, Creatinine, LFTs and
send results to PCP and fax to Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 432**]
21. Heparin Flush 100 unit/mL Kit Sig: Two (2) units Intravenous
once a day: 10 ml NS followed by 2 ml of 100 Units/ml heparin
(200 units heparin) each lumen Daily and PRN. Inspect site every
shift.
.
Disp:*5 week supply* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
- Sepsis
- Osteomyelitis
.
Secondary diagnosis:
- Diabetes mellitus type 2
- Peripheral neuropathy
- Obstructive sleep apnea
- Hypercholesterolemia
Discharge Condition:
Stable, ambulatory with assistance
Discharge Instructions:
You were admitted with a foot ulcer/infection and found to have
sepsis. While in the hospital you had 2 podiatry surgeries and
received antibiotics for the infection. You will need to
continue to receive antibiotics for a total of 6 weeks.
Please take all medications as directed. You will be taking
vancomycin IV twice daily to complete a 6 week course. You will
also take flagyl and levofloxacin as directed for 6 weeks.
You have also been prescribed pain medicaiton. A fentanyl patch
to be replaced every 3 days. Also, percocet as needed for
breakthrough pain. Do not drive or operate heavy machinery
while taking these medications.
If you develop fever, chills, shortness of breath, chest pain,
or any other symptom that concerns you, call your doctor or if
unavailable, go to the emergency room.
Please attend all follow up appointments.
Continue to check your blood sugar regularly and administer
insulin as directed by your doctor. If your blood sugar is less
than 60 or greater than 350, call your doctor.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2188-4-1**] 11:40
Provider: [**Name Initial (NameIs) **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2188-4-16**] 3:30
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2188-5-5**] 10:00
You will need weekly vanco trough, CBC, LFTs, BUN/Cr faxed to
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 432**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
[
"0389",
"51881",
"78552",
"5070",
"2851",
"99592",
"32723",
"2720"
] |
Admission Date: [**2169-7-5**] Discharge Date: [**2169-7-6**]
Date of Birth: [**2108-4-23**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Right lower quadrant pain
Major Surgical or Invasive Procedure:
Diagnostic laparoscopy
History of Present Illness:
This is a 61F with PMH of chronic right lower quadrant pain who
presented for elective laparoscopy. During laparoscopy patient
received 2mg of versed, 200mcg of Propofol and 200mcg of
Fentanyl. She woke up after the procedure at 15.20,
opened her eyes and moved both arms after that she did not
respond or move so neurology was called to rule out stroke.
Past Medical History:
Hypertension
Chronic RLQ pain
Melanoma s/p excision x2
Past Surgical History:
Back melanoma excision x2, L axillary SLNBx ([**Doctor Last Name 519**])
Laparoscopic appendectomy ([**5-/2168**]), tubal ligation
Social History:
Lives with husband. [**Name (NI) 1403**] as an estimator for a sand/[**Doctor Last Name 5691**]
company. Former heavy smoker, social EtOH, no illicits, on
vicodin for pain but takes infrequently and doesn't like to take
it
Family History:
non-contributory
Physical Exam:
VITAL SIGNS - Temp 97.8 F, BP 131/65 mmHg, HR 82 BPM, RR 17 X',
O2-sat 96% RA
GENERAL - well-appearing woman in NAD, comfortable, not
jaundiced (skin, mouth, conjuntiva). Normal breathing pattern.
No dolls eyes.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
cannot assess pharynx or uvula, mouth is closed and cannot open,
TMJ looks good, pupils very dilated up to 6 mm with normal
reflexes; patient does not close or move eyes upon positioning
hand
NECK - supple, no thyromegaly, JVD 7 cm, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. Wounds look clean and with no drainage
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEUROLOGIC:
Mental status: Unresponsive, Not cooperative with exam,
affect not evaluated. Does not follow commands. Eyes closed.
Does not respond to pain (even pressing fingers against metal or
sternal rub). Resists opening jaw
Cranial Nerves:
Pupils equally round and reactive to light, 6 to 3 mm
bilaterally. Non papilledema on fundoscopic exam.
Pertinent Results:
CT Head: No hemorrhage. If there is concern for an acute infarct
an MRI can be obtained.
CTA Head: No vascular occlusion, stenosis or aneurysm > 3mm.
Hypoplastic R P1 segment.
MRI (prelim): No acute intracranial abnormality. No diffusion
weighted abnormalities seen. Small scattered periventricular
FLAIR hyperintensities, non-specific, may represent small vessel
ischemic changes.
Brief Hospital Course:
Patient underwent an elective procedure to assess her right
lower quadrant pain. She was taken to the operating room by Dr.
[**Last Name (STitle) 519**] on [**2169-7-5**]. There were no complications to the procedure.
She was extubated and taken to the post-anesthesia care until in
stable condition.
While in the PACU, she became progressively obtunded and
somnolent. Code stroke was inititated. All head imagings were
obtained and read as normal. Admitted to ICU for frequent neuro
checks, remained stable. Gradually regained consciousness and
was at baseline mental status. [**Month (only) 116**] have been due to medications
received peri-operatively resulting in catatonic effect vs
conversion disorder, although cause is unclear. Discharged with
surgery followup and PRN vicodin for post-op pain control.
Medications on Admission:
Atenolol 50 mg daily
Hydrochlorothiaziede 25 mg daily
Tylenol 1000 mg q4-6 hrs PRN pain
Vicodin 5/500 1 tab q5-6 hrs pRN pain
Meclizine 25 mg PRN vertigo
Discharge Medications:
1. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Right lower quadrant pain, [**Last Name (un) 5487**] etiology
Altered mental status after surgery, now at baseline
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs [**Known lastname 47716**],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were electively admitted for an
exploratory laparoscopy of your abdomen to further work up your
abominal pain. It was normal. Unfortunately we did not find the
cause of your pain. Your course was complicated by some
somnolence, close to coma and there was concern that there could
have been a brain damage. The neurologist were consulted and you
had multiple CT scans and MRIs of your brain, which were normal
(preliminary reads). You woke up ~12 hours after the anesthesia
and were back to your baseline. You can follow up with your
primary care and with Dr. [**Last Name (STitle) 519**] in 2 weeks.
We think you had either a catatonic or conversion reaction to
one of the medications you had during the surgery. You got
normal doses and very common medications. You should discuss
this with your doctors before [**Name5 (PTitle) 691**] [**Name5 (PTitle) **] surgery. The list of
medications you got is:
Midazolam
Lidocaine
Rocuromium
Cefazolin
Dexamethasone
Ondansetron
Glycopyrrolate
Fentanyl
Propofol
Succinylcholine
Ephedrine
Hydromorphone
Neostigmine
Ketorolac 30 mg
Pls call or return to ED if fever > 101, chest pain, shortness
of breath, unable to maintain oral hydration, severe pain
unresolved for 24 hrs, redness or drainage to incision.
You can shower, no baths. Refrain from heavy lifting until >
15lbs. Continue using ice pack to incision.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 519**] in [**3-16**] weeks, pls call for an
appointment.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2169-8-16**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 19462**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] F.
Address: [**Location (un) 25560**], [**Location (un) **],[**Numeric Identifier 25561**]
Phone: [**Telephone/Fax (1) 25562**]
Appt: [**7-12**] at 11:15am
Name: [**Last Name (LF) 519**], [**First Name11 (Name Pattern1) 518**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], PHD
Location: [**Hospital1 **]
Address: [**Location (un) **], STONE 929, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 6554**]
Appt: We are working on an appt for you within the next few
weeks. The office will call you at home with an appt. IF you
dont hear from them by tomorrow, please call them directly to
book.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2169-7-6**]
|
[
"4019",
"V1582"
] |
Admission Date: [**2178-3-23**] Discharge Date: [**2178-3-30**]
Date of Birth: [**2150-3-27**] Sex: F
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 27 year old
female admitted to the Transplant Surgery service as a live
liver donor. The patient was otherwise healthy female with
no past medical history except for attention deficit
disorder.
PAST SURGICAL HISTORY: Her past surgical history included
only a hysteroscopy and a tubal ligation for endometrial
cysts and menorrhagia and some breast implants.
MEDICATIONS ON ADMISSION: Concerta for her attention deficit
disorder.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: The patient was a nonsmoker and did not use
alcohol.
HOSPITAL COURSE: The patient was admitted for a right
hepatic lobectomy. She underwent the procedure without
complications. Postoperatively, she was in the Intensive
Care Unit for monitoring and was extubated. She was sent to
the floor on postoperative day number one, was out of bed and
tolerating clear liquids. She had an uncomplicated course
with some pain issues which were addressed promptly.
Eventually, she was taking Dilaudid and Toradol. On
postoperative day number four, she was able to tolerate
regular diet. On postoperative day number six, she was
diagnosed with a urinary tract infection on urinalysis and
started on Ciprofloxacin. She was tolerating regular diet
and was discharged home with only Dilaudid 1 to 2 mg q2-
3hours and Vicodin one to two tablets p.o. q6hours,
Ciprofloxacin five day course for urinary tract infection
with a follow-up scheduled at Transplant Center.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Status post donor right hepatic
lobectomy.
MEDICATIONS ON DISCHARGE:
1. Dilaudid 1 to 2 mg q2-3hours.
2. Vicodin one to two tablets p.o. q6hours.
3. Ciprofloxacin five day course.
FOLLOW UP: The patient's follow-up is scheduled at the
Transplant Center prior to discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PhD [**Numeric Identifier 8353**]
Dictated By:[**Last Name (NamePattern1) 30263**]
MEDQUIST36
D: [**2178-4-22**] 19:39:23
T: [**2178-4-22**] 19:57:59
Job#: [**Job Number 50800**]
cc:[**Last Name (NamePattern4) 42796**]
|
[
"5990"
] |
Admission Date: [**2118-9-13**] Discharge Date: [**2118-9-19**]
Date of Birth: [**2056-7-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2118-9-13**] AVR (Mechanical St. [**Male First Name (un) 923**])
History of Present Illness:
61 year old gentleman with syncopal episodes. Work-up revealed
severe aortic stenosis with an aortic valve area of 0.6cm2.
Past Medical History:
Hypercholesterolemia
Rheuamatic fever
GERD
Vertigo
Chronic lower back pain
syncope
Underlying slow sinus rhythm
Right thigh injury
Social History:
Lives with wife in [**Name (NI) 932**]. Occassional glass of wine.
Family History:
Sister with congenital heart disease
Physical Exam:
BP:(R) 145/92 (L) 144/87 56 regular
GEN: WDWN in NAD
SKIN:No rashes or lesions
HEART: RRR, 4/6 systolic mumur
LUNGS: Clear
ABD: Soft, benign
EXT: Warm, no edema
Pertinent Results:
[**2118-9-18**] 09:20AM BLOOD WBC-6.0 RBC-3.26* Hgb-10.1* Hct-29.9*
MCV-92 MCH-30.8 MCHC-33.7 RDW-13.2 Plt Ct-201#
[**2118-9-19**] 06:25AM BLOOD PT-17.5* INR(PT)-2.0
[**2118-9-16**] CXR
Comparison is made to [**2118-9-15**]. No left apical pneumothorax is
identified. Cardiac size remains mildly enlarged. There is no
CHF or effusion. Patchy bilateral lower lobe atelectasis is
unchanged.
[**2118-9-13**] EKG
Sinus bradycardia. Compared to the previous tracing of [**2118-8-22**]
multiple
abnormalities as previously noted persist without major change.
Brief Hospital Course:
Mr. [**Known lastname 59201**] was admitted to the [**Hospital1 18**] on [**2118-9-13**] for surgical
management of his aortic valve disease. He was taken directly to
the operating room where he underwent an aortic valve
replacement with a 23mm St. [**Male First Name (un) 923**] regent mechanical heart valve.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mr. [**Known lastname 59201**] [**Last Name (Titles) **]e neurologically intact and was extubated. He was then
transferred to the cardiac surgical step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. Beta blockade and aspirin were started. Coumadin was
started for anticoagulation for his mechanical heart valve. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. As his INR was slow to
become therapeutic, heparin was started in the interim. Mr.
[**Known lastname 59201**] continued to make steady progress and was discharged home
on postoperative day six. He will follow-up with Dr. [**Last Name (Prefixes) 16706**], his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Pravachol
Folate
Discharge Medications:
1. Pravachol 10 mg Tablet Sig: One (1) Tablet PO once a day.
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 BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO once a day
for 2 days: Check INR on [**9-21**] with results to Dr. [**First Name (STitle) **] Goal
2.5-3.5.
Disp:*45 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
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 once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
AS
hyperlipidemia
LBP
GERD
Vertigo
Right hernia repair.
Discharge Condition:
Good.
Discharge Instructions:
Shower daily, wash incision with mild soap and water and pat
dry. No lotions, creams powders or baths.
Call with temperature greater than 101, or redness or drainage
from incision, or weight gain more than 2 pounds in one day or
five in one week.
No heavy lifting (>10 pounds) or driving until follow up with
srgeon or while taking narcotic pain medicine.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**First Name (STitle) **] 2 weeks (call office on [**9-27**] for appointment)
INR f/u and coumadin dosing will be done by Dr. [**First Name (STitle) **] after
[**2118-9-27**]. (Dr. [**First Name (STitle) **] is on vacation until [**9-27**], please call Dr. [**Last Name (STitle) **]
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2546**] office with INR results until then)
Completed by:[**2118-10-14**]
|
[
"53081",
"2724",
"2720"
] |
Admission Date: [**2111-5-22**] Discharge Date: [**2111-5-31**]
Date of Birth: [**2054-4-22**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This patient is a gentelman who
initially admitted to an outside hospital on [**2111-5-21**]
with a complaint of intermittent chest pain occurring prior
to the day of that admission at rest and also with
activities. He complained of chest pain with swelling and
burning sensation, nonradiating and not associated with
shortness of breath, diaphoresis, nausea or vomiting or
palpitations. On the electrocardiogram during admission
showed ST elevation in 3 and AVF and troponin peak at 1.8
with CK of 172. He was treated wit Lovenox and transferred
to the [**Hospital1 69**] for further
evaluation.
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia,
and gastric regurgitation disease.
ALLERGIES: The patient has no known drug allergies.
HOME MEDICATIONS:
1. Lipitor 10 q.d.
2. Procardia 90 q.d.
3. Lopressor.
4. Aspirin.
PHYSICAL EXAMINATION ON ADMISSION: This is a patient who is
alert, oriented and in no acute distress. Neck has no JVD.
There is a bilateral carotid bruits. Chest si clear to
auscultation. Regular rate and rhythm with regular heart
sounds. No murmurs. Extremities have all palpitations
throughout and no edema.
LABORATORY: White blood cell count 11.3, hematocrit is 47.4
and platelets are 268. Electrolytes are within normal
limits. His CK is 176 and troponin is 1.81.
HOSPITAL COURSE: The patient was evaluated by the Cardiac
Surgery consulting service and also was sent to the
catheterization laboratory on the 20th where he was found to
have a cerebral vascular disease with 80 to 90% occlusion of
the left anterior descending coronary artery, diffuse ectasia
without high grade focal stenosis on the left circumflex and
a diffuse ectasia 95% stenosis in the mid right coronary
artery.
The patient was explained the risks and benefits of having a
coronary artery bypass graft surgery and he was taken to the
Operating Room on [**2111-5-25**] where he underwent a coronary
artery bypass graft for three vessels, left internal mammary
coronary artery to left anterior descending coronary artery
and vein graft to posterior descending coronary artery and
obtuse marginal. He was doing well during the procedure.
The cardiopulmonary time was 98 minutes and cross clamp time
was 64 minutes. He was subsequently transferred to the CSRU
intubated for further recovery. His Intensive Care Unit stay
was unremarkable. He was started on Lopresor for heart rate
control and Lasix for diuresis postoperative day number one.
He was then transferred to the regular floor having his
chest tube and pacing wires removed. His recovery was
unremarkable. He was seen by physical therapy during the
stay and it was determined that he is functioning to be able
to go home. His beta blocker was adjusted accordingly in the
recovery course to provide better rate control as his blood
pressure tolerates.
Th[**Last Name (STitle) 1050**] is discharge on the [**5-31**] to home. He is
instructed to call for a follow up appointment to his primary
cardiologist in two weeks and also with Dr. [**Last Name (Prefixes) **] for
follow up appointments. He is instructed to call a physician
or come to the Emergency Room with chest pain or wound
drainage.
DISCHARGE MEDICATIONS: He is instructed to take his home
medication except antihypertensives and he is given
prescriptions for 45 tablets of Percocet, Lipitor, aspirin,
Zantac, Colace and Lasix 40 mg b.i.d. for two weeks.
Potassium 10 milliequivalents b.i.d. for two weeks and
Metoprolol 50 mg b.i.d. for one month supply.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS:
Coronary artery disease status post coronary artery bypass
graft times three.
DISCHARGE STATUS: To home.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 6276**]
MEDQUIST36
D: [**2111-6-3**] 09:42
T: [**2111-6-3**] 09:55
JOB#: [**Job Number 48194**]
cc:[**Name8 (MD) 48195**]
|
[
"41071",
"41401",
"4019",
"2720"
] |
Admission Date: [**2168-3-3**] Discharge Date: [**2168-3-17**]
Date of Birth: [**2168-3-3**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 10132**] was the 2.575 kilogram product of a
34-2/7-week gestation born to a 39-year-old G5, P2 now 3
mother.
PRENATAL SCREENS: A-positive, antibody negative, hepatitis
surface antigen negative, RPR nonreactive, rubella immune,
GBS unknown.
This pregnancy complicated by marginal previa and preterm
labor at 32-3/7 weeks. Mother was admitted to antepartum
floor and given magnesium sulfate and betamethasone. On day
of delivery, infant delivered by repeat section. No perinatal
risk factors, sepsis risk factors. Ruptured membranes at time
of delivery with clear fluid. Infant emerged with good tone
and spontaneous cry. Routine drying, suctioning, and
stimulation provided. Apgars were assigned as 8 and 9.
PHYSICAL EXAM ON ADMISSION: Weight 2.575 kilograms (75th
percentile), length 47.5 cm (75th percentile), head
circumference 33 cm (75th percentile). Nondysmorphic infant
with mild grunting, though pink on radiant warmer. Anterior
fontanel is soft and flat. Red reflex on the left visible.
Need to recheck right eye. Palate: Intact. Ears: Normal set.
Neck: Supple. Clavicles: Intact. Lungs: Clear to apex with
fair aeration, mild retractions and grunting. Cardiovascular:
Regular rate and rhythm, no murmur. Two-plus femoral pulses.
Abdomen: Soft, positive bowel sounds, no hepatosplenomegaly.
GU: Normal male. Testes: Down bilaterally. Patent anus. No
sacral anomalies. Hips: Stable. Extremities: Pink and well
perfused. Neuro: Symmetric tone, moves, grasp, Moro present.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Infant
was initially admitted to the newborn intensive care unit,
placed on CPAP for a total of 48 hours at which time he
weaned to room air and has been stable on room air since that
time. He has had occasional apnea and bradycardia episodes
with an increase following his circumcision and vaccination.
His last documented episodes were on [**2168-3-11**].
Cardiovascular: No issues.
Fluid and electrolytes: Initially started on 60 cc per
kilogram per day of D10W. Enteral feedings were initiated on
day of life 3. Infant is currently ad-lib feeding Enfamil 24
calorie taking in adequate amounts. His discharge weight is
2495 grams
GI: Peak bilirubin was on day of life #5 of 13.3/0.3. Infant
was treated with phototherapy. Issue has since resolved.
Hematology: Hematocrit on admission was 49.4. He has not
required any blood transfusions during this hospital course.
Infectious disease: CBC and blood culture obtained on
admission. CBC was benign. White count was 11.3. Platelets
were 276, 27 polys, 0 bands, 1 metamyelocytes, 1 myelocyte, 1
promyelocyte. Infant did not receive antibiotics and blood
cultures remained negative at 48 hours.
Neuro: Infant has been appropriate for gestational age.
Sensory: Hearing screen was performed with automated auditory
brainstem responses and the infant passed both ears.
CONDITION AT DISCHARGE: Is stable.
DISCHARGE DISPOSITION: Is to home.
PRIMARY PEDIATRICIAN: Is [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 30207**]. Telephone number
is ([**Telephone/Fax (1) 61998**].
FEEDS AT DISCHARGE: Continue ad-lib feeding of Enfamil 24
calorie.
MEDICATIONS: Not applicable.
CAR SEAT POSITION SCREENING: Infant was screened for 90
minutes in the car seat and passed the screening.
STATE NEWBORN SCREENS: Have been sent per protocol and had
been within normal limits.
IMMUNIZATIONS: Infant received hepatitis B vaccine on
[**2168-3-11**]. Received Synagis vaccine on [**2168-3-11**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1. Born at less than 32
weeks; 2. Born between 32 and 35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings; or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DISCHARGE DIAGNOSES: Premature infant, transitional
respiratory distress, rule out sepsis, mild
hyperbilirubinemia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2168-3-16**] 21:44:17
T: [**2168-3-17**] 04:18:12
Job#: [**Job Number 65827**]
|
[
"7742",
"V290"
] |
Admission Date: [**2123-4-2**] Discharge Date: [**2123-4-6**]
Date of Birth: [**2063-10-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis
Endoscopy
History of Present Illness:
59 y/o M with hx of hepatitis C cirrohsis who presents to the
emergency room today with hematemesis. He had been feeling well
except for mild fluid overload and back pain until yesterday
when he spit up about a cupful of blood. He denies abdominal
pain, nausea, vomiting, cough, fevers, chills. Has mild abominal
pain and increased bloating. Has chronic back pain as well.
Of note, he had recently been hospitalized at [**Hospital **] hospital
and discharged a little over a week ago. He had problems with
encephalopathy, increased fluid overload. He had a 3L
paracentesis, but per him, no SBP. He was having fevers and
chills at that time. Also, while hospitalized, he was having
difficulty breathing, but that improved with the paracentesis.
In the ED, initial vs were T 97.2, p 79, bp 105/66, r 20, 97% on
RA. Patient was started on an octreotide gtt and given protonix
40 mg IV and zofran in the ED. He did not receive any blood
products in the ED.
On the floor, patient is in bed, comfortable except for his
chronic back pain. Does not complain of dizziness,
light-headedness, stomach ache, nausea, vomiting.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
# Hepatitis C Cirrhosis
-completed four years in the COPILOT trial in [**2117-9-8**]. He
was treated with interferon and ribavirin prior to that but did
not have a sustained virologic response
# Esophageal Varices
-s/p banding multiple times, most recently [**2122-3-8**]
# Ascites
Social History:
- Tobacco: yes, few cigarettes daily
- Alcohol: used to drink when younger; no drinking in 9+ years
- Illicits: none
Family History:
dad with DM, mom with COPD; otherwise non-contributory
Physical Exam:
Vitals: T 97.6, P 88, BP 123/62, R 15, 97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: mildly distended, firm, tympanic, epigastric point
tenderness, no rebound or guarding, positive BS
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ B edema
Pertinent Results:
LABS ON ADMISSION:
[**2123-4-2**] 02:20PM PT-19.6* PTT-43.8* INR(PT)-1.8*
[**2123-4-2**] 02:16PM AMMONIA-43
[**2123-4-2**] 02:00PM GLUCOSE-104* UREA N-8 CREAT-0.8 SODIUM-133
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-11
[**2123-4-2**] 02:00PM ALT(SGPT)-22 AST(SGOT)-53* ALK PHOS-88 TOT
BILI-4.1*
[**2123-4-2**] 02:00PM LIPASE-32
[**2123-4-2**] 02:00PM ALBUMIN-2.2*
[**2123-4-2**] 02:00PM WBC-7.3 RBC-3.21* HGB-11.6* HCT-34.4*
MCV-107* MCH-36.0* MCHC-33.6 RDW-15.2
[**2123-4-2**] 02:00PM NEUTS-67.4 LYMPHS-18.0 MONOS-11.3* EOS-2.2
BASOS-1.1
[**2123-4-2**] 02:00PM PLT COUNT-112*
[**2123-4-1**] 10:40AM UREA N-9 CREAT-0.9 SODIUM-132* POTASSIUM-4.2
CHLORIDE-95* TOTAL CO2-29 ANION GAP-12
[**2123-4-1**] 10:40AM estGFR-Using this
[**2123-4-1**] 10:40AM ALT(SGPT)-23 AST(SGOT)-57* ALK PHOS-90 TOT
BILI-4.8* DIR BILI-1.6* INDIR BIL-3.2
[**2123-4-1**] 10:40AM ALBUMIN-2.4*
[**2123-4-1**] 10:40AM AFP-4.3
[**2123-4-1**] 10:40AM WBC-8.0 RBC-3.30* HGB-11.7* HCT-36.5*
MCV-111* MCH-35.6* MCHC-32.2 RDW-14.4
[**2123-4-1**] 10:40AM NEUTS-68 BANDS-0 LYMPHS-16* MONOS-13* EOS-1
BASOS-1 ATYPS-1* METAS-0 MYELOS-0
[**2123-4-1**] 10:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL TARGET-OCCASIONAL
[**2123-4-1**] 10:40AM PLT SMR-LOW PLT COUNT-102*
[**2123-4-1**] 10:40AM PT-20.0* INR(PT)-1.8*
[**2123-4-1**] 10:40AM PT-20.0* INR(PT)-1.8*
.
Micro:
[**2123-4-2**] 7:28 pm PERITONEAL FLUID PERITONEAL.
GRAM STAIN (Final [**2123-4-3**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2123-4-6**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
Images: CXR [**2123-4-3**]
IMPRESSION: Blunting of the posterior costophrenic sulci likely
due to small pleural effusions.
.
[**2123-4-3**] Abdominal Ultrasound
IMPRESSIONS:
1. Cirrhotic liver, without focal liver lesion seen.
2. Splenomegaly as before. New moderate ascites since [**2122-8-5**].
3. Patent hepatic vasculature, with normal hepatopetal flow
within portal veins.
.
Discharge labs:
[**2123-4-6**] 06:00AM BLOOD WBC-4.6 RBC-2.89* Hgb-10.5* Hct-31.4*
MCV-109* MCH-36.3* MCHC-33.5 RDW-16.4* Plt Ct-95*
[**2123-4-6**] 06:00AM BLOOD PT-20.1* PTT-43.4* INR(PT)-1.9*
[**2123-4-6**] 06:00AM BLOOD Glucose-79 UreaN-12 Creat-0.7 Na-134
K-3.9 Cl-103 HCO3-26 AnGap-9
[**2123-4-6**] 06:00AM BLOOD ALT-17 AST-44* LD(LDH)-277* AlkPhos-70
TotBili-2.9*
[**2123-4-6**] 06:00AM BLOOD Albumin-1.8* Calcium-7.6* Phos-3.6 Mg-2.1
.
Iron studies:
[**2123-4-5**] 06:36AM BLOOD calTIBC-127* VitB12-1301* Folate-10.2
Ferritn-522* TRF-98*\
.
EGD [**4-5**]:
Unable to intubate the esophagus secondary to patient agitation
and discomfort. Unable to increase sedatives secondary to
hypotension to 70's. Responded to 1.5 L fluid bolus. Patient
currently stable. NPO after midnight. EGD tomorrow under MAC
anesthesia.
.
EGD [**4-6**]:
Small AVM at GE junction
Varices at the lower third of the esophagus and gastroesophageal
junction
Erythema, congestion, abnormal vascularity and mosaic appearance
in the whole stomach compatible with portal hypertensive
gastropathy
Otherwise normal EGD to third part of the duodenum
Recommendations: grade I esophageal varices. Not large enough to
band. Portal hypertensive gastropathy. Please continue current
management.
Brief Hospital Course:
Mr. [**Known lastname 31469**] is a 59 year old man with ESLD secondary to hepatitis
C cirrhosis who presented with an episode of
hemoptysis/hematemesis. He was initially admitted to the ICU out
of concern for ongoing bleeding. His hematocrit remained stable.
.
# Hematemesis/Hemoptysis: Unclear initially if episodes of
hemoptysis or hematemesis. Then, patient clarified episode as
hemoptysis (no vomiting, just coughed up blood gob). He has a
history of varices requiring banding. Hct drifted down slightly
but then stable throughout hospitalization. [**Hospital1 **] PPI. Attempted
EGD on [**4-5**], but patient hypotensive with increased sedation
needed to prevent gagging. As such, procedure did not occur. On
[**4-6**] patient sedated with general anesthesia and underwent EGD.
No evidence of active bleed, and no varices requiring banding.
Patient tolerated EGD well, was feeling well after procedure
ended. Discharged later that day.
Given GI was not believed to be source of hemoptysis, set-up
patient with pulmonologist appointment and CT scan of the chest;
this was explained to patient. There is obviously concern for
malignancy in smoker, 59 y/o male, and we feel this needs a
pulmonary work-up with imaging and specialist investigation.
Patient and pulmonologist aware of need for imaging and
appointment.
.
# Abdominal Pain: Resolved. No evidence of SBP.
.
# Fatigue: Likely due to anemia, hypotension, cirrhosis.
Monitored, keen to go home.
# Ascites: Restarted furosemide and spironolactone.
.
# Hepatitis C Cirrhosis: Continue current treatment of
furosemide, nadolol, and spironolactone.
.
# Back Pain: Chronic and stable. Oxycodone - home regimen.
.
# ?COPD: Patient without reported history of COPD but on
inhalers at home. Continue home medications
.
Code: Mr. [**Known lastname 31469**] was a full code during this admission.
Medications on Admission:
# Fluticasone 50 mcg nasally 2 sprays daily
# Adviar 100-50 mcg [**Hospital1 **]
# Lasix 40 mg daily
# Ketoconazole cream [**Hospital1 **]
# Lactulose 30 mg TID PRN
# Nadolol 10 mg daily
# Oxycodone 5 mg q6hrs PRN
# Protonix 40 mg daily
# Potassium Chloride 20 mg daily
# Spironolactone 100 mg daily
# Sonata 10 mg qHS PRN
# Tylenol 1000 mg [**Hospital1 **] PRN
# Tums PRN
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Zaleplon 10 mg Capsule Sig: One (1) Capsule PO QHS (once a
day (at bedtime)) as needed for insomnia.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for dyspepsia.
8. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for severe pain.
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
12. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO
three times a day as needed for confusion or constipation.
13. CT scan at [**Hospital1 18**] [**Hospital Ward Name 516**] Radiology, before [**2123-5-7**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hepatitis C Cirrhosis
Hemoptysis
Esophageal varices
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital with bleeding. There was a concern that
you may have been bleeding from varices in your esophagus. You
underwent an EGD or endoscopy with anesthesia which used a
camera to look at your esophagus and stomach. This did not show
bleeding; it only showed very small varices that need to be
monitored every 6 months. Your blood counts remained stable
while you were in the hospital.
You will need to follow up with a pulmonary (lung) doctor to
make sure that the blood you coughed up was not coming from your
lungs. Before going to the appointment with the pulmonologist on
[**5-7**], please have a CT scan done at [**Hospital1 18**], at your convenience.
It is important that they have the results of the CT scan when
you go to the appointment with the lung doctor, so that they can
take care of you.
We made no changes to your medications. Please continue your
home medications as prescribed.
Followup Instructions:
Because you coughed up blood, we would like you to have your
lungs examined. Please go to [**Hospital1 18**] [**Hospital Ward Name 516**] Radiology to have
a CT scan (please call the attached phone # first, to schedule
an appointment for the scan). Also, please go to the following
important appointment at the Pulmonary (Lung) clinic:
[**Last Name (LF) 2974**], [**5-7**] at 8:30AM; [**Hospital Ward Name 23**] Building, [**Location (un) 436**],
Medical specialties. Dr. [**First Name (STitle) 437**]. [**Telephone/Fax (1) 612**].
Please have the CT scan done before the appointment so that its
results can be used to guide your care.
.
Previously-scheduled appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2123-4-14**] at 11:10
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2123-4-7**]
|
[
"496",
"3051"
] |
Admission Date: [**2106-11-24**] Discharge Date: [**2106-11-29**]
Date of Birth: [**2027-11-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Dilaudid
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain, dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2106-11-25**] Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to
PDA w/ y-graft to PLB, SVG to Diag w. y-graft to Ramus)
History of Present Illness:
79 y/o male c/o chest pain and dyspnea on exertion with h/o
aortic stenosis who had an abnormal stress test. Refered for
cardiac cath which revealed severe threee vessel disease.
Past Medical History:
Hyperlipidemia, Hypertension, Chronic Obstructive Pulmonary
Disease, Arthritis, Prostate Cancer s/p Prostatectomy, Stroke
[**2099**], Carotid Artery Disease, s/p Appendectomy
Social History:
Denies tobacco. Social ETOH.
Family History:
non-contributory
Physical Exam:
VS: 71 18 161/82 5'6" 185#
Gen: Elderly WD/WN male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD, left carotid bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, trace edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2106-11-28**] 06:55AM BLOOD WBC-10.2 RBC-2.96* Hgb-8.7* Hct-25.7*
MCV-87 MCH-29.4 MCHC-33.9 RDW-14.1 Plt Ct-197
[**2106-11-29**] 07:30AM BLOOD PT-21.9* INR(PT)-2.1*
[**2106-11-28**] 06:55AM BLOOD PT-16.1* INR(PT)-1.4*
[**2106-11-27**] 07:45AM BLOOD PT-15.8* INR(PT)-1.4*
[**2106-11-28**] 06:55AM BLOOD Glucose-114* UreaN-21* Creat-0.8 Na-134
K-4.7 Cl-103 HCO3-24 AnGap-12
[**11-25**] Echo: PRE-BYPASS: The left atrium is mildly dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. No left
ventricular aneurysm is seen. There is moderate global left
ventricular hypokinesis (LVEF =30 %). Overall left ventricular
systolic function is moderately depressed (LVEF= 30 %). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis(area
1.5 cm2). Mild to moderate ([**12-1**]+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
Post_Bypass: Normal Right ventricular systolic function. Overall
LVEF 45%. Mild AS, Mild AI. Thoracic aortic contour is intact.
Brief Hospital Course:
Mr. [**Known lastname 25288**] was admitted one day prior to surgery secondary to
being on Coumadin and he required a pre-op Echo. On [**11-25**] he was
brought to the operating room where he underwent a coronary
artery bypass graft x 5. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Later on op
day he was weaned from sedation, awoke neurologically intact and
extubated. On post-op day one he was started on beta blockers
and diuretics and gently diuresed towards his pre-op weight.
Later on this day he was transferred to the telemetry floor for
further care. On post-op day two his chest tubes were removed.
On post-op day three his epicardial pacing wires were removed.
He had atrial fibrillation for which he was started on
amiodarone. He was converted to sinus rhythm. He was restarted
on coumadin for history of CVA. He was ready for discharge to
rehab on POD #4.
Medications on Admission:
Coumadin 2.5mg except friday (last dose 12/21), Lipitor 20mg qd,
Prilosec 20mg [**Hospital1 **], Celebrex 200mg qd, MVI qd, Vit C and E qd,
Aspirin 81mg qd, Plavix 600mg on [**2106-11-19**]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO daily ().
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400 mg daily x 1 week, then 200 mg daily ongoing until
dc'd by cardiologist.
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
check INR [**11-30**] and dose for CVA/Afib.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks: then reassess need for diuresis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
PMH: Hyperlipidemia, Hypertension, Chronic Obstructive Pulmonary
Disease, Arthritis, Prostate Cancer s/p Prostatectomy, Stroke
[**2099**], Carotid Artery Disease, s/p Appendectomy
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.
Followup Instructions:
[**Hospital 409**] clinic on [**Hospital Ward Name 121**] 6 in 2 weeks
Dr. [**Last Name (STitle) 4469**] in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2106-11-29**]
|
[
"41401",
"9971",
"42731",
"2724",
"4019",
"496"
] |
Admission Date: [**2122-5-9**] Discharge Date: [**2122-5-15**]
Date of Birth: [**2070-2-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Tachypnea and tachycardia noted at facility
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy tube placement
right internal jugular vein central venous catheter placement
History of Present Illness:
52 yo M with h/os anoxic brain injury [**2-12**] substance abuse s/p
trach and PEG [**1-/2122**] (which occurred in [**Hospital 5503**] Rehab),
recent admission for G-tube related complication discharged on
[**2122-5-4**] transferred from [**Hospital **] Rehab for tachypnea and
tachycardia.
.
Of note, patient was recently admitted from [**Date range (1) 110683**] for
malpositioned G tube (after a manual G-tube replacement in the
rehab)in the left rectus muscle complicated by sepsis, s/p
debridement and later replacement. He was found to have urinary
tract infection during that admission with Klebsiella and
Psuedomonas and was discharged on Bactrim for UTI.
.
Patient was noted to have 1 day of tachypnea and tachycardia.
His RR was up to 40s with abdominal breathing. He was started
on ceftin 500 mb [**Hospital1 **] x 7 days on [**5-8**] for UTI in additional to
the Bactrim that he was discharged on. Flagyl 500 mg TID was
also started for planned x 10 days for ? C. diff given increased
stool frequency. Outside lab noted for WBC 15.6, Hgb 14, Hct
40, Plt 323, Diff of 82.6% neutrophils, Na 132, K 4.3, Cl 95,
HCO3 21, BUN 25, Crt 1. Upon transfer, VS were BP 112/70, HR
116, RR 40, T 98.6, pOx 95 RA.
.
En route, HR was 115, SBP 97/50 (received 300 cc NS bolus x 1),
pOx mid-90s on 35 % TM, AF. FSBS 135
.
In the ED, initial VS were: 99.0 118 118/76 32 94% 50% o2 mask
via trach. Patient was noted to be unresponsive (baseline) with
aniscoria left 4 mm and right 6 mm, + crackles. Rectal
temperature was noted to be 104. He got 1000 mg IV Tylenol. He
also received IVF and metoprolol 5 mg iv x 1 for sinus
tachycardia. EKG showed sinus tachycardia at 117, normal axis,
normal interval, no STT changes, TWI III, similar to prior.
Labs were significant for Hgb 11.1 (down from 14.4), ALT 46 but
otherwise normal LFTs, baseline chemistry panel. Portal CXR
showed low lung volumes with right lung atelectasis and no
pleural effusion, no evidence of pneumonia. UA was +. Blood
and urine cultures were sent. ABG 7.54/29/75/26. Lactate 1.5.
Patient was given vanc/zosyn/levofloxacin. CT abd showed
extensive gallbladder wall thickening and fat stranding toward
the duodenum and pancreatic head, c/w cholecystitis. Liver U/S
did not show obvious stone. General surgery was consulted and
did not think that patient was a surgical candidate.
.
Upon arrival to the MICU, patient is not-interactive.
Past Medical History:
- TBI secondary to anoxia during substance overdose
- s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1003**] G tube placement [**2122-4-18**]
- s/p exploratory G tube tract incision and drainage of the
retro-rectus/peri-rectus space and drain placement [**2122-4-14**]
- s/p Tracheostomy and PEG placement [**1-/2122**]
- Sepsis secondary to acute cholecystitis with placement of
drain [**4-/2122**]
Social History:
according to guardian
- from [**Name (NI) **]
- h/o substance abuse, was on methadone
- unclear if used EtOH or smoked
- no kids
Family History:
Not addressed this admission
Physical Exam:
Physical Exam on Admission
General: not interactive, not oriented
HEENT: Sclera anicteric, MMM, EOMI, aniscoria left 4 mm and
right 6 mm
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: coarse breath sounds, no wheezes/ronchi/crackles
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or
guarding, G-tube in place, skin around appeared
erythematous/firm
GU: + Foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: PERRLA but aniscoria, gait did not examine, withdrawals
from pain, decorticate posturing
.
Discharge:
Vitals: 98 121/78 95 98%RA
General: not interactive
HEENT: Aniscoria left pupil 4 mm and right pupil 6 mm; former
LIJ site with no bleeding or hematoma
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: coarse breath sounds, no wheezes/ronchi/crackles
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or
guarding, G-tube in place, no purulent drainage. Perc
cholecystostomy tube in place draining greenish-brown fluid
GU: + Foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: decorticate posturing
SKin: notable for stage I sacral decub;
Pertinent Results:
Labs on Admission
[**2122-5-9**] 10:15AM BLOOD WBC-12.2* RBC-3.44* Hgb-11.1*# Hct-33.7*#
MCV-98 MCH-32.3* MCHC-33.0 RDW-13.7 Plt Ct-268
[**2122-5-9**] 10:15AM BLOOD Neuts-84.5* Lymphs-10.0* Monos-4.1
Eos-0.8 Baso-0.5
[**2122-5-9**] 10:15AM BLOOD PT-14.9* PTT-27.6 INR(PT)-1.4*
[**2122-5-9**] 10:15AM BLOOD Ret Aut-1.9
[**2122-5-9**] 10:15AM BLOOD Glucose-117* UreaN-35* Creat-0.8 Na-133
K-3.9 Cl-99 HCO3-23 AnGap-15
[**2122-5-9**] 10:15AM BLOOD ALT-46* AST-26 LD(LDH)-228 AlkPhos-46
TotBili-0.3
[**2122-5-9**] 10:15AM BLOOD Lipase-43
[**2122-5-9**] 10:15AM BLOOD Albumin-3.0* Calcium-7.9* Phos-2.9 Mg-2.4
Iron-22*
[**2122-5-9**] 10:15AM BLOOD calTIBC-182* Hapto-382* Ferritn-1013*
TRF-140*
[**2122-5-9**] 10:28AM BLOOD Type-ART FiO2-35 pO2-75* pCO2-29*
pH-7.54* calTCO2-26 Base XS-2 Intubat-NOT INTUBA
[**2122-5-9**] 11:00AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.024
[**2122-5-9**] 11:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2122-5-9**] 11:00AM URINE RBC-5* WBC-46* Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
[**2122-5-9**] 11:00AM URINE CastGr-6* CastHy-2*
[**2122-5-9**] 11:00AM URINE AmorphX-RARE CaOxalX-OCC
[**2122-5-9**] 11:00AM URINE Mucous-FEW
Micro:
[**5-9**] blood cx x2: gram positive cocci in clusters x1/4 bottles
[**5-10**] blood cx x2: pnd
[**5-9**] urine cx:
[**2122-5-9**] 11:00 am URINE **FINAL REPORT [**2122-5-11**]**
URINE CULTURE (Final [**2122-5-11**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 4 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 I
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ 8 I
[**5-9**] sputum cx: cancelled
[**5-9**] bile cx: pnd (0PMNs, 0org)
[**5-10**] C diff assay: negative
[**5-10**] urine cx: pnd
[**5-11**] blood cx: pnd
.
Images:
CT abd/pelvis with and without contrast [**5-9**]
Acute cholecystitis, new from prior study. Likely bibasilar
atelectasis but superimposed pneumonia is not excluded.
.
CXR [**5-9**]
IMPRESSION: Right basilar atelectasis. Otherwise, no acute
intrathoracic process.
.
CTA IMPRESSION:
1. No pulmonary embolus to the segmental levels.
2. 2-cm right middle lobe opacity may represent focal
atelectasis versus nodule. Recommend 3-month follow-up CT.
.
[**2122-5-9**]
- IR percutaneous chole tube
.
Discharge labs:
[**2122-5-15**] 06:30AM BLOOD WBC-7.1 RBC-3.97* Hgb-12.9* Hct-38.6*
MCV-97 MCH-32.6* MCHC-33.5 RDW-14.0 Plt Ct-454*
[**2122-5-15**] 06:30AM BLOOD Plt Ct-454*
[**2122-5-15**] 06:30AM BLOOD Glucose-125* UreaN-13 Creat-0.5 Na-133
K-4.5 Cl-101 HCO3-24 AnGap-13
[**2122-5-10**] 03:59AM BLOOD ALT-37 AST-30 AlkPhos-38* TotBili-0.4
[**2122-5-14**] 06:40AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.3
Brief Hospital Course:
SUMMARY: 52 yo M with h/o anoxic brain injury [**2-12**] substance
abuse s/p trach and PEG, recent G tube placement complication
s/p exploratory tract incision and drainage with replacement,
who presented to MICU [**5-9**] with sepsis and transferred to floor
for further management.
# Sepsis/SIRS: the most likely source of infection was acute
cholecystitis, and a drain was placed in the gallbladder. The
patient completed a 7 day course of tigecycline in-house per ID
recommendations. He grew a pseudomonas species in his urine,
which the ID team felt was most likely colonization.
# Tachycardia: The patient was noted to be tachycardic to 140s
(sinus), and was ruled out for a pulmonary embolism. He was
restarted on previous doses of metoprolol after significant
volume resuscitation.
# Lung nodule: Will need follow-up CT in 3 months, pending
change in overall goals of care.
# Anemia: Improved during the course of admission, and no
evidence for bleeding.
# Pressure ulcer: Stage I, over buttock, will need good wound
care and frequent repositioning.
# Nutrition: The patient has a history of infections at the site
of his G-tube. It will be important to closely monitor the site,
with routine care. This was not an active issue this admission.
# Code Status: The patient is Full Code, with a court appointed
guardian. Changes in clinical status should be discussed with
the guardian. The prognosis overall of the patient's grim chance
of neurological recovery was discussed this admission, and the
guardian is exploring options through the court system to
potentially make the patient DNR/DNI, however currently he is
full code.
# Communication: [**First Name5 (NamePattern1) 8214**] [**Last Name (NamePattern1) 8215**] [**Telephone/Fax (1) 8216**] (court appointed
guardian). Okay to speak with [**Name (NI) 17148**] (sister [**Telephone/Fax (1) 110684**];
[**Telephone/Fax (1) 110685**]), [**Name (NI) **] [**Name (NI) **] (friend [**Telephone/Fax (1) 110686**])
==============================
Transitional issues:
-Needs to be taken to f/u appointment with surgery to evaluate
biliary drain
-Pending goals of care, the patient should have repeat chest CT
scan in 3 months (early [**Month (only) 216**]) to evaluate a lung nodule
Medications on Admission:
per [**Hospital1 **] Record
- metoprolol tartrate 50 mg every 6 hours, via G tube
- colace 25 mg [**Hospital1 **]
- heparin 5000 units TID
- vitamin C 500 mg daily
- famotidine 20 mg [**Hospital1 **]
- bactrim DS 1 tab [**Hospital1 **]- for UTI, [**Date range (1) 12721**] (discharged med from
prior admission for intended 10 day course)
- ceftin 500 mg [**Hospital1 **] x 7 days [**5-8**]- for ?
- flagyl 500 mg TID x 10 days [**5-8**]- for loose stool (diagnosed
- acidophilus x 30 days ppx
- ISS
- miralax 17 g prn
- senna [**Hospital1 **] prn
- MOM 30 mL daily prn for constipation
- dulcolax 10 mg suppository rectally daily prn
- fleet enema 1 rectally daily prn
- maalox 30 mL q6h prn
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
7. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as
needed for constipation.
8. Fleet enema
1 enema PR PRN constipation
9. Oxygen Therapy
Continuous bland aerosol mask 40 % Via Trach Mask
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Acute cholecystitis with sepsis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Not interactive, withdraws to pain
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 110682**] was admitted for an infection, and was treated
with a course of IV antibiotics to kill the infection, which
likely originated from an infected gallbladder. His antibiotic
course has completed. He also had a drainage catheter placed in
his gallbladder, to drain the infection.
.
He also had a test to rule out a blood clot in the lung, called
a CTA of the chest, and this test was negative (there was no
blood clot).
.
Please STOP previous antibiotics, including bactrim, ceftin,
flagyl. It will be very important to follow-up at the scheduled
surgery appointment to have the gallbladder drain evaluated.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2122-5-26**] at 1:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
Completed by:[**2122-5-15**]
|
[
"0389",
"5990",
"2761",
"5180",
"2859"
] |
Admission Date: [**2174-8-15**] Discharge Date: [**2174-9-2**]
Date of Birth: [**2103-11-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
worsening shortness of breath, chest pain
Major Surgical or Invasive Procedure:
CoreValve on [**2174-8-16**]
History of Present Illness:
Ms. [**Known lastname 16905**] is a 70-year-old woman who was
referred with critical aortic stenosis.
In [**2173-10-18**], she suffered a syncopal episode and presented
to [**Hospital2 **] [**Hospital3 6783**] Hospital where evaluation documented critical
aortic stenosis by both catheterization as well as
echocardiography. Coronary angiography at that time
demonstrated
an occluded proximal LAD, moderate diffuse disease in the LCx,
and an occluded RCA. There was a patent SVG to the right
coronary and a patent SVG tot he LAD. Quantitation of her aortic
stenosis yielded a mean transvalvular gradient of 46 mmHg and a
valve area of 0.6 by Fick estimate. At that time, the patient
reportedly had a significantly elevated pulmonary arterial
pressure of systolic of 115mmHg, though no wedge pressure was
available in the report. She was evaluated by Dr. [**Last Name (STitle) 50180**] of
Cardiothoracic Surgery at [**Hospital2 **] [**Hospital3 6783**] and deemed to be
prohibitively high-risk candidate for traditional aortic valve
surgery.
Over the ensuing six months, the patient has had recurrent
episodes of syncope as well as falls due to gait instability.
She
has continued to have exertional chest pressure, but no
palpitations and she has been hospitalized several times
following falls at home. She has profound dyspnea on exertion
(NYHA Class III) and has had several episodes of syncope per
month. She now reports onset of chest discomfort after 15 feet
of
walking.
She has met inclusion criteria for Corevalve study and does
not meet exclusion criteria. Her findings have been reviewed,
submitted, and accepted for the Extreme arm Corevalve study.
Since last seen in office, she is only able to ambulate
short distances (room to room) due to shortness of breath. She
comes in this am somewhat lethargic and diaphoretic, blood
glucose was 43, she was treated with 1/2 amp of D50w, and oral
juice, blood glucose 188. Patient somnolent, family reports she
took 2 doses of clorazepam at 2am. Patient reports she has been
anxious about procedure and has been unable to sleep. Answers
questions appropriately, somnolent unless verbally stimulated.
ABG done on baseline O2 3L nc. Acceptable findings.
NYHA Class: III-IV
Past Medical History:
1. aortic stenosis
2. aortic valvuloplasty [**2174-3-24**]
3. CAD - s/p CABG x 2 ([**2159**]), PCI, chronic RBBB
4. COPD - home oxygen x 5 years
5. severe pulmonary hypertension
6. diabetes
7. hypertension
8. hyperlipidemia
9. obstructive sleep apnea -has own CPAP machine
10. obesity
11. renal insufficiency
12. osteoarthritis
13. situational depression
14. presbyopia
15. gout
16. nasal fracture secondary to [**2159**]7. cholecystectomy
[**80**]. knee pain s/p [**2080**]9. ventral hernia
Social History:
SOCIAL HISTORY: She lives with her sister, [**Name (NI) 4248**]. She has another
sister, [**Name (NI) 37620**] who assists with her [**Name (NI) 5669**]. Ambulates at home
with
walker, uses wheelchair when out of house. Has 4 steps to enter
home, and chair lift once inside. Currently, physical therapy
sees her once weekly for her knee injury.
[**Name (NI) 37620**] [**Name (NI) **] (sister) [**Telephone/Fax (1) 88728**]
[**Doctor First Name **] (neice) [**Telephone/Fax (1) 88729**]
Average Daily Living:
Live independently Yes [x] No [ ]
Bathing [ ] Independent [x] Dependent
Dressing [ ] Independent [x] Dependent
Toileting [x] Independent [ ] Dependent
Transferring [ ] Independent [x] Dependent
Continence [x] Independent [ ] Dependent
Feeding [x] Independent [ ] Dependent
Family History:
FAMILY HISTORY: Positive for diabetes and coronary artery
disease. Her father died in his 50s of an MI and her mother died
at 98 of a CVA.
Physical Exam:
ADDMISSION EXAM:
Pulse: 46, B/P: Right 143/57, Resp: 18, O2 Sat: 95 (O2 2.5L),
Temp: 93.5 ax
Height: 160cm Weight: 98.6kg
General: Elderly heavy set female in wheelchair with O2 notably
SOB with conversation.
Skin: Pale, skin warm and dry.
HEENT: Normocephalic. Anicteric.
Neck: Supple, trachea midline. Bilat. carotid bruit vs. murmer.
Chest: Able to speak in short phrases only.
Heart:murmer throughout
Abdomen: Rotund, soft, (+)bowel sounds.
Extremities: 2+ lower extremity edema bilaterally. Bilateral
knee
pain.
Neuro: A+O x 3, c/o pain to bilateral knees. Somnolent,
upperextremities. UE's muscle wasting.
Pulses: palpable peripheral pulses
DISCHARGE EXAM:
Temp: 98 HR: 60 RR: 18 BP: 130/47 O2 sat 96% RA. Weight 83.3 kg.
.
GENERAL: 70 yo F in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated.
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2, 1/6 systolic murmur at RUSB, Normal in quality and
intensity RRR no murmurs rubs or gallops
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: feet warm, no edema, pulses palp. Left groin with large
open wound from surgical cutdown s/p bovine patch and staple
closure (staples now removed). Wound has dehiscence in the upper
proximal portion. Wound has circumferential redness and mild
yellow drainage and copious tan serous drainage from an
underlying seroma. See page 1 for dressing instructions.
NEURO: CNs II-XII intact. 4/5 strength in U/L extremities.
SKIN: no rash
PSYCH: appears calm today, A/O.
Pertinent Results:
Cardiac Catheterization: ([**2174-3-24**] [**Hospital1 112**] - valvuloplasty)
Diagnostic results-
Two Vessel CAD involving the LAD and RCA
s/p CABG: all grafts patent
s/p CABG: 2 patent of 2 total grafts
Elevated Right Heart Filling Pressures RA= 24 mmHg
Elevated Right Heart Filling Pressures RV= 102/20 mmHg
Elevated Right Heart Filling Pressures PA= 96/34 (57) mmHg
Elevated Left Heart Filling Pressures [**Last Name (un) 5767**] PCWP = 26 mmHg
Aortic stenosis: severe
Aortic calculated [**Location (un) 109**]: 0.59 cm2
Aortic mean gradient: 63.2
.
Echocardiogram: TTE (Complete) Done [**2174-7-8**] at 1:00:00 PM
FINAL
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55%
Left Ventricle - Stroke Volume: 63 ml/beat
Left Ventricle - Cardiac Output: 4.02 L/min
Left Ventricle - Cardiac Index: 2.19 >= 2.0 L/min/M2
Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec
Aortic Valve - Mean Gradient: 37 mm Hg
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
IMPRESSION: Critical calcific aortic stenosis. Symmetric LVH
with
normal global and regional systolic function. Mild to moderate
mitral regurgitation. Severe pulmonary hypertension.
EKG: [**2174-6-17**] 10:43:36 AM
ECG interpreted by ordering physician.
[**Name10 (NameIs) 357**] see corresponding office note for interpretation.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 130 150 488/493 59 86 21
CT: ([**2174-7-8**])
IMPRESSION:
1. Evidence of known aortic stenosis. Measurements regarding the
aortic valve as well as iliac arteries will be provided
separately.
2. Extensive aortic calcifications with no evidence of
dilatation.
3. Anterior abdominal hernia containing part of the transverse
colon, with no evidence of obstruction at this point.
4. Pulmonary nodules that, based on the size, should be
reevaluated in one year.
5. Status post CABG with what appears to be patent bypass to
distal LAD and PDA.
6. Borderline mediastinal lymph nodes that might be reevaluated
on subsequent study.
7. Evidence of pulmonary hypertension.
8. Right hypodense kidney lesion as well as hypodense liver
lesion that should be correlated with ultrasound.
9. Diffuse enlargement of the thyroid with multiple nodules that
might be evaluated by thyroid ultrasound.
PFT's:
[**Hospital3 14325**];s Hospital at WMC
FVC 1.06 (39%)
FEV1 0.75 (36%)
FEV1/FVC 71 (92%)
TLC 2.45 (50%)
FRC 1.48 (53%)
IC 0.97 (46%)
RV 1.38 (64%)
RV/TLC 56 (130%)
DLCO 5.50 (24%)
DLCO/VA 3.82 (72%)
.
CTA AORTA/BIFEM/ILIAC RUNOFF [**8-31**]:
Impression: Lung volumes demonstrate marked reduction in the
TLC, FRC, RV, and VC. Spirometry demonstrates a much reduced
FVC
and FEV1 with a normal FEV1/FVC. The DLCO is mildly reduced.
.
IMPRESSION:
1. Large postop seroma in the left inguinal region measuring 8.7
x 9.8 x 6.7 cm.
2. Diffuse soft tissue stranding and mild swelling of the left
leg compared to the right.
3. Right upper lobe tree-in-[**Male First Name (un) 239**] opacities concerning for
aspiration with
small bilateral simple pleural effusions.
4. Patent arterial system with no flow-limiting stenoses noted.
5. Grade 1 anterolisthesis of L4 on L5.
.
[**8-23**] ECHO:
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 65%). The right ventricular free wall
is hypertrophied. Right ventricular chamber size is normal. with
borderline normal free wall function. The aortic root is mildly
dilated at the sinus level. An aortic CoreValve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
A mild paravalvular aortic valve leak is present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. There is
a minimally increased gradient consistent with trivial mitral
stenosis. Moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] 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.
.
ECG [**8-26**]:
Sinus rhythm with probable biventricular pacemaker. Intra-atrial
conduction defect with atrial tracking. Since the previous
tracing of [**2174-8-21**] atrial pacing is no longer present.
.
VS on discharge:
temp 98, HR 60, RR 18, BP 130/70, O2 sat 97% RA. Weight: 83.3
kg.
.
Exam on Discharge:
GENERAL: 70 yo F in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated.
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2, 1/6 systolic murmur at RUSB, Normal in quality and
intensity RRR no murmurs rubs or gallops
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: feet warm, no edema, pulses palp. Left groin with mod tan
serous drainage r/t underlying wound seroma, decreasing today.
Also has mild circumferential redness that is improving with
small yellow purulent drainage.
NEURO: CNs II-XII intact. 4/5 strength in U/L extremities.
SKIN: no rash
PSYCH: appears calm today, A/O.
Brief Hospital Course:
IMPRESSION: 70yo female with severe symptomatic aortic stenosis
including chest pain and near syncope with significant COPD,
continuous home O2, and moderate to severe pulmonary
hypertension. h/o CABG x 2 with patent grafts.
1.Symptomatic Aortic Stenosis: Patient had a critical AS (area
0.6cm2) and received a percutaneous bioprosthetic aortic valve
replaement on [**8-16**]. She was started on plavix and was
maintained on her 81 mg aspirin dose. Procedure was complicated
by AV dissociation with junctional escape rhythm and ventricular
tachycardia requiring cardioversion x2. A permanent pacemaker
was placed from the left subclavian and the patient was AV
sequentially paced at 80 bpm. Procedure was otherwise
successful. Post-operatively she required intubation and
pressure support for three days. Pt was also NO for pulm htn
after procedure and ultimately weaned to 100% O2. Vent was
weaned and blood pressures improved and pt was extubated on [**8-19**].
On [**2174-8-23**], a post-procedure echo showed a normal trans aortic
gradient. A mild paravalvular aortic valve leak was present. She
has had a slow recovery but reports decreased DOE with
ambulation, no chest pain and no episodes of syncope. She is
scheduled for cardiac f/u in 2 weeks.
.
2. COPD/pulmonary HTN/sleep apnea: An admimssion ABG and CXR
were preformed which showed: 121/51/7.38/31. As mentioned above,
she required extended intubation post procedurally. Pulmonary
was consulted and she was weaned off NO with 100%O2 and vent
settings were weaned. Pt was extubated on [**8-19**] and tolerated
home O2 of 3L NC and CPAP for OSA. She needs to be encouraged to
bring in her CPAP machine from home to use.
.
3. Left femoral artery injury: Iatrogenic left femoral injury
during fem-fem bypass was repaired with bovine pericardium,
closed [**8-17**] at bedside. Staples were kept in place until [**8-30**].
Incision site was complicated by cellulitis and CTA with runoff
of lower extremity did not show evidence of infected graft. Gram
stain showed GNR, GPC, GPR, speciated pseudomonas. She was
started on IV antibiotics and discharged on vancomycin and Zosyn
IV until [**9-12**] (total of 2 week course)and then needs to be
changed to ciprofloxacin PO for another 2 week course. Please
see page one for specific dressing changes and contact number
for concerns or questions. She was scheduled for a f/u appt with
Dr. [**Last Name (STitle) 22423**] in 2 weeks. Fluconazole was started to treat a
presumed vaginal yeast infection.
.
5. Complete heart block: Procedure was complicated by AV
dissociation with Vtach s/p two cardioversions and DDD PPM was
placed. On [**8-23**] device was interrogated revealing intrisic rhythm
of complete heart block without escape and PPM was A-V
sequential paced at rate of 60.
.
6. Diabetes: Pt was managed on insulin ss and home standing
insulin. HgbA1C was 6.2.
.
7. CKD: baseline Cr is 1.5. After corevalve, cr elevated to 2.3
secondary to prerenal etiology, then decreased to under her
baseline at 1.3.
.
8. Depression/anxiety: Pt has a long history of depression and
had symptoms of impaired coping with her prolonged
hospitalization. She has an outpatient psychiatrist who sees her
frequently. Psych was consulted and did not recommend any
changes to her anti depressants but advised haldol at HS. This
was started but stopped at discharge because of mild tremor. Her
sleep has improved and anxiety decreased during her hospital
stay. She would benefit from a psychiatric consultation at
rehab.
Medications on Admission:
ASA 81mg daily
metoprolol tartrate 12.5mg daily
simvastatin 20mg qhs
furosemide 20mg [**Hospital1 **]
metolazone 2.5mg 2x/week (qmon&fri)
insulin glargine (Lantus) 22units daily (pt regulates- varies)
insulin Lispro (humalog)3u bkfst,2u lunch,8u dinner, 3u hs
potassium chloride 20meq tid
ferrous sulfate 325mg daily
lansoprazole 30mg daily
MVI 1 tab daily
Allopurinol 150 daily
Buproprion HCL SR 200mg [**Hospital1 **]
clonazepam 2mg qhs
excitalopram Oxalate (Lexapro) 30mg daily
nitroglycerin SL 0.4mg SL prn chest pain
trazodone 100mg qhs prn insomnia
hydrocodone-acetaminophen 5/500mg 1-2 tabs q6h prn pain
oxygen 3L nasal cannula continuously
tolterodine (detrol) 2mg po bid
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID (2 times a day).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks: Start only after IV antibiotics is done on [**9-12**], then
continue for 2 week course.
8. Vancomycin 1000 mg IV Q 24H
Monitor levels closely and dose based on goal peak and trough.
Please consult pharmacy for assistance in dosing.
9. Piperacillin-Tazobactam 4.5 g IV Q8H
Cont for total of two weeks, last day is [**2174-9-12**].
10. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
11. ferrous sulfate 324 mg (65 mg iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
12. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
13. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for anxiety.
15. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for insomnia.
16. hydrocodone-acetaminophen 5-500 mg Capsule Sig: [**12-19**] Capsules
PO three times a day as needed for pain.
17. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
18. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Lantus 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous at bedtime.
20. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous four times a day: see attached sliding scale.
21. fluconazole 100 mg Tablet Sig: 1.5 Tablets PO once a day for
2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Aortic stenosis s/p corevalve placement
Complete heart block
Acute on Chronic Diastolic congestive heart failure
Coronary artery disease
Chronic Obstructive pulmonary disease on home oxygen
Diabetes mellitus
Obstructive sleep apnea
Acute on Chronic kidney injury
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 Mrs. [**Known lastname 16905**],
You were admitted to the hospital for placement of a corevalve
prosthesis because of your aortic stenosis. You had some
hypotension after the procedure and needed medicine to keep your
blood pressure up. You developed some fluid overload and
required lasix to get rid of the extra fluid. You were on a
breathing tube that was removed on [**8-19**]. Your rhythm was slow and
a pacemaker was implanted. This will need to be followed every 6
months to make sure it is working properly. The left groin site
where the catheters were is slow to heal, has had a lot of
drainage and is mildly infected. You will need to continue
intravenous antibiotics for 2 weeks and get frequent dressing
changes.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start Zosyn and vancomycin for the infection in the groin
2. Metoprolol was changed to a long acting verson
3. Furosemide was increased to 40 mg twice daily
4. Start Plavix to decrease the chance of a blood clot on the
new valve
5. Metolazone was held for now
6. Decrease potassium to once daily
7. Decrease lexapro to 20 mg daily
8. discontinue Detrol
9. Start lisinopril 5 mg daily to lower your blood pressure and
help your heart pump better.
10. Start fluconazole to treat the vaginal yeast infection from
the antibiotics.
Followup Instructions:
Vascular:
Department: VASCULAR SURGERY
When: THURSDAY [**2174-9-15**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
***Please have your pcp send an insurance referral to Dr
[**Last Name (STitle) 88730**] office before the visit. Fax to [**Telephone/Fax (1) 17352**]
.
Department: CARDIAC SERVICES
When: FRIDAY [**2174-9-16**] at 9:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2174-9-16**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2174-9-16**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"4168",
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"V5867"
] |
Admission Date: [**2161-6-30**] Discharge Date: [**2161-7-21**]
Date of Birth: [**2129-8-16**] Sex: F
Service: LIVER TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old
female status post liver transplant twice in [**2161-3-26**]. The
patient had primary sclerosing cholangitis and cirrhosis of
her native liver and patient underwent a liver transplant on
[**2161-4-13**]. The operation was complicated by
intraoperative thrombosis and the patient had a repeat
transplant on [**2161-4-19**]. That operation was complicated
by portal vein thrombosis and cerebral edema and the patient
had ICP monitor placed and was trached on [**2161-5-6**].
The patient also had a G-tube placed at that time. The
patient had a prolonged hospital course at that time and was
discharged to rehab. However, at rehab she was tolerating
tube feeds. Prior to admission the patient complained of
some indigestion, some nausea and vomiting and on the morning
of admission the patient had bouts of emesis. A couple hours
prior to admission the patient became cyanotic and
unresponsive and patient was then transported to the
Emergency Room at [**Hospital1 69**]. In
the Emergency Room the patient was emergently intubated and
central line was then placed and patient was started on
intravenous fluids. The patient required some pressors for
her blood pressure support and patient underwent CT scan
which showed large ventricle size and severe atrophy of her
brain. CT of the chest showed bilateral large inferior lobe
consolidation, question aspiration pneumonia and abdominal CT
showed dilated stomach along with dilated duodenum. The
patient was admitted to the Intensive Care Unit and underwent
a somewhat prolonged hospital course.
PAST MEDICAL HISTORY: Includes primary sclerosing
cholangitis, cirrhosis, ulcerative colitis, psoriasis,
cerebral edema and seizure.
PAST SURGICAL HISTORY: Two liver transplants
placement, tracheostomy and also G-tube placement and
cerebral edema.
MEDICATIONS ON ADMISSION: She was on Neoral 150 b.i.d.,
CellCept one gram p.o. b.i.d., prednisone 10 mg p.o. q. day,
Diflucan 400 mg p.o. q. day and Valcyte 450 mg p.o. q. day.
She was on Bactrim, Keppra 1000 mg p.o. b.i.d., amantadine 50
mg p.o. b.i.d., Osmolite 400 mg p.o. q. 6h. and Reglan 10 mg
p.o. b.i.d., Protonix 40 mg p.o. q. day, Lopressor 100 mg
p.o. q. 6h.
HOSPITAL COURSE BY SYSTEM: Neurological: The patient was
initially unresponsive and the Neurology Service and
Neurosurgery Service were then consulted. There was a
question of whether the patient had increased cerebral edema
and had increased intracranial pressure due to her large
ventricular size. A CT scan that was done several weeks
prior at [**Hospital6 1129**] was obtained and
showed the ventricular size had not increased so Neurosurgery
held off on drain placement. Neurology recommended EEG so
EEG was then obtained which showed no seizure activity and
diffuse metabolic encephalopathy. The patient underwent MRI
which showed question of small new infarct and Neurology
recommended continuing the Keppra.
Cardiovascular: The patient was initially hypotensive and
throughout the hospital course the patient's pressure has
normalized and patient became increasingly tachycardic. She
was started back on her Lopressor dose and her heart rate was
then stabilized. Propofol was weaned off and the patient was
then stable from a cardiovascular standpoint.
Respiratory: The patient required prolonged intubation and
patient underwent percutaneous tracheostomy by Dr. [**Last Name (STitle) **]
on [**2161-7-16**]. Post-tracheostomy the patient did well and
she tolerated the trach mask.
Gastrointestinal: The patient had a feeding
tube placed for nutritional support. G-tube was not used and
on [**7-20**] the patient had an upper GI study which showed
normal gastric emptying and there was no sign of duodenal
dilatation. Patient was resumed tube feed by her G-tube.
Infectious Disease: Initially on presentation the patient
had a fever spike and she also had possible Clostridium
difficile. The patient was placed on vancomycin, Zosyn and
Flagyl for a total of a 21 day course. Vancomycin, Zosyn and
Flagyl were then discontinued on [**2161-7-20**].
Hematology: The patient's hematocrit has been stable and did
not require any transfusion or products.
Renal: The patient's renal function when she first came to
the hospital her creatinine had risen to 3.5 and with
intravenous hydration, creatinine gradually came down to base
level which was 0.9 to 1.0. Prior to discharge patient's
creatinine was stable at 1.0.
Hepatology: The patient's liver function enzymes have always
been normal. She had ultrasound of her liver done which
showed normal flow in the portal vein and also in the hepatic
artery as well as hepatic vein and her alk phos and total
bilirubin have all remained normal.
Prior to discharge, patient was afebrile. Vital signs were
stable. Her cultures were persistently negative.
Neurologically, she had improved. Right now, patient follows
commands and eyes were tracking. Cardiovascularly, the
patient has been stable on Lopressor. The patient will be
continued on Lasix 20 mg IV q. day. Respiratory-wise, the
patient has a trach which she tolerates trach mask. The
patient will be continued on her trach mask. Her chest was
clear bilaterally. Sputum has been negative.
Gastrointestinal-wise, the patient has been tolerating tube
feeds by her G-tube and she will be continued on the tube
feeds via G-tube. Genitourinary: The patient's creatinine
prior to discharge was 1.0 and the patient's Foley catheter
can be discontinued. Infectious Disease-wise, there were no
issues. All the antibiotics have been discontinued and
patient's cultures have remained negative. Transplant-wise,
she will remain on the cyclosporin, CellCept and prednisone
for immunosuppressants.
DISCHARGE DIAGNOSES: Include: Aspiration pneumonia,
hydrocephalus, sepsis, status post liver transplant times
two, primary sclerosing cholangitis, cirrhosis, ulcerative
colitis, psoriasis, cerebral edema and seizure.
DISCHARGE MEDICATIONS: Include:
1. Duoneb one to two puffs q. 6h. p.r.n.
2. Neoral 275 p.o. b.i.d.
3. Lasix 20 mg IV q. day.
4. Heparin subcu 5000 units b.i.d.
5. Insulin sliding scale.
6. Lansoprazole 30 mg p.o. q. day.
7. Keppra 1000 mg p.o. b.i.d.
8. Lopressor 125 mg p.o. t.i.d. Hold for systolic pressure
less than 100 or heart rate less than 60.
9. CellCept [**Pager number **] mg p.o. b.i.d.
10. Prednisone 7.5 mg p.o. q. day.
11. Bactrim one tab p.o. q. day.
12. ___________ 450 mg p.o. b.i.d.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Discharged to rehab.
DISCHARGE INSTRUCTIONS: The patient is to follow up at the
[**Hospital 1326**] Clinic once q. week and patient is to get blood
drawn Monday and Thursday.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern4) 32455**]
MEDQUIST36
D: [**2161-7-21**] 13:58:25
T: [**2161-7-21**] 14:30:15
Job#: [**Job Number 32456**]
|
[
"5070",
"0389",
"99592",
"51881",
"2767"
] |
Admission Date: [**2151-4-4**] Discharge Date: [**2151-4-10**]
Date of Birth: [**2086-12-23**] Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
VF arrest
Major Surgical or Invasive Procedure:
Arterial Line
Central Venous Line
Mechanical Intubation
Dialysis
History of Present Illness:
Patient's name per driver license is [**Known firstname **] [**Known lastname **] of [**Doctor First Name 92582**],
[**State 108**]. Phone number is [**Telephone/Fax (1) 92583**]. Next of [**Doctor First Name **] is [**Name (NI) 7279**]
[**Name (NI) **] (wife). Phone number is [**Telephone/Fax (1) 92583**].
64M history of Prinzmetal's angina transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
to [**Hospital1 18**] s/p cardiac arrest. He has a history of recurrent chest
pain due to "coronary artery spasm" per wife with extensive
evaluation. He is very athletic.
While driving, the patient complained of acute onset of chest
pain. He took aspirin as usual. Approximately 20 minutes after
onset of chest pain, the patient had an acute alteration of
mental status. She pulled off the road and started CPR but could
not get a pulse.
EMS arrived and the patient was undergoing CPR. Total downtime
was approximately 7 minutes prior to arrival EMS. On arrival of
EMS the patient was in ventricular fibrillation. The patient was
intubated with 7.5 ETT placed at 22 and ACLS was initiated with
epinephrine and shocks for ventricullar fibrillation.
Pt was brought to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] during which he received 3 shocks
for fine ventricullar fibrillation. He was given lidocaine 100
mg x 2 and epinephrine 1 mg x 4. He transiently converted to
asystole and then back to V. fib. He also received 150 mg
amiodarone. He was also given magnesium and IV calcium. And
thereafter appeared to be hypotensive and bradycardic, and was
given atropine. Because of persistent hypotension and
bradycardia, a dopamine drip was initiated. Patient was packed
with ice and transported via med flight.
Per Med Flight documentation, patient received dopamin @ 15
mcg/kg/min, fentanyl 100 mcg in 50 mcg doses, amiodarone 1
mg/min. Vent settings were SIMV/PS 400x18 PEEP 7 PS 10 cm FiO2
100 %.
The patient was noted to have pulmonary edema on chest x-ray on
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. ECG prior to transport showed an idioventricular
rhythm with wide complex rhythm.
In the [**Hospital1 18**] ER, initial VS were HR 92 102/85 RR 19 pOx 97 on
100%, 500x18, volume-control. His initial rhythm on arrival was
narrow complex.
An arterial line was placed in left groin. Central line was
placed in the left groin as well. Per ER reports, lines were
placed in sterile fashion although documentation was not sent
with ER paperwork. This has been requested.
CXR was performed showing diffuse bilateral opacities with air
bronchograms suggesting severe pulmonary edema, potentially
capillary permeability edema. Cardiac size was within normal
limits.
Labs were performed
CBC WBC 18 Hct 53 MCV 104 Plt 175 with differential N 81 B 7 L
12 INR 1.4 PT 14.7 PTT 51.7
CK 997 CK-MB 104 cTropnT 1.52
pH 7.09 pCO2 46 pO2 83 HCO3 15 Lactate 8.2 (from 10.4). After
ABG showed significant acidosis, RR was increased.
Cardiology was consulted and recommended admission to CCU for
post-arrest care. He was loaded plavix 600 mg PO x 1, aspirin
325 mg PO x 1, and started on heparin infusion.
The post-arrest consult service was consulted. Artic Sun cooling
protocol was initiated with goal temperature of 33 x 24 hours
(cooling start time: 15:10 on [**2151-4-4**]) and sedated to RASS -5.
He was given midazolam 2 mg/hr, fentanyl 50 mcg/hr, vecuronium
10 mg IV x 1 in addition to amiodarone 1 mg, dopamine 20 mg/kg.
Patient also became hypotensive (SBP 80-90s). His dopamine was
increased from 15 to 20, and he was started on levophed.
Admission Vitals: T 34.5 HR 86 BP 96/84 pOx 97 on 100%, 500x22,
volume-control.
.
Patient is not able to provide ROS given sedated.
.
In CCU, ECHO showed relatively preserved LVEF, no global wall
motion abnormalities, ? pericardial effusion, worse at apex.
Limited study.
Family meeting held with wife at bedside with CCU. She was
updated on clinical situation including cardiac arrest,
neuroprotection strategy, and potential for poor prognosis. She
will visit tonight.
Past Medical History:
? Prinzmetal's angina. Patient was last hospitalized in [**Month (only) 1096**]
for chest pain and diaphoresis. Per wife, negative cardiac
work-up.
Social History:
unable to obtain as sedated
Family History:
unable to obtain as sedated
Physical Exam:
Vitals: 97.7F, HR 70, BP 126/65, 99% CMV 26/500/40%/5
General: Intubated, sedated, does not respond to voice or follow
simple commands, artic sun pads in place
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Soft crackles at bases, no wheezes, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On Admission:
[**2151-4-4**] 02:45PM PT-14.7* PTT-51.7* INR(PT)-1.4*
[**2151-4-4**] 02:45PM PLT SMR-NORMAL PLT COUNT-175
[**2151-4-4**] 02:45PM NEUTS-81* BANDS-7* LYMPHS-12* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2151-4-4**] 02:45PM WBC-18.0* RBC-5.07 HGB-17.3 HCT-53.0*
MCV-104* MCH-34.1* MCHC-32.7 RDW-13.5
[**2151-4-4**] 02:45PM CALCIUM-8.7 MAGNESIUM-2.6
[**2151-4-4**] 02:45PM CK-MB-104* MB INDX-10.4*
[**2151-4-4**] 02:45PM cTropnT-1.52*
[**2151-4-4**] 02:45PM CK(CPK)-997*
[**2151-4-4**] 02:45PM estGFR-Using this
[**2151-4-4**] 02:45PM GLUCOSE-224* UREA N-14 CREAT-1.4* SODIUM-140
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-15* ANION GAP-24*
[**2151-4-4**] 02:55PM LACTATE-10.4*
[**2151-4-4**] 02:55PM TYPE-[**Last Name (un) **] RATES-/18 TIDAL VOL-500 PEEP-5
O2-100 INTUBATED-INTUBATED VENT-CONTROLLED
[**2151-4-4**] 03:07PM VoidSpec-[**First Name9 (NamePattern2) 21799**] [**Male First Name (un) **]
[**2151-4-4**] 03:25PM LACTATE-8.2*
[**2151-4-4**] 03:25PM TYPE-ART TEMP-35.1 RATES-18/ TIDAL VOL-500
PEEP-5 O2-100 PO2-73* PCO2-64* PH-7.03* TOTAL CO2-18* BASE
XS--15 AADO2-579 REQ O2-95 INTUBATED-INTUBATED VENT-CONTROLLED
[**2151-4-4**] 03:56PM TYPE-ART TEMP-34.7 RATES-26/ TIDAL VOL-600
PEEP-12 O2-100 PO2-83* PCO2-46* PH-7.09* TOTAL CO2-15* BASE
XS--15 AADO2-587 REQ O2-96 -ASSIST/CON INTUBATED-INTUBATED
[**2151-4-4**] 05:51PM PT-16.4* PTT-150* INR(PT)-1.5*
[**2151-4-4**] 05:51PM PLT COUNT-140*
[**2151-4-4**] 05:51PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-2+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL BURR-2+
[**2151-4-4**] 05:51PM NEUTS-90* BANDS-5 LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2151-4-4**] 05:51PM WBC-18.2* RBC-5.36 HGB-17.4 HCT-54.8*
MCV-102* MCH-32.4* MCHC-31.7 RDW-13.9
[**2151-4-4**] 05:51PM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-6.6*
MAGNESIUM-2.3
[**2151-4-4**] 05:51PM CK-MB-275* MB INDX-13.7* cTropnT-7.32*
[**2151-4-4**] 05:51PM ALT(SGPT)-213* AST(SGOT)-412* CK(CPK)-[**2145**]*
ALK PHOS-126 TOT BILI-1.0
[**2151-4-4**] 05:51PM GLUCOSE-241* UREA N-16 CREAT-1.4* SODIUM-141
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-11* ANION GAP-26*
[**2151-4-4**] 06:00PM freeCa-1.17
[**2151-4-4**] 06:00PM GLUCOSE-223* LACTATE-8.4*
[**2151-4-4**] 06:00PM TYPE-ART PO2-104 PCO2-41 PH-7.10* TOTAL
CO2-13* BASE XS--16
[**2151-4-4**] 09:47PM LACTATE-10.5*
[**2151-4-4**] 09:47PM TYPE-ART TEMP-33.2 PO2-175* PCO2-30* PH-7.25*
TOTAL CO2-14* BASE XS--12 INTUBATED-INTUBATED
Relevant Labs:
[**2151-4-5**] 04:17AM BLOOD PT-15.0* PTT-32.5 INR(PT)-1.4*
[**2151-4-6**] 09:21PM BLOOD PT-17.4* PTT-34.9 INR(PT)-1.6*
[**2151-4-9**] 03:07AM BLOOD PT-29.4* PTT-68.2* INR(PT)-2.8*
[**2151-4-6**] 09:21PM BLOOD Fibrino-348
[**2151-4-6**] 04:10AM BLOOD Glucose-127* UreaN-31* Creat-2.1* Na-135
K-5.7* Cl-110* HCO3-13* AnGap-18
[**2151-4-6**] 10:09AM BLOOD Glucose-136* UreaN-38* Creat-2.6* Na-134
K-6.5* Cl-107 HCO3-15* AnGap-19
[**2151-4-4**] 05:51PM BLOOD ALT-213* AST-412* CK(CPK)-[**2145**]*
AlkPhos-126 TotBili-1.0
[**2151-4-5**] 12:03AM BLOOD ALT-146* AST-380* CK(CPK)-2527*
[**2151-4-5**] 04:17AM BLOOD ALT-166* AST-400* CK(CPK)-2887*
[**2151-4-6**] 04:10AM BLOOD ALT-125* AST-270* CK(CPK)-1889*
AlkPhos-34* TotBili-0.5
[**2151-4-4**] 02:45PM BLOOD cTropnT-1.52*
[**2151-4-4**] 05:51PM BLOOD CK-MB-275* MB Indx-13.7* cTropnT-7.32*
[**2151-4-5**] 12:03AM BLOOD CK-MB-411* MB Indx-16.3* cTropnT-7.22*
[**2151-4-5**] 04:17AM BLOOD CK-MB-GREATER TH cTropnT-7.42*
[**2151-4-6**] 04:10AM BLOOD CK-MB-375* MB Indx-19.9* cTropnT-5.42*
[**2151-4-6**] 09:21PM BLOOD Hapto-<5*
[**2151-4-6**] 09:21PM BLOOD D-Dimer-3660*
[**2151-4-7**] 05:26AM BLOOD Hapto-15*
[**2151-4-8**] 10:10AM BLOOD Hapto-119
[**2151-4-5**] 12:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Barbitr-NEG Tricycl-NEG
[**2151-4-4**] 03:25PM BLOOD Type-ART Temp-35.1 Rates-18/ Tidal V-500
PEEP-5 FiO2-100 pO2-73* pCO2-64* pH-7.03* calTCO2-18* Base
XS--15 AADO2-579 REQ O2-95 Intubat-INTUBATED Vent-CONTROLLED
[**2151-4-5**] 09:28AM BLOOD Type-ART Temp-33 pO2-99 pCO2-24* pH-7.28*
calTCO2-12* Base XS--13
[**2151-4-4**] 02:55PM BLOOD Lactate-10.4*
[**2151-4-4**] 03:25PM BLOOD Lactate-8.2*
[**2151-4-4**] 06:00PM BLOOD Glucose-223* Lactate-8.4*
[**2151-4-5**] 10:55PM BLOOD Lactate-5.4*
[**2151-4-9**] 10:05AM BLOOD Glucose-139* Lactate-1.9
Studies:
[**4-4**] EEG:
IMPRESSION: This telemetry captured no pushbutton activations.
The
recording showed a burst suppression pattern throughout. It did
not
change appreciably over the course of the record. There were no
electrographic seizures.
[**4-5**] EEG:
This telemetry captured one pushbutton activation. It
showed some muscle activity on EEG without signs of
electrographic
seizure. There was some chin movement seen clinically on video.
Overall, the patient remained in a burst suppression pattern
throughout
but, later in the record, there was some muscle artifact. There
were no
clear epileptiform features or electrographic seizures.
[**4-7**] EEG: This telemetry captured no pushbutton activations. The
background was of such low voltage that no activity or clearly
cortical
origin could be discerned. [Of note, this monitoring recording
was not
performed with technological investigations to determine the
presence or
absence of cortical activity.] The recording suggests an
extremely
severe encephalopathy. This assumes the absence of sedating
medication.
[**4-8**] EEG
Markedly abnormal portable EEG due to the profound suppression
of the background rhythm such that no electrolytes or video
cortical origin was observed. There were some deflections
attributed to
movement artifact. It should be noted that this study was
performed as
a routine portable EEG without using technical specifications
for
obtaining an "electrocerebral silence" record. The very low
voltage
background without apparent reactivity indicates a very poor
prognosis
assuming that the lower voltages or not too sedating
medications,
hypotension, or hypothermia at the time.
[**4-4**] Echo:
Normal biventricular cavity sizes with preserved global
biventricular systolic function. Mildly dilated descending
thoracic aorta. No definite pathologic valvular flow identified.
Brief Hospital Course:
64M history of ? Prinzmetal's angina s/p witnessed VF arrest
with ROSC after defibrillation and ACLS who despite cooling
protocol and supportive therapy developed poor indicators of
perfusion (presenting lactate 10.4) and multi-organ failure with
hypotension requiring pressor support, acute respiratory
failure, acute renal failure, evolving shock liver, and impaired
neurological status after completion of rewarming and withdrawal
of sedation. Care was ultimately withdrawn per family, and the
patient passed away.
# s/p cardiac arrest
Patient s/p witnessed VF arrest in field. Prior cardiac work-up
negative in setting of chest pain episodes in past attributed to
coronary spasm. Etiology of current arrest was uncertain - may
be ischemic etiology vs. rhythm disturbance in setting of
coronary vasopasm. No evidence of STEMI. The pt's echo did not
demonstrate any systolic dysfunction which would be expected if
there were a large MI. Given downtime in field, pt had shock
with resultant multi-organ damage. Pt was initiated on Arctic
sun cooling protocol. Pt was placed on heparin infusion
initially for concern of thrombotic etiology of arrest, pt given
plavix and aspirin. Pt required pressor support with dopamine
and norepinephrine. The norepinephrine was able to be weaned
off. The dopamine was withdrawn with the rest of his care at
the family's request when it was clear that there would be no
meaningful neurologically recovery.
# Neuroprotection s/p arrest: Pt was initiated on Arctic Sun
cooling protocol s/p arrest. After rewarming, neurology
conducted serial exams and EEGs. This revealed anoxic brain
injury post-cooling with incomplete brainstem reflexes and flat
EEG showing no identifable brain activity and no reactivity to
stimulation. This occurred despite being fully off sedation.
These results were discussed with the family who subsequently
decided to withdraw care.
# Acute (uncompensated) primary respiratory acidosis, with
metabolic acidosis, with increased anion gap:
Patient had acute hypoxemic and hypercarbic respiratory failure
as result of arrest, s/p intubation and mechanical ventilation.
Decreased perfusion also lead to anion gap metabolic acidosis.
Pt was aggressively fluid resuscitated and was given HCO3
boluses as needed to correct lactic acidosis. Pt was
hyperventilated to correct respiratory acidosis. CVVH was
initiated. Pt's ABGs and lactates improved with these measures.
# Pulmonary edema
Patient had pulmonary edema in setting of cardiac arrest, shock,
most likely a mixed picture of both cardiogenic and
non-cardiogenic pulmonary edema. Aggressive fluid resuscitation
worsened pulmonary edema. The patient was started on CVVH to
remove fluid, which improved edema and decreased vent
requirements
# Acute renal failure:
Cr on admission 1.4 (eGFR 51) with unknown baseline. Patient
became anuric with worsening kidney function and fast rise in
potassium. Etiology likely pre-renal with ATN given prolonged
hypotension. Pt's acute renal failure necessitated CVVH. This
was used to normalize electrolytes, assist with pt's acid base
status, and remove fluid when the patient developed severe
pulmonary edema.
# Thrombocytopenia/Fingertip ischemia:
Most likely this occurred in setting of severe illness resulting
in suppression of platelet production. Other etiologies include
low grade DIC in setting of mostly normal DIC labs, sepsis, and
HIT. PF4 antibody was negative and 4T score was low, so HIT
unlikely. Coombs negative. Argatroban was initiated but then
stopped. Fingertip ischemia most likely from hypotension and
pressors.
# Leukocytosis/Low grade fever
WBC normalized, but pt did have elevated temperature which
required increased cooling. No clear localizing source. Pt
started on vancomycin and zosyn.
# Transaminitis
Unknown baseline. Elevation likely in setting of shock liver
from poor perfusion
Medications on Admission:
Xanax prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiac arrest
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2151-4-18**]
|
[
"5845",
"51881",
"2767",
"2875"
] |
Admission Date: [**2177-11-17**] Discharge Date: [**2177-11-18**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
L sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 85 year-old right handed male with past medical
history significant for HTN, afib on Coumadin, DMII, who
presented to his PCP with left sided weakness and was found at
[**Location (un) **] to have a large right BG bleed that tracks into the
lateral ventricles all the way to the fourth, with shift.
The patient reportedly (this is all through notes and
conversation with EMS) the patient reportedly wasn't feeling
well
and had a appointment with his PCP this afternoon. At the PCP's
office he apparently had left sided weakness and was sent
emergently to the ED at [**Location (un) **]. At [**Location (un) **] he acutely worsened
and had a change in mental status and became acutely
non-responsive and was intubated. He had a CT of the head and
was found to have a large right sided IPH, with some extension
in
the ventricle and a hint of blood in the fourth ventricle. His
INR was found to be 7.9. He was not reversed at this point and
sent to [**Hospital1 18**]
Here he was reversed with factor 9 and FFP and given vitamin K.
His exam was notable for bilateral fixed (but surgical pupils),
no right corneal reflex, extensor posturing with both arms and
triple flexing with both legs. He had an intact gag, and was
overbreathing the vent. He had a repeat head CT which showed a
large increase in the size of the bleed, with 1.6cm of shift and
possible uncal herniation. Neurosurgery was made aware and felt
this was catastrophic bleed and not amenable to surgery. He was
given mannitol and admitted to the unit.
There was a brief discussion with family who currently want
everything done.
Past Medical History:
- HTN
- A.fib
- DM II
- gait disorder unspecified
- polyuria
Social History:
Lives with his wife, daughter and daughter's family.
Was independent in ADLs. No tob/etoh/drugs
Family History:
Unknown
Physical Exam:
Initial exam in the ED
Physical Exam:
Vitals: T:96.1 P:62 R: 16 BP:132/105 SaO2:100
General: Intubated, sedated but bucking vent
HEENT: NC/AT, no scleral icterus noted,
Neck: Supple, no carotid bruits appreciated.
Pulmonary: mechanical breath sounds bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Neurologic:
-Mental Status: bucks vent, does not open eyes to noxious, does
not follow any commands
-Cranial Nerves:
I: Olfaction not tested.
II: both surgical, fixed, 4mm, doesn't blink to threat reliably
III, IV, VI: Has dolls eyes in both directions
V, VII: Clear corneal on left, not obvious on right
IX, X: Gag and cough intact
-Motor: Extensor postures both upper extremities, and triple
flexes with both legs b/l
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 3 3
R 2 2 2 3 2
clonus on left
Toes were upgoing bilaterally
Discharge EXAM
Was called at 19:17 to see patient who was reported to have
expired.
Patient was unresponsive
Pupils were 6 mm bilaterally and nonreactive to light
No spontaneous breathing
No heart sounds
Patient was pronounced dead at 19:20
Pertinent Results:
CT brain [**11-18**]
IMPRESSION:
1. Markedly increase in massive expanding right frontoparietal
intraparenchymal hematoma, now with massive hematoma replacing
the mid brain and pons extending to the lateral ventricles and
fourth ventricle.
2. Increased adjacent edema and mass effect with marked
transtentorial and peritonsillar herniation which increased
since prior study of [**2177-11-17**].
3. Increased obstructive hydrocephalus.
Brief Hospital Course:
Patient admitted on [**2177-11-17**] with known right massive
intraparenchymal cerebral hemorrhage with intraventricular
extension. The hemorrhage extended into the midbrain and pons -
thus, this was not a lesion from which the patient had a chance
of making a meaningful neurologic recovery.
INR was supratherapeutic.
Patient's family was informed of dire prognosis and elected to
make him CMO.
Was called to bedside at 19:17. Patient had expired. Family was
notified and declined autopsy. ME notified who declined autopsy.
Organ bank notified and declined case.
Medications on Admission:
- Glyburide 2.5mg qd
- Coumadin 2.5 3 days a week, 3mg the other days
Discharge Medications:
- patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2177-11-18**]
|
[
"4019",
"42731",
"25000",
"V5861"
] |
Admission Date: [**2154-5-12**] Discharge Date: [**2154-5-18**]
Date of Birth: [**2077-1-4**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Transfered for ERCP for elevated Bilirubin and concern for
cholangitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
77 yo M with h/o HTN, PAF p/w N/V/abdominal pain and poor PO
intake to an OSH, who was found to have elevated LFTs and
transferred here for ERCP. He initially developed N/V (no
hematemesis) about 1 week ago with associated abdominal pain
from the wretching, and thought that this was secondary to
gastroenteritis. The next few days he had poor PO intake. He
went to see his [**Name8 (MD) 6435**] NP and was treated with belladonna and a
medication that he can't remember with some improvement.
However, his symptoms returned and he felt progressively weaker,
culminating in a fall at home from his bed with head injury, but
no LOC. After the fall, he was unable to get help for 5 hours
before contacting his daughter and being brought into the
hospital. He presented to the ED at [**Location (un) **] on [**5-11**] where he
was found to be hypotensive with elevated LFTs and CK and a temp
to 101. He was also found to have ARF with a Cr 2.4 which
improved to 1.6 with hydration, and a leukocytosis of 13.4. He
was noted to have some small lacerations on his face in the ER,
which were stitched up, and had a head CT which was negative for
acute intracranial abnormality. His admission cardiac enzymes
were CK 9000, MB 51 and troponin 0.1 (negative). The troponin
remained flat, and his other enzymes normalized with hydration
to CK 3700, MB 13. His LFTs on admission included an AST 175
(peak 231), ALT 85, Bili 12.8 (peak 14.8). Lipase and amylase
were 181 and 186, respectively, about 1.3 times normal. An
ammonia level was normal. An abdominal ultrasound showed a
normal sized GB, intrahepatic and extrahepatic biliary ductal
dilatation, a dilated CBD measuring 1.0 cm, + sludge, a limited
evaluation of the pancreas and no visualized stones. A CXR
showed a large hiatal hernia witha associated LLL atelectasis.
A chest CT was ordered for further evaluation and showed a large
hiatal hernia extending to both hemithoraces with associated
adjacent atelectasis, without infiltrate or pleural effusion
seen. While in the ED, he developed an episode of SVT with
associated SOB and wheezing and that resolved on its own. The
patient was admitted to the MICU for monitoring and hydration.
In the MICU, he was started on levophed which was titrated off
early in the AM, unasyn 3 g Q6. His CVP was 17-18. He became
wheezy later that AM with a desaturation to 70% and his O2 was
increased from 2LNC to a 100% FM. He was found to be in AF with
RVR with rate 150, and a CXR showing pulmonary edema. He was
given lopressor, SL NTG, 40 mg IV lasix. His BP became
unsteady, and he was given an IV bolus with no effect and
started on a neosynephrine drip. An ABG was
7.23/36/156/14.7/98.7, and his IVF were changed to D5 with 3
Amps HCO3 at 150 cc/hr. A repeat ABG was 7.38/30.4/256/17.7.
The patient's antibiotics were also switched to gentamicin,
unasyn Q6 and levaquin just prior to transfer. GI was consulted
during his evaluation, and recommended an MRCP. As an MRCP was
not possible given the patient's multiple pumps, the decision
was made to transfer the patient to [**Hospital1 18**] for consideration of
ERCP and for tertiary care. Just prior to transfer, the patient
had another episode of flash pulmonary edema, and was given a
total of 15 mg lopressor without benefit, 10 mg diltiazem with
control of his rate, placed on a diltiazem drip, SL NTG x1 and 1
mg of morphine.
.
ROS: He reports low grade fevers at home to 99-100, no further
nausea, vomiting or abdominal pain, no diarrhea (though stools
are slightly loose), last BM yesterday, no black or bloody
stools, no chest pain, sob, dysuria.
Past Medical History:
HTN
PAF - on anticoagulation and rate control therapy
in-situ skin carcinomas, none metastatic, s/p multiple excisions
TTE 2 years ago - EF 65% with trace MR
[**First Name (Titles) **]
[**Last Name (Titles) **] cancer in remission
gout
s/p L CEA
s/p hernia repair
Social History:
SH: The patient lives alone in an apartment. Denies current use
of cigarettes - quit 50 years ago, 15 year smoking history. He
drinks alcohol very occasionally. He is retired, but does work
for a car dealer.
Family History:
FH: noncontributory
Physical Exam:
On admission to [**Hospital Unit Name 153**]
T 97.8 P 99 BP 119/80 RR 28 98% on 100% NRB
Gen: WDWN man lying in bed in NAD
HEENT: PERRLA, EOMI, icteric, OP clear, dry mucous membranes
Neck: RIJ line in place, no erythema
CV: RRR, nl s1, s2, no m/g/r
Lungs: expiratory wheezes throughout
Abd: BS+, soft, NT, tympanic, no dullness
Ext: warm and well-perfused, no edema
Neuro: A&Ox3 CN 2-12 intact, [**5-17**] UE strength, 3+/5 hip flexors,
o/w [**5-17**] LE strength, reflexes not elicited in biceps, patellar
or ankles bilaterally
Skin: yellow
Pertinent Results:
Labs/Studies:
ADMISSION LABS:
WBC-19.3* RBC-4.43* Hct-42.0 MCV-95 Plt Ct-164
Neuts-88* Bands-7* Lymphs-2*
PT-17.8* PTT-60.0* INR(PT)-1.7*
Fibrino-656*
Glucose-121* UreaN-26* Creat-1.0 Na-131* K-3.3 Cl-96 HCO3-22
AnGap-16
ALT-89* AST-170* LD(LDH)-353* CK(CPK)-1687* AlkPhos-301*
Amylase-108* TotBili-14.8* DirBili-13.0* IndBili-1.8
Lipase-263*
Albumin-2.4* Calcium-7.2* Phos-2.4* Mg-1.5*
[**2154-5-13**] 12:18AM BLOOD Cortsol-32.7*
[**2154-5-13**] 02:06AM BLOOD Cortsol-45.0*
HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM
HBc-NEGATIVE
BLOOD HCV Ab-NEGATIVE
DISCHARGE LABS:
[**2154-5-18**] 04:45AM BLOOD WBC-11.1* RBC-4.38* Hgb-14.6 Hct-41.7
MCV-95 MCH-33.2* MCHC-34.9 RDW-15.1 Plt Ct-328
[**2154-5-18**] 04:45AM BLOOD Plt Ct-328
[**2154-5-18**] 04:45AM BLOOD Glucose-82 UreaN-34* Creat-1.1 Na-132*
K-3.3 Cl-96 HCO3-28 AnGap-11
[**2154-5-18**] 04:45AM BLOOD ALT-63* AST-68* AlkPhos-296* TotBili-3.9*
[**2154-5-13**] 06:00AM BLOOD Lipase-225*
[**2154-5-18**] 04:45AM BLOOD Mg-1.8
EKG at OSH: AF with RVR and new RBBB (by report)
.
[**2154-5-11**] head CT - no intracranial hemorrhage, mass effect, shift
of normally seen midline structures or hydrocephalus.
[**Doctor Last Name 352**]/white matter differentiation is well maintained. osseous
and soft tissue structures are unremarkable. visualized
paranasal sinuses and mastoid air cells are clear.
.
[**2154-5-11**] Chest CT - There is a large hiatal hernia extending to
both hemithoraces with associated adjacent atelectasis. No
infiltrate or pleural effusion is seen. The remaining
mediastinal structures are unremarkable. The visualized portion
of the abdominal organs are unremarkable.
.
[**2154-5-11**] Portable Chest - comparison was made to prior study
dated [**2152-3-28**]. There is a large hiatal hernia with associated
adjacent atelectasis. No pleural effusion or infiltrate seen.
.
[**2154-5-11**] Abdominal ultrasound - Gallbladder is not significantly
distended. No significant gallbladder wall thickening. There
is intrahepatic and extrahepatic biliary ductal dilatation. The
CBD measures 1.0 cm which is abnormally dilated for the
patient's age. There is normal appearance of the liver and
bilateral kidneys. The right kidney measures 10.9 cm and the L
kidney length measures 12.0 cm. The spleen measures 9.9 cm.
Limited evaluation of the pancreas, abdominal aorta and IVC.
Large amount of biliary sludge is identified within the
gallbladder but gallstones are not identified.
EKG here: NSR at 92 (seems to be sinus rhythm - p waves seen in
V1, but difficult to see elsewhere, regular rate), nl axis, 1st
degree AV block, RBBB, TW in III, V1
ERCP: single CBD stone removed with drainage of frank pus.
Brief Hospital Course:
77 yo M with ascending cholangitis with hypotension and acute
renal failure admitted to the ICU. Hospital course outlined by
problem:
.
# ASCENDING CHOLANGITIS - Due to choledocholithiasis. The pt
had an abd US prior to the procedure showing CBD dilation to
1.4cm (OSH 1.0). His initially white counte was elevated with
7% band forms. He was intubated for an emergent ERCP where a
common bile duct stone was removed followed by drainage of frank
pus. A biliary stent was placed. It was elected to bring him
back for a repeat ERCP in one month for stent removal followed
by sphincterotomy at that time. He was continued on unasyn.
His wbc, fevers, total bilirubin, pancreatic enzymes, and liver
enzymes all improved after the stone was removed. He was
transitioned to ciprofloxacin for a total of 10 days (total 14
day course of antibiotics ending [**2154-5-23**]). He was not evaluated
by general surgery while here but will see his primary care
physician to have an evaluation closer to home. He will need to
wait 6 weeks before having this done to limit complications from
concurrent pancreatitis (biliary leak, poor anastamosis, etc).
Blood cultures remained sterile throughout his stay.
.
# HYPOTENSION - Thought from his biliary sepsis. WAs continued
on pressors but these were weaned quickly with IVF resusciation
and treatment of his obstruction. A transthoracic
echocardiogram was performed which demonstrated normal LV
function (no wall motion abnormalities and an ejection fraction
>55%). His e/a ratio was >1 suggesting either
pseudonormalization or normal diastolic relaxation. Given that
his blood pressure dropped when his ventricular rate rose with
atrial fibrillation it is likely that he may have decreased
compliance of his LV from longstanding hypertension. He became
hypertensive during hospitalization, and was restarted on
metoprolol and enalapril, but home HCTZ was held in the post
pancreatitis period.
.
# ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE - He
continued to have atrial fibrillation throughout his stay here.
Prior to transfer he had had a single episode of atrial fib >1
yr ago but this had resolved. Then on presentation to his
initial hospital, he was noted to be in atrial fibrillation and
would develop a rapid ventricular response associated with drops
in his blood pressure. After his hypotension resolved, we
increased his lopressor to maintain better rate control. His
rate decreased with this as well as with continued treatment of
his cholangitis - less catecholamines likely led to less AV
nodal conductivity. His CHADS2 score is 2 and so he will
benefit from anticoagulation for stroke prevention in the long
run. However we elected not to start coumadin prior to
discharge given his need to undergo sphincterotomy in 1 month.
After this is performed, coumadin may be started by his primary
care physician. [**Name10 (NameIs) **] was discharged on aspirin and metoprolol.
.
# RESPIRATORY FAILURE - Intubated for airway protection and
general anesthesia for the ERCP then kept intubated until the
morning. Extubated on next day without difficulty. AFter
extuabation he was noted to have some stridor on physical exam
and so was treated with a short course of IV Decadron. This
stridor improved and was never associated with an increase in
work of breathing.
.
# RHABDOMYOLOSIS - Likely related to his fall with immobility
for 5 hrs as well as his systemic inflammatory response from
cholangitis. He did have acute renal failure. He was hydrated
aggressively to maintain a urine output >100cc/hr. His creatine
and CKs iomproved over the next several days.
.
# ACUTE RENAL FAILURE - Urine studies suggested a prerenal
etiology most likely from his hypotension from sepsis.
Rhabdomyolysis may have contributed to some of the renal
toxicity as well as his SIRS response to infection. This
improved with aggressive hydration and treatment of his
infection and he was at baseline at discharge.
.
# REHAB He was evaluated by physical therapy who noted him to be
well below his baseline. He was transferred to a rehab center
for further care once his medical issues were resolved. Follow
up with the ERCP division was arranged while he was here. He
will need to be evaluated by general [**Doctor First Name **] for a cholecystectomy
in 6 weeks as well as be started on coumadin for his atrial
fibrillation.
Medications on Admission:
prilosec 150 mg
vaseretic (enalopril/HCTZ) 10/25 QD
allopurinol 300 mg PO QD?
Metoprolol (tartrate?) 25 mg QD
Ecotrin 325 mg QD
.
Transfer medications:
Neosynephrine drip at 100 mcg/min
Diltiazem drip 5 mg/hr
Bicarb D5 with 3 Amps 150 cc/hr
Heparin drip 1250 U/hr
Gentamicin x 1
Unasyn Q6, next dose at 2 AM
Levaquin QD
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day): may discontinue when ambulating
adequately.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours: maximum 2 grams daily.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
9. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: last day [**2154-5-23**].
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB/wheeze.
13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
gallstone pancreatitis
ascending cholangitis
atrial fibrillation with rapid ventricular response
congestive heart failure from arrythmia
hypotension
respiratory failure with intubation
Discharge Condition:
stable, feeling well and ready for rehabilitation
Discharge Instructions:
If you have any abdominal pain, yellowing of the skin, fever,
nausea, vomiting, then contact your primary care physician
immediately or return to the ED.
Followup Instructions:
Please get a follow up ERCP as scheduled:
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2154-6-17**] 9:30
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2154-6-17**] 9:30
.
GENERAL SURGERY: Ask your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7962**], to have you see a
general surgeon to evaluate you for taking out your gallbladder
in 6 weeks.
.
Primary Care follow up: Please schedule a follow up appointment
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7962**] (PCP) within 7 days of leaving the
hospital.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"0389",
"99592",
"5849",
"51881",
"4280",
"42731",
"2761",
"4019"
] |
Admission Date: [**2190-11-18**] Discharge Date: [**2190-11-21**]
Date of Birth: [**2118-8-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fever with abdominal pain, transferred from MICU after ERCP
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
72 y/o M w/ h/o cholecystectomy, CBD stones p/w fever and
abdominal pain for the last week. Patient has a long standing
h/o CBD stones and has had cholecystitis in past for which he
underwent gall bladder surgery. He has recurrent h/o CBD stones
with fever and abdominal pain. He has been on antibiotics in the
past. For the last week, he has been having fever to around 102
degrees with intermittent abdominal pain. It was associated with
dark discoloration of urine. Patient did not notice any changes
in the stool color. Not associated with yellowish discoloration
of sking or pruritis.
.
Patient was admitted to the MICU for ERCP. In the MICU, he had a
BP of 90/50, HR of 90-100. He was started on Unasyn, Flagyl 500
mgIV, Hydrocortisone 100 mg IV (stress dose steroid), 3L NS. An
ERCP was performed which showed pus and sludge extruding from
biliary tree. A stent placed in the CBD.
Past Medical History:
Multiple sclerosis
COPD
Neurogenic bladder
H/O [**First Name3 (LF) 499**] CA s/p resection
s/p cholecystectomy
s/p resection of RUL lesion (benign)
.
Social History:
Lives at home with wife. [**Name (NI) **] has a 55yr pack smoking history. He
was a social drinker in college.
Family History:
Wife: Renal [**Name (NI) 3730**]
Mother: [**Name (NI) **] ca
Physical Exam:
Vitals: 98.3, 120/77, 85, 20, 97/2L
Gen: confortable, AAOx3
HEENT: mildly icteric sclera, PERRLA, EOMI, MMM
Heart: distant heart sounds, faint S1/S2, murmurs not
appreciable
Lungs: occasional rhonchi in upper lobes bilaterally
Abd: soft/ND/NT, BS+, epigastric hernia site
Ext: 1+ pedal edema
Neuro: no focal deficits
Pertinent Results:
ERCP S&I ([**Numeric Identifier 39322**]) PORT [**2190-11-18**]
Extrahepatic bile duct dilatation. The small filling defect was
proved to be sludge and pus by report of the ERCP. ERCP during
the procedure.
*
[**2190-11-21**] 07:00AM BLOOD WBC-7.4 RBC-3.75* Hgb-10.8* Hct-34.0*
MCV-91 MCH-28.9 MCHC-31.8 RDW-14.6 Plt Ct-187
[**2190-11-18**] 03:10PM BLOOD Neuts-64 Bands-28* Lymphs-3* Monos-3
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2190-11-18**] 03:10PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ Stipple-1+
Tear Dr[**Last Name (STitle) **]1+
[**2190-11-21**] 07:00AM BLOOD Plt Ct-187
[**2190-11-21**] 07:00AM BLOOD Glucose-114* UreaN-6 Creat-0.5 Na-145
K-3.1* Cl-100 HCO3-37* AnGap-11
[**2190-11-21**] 07:00AM BLOOD ALT-85* AST-26 LD(LDH)-221 AlkPhos-161*
TotBili-0.7
[**2190-11-20**] 07:12AM BLOOD Lipase-27
[**2190-11-21**] 07:00AM BLOOD Calcium-9.0 Phos-2.1* Mg-1.6
[**2190-11-18**] 08:55AM BLOOD Cortsol-13.7
[**2190-11-18**] 08:55AM BLOOD CRP-22.6*
[**2190-11-18**] 03:10PM BLOOD HoldBLu-HOLD
[**2190-11-18**] 11:15AM BLOOD Type-MIX
[**2190-11-18**] 04:54PM BLOOD Lactate-0.9
[**2190-11-18**] 11:15AM BLOOD O2 Sat-77
Brief Hospital Course:
# Cholangitis: Presented with clinical picture of Cholangitis.
Had an ERCP stent placement. Was started on unasyn. Bl Cx were
drawn which were negative.
.
# Hypotension: Initially had SBP 90/50 in ED, responded to IVF.
Was put on stress dose steroids in ED, which was switched over
to regular steroid dose which he had been taking as an
outpatient. We held his lopressor.
.
# Urinary retention: was most likely from Neurogenic bladder [**2-10**]
Multiple sclerosis. He had a foley placed for retention which
was then D/C'ed.
.
# Guiaic positive stools: He had guaiac pos stools. His HCT was
stable and he did not have any active bleeding.
.
# UTI: UA on admission showed [**10-28**] WBC's, UCx grew E.coli. He
was continued on unasyn.
.
# HTN: continued on lopressor
.
# MS - on daily steroids
.
# COPD - continued on nebs
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Cholangitis
COPD
Urinary tract infection
Multiple sclerosis
History of [**Hospital1 499**] cancer
Neurogenic bladder
Discharge Condition:
all vitals are stable.
Discharge Instructions:
Please take all your medications and follow up with all your
appointments. Please report to the ED or to your physician if
you have worsening symptoms or any concerns at all.
Followup Instructions:
Please make an appointment to see your Primary care physician [**Last Name (NamePattern4) **]
[**7-18**] days.
.
Please make an appointment to see your Gastroenterologist in [**2-11**]
weeks.
Completed by:[**2190-12-1**]
|
[
"5990",
"496"
] |
Admission Date: [**2189-2-9**] Discharge Date: [**2189-2-16**]
Date of Birth: [**2104-8-19**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Duodenal perforation after ERCP.
Major Surgical or Invasive Procedure:
-[**2189-2-9**] ERCP complicated by duodenal perforation
-[**2189-2-10**] External biliary drain placement by interventional
radiology
History of Present Illness:
84F w/ possible duodenal perforation during ERCP today. Pt w/
complicated medical history including A-fib requiring coumadin,
hypertension and CHF initially presented to [**Hospital 4199**] Hospital ED
three days ago w/ fatigue, diarrhea & hypotension. Noted to be
guiac positive with Hct down to 14 from her baseline 36. Her INR
was supratherapeutic at 16. Anticoagulation was reversed w/ Vit
K, she had a central line placed and was admitted to the ICU
where she received several units of PRBCs and FFP. After
stabilization of her bleeding and blood pressure, she underwent
CT abdomen which demonstrated a mass in the head of her
pancreas. She was seen by Dr. [**First Name (STitle) **] of heme-onc at that time.
She was sent to [**Hospital1 18**] for ERCP and possible stent placement.
During the procedure a 2cm perforation was noted in the
duodenum. The procedure was terminated without sphincterotomy,
an NGT was placed, and surgery urgently consulted.
Past Medical History:
PMH:
- Atrial fibrillation, on coumadin
- CHF
- HTN
- Depression
- Hard of hearing
.
PSH:
- appendectomy
- cholecystectomy
Physical Exam:
Physical Exam on Admission:
97.9 110AF 115/80 18 100%RA
Somnolent, somewhat confused (A&O to self)
Icteric skin, scleral icertus
No cervical, supraclavicular or axial lymphadenopathy
Irreg irreg
CTA bilat
Abd w/ well healed midline surgical scar. Soft. Nontender
throughout. No guarding. No tympanny. No shake tenderness.
Lower extremities edematous w/ brawny skin changes
.
Physical Exam on Discharge:
All vital signs stable
irreg irreg, no m/r/g
CTA bilaterally
Abd soft, non-tender, mildly distended, +BS all 4 quadrants, RUQ
biliary drain in place with bilious output
Pertinent Results:
[**2189-2-9**] 04:26PM BLOOD WBC-6.9 RBC-3.67* Hgb-11.8* Hct-34.1*
MCV-93 MCH-32.0 MCHC-34.5 RDW-18.1* Plt Ct-193
[**2189-2-12**] 01:07AM BLOOD WBC-7.1 RBC-3.32* Hgb-10.6* Hct-31.0*
MCV-93 MCH-32.0 MCHC-34.4 RDW-17.7* Plt Ct-219
[**2189-2-9**] 04:26PM BLOOD Neuts-86.1* Lymphs-7.1* Monos-5.5 Eos-0.9
Baso-0.4
[**2189-2-9**] 04:26PM BLOOD PT-14.0* PTT-32.2 INR(PT)-1.3*
[**2189-2-12**] 01:07AM BLOOD Glucose-64* UreaN-15 Creat-0.5 Na-136
K-4.1 Cl-100 HCO3-25 AnGap-15
[**2189-2-9**] 04:26PM BLOOD ALT-62* AST-91* AlkPhos-480*
TotBili-10.1* DirBili-6.3* IndBili-3.8
[**2189-2-10**] 01:39AM BLOOD ALT-56* AST-65* AlkPhos-465*
TotBili-12.1*
[**2189-2-11**] 02:04AM BLOOD ALT-39 AST-42* LD(LDH)-145 AlkPhos-374*
TotBili-6.8*
[**2189-2-12**] 01:07AM BLOOD ALT-27 AST-22 LD(LDH)-160 AlkPhos-286*
TotBili-4.9*
[**2189-2-10**] 02:25PM BLOOD Type-ART Temp-37 Tidal V-600 FiO2-50
pO2-261* pCO2-35 pH-7.51* calTCO2-29 Base XS-5 Intubat-INTUBATED
Vent-CONTROLLED Comment-ETT
[**2189-2-10**] 03:55PM BLOOD Glucose-73 Lactate-1.3 Na-133 K-3.4
Cl-101
.
[**2189-2-9**] CT a/p with PO/IV contrast:
1. Significant amount of retroperitoneal free air with
discontinuity of the wall of the 2nd part of the duodenum. The
tip of the NG tube lies adjacent to this area of
discontinuation. Findings are consistent with duodenal
perforation.
2. Moderate amount of intra-abdominal ascites.
3. Small bilateral pleural effusions.
4. 4.8 cm pancreatic head mass consistent with neoplasm.
5. Enhancing liver lesion suspicious for metastasis.
6. Intra- and extra-hepatic biliary duct dilation due to
pancreatic neoplasm.
.
[**2189-2-10**] External Biliary Drain placement:
1. Obstruction of the distal common bile duct on the basis of
extrinsic
compression by extraluminal mass. Obstruction was unable to be
crossed by the guidewire.
2. Moderate diffuse intrahepatic biliary ductal dilatation.
3. Incidental demonstration of pneumoretroperitoneum.
4. Successful placement of 8.0 French external biliary drainage
catheter into the common bile duct via the right anterior
intrahepatic segmental duct.
.
[**2189-2-13**] CT a/p with PO and IV contrast:
IMPRESSION:
1. Persistent extensive retroperitoneal free air predominantly
within the
right hemiabdomen; however, with interval decrease to prior. No
extraluminal oral contrast or retroperitoneal collection here.
2. Similar anasarca, ascites and third spacing.
3. Interval increase in bilateral non-hemorrhagic pleural
effusions with
bibasilar atelectasis at the lung bases.
4. Known large pancreatic head mass consistent with neoplasm.
5. Similar enhancing liver lesion concerning for metastasis.
6. No intrahepatic biliary duct dilation; status post external
biliary
drainage catheter into the common bile duct.
7. Similar prominent retroperitoneal lymph nodes.
Brief Hospital Course:
Post her ERCP for pancreatic head mass the patient was
transferred to the TSICU with NGT in place given concern for
duodenal perforation. She was initially emperically begun on
unasyn/fluconazole, subsequently narrowed to unasyn alone. She
was kept NPO with IVF and the NGT in place, with HR control with
IV lopressor and digoxin. CT a/p with NGT and IV contrast
demonstrated massive pneumoperitoneum/RP free air consistent
with duodenal perforation. Her abdomen remained soft during this
time with very mild epigastric discomfort, and she did not
display septic signs. She underwent external biliary drain (in
common bile duct) placement by IR on [**2189-2-11**]. The drain was not
able to be internalized at that time secondary to peri-ampullary
swelling. She returned to IR on [**2189-2-12**] for attempt at
internalization of her biliary drain. However, shortly after
anesthesia induction/intubation, pt's BP decreased along w/ RVR,
treated accordingly by anesthesia. They noted possible inferior
ST wave depressions despite normalization of BP after HR
control. The decision to abort the procedure was made and
patient was reversed and extubated. Formal cardiac rule-out back
in TSICU was negative by clinical exam, EKG and cardiac enzymes.
The family decided not to pursue attempt to internalize drain
the next day. Instead, they requested repeat CT scan, which
showed no active extravasation of contrast from the duodenum.
Her diet was advanced, and on the day of discharge, HD8, she was
tolerating a regular diet. [**2189-2-14**] CDiff returned positive and
she was begun on IV flagyl (in addition to her IV unasyn). On
discharge external biliary catheter was in place, and the family
was instructed to follow up with Dr. [**First Name (STitle) **]. Future discussion
regarding internalization of the drain may be undertaken at that
time. Her home coumadin was restarted (2.5 mg) on HD8, [**2189-2-16**],
and she should have her INR checked on [**2189-2-17**] at rehab. She was
discharged to rehab on [**2189-2-16**], HD8, tolerating a regular diet
with external biliary drain in place, to complete a course of
augmentin given her duodenal perforation, and po flagyl given
her Cdiff + stool. In addition to follow-up with Dr. [**First Name (STitle) **],
follow up appointment was also arranged with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
(hematology-oncology) of [**Hospital 4199**] Hospital on discharge (who had
seen her while at [**Last Name (un) 4199**] after her pancreatic mass head was
seen on imaging), and discharge summary was sent to Dr.[**Name (NI) 39123**]
office.
Medications on Admission:
- Metoprolol 100mg [**Hospital1 **]
- Lisinopril 5mg [**Hospital1 **]
- Amlodipine 5mg daily
- Digoxin 0.125mg daily
- Coumadin 2.5mg daily
- Lasix 80mg every other day
- KCl 20mEq PO daily
- Sertraline 100mg daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
9. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for
14 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
ERCP complicated by duodenal perforation
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 for an ERCP procedure to evaluate a mass at
the head of your pancreas. The procedure was complicated by a
perforation of your duodenum, and you were started on IV
antibiotics and underwent a bile-duct drain placement by the
interventional radiologists. The drain was not able to be
internalized because you did not tolerate the anesthesia for
this procedure, and your family elected to hold off on having it
internalized for now. You are being discharged with an external
drain in place, which visiting nurses will help you empty and
care for. You are being discharged on oral antibiotics which you
should continue to take (both for your duodenal perforation and
for a colon infection called "C Diff" which you developed while
in the hospital). Please return to the ED or call Dr.[**Name (NI) 5067**]
office if you experience fevers/chills/nausea/vomiting, have
uncontrollable abdominal pain, notice a change in color in your
drain output, or if the drain becomes dislodged. If you would
like to have the drain internalized in the future you will need
to schedule an appointment through Dr.[**Name (NI) 5067**] office to have
this done (re-attempted) by interventional radiology.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] at [**Hospital 4199**] Hospital of
hematology-oncology to discuss the best next steps going forward
for your pancreatic mass (possibly chemotherapy). His office
number is [**Telephone/Fax (1) 56671**]. An appointment has been scheduled for
you on [**3-5**] at 1:30pm (Level B, [**Hospital 4199**] Hospital)
.
You are scheduled to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
hepatobiliary surgery on Monday [**3-9**] at 3:15 PM. The office
is located in the [**Location (un) 470**] of the [**Hospital Unit Name **] at [**Hospital1 18**] ([**Last Name (NamePattern1) 12939**], [**Location (un) 86**], [**Numeric Identifier 718**]). Please call the office at
[**Telephone/Fax (1) 2998**] if you need to reschedule this appointment.
Completed by:[**2189-2-16**]
|
[
"2851",
"4280",
"42731",
"4019",
"311",
"V5861"
] |
Admission Date: [**2169-7-1**] Discharge Date: [**2169-8-11**]
Date of Birth: [**2123-11-9**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Levofloxacin / Methotrexate
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Rash, bleeding
Major Surgical or Invasive Procedure:
Right IJ
Left IJ
Lumbar puncture
Tracheostomy & PEG
Bronchoscopy x 2
Bone marrow biopsy
History of Present Illness:
History obtained from records. The pt is a 45 yo woman with
eczema, rheumatoid arthritis, hypertension, h/o nephrolithiasis
recently started on cefazolin for two days followed by
levofloxacin for a superinfection of her eczema who intially
presented to [**Hospital3 **] Hospital complaining of hemoptysis x 3
days. Initial labs were concerning for pancytopenia with a WBC
less than 0.2, Hct of 26 and platelets of 7. She was intubated
in the field for airway protection and med-flighted to [**Hospital1 18**] for
further evaluation.
.
In the ED, her VSs were 100, 116, 93/53, 18, 100% vented. She
received a 4-pack of platelets, lorazepam 2 IV, acetaminophen
650 and midazolam 2 IV. A CXR revealed ? RUL atelectasis, and a
head CT revealed no acute intracranial hemorrhage.
Past Medical History:
Eczema
hypertension
nephrolithiasis
Rheumatoid arthritis
Uterine fibroids
Social History:
smokes 4 packs/wk. drinks 2 beers/day
Family History:
adopted
Physical Exam:
Vitals: T: 97.9 BP: 88/60 P: 109 R: 29 SaO2: 100%
General: sedated, intubated
Skin: multiple excoriated, erythematous ezcematous lesions all
over her skin, no bullous lesions noted
HEENT: anicteric, bleeding from conjunctiva, nares and
oropharynx
Neck: no significant JVD
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: tachycardic, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no splenomegaly
Extremities: No edema, 2+ radial, DP pulses b/l
Neurologic: sedated, intubated
Pertinent Results:
[**2169-6-30**]
WBC-0.2* RBC-2.19* Hgb-8.3* Hct-23.9* MCV-109* MCH-37.8*
MCHC-34.7 RDW-19.4* Plt Ct-5*
Neuts-0* Bands-0 Lymphs-92* Monos-0 Eos-8* Baso-0 Atyps-0
Metas-0 Myelos-0
Hypochr-2+ Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-OCCASIONAL
Polychr-Spheroc-1+ Ovalocy-OCCASIONAL Target-NORMAL
Schisto-OCCASIONAL Burr-1+ Tear Dr[**Last Name (STitle) **]1+ Acantho-1+
PT-12.0 PTT-27.3 INR(PT)-1.0
Fibrino-1332*
Ret Man-.2*
Glucose-100 UreaN-138* Creat-3.7* Na-141 K-4.3 Cl-107 HCO3-12*
AnGap-26*
ALT-24 AST-50* AlkPhos-63 Amylase-119* TotBili-2.1*
Albumin-2.2* | Hapto-337* | Lactate-1.4
Type-ART Temp-37.7 pO2-459* pCO2-23* pH-7.31* calTCO2-12* Base
XS--12
.
[**2169-8-11**]:
WBC 12.3 Hgb 10.6 Hct 31.7 MCV 101 Plt Ct 526
Glu 90 BUN 12 Cr 0.5 NA 138 K 4.6 Cl 104 HCO3 23
Ca-9.9 P-5.1* Mg-2.0
.
CHEST X-RAY ([**2169-6-30**])
IMPRESSION:
1. Band of opacity projecting over the right upper chest likely
representing atelectasis. However, other underlying processes,
including neoplasm or infection can't be excluded. Follow-up
radiograph to evaluate clearance or CT chest is recommeded.
2. Likely mild CHF.
.
BIOPSY ([**2169-6-30**])
#1. Skin, left medial thigh, punch biopsy (A):
a. Ulcer with yeasts within ulcer bed, subjacent upper dermis,
and focally within superficial dermal small vessel, and abundant
surface gram positive cocci (see note).
b. Background psoriasiform dermatitis with paucicellular
superficial dermal perivascular lymphocytic infiltrate and rare
eosinophils (see note).
#2. Skin, left medial thigh, direct immunofluorescence:
a. No IgG, IgA, IgM, C3 deposits found between keratinocytes of
the epidermis or along the basement membrane zone.
b. C3 is noted within the scale (? near ulcer) consistent with
psoriasiform dermatitis or non-specific if near ulcer.
c. Non-specific fibrinogen deposits present in the dermis.
#3. Skin, left leg, punch biopsy (B):
a. Psoriasiform dermatitis with parakeratotic scale containing
neutrophil aggregates.
b. No fungi or bacteria seen in PAS, GMS, and Gram stained
sections.
.
Note: No acantholysis or bulla are seen (multiple levels
examined). Abundant yeasts are present within the ulcer bed,
upper reticular dermis, and one small superficial blood vessel.
While this may represent surface colonization, in the setting of
pancytopenia, this raises concern for a disseminated yeast
infection. Blood cultures may be further illustrative.
.
The background skin shows a psoriasiform dermatitis, the
differential of which includes psoriasis, and as there are rare
eosinophils, a psoriasiform drug reaction, and possibly
impetiginized atopic dermatitis.
.
*******************
BONE MARROW BIOPSY ([**2169-7-1**])
*******************
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS: Markedly hypocellular marrow in keeping with a
hypoplastic / aplastic process, see note.
Note: The aplasia may be primary or secondary from a marrow
insult from drugs, infection, immune, or toxic/metabolic causes.
Clinical correlation recommended.
.
*******************
CT TORSO ([**2169-7-8**])
*******************
IMPRESSION:
Right upper lobe pneumonia. Bilateral pleural effusions
associated with atelectasis of the lower lobes.
Splenic and left kidney infarcts.
Mild fluid overload.
Right rib fractures.
Mediastinal, axillary and mesenteric lymphadenopathy is likely
reactive.
.
TRANS-THORACIC ECHO ([**2169-7-10**])
IMPRESSION: Normal study. No 2D echocardiographic evidence for
endocarditis or pathologic flow identified.
Compared with the prior study (images reviewed) of [**2169-7-3**], the
findings are similar (heart rate is slower).
.
MRI HEAD ([**2169-7-14**])
IMPRESSION: Multiple infarcts are identified involving the right
frontal and parietal lobe, left frontal lobe and left cerebellar
hemisphere. Infarcts in the right frontal lobe in the MCA
territory demonstrate enhancement. The findings are indicative
of acute/subacute infarcts. The enhancement in the right MCA
territory infarct may indicate more subacute nature. Although
there are no MRI signs of septic emboli such as abscess, given
patient's clinical history, clinical correlation is recommended.
Findings were discussed with Dr. [**First Name (STitle) 805**] at the time of
interpretation of this study on [**2169-7-13**].
.
CT CHEST W/O CONTRAST [**2169-8-3**]
IMPRESSION:
1. Improving right upper lobe consolidation with residual
opacity likely due to slowly resolving pneumonia.
2. Several bilateral noncalcified lung nodules measuring up to 8
mm. As these were largely obscured by preexisting areas of
consolidation atelectasis on the previous study, their time
course is uncertain. Differential diagnosis includes previous
and active infection (e.g. granulomatous infection) versus
metastatic foci.
Consider a followup CT scan in four to six weeks to document
anticipated complete resolution of the right upper lobe
abnormality and to re-assess the lung nodules.
Brief Hospital Course:
The patient is a 45 yo woman originally admitted on [**7-1**] from an
[**Hospital **] transferred from the MICU to the floor on [**7-25**], admitted for
pancytopenia with hemoptysis, intubated for airway protection.
Her pancytopenia has now resolved, likely due to Mycoplasma
infection versus medication-induced aplasia. She had a prolonged
and difficult wean from the ventilator, s/p tracheostomy and
PEG, now doing well s/p trach decannulation. She has a
persistent rash c/w psoriasis, improving on topical steroids.
She has hypercalcemia and hyperphosphatemia of unclear etiology,
improving on [**Name (NI) **].
.
Respiratory failure. The patient presented to OSH on [**2169-6-30**]
with hemoptysis which was [**1-20**] new pancytopenia. She was
intubated for airway protection before transport here. On
bronchoscopy, she initially had bleeding from the RUL. On CXRs
and CT, she had had some intermittent right upper lobe collapse
vs PNA, and bibasilar atelectasis. During her ICU course at
[**Hospital1 18**], she was difficult to wean off the vent due to volume
overload, possible mycoplasma infection, and ICU myopathy, with
EMG/NCVs showing myopathy with ongoing denervation. She got PEG
and tracheostomy on [**2169-7-18**], on [**7-19**] was weaned to trach mask,
cleared for PMV on [**7-20**]. Repeat chest CT on [**8-3**] showed
resolving RUL consoldiation, also several bilateral noncalcified
lung nodules, possibly c/w granulomatous disease. Pulmonary was
consulted, and deferred further work-up at this time, and will
follow-up with repeat chest CT in 3 months. Her tracheostomy
was decannulated on [**8-10**], and she has been saturating in the
high 90s at rest and while ambulating with PT.
.
Pancytopenia: The patient was seen by hematology, and had a bone
marrow biopsy, consistent with primary or secondary hypocellular
aplasia. She was given supportive transfusions, and treated with
leucovorin and filgrastim for her pancytopenia. The likely
diagnosis is secondary marrow aplasia, due either to Mycoplasma
or drug-induced (levofloxacin vs. Keflex vs. diflunisol vs.
Embrel). Her condition improved, and by transfer to the floor
her pancytopenia had resolved with normal WBC, and platelets,
Hct of 30. On discharge, she had a persistent mild
leukocytosis to 12,000, Hct 31, Plt 536. She was discharged on
B12 and folate, to follow-up with hematology. If she is to see
rheumatology or dermatology for her RA or psoriasis in the
future, careful consideration should be made about the use of
any immunosuppressive agents given these may have caused her
pancytopenia.
.
Fevers: She had persisent fevers to 101 while in the MICU, which
was originally thought to be [**1-20**] febrile neutropenia. She was
started on IV vancomycin and ceftazidime for febrile neutropenia
on admission, and completed a two-week course. She was also
briefly on doxycycline [**Date range (1) 27564**] until serologies for
tick-[**Location (un) **] diseases from the OSH came back negative. She was
also started on fluconazole for concern for invasive fungal
infection (see below). However, after discontinuation of all
antibiotics after [**7-12**], she was persistently febrile with no
source. Rheumatology was also consulted, and did not believe
her presentation was consistent with vasculitis. On review of
her fever curve, ID consult noted she had defervesced while on
doxycycline. Her Mycoplasma IgM was positive and IgG was weakly
negative (670, postive is 770), though it was possible could not
mount a proper response due to her recent pancytopenia. She
was restarted on doxycycline on [**7-16**] for a two-week course for
presumed disseminated Mycoplasma infection, and has since
defervesced.
.
Psoriasis: When she presented to OSH, she had a dramatic
desquamating rash that affected her trunk as well as her
extremities. She was seen by dermatology, with skin biopsy
showing psoriasiform background in the dermis, and an
infiltration of fungal organisms, including around dermal
vessels. Cultures from her wound biopsy and urine proceeded to
grow [**Female First Name (un) **] albicans, sputum showed budding yeast. The
patient was therefore treated with fluconazole for 10 days from
[**Date range (1) 74297**]. Dermatology was re-consulted on the floor, and
recommended topical steroids for psoriasis, and suggested
phototherapy on discharge.
.
Hypercalcemia/Hyperphosphatemia: The patient was noted to have
slowly increasing phosphorus levels after transferred to the
floor. Her calcium also began to rise. She was placed on a low
phosphorus diet, without resolution of these abnormalities.
Renal and endocrine were consulted. She has an appropriate
renal clearance of calcium and phosphorus, and an appropriately
low PTH. Chest CT was concerning for possible granulomatous
disease but vitamin D (25, and [**1-12**]) were both low normal. At
discharge, there is no clear etiology for her
hypercalcemia/phosphatemia. Both these levels have come down
and are stable on [**Month/Year (2) **]. PTH-rp and FGF23 mutation analysis
are still pending at discharge. Her electrolytes will be
monitored by her VNA and PCP, [**Name10 (NameIs) **] she will follow-up with
endocrine.
.
Strokes/Question of Hypercoagulability: Neurology was consulted
for difficulty weaning of the ventilator. As stated above, they
postulated that possible contributions could include steroid
myopathy, and prolonged encephalopathy. Head MRI on [**7-13**]
revealed multiple bilateral acute and subacute infarcts. She
also was found to have wedge shaped infarcts in her kidyney and
spleen on abdominal CT. Several echos showed no intracardiac
embolic source. Rheumatology was consulted, and did not think
this was consistent with vasculitis. Heme-onc was consulted and
a hypercoagulabity workup was done. Anticardiolipin IgG and IgM
were weakly positive, but Heme did not think this was consistent
with antiphospholipid antibody syndrome as this can be seen with
infection and acute illness. She will follow-up with Heme for
further outpatient work-up. She appears to have no residual
neurological deficits.
.
Acute Renal Failure: The patient was found to be in ARF on
admission. Urine eosinophils were negative, making AIN
unlikely. Her presumed diagnosis was ATN, and her creatinine
slowly normalized with hydration, with normal renal function at
discharge.
.
Anxiety/Depression: The patient had significant
anxiety/depression during her long MICU stay, which possibly
contributed to her long wean from the ventilator. On [**7-25**], She
was started on an SSRI, with significant improvement in affect
and mood on the floor.
.
FEN: The patient is s/p PEG on [**7-18**]. By transfer to the floor
on [**7-25**], she was cleared for a normal diet, and was taking
adequate Pos by discharge. She will follow-up with Thoracics
for PEG pull on [**8-29**].
Medications on Admission:
Omeprazole 20 daily
Lisinopril 20 daily
Metoprolol 50 [**Hospital1 **]
Ciprofloxacin
Diflunisal 500 [**Hospital1 **]
Prednisone 40mg x3 days ([**2169-6-26**]), then taper
Embrel
Discharge Medications:
1. AFO
Please provide AFO to patient [**Known firstname **] [**Known lastname 37080**], patient of Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for right-sided foot drop. Patient has a size 7.5
inch foot.
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)) as needed for pruritis.
Disp:*30 Tablet(s)* Refills:*2*
6. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
Disp:*1 tube* Refills:*2*
7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash.
Disp:*1 tube* Refills:*0*
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*1 tube* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
1) Pancytopenia
2) Respiratory failure s/p tracheostomy and PEG
3) Psoriasis
4) Acute/Subacute Strokes
5) Hyperphospatemia/Hypercalcemia
Discharge Condition:
The patient's pancytopenia is largely resolved, with a mild
persistent anemia, Hct stable at 31. Her tracheostomy was
decannulated the day prior to discharge, and she is saturating
in the high 90s and able to ambulate well with physical therapy.
She is able to eat a regular adult diet, and PEG will be
removed [**8-29**]. She continues to have hyperphosphatemia and
hypercalcemia, improved since starting [**Month/Year (2) **].
Discharge Instructions:
You were admitted because of low blood counts that caused you to
bleed from your lungs. You had a bone marrow biopsy to help
determine the cause of your low blood counts, which may have
been either a medication you were taking (Keflex, Levofloxacin,
Embrel, or Diflunisil) or an infection (Mycoplasma). You were
given antibiotics for this infection. You were put on a
ventilator and got a tracheostomy tube in your neck to help you
breathe, which was taken out yesterday. You got a feeding tube
in your stomach to help you eat. You had a skin biopsy, which
showed that your rash is psoriasis, and you were started on
topical steroids. Your labs showed you have high levels of
phosphorus and calcium, and you were started on a medication
([**Month/Year (2) **]) to lower these levels.
.
Please take all new medications as prescribed. Please make sure
to attend all follow-up appointments below. The visiting nurses
will be drawing labs that your primary care doctor will be
monitoring, and he may call you to adjust the dose of [**Month/Year (2) **].
.
Please contact your doctor or go to the emergency room if you
have fever>101, chills, chest pain, abdominal pain, shortness of
breath, bleeding, or any other concerns.
Followup Instructions:
You have an appointment with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 36086**], at [**Hospital **] Health Center, on [**2169-8-16**] at 3:10pm.
His number is [**Telephone/Fax (1) 31979**].
.
You have an appointment with Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **], with
Thoracic Surgery, for removal of your feeding tube, on [**2169-8-29**]
at 11:00am. You should go to [**Hospital Ward Name 23**] [**Location (un) **] for a chest
x-ray at 10:30am prior to this appointment. His number is
[**0-0-**].
.
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with Dermatology
on [**2169-9-7**] at 11:00 am at [**Hospital1 18**] [**Location (un) 55**] at [**Street Address(2) 74298**].
[**Location (un) 55**], MA. His number is ([**Telephone/Fax (1) 31239**]. His office
will call you if appointments become available on [**2169-8-29**].
.
You have an appointment with Dr. [**First Name4 (NamePattern1) 1726**] [**Last Name (NamePattern1) 7711**] with
Endocrinology at 8:30am on [**2169-9-11**]. His office is located at
[**Hospital1 18**] [**Last Name (un) 469**] [**Location (un) 436**]. His number is ([**Telephone/Fax (1) 74299**].
.
You have an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**] with Hematology
on 10:30 am on [**2169-9-22**]. His office is located at [**Hospital1 18**] on
[**Hospital Ward Name 23**] [**Location (un) **]. His number is ([**Telephone/Fax (1) 74300**].
.
You have an appointment to get a repeat chest CT scan on
[**2169-11-2**] at 1:00pm at [**Hospital1 18**] on [**Last Name (un) 469**] [**Location (un) **]. You should
not eat for 3 hours before. You then have an appointment with
Dr. [**First Name8 (NamePattern2) 4944**] [**Last Name (NamePattern1) **], with Pulmonology on [**2169-11-6**] at 1:00pm. Her
number is ([**Telephone/Fax (1) 513**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2169-8-11**]
|
[
"51881",
"5845",
"2762",
"4019"
] |
Admission Date: [**2154-8-19**] Discharge Date: [**2154-8-23**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Insertion of Metronic Dual Chamber Adapta L pacemaker
History of Present Illness:
[**Age over 90 **]M with a history of CAD s/p CABG in [**2124**] and recent admissions
([**8-6**]) for inferior STEMI s/p DES in SVG-LAD and CP r/o MI ([**8-17**],
d/c'ed [**8-18**]), CHF, paroxysmal atrial fibrillation (not on
anticoagulation) p/w substernal chest pain, and was found to
have A-fib w/ RVR.
.
His symptom started at 3pm. He was asleep, and woke up because
of chest pain. Pain was described as midsternal, with radiation
to both arms, very similar to the pain he had during prior
ischemic events, but gradually worsening to [**11-11**], with no
diaphoresis, sob, n/v. He tried two sl nitro, but did not help.
.
Of note, he was recently admitted for an inferior wall STEMI
with peak CK-MB of 41 and troponin of 1.03. He underwent urgent
cardiac cath for revascularization with occluded SVG-RCA. Cath
was complicated by hypotension with IABP insertion. Repeat
angiography of SVG-LAD revealed 95 % stenosis of its ostium and
underwent PTCA and one drug-eluting stent. Post-procedure ECHO
showed EF 30 % similar to previous baseline. He was subsequently
discharged with plavix, aspirin, atorvastatin, and lisinopril.
He was placed on low-dose beta blockade but experienced
bradycardia.
.
In the ED, initial vitals were 113 91/63 12 98% 1L Nasal
Cannula.
Pt rated pain [**11-11**] upon arrival. He had ASA 325 X1, 4mg
Morphine IV x1 which helped. He also received Amiodarone bolus
of 150 mg over 15 mins x2. Heart rate dropped from 125 bpm to 96
bpm after 2nd dose. Then Amiodarone gtt started at 1mg/hr. Pt
states pain is 0/10 at this time.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope, claudication.
.
Other ROS is notable for vision loss (only perceptable to light)
on the right side. Pt unclear about when it started exactly, but
likely within a month. Pt also c/o hesitency during urination,
which has been a chronic issue.
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.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: in [**2124**] and 2 vessel SVG stenting in [**2148**] followed by
failed attempt to open an occluded OM branch on [**3-/2149**] due to
persistent angina.
-PERCUTANEOUS CORONARY INTERVENTIONS:
s/p DES to SVG-RCA and SVG-LAD ([**2148**]). SVG to OM known occluded.
3. OTHER PAST MEDICAL HISTORY:
- CAD s/p MI, CABG, PCI as above.
- AAA s/p repair
- Chronic systolic CHF (EF 25-30%)
- Hyperlipidemia
- Chronic kidney disease (baseline creatinine 1.6-2.2)
- s/p L carotid endarterectomy [**2143**]
- s/p cholecystectomy
- GERD
- hearing loss
- Nephrolithiasis
- Mesenteric ischemia (celiac artery stenosis, occluded [**Female First Name (un) 899**])
- Dizziness
- Chronic pleural effusion s/p talc pleuridesis
Social History:
Lives alone, but sons lives within [**Street Address(2) 46372**] and involved
in care. No HHA or other help at home. Quit smoking >40y ago;
used to smoke 3ppd x 20 years. No alcohol. No recreational
drugs.
Family History:
Father died of MI in 70s
Physical Exam:
ADMISSION EXAM
VS: T=97.6 BP=105/60 HR=91 RR=19 O2 sat= 99% on 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No visual acuity on
the right, Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
NECK: Supple with JVP of 2 cm above clavicle
CARDIAC: irregularly irregular rhythm, good s1, s2 with no
murmurs appreciated.
LUNGS: No chest wall deformities, Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
EXT: 2+ pitting edema to ankles bilaterally
DISCHARGE EXAM
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Visual acuity on the
right is only limited to sensation of light, Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: No JVP elevation
CARDIAC: irregularly irregular rhythm, good s1, s2 with no
murmurs appreciated.
LUNGS: No chest wall deformities, Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
EXT: 2+ pitting edema to ankles bilaterally
Pertinent Results:
ADMISSION LABS
[**2154-8-18**] 09:18AM BLOOD WBC-5.3 RBC-3.51* Hgb-11.2* Hct-33.3*
MCV-95 MCH-31.9 MCHC-33.7 RDW-15.7* Plt Ct-111*
[**2154-8-19**] 07:50PM BLOOD Neuts-82.2* Lymphs-12.9* Monos-3.6
Eos-0.9 Baso-0.5
[**2154-8-18**] 01:11AM BLOOD PTT-48.2*
[**2154-8-18**] 09:18AM BLOOD PT-15.1* PTT-42.2* INR(PT)-1.3*
[**2154-8-18**] 09:18AM BLOOD Glucose-155* UreaN-33* Creat-1.8* Na-140
K-4.5 Cl-103 HCO3-30 AnGap-12
[**2154-8-18**] 09:18AM BLOOD CK-MB-4 cTropnT-0.25*
.
PERTINENT LABS
[**2154-8-19**] 07:50PM BLOOD cTropnT-0.24*
[**2154-8-20**] 05:31AM BLOOD CK-MB-14* MB Indx-13.6* cTropnT-0.51*
[**2154-8-20**] 11:35AM BLOOD CK-MB-15* MB Indx-13.8* cTropnT-0.62*
[**2154-8-20**] 05:31AM BLOOD Digoxin-0.7*
.
DISCHARGE LABS
[**8-23**] COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2154-8-23**] 06:10 4.0 3.44* 10.9* 31.8* 93 31.6 34.2 15.5 110*
[**8-23**] RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2154-8-23**] 06:10 951 35* 1.8* 141 4.2 104 30 11
.
PERTINENT STUDIES
# Portable CXR [**8-17**]
UPRIGHT AP VIEW OF THE CHEST: The patient is status post median
sternotomy, CABG. There is moderate enlargement of the cardiac
silhouette which is unchanged. The aorta is mildly tortuous and
diffusely calcified, which is stable. Multiple calcified
mediastinal and hilar lymph nodes are again demonstrated. There
is mild pulmonary vascular congestion. Increasing opacification
of the right lung base may represent worsening atelectasis,
pulmonary edema, or infection. Blunting of the right
costophrenic angle is redemonstrated suggestive of a small
pleural effusion. There is no pneumothorax. No acute osseous
abnormalities are seen.
IMPRESSION:
1. Mild pulmonary vascular congestion.
2. Increasing patchy opacity in the right lung base may reflect
worsening
atelectasis, edema, or infection. Small right pleural effusion,
unchanged.
.
# Portable CXR [**8-21**]
INDICATION: [**Age over 90 **]-year-old man with tachybrady syndrome status post
dual-chamber pacemaker implant using the axillary vein. Question
any pneumothorax.
The lungs are well expanded and show mild bilateral interstitial
opacities. The cardiac silhouette is top normal. The
mediastinal silhouette and hilar contours are normal. No pleural
effusions or pneumothorax is present. A left-sided pacer
terminates with its leads in the right atrium and right
ventricle appropriately. Sternal wires are intact.
IMPRESSION:
Mild interstitial edema. No pneumothorax.
.
# CXR PA/Lateral [**8-22**]
FINDINGS: Lungs are well expanded. Left lung field is clear
without vascular congestion or pulmonary edema. The right lung
shows chronic apical changes with scarring and nodular
thickening of the apical pleura and a prominent minor fissure
which are unchanged since at least [**2153-10-3**]. Compared with
radiograph on [**8-21**] and after accounting for difference in
positioning and technique, there is mild worsening of the right
lower lobe opacity with obscuring of the right hemidiaphragm.
Blunting of the right pleural sulcus is likely due to tiny
pleural effusion or pleural scarring with retraction and has
been present since at least [**2153-10-3**]. Cardiomediastinal
and hilar contours are unremarkable. The aorta is tortuous.
Pacemaker leads are in standard positions and unchanged from
prior exam on [**8-21**]. Sternotomy wires
are intact. There is no evidence of pneumothorax.
IMPRESSION:
1. Pacemaker leads in standard position in right atrium and
ventricle.
2. No evidence of pneumothorax.
3. Mild interval worsening of right lower lobe opacification.
Otherwise,
unchanged from exam on [**2154-8-21**].
Brief Hospital Course:
[**Age over 90 **]M with a history of CAD s/p CABG and multiple stents, CHF,
paroxysmal atrial fibrillation p/w substernal chest pain, A-fib
w/ RVR, but later developed sinus bradycardia and underwent
pacemaker placement.
.
# A-fib with RVR
Patient presented with A-fib with RVR in the setting of recent
STEMI s/p restenting of SVG-LAD. On presentation he was in
[**11-11**] chest pain with HR in 110-120s with no evidence of
ischemia on EKG, but a slight increase in cardiac enzymes on the
second day, consistent with demand ischemia. A decision of
chemical conversion was made after first seen in the ED, given
his intolerance to b-blocker and good response to amioderone for
SVT during prior admission. Pt responded well to amiodarone,
with complete resolution of chest pain and tachycardia.
However, he later developed mixed sinus / junctional bradycardia
in 30-40s with stable blood pressure. We discontinued
amiodarone. EP consult was initiated. After discussing with
patient and his family, a decision was made to place a
pacemaker. Patient tolerated the procedure well without
complications. We hope with the pacemaker, patient would be
able to tolerate optimal medical management for his A-fib to
prevent rapid ventricular rate and demand ischemia. Of note,
patient has a CHADS score of 3, but was never treated wit
anti-coagulation. After discussing with family, we decided not
to start anti-coagulation, given his age and risk of
life-threatening bleeding.
OUTPATIENT ISSUES:
- Increased amiodarone to 200 mg daily
- Started metoprolol succinate 50 mg daily
.
# CAD:
Patient had recent STEMI s/p stent placement in SVG-LAD. His
chest pain on presentation was not associated with EKG changes.
There was a transient slight elevation of cardiac enzymes,
likely a result of demand ischemia secondary to rapid
ventricular rate during A-fib. Heparin drip was provided
initially given the unclear ACS picture on presentation, but
stopped shortly afterwards. His home medications were
continued, including aspirin, plavix, pravastatin and isosorbid
mononitrate. We temporarily discontinued lisinopril because of
patient's low blood pressure.
OUTPATIENT ISSUES:
- Changed to pravastatin from atorvastatin for insurance
purposes.
- Please consider restarting lisinopril if patient's blood
pressure tolerates
.
# CHF
Patient has a documented history of CHF likely secondary to his
long standing CAD, with stable LVEF at 30% and mild to moderate
MR on recent ECHO. Of note, he had a history of refractory
pleural effusion requiring talc pleuridesis. During this
hospitalization, we temporarily discontinued his furosemide
given his bradycardia. Nonetheless, patient maintained stable
volume status without clinical evidence of CHF. Patient was
discharged on only his morning dose of furosemide considering
the lack of need for diuresis during this admission.
OUTPATIENT ISSUES:
- Changed to furosemide 80 mg qAM only (from 80 mg qAM and 40 mg
qPM). Please optimize diuresis as needed.
.
# Right eye vision loss
Patient reported vision loss in his right eye for an unknown
duration, likely started during his recent hospitalization for
STEMI. He was seen by our ophthalmology team, and was found to
have a subretinal hemorrhage, involving the macula. This
unfortunate incident could have potentially happened in the
setting of anti-platelet treatment for his cardiac problems.
OUTPATIENT ISSUES:
- Patient has an outpatient ophthalmology appointment on [**8-26**].
CHRONIC ISSUES
# HTN
Patient has a documented history of HTN. However, he was
hypotensive to normotensive throughout this hospitalization. We
temporarily discontinued his lisinopril, isosorbid mononitrate
and furosemide, and restarted him on isosorbid mononitrate,
decreased dose of furosemide, but no lisinopril.
OUTPATIENT ISSUES
- please consider restarting lisinopril given patient's history
of CAD and CHF.
.
# Chronic renal insufficiency
Patient's Cr was at his recent baseline of 1.8-2.0. It appeared
that his renal insufficiency only started to worsen in the past
two years. His renal insufficiency could certainly be a result
of poor forward flow secondary to CHF. However, patient did
endorse symptoms associated with BPH, and was found to have
moderate retention despite spontaneous urination. The
post-renal obstruction could be a component causing his renal
insufficiency, and potentially be reversible.
OUTPATIENT
- please consider evaluation for BPH
.
# GERD
Patient has a documented history of GERD. We continued his home
medicine Ranitidine 150 mg daily.
.
TRANSITIONAL ISSUES
- Patient has a code status of DNR/DNI. It was temporarily
reversed to full only during the pacemaker placement.
- Patient has cardiology appointment on [**9-2**], Ophthalmology
appointment on [**8-26**] and primary care appointment on [**9-4**].
Medications on Admission:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO MONDAY,
WEDNESDAY, AND FRIDAY ().
2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM and 0.5
QPM.
4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain .
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day. Disp:*30 Tablet(s)* Refills:*2*
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Medications:
1. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. Outpatient Lab Work
Please check Chem-7, CBC on Monday [**8-26**] with results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**]
Fax: [**Telephone/Fax (1) 7531**]
15. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Caregroup
Discharge Diagnosis:
Acute Coronary Ischemia Type 2
Acute on Chronic Systolic congestive heart failure
Atrial fibrillation with rapid ventricular response
Chronic Kidney Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with chest pain and a fast heart rate. The
medicines you were given caused your heart rate to be too low
and a pacemaker was inserted on [**2154-8-21**]. Your chest pain is gone
but because you still have blockages in your arteries, you will
probably have more chest pain in the future. Chest pain that
lasts only seconds and goes away completely should not be
concerning. Chest pain that lasts more than seconds can be
treated with one nitroglycerin tablet every 5 minutes, no more
than 2 tablets total. If you still have chest pain after
nitroglycerin tablets or if the chest pain is severe, call 911
or Dr. [**Last Name (STitle) **]. Your urine has some bacteria in it, you have been
started on antibiotics for a 7 day course.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Take pravastatin instead of atorvastatin. This will be
covered by your insurance.
2. Increase amiodarone to 200 mg daily to prevent atrial
fibrillation and a fast heart rate
3. Start Metoprolol succinate daily to prevent chest pain
4. Decrease furosemide to 80mg in the morning for now. If you
see that your rate is increasing, Dr. [**Last Name (STitle) **] can increase the
dose again.
5. Stop lisinopril for now, Dr. [**Last Name (STitle) **] will restart it if needed
as your blood pressure has been low.
6. Start ciprofloxacin to treat the bacteria in your urine
.
Please get labs checked on Monday [**8-26**] when you are at the
[**Hospital Ward Name 23**] clinical center. You can bring the prescription for the
labs with you.
Dressing can come off the pacer site on Saturday and you may
shower. Do not remove the steri strips. No soap over the
incision site. No lifting more than 5 pounds or reaching over
your head with your left arm for 6 weeks.
Followup Instructions:
Department: [**Hospital3 1935**] CENTER
When: MONDAY [**2154-8-26**] at 1:05 PM
With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2154-9-2**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2154-9-2**] at 3:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: WEDNESDAY [**2154-9-4**] at 8:30 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"42731",
"4280",
"41401",
"40390",
"5859",
"2724",
"53081",
"V4581",
"V4582"
] |
Admission Date: [**2184-1-15**] Discharge Date: [**2184-1-21**]
Date of Birth: Sex: M
Service: NEUROLOGY
ADMISSION DIAGNOSIS: Stroke.
DISCHARGE DIAGNOSIS: Stroke, status post TPA.
HISTORY OF PRESENT ILLNESS: This is an 80 year old
the evening of [**2184-1-14**], when the patient had acute onset of
right sided weakness during a card game. He slumped over in
his chair at the table and had no loss of consciousness, but
was not able to speak afterwards.
Paramedics were called and the patient was brought to [**Hospital1 1444**] Emergency Department where on
Head CT showed no hypodensity and no evidence of any
hemorrhage.
The patient at that point was noted to have a NIH
stroke scale of 19. He was considered to be a TPA candidate and
had no contraindications.
The patient received TPA approximately one hour and forty
minutes after onset of symptoms and was afterwards monitored
in the unit. The patient's post TPA course was significant
for agitation with the patient receiving 19 mg of
Lopressor and 10 mg of Ativan in the Emergency Department for
blood pressure and agitation control.
The patient was monitored in the Neurosurgical Intensive Care
Unit for post TPA monitoring for any evidence of hemorrhage.
The patient's agitation continued with some alteration in
mental status.
An electroencephalogram was performed which showed diffuse
swelling though no epileptiform activity. The patient had
carotid ultrasounds performed which were normal. A
transthoracic echocardiogram showed an ejection fraction of
30 to 40% and no evidence of any cardiac etiology of his
stroke.
Magnetic resonance scan was performed which showed an area of
restricted diffusion in the left basal ganglia and insular
cortex, otherwise no structural abnormality. The patient's
MRA showed normal Circle of [**Location (un) 431**] as well as otherwise normal
vessels.
The patient was transferred to the floor and continued to
improve with regards to his examination. Speech and Swallow
was consulted which recommended a regular diet for the
patient as well as further speech therapy secondary to mild
dysarthria.
Physical examination at discharge - On general examination,
the patient's lungs are clear to auscultation bilaterally.
Cardiac examination reveals a regular rate and rhythm with no
murmur. The abdomen is soft, nontender, nondistended.
Extremities are warm and well perfused. On neurological
examination, the patient is awake and alert, in no acute
distress. The patient is oriented to person, date and [**Hospital3 **] Hospital. Speech is fluent with normal naming and
normal repetition. Attention is good with days of the week
backwards. On cranial nerve examination, the patient's
pupils are equally round and reactive to light. Extraocular
movements are intact with no nystagmus present. Fundi appear
normal. Facial movements are symmetric. Tongue and palate
are midline with full range of movement. There is normal
sternocleidomastoid and trapezius strength. On motor
examination, the patient has full strength on the left side
and mild 4+ out of 5 weakness on the right in an upper motor
neuron distribution. The patient's reflexes are symmetric
and 1+ bilaterally. Sensation is intact bilaterally to light
touch and pin prick. The patient has mildly slow rapid
alternating movements and finger-nose-finger though steady
and accurate. The patient's gait is significant for mild
unsteadiness. The patient's evaluation by physical therapy
and occupational therapy recommends rehabilitation secondary
to gait.
Anticipated discharge is on [**2184-1-21**], to rehabilitation at
[**Hospital3 **].
CONDITION ON DISCHARGE: Good.
The patient is to receive occupational therapy and physical
therapy and speech and language therapy at rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Synthroid 137 mcg p.o. q.d.
2. Fluoxetine 20 mg p.o. q.d.
3. Zantac 150 mg p.o. b.i.d.
4. Oxycontin 20 mg p.o. t.i.d.
5. Lopressor 12.5 mg p.o. b.i.d.
6. Percocet one tablet p.o. q6hours p.r.n. back pain.
7. Senokot one to two tablets p.o. p.r.n. constipation.
8. Milk of Magnesia 30 ccs p.o. q.d. p.r.n. constipation.
9. Albuterol MDI two puffs q4hours p.r.n. wheezing.
10. Aspirin 325 mg p.o. q.d.
FOLLOW-UP: The patient will follow-up in neurology with the
stroke team in approximately one month. In the meantime, he
will be kept on Aspirin as adequate anticoagulation following
his stroke and will receive appropriate physical therapy and
occupational therapy as well as speech therapy at
rehabilitation. The patient will continue on his outside
regimen of Percocet and Oxycontin for pain control of spinal
stenosis.
[**Last Name (LF) **],[**Name8 (MD) **] M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 38109**]
MEDQUIST36
D: [**2184-1-20**] 18:01
T: [**2184-1-20**] 18:40
JOB#: [**Job Number 105448**]
|
[
"4019",
"41401",
"412",
"V4582"
] |
Admission Date: [**2163-5-14**] Discharge Date: [**2163-5-15**]
Date of Birth: [**2114-6-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
48 y/o M w/hx of EtOH abuse who presented to [**Hospital3 **] on [**2163-5-13**] c/o hematemesis. He was a somewhat vague
historian, but c/o persistent n/v of bright red blood. Denied
melena. Noted decreased UOP. Drinks daily, with last drink at
midnight on day of admission. In [**12-29**], he was admitted to [**Hospital **] with CP, noted to have Hct 28, and had an EGD that
revealed mild reflux esophagitis, no varices, and small gastric
ulcerations.
On [**5-13**], he called EMS c/o hematemesis. At that time he was
hypotensive to 80/40, pulse 67. Labs revealed ABG 6.97/41/141,
Hct 20, plt 39, INR 1.6, creatinine 12.1, bicarb 11, calcium 5,
bili 8.3, AST 587, ALT 158, alk phos 433. He had an EGD which
revealed fresh large clot traveling down the entire length of
the esophagus. No varices. Large fresh thrombus in fundus.
There was concern that some of the bleeding was from his
nasopharynx, and ENT visualized a laceration in his right
nasopharynx that they packed extensively. He was begun on
octreotide and protonix, given 9 units PRBC and 12 pk of
platelets. Placed on levophed and neo. Given IVF w/sodium
bicarb but remained anuric. They placed a subclavian dialysis
catheter and emergently dialyzed him on [**5-14**]. Later that day he
was transferred to [**Hospital1 18**]. During the [**Location (un) 7622**], he became
hypotensive and was begun on vasopressin. He was bleeding from
his eyes, nose, and ETT.
Past Medical History:
HTN
Anemia
GI bleed [**12-29**] (small gastric antral ulcers, ? due to NSAIDs)
Bilateral OA of hips
EtOH abuse
Social History:
lives with his brother. used to work as a welder and was
exposed to benzene per family. currently on disability [**1-26**] OA.
Drank heavily between [**12-28**] and 1/05 per family, but they do not
believe he had been drinking since [**12-29**] although pt reported
that he had been upon admission. Family denies tobacco or other
drugs.
Family History:
sister died during PTCA at 37 y/o, mother died of CVA
Physical Exam:
T: 96 P: 77 BP: 100/57
Vent 500 x 16, PEEP 5, FiO2 60%
Gen: intubated/sedation
HEENT: dried bloodon eyes, nasal packing, mouth
Lungs: coarse anteriorly, diminished breath sounds at bilateral
bases
CV: RRR, no m/r/g
Abd: distended, nontender, hypoactive bowel sounds
Ext: trace pedal edema, 1+ dp pulses bilaterally
Skin: cool extremities, poor capillary refill
Pertinent Results:
[**2163-5-14**] 08:53PM BLOOD WBC-3.7* RBC-3.73* Hgb-12.1* Hct-33.2*
MCV-89 MCH-32.5* MCHC-36.5* RDW-18.0* Plt Ct-68*
[**2163-5-15**] 12:23AM BLOOD Hct-30.6*
[**2163-5-15**] 04:09AM BLOOD WBC-4.8 RBC-3.53* Hgb-11.2* Hct-30.9*
MCV-87 MCH-31.7 MCHC-36.3* RDW-17.5* Plt Ct-49*
[**2163-5-15**] 08:04AM BLOOD WBC-6.8 RBC-4.03* Hgb-12.5* Hct-36.0*
MCV-89 MCH-31.0 MCHC-34.7 RDW-17.2* Plt Ct-38*
[**2163-5-15**] 02:48PM BLOOD Hct-31.5* Plt Ct-85*#
[**2163-5-14**] 08:53PM BLOOD PT-32.2* PTT-150* INR(PT)-6.8
[**2163-5-15**] 12:23AM BLOOD PT-17.6* PTT-76.5* INR(PT)-2.1
[**2163-5-15**] 08:04AM BLOOD PT-15.6* PTT-51.5* INR(PT)-1.6
[**2163-5-14**] 08:53PM BLOOD Fibrino-418*
[**2163-5-14**] 09:52PM BLOOD FDP-40-80
[**2163-5-15**] 04:09AM BLOOD Fibrino-398
[**2163-5-14**] 08:53PM BLOOD Glucose-155* UreaN-53* Creat-7.2* Na-137
K-3.3 Cl-104 HCO3-16* AnGap-20
[**2163-5-15**] 04:09AM BLOOD Glucose-95 UreaN-48* Creat-6.4* Na-141
K-3.6 Cl-99 HCO3-14* AnGap-32*
[**2163-5-15**] 08:04AM BLOOD Glucose-85 UreaN-42* Creat-5.6* Na-136
K-6.3* Cl-95* HCO3-10* AnGap-37*
[**2163-5-15**] 11:20AM BLOOD Glucose-360* UreaN-36* Na-138 K-3.6
Cl-89* HCO3-18* AnGap-35*
[**2163-5-15**] 07:10PM BLOOD Glucose-279* UreaN-31* Creat-4.0*# Na-136
K-5.2* Cl-83* HCO3-12* AnGap-46*
[**2163-5-14**] 08:53PM BLOOD ALT-176* AST-747* LD(LDH)-1120*
AlkPhos-487* Amylase-51 TotBili-14.0*
[**2163-5-14**] 09:52PM BLOOD CK(CPK)-68 DirBili-0.2
[**2163-5-15**] 04:09AM BLOOD ALT-155* AST-682* AlkPhos-434*
TotBili-12.8*
[**2163-5-14**] 08:53PM BLOOD Lipase-1260*
[**2163-5-15**] 11:20AM BLOOD CK-MB-15* cTropnT-<0.01
[**2163-5-14**] 08:53PM BLOOD Ammonia-507*
[**2163-5-14**] 09:52PM BLOOD Acetone-NEGATIVE Osmolal-308
[**2163-5-14**] 09:52PM BLOOD Cortsol-151.4*
[**2163-5-14**] 09:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.5
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2163-5-14**] 09:07PM BLOOD Type-ART pO2-123* pCO2-46* pH-7.20*
calHCO3-19* Base XS--9
[**2163-5-14**] 11:12PM BLOOD Type-ART pO2-61* pCO2-36 pH-7.33*
calHCO3-20* Base XS--6
[**2163-5-15**] 12:11AM BLOOD Type-ART pO2-69* pCO2-35 pH-7.29*
calHCO3-18* Base XS--8
[**2163-5-15**] 01:00AM BLOOD Type-ART pO2-74* pCO2-35 pH-7.30*
calHCO3-18* Base XS--7
[**2163-5-15**] 05:32PM BLOOD Type-ART Temp-35.0 Rates-36/ Tidal V-450
PEEP-15 FiO2-80 pO2-78* pCO2-31* pH-7.34* calHCO3-17* Base XS--7
AADO2-469 REQ O2-79 -ASSIST/CON Intubat-INTUBATED
[**2163-5-14**] 09:07PM BLOOD Glucose-146* Lactate-6.8*
[**2163-5-15**] 02:04AM BLOOD Lactate-10.8*
[**2163-5-15**] 04:23AM BLOOD Lactate-12.6*
[**2163-5-15**] 08:29AM BLOOD Glucose-80 Lactate-15*
[**2163-5-15**] 03:07PM BLOOD Lactate-19.2*
[**2163-5-15**] 07:20PM BLOOD Glucose-287* Lactate-26.3*
CXR: IMPRESSION: 1) ET tube in satisfactory position.
2) Right central line tip approximately at SVC/RA junction.
3) Feeding tube tip high, probably in region of GE junction.
This was called to the nurse caring for this patient.
4) Patchy increased density right perihilar and left
retrocardiac region.
Brief Hospital Course:
He was admitted to the MICU service. He was felt to have
alcoholic hepatitis and pancreatitis, with a GI bleed of unclear
source, and ARF. His respiratory failure was felt due to
anasarca from the massive amt of fluids and blood products he
required. He was given levofloxacin, empiric decadron, and
continued on pressors. He was placed on CVVH on admission
because he was anuric, acidemic, and difficult to
oxygenate/ventilate. Bladder pressure was checked at was
elevated at 28, but he had no ascites on abdominal ultrasound.
Surgery was called re: abdominal compartment syndrome but did
not feel he had any indications for surgery. He was placed on
paralytics, resulting in decreased abd pressure. He was
transfused 3 add'l units of PRBCs and 9 of FFP. He continued to
require additional pressors, including dopamine, levophed, and
vasopressin. Because of his multi-organ system failure and grim
prognosis, a family meeting was held. He had worsening acidosis
and hypotension despite maximum pressors. The family decided to
change goals of care to comfort measures only, and he died on
[**2163-5-15**].
Medications on Admission:
Meds at home:
lovastatin
atenolol
lisinopril
combivent
lactulose
Meds on transfer:
levophed
neosynephrine
vasopressin
octreotide
protonix
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
GI bleed
Hepatitis
Lactic Acidosis
Acute Renal Failure
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"0389",
"51881",
"5845",
"99592",
"4019",
"49390"
] |
Admission Date: [**2134-4-14**] Discharge Date: [**2134-4-20**]
Date of Birth: [**2080-6-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Epinephrine / Ambien
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
choledocholithiasis
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and sphincteroplasty was performed. Not
all stones were removed and a 10FRx5cm double pigtail plastic
stent was placed.
History of Present Illness:
Ms. [**Known lastname 28893**] is a 53 year old woman with a past medical history
significant for schizophrenia, depression, fibromyalgia, chronic
fatigue syndrome, and a recent admission for gallstone
pancreatitis complicated by cholangitis.
She presented to [**Hospital1 18**] for an elective ERCP. She underwent a
complicated procedure with sphincteroplasty and extraction of
multiple stones. Complete bile duct clearance was not achieved
and she required a stent placement. Per the ERCP team, the
intubation was difficult and the back of the throat was noted to
be edematous and bleeding as the scope was passed many times to
complete this procedure. After the procedure, she had laryngeal
edema and oral bleeding. She remained intubated after the
procedure and was admitted to the ICU.
Past Medical History:
Fibromyalgia
Chronic fatigue syndrome
Depression
Schizophrenia
Previous Admission: The patient was initially admitted to [**Hospital1 18**]
under from [**Date range (1) 90061**] with gallstone pancreatitis and cholangitis.
Her hospital course was complicated by hypotension and and
required admission to the SICU. At that time, she underwent ERCP
with sphincterotomy and a double pig-tail stent placement. She
was also treated with ciprofloxacin and Flagyl with improvement
in her LFTs, Tbili, and abdominal pain. Of note, her hospital
course was also complicated by hypoxemia with activity of
unclear etiology, but was discharged without supplemental oxygen
after a CTA ruled out PE.
Past Surgical History: laparoscopic exploration
Social History:
Social History: Lives alone, denies tobacco, EtOH, drugs
Family History:
Unknown
Physical Exam:
Admission (ICU):
99.2 99/58 90 17 99% (on vent)
Gen: NAD, intubated, sedated
HEENT: endotracheal tube in place, mmm
CV: RRR, nl s1 and s2, no m/r/g
Pulm: CTAB
Abd: obese, soft, nontender, nondistended, + bs
Ext: no c/c/e
Discharge Exam:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
No pain with eating a regular diet. Mild RUQ tenderness of
physical exam.
Pertinent Results:
Admission Laboratory Studies:
[**2134-4-14**] 10:57PM TYPE-ART PO2-86 PCO2-43 PH-7.37 TOTAL CO2-26
BASE XS-0
[**2134-4-14**] 10:57PM LACTATE-3.5*
[**2134-4-14**] 02:30PM UREA N-11 CREAT-0.7 SODIUM-143 POTASSIUM-4.3
CHLORIDE-102 TOTAL CO2-27 ANION GAP-18
[**2134-4-14**] 02:30PM ALT(SGPT)-123* AST(SGOT)-89* ALK PHOS-217*
AMYLASE-30 TOT BILI-0.9 DIR BILI-0.4* INDIR BIL-0.5
[**2134-4-14**] 02:30PM LIPASE-29
[**2134-4-14**] 02:30PM ALBUMIN-4.5
[**2134-4-14**] 02:30PM WBC-12.9* RBC-4.24 HGB-13.6 HCT-40.7 MCV-96
MCH-32.0 MCHC-33.3 RDW-15.8*
[**2134-4-14**] 02:30PM NEUTS-74.0* LYMPHS-19.7 MONOS-3.5 EOS-2.5
BASOS-0.4
[**2134-4-14**] 02:30PM PT-12.3 INR(PT)-1.0
Discharge Laboratory Studies:
ERCP [**2134-4-14**]:
Findings:
-Esophagus: Limited exam of the esophagus was normal
-Stomach: Limited exam of the stomach was normal
-Duodenum: Limited exam of the duodenum was normal
-Major Papilla: Normal major papilla with stent in-situ.Stent
removed with snare.Previous sphincterotomy noted.
-Cannulation: Cannulation of the biliary duct was successful
and deep with a sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
-Biliary Tree: Many stones that were causing partial obstruction
were seen at the biliary tree.Sphincterotomy was extended with a
balloon sphincteroplasty using a 10 and 12mm balloon.Multiple
stones were removed with a balloon catheter.As duct clearance
could not be achieved with the balloon a basket was used to
retrive rest of the stones. The stones could not be completely
removed as the basket was impacted at the ampulla.Basket was
successfully removed with a rat-toothed forceps.Due to prolonged
procedure further attempts to clear duct were not made and a
10FRx5cm double pigtail plastic stent was inserted successfully.
Impression: Normal major papilla with stent in-situ.Stent
removed with snare.
-Previous sphincterotomy noted.
-Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
-Contrast medium was injected resulting in complete
opacification.
-Bile duct was dilated to 12 mm.
-Many stones that were causing partial obstruction were seen at
the biliary tree.
-Sphincterotomy was extended with a balloon sphincteroplasty
using a 10 and 12mm balloon.
-Multiple stones were removed with a balloon catheter.
-As duct clearance could not be achieved with the balloon a
basket was used to retrieve rest of the stones.
-The stones could not be completely removed as the basket was
impacted at the ampulla.
-Basket was successfully removed with a rat-toothed forceps.
-Due to prolonged procedure further attempts to clear duct were
not made and a 10FRx5cm double pigtail plastic stent was
inserted successfully.
CXR [**2134-4-14**]:
An endotracheal tube ends 4.7 cm above the carina. Lung volumes
are low.
Cardiac, mediastinal and hilar contours are unchanged. A dense
left basilar
opacity obscures the left hemidiaphragm, possibly aspiration,
pneumonia or
atelectasis. On the right, there is no pleural effusion and
there is no
pneumothorax. There is mild interval progression of pulmonary
vascular
congestion.
Brief Hospital Course:
Ms. [**Known lastname 28893**] is a 53 year old woman with a past medical history
significant for schizophrenia, depression, fibromyalgia, and a
recent admission for gallstone pancreatitis complicated by
cholangitis. She presented to [**Hospital1 18**] for an elective ERCP. This
was a complicated procedure due to high gallstone burden and
post-procedure laryngeal edema and bleeding. She remained
intubated after the procedure and was admitted to the ICU. Her
ICU course was uncomplicated and she was extubated on [**4-15**].
She was transferred out to the floor for further management
including observation, advancement of diet, and a 5-day course
of post-procedure ciprofloxacin as recommended by the ERCP team.
The general surgery team was consulted for evaluation for
cholecystectomy. This was offered to the patient but she
declined surgery. She will need a repeat ERCP in 2 months for
stent removal and further stone extraction considering not all
stones were able to be removed during procedure during this
admission.
The patient was evaluated by our social work and psychiatry
consult service. She is felt to have the capacity currently to
decline surgery. She has good home services (a psych team that
makes home visits multiple times per week) and scheduled
follow-up with her primary care doctor and it is hoped that she
will become amenable to cholecystectomy. If not, the issue of
capacity to decline should be re-addressed as her long term risk
of life threatening complication is extremely high.
Home Clozaril was continued for schizophrenia.
Medications on Admission:
Lopid 600 mg po bid
Zantac 150 mg daily
Senna qhs
APAP
Clozaril 200 mg po qhs
Bisacodyl qhs
Ca-Vit D
Discharge Medications:
1. clozapine 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day as
needed for heartburn.
4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain.
6. bisacodyl 10 mg Suppository Sig: One (1) tablet Rectal once a
day as needed for constipation.
7. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Doctor First Name **] services - VNA
Discharge Diagnosis:
Choledocholithiasis with obstruction
Schizophrenia
Fibromyalgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
No pain with eating a regular diet.
Discharge Instructions:
Dear Ms. [**Known lastname 28893**],
You were admitted for an ERCP. During this procedure, you were
noted to have multiple gallstones. They were not able to remove
all of these stones and a plastic stent was placed. You will
need to return in 2 months to have this stent removed and to
have the rest of the stones removed.
We also recommend that you have your gall bladder removed to
prevent this from happening again. You are declining this at
this time. If you change your mind and would like to schedule a
surgery please call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2998**]. In the
meantime, please discuss this further with your primary care
doctor
We treated you with antibiotics and your last dose was on [**4-19**].
We made no other changes to your medications.
Followup Instructions:
Please return in 2 months to have your stent removed and
additional gallstones removed. Your primary care doctor can help
you schedule this procedure.
If you decide to have your gall bladder removed please call Dr. [**Name (NI) 76749**] office at [**Telephone/Fax (1) 2998**]. In the meantime, please discuss
this further with your primary care doctor.
Name: [**Name6 (MD) **] [**Last Name (NamePattern4) 90062**],MD
Specialty: Internal Medicine
When: Friday [**4-30**] at 11:30am
Address: [**Street Address(2) 78853**], [**Location (un) **],[**Numeric Identifier 78233**]
Phone: [**Telephone/Fax (1) 51033**]
|
[
"2724"
] |
Admission Date: [**2144-1-28**] Discharge Date: [**2144-2-5**]
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old
female with a history of congestive heart failure, chronic
obstructive pulmonary disease who now presents from [**Hospital3 15416**] with substernal chest pain since 5 p.m. today. The
patient was recently admitted to [**Hospital1 190**] for CHF exacerbation. The substernal chest
pain started while she was sitting down for dinner. It
started in the epigastric area and slowly spread to her back
in a fan like pattern. She described the pain as [**9-17**]. She
reports accompanying shortness of breath, diaphoresis, but
denies radiation to the arms, dizziness, palpitations, loss
of consciousness or diaphoresis. Her pain was relieved in
the Emergency Room with IV Nitroglycerin. Her EKG
demonstrated rapid atrial fibrillation with rate related ST
depressions. Her rapid ventricular rate was rate controlled
with Diltiazem in the Emergency Room. Her episodes of pain
have been occurring intermittently since [**2143-2-7**].
Patient has a history of congestive heart failure with prior
admissions. She reports increasing dyspnea on exertion. She
denies any calf tenderness or swelling. She does have a mild
productive cough. She also complains of nausea in the last
few days with decreased appetite. She denies any abdominal
pain or changes in bowel or bladder habits. She denies any
bright red blood per rectum with melena.
PAST MEDICAL HISTORY: Coronary artery disease, status post
myocardial infarction in [**1-10**], percutaneous transluminal
coronary angioplasty to the right coronary artery.
Congestive heart failure, echocardiogram in [**11-8**]
demonstrated an EF of 20% and mitral regurgitation of 3+.
Paroxysmal atrial fibrillation. NSVT status post pacer and
ICD placement. Cerebrovascular accident. Hypertension.
Hypothyroidism. Chronic obstructive pulmonary disease with
home oxygen dependence. Diabetes mellitus. Chronic renal
insufficiency. Chronic low back pain. Abdominal aortic
aneurysm, 4 cm thoracic and 3.9 by 4.4 cm infrarenal
abdominal aortic aneurysm.
MEDICATIONS: Univasc 7.5 mg po q d, Atenolol 12.5 mg po q
day, Atrovent 2 puffs po bid, Protonix 40 mg po bid, Coumadin
4 mg po q day, Lasix 60 mg po q d, Serevent 2 puffs po bid,
Amiodarone 100 mg po q day, Levoxyl 100 mcg po q day,
Compazine Spansules 10 mg po q 12 hours prn.
SOCIAL HISTORY: The patient is currently a resident at
[**Hospital3 537**]. She is followed by [**Hospital **] Medical Group. The
patient is a former smoker (one pack per day times 30 years).
The patient denies any alcohol use. Code status is DNR/DNI.
Next of [**Doctor First Name **] is [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 104017**].
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Temperature 97.8, pulse 132, blood
pressure 110/61, respiratory rate 18, satting 96% on four
liters via nasal cannula. General: Alert and oriented times
three, no acute distress. HEENT: Pupils are equal, round,
and reactive to light, extraocular movements intact, moist
mucus membranes, no lymphadenopathy. Neck supple.
Cardiovascular, S1 and S2, irregular rhythm, [**2-12**] holosystolic
murmur at the left lower sternal border. Pulmonary, mild
bibasilar crackles, rhonchi at the right upper lobe,
decreased breath sounds globally. Abdomen, nontender, non
distended, soft, positive bowel sounds. Extremities, 2+
pitting edema bilaterally with mild stasis changes, pulses 1+
bilaterally. Neurological, cranial nerves II through XII
intact.
LABORATORY DATA: On admission white blood cell count 10,
hematocrit 35.9, platelet count 223,000 with INR of 1.4, PTT
26.3, PT 14, sodium 139, potassium 4.3, chloride 96, CO2 30,
BUN 36, creatinine 1.5, glucose 245, calcium 9.1, phosphorus
2.6, magnesium 1.9. CK 111, MB fraction 2 and troponin less
than 0.3. EKG, atrial fibrillation, rate 133, ST depressions
in leads V4 through V6, axis negative 30 degrees. Chest
x-ray, increased vascular markings in the upper zones,
peribronchial cuffing.
HOSPITAL COURSE: The patient is an 86-year-old woman with
congestive heart failure, coronary artery disease, who was
admitted with intractable chest pain and atrial fibrillation
with rapid ventricular rate. The patient was initially
admitted to C Med for further evaluation and management.
At time of admission the patient's symptoms were felt to be
likely secondary to her atrial fibrillation with a rapid
ventricular rate. The patient had been started on Diltiazem
for rate control in the Emergency Room and was continued on
Amiodarone as well. Given the patient's suggestion of a CHF
exacerbation based on pulmonary and x-ray findings, it was
decided to hold the patient's Atenolol, provide afterload
reduction with Univasc, and provide the patient with Lasix
prn. In addition, the patient was continued on Aspirin for
her history of coronary artery disease and her Coumadin was
held and the patient was started on a Heparin drip. The
patient's symptoms were felt to be potentially consistent
with unstable angina and she was therefore ruled out with
three sets of negative enzymes. It was determined to treat
the patient's CHF exacerbation and then determine whether
patient might benefit from a stress test to assess the areas
of cardiac muscle at risk. It was also felt that the
patient's CHF exacerbation may be related to rapid
ventricular rate, demand ischemia, and loss of atrial kick
due to her atrial fibrillation. The patient subsequently
ruled in for a myocardial infarction with her second troponin
elevated at 13. Her EKG changes improved with rate control,
however, the patient's CHF did not significantly respond to
Lasix therapy. A cardiology consult was obtained in order to
specifically address the possibility of electrical
cardioversion. Cardiology consult felt it was unclear which
event had prompted the others, whether the atrial
fibrillation and CHF had proceeded the MI or vice versa,
however, given her multiple secondary problems, it was felt
that the base treatment would be electrical cardioversion.
Discussion was held with the patient and with her family
after which the patient persisted in stating that she as not
sure she wanted the procedure done. Given the patient's
reluctance to undergo electrical cardioversion, it was
therefore determined to continue the patient on Diltiazem
drip to maintain a heart rate in the 60's as well as continue
diuresis with Lasix and Amiodarone therapy.
Over the next day the patient's chest pain completely
resolved, however, she remained tachycardic and mildly short
of breath and complained of palpitations. Her
antihypertensive medications continued to be held given her
mildly low blood pressures and she was continued on Diltiazem
drip given her poor response to po Diltiazem. The patient's
pulmonary status continued to be treated with Lasix prn as
well as aggressive nebulizer therapy and supplemental oxygen.
In addition, the patient's elevated creatinine was felt to be
secondary to her CHF, presenting a prerenal type picture. A
urinalysis upon admission demonstrated small leukocyte
esterase but no bacteria. However, given mild elevation in
her white blood cell count, the patient was empirically
started on Levofloxacin awaiting cultures.
The patient was found not to respond to further medical
therapy and was subsequently found to be in atrial
fibrillation with a heart rate in the 100's and a blood
pressure which dropped as low as 78/48. Given the patient's
tachycardia and significant hypotension, she subsequently
underwent DC cardioversion with anesthesia present for
sedation. This cardioversion successfully placed the patient
in sinus rhythm. However, she spontaneously converted back
to atrial fibrillation within the next few hours. Given the
patient's hypotension and rapid atrial fibrillation now
status post cardioversion, she was subsequently transferred
to the CCU for further intensive management. On initial
presentation to the CCU the patient did not appear volume
overloaded based on pulmonary and the remainder of the
physical examination. Her elevated BUN and creatinine
suggested the patient may actually be dry and she was given a
small fluid challenge to which she responded with increased
shortness of breath and decrease in oxygen saturation. She
was therefore subsequently treated with aggressive Lasix
therapy, nebulizers and supplemental oxygen as needed. The
patient was continued on Diltiazem drip in an effort to
control her heart rate in the 70's. It was felt that the
patient was demonstrating low output CHF with a decreasing
blood pressure, overall volume overload, and acute renal
failure. Given the patient's multiple other medical problems
and given the patient was DNR/DNI and refused any invasive
procedures, the CCU team felt that the options were severely
limited and a family meeting was planned to discuss the
patient's prognosis. Over the next few days the patient's
blood pressure was maintained with IV fluid administration
and her antihypertensives were held. However, this resulted
in lower oxygen saturations requiring increased oxygen
supplementation. However, the patient was strict about her
DNR/DNI wishes and refused inotropic pressors as well. The
patient was continued on Amiodarone and Digoxin was added to
her regimen for further rate control in addition to
Diltiazem. Following an extensive discussion with the family
and with the patient regarding the patient's lack of response
to medical management, and the patient clearly stating she
did not desire any further interventions or inotropic
therapy, it was determined to make the patient comfort
measures only. The patient was therefore continued on her
current IV npo antibiotics as well as provided with Morphine
and Ativan for pulmonary comfort, however, no new medications
were added to her regimen. The patient was therefore
subsequently transferred out of the ICU and back to a more
private room on the floor. Over the next few hospital days
as efforts remained to keep the patient very comfortable, she
continued to require more increasing doses of Ativan and
Morphine for relief of dyspnea and air hunger. The patient
found it hard to swallow her pills and therefore all po
medications were discontinued. Discussions were had with
palliative care reference, a referral to hospice. The
patient subsequently became unresponsive but appeared
comfortable on her current medication regimen. The patient
subsequently passed away at 8 a.m. on [**2144-2-5**]. The patient's
family was notified and refused an autopsy at this time.
Notification was provided to the patient's attending.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2144-6-10**] 15:38
T: [**2144-6-11**] 08:38
JOB#: [**Job Number **]
|
[
"4280",
"42731",
"41071",
"5849",
"V5861",
"25000",
"2449"
] |
Admission Date: [**2110-5-8**] Discharge Date: [**2110-5-13**]
Date of Birth: [**2055-12-2**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8480**]
Chief Complaint:
Submental and mandibular periapical abscesses
Major Surgical or Invasive Procedure:
I/D Neck (submental) abscess
Removal mandibular teeth
History of Present Illness:
54 year old male with history of coronary artery disease s/p
stent and CABG, type 2 diabetes, depression, peptic ulcer
disease who presents with dental pain, submental swelling
concerning for Ludwig's angina. The patient had dental pain in
his right mandible area starting Saturday morning. He took a
long nap in the afternoon and awoke with worsened ache so he
applied orajel to the area. Of note, the patient has poor
dentition at baseline and "hate dentists." He developed swelling
Sunday, [**2110-5-4**] that progressed, with worsening pain and
subjective fevers. The pain radiated up to his ears and felt
like a deep/posterior sore throat. The swelling became firm and
enlarged by Monday and his tongue also felt swollen, making it
difficult to talk because of the pain. The patient presented
initially to [**Hospital6 3105**] on Wednesday (yesterday)
where CT maxillofacial showed a 3.5X3.2X2 cm abscess. The
patient received clindamycin and potassium repletion prior to
transfer to [**Hospital1 18**] and endorsed significant improvement in pain
and swelling afterwards. He describes mild odynophagia but no
dyspnea/orthopnea, dysphagia, trismus, stridor.
.
In the ED, VS initially T98.0, HR90, BP118/73, RR16, 100% on RA.
The patient received additional coverage with Vancomycin given
that the patient works at [**Hospital6 **] (for MRSA). Labs
drawn were stable except for borderline INR 1.2, leukocytosis to
12.8 with left shift and lactate 2.3. Blood cultures were sent.
EKG with ST depression in V2-V5 so given full dose aspirin. ENT
was consulted and performed laryngoscopy demonstrating stable
airway. OMFS was also consulted for abscess management. Panorex
performed pre-operatively and reviewed by OMFS.
.
ROS: Denies night sweats, headaches, vision changes, rhinorrhea,
cough, chest pain, abdominal pain, nausea, vomiting, diarrhea.
In particular, denies dyspnea, dysphagia, +odynophagia
.
Past Medical History:
* Coronary artery disease s/p stent in [**2101**] and CABG X3 [**2107**]
* Depression
* Peptic ulcer disease
* Type 2 diabetes mellitus
Social History:
Works at [**Hospital6 **] at the Data Center. Denies
tobacco (quit [**2108-9-20**], previously 2 ppd X 30 years); denies
illicit drugs. Rare alcohol. Happily married, second marriage.
Two children (27 yo, 32 yo) from first marriage, 18 yo and 15 yo
from this marriage.
Family History:
Father had diabetes, stroke, died of CHF at 61 years old. Mother
also died of CHF at 61 yo. Multiple aunts/uncles died of CHF.
Grandparents lived into their 90s.
Physical Exam:
VS: Temp: 97.0 BP: 133/75 HR: 92 RR: 16 O2sat 92% on RA (lying
at 30 degree angle)
GEN: Pleasant, comfortable, NAD, alert and oriented, diaphoretic
Oral: Anterior submental region tender/firm predominantly on
right side. Mild erythema or neck on right side of midline,
+warmth, +TTP. Tender area of fluctuance palpable on right. Poor
dentition, +halitosis.
No trismus. Able to open mouth gradually. Cervical
lymphadenopathy. No active purulent drainage.
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no jvd
Nasal septal deviation. No stridor audible.
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Alert and oriented, cranial nerves grossly intact.
Strength and sensation grossly intact.
.
Pertinent Results:
[**2110-5-12**] 04:00PM BLOOD WBC-6.6 RBC-4.37* Hgb-13.4* Hct-37.5*
MCV-86 MCH-30.6 MCHC-35.7* RDW-13.6 Plt Ct-316
[**2110-5-8**] 05:13AM LACTATE-1.5
[**2110-5-8**] 04:49AM GLUCOSE-259* UREA N-26* CREAT-1.0 SODIUM-132*
POTASSIUM-3.2* CHLORIDE-91* TOTAL CO2-24 ANION GAP-20
[**2110-5-8**] 04:49AM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-1.6
[**2110-5-8**] 04:49AM WBC-10.9 RBC-4.43* HGB-13.5* HCT-38.0* MCV-86
MCH-30.5 MCHC-35.6* RDW-14.0
[**2110-5-8**] 04:49AM PLT COUNT-211
[**2110-5-8**] 04:49AM PT-14.6* PTT-22.3 INR(PT)-1.3*
[**2110-5-7**] 10:35PM LACTATE-2.3*
[**2110-5-7**] 10:30PM GLUCOSE-233* UREA N-24* CREAT-1.1 SODIUM-133
POTASSIUM-3.4 CHLORIDE-90* TOTAL CO2-26 ANION GAP-20
[**2110-5-7**] 10:30PM estGFR-Using this
[**2110-5-7**] 10:30PM cTropnT-<0.01
[**2110-5-7**] 10:30PM WBC-12.8* RBC-4.76 HGB-14.6 HCT-40.6 MCV-85
MCH-30.6 MCHC-35.8* RDW-14.0
[**2110-5-7**] 10:30PM NEUTS-81.9* LYMPHS-11.6* MONOS-5.5 EOS-0.6
BASOS-0.4
[**2110-5-7**] 10:30PM PLT COUNT-227
[**2110-5-7**] 10:30PM PT-14.2* PTT-21.0* INR(PT)-1.2*
.
Panorex pending
.
Blood cultures X2 pending
.
EKG: Normal sinus rhythm, normal axis, QTc 431, moderate R wave
progression, TWI (biphasic) in V2-V4. Less pronounced on EKG
from OSH [**2108-12-21**] (TWI in V1, ?V2).
.
Imaging:
CT maxillofacial with contrast (OSH): 3.5X3.2X2cm likely abscess
in the FOM asymmetric to the right with adjacent cellulitis and
reactive lymphadenopathy. This has no clear connection to apical
tooth abscess. There is evidence of multifocal maxillary and
mandibular apical tooth abscesses. The airway remains patent.
.
Panorex: retained root tips #2,18,19,30; PARL
#2,3,6,7,10,11,14,18,19,24,28,30; carious #5-8,10,11,20,28,29;
generalized moderate periodontitis
.
WOUND CULTURE (Final [**2110-5-11**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
Brief Hospital Course:
54 year old male with history of hypertension, hyperlipidemia,
coronary artery disease s/p stent and CABG, type 2 diabetes,
depression, peptic ulcer disease who presents with Ludwig's
angina.
.
# Ludwig's Angina: Sent to ICU for airway monitoring. Seen on CT
maxillofacial with contrast. Evaluated by ENT and OFMS. Likely
etiology is poor dentition, gingivitis and diabetes. Currently
protecting airway. Started on continue Vancomycin and
Clindamycin IV. Given decadron 10mg X1 to assist with swelling.
Planned extra-oral and intra-oral incision and drainage of
submental abscess with ENT. OFMS will try to do teeth
extractions in OR as well. Made NPO in ICU. Started peridex
mouthwash twice daily, follow-up blood cultures X2. Monitor
closely for airway; would need Trauma Surgery/ACS involved for
emergent surgical airway if decompensates. washout uneventful in
OR and all mandibular teeth extracted. See op note for details.
On floor did well post-op and transitioned to diabetic soft
diet. No further fevers and tolerated packing changes without
problem. His neck abscess cavity remained large and was packed
with iodoform gauze on a [**Hospital1 **] basis. He and his wife were
instructed in how to perform this and were insistent at the time
of discharge that she would perform the dressing changes on her
own. She was not at all interested in having a visiting nurse
help with the dressing changes. They agreed to monitor the wound
closely and call or return to the office with any concerning
changes.
.
# Coronary artery disease: s/p stent in [**2101**] and CABG X3 [**2107**].
New EKG concerning in anterior leads similar to [**2108-12-21**] [**Hospital1 2177**]
EKG. Continue metoprolol but will switch to tartrate 50mg
[**Hospital1 **],lisinopril, HCTZ,aspirin 81, atorvastatin 80mg daily.
.
# Type 2 diabetes mellitus: Possibly poor glucose control given
dental infection. On glipizide and metformin at home. Was
started on insulin sliding scale, but remained high. After d/c
of IVF and changing IV to PO antibiotics, sugars normalized and
patient was stable on home regimen. He does appear to have poor
control at baseline and will follow up with PCP regarding need
for titrating meds.
.
# Depression: Stable, continue celexa
.
# Peptic ulcer disease: Stable, continue protonix 40mg daily
Medications on Admission:
* Metoprolol succinate 100mg daily
* Lisinopril 10mg daily
* Hydrochlorothiazide 25mg daily
* Aspirin 81mg daily
* Atorvastatin 80mg daily
* Metformin 500mg twice daily
* Glipizide 5mg twice daily
* Protonix 40mg daily
* Celexa 30mg daily
* Vitamin D3 5000 units weekly
* Viagra 25mg PRN
.
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*28 Capsule(s)* Refills:*0*
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. atorvastatin 80 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. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK ([**Doctor First Name **]).
7. chlorhexidine gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day) for 14 days.
Disp:*140 ML(s)* Refills:*0*
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 14 days: eat yogurt or probiotics while on
antibiotics.
Disp:*112 Capsule(s)* Refills:*0*
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Submental Abscess, mandibular periapical abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*New swelling of the area under your chin, or increased drainage
that is foul smelling. Fevers or chills. Any difficulty
breathing or feeling of swelling in your mouth.
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-29**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in [**6-29**] days. You should call
his office at [**Telephone/Fax (1) 2349**] to schedule this.
|
[
"25000",
"V4581",
"V4582",
"311",
"V1582"
] |
Admission Date: [**2103-8-29**] Discharge Date: [**2103-9-20**]
Date of Birth: [**2103-8-29**] Sex: M
Service: NB
HISTORY: Baby boy [**Known lastname 47766**] was born with extremely low
birth weight, preterm male infant delivered by emergent
cesarean section after the mother had an eclamptic seizure.
Mother is a 43 year old G5, P3 now 4. EDC [**2103-12-13**]
with a gestational age at birth of 24 and 6/7 weeks. Mother
has a history of type 2 diabetes and chronic mild
hypertension. She was admitted to the [**Hospital1 18**] on [**2103-8-23**] with new elevation in blood pressure and a headache with
concern for possible preeclampsia. She was treated with
magnesium sulfate and close monitoring with good improvement
of her blood pressure. PIH work up was unremarkable with only
mild elevation of LFTs. On the morning of delivery she became
severely hypertensive and then developed seizures requiring
immediate delivery with general anesthesia. The infant
emerged severely hypotonic with no respiratory effort and a
heart rate in the 80's. The baby responded with bag mask
ventilation and showed improvement in heart rate without much
movement. The infant was then intubated and transferred to
the NICU for further care. The infant demonstrated some
intermittent spontaneous breathing and some movement but
still was quite hypotonic.
Mother's prenatal screen: Blood type A positive, antibody
negative, HBSAG negative, rubella immune, RPR nonreactive,
GBS unknown. The infant had Apgars of 4, 6 and 7 at 1, 5 and 10
minutes.
PHYSICAL EXAMINATION: Birth weight of 650 grams which is
15th percentile, length of 31 cm which is 20th percentile,
head circumference of 22 cm which is 15th percentile. HEENT
showed anterior fontanel soft and flat with normal facies and
fused eyelids. Neck supple. Skin ruddy pink with some
bruising present. RESPIRATORY: Breath sounds equal, clear
with good air entry. Orally intubated. CARDIOVASCULAR SYSTEM:
Normal S1 and S2. No murmurs. Well perfused. ABDOMEN: Soft,
slightly full with apparent bowel loops after bagging and a 3-
vessel cord. GENITOURINARY: Normal male. Testes not
descended. NEUROLOGIC: Tone overall decreased which improved
slightly with more reaction to touch over the first 2 hours
of life. Cord arterial blood gas was 7.06 pH and the CO2 was
76. The venous gas was 7.09 pH with CO2 of 68. The infant's
initial blood gas in the NICU was 7.32, 35, 46 on high FIO2
with a map of 10.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The
infant was placed on high frequency ventilation and was given
2 doses of surfactant. The infant remained on high frequency
ventilation until [**2103-9-1**]. On the newborn day after
the second dose of surfactant the infant quickly weaned down
to very low ventilator setting on high frequency ventilation.
He was switched over to conventional ventilation on day of
life 3, [**2103-9-1**] and remained on low ventilator
settings at that time. He was started on caffeine on day of
life 6, [**2103-9-4**], at which time he still remained on
very low ventilator setting. His ventilator settings remained
low to moderate since that time with intermittent chest x-ray
showing areas of atelectasis and hyaline membrane disease. On
[**2103-9-19**], in the p.m. the infant had increasing
ventilator settings due to total lethargy and worsening blood
gases. The infant was changed over to high frequency
ventilation at 10:30 p.m. on [**2103-9-19**], due to
increased settings and poor blood gases. The infant at that
time is on high frequency ventilation with an amplitude of
36, a MAP of 15 and 70% FIO2 with capillary blood gas of
7.30, 42. The infant does not have an A line in at this time.
The infant did receive a single dose of bicarbonate earlier
this afternoon. Chest x-ray done this evening showed 7.5 ribs
expansion with some scattered areas of atelectasis in the
lung fields, ET tube in good placement. The caffeine had been
discontinued on [**2103-9-15**], due to the fact that the
ventilator settings were moderate at that time.
CARDIOVASCULAR: UAC and UVC were placed on the newborn day.
The UVC were discontinued due to bluing of the toes on the
right foot shortly after the UVC was inserted. The infant has
been hemodynamically stable and did not require any pressor
support and has not had a murmur audible until an
intermittent murmur was audible on day of life 15 which is
[**2103-9-13**]. Echocardiogram was done on [**2103-9-13**], which showed a small membranous VSD, PFO and a small
PDA with a left to right flow. The PDA was not treated. The
infant has remained hemodynamically stable with normal blood
pressures and heart rate.
FLUIDS, ELECTROLYTES AND NUTRITION: The infant was started on
parenteral nutrition on the newborn day. The infant remained
NPO until day of life 4 on [**2103-9-2**]. The infant was
started on trophic feedings at that time of breast milk. The
infant had a slow feeding advance and reached full enteral
feeding by [**2103-9-17**] at which time the caloric density
was concentrated to a maximum caloric density of breast milk
26 calorie per ounce at 150 ml per kg per day. The infant was
made NPO on [**2103-9-19**] due to abdominal distension,
bilious vomiting, and heme positive stools. A KUB was done at
that time which showed pneumatosis and dilated loops of
bowel. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 37079**] was placed to low continuous suction at
that time and serial KUB's have been followed. The KUB's
remain abnormal with fixed loops of bowel. The abdomen was
pink in the day earlier on [**2103-9-19**] and through the
course of overnight into [**2103-9-20**], the abdomen has
presented with some duskiness and tenderness and guarding.
There are no bowel sounds. The [**Last Name (un) 37079**] continues to drain
bilious secretions. Most recent weight of the infant is 799
grams and that was on [**2103-9-19**]. The infant also did
have hyperbilirubinemia in the first couple of weeks of life
and had a peak bilirubin level of 3.5/0.5 which was on day of
life 5. The infant received a total of 10 days of
phototherapy, the most recent bilirubin level being 3.1/0.3
on [**2103-9-16**].
HEMATOLOGY: The infant's blood type is O positive, DAT
negative. The infant has received numerous blood
transfusions, packed red blood cell transfusions. Hematocrit
at birth was 51.6, platelet count of 127. Most recent blood
transfusion was given on [**2103-9-19**] with a total of 20
ml per kg per day and the infant is just completing that
second aliquot of packed red blood cells at the time of
transfer. The hematocrit prior to transfusion was 35 with a
platelet count of 300. The infant had been started on iron
and vitamin E on [**2103-9-18**]. These have subsequently
been discontinued when the infant was made NPO. PT and PTT
were drawn on [**2103-9-19**]. The PT was 14, the PTT was
49.
INFECTIOUS DISEASE: CBC and blood culture were screened on
admission to the NICU. The white blood cell count at the time
of admission was 3.8 with 29 poly's and 0 bands. 24 hours
later the white count did increase and the ANC improved.
White count was 4.4 with 66 poly's and 6 bands. The infant
received a total of 7 days of ampicillin and gentamycin due
to the initial neutropenia and sepsis risk factors due to
prematurity and clinical status. The neutropenia did improve
and was gone by the CBC on [**2103-9-6**]. CBC and blood
culture were screened on [**2103-9-10**], day of life 12 due
to heme positive stool at that time and concerns for sepsis
with some lethargy and mildly increased ventilator setting.
The CBC at that time showed 16.4 whites with 48 poly's and 10
bands, 2 meta's and 1 myelo, RT ratio of 0.21. The infant was
started on vancomycin and gentamicin as a rule out sepsis. A
trach aspirate culture was sent on [**9-13**] which showed
gram positive cocci and gram positive rods. The antibiotics
were switched to oxacillin and gentamicin at that time from
the vancomycin and gentamycin and the infant continued on the
oxacillin and gentamycin until [**2103-9-19**] when the
infant was changed to vancomycin and gentamycin and
clindamycin. On [**2103-9-19**] in the a.m. when the infant
developed pneumatosis. A repeat CBC and blood culture was
sent at that time. The white count was 4.5 with 40 poly's, 18
bands, and 25 lymphs. Gentamycin levels were done on [**2103-9-19**] with levels of 1.2 and 5.9. Blood cultures have all
remained negative. Lumbar punctures have been held due to the
neurologic sequelae on ultrasound.
NEUROLOGY: The infant has had numerous head ultrasounds. The
first scan was done on [**2103-8-30**] which showed mild
ventriculomegaly with a left greater than the right and a
right posterior fossa hemorrhage and there was question of
some blood in the 4th ventricle versus compression at that
time. On [**2103-8-31**] a repeat head ultrasound was done
and there was noted to be some parenchymal involvement at
that time and also reversal of diastolic flow. On [**2103-9-1**], [**2103-9-7**], and [**2103-9-12**], all of those
ultrasounds showed no change. On [**2103-9-3**] there was a
more organized clot in the posterior fossa with no blood in
the 4th ventricle and no compression at that time; On [**2103-9-19**] the ultrasound was the same as on [**2103-9-3**].
The infant's head circumferences have been fairly stable with
most recent head circumference of 23. Fontanels were soft and
flat. The infant's neurologic condition has changed
significantly in the last 24 hours. The infant has become
lethargic with no tone, minimal movement and minimal response
to pain.
SENSORY: No hearing screens have been performed
OPHTHALMOLOGY: Eye exams have not been done thus far.
PSYCHOSOCIAL: [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] social
worker has been involved with the family during family
meetings. There are no active issues at this time and the
social worker can be reached at [**Telephone/Fax (1) 8717**]. The parents are
Spanish speaking only and you have frequent updates with the
interpreter present.
CONDITION ON DISCHARGE: Critical.
DISCHARGE DISPOSITION: Transferred to 7 North [**Hospital3 18242**] for further evaluation of necrotizing enterocolitis
with worsening clinical status.
NAME OF PRIMARY PEDIATRICIAN: Undecided.
CARE RECOMMENDATIONS:
1. Continue management for unstable infant with necrotizing
enterocolitis at Children Hospital. The infant is
presently NPO on PN. Most recent KUB and chest film were
done at midnight which were unchanged from the two
previous films.
2. Numerous state newborn screens have been sent with the
most recent one being sent on [**2103-9-20**].
3. Immunizations received: No immunizations have been given.
DISCHARGE DIAGNOSIS:
1. Extremely low birth weight infant.
2. Prematurity, born at 24 and 6/7 weeks gestation.
3. Respiratory distress syndrome.
4. Sepsis, treated.
5. Hyperbilirubinemia, resolved.
6. Iatrogenic anemia, treated.
7. Intraventricular hemorrhage, evolving.
8. Necrotizing enterocolitis, ongoing.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2103-9-20**] 01:50:37
T: [**2103-9-20**] 04:34:26
Job#: [**Job Number 69009**]
|
[
"7742",
"486"
] |
Admission Date: [**2174-8-18**] Discharge Date: [**2174-8-29**]
Date of Birth: [**2112-11-24**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Confusion/lethargy
Major Surgical or Invasive Procedure:
[**2174-8-24**]: Esophagogastroduodenoscopy
[**2174-8-25**]: Visceral angiography, intracranial angiography with
embolization
[**2174-8-25**]: Exploratory laparotomy, decompressive laparotomy
[**2174-8-25**]: Abdominal washout
[**2174-8-27**]: Abdominal washout
History of Present Illness:
This is a 61 yom with Hep C cirrhosis genotype I with grade II
varices and hepatic encephalopathy on lactulose/rifaximin with
calculated MELD score of 22 as of [**2174-8-11**]. He is currently
on the liver Tx list with workup complete. He was recently
admitted on [**6-/2174**] for volume overload now presenting with
confusion and lethargy. Most of the history is obtained from
his daughter who reports an acute decompensation yesterday with
increaed confusion. He has been taking lactulose 6x/day in
addition to miralax but has not had any BM for 2 days. He
denies any increase in ascites, fevers, CP, SOB, abd pain, or
increased swelling of his extremities. His daughter does note
an increase in his jaundice. He denies any blood in his stool
or melena.
.
On the floor, pt is interactive but slow to respond and appears
to be searching for words. He appears frustrated by his
confusion.
Past Medical History:
1. HCV cirrhosis: genotype I
-grade II varices no h/o variceal bleeding
-hepatic encephalopathy on lactulose/rifaximin (admitted [**Month (only) **]
[**2173**] and [**2174-6-27**])
2. IDDM
3. Hemorrhoids
Past Surgical History:
R hip replacement x 2, remote appendectomy.
Social History:
Married, has 3 daughters. [**Name (NI) **] works as an engineer at Teradyne
(on short-term disability). He denies any alcohol use or tobacco
use. Remote history of IVDA.
Family History:
Mom with DM.
Physical Exam:
ADMISSION EXAM
Vitals: 97.3 130/80 55 18 100% RA
General: Pleasant AA male in NAD. He is oriented to person,
place and year, but not month.
HEENT: OP dry, EOM intact. Scleral icterus present
Neck: Supple
Heart: RRR no m/r/g
Lungs: CTAB
Abdomen: Soft, NT, ND, no palpable liver
Extremities: Trace edema bilaterally in the LE
Neurological: A/o x2.5. asterixis present
DISCHARGE EXAM
Expired
Pertinent Results:
ADMISSION LABS:
[**2174-8-18**] 04:40PM BLOOD WBC-4.9 RBC-2.69* Hgb-8.9* Hct-27.4*
MCV-102* MCH-33.2* MCHC-32.6 RDW-18.4* Plt Ct-42*
[**2174-8-18**] 04:40PM BLOOD Neuts-56.7 Lymphs-31.4 Monos-11.2*
Eos-0.2 Baso-0.4
[**2174-8-18**] 04:40PM BLOOD PT-30.3* PTT-62.3* INR(PT)-3.0*
[**2174-8-18**] 04:40PM BLOOD Glucose-177* UreaN-15 Creat-1.1 Na-117*
K-5.0 Cl-87* HCO3-25 AnGap-10
[**2174-8-18**] 04:40PM BLOOD ALT-182* AST-492* LD(LDH)-630*
AlkPhos-218* TotBili-8.2*
[**2174-8-18**] 04:40PM BLOOD Albumin-1.9* Calcium-9.2 Phos-2.9 Mg-1.7
Iron-130
CT abdomen/pelvis [**2174-8-24**]:
1. No intra-abdominal hemorrhage.
2. Sequelae of portal hypertension including varices and
moderate perihepatic simple ascites.
3. Severe degenerative changes of the left hip.
Visceral arteriography [**2174-8-25**]:
1. Normal celiac artery angiogram with selective catheterization
of the gastroduodenal artery and left gastric artery.
2. Normal superior mesenteric artery angiogram.
3. No active arterial extravasation from the visceral aortic
branches.
TTE [**2174-8-26**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). There is a mild resting left
ventricular outflow tract obstruction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2174-7-4**], the
LV cavity is slightly smaller, there is some turbulence in the
LVOT with a mild functional outflow tract gradient.
TTE [**2174-8-28**]:
The left atrium and right atrium are normal in cavity size. Left
ventricular systolic function is hyperdynamic (EF>75%). No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. There is no mitral valve prolapse. No
mass or vegetation is seen on the mitral valve. Physiologic
mitral regurgitation is seen (within normal limits). Tricuspid
regurgitation is present but cannot be quantified. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. No interval change in comparison to [**2174-8-26**].
Brief Hospital Course:
61-year-old African-American pleasant male with genotype 1
hepatitis C-induced cirrhosis who is on the liver transplant
list presenting with confusion/lethargy [**12-29**] to encephalopathy
and/or hyponatremia.
.
Pertaining to his hospital course [**2174-8-18**] to [**2174-8-24**]:
.
# Hep C cirrhosis with HE: Pt is on the liver transplant list
with Meld of 28 on admission. Family had noted an increase in
confusion over past few days prior to admission in setting of
not having BMs despite taking his lactulose and miralax.
Patient was given frequent lactulose with miralax and started
stooling adequately. Mental status and asterixis was waxing and
[**Doctor Last Name 688**] throughout his hospital stay. He was also continued on
rifaximin and nadolol. His infectious workup was negative. His
lasix was initially held given hyponatremia.
.
# Hyponatremia: Pt with Na+ of 117 on admisssion. He has
chronically low sodium, however his baseline was 125. His renal
ultrasound was normal. Renal was consulted and after he did not
respond to fluid restriction, he was started on one dose of
tolvaptan, however did not respond and this was discontinued.
After starting the tolvaptan his urinary output decreased and
there was concern for HRS. He was about to be challenged with a
volume challenge when he was no longer holding his pressures and
required transfer to the unit.
.
# DM - Pt was given 5U of glargine nightly (takes levamir at
home). He was also maintained on insulin sliding scale while in
the hospital.
.
On [**8-24**]- the patient became oliguric, and developed hypotension
despite fluid bolus and hypothermia and was felt that he could
have sepsis of unknown origin and he was transferred to the
SICU.
Pertaining to his hospital course [**2174-8-24**] to [**2174-8-29**]:
.
On [**2174-8-24**], the patient was transferred to the SICU on the
transplant surgery service for hypothermia (T 93) and
hypotension (SBP 80). Blood and urine cultures were repeated,
which showed no growth. Blood was also negative for fungemia.
He was transfused 2u PRBC for hct 24.7, after which hct 22.1.
Rectal exam revealed positive occult blood without gross blood.
Nasogastric lavage revealed coffee grounds fluid which did not
clear significantly after 1L lavage. He was further transfused
and started on octreotide and pantoprazole gtts. He was
intubated and EGD found no obvious source of bleeding.
Bronchoscopy found no obvious bleed. He developed epistaxis,
for which ENT was consulted, and his nasopharynx was packed.
.
On [**2174-8-25**], he was taken to IR. Arteriography of the celiac
and superior mesenteric arteries revealed no obvious UGI bleed.
Bilateral inferior maxillary arteries were embolized for his
continued epistaxis. At the end of the procedure, his abdomen
was distended and he was increasingly difficult to ventilate.
He was brought emergently to the operating room for
decompressive laparotomy, which revealed no intraperitoneal
bleed or hematoma. He was left with an open abdomen and
returned to the SICU. He developed worsening hypotension,
requiring norepinephrine gtt, and his abdomen was re-explored,
revealing some blood, but insufficient to explain his
transfusion requirements. Bloodwork (low haptoglobin, high LDH)
suggested hemolysis with no clear aetiology.
.
On [**2174-8-26**], hypothermia resolved and CVVH was started for
worsening renal function. He continued to have a mild ooze from
his nose and mouth and was transfused for hct <30.
.
On [**2174-8-27**], he underwent abdominal washout at the bedside,
which was unrevealing. There was again no obvious source of
bleeding. The bowel appeared less edematous and the Ioban
dressing was replaced. Post-operatively, he required additional
vasopressors, and vasopressin gtt was added. For sedation,
propofol gtt was changed to fentanyl and midazolam gtts.
Cortisol stimulation test was equivocal.
.
On [**2174-8-28**], he remained hypotensive and continued to bleed
from JP, NGT, left ear, and mouth. Refractory hypotension to
pressors, some response to volume. Bedside ECHO showed
hyperdynamic empty LV and hypodynamic strained RV with PAP in
the 60's. started nitric oxide with improved BP, PaO2. Switched
to meropenem and Micafungin for broad empiric coverage. brief
episode of Afib with RVR. Spontaneous conversion to SR.
Delisted from liver transplant list on account of his critical
illness. Overnight, his hypotension worsened, requiring up to
three vasopressors, though these were weaned to one by morning.
.
On [**2174-8-29**], in the morning, he received 2 units PRBCs for a
hematocrit of 26.1, with response in hematocrit to 30.6, but
subsequent continued decline to 29.1. He received 1 unit of
frozen plasma with no subsequent change in INR. In the early
afternoon, per the patient's family's request, the patient was
rendered comfort measures only, and he died at 14:20.
Medications on Admission:
Calcium plus D3
clotrimazole 10mg troche 5x daily
Vitmain D2 [**Numeric Identifier 1871**] U q week
lasix 20mg po bid
levemir 5U nightly
humalog up to 20U daily as needed
lactulose 30ml po 6x daily
nadolol 20mg po daily
omeprazole 20mg po daily
polyethylene glycol 3350 17g powder daily when no BM
rifaximin 550mg po bid
spironalactone 50mg po daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
He who has gone, so we but cherish his memory.
Followup Instructions:
None.
Completed by:[**2174-8-30**]
|
[
"5845",
"51881",
"0389",
"99592",
"78552",
"2761",
"2767",
"2875",
"4168",
"25000",
"V5867"
] |
Admission Date: [**2168-5-6**] Discharge Date: [**2168-5-12**]
Date of Birth: [**2085-11-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Codeine / Ativan / Ciprofloxacin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mrs. [**Known lastname 2520**] is a 82 yo woman with COPD (FEV1 0.92, 66% predicted)
with a h/o hypercarbic respiratory failure s/p intubation x2 and
trach x1 (now decanulated), hypertension and DM2 who developed
worsening SOB last night with cough. She went to her PCPs
office, was found to be in respiratory distress with O2 sats in
the 80-90% range. She received 2 nebs, and was sent to the ED by
EMS.
.
In the ED, her initial VSs were HR 70 BP 198/88 RR 40 94% neb.
Noted to be lethargic, SOB with audible wheezes and 3+ edema to
knees b/l. Received albuterol-ipratropium neb x2,
methylprednisolone 80mg, azithromycin 500 mg, ceftriaxone 1 gm,
Mg 2gm. Foley placed. ABG 7.19/118/72.
.
The pt was placed on BIPAP and sent to the MICU for further
management.
.
Upon arrival to the MICU, she was somnolent, so no further
history was obtainable.
.
Per the pt's daughter, the pt ahd been complaining of fatigue
for the past couple of weeks, at which time she stopped
quetiapine. Over the last four days, the pt's shortness of
rbeath significantly worsened.
Past Medical History:
- Respiratory failure: Admitted to BIMDC in [**1-14**] after cardiac
arrest, presumed to be secondary respiratory failure. She had a
tracheostomy at that time. She was decannulated on [**2167-6-19**] and
tolerated the procedure well. Had another admission [**Date range (1) 18088**]/07
with hypercarbic respiratory failure and brief intubation,
thought due to oversedation with ambien, and probable underlying
obesity hypoventilation syndrone and obstructive sleep apnea
- Hypertension
- Type 2 Diabetes
- Lymphoma, s/p chemotherapy several years ago and s/p XRT [**11-12**]
(unclear where radiation was targeted to) - followed at [**Hospital1 2025**]
- Glaucoma
- Cataracts, baseline anisocoria (R pupil)
Social History:
Lives at home with her daughter, at baseline very active. No
tobacco/EtOH/illicits currently. Receives medical care primarily
from B&W and [**Hospital1 2025**].
Family History:
unable to obtain
Physical Exam:
Vitals: T: 97.1 BP: 124/60 P: 66 R: 22 SaO2: 90%
General: Does not arouse to sternal rub, moves all extremities
HEENT: NCAT, eyes closed shut [**1-9**] BIPAP mask
Neck: old trach scar, no significant JVD
Pulmonary: decreased breath sounds throughout, scattered wheezes
Cardiac: difficult to appreciate heart sounds, sounds regular,
no whopping murmur
Abdomen: obese, soft, ND
Extremities: Chronic venous stasis changes bilaterally
Pertinent Results:
[**2168-5-6**] 11:28AM BLOOD WBC-13.5* RBC-4.58 Hgb-12.2 Hct-39.6
MCV-87 MCH-26.7* MCHC-30.8* RDW-14.6 Plt Ct-261
[**2168-5-7**] 05:43AM BLOOD WBC-11.3* RBC-4.52 Hgb-12.1 Hct-39.7
MCV-88 MCH-26.7* MCHC-30.4* RDW-14.4 Plt Ct-269
[**2168-5-8**] 02:00AM BLOOD WBC-9.6 RBC-4.15* Hgb-11.1* Hct-34.9*
MCV-84 MCH-26.7* MCHC-31.8 RDW-14.5 Plt Ct-219
[**2168-5-6**] 11:28AM BLOOD Plt Ct-261
[**2168-5-6**] 11:28AM BLOOD Glucose-287* UreaN-34* Creat-1.1 Na-142
K-6.8* Cl-98 HCO3-39* AnGap-12
[**2168-5-7**] 05:43AM BLOOD Glucose-260* UreaN-34* Creat-1.1 Na-145
K-5.4* Cl-100 HCO3-41* AnGap-9
[**2168-5-8**] 02:00AM BLOOD Glucose-225* UreaN-36* Creat-0.9 Na-143
K-4.5 Cl-101 HCO3-41* AnGap-6*
[**2168-5-6**] 11:28AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.4
[**2168-5-7**] 05:43AM BLOOD Calcium-8.9 Phos-5.5* Mg-2.8*
[**2168-5-6**] 11:28AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2168-5-6**] 12:16PM BLOOD Type-ART Rates-/26 pO2-72* pCO2-118*
pH-7.19* calTCO2-47* Base XS-11 -ASSIST/CON Intubat-NOT INTUBA
[**2168-5-6**] 03:38PM BLOOD Type-ART pO2-71* pCO2-93* pH-7.27*
calTCO2-45* Base XS-11
[**2168-5-8**] 01:00PM BLOOD Type-ART pO2-91 pCO2-59* pH-7.46*
calTCO2-43* Base XS-14
[**2168-5-10**] 12:55AM BLOOD Type-ART pO2-61* pCO2-51* pH-7.48*
calTCO2-39* Base XS-12
[**2168-5-11**] 03:24AM BLOOD Type-ART Temp-37.0 O2 Flow-2 pO2-83*
pCO2-50* pH-7.45 calTCO2-36* Base XS-8 Intubat-NOT INTUBA
Comment-CPAP
[**2168-5-6**] 11:37AM BLOOD Glucose-267* Lactate-1.2 Na-145 K-4.6
Cl-89* calHCO3-42*
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2168-5-10**] 2:48 AM
CHEST (PORTABLE AP)
Reason: eval for interval change
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with COPD, OSA, admitted with hypercarbic resp
failure, COPD exacerbation
REASON FOR THIS EXAMINATION:
eval for interval change
HISTORY: COPD, admitted with hypercarbic respiratory failure.
FINDINGS: In comparison with the study of [**5-9**], the various
tubes have been removed. Bilateral pleural effusions persist,
substantially more prominent on the right. Retrocardiac
opacification is again seen, consistent with atelectasis. The
possibility of supervening basilar pneumonia cannot be excluded.
No evidence of pulmonary vascular congestion.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2168-5-10**] 8:48 AM
Brief Hospital Course:
# Hypercarbic respiratory failure: The patient's hypercarbic
respiratory failure was thought to be secondary to a combination
of obesity hyperventilation syndrome, oversedation from
seroquel/tylenol PM, and a possible COPD flare with possible
retrocardiac infiltrates on imaging reflecting a PNA. The
patient was started on pulse steroids and
ceftriaxone/azithromycin for CAP. Despite these measures the
patient continued to be hypercarbic and on HD #2 required
intubation. After 48 hours the ventilator was successfully
weaned. She continued on CPAP while sleeping and was sent to the
floor for further management. She was satting well on RA on the
floor with good airmovement. Her ambulatory saturation stayed
between 90 and 95%. She was sent out with
instructions/prescriptions to finish a total 7 day course of
antibiotics (azithromycin changed to PO, ceftriaxone change to
cefpodoxime PO) and to steroid taper per her PCP's instruction.
She was arranged a close PCP [**Name9 (PRE) 702**] and [**Name Initial (PRE) **] pulmonology
follow-up in one month.
# DM2: As her home dose of NPH was unknown upon admission, 20 U
qday was given with RISS. Her BG ranged from 100s to 300s
during her stay and was likely exacerbated by her steroids.
Upon discharge, her home dose of NPH was still unclear, though
her daughter thought it was 40 U qAM and roughly 28 U qPM. She
was given instructions to take 40 U qAM starting on the day
after discharge, check her BG at least 3x per day (she was
already checking at home), call her PCP/coverage for any BG >
300, call PCP on day after discharge to ensure doses and
formulate plan, and follow-up with PCP for scheduled appointment
4 days after discharge. Pt and daughter were counseled on signs
of hypoglycemia, to check BG if she experienced any of them, and
to call PCP/coverage or go to ED if low. They were agreeable to
the plan.
# Hypertension: The patient's metoprolol was discontinued out of
concern for bronchospasm. She was started on an acei with good
control. She was discharged on 5mg lisinopril, which can be
titrated up prn, and her home lasix dose.
# Hypercholesterolemia: Simvastatin 20.
# Code status: The patient was full code during her stay and
required intubation. However, after extubation she went back
and forth regarding her code status. She should have her code
status clarified with both her primary care doctor and her
daughter as an outpatient.
Medications on Admission:
Timoptic 0.25 % Drops One (1) Ophthalmic twice a day: left eye.
Alphagan P 0.15 % Drops One (1) Ophthalmic twice a day: left
eye.
Trusopt 2 % Drops One (1) Ophthalmic twice a day: left eye.
Cosopt 2-0.5 % Drops Two (2) Ophthalmic twice a day: right eye.
Insulin NPH 40u qam
Furosemide 40mg [**Hospital1 **]
Simvastatin 20mg daily
Omeprazole 20mg daily
Metoprolol 12.5mg [**Hospital1 **]
Trazodone 50mg qhs
Discharge Medications:
1. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Hospital1 **]: Forty
(40) Units Subcutaneous qAM.
2. Simvastatin 40 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
3. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
4. Trazodone 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime)
as needed.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
7. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Prednisone 10 mg Tablet [**Hospital1 **]: Three (3) Tablet PO once a day
for 9 days: take 3 pills (30mg) for 3 days, then 2 pills (20mg)
for 3 days, then 1 pill (10mg) for 3 days, then stop.
Disp:*18 Tablet(s)* Refills:*0*
9. Azithromycin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
10. Cefpodoxime 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day
for 1 days: take your first dose early tomorrow ([**2168-5-13**]).
Disp:*2 Tablet(s)* Refills:*0*
11. Timoptic 0.25 % Drops [**Month/Day/Year **]: One (1) Ophthalmic twice a day:
left eye. continue taking as you were at home before your
hospitalization.
12. Alphagan P 0.15 % Drops [**Month/Day/Year **]: One (1) Ophthalmic twice a
day: left eye. continue taking as you were at home before your
hospitalization.
13. Trusopt 2 % Drops [**Month/Day/Year **]: One (1) Ophthalmic twice a day: left
eye. continue taking as you were at home before your
hospitalization.
14. Cosopt 2-0.5 % Drops [**Month/Day/Year **]: Two (2) Ophthalmic twice a day:
right eye. continue taking as you were at home before your
hospitalization.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary:
hypercapneic respiratory failure
.
Secondary:
- Hypertension
- Type 2 Diabetes
- Lymphoma, s/p chemotherapy several years ago and s/p XRT [**11-12**]
(unclear where radiation was targeted to) - followed at [**Hospital1 2025**]
- Glaucoma
- Cataracts, baseline anisocoria (R pupil)
- Anxiety
Discharge Condition:
good, satting well.
Discharge Instructions:
You were seen at [**Hospital1 18**] for respiratory failure. This was likely
a result of your underlying lung disease and possibly
exacerbated by sedating medications that you were taking. You
should avoid taking tylenol PM with seroquel. You should use
your BIPAP face mask EVERYTIME you sleep. You are also on
antibiotics for a possible pneumonia and a tapering dose of
steroids (see medication list and prescriptions).
.
You refused to go to an acute rehabilitation inpatient center.
You will need supervision as much as possible when you are at
home. You and your daughter have assured us that between your
daughter, your sister, and your cousin, you will have ample
supervision.
.
Please follow-up as below.
.
Please continue you NPH insulin as below. Your blood sugar may
be higher because of the steroids. Because we are tapering
them, it is best not to add more insulin at this time. Please
check your blood sugar three times a day at least and call Dr.
[**Last Name (STitle) **] or his coverage if it is above 300.
.
You should call your primary care provider or return to the
emergency department if you have worsening shortness of breath,
wheezing, fever greater than 101.4 degrees F, confusion,
excessive sleepiness, difficulty being awoken, blood sugar above
300, or any other symptoms that concern you.
Followup Instructions:
An appointment has been made for you with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
on Monday [**2168-5-16**] at 9:45am in [**Location (un) 538**]. His number is
[**Telephone/Fax (1) 18745**].
.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2168-6-9**] 1:10
.
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2168-6-9**] 1:30
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2168-6-9**] 1:30
.
Please call if you need to reschedule any of the above
appointments.
|
[
"51881",
"486",
"5119",
"25000",
"4019",
"32723",
"V5867"
] |
Admission Date: [**2179-2-19**] Discharge Date: [**2179-2-23**]
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86F walking up an indoors ramp, recalls reaching for ledge
per her usual habit (does this to get over the top of the ramp).
LOC, by report hit head against wall. Next memory is of being
at
[**Hospital3 **]. CT head @ OSH showed thin R occipital
subdural
hematoma, transferred here. Denies HA, CP, SOB, bladder/bowel
incontinence. No prior episodes of LOC, no seizure history.
Past Medical History:
HTN, glaucoma, OA, mild CHF, DCIS
Social History:
Lives at home without assistance but rents basement
room. No EtOH, no tob.
Family History:
not contributary
Physical Exam:
PHYSICAL EXAM:
O: T: 99.6 BP: 150/82 HR: 78 R 12 100%RA O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2mm, miotic. Mild R upper lid ptosis, no change
per patient and family member. EOMs
Neck: Supple. No carotid bruits.
Lungs: B/l dependent crackles, R > L.
Cardiac: RRR. S1/S2. Grade [**3-16**] holosystolic ejection murmur. No
rubs, gallops.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 1+ b/l LE edema, nonpitting.
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. Mild 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 voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-15**] throughout. No pronator drift
Sensation: Intact to light touch.
Reflexes: B T Br Pa Ac
Right 2 2
Left 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2179-2-19**] 08:18PM CK-MB-5 cTropnT-<0.01
[**2179-2-19**] 08:18PM PHENYTOIN-14.0
[**2179-2-19**] 08:18PM PHENYTOIN-14.0
[**2179-2-19**] 08:18PM CK-MB-5 cTropnT-<0.01
[**2179-2-19**] 08:18PM WBC-8.1 RBC-3.15* HGB-9.9* HCT-27.9* MCV-88
MCH-31.5 MCHC-35.6* RDW-14.2
[**2179-2-19**] 08:18PM PLT COUNT-153
[**2179-2-19**] 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
Patient was admitted to Neurosurgery Service. She was found to
have a small right cerebral convexity subdural hematoma
measuring approximately 6 mm from the inner table of the skull
on admission CT head. There was no change in her CT head the
next day. The patient was started on Dilantin for seizure
prophylaxis. Her Aspirin was held. No surgical intervention was
recommended. Ct C-spine and LENIs (lower extremity noninvasive
doppler us ) were within normal limits. Patient had a medicine
consult for concern of falls. It was thought that the patient
should have an outpatient echocardiogram. Orthostatics checked
and were...Medicine service thought the etiology of falls were
mechanical. She was evaluated by PT/OT who thought she was safe
for home and with home services. Patient was set up with a new
primary care doctor and should have the outpatient
echocardiogram. Her toe nails were ingrown and outpatient
podiatry appointment made.
Medications on Admission:
atenolol 100', lisinopril 40',
lasix 40', fexofenadine 60', pilocarpine gtt, 4% etopic gtt, [**1-12**]
ASA', MVI
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pilocarpine HCl 1 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Traumatic Right sided subdural hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Need to follow up with your primary care and schedule an
outpatient echocardiogram to due to aortic murmur
Return if you if you develop worsening headache, nausea,
vomitting, difficulty with your vision dizziness or other
difficulties
Followup Instructions:
1) Dr. [**Last Name (STitle) 1683**] would like you to follow up with the [**Hospital1 18**]
Geriatrics Service. You should call [**Telephone/Fax (1) 719**] for an
appointment. You can ask for Dr. [**Last Name (STitle) 1603**] or Dr. [**Last Name (STitle) 713**].
2) Follow up with Dr. [**Last Name (STitle) **] in 4 weeks with a head CT, call
[**Telephone/Fax (1) 1669**] for an appointmentProvider: [**Name6 (MD) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 17898**] Date/Time:[**2179-3-2**] 1:00
3. Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2179-3-2**]
10:45
4. Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2179-3-2**]
11:15
5. Provider: [**Name11 (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 17898**]
Date/Time:[**2179-3-2**] 1:00
|
[
"4280",
"4019"
] |
Admission Date: [**2142-9-7**] Discharge Date: [**2142-9-10**]
Date of Birth: [**2122-3-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
tylenol PM and naproxen overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
20 yo F, with hx of depression w/ SI on Effexor, no previously
established care here at [**Hospital1 18**], p/w tynenol / NASIADS overdose
in setting of a suidical attempt.
.
Of note, night prior to admission pt heard from her boyfriend
that his friends do not like her and don't want her around
anymore. At 10pm, pt took 50 tylenol PM, 30 naproxen and an
unknown amount of excedrin and a bottle of wine. Pt called the
suicidal hotline and was sent to [**Hospital1 18**] by ambulance.
.
In the ED, initial VS were: Initial ASA 7.3 and tylenol 14 and
EtOH 158. Two hours later, her ASA increased to 22.4, tylenol
increased to 76. Toxicology was consulted and decided to admit
to MICU for NAC protocol.
.
On arrival to the MICU, 98.6, 109, 109/48, 18, 98% on RA
Past Medical History:
History of SI attempt at age 15 per her mother, pt denies.
Depression
Social History:
[**University/College 5130**] 3rd year student, digital arts major. History of SI
attempt at age 15 per her mother, pt denies. Drinks alcohol [**11-26**]
times per week, 3 drinks per time. Denies tobacco or drug use.
Family History:
Mother and aunts have depression
Physical Exam:
ADMISSION EXAM
General: Lying in bed, breathing comfortably, interactive,
stable.
HEENT: PERRL, anicteric sclera, OP clear.
CV: S1S2 RRR w/o m/r/g??????s.
Lungs: CTA bilaterally w/o crackles or wheezing. Good air
movement.
Ab: Positive BS??????s, mild diffuse tenderness with deep palpation,
non-distended, no HSM.
Ext: No c/c/e.
Neuro: Awake, alert, appropriately oriented, no focal motor
deficits noted. No asterixis.
DISCHARGE EXAM:
VS: 97.3 103 110/80 20 99% RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no lymphadenopathy. neck supple.
Cards: RRR, no murmurs/gallops/rubs.
Pulm: CTAB, no crackles or wheezes
Abd: soft, NT ND
Extremities: wwp, no edema.
Skin: warm and dry
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities
with sensation intact.
Pertinent Results:
ADMISSION LABS
[**2142-9-7**] 01:53AM BLOOD WBC-8.1 RBC-5.45* Hgb-11.7* Hct-34.6*
MCV-63* MCH-21.4* MCHC-33.7 RDW-14.8 Plt Ct-308
[**2142-9-7**] 01:53AM BLOOD Neuts-55.7 Lymphs-38.9 Monos-4.6 Eos-0.4
Baso-0.4
[**2142-9-7**] 01:53AM BLOOD PT-11.5 PTT-25.1 INR(PT)-1.0
[**2142-9-7**] 01:53AM BLOOD Glucose-113* UreaN-10 Creat-0.7 Na-139
K-3.1* Cl-105 HCO3-19* AnGap-18
[**2142-9-7**] 01:53AM BLOOD ALT-11 AST-19 AlkPhos-53 TotBili-0.2
[**2142-9-7**] 01:53AM BLOOD Albumin-5.0 Calcium-9.6 Phos-2.0* Mg-2.0
PERTINENT LABS
[**2142-9-7**] 01:53AM BLOOD ASA-7.3 Ethanol-158* Acetmnp-14
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2142-9-7**] 04:24AM BLOOD ASA-22.4 Acetmnp-76*
[**2142-9-7**] 07:05AM BLOOD ASA-22.4 Acetmnp-55*
[**2142-9-7**] 09:50AM BLOOD ASA-18.4 Acetmnp-26
[**2142-9-7**] 12:20PM BLOOD ASA-16.0 Acetmnp-15
[**2142-9-7**] 03:01PM BLOOD ASA-11.9 Acetmnp-7*
[**2142-9-8**] 12:52AM BLOOD ASA-NEG Acetmnp-NEG
PERTINENT STUDIES
CXR ([**9-7**])
Cardiomediastinal contours are normal. The lungs are clear.
There is no
pneumothorax or pleural effusion.
IMPRESSION: No evidence of acute cardiopulmonary abnormalities.
[**2142-9-9**] 07:05AM BLOOD WBC-8.4 RBC-4.95 Hgb-10.6* Hct-31.4*
MCV-63* MCH-21.4* MCHC-33.8 RDW-15.0 Plt Ct-244
[**2142-9-9**] 07:05AM BLOOD PT-11.7 PTT-24.2 INR(PT)-1.0
[**2142-9-7**] 01:53AM BLOOD Neuts-55.7 Lymphs-38.9 Monos-4.6 Eos-0.4
Baso-0.4
[**2142-9-9**] 07:05AM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-137 K-4.3
Cl-104 HCO3-27 AnGap-10
[**2142-9-9**] 07:05AM BLOOD ALT-14 AST-17 AlkPhos-43 TotBili-0.5
[**2142-9-9**] 07:05AM BLOOD Calcium-9.7 Phos-4.5# Mg-2.0
[**2142-9-7**] 09:50AM BLOOD calTIBC-321 Ferritn-58 TRF-247
[**2142-9-8**] 12:52AM BLOOD ASA-NEG Acetmnp-NEG
Brief Hospital Course:
20 yo F with hx of depression and suicidal ideation, currently
on Effexor, no previously established care here at [**Hospital1 18**], p/w
tynenol / ASA overdose in setting of a suidical attempt.
.
ACTIVE ISSUES
# Tylenol intoxication: Pt self-reported an overdose of large
quantity of acetominophen (>25 gram). The low tylenol level and
lack of elevation in LFT does not support overdose of such
extent. However, the benadryl in Tylenol PM could potentially
delay the absorption and administration of alcohol in the same
time could be hepatic protective by competing with tylenol for
cytochrome C. An N-acetylcysteine protocol was initiated at ED
and continued initially in the MICU. Her Tylenol level was
trended till non-detectable.
.
# ASA intoxication: The elevated ASA level is likely a result
from Excedrin overdose. Pt was treated conservative with fluid
hydration, and monitored closely on the rising ASA level. There
was an anion gap initially, which was closed shortly after
treatment. Her ASA level was trended till non-detectable.
.
# SI: Pt had a history of depression and suicidal ideation. She
was evaluated by on-call psychiatrist in the ED. The
psychiatrist at her college was notified. We restarted her
effexor after her nausea resolved. Medically cleared for
transfer to psychiatric facility.
.
CHRONIC ISSUES
# Anemia: Pt has known anemia from thalassemia. No transfusion
given. No evidence of iron deficiency.
.
Transitions of care:
Outpatient management of anemia.
Medications on Admission:
Venlafaxine XR 225 mg PO
altavera
Discharge Medications:
1. venlafaxine 225 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
2. Altavera (28) 0.15-30 mg-mcg Tablet Sig: as directed
previously Tablet PO Daily ().
Discharge Disposition:
Extended Care
Facility:
Four Winds Saratoga
Discharge Diagnosis:
Primary:
tylenol / aspirin overdose
Secondary:
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital for taking too much tylenol and
aspirin. You were treated for this and improved and were deemed
medically clear for transfer to a facility that specializes in
psychiatric care.
REGARDING YOUR MEDICATIONS...
no changes were made to your medications
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
Followup Instructions:
Otherwise, please followup with your primary care physician
[**Name Initial (PRE) 176**] 7-10 days regarding the course of this hospitalization.
Completed by:[**2142-9-10**]
|
[
"2762",
"311"
] |
Admission Date: [**2194-4-17**] Discharge Date: [**2194-4-20**]
Date of Birth: [**2128-4-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Motrin / Latex / IV Dye, Iodine Containing / trees
and grass
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Fatigue, black stools
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
66 yo W with a hx of ITP (questionable dx), Cirrhosis, Epilepsy,
GERD, HTN, and chronic pain presenting with worsening fatigue
and dark stools for 2-3 days and admitted to the ICU for
hypotension. Hct checked at OSH was 27 (down from a baseline in
the high 30s). Her [**Hospital1 18**] Hematologist referred her to our ED for
further evaluation. On presentation, BP in the 90/60 range with
HR 60-70 (takes low-dose BB at home) and patient in no acute
distress complaining of some mild fatigue and lightheadedness.
Hct in ED 27.9 with plts of 74. She was given 2L NS in the ED, 1
pack of plts, and 1 U pRBC. Rectal exam in the ED was notable
for guiaic positive brown stool. NG Lavage was requested, but
not performed.
.
An abdominal CT was done for further evaluation of the abdominal
pain, which she has had since having a hysteroscopy + D&C done
on [**2194-3-27**] at [**Hospital1 18**]. Per preliminary read, it showed a cirrhotic
liver with some peri-hepatic fluid, but was otherwise
unremarkable for source of Hct drop. GI was consulted and
recommended PPI bolus + drip, they will evaluate her this AM.
.
On arrival to the [**Hospital Unit Name 153**], the patient reports that she has been
feeling weakness and fatigue since her recent hospital
discharge, occasional increased dyspnea on exertion, and
intermittent chest pain. She denies hematemesis or hematochezia.
Regarding her recent hospitalization, she reports that she
presented to OSH for evaluation of an excruciating headache. She
states she had a reaction to the anesthesia from her recent
procedure possibly complicated by depakote therapy, and had high
ammonia levels. She spent two weeks in the hospital and at that
time her Depakote was weaned off and Keppra started.
.
Review of sytems:
+ per HPI
- for fever, chills, sweats, nausea, vomiting, prutitus,
dysuria, rashes. No hx of known liver disease, hepatitis, blood
transfusions, or IV drug use.
Past Medical History:
ITP-extent of evaluation unclear
[**Name2 (NI) 87200**] bleeding s/p D&C
GERD
EPILEPSY
POLIO, wheel chair bound
HTN
HLD
PTSD
Social History:
Wheelchair bound [**2-12**] polio
Married, no children
No tobacco, Hx of or current ETOH or IV drug use
Family History:
No hx of liver disease
Grandmother with Myasthenia [**Name (NI) **]
Mother with Breast Ca
Physical Exam:
ADMISSION Physical Exam:
VS: 95.2, 91/46, 56, 17, 96% on RA
General: alert, oriented, no acute distress, obese, pale
complexion
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, obese, tender to deep palpation diffusely
with voluntary guarding throughout
Ext: warm, well perfused, symmetric pulses, 1+ pitting edema
Neuro: face symmetric, moves all four extremities
Pertinent Results:
[**2194-4-19**] 07:45AM BLOOD WBC-6.2 RBC-2.99* Hgb-10.3* Hct-30.1*
MCV-101* MCH-34.5* MCHC-34.3 RDW-15.6* Plt Ct-81*
[**2194-4-18**] 01:48PM BLOOD Hgb-10.2* Hct-29.9*
[**2194-4-18**] 04:18AM BLOOD WBC-6.2 RBC-2.86* Hgb-9.7* Hct-28.5*
MCV-100* MCH-34.0* MCHC-34.0 RDW-16.3* Plt Ct-73*
[**2194-4-17**] 08:18PM BLOOD WBC-7.5 RBC-3.07* Hgb-10.6* Hct-31.0*
MCV-101* MCH-34.5* MCHC-34.2 RDW-16.3* Plt Ct-76*
[**2194-4-17**] 03:00PM BLOOD WBC-5.1 RBC-2.80* Hgb-9.6* Hct-28.8*
MCV-103* MCH-34.2* MCHC-33.2 RDW-16.3* Plt Ct-76*
[**2194-4-17**] 07:24AM BLOOD WBC-5.6 RBC-2.74* Hgb-9.5* Hct-28.3*
MCV-103* MCH-34.8* MCHC-33.7 RDW-16.2* Plt Ct-UNABLE TO
[**2194-4-17**] 12:51AM BLOOD WBC-6.2 RBC-2.71*# Hgb-9.6*# Hct-27.9*#
MCV-103* MCH-35.3* MCHC-34.3 RDW-15.8* Plt Ct-74*
[**2194-4-17**] 12:51AM BLOOD Neuts-67.5 Bands-0 Lymphs-21.6 Monos-4.2
Eos-2.7 Baso-0.5
[**2194-4-19**] 07:45AM BLOOD Plt Ct-81*
[**2194-4-19**] 07:45AM BLOOD PT-16.7* PTT-30.9 INR(PT)-1.5*
[**2194-4-18**] 04:18AM BLOOD Plt Ct-73*
[**2194-4-18**] 04:18AM BLOOD PT-16.6* PTT-31.6 INR(PT)-1.5*
[**2194-4-17**] 08:18PM BLOOD Plt Smr-VERY LOW Plt Ct-76*
[**2194-4-17**] 07:24AM BLOOD Plt Smr-UNABLE TO Plt Ct-UNABLE TO
[**2194-4-17**] 12:51AM BLOOD Plt Ct-74*
[**2194-4-17**] 12:51AM BLOOD PT-15.2* PTT-28.0 INR(PT)-1.3*
[**2194-4-17**] 07:24AM BLOOD Fibrino-366
[**2194-4-19**] 07:45AM BLOOD Glucose-121* UreaN-12 Creat-0.8 Na-141
K-3.7 Cl-109* HCO3-25 AnGap-11
[**2194-4-18**] 04:18AM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-142
K-3.9 Cl-111* HCO3-22 AnGap-13
[**2194-4-17**] 12:51AM BLOOD Glucose-104* UreaN-20 Creat-0.8 Na-143
K-4.1 Cl-110* HCO3-27 AnGap-10
[**2194-4-19**] 07:45AM BLOOD ALT-30 AST-57* LD(LDH)-264* AlkPhos-83
TotBili-0.9
[**2194-4-18**] 04:18AM BLOOD ALT-31 AST-57* AlkPhos-82 TotBili-1.0
[**2194-4-17**] 12:51AM BLOOD ALT-36 AST-68* LD(LDH)-301* AlkPhos-110*
TotBili-0.4
[**2194-4-18**] 01:48PM BLOOD proBNP-261
[**2194-4-19**] 07:45AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8
[**2194-4-18**] 04:18AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.2 Iron-58
[**2194-4-17**] 12:51AM BLOOD Albumin-3.3* Cholest-143
[**2194-4-18**] 04:18AM BLOOD calTIBC-325 Ferritn-97 TRF-250
[**2194-4-17**] 02:39PM BLOOD calTIBC-339 Ferritn-86 TRF-261
[**2194-4-17**] 12:51AM BLOOD Hapto-21*
[**2194-4-17**] 12:51AM BLOOD Triglyc-82 HDL-66 CHOL/HD-2.2 LDLcalc-61
[**2194-4-17**] 12:51AM BLOOD TSH-4.4*
[**2194-4-18**] 04:18AM BLOOD HBsAb-PND HBcAb-PND HAV Ab-PND
[**2194-4-17**] 02:39PM BLOOD HAV Ab-POSITIVE
[**2194-4-17**] 12:51AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE HAV
Ab-NEGATIVE
[**2194-4-17**] 02:39PM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2194-4-17**] 02:39PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-PND
[**2194-4-17**] 02:39PM BLOOD AFP-3.0
[**2194-4-17**] 02:39PM BLOOD IgG-1556
[**2194-4-18**] 04:18AM BLOOD HCV Ab-PND
[**2194-4-17**] 12:51AM BLOOD HCV Ab-NEGATIVE
[**2194-4-17**] 02:39PM BLOOD CERULOPLASMIN-PND
[**2194-4-17**] 02:39PM BLOOD ALPHA-1-ANTITRYPSIN-PND
.
ECHO-The left atrium is elongated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF >55%).
The right ventricular cavity is mildly dilated with normal free
wall contractility. The number of aortic valve leaflets cannot
be determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Mildly dilated right ventricle with vigorous global
biventricular systolic function. Mild mitral regurgitation. Mild
pulmonary hypertension.
.
[**4-17**] CT abd/pelvis-MPRESSION:
1. Cirrhotic liver with small amount of perihepatic and trace
mesenteric,
paracolic gutter, and pelvic ascites. Spleen upper limits of
normal in size.
2. Colonic diverticulosis without diverticulitis.
3. Cholelithiasis without evidence for cholecystitis.
4. Uterus was better evaluated on recent prior ultrasound.
Multiple incidental findings without any acute inflammatory
changes on this non-contrast examination, which limits
evaluation for fine parenchymal detail.
.
[**4-17**] CXR-FINDINGS: Relatively low lung volumes. Signs of
mild-to-moderate pulmonary edema. Moderate cardiomegaly. No
visible nasogastric tube on the radiograph. No evidence of
pneumonia. No larger pleural effusions.
.
RUQ u/s-IMPRESSION:
1. Irregular heterogeneous-appearing liver suggestive of
cirrhosis with no
focal lesions.
2. Cholelithiasis without cholecystitis.
3. Mild splenomegaly.
4. Minimal free fluid in the Morison's pouch.
5. Patent portal vein, hepatic veins, hepatic artery, and the
inferior vena cava.
.
CXR [**4-19**]-Cardiomegaly is moderate-to-severe in particular
involving the left ventricle, unchanged. Mediastinal contours
are stable. There is diffuse interstitial engorgement, right
more than left, grossly unchanged since [**4-17**]. The right PICC
line tip can be seen to the level of low SVC. Small amount of
pleural effusion cannot be excluded bilaterally.
.
[**4-18**] UENI-IMPRESSION: No deep venous thrombosis of the left upper
extremity.
.
[**4-20**] LENI-
IMPRESSION: No right lower extremity deep venous thrombosis. The
deep veins in the calf are not visualized.
Brief Hospital Course:
66 yo W with ITP(?), possible cirrhosis, presents with anemia
and hypotension in the setting of [**2-13**] days of dark stools. Given
substantial Hct drop, and hypotension admitted to [**Hospital Unit Name 153**] for
continued evaluation and monitoring of status.
.
# acute blood loss Anemia/gastrointestinal bleeding- Patient
presented with Hct about 10 points lower than recent baseline,
as well as symptoms of fatigue, weakness, dyspnea on exertion.
She reported 3 days of black tarry stools, concerning for upper
GI bleed. Rectal exam revealed guaiac positive brown stool and
the Pt had no melena during her [**Hospital Unit Name 153**] stay. CT A/P revealed no
evidence of bleed. Given her new CT finding of cirrhosis (and
laboratory findings supporting this), GI/Hepatology was
consulted who performed an EGD that revealed grade II
non-bleeding varices and portal gastropathy, the likely source
of her blood loss. She was started on nadolol, [**Hospital1 **] PPI, and
sucralfate. Pt transfused 1 unit of PRBCs on [**4-17**]. HCT on
discharge 31.
.
# Hypotension: Clinic notes show SBP ranges 120??????s. Given recent
bleed, hypovolemic hypotension is likely and responded to IV
fluid boluses. She did not appear septic; however given
cirrhosis/ascites with possible UGI bleed, translocation of
intestinal flora is possible. She was started on a 7 day course
of Ciprofloxacin. Hypotension did not reoccur on the medical
floor.
.
# Thrombocytopenia: Initially detected in late [**2193**] after
presenting to the ED with epistaxis. Extent of work up unclear
from records available in [**Name (NI) **]. [**Month (only) 116**] be related to underlying
cirrhosis rather than ITP (as initially suspected). Pt has a
schedule hematology follow up.
.
#Cirrhosis: Has never had a formal evaluation.
Cirrhotic-appearing liver and ascites seen on CT imaging.
Varices seen on EGD, pt with thrombocytopenia, elevated INR, and
likely encephalopathy with elevated ammonia level at OSH. No
strong risk factors for viral hepatitis and no ETOH use. [**Month (only) 116**] be
[**2-12**] AI hepatitis or NASH based on lab work-see results section.
Hepatitis serologies are still pending at the time of discharge.
The patient will follow up with Dr. [**Last Name (STitle) 497**] after discharge for
further treatment and assessment.
.
#Pulmonary edema/noctural hypoxia- Chest xray had findings
consistent with pulmonary edema. She also had peripheral edema
on exam and reported long standing orthopnea. It also appears
that outpatient furosemide was recently discontinued. An
echocardiogram was obtained that showed an EF of 55%, a mildly
dilated RV, and vigorous global biventricular systolic function.
Repeat CXR showed stable interstitial markings. Pt was on room
air during the day. She did have desats at night and has known
OSA. Pt was not discharged on lasix given the above.
.
#?allergic reaction: Pt reported 2 inner lip lesions on day of
discharge. She denied any mouth/tongue/lip/facial swelling, rash
or SOB. Pt stated this happened prior when she was exposed to
latex. Her room was latex free and there are no latex gloves on
the floor. This was monitored during the day of discharge and
did not worsen. Pt has an epi pen at home in case of severe
allergic reaction. She was advised to continue to monitor
symptoms at home. She knows how to use the epi pen.
.
# Seizure D/O: Continued outpt regimen of Keppra 250 mg [**Hospital1 **] and
Zonegran 200 mg qhs
.
# Chronic Pain: Continued outpt Lyrica daily and oxycodone PRN.
Pt given rx for 8 tablets of oxycodone upon discharge.
.
# Asthma: Continued outpatient Flovent [**Hospital1 **]
.
# HTN: Initially held antihypertensives given suspected GI bleed
and hypotension. However as this stabilized, she was started on
nadolol for varices and her metoprolol was stopped.
.
#RLE edema-LENI negative for DVT. LUE edema-neg for DVT
.
# HLD: held simvastatin as LDL 60 and given dx of cirrhosis
.
# FULL CODE confirmed
.
# Contact with husband [**Doctor First Name **] at [**Telephone/Fax (1) 87201**]
Medications on Admission:
- latanoprost [Xalatan] 0.005 % Drops 1 drop by eye daily
- tizanidine 2 mg Tablet 1 Tablet(s) by mouth daily
- pramipexole 1.5 mg Tablet 1 Tablet(s) by mouth hs
- lyrica 300 mg qhs
- simvastatin 20 mg Tablet 1 Tablet(s) by mouth daily
- metoprolol tartrate 25 mg Tablet 1 Tablet(s) by mouth daily
- flovent 220 2 twice daily
- keppra 250 mg [**Hospital1 **]
- imitrex 50 rarely
- oxycodone 5 mg [**1-12**] q4-6 PRN pain
- zonegran 100 mg 2 caps at bedtime
- acetaminophen 650 mg daily 1 tab q 4-6 hrs
Discharge Medications:
1. latanoprost 0.005 % Drops Sig: One (1) Ophthalmic once a
day.
2. Lyrica 300 mg Capsule Sig: One (1) Capsule PO at bedtime.
3. pramipexole 1.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. zonisamide 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
9. 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:*0*
10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to produce [**2-13**] bowel movements daily.
Disp:*qs ML(s)* Refills:*0*
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-12**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain: Do not drive when taking this medication.
Take only as directed.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Life Care At Home of Mass
Discharge Diagnosis:
cirrhosis of the liver
acute blood loss anemia due to gastrointestinal
bleeding/gastritis
varices
thrombocytopenia
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 bleeding from your gastrointestinal
tract. For this, you underwent an endoscopy that showed varices
and gastritis. You were given a blood transfusion. You were also
found to have evidence of cirrhosis of the liver and were
evaluated by the hepatology (liver) team. You were started on
nadolol, cipro, protonix and lactulose for this. The cause of
the cirrhosis is still being determined. You should be sure to
follow up with Dr. [**Last Name (STitle) 497**] in clinic for continued care.
.
You reported some sores on your lower lip on day of discharge,
but did not have lip/mouth/tongue swelling or shortness of
breath. Your symptoms did not worsen during admission. Please
continue to monitor your symptoms. You already have an epi pen
at home and can use this as directed/as needed if your symptoms
were to worsen.
.
Medication changes:
1.start nadolol and stop metoprolol
2.continue Cipro for 4 more days
3.start protonix 40mg twice a day
4.start lactulose take so that you have ~3bowel movements daily
.
Please take all of your medications as prescribed and follow up
with the appoints below.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 4154**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) **] to
schedule a follow up appointment after discharge.
.
Please also call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at ([**Telephone/Fax (1) 3618**] to
schedule a follow up appointment after discharge. The office is
aware that you need an appointment.
.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2194-4-30**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2194-5-5**] at 10:00 AM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 2928**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"2851",
"4019",
"53081",
"2724",
"49390",
"32723"
] |
Admission Date: [**2133-12-2**] Discharge Date: [**2133-12-9**]
Date of Birth: [**2055-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Chicken Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
scapular discomfort with associated dyspnea
Major Surgical or Invasive Procedure:
[**2133-12-4**] CABG x2 (LIMA to LAD, SVG to OM 1)
History of Present Illness:
78 year old male with known history of
hypertension presents to OSH complaining of discomfort in his
scapular area and associated dyspnea for approximately 48 hours.
He denies substernal chest pain and denies radiation of scapular
discomfort.Cardiac workup at OSH revealed new rapid atrial
fibrillation and coronary cath showed multivessel coronary
artery
disease. He was transferred to [**Hospital1 18**] for cardiac surgery
evaluation of coronary artery revascularization.
Of note he just completed a Z-pack for bronchitis 3 weeks ago.
Pt
states he has chronic bronchitis. Denies cough or shortness of
breath at admission.
Past Medical History:
new onset atrial fibrillation
hypertension, Gout, chronic back pain,
nocturnal SOB, chronic bronchitis
Social History:
Lives with:wife
Contact: Phone #
Occupation:retired
Cigarettes: Smoked no [] yes [x] Hx: quit 23yo. [**2-5**] PPD x 35y
Other Tobacco use:
ETOH: < 1 drink/week [] [**2-9**] drinks/week [x] >8 drinks/week []
last glass of wine was Sun [**2133-11-29**]
Family History:
Father :74 died of CHF, c/b CVA Mother -no cardiac dz
Physical Exam:
Pulse:77 Resp: 20 O2 sat: 99% on 2Lpm nc
B/P Righ151/86
Height: 70" Weight:214 #
General:
Skin: Warm [x] Dry [x] intact [x]
HEENT: NCAT [x] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] JVD []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema [x] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right:2+ Left:2+
Carotid Bruit-none Right: Left:
Pertinent Results:
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. There are filamentous
strands on the aortic leaflets consistent with Lambl's
excresences (normal variant). There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results at time of surgery.
POST-BYPASS: The patient is A paced. The patient is on no
inotropes. Biventricular function is unchanged. Mild (1+) aortic
regurgitation is seen. Mitral regurgitation is unchanged. The
aorta is intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician
[**2133-12-8**] 09:40AM BLOOD WBC-12.0* RBC-3.39* Hgb-10.5* Hct-31.3*
MCV-92 MCH-30.9 MCHC-33.5 RDW-13.7 Plt Ct-453*
[**2133-12-8**] 09:40AM BLOOD PT-12.5 INR(PT)-1.2*
[**2133-12-8**] 09:40AM BLOOD Glucose-152* UreaN-32* Creat-1.5* Na-141
K-4.0 Cl-101 HCO3-31 AnGap-13
[**2133-12-3**] 02:24AM BLOOD ALT-20 AST-23 LD(LDH)-148 AlkPhos-43
Amylase-60 TotBili-0.5
[**2133-12-3**] 02:24AM BLOOD Lipase-33
[**2133-12-3**] 02:24AM BLOOD %HbA1c-5.3 eAG-105
[**2133-12-3**] 02:24AM BLOOD %HbA1c-5.3 eAG-105
[**2133-12-9**] 05:47AM BLOOD WBC-8.0 RBC-3.14* Hgb-9.6* Hct-28.9*
MCV-92 MCH-30.7 MCHC-33.4 RDW-13.9 Plt Ct-434
[**2133-12-9**] 05:47AM BLOOD PT-12.7* INR(PT)-1.2*
Brief Hospital Course:
Admitted from OSH [**12-2**] and pre-op w/u completed. Remained on IV
NTG and IV heparin for pre-op A Fib. Underwent surgery with Dr.
[**Last Name (STitle) **] on [**12-4**] and was transferred to the CVICU in stbale
condition on titrated phenylephrine and propofol drips.
Extubated that evening and was transfered to the floor on POD #1
to begin increasing his activity level. Chest tubes and pacing
wires removed per protocol. Gently diuresed toward his pre-op
weight and beta blockade titrated. Went into A Fib again on POD
#2 and was started on amiodarone. Coumadin was also started on
POD #4. Target INR is 2.0-2.5 for A Fib.First INR check tomorrow
with results to PCP [**Name Initial (PRE) 40510**]. Converted to SR and was cleared
for discharge to home with VNA on POD #5. BUN/ creatinine check
tomorrow with results to cardsiac surgery office. All f/u appts
were advised.
Medications on Admission:
HCTZ 12.5 mg daily
Atenolol 25 mg daily
Aspirin 81 daily
Allopurinol ?mg daily -pt thinks its 50mg daily
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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
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:*1*
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or fever .
Disp:*50 Tablet(s)* Refills:*0*
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: through [**12-13**]; then 200 mg [**Hospital1 **]
[**Date range (1) 40511**];then 200 mg daily ongoing.
Disp:*80 Tablet(s)* Refills:*1*
8. Outpatient Lab Work
please draw BUN/creatinine Thurs [**12-10**] with results to cardiac
surgery office [**Telephone/Fax (1) 170**]
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 5 days.
Disp:*5 Tablet Extended Release(s)* Refills:*0*
12. warfarin 1 mg Tablet Sig: daily dosing per Dr. [**Last Name (STitle) 40510**]
Tablet PO Once Daily at 4 PM: dosing today only [**12-9**] is 3 mg;
all further daily dosing per Dr. [**Last Name (STitle) 40510**].
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 40512**] Health Care
Discharge Diagnosis:
coronary artery disease s/p cabg x2
atrial fibrillation
hypertension, Gout, chronic back pain,
nocturnal SOB, chronic bronchitis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema .............
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw Thurs [**12-10**]
Results to Dr. [**Last Name (STitle) 40510**] phone [**Telephone/Fax (1) 40513**] or fax [**Telephone/Fax (1) 40514**]
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] Wed [**1-6**] at 1:45pm
Cardiologist:Dr. [**Last Name (STitle) 4922**] on [**1-7**] at 3:00pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Thurs [**1-14**] @ 10:30 AM , [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] 7
Wound check Nurse: [**Hospital Ward Name **] , [**Hospital Unit Name **] on [**12-17**] at 10:45am
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 40510**] in [**4-7**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw Thurs [**12-10**]
Results to Dr. [**Last Name (STitle) 40510**] phone [**Telephone/Fax (1) 40513**] or fax [**Telephone/Fax (1) 40514**]
*** please draw BUN/creatinine on Thursday [**12-10**] with results to
cardiac surgery office [**Telephone/Fax (1) 170**]
Completed by:[**2133-12-9**]
|
[
"41401",
"42731",
"4019"
] |
Admission Date: [**2145-5-4**] Discharge Date: [**2145-5-27**]
Date of Birth: [**2122-2-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Fevers, rigors, rigidity
Major Surgical or Invasive Procedure:
VP shunt tap
Endotrachial intubation and mechanical ventilation
History of Present Illness:
23 year old F with rollover MVC in [**12/2144**] and resulting TBI s/p
craniectomy who was recently admitted to neurosurgery service in
[**2-/2145**] for a cranioplasty. Presenting from rehab with fevers,
rigors, and report of myoclonic jerks. Also a report of
vomiting. According to rehab records, had dose of Keppra
increased approximately 1 week ago. Family notes that patient
has not been herself in last several days and was having more
frequent shaking episodes. They felt like she was becoming ill
and had her sent to ED.
.
In the ED, initial vs were: T 97.8, HR 92, BP 113/73, RR 16,
O2Sat 100%. Shortly after arrival to triage, patient
decompensated with increased temp and HR. Patient was felt to be
having seizure and was given several pushes of lorazepam IV.
Rectal temp shortly into ED course was 103 rectally and climbed
to 105 during ED course. Concordant with spike in temp, HR
climbed as high as 162, and was reportedly sinus tach. Received
5L NS through ED stay. Patient was cooled with ice and was given
acetaminophen. Also felt to be in respiratory distress shortly
after spiking a fever and was intubated. Fentanyl and midazolam
given for sedation. Initial labs significant for lactate of 4.9
and WBC of 14. U/A showed 54 WBC and many bacteria. CSF was
obtained from VP shunt and showed 1 WBC, 1 RBC, nml protein, nml
glucose. Patient was given Vancomycin, Ceftriaxone, and Pip/Tazo
for empiric treatment of fevers. Neurosurgery was consulted in
ED and will follow patient on consult service. Toxicology
consult was called in and and they reviewed meds for possible
causes of serotonin syndrome or NMS. Prior to transfer to the
MICU vitals were: T 101, HR 85, BP 107/58, RR 18, O2Sat 97%
intubated.
.
Review of systems:
Unable to obtain given altered mental status
Past Medical History:
1) Rollover MVC with resulting traumatic brain injury ([**12/2144**])
- multiple facial fractures
2) s/p craniectomy
3) s/p VP shunt
4) s/p Trach/PEG with reversal of trach
Social History:
Currently resides at [**Hospital3 **]. Has a very involved and
supportive family.
Family History:
Reviewed and non-contributory
Physical Exam:
On Admission:
VS: T 97.7, HR 84, BP 95/44, RR 18, O2Sat 100% on AC Vt 400, f
18, PEEP 5, FiO2 70%
GEN: Sedate, unresponsive, appears comfortable
HEENT: Left eye with roving eye movements and left pupil reacts
4mm to 3mm, right eye with pupil fixed and dilated at 6 mm,
right slcera edema, right conjunctival serous exudate,
non-purulent
NECK: Closed stomal scar in site of former tracheostomy
PULM: CTAB
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS+, soft, NT, ND, slightly tympanic, G-tube in place
without surrounding skin breakdown or erythema
EXT: BLE with foot plantar flexion and internal rotation
SKIN: No rashes or breakdown
NEURO: Does not follow simple commands, intermittent increased
tone in upper extremities, no rigidity, no clonus
.
At discharge:
GEN: Sleeping, appears comfortable, does not open eyes to voice
HEENT: Left pupil 5mm and reactive, right eye with pupil fixed
and dilated at 6 mm, does not blink to threat
NECK: tracheostomy in place
PULM: Clear anteriorally, no wheezes/rales/rhonchi
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS+, soft, NT, ND, G-tube in place without surrounding skin
breakdown or erythema
EXT: BLE with foot plantar flexion and internal rotation
SKIN: No rashes or breakdown
NEURO: Does not follow simple commands, intermittent increased
tone in upper extremities, no posturing
Pertinent Results:
Admission labs:
[**2145-5-4**] 06:15PM BLOOD WBC-14.0*# RBC-4.55# Hgb-12.9# Hct-39.5#
MCV-87 MCH-28.4 MCHC-32.8 RDW-16.9* Plt Ct-310
[**2145-5-4**] 06:15PM BLOOD Neuts-60.7 Lymphs-29.8 Monos-7.1 Eos-1.8
Baso-0.6
[**2145-5-5**] 03:39AM BLOOD PT-14.9* PTT-29.9 INR(PT)-1.3*
[**2145-5-4**] 06:15PM BLOOD Glucose-111* UreaN-23* Creat-0.7 Na-141
K-4.9 Cl-100 HCO3-26 AnGap-20
[**2145-5-4**] 06:15PM BLOOD ALT-28 AST-30 CK(CPK)-85 AlkPhos-73
TotBili-0.5
[**2145-5-5**] 03:39AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9
.
CSF Studies:
[**2145-5-4**] 09:24PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
Lymphs-74 Monos-22 Macroph-4
[**2145-5-21**] 02:56PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
Lymphs-100 Monos-0
[**2145-5-4**] 09:24PM CEREBROSPINAL FLUID (CSF) TotProt-83*
Glucose-71
[**2145-5-21**] 02:56PM CEREBROSPINAL FLUID (CSF) TotProt-59*
Glucose-82
.
[**2145-5-4**] CXR:
IMPRESSION: Mild bibasilar atelectasis in the setting of reduced
lung
volumes.
.
[**2145-5-4**] Head CT:
1. Stable extra-axial collection overlying the right cerebral
convexity since [**2145-4-9**].
2. The left frontal subdural collection with small curvi-linear
hyperdense
component appears similar in attenuation but overall is slightly
larger than [**2145-4-9**].
3. No area of abnormal enhancement. If clinical concern remains
high for
infection, MRI is a more sensitive exam.
.
[**2145-5-5**] EEG:
IMPRESSION: This is an abnormal continuous EEG, due to
consistently lower amplitude activity seen over the right
hemisphere, with less high frequency activity and occasional
periods of delta slowing, consistent
with a large underlying structural lesion involving the cortex
on the right. In addition, the presence of mixed diffuse alpha
and beta frequency activity, seen best over the left hemisphere
throughout most of the tracing is consistent with pharmacologic
sedation. The pushbutton event occurring on [**5-5**] at 8:13 pm
appears to be clinically and electrographically consistent with
shivering. There were no epileptiform features seen.
.
[**2145-5-10**] MRI:
IMPRESSION:
1. Post-traumatic severe encephalomalacia of the right temporal
lobe, with ex vacuo dilatation of the temporal [**Doctor Last Name 534**] of the right
lateral ventricle.
2. Mild to moderate right frontoparietal encephalomalacia.
3. Right epidural and bilateral subdural hematomas, minimally
changed since [**2145-5-4**].
4. No acute superimposed process.
.
[**2145-5-16**] MR Pituitary:
IMPRESSION: Motion artifact somewhat limits the examination.
There is no
definite pituitary mass. Lobular contour of the pituitary
contents likely is secondary to this motion artifact as well as
prominent adjacent pachymeningeal enhancement. There is no mass
effect upon the optic chiasm, and the pituitary stalk is
midline.
.
MICROBIOLOGY:
[**2145-5-4**] Urine culture:
URINE CULTURE (Final [**2145-5-8**]):
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available on
request.
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML.. 2ND MORPHOLOGY.
Piperacillin/tazobactam sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
KLEBSIELLA OXYTOCA
| KLEBSIELLA OXYTOCA
| |
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 64 I
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
CSF GRAM STAIN (Final [**2145-5-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method, please
refer to hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2145-5-7**]): NO GROWTH.
.
[**2145-5-5**] Sputum culture/Gram Stain:
GRAM STAIN (Final [**2145-5-5**]):
[**10-26**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
.
RESPIRATORY CULTURE (Final [**2145-5-8**]):
RARE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
GRAM NEGATIVE ROD(S). RARE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 1 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**5-10**] Sputum Cx and gram stain:
GRAM STAIN (Final [**2145-5-10**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2145-5-13**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ENTEROBACTER CLOACAE. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ENTEROBACTER CLOACAE
| |
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S 2 S
CEFTAZIDIME----------- 4 S =>64 R
CEFTRIAXONE----------- 32 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R 4 S
MEROPENEM------------- 8 I 1 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ =>16 R <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2145-5-16**] 2:09 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2145-5-20**]**
GRAM STAIN (Final [**2145-5-16**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2145-5-20**]):
RARE GROWTH Commensal Respiratory Flora.
ENTEROBACTER CLOACAE. RARE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/tazobactam sensitivity testing available
on request.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 16 S
CEFEPIME-------------- 2 S 16 I
CEFTAZIDIME----------- =>64 R 4 S
CEFTRIAXONE----------- 16 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 4 S =>16 R
MEROPENEM------------- 4 S 4 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2145-5-22**] 4:25 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2145-5-26**]**
GRAM STAIN (Final [**2145-5-22**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): YEAST(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2145-5-26**]):
RARE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**]. SECOND MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 32 I 16 S
CEFEPIME-------------- 8 S 16 I
CEFTAZIDIME----------- 4 S 8 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM------------- 4 S =>16 R
PIPERACILLIN/TAZO----- 16 S 32 S
TOBRAMYCIN------------ =>16 R =>16 R
Brief Hospital Course:
23 year old F with rollover MVC in [**12/2144**] and resulting TBI s/p
craniectomy who was recently admitted to neurosurgery service in
[**2-/2145**] for a cranioplasty. Presents from rehab with fevers and
worsening twitching and shaking. Ms. [**Known lastname 1968**] had extended MICU
course for central dysautonomia with difficult to control
sympathetic storm, respiratory failure, ventilator acquired
pneumonia.
.
#. Central dysautonomia: Patient had presumed seizure [**5-7**] prior
to admission. She was intubated in the emergency department for
airway protection. It was suspected that patient is susceptible
to seizures due to history of TBI and had decreased seizure
threshold in setting of infection and fevers. She was admitted
to the medical intensive care unit with neurology following
patient. She has several days of continuous EEG monitoring that
were not consistent with seizures. VP shunt was tapped and was
negative for infectious process in CNS. MRI of the head was
performed which did not show any acute processes or changes from
prior. Patient's symptoms were somewhat controlled while on
versed, but with decreased sedation, she had symptoms of
hypertension, tachycardia, fever, diaphoresis, pupillatory
dilataion, and muscle contraction. Neurology felt that patient's
symptoms were secondary to sympathetic storm from central
dysautonomia. She was started on a regimen of clonidine,
labetolol and bromocriptine to help control these episodes, but
had ongoing shaking activity with pyrexia, tachycardia, and
hypertension. She was briefly tried on dantrolene which was
thought to worsen her fevers and spasticity. Her regimen was
eventually adjusted to standing clonidine, bromocriptine,
propranolol, and baclofen with relatively good control. She was
extubated and a tracheostomy was placed, patient was on trach
mask and did not require venting at time of discharge. Per
neurology, the prognosis of these episodes is unclear and it may
take months for the sympathetic system to downregulate. In the
acute setting of the sympathetic storms, morphine, tylenol, or
motrin can be tried to control pyrexia and diaphoresis. We are
attempting to minimize the use of benzodiazepines. Patient was
also continued on her home keppra. She should follow up with the
neurologists at rehab as well as her outpatient neurosurgeon for
the long-term management of her TBI. Should call Dr. [**Last Name (STitle) 88235**]
office to schedule a follow-up appointment for the sympathetic
dysfunction.
.
#. Fevers: Urine culture show klebsiella and sputum cx show
enterobacter, pseudomonas and MSSA. CSF sample from VP shunt had
only 1 WBC, which is not concerning for CNS infection.
Toxicology consulted and does not believe NMS was an issue at
this time. Patient had repeated sputum samples which grew
pseudomonas and enterobacter. Her initial sample was sensitive
to cefepime and she was treated with this for nearly 2 weeks,
she also completed a course of vancomycin. A repeat sputum
returned pseudomonas with only intermediate sensitivity to
cefepime, and greater sensitivity to meropenem. She was changed
to meropenem on [**2145-5-24**] but subsequent sputum culture returned
resistant to meropenem and sensitive to ceftazidime. She was
started on cftazidime on [**2145-5-26**] and should complete a 2-week
course (last day [**2145-6-8**]). She is likely colonized with a few
different strains of pseudomonas and has bronchiectasis. Though
fevers may be in setting of infection, they may also be due to
central dysautonomia and patient has ongoing spiking throughout
the day sometimes accompanied by tachycardia and hypertension.
Episodes are sometimes self-resolved and often require morphine
1-2mg IV, tylenol, or motrin and cooling blanket to break the
acute sympathetic storm.
.
# Traumatic brain injury: pt s/p MVA in [**12/2144**] with subsequent
resulting in TBI with baseline non-verbal status and 3-month
stay at rehab. Her progress at [**Hospital1 **] has been slow and she
continues to have large baseline neurologic deficits. She will
be discharged to a MACU from the MICU here and will discuss
subsequent placement. She needs ongoing neurorehabilitation and
should follow up with her neurosurgeon and the neurology team at
[**Hospital 100**] Rehab.
Medications on Admission:
Medications: *From [**Hospital3 **] Records*
1) Adderall 5 mg daily
2) Akwa tears (polyvinyl alcohol) both eyes QID
3) Atrovent (ipratropium bromide) 0.5 mg neb Q6H PRN: dyspnea
4) Dantrium (dantrolene sodium) 50 mg [**Hospital1 **]
5) Dulcolax (bisacodyl) supp 10 mg PR PRN: constipation
6) Folvit (folic acid) 1 mg daily
7) Fragmin (dalteparin inj) 5000 units subcut daily
8) Ilotycin (erythromycin base oph) 1 application to right eye
QID (last day [**5-6**])
9) Inderal (propranolol) 10 mg Q8H
10) Keppra (levetiracetam) 1000 mg [**Hospital1 **]
11) Lacri-lube ointment both eyes QHS
12) Mycostatin powder (nystatin powder) [**Hospital1 **] PRN: rash
13) Oralbalance PO TID
14) Roxicodone (oxycodone) liquid 5 mg Q4H:PRN pain
15) Sarna lotion TID PRN:redness
16) Sodium chloride neb 3mL inh PRN: coughing
17) Symmetrel Liq (amantadine) 200 mg morning and lunch
18) Tylenol (acetaminophen) 650 mg Q4H PRN:pain
19) Vitamin B-1 100 mg QHS
20) Vitamin C liq 500 mg [**Hospital1 **]
21) Zegerid (omeprazole) 40 mg packet QHS
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
2. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO
DAILY (Daily).
3. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: One (1)
Drop Ophthalmic QID (4 times a day).
6. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
7. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
8. 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.
9. levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: [**2134**] ([**2134**]) mg PO Q 12H
(Every 12 Hours).
10. miconazole nitrate 2 % Powder [**Year (4 digits) **]: One (1) Appl Topical QID
(4 times a day) as needed for RASH.
11. bromocriptine 2.5 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO TID (3
times a day).
12. gabapentin 300 mg Capsule [**Year (4 digits) **]: Two (2) Capsule PO TID (3
times a day).
13. clonidine 0.1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times
a day).
14. ibuprofen 100 mg/5 mL Suspension [**Year (4 digits) **]: Six Hundred (600) mg
PO Q8H (every 8 hours) as needed for fever.
15. propranolol 40 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO QID (4 times
a day).
16. baclofen 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO TID (3 times a
day).
17. morphine 5 mg/mL Solution [**Year (4 digits) **]: 1-2 mg Injection Q2H (every 2
hours) as needed for agitation.
18. ceftazidime 2 gram Recon Soln [**Year (4 digits) **]: One (1) Recon Soln
Injection Q8H (every 8 hours): last day = [**2145-6-8**]. Each dose
should be infused over 3 hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Central dysautonomia / sympathetic storms
Traumatic brain injury
Hospital-community acquired pneumonia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 1968**],
You were admitted to [**Hospital1 18**] with seizure-like activity. We
performed several tests that did not show seizure activity being
generated by your brain. Our neurology team followed you closely
and believes that you have sympathetic discharges that cause
fevers, fast heart rate, and high blood pressure. We started
several medications to help control these episodes though it may
take some time for them to subdue. We also found that you had a
pneumonia for which you were treated with antibiotics.
You had a tracheostomy placed while you were in the hospital,
and will be going to a rehabilitation facility for further care.
You will follow up with the neurologists there.
We made the following changes to your medications:
- START baclofen, bromocriptine, propranolol and clonidine to
help control your sympathetic storm episodes
- CONTINUE ceftazidime for two weeks for treatment of the
bacteria in your lungs (last day = [**2145-6-8**]
Followup Instructions:
Please follow up with the neurologists at your rehab facility
and your regular outpatient neurosurgeon.
We have placed a call in to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1274**] office and
left them a message. You need to follow up with Dr. [**Last Name (STitle) 1274**]
within the next month for your hospitalization. The office
number is [**Telephone/Fax (1) 8139**]. If you have any questions or concerns
please call the office as well.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"486",
"2762",
"2760",
"5990",
"2859"
] |
Admission Date: [**2104-11-13**] Discharge Date: [**2104-11-20**]
Date of Birth: [**2104-11-13**] Sex: M
Service: Neonatology
HISTORY: Thirty-seven and 5/7 weeks gestational age infant
admitted with asymmetric intrauterine growth restriction.
MATERNAL HISTORY: Mom is a 31-year-old G3 P2-3 woman.
Antepartum screens as follows: Blood type B positive,
antibody negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, GBS negative.
PREGNANCY HISTORY: EDC [**2104-11-29**] for an estimated gestational
age of 37-5/7 weeks based on last menstrual period with
confirmatory 13 week ultrasound. Pregnancy complicated by
severe intrauterine growth restriction attributed to
placental insufficiency in the absence of other apparent
etiologies. Induction on day of birth leading to spontaneous
vaginal delivery under epidural anesthesia with rupture of
membranes two hours prior to delivery yielding clear amniotic
fluid. No intrapartum maternal fever or fetal tachycardia,
no fetal distress. Of note, placenta is small and calcified
per delivering obstetrician.
DELIVERY ROOM COURSE: Infant emerged with good tone and cry,
dry bulb suctioned, free flow oxygen administered. Apgars
eight at one minute and nine at five minutes, transferred
uneventfully to the NICU for monitoring given growth
restriction.
PHYSICAL EXAM ON ADMISSION: Birth weight is 1680 grams, head
circumference 32 cm, length 42.5 cm. Infant very well
appearing, but significantly growth restricted. Vital signs:
Heart rate 146, respiratory rate 40-60, blood pressure 86/49
with a mean of 61, temperature 98.1, and oxygen sat of 100%
in room air. HEENT: Anterior fontanel is open and flat,
nondysmorphic. Palate intact. Neck and mouth normal. Red
reflex bilaterally. Chest without retractions, good breath
sounds bilaterally, no crackles. Cardiovascular: Well
perfused, regular, rate, and rhythm, femoral pulses normal,
no murmur. Abdomen is soft, nondistended, no organomegaly,
and no masses. Bowel sounds active. Anus patent. Three
vessel umbilical cord. GU: Normal male genitalia. Testes
descended bilaterally. Neurologic is alert, active,
responsive to stimulation and axial and appendicular tone
normal, moving all limbs symmetrically. Grasps normal.
Normal sucking, Moro, and gagging reflexes. Facial
movements symmetrical. Skin: Intact. Spine: Straight, no
dimple. Extremities: Hips stable.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Patient is breathing comfortably on room air
throughout admission, maintaining normal oxygen saturations.
2. Cardiovascularly: Patient cardiovascularly stable
throughout admission with normal blood pressures, no murmur.
3. FEN: Patient initially with low glucoses between 25 and
38. IV placed and patient started on D10W at 60 cc/kg/day
with normalization in blood glucoses. Patient transitioned
to off IV on day of life one, maintaining normal glucoses.
Advanced to full adlib feeds. Weaned off IV fluids by day of
life four and maintaining normal glucoses. Patient gradually
advanced on p.o. feeds advancing to full feeds by day of life
four. Kilocalories gradually advanced, and patient tolerated
this well.
At time of discharge, patient is taking bottle feeds of
NeoSure 28 or breast milk 28 made with 4 kcal/oz by
concentration of NeoSure powder and 4 kcal/oz by corn oil for
a minimum of four feeds per day, plus breast feeding adlib.
Maintaining normal glucoses. Patient gaining weight well on
this regimen. Weight at discharge 1760 grams.
4. GI: Bilirubin levels monitored and bilirubin peak of
11.7/0.3 on day of life. The patient is started on single
phototherapy, bilirubin down to 8.7/0.3 on day of life six,
and phototherapy discontinued. Rebound bilirubin on day of
life seven down to 7.5/0.2. Patient had a significant diaper
rash during hospitalization thought secondary to initial
supplementation of feeds with Polycose. Polycose removed
from feeds and diaper rash is improving at this time.
5. Hematology: Hematocrit checks on admission at 64.1.
Patient did not require any blood products during this
hospitalization.
6. ID: The patient had no infectious disease issues during
this hospitalization.
7. Sensory: Audiology: Hearing screen was performed with
automated auditory brain stem responses and baby passed
bilaterally.
8. Hepatitis B: Patient received hepatitis B vaccination on
[**11-19**].
9. Psychosocial: [**Hospital1 69**] Social
Work involved with the family. The contact social worker can
be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged to home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**], phone number
[**Telephone/Fax (1) 50432**].
CARE AND RECOMMENDATIONS: Feeds at discharge: NeoSure 28,
breast milk 28 with 4 kcal/oz by NeoSure powder concentration
and 4 kcal/oz by corn oil, minimum of four feeds per day plus
breast feeding adlib.
MEDICATIONS: Fer-In-[**Male First Name (un) **] 0.15 cc p.o. q.d.
STATE SCREEN: Newborn state screen sent and pending at time
of discharge.
IMMUNIZATIONS: Received hepatitis B on [**11-19**].
FOLLOW-UP APPOINTMENT: Follow up scheduled with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] on [**2104-11-21**].
DISCHARGE DIAGNOSES:
1. Term male infant.
2. Asymmetry intrauterine growth restriction.
3. Status post hypoglycemia.
4. Status post hyperbilirubinemia.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 50027**]
MEDQUIST36
D: [**2104-11-20**] 12:21
T: [**2104-11-20**] 12:21
JOB#: [**Job Number 50433**]
|
[
"V053"
] |
Admission Date: [**2134-1-21**] Discharge Date: [**2134-1-25**]
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]yoM s/p witnessed mechanical fall backwards on stairs
carrying groceries hitting back of head. +LOC at scene, per EMS
awoke and became responsive but disoriented en route to OSH.
SDH
seen on imaging and transferred to [**Hospital1 18**]. Endorses headache,
nausea without emesis, denies pain elsewhere. Unclear baseline
mental status, per EMS patient visiting from [**State 108**]. Not on
anticoagulation.
Past Medical History:
HTN, gout, CAD s/p CABG
Social History:
visiting from [**State 108**], unknown tob/EtOH
Family History:
NC
Physical Exam:
Gen: Comfortable, NAD.
HEENT: Pupils: equal round reactive 4 to 2 mm b/l, EOMs intact
hearing better on right side
Neck: Supple, collar in place
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. no deformity
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person but not place, date, month, or
season.
Language: Speech fluent with good comprehension.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice. Right better than Left
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-22**] throughout. No pronator drift
Sensation: Intact to light touch b/l
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes equivocal bilaterally
On Discharge:
xxxxx
Pertinent Results:
CT C-Spine [**1-21**]
1. No evidence of acute fracture.
2. Moderate cervical spondylosis with moderate central canal
narrowing,
particularly at C2/3, C3/4 and C4/5. These degenerative changes
put the
patient at high risk for significant cord injury even minor
minor trauma. If there is concern for cord injury, then an MRI
can be obtained if there are no contraindications for the use of
MRI.
3. Hyperdense material abutting C1-C2 in the prevertebral space
and posterior to the dens likely represents pannus formation and
is not felt to be hemorrhage.
Brief Hospital Course:
Patient presented to [**Hospital1 18**] from an Outside Hospital and was
admitted to the ICU for monitoring and care. He remained stable
in the ICU and on [**1-21**] he had a Head Ct which was consistent with
left frontoparietal subdural hematoma with less mass effect and
shifting towards the right. The right subdural hematoma remains
unchanged. Subdural hematoma identified along the tentorium and
right temporal contusion. The patient was started on Dialntin as
seizure prophylaxis. A chest x ray was performed which was
consistent with Left lower lobe consolidative opacity.
On [**1-22**] the patient exam was stable and he was transferred to the
floor. A physical therapy evaluateion was performed and the
patient was evaulated and determined to be a canidate for
disposition to a rehabilitation center.
On [**1-23**], A repeat head CT was performed and found to be stable,
The was a head laceration that had been closed with staples at
the time of injury and these were removed. The site was
cleaned, as teh wound was very superficial, no staples were not
replaced. The serum sodium level was NA 135. On exam the
patient was alert and oriented to person only. He was following
commands consitently and moving all extremities consistently. A
Mri of the cervical spine was performed which was consistent
with no evidence for acute traumatic injury. Multilevel
degenerative changes
On [**1-24**], The patient was slightly tachycardic in the 80s-110 and
IVF was initiated at 60cc/hr x 1 liter. He was noted to have
poor po intake and ensure was added TID to meals. The patient
serum magnesium/phosphate/ postassium were low and repleated.
The cervical spine was cleared and the hard cervicla collar was
removed.
On [**1-25**], The dilantin level 11. Again the serum potassium,
magnesium, phosphate, and calcium were low and repleated. The
patient's heart rate was in the 80-90s. On exam the patient was
alert to name, for the datehe stated "[**2134**]". The patient was
not oriented to place. The patient exhibited full strength.
There was no pronator drift and the patient has decreased
hearing which is his baseline. The patient had some intermittent
low grade temps of 99 and incentive spirometry was ordered.
The patient was cleared for discharge to rehab at the
recommendation of PT & OT. His son was [**Name (NI) 653**] and in
agreement with this plan.
Medications on Admission:
allopurinol 100', lisinopril 10', omeprazole 40', simvastatin
40', diltiazem 240'
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. diltiazem HCl 120 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day): discontinue after [**2134-1-26**].
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Left Subdural Hematoma
Right Temproparietal heamtoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, do not
resume these until you are cleared by your surgeon.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine. You only need to take this through [**2134-1-26**] then it can
be discontinued.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 6 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.
?????? It was noted that your blood sugars were slightly elevated
during your hospitalization. A HgbA1C was sent during your stay
but the results were still pending at time of discharge. Please
follow up with your PCP to discuss this result and to determine
if any intervention is needed.
Completed by:[**2134-1-25**]
|
[
"4019",
"V4581"
] |
Admission Date: [**2123-6-9**] Discharge Date: [**2123-6-12**]
Date of Birth: [**2061-10-9**] Sex: M
Service: CME
SERVICE: CCU
HISTORY OF PRESENT ILLNESS: This is a 61 year old Caucasian
male patient with a history of coronary artery disease status
post RCA stent in [**2121-8-7**], who presented to an outside
hospital with a several day history of progressive substernal
chest pressure radiating to his left arm. The patient states
that this pain became progressively worse over the last five
days but responded to Pepcid. The patient denies any
exertional component to the chest pain but given that it
worsened over the previous five days, he went to the outside
hospital and was found to have anterior ST elevations and
inferior ST depressions. The patient was subsequently
started on heparin, aspirin, Tirofiban and Lopressor and
transferred to [**Hospital1 69**] for
angioplasty.
REVIEW OF SYSTEMS: On review of systems, the patient denies
any associated shortness of breath, lightheadedness,
dizziness, palpitations, nausea or vomiting. He states that
this chest pain is similar to his previous episode of chest
pain in [**2121**] at which time he received a stent in his RCA,
but at that time the pain was radiating to the other arm.
The patient's blood pressure on admission is 150/90 with a
heart rate in the 60s with an EKG notable for ST elevations
in V1 through V4 as well as inferior reciprocal changes. The
patient was directly taken to the Cardiac Catheterization
Laboratory where he was noted to have 100 percent left
anterior descending ostial lesion and two Taxus stents were
placed. The patient was subsequently transferred to the
Coronary Care Unit for care.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post right coronary artery
stent in [**2121-8-7**] at which time the patient
presented with chest pressure and a positive stress test.
1. Diabetes mellitus type 2 currently on oral hypoglycemics.
1. Hypercholesterolemia.
MEDICATIONS:
1. TriCor 57 mg.
2. Lisinopril 5 mg q day.
3. Glucophage 1000 mg p.o. twice a day.
4. Avandia 4 mg q day.
5. Lopressor 25 mg twice a day.
6. Lipitor 10 mg q day.
7. Aspirin 81 mg q day.
8. Viagra p.r.n.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Afebrile; blood pressure 124/74; heart
rate 67; respiratory rate 11; 99 percent on room air. In
general, overweight male in no acute distress. HEENT:
Pupils equal, round and reactive to light. Extraocular
movements intact. Moist mucous membranes. Oropharynx is
clear. Neck: Supple with full range of motion. No evidence
of jugular venous distention. Lungs are clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm, normal S1 and S2. No murmurs, rubs or gallops.
Abdomen: Soft, nontender, nondistended. Normoactive bowel
sounds. Extremities: One plus dorsalis pedis and posterior
tibialis pulses bilaterally. No evidence of clubbing,
cyanosis or edema.
LABORATORY DATA: White blood cell count 7.2, hematocrit
44.4, platelets 170. Sodium 135, potassium 4.4, chloride
103, bicarbonate 21, BUN 7, creatinine 0.6, platelets 244.
CK 142, troponin 1.75.
HOSPITAL COURSE:
1. CORONARY ARTERY DISEASE: As noted previously, the patient
was admitted with five days of stuttering chest pressure;
found to have ST elevations in V1 through V4 and
reciprocal inferior changes. The patient was directly
taken to the Cardiac Catheterization Lab where he was
noted to have a 100 percent ostial left anterior
descending lesion and received two Taxus stents with
resulting TIMI-3 flow. The patient was transferred on to
the Coronary Care Unit after his intervention and received
18 hours of Aggrastat in addition to aspirin, Plavix, beta
blocker and atorvastatin. The patient's beta blocker was
titrated up and eventually switched over to Toprol XL.
1. CONGESTIVE HEART FAILURE: After the patient was taken for
PTCA and stent he had an echocardiogram that was
significant for an ejection fraction of 20 to 25 percent
with anterior septal / anterior apical akinesis as well as
inferior hypokinesis / akinesis. The patient was
subsequently started on a heparin drip given his apical
akinesis. As noted previously, he was restarted on a beta
blocker after his PTCA and stenting. His beta blocker
dose was titrated as allowed by his blood pressure and
heart rate. The patient was also started on an ACE
inhibitor which was also titrated as tolerated by his
blood pressure. The patient was started on Coumadin which
was continued throughout the remainder of his
hospitalization for apical akinesis. As the patient's INR
did not increase above 2.0, the patient was transitioned
to Lovenox prior to discharge.
It is anticipated that the patient will continue on Lovenox
as an outpatient until his INR is therapeutic. His INR will
be followed by his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
who will adjust his Coumadin dose as necessary.
1. RHYTHM: The patient was monitored on telemetry throughout
his hospitalization and had no notable events. Given his
significant myocardial infarction and ejection fraction of
20 to 25 percent, he will be followed by the
Electrophysiology cardiologist as an outpatient.
1. DIABETES MELLITUS TYPE 2: The patient's oral
hypoglycemics were held 48 hours around his cardiac
catheterization. These were restarted and the patient had
adequate glycemic control prior to discharge.
1. RENAL: The patient's creatinine was followed throughout
his hospitalization given his significant dye load during
this cardiac catheterization. He had a normal and stable
creatinine.
CONDITION ON DISCHARGE: Good, chest pain free.
DISCHARGE STATUS: The patient is discharged to home.
DISCHARGE DIAGNOSES:
1. Myocardial infarction status post PTCA / stent to the left
anterior descending.
1. Diabetes mellitus type 2.
1. Hypercholesterolemia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q day.
2. Plavix 75 mg p.o. q day.
3. Atorvastatin 40 mg p.o. q day.
4. Lisinopril 20 mg p.o. q day.
5. Metoprolol XL 200 mg p.o. q day.
6. Metformin 1000 mg p.o. twice a day.
7. Rosiglitazone 4 mg p.o. q day.
8. Coumadin 5 mg p.o. q h.s.
9. Enoxaparin sodium 120 mg subcutaneously q 12 hours.
FOLLOW UP:
1. The echocardiogram office will call the patient to
schedule a followup echocardiogram for three weeks after
discharge.
1. The electrocardiologist will call the patient to schedule
a followup appointment for one month after discharge.
1. The patient is encouraged to schedule a followup
appointment with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], within one week after discharge. He will have his
blood drawn on [**Last Name (LF) 766**], [**6-14**], the results of which will
be sent to his primary care physician who will adjust his
Coumadin dose as necessary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 4958**]
Dictated By:[**Last Name (NamePattern1) 12325**]
MEDQUIST36
D: [**2123-6-12**] 14:33:07
T: [**2123-6-12**] 18:00:28
Job#: [**Job Number **]
|
[
"41401",
"2720",
"25000"
] |
Admission Date: [**2112-11-22**] Discharge Date: [**2112-12-21**]
Date of Birth: [**2086-8-26**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13787**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Intubated on [**2112-11-24**]
Extubated on [**2112-12-3**]
History of Present Illness:
The patient is a 26 year old woman with a history of seizures
since age 21 following head trauma in a motor vehicle accident
now presenting with a seizure earlier today. The patient is
unable to give a coherent and reliable history so most details
are taken from her home care taker [**Female First Name (un) **], who I spoke to on the
phone. She tells me that the patient was sleeping on the sofa
as
she walked by the room. She woke her up and asked her if
everything was okay. She told her "my mouth hurts". The
patient
then tried to get off the sofa, fell to her knees and began an
episode of whole body shaking that lasted about a minute or so.
During the seizure, dropped her torso to the floor and hit her
face on the ground. Her face was bleeding. After the seizure
she was confused and somewhat lethargic. [**Female First Name (un) **] then activated
EMS and the patient was brought to [**Hospital1 18**] for further management.
She was last seen in our ED 3 days ago with nausea and vomiting.
She was unable to take PO medications because of these symptoms
including her AEDs. She was sent home after receiving IV
fluids.
She had recently had teeth extracted and had a good deal of pain
in the mouth that also inhibited her from eating/swallowing.
She had been treated with an unknown anti-biotic for the
presumed dental infection.
Her last EEG in [**4-9**] showed generalized spike and slow wave
discharges in the 3 hz range. Her head MRI in [**3-12**] showed mild
cerebellar atrophy.
Past Medical History:
-h/o mva in [**2107**]
-h/o seizures
-h/o anxiety
-mild mental retardation
-asthma
Social History:
-lives in a private home-hospice
-no smoking or tobacco use
-is responsible for obtaining and taking medications
Family History:
-largely unknown
Physical Exam:
Vitals: 99.9 66 144/91 16
General: Well nourished in no acute distress
Head: marked swelling of left cheek
Neck: supple, in hard collar
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema
.
Neurologic Examination
(s/p 4 mg of iv morphine):
pt. sleepy but arousable; oriented to self but did not know the
month or year; could not tell me where she is; somewhat
uncooperative with exam; did not know 7 quarters in 1.75 but
could tell me the president of US; pupils equal round and
reactive to light; blinks to threat b/l; face symmetric;
increased tone throughout (possible though that this was
volitional resistance); moves all extremities equally, withdraws
to pain on all limbs; reflexes 2+ throughout; gait exam
deferred.
Pertinent Results:
[**2112-11-22**] 02:10PM BLOOD WBC-7.5 RBC-3.57* Hgb-11.1* Hct-33.7*
MCV-94 MCH-31.0 MCHC-32.9 RDW-13.3 Plt Ct-326
[**2112-11-23**] 06:59AM BLOOD WBC-6.5 RBC-3.23* Hgb-10.0* Hct-28.6*
MCV-88 MCH-31.0 MCHC-35.0 RDW-13.6 Plt Ct-280
[**2112-11-24**] 07:30AM BLOOD WBC-20.4*# RBC-3.36* Hgb-10.2* Hct-31.2*
MCV-93 MCH-30.4 MCHC-32.6 RDW-13.8 Plt Ct-272
[**2112-11-25**] 05:19AM BLOOD WBC-21.0* RBC-2.64* Hgb-8.1* Hct-25.0*
MCV-95 MCH-30.7 MCHC-32.3 RDW-13.9 Plt Ct-242
[**2112-11-26**] 03:01AM BLOOD WBC-15.9* RBC-2.86* Hgb-9.1* Hct-26.1*
MCV-91 MCH-31.9 MCHC-35.0 RDW-15.0 Plt Ct-179
[**2112-11-28**] 02:12AM BLOOD WBC-6.1 RBC-2.77* Hgb-8.5* Hct-25.4*
MCV-92 MCH-30.8 MCHC-33.7 RDW-14.5 Plt Ct-225
[**2112-12-18**] 03:10PM BLOOD WBC-3.4* RBC-4.15* Hgb-12.9 Hct-35.5*
MCV-86 MCH-31.1 MCHC-36.3* RDW-14.4 Plt Ct-264
[**2112-12-21**] 07:15AM BLOOD WBC-5.0 RBC-3.92* Hgb-12.1 Hct-34.9*
MCV-89 MCH-30.9 MCHC-34.8 RDW-14.4 Plt Ct-242
.
[**2112-11-22**] 02:10PM BLOOD Neuts-76.1* Lymphs-19.7 Monos-3.9 Eos-0.1
Baso-0.1
[**2112-11-25**] 05:19AM BLOOD Neuts-75* Bands-3 Lymphs-14* Monos-7
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2112-12-3**] 03:51AM BLOOD Neuts-62.4 Lymphs-29.0 Monos-6.7 Eos-1.5
Baso-0.4
.
[**2112-11-24**] 07:30AM BLOOD PT-12.9 PTT-28.6 INR(PT)-1.1
[**2112-11-22**] 02:10PM BLOOD PT-12.1 PTT-26.1 INR(PT)-1.0
[**2112-11-27**] 04:14AM BLOOD PT-12.7 PTT-34.4 INR(PT)-1.1
[**2112-12-5**] 08:00AM BLOOD PT-12.7 PTT-28.2 INR(PT)-1.1
[**2112-11-25**] 09:04AM BLOOD Fibrino-374
[**2112-11-25**] 01:45PM BLOOD Fibrino-403* D-Dimer-1252*
[**2112-12-5**] 08:00AM BLOOD Ret Aut-1.6
[**2112-11-22**] 02:10PM BLOOD Glucose-121* UreaN-9 Creat-0.5 Na-137
K-4.2 Cl-98 HCO3-21* AnGap-22*
[**2112-11-23**] 06:59AM BLOOD Glucose-100 UreaN-8 Creat-0.4 Na-137
K-3.6 Cl-100 HCO3-26 AnGap-15
[**2112-11-24**] 07:30AM BLOOD Glucose-161* UreaN-5* Creat-0.4 Na-135
K-3.4 Cl-98 HCO3-24 AnGap-16
[**2112-11-25**] 05:19AM BLOOD Glucose-101 UreaN-5* Creat-0.3* Na-140
K-3.7 Cl-112* HCO3-21* AnGap-11
[**2112-11-25**] 01:45PM BLOOD Glucose-107* UreaN-4* Creat-0.4 Na-140
K-3.8 Cl-110* HCO3-21* AnGap-13
[**2112-11-28**] 05:52AM BLOOD Glucose-132* UreaN-4* Creat-0.2* Na-136
K-3.9 Cl-106 HCO3-24 AnGap-10
[**2112-11-29**] 04:30AM BLOOD Glucose-132* UreaN-4* Creat-0.3* Na-138
K-4.1 Cl-100 HCO3-29 AnGap-13
[**2112-12-18**] 03:10PM BLOOD Glucose-82 UreaN-12 Creat-0.4 Na-126*
K-4.8 Cl-91* HCO3-23 AnGap-17
[**2112-12-19**] 07:20AM BLOOD Glucose-91 UreaN-16 Creat-0.4 Na-132*
K-4.8 Cl-99 HCO3-23 AnGap-15
[**2112-12-20**] 08:15AM BLOOD Glucose-123* UreaN-14 Creat-0.4 Na-134
K-4.4 Cl-101 HCO3-23 AnGap-14
[**2112-12-21**] 07:15AM BLOOD Glucose-89 UreaN-10 Na-137 K-4.6 Cl-105
HCO3-22 AnGap-15
[**2112-11-22**] 02:10PM BLOOD ALT-23 AST-50* LD(LDH)-464* CK(CPK)-343*
AlkPhos-77 Amylase-83 TotBili-0.2
[**2112-11-24**] 07:30AM BLOOD ALT-15 AST-26 AlkPhos-65 TotBili-0.2
[**2112-11-25**] 01:45PM BLOOD ALT-9 AST-20 LD(LDH)-232
[**2112-11-29**] 04:30AM BLOOD ALT-10 AST-26 LD(LDH)-309* AlkPhos-57
TotBili-0.1
[**2112-12-16**] 07:10AM BLOOD ALT-12 AST-21 AlkPhos-111 TotBili-0.3
[**2112-12-21**] 07:15AM BLOOD Calcium-9.8 Phos-4.2 Mg-1.8
[**2112-11-23**] 06:59AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.5*
[**2112-12-5**] 08:00AM BLOOD calTIBC-229* VitB12-765 Hapto-142
Ferritn-160* TRF-176*
[**2112-12-5**] 08:00AM BLOOD Homocys-5.8
[**2112-11-22**] 02:10PM BLOOD Triglyc-126 HDL-46 CHOL/HD-3.4 LDLcalc-84
[**2112-11-26**] 05:52PM BLOOD Ammonia-60*
[**2112-11-27**] 04:14AM BLOOD Ammonia-60*
[**2112-11-29**] 04:30AM BLOOD Ammonia-41
[**2112-11-22**] 02:10PM BLOOD TSH-3.5
[**2112-12-3**] 03:51AM BLOOD PTH-33
[**2112-11-22**] 02:10PM BLOOD Valproa-10*
[**2112-11-23**] 12:50PM BLOOD Valproa-56
[**2112-11-24**] 01:59AM BLOOD Phenyto-10.2 Valproa-73
[**2112-12-15**] 07:10AM BLOOD Phenyto-4.5* Valproa-54
[**2112-12-16**] 07:10AM BLOOD Phenyto-3.8* Valproa-57
[**2112-12-17**] 07:05AM BLOOD Valproa-70
[**2112-12-18**] 06:55AM BLOOD Valproa-73
[**2112-12-19**] 07:20AM BLOOD Valproa-45*
[**2112-12-20**] 08:15AM BLOOD Phenyto-<0.6* Valproa-87
[**2112-12-21**] 07:15AM BLOOD Valproa-40*
[**2112-12-3**] 04:20AM BLOOD Type-ART PEEP-5 pO2-182* pCO2-44 pH-7.39
calHCO3-28 Base XS-1 Comment-PS = 12
[**2112-12-2**] 02:43PM BLOOD Type-ART PEEP-5 FiO2-40 pO2-174* pCO2-39
pH-7.39 calHCO3-24 Base XS-0 Intubat-INTUBATED Vent-SPONTANEOU
[**2112-11-25**] 05:20PM BLOOD Type-ART Temp-37.4 pO2-173* pCO2-36
pH-7.31* calHCO3-19* Base XS--7 Intubat-NOT INTUBA
[**2112-11-25**] 03:56PM BLOOD Lactate-2.8*
[**2112-11-25**] 03:56PM BLOOD freeCa-1.18
Sodium [**12-14**]: 133 [**12-15**]: 128 [**12-16**]: 123 [**12-17**]: 121
[**12-18**]: 120 [**12-19**]: 123 [**12-20**]: 126 11/16:132
.
[**11-25**]: CSF WBC 0 RBC 0 Polys 60 Lymphs Monos 10
CHEMISTRY TotProt 11 Glucose 81 LD(LDH) 20
.
CT sinus [**11-22**]:IMPRESSION: Extensive soft tissue swelling over
left face. Small left nasal spine fracture.
.
CT spine [**11-22**]: IMPRESSION: Malalignment likely secondary to
positioning. However, if there are neurological symptoms or
focal pain, MRI imaging of the cervical spine could be
considered. No acute fracture or prevertebral soft tissue
swelling.
.
CT head [**11-22**]: IMPRESSION: No acute intracranial hemorrhage or
visualized skull fracture. For more details concerning the
facial bones, please see facial bone CT.
.
CXR [**11-23**]:IMPRESSION: No evidence of aspiration or pneumonia.
.
EEG [**11-23**]:MPRESSION: Abnormal EEG due to the frequent right
frontal and
bifrontal bursts of spike and sharp wave activity and due to the
right
frontal and generalized slowing. These findings suggest a focal
epileptogenic area in the right frontal region. There were no
prolonged
discharges or electrographic seizures. The background rhythm was
dominated by faster beta frequencies, likely a medication
effect.
.
CXR [**11-24**] for line placement:
A right subclavian vascular catheter terminates in the lower
superior vena cava. There is no evidence of pneumothorax. There
is worsening consolidation within the left retrocardiac region,
which may be due to an evolving area of pneumonia or aspiration.
.
CXR [**11-24**]:
New consolidation in the left lower lobe is most likely
aspiration perhaps progressed to pneumonia. Upper lungs are
grossly clear. Heart size is normal. No pleural effusion.
Because of the clear delineation of dilated small bowel loops in
the upper abdomen, I would recommend an abdominal examination to
exclude pneumoperitoneum.
--Abd x-ray showed no free air
.
EEG [**11-24**]:IMPRESSION: This 24-hour video EEG telemetry captured
numerous
pushbutton events for electrographic seizures. Most of these
seizures
consisted of focal twitching of the left face and left arm. The
EEG
during this time showed high voltage rhythmic [**2-7**] Hz spike and
wave and
polyspike and wave discharges most prominent over the right
frontal
region but seen in a broader fashion over the right
fronto-temporal
region. Interictally, the background consisted of a high voltage
mixed
theta and delta frequency slowing. At times, this activity
seemed
somewhat rhythmic and could represent non-convulsive status
epilepticus.
Overall, given the appearance of the background as well as the
number of
frequent seizures, this EEG represents non-convulsive status
epilepticus
with frequent focal motor seizures with twitching of the left
side of
face and left arm and shoulder region.
.
Neck CT [**11-25**]:CONCLUSION: Right subclavian central venous
catheter in situ. No hematoma or fluid collection can be seen at
the insertion site, or elsewhere within the neck. No cervical
lymphadenopathy.
.
Head CT [**11-25**]:FINDINGS: There is extensive beam hardening
artifacts arising from the overlying EEG leads, severely
effecting image quality. Allowing for this limitation, basilar
cisterns appear patent, and no obvious hemorrhage is identified.
IMPRESSION: Suboptimal study due to the above-mentioned
technical factors. No obvious hemorrhage,hydrocephalus or mass
effect. Suggest a followup study, if there is ongoing clinical
indication.
.
EEG [**11-25**]:IMPRESSION: this 24-hour video EEG telemetry shows a
markedly abnormal background with slowing in the mixed theta and
delta frequency.In addition, there are periodic lateralized
epileptiform discharges seen
primarily over the right frontal region but seen in a widespread
fashion
over the right hemisphere. These discharges typically were 1 Hz
in
frequency or slower. There were seven pushbutton events recorded
for
brief shrugging movements of the shoulders as well as twitching
movements of the face. Clinically, these movements appear to be
consistent with seizure activity. There was no clear change in
the EEG
background as described previously with these clinical
movements.
Compared to the prior days' recordings, there did not appear to
be any
episodes of status epilepticus recorded during this telemetry.
The
background shows a marked encephalopathy with periodic
lateralized
epileptiform discharges seen.
.
EEG [**11-26**]:IMPRESSION: This 24-hour video EEG telemetry captured
four pushbutton events with no clear electrographic seizures
recorded with these episodes. From the video, it was unclear
what the clinical correlation was for three of these pushbutton
events. For one of the pushbutton events, the patient
demonstrated some rhythmic eye blinking. There was no clear
electrographic correlation noted with any of these pushbutton
events. As seen previously, the background showed generalized
slowing which suggests an encephalopathy. There was also
periodic epileptiform discharges seen primarily over the right
frontal region with spread over the right hemisphere. These
periodic lateralized epileptiform
discharges never became quite rhythmic enough to suggest ongoing
seizure
activity or status epilepticus.
.
EEG [**11-27**]:IMPRESSION: This 24-hour video EEG telemetry captured
no pushbutton
events and no clear electrographic seizures. As seen previously,
the
background of the EEG was in the delta frequency range
suggestive of an
encephalopathy. In addition, there were periodic lateralized
epileptiform discharges seen over the right frontal lobe but
with spread
over the entire hemisphere on the right. These discharges never
became
rhythmic or frequent enough to warrant a consideration for
status
epilepticus.
.
EEG [**11-28**]:IMPRESSION: This telemetry captured a single
pushbutton activation.
There was some abnormal left arm movement at the time but no
electrographic seizure recorded. Otherwise, the record showed
persistent right frontal, right hemisphere, and more generalized
discharges. Those episodes with frequencies of 1 Hz or greater
might be
considered electrographic seizures. They were detailed above. In
addition, there were frequent episodes of right frontal more
rhythmic, 2
Hz, discharges that could also be considered electrographic
seizures.
These lasted for up to 30 seconds at a time and occurred about a
dozen
times over the recording. Nevertheless, they did not appear to
have a
clinical correlate, i.e. were not associated with abnormal
jerking or
other movements.
.
EEG [**11-29**]:IMPRESSION: This telemetry contined to show a very
abnormal background
with extremely frequent right fronto-temporal and right
hemisphere and
generalized epileptiform sharp wave discharges. Occasionally,
and
probably less frequently than on the previous day, these reached
a 1 Hz
and rhythmic appearance suggesting ongoing seizures, but there
was no
clear clinical concomitant. Overall, the recording did not show
much
change from the previous day.
.
EEG [**11-30**]:IMPRESSION: This bedside telemetry showed continued
right frontal sharp
wave discharges with spread somewhat more generally most of the
time.
The background was slow throughout. The discharges seldom
reached a 1
Hz frequency and did not appear to represent ongoing seizures
though the
area is likely one of potential epileptogenesis. No
electrographic
seizures were recorded.
.
EEG [**12-1**]:IMPRESSION: This telemetry showed no electrographic
seizures but
continued frequent right frontal sharp wave discharges, often
with a
broader distribution. Nevertheless, the discharge were less
frequent
and prominent than on earlier days' recordings. There were very
few
periods with rhythmic discharges. No electrographic seizures
were
captured.
.
EEG [**12-2**]:IMPRESSION: This telemetry monitored cerebral function
at the bedside
from [**Date range (1) 59856**]. It showed a slow and disorganized
background
suggestive of encephalopathy, possibly in turn due to medication
effect.
Right frontal discharges, some extending much more broadly, were
still
present and frequent but abated substantially over the course of
the
24-hour period. No electrographic seizures were evident.
.
EEG [**12-3**]:IMPRESSION: This intermittent monitoring study at the
bedside showed a
profound widespread encephalopathy throughout. There were
continued
right frontal and more generalized epileptiform discharges, but
these
were far less frequent than on earlier recordings and did not
become
rhythmic. A tachycardia was noted.
.
EEG [**12-4**]:IMPRESSION: This telemetry captured a single
pushbutton activation.
There were no changes in the EEG record at the time. Throughout
the
rest of the 24-hour period the background showed a widespread
encephalopathy. Faster frequencies were probably related to
benzodiazepine medications. A tachycardia was noted. There were
occasional right frontal epileptiform discharges but no
sustained runs
or electrographic seizures.
.
EEG [**12-5**]: IMPRESSION: This telemetry captured two pushbutton
activations. They
continued to show an encephalopathy with occasional right
frontal
epileptiform discharges, but there were no changes in the
background at
the time of the pushbutton activations, and there were no clear
electrographic seizures.
.
CXR [**12-6**]: A nasogastric tube courses below the diaphragm. There
has been interval extubation and removal of a central venous
catheter. The heart size is normal, and the lungs appear grossly
clear, with resolution of previously reported opacities. No
pneumothorax or pleural effusion is evident.
.
MRI [**12-9**]:IMPRESSION: Limited examination, terminated since the
patient was nauseated following gadolinium administration. No
gross structural abnormality is seen. There are prominent flow
voids in the posterior midline, between the occipital lobes.
This likely represents a venous malformation, but an
arteriovenous abnormality should also be considered. Complete
evaluation is recommended when the patient is able to return.
.
Video Swallow [**11-12**]:FINDINGS: There is severe weakness of the
oral and pharyngeal phases. There is impairment of the bolus
formation and control with premature spillover. Oral transit was
prolonged.
During the pharingeal phase there was swallow delay with
decreased pharingeal elevation. The epiglotic deflection was
absent. Patient had penetration and aspiration with thin
liquids.
IMPRESSION: Moderate to severe swallowing impairment as
described above. Please review speech and swallow therapist
recommendations.
.
Brief Hospital Course:
1. Epilepsy
This is a 26 year old woman with a history of epilepsy who
presented with increased seizure frequency after not getting
medications in the setting of recent oral surgery, infection and
vomiting. An EEG revealed multi-focal epileptic activity,
right>left frontal as well as some left temporal activity. She
was transferred to the step-down unit and treated as
non-convulsive status epilepticus with intermittent focal motor
status. She was transferred to the ICU on [**11-24**] after increased
seizure frequency with left face/arm/hand twitching and
tonic/clonic activity. She continued to have left arm twitching
that did not correspond to the C4 spikes; it was felt that the
arm twitching was an epilepsia partialis continuum. There was
some difficulty getting therapeutic levels on Dilantin/Depakote
so Dilantin was weaned off and the patient was started on
Trileptal. Trileptal had to be dc'd due to hyponatremia (Na
down to 120 on [**12-17**]). Hyponatremia improved after stopping
Trileptal and with the addition of diamox. Patient was started
on Keppra for her seizures. She remained seizure free with no
clear electrographic seizures for several days. She was
discharged to rehab on Keppra 1000 mg qAm and 1500 mg qPM, as
well as Depakote 1500 mg TID. The left arm twitching then
stopped several days before discharge. She was on ativan 1 mg
q6 hours during her admission. She was sent to rehab with Ativan
1 mg q8 hrs with instructions to wean her off Ativan over 3
weeks (reduce daily dose by 1 mg every week).Her neurologic exam
was remarkable for lethargy, inattentive mental status and left
hemiparesis. An MRI was done to evaluate left sided weakness and
showed a left occipital lesion concerning for venous
malformation.
2. Infectious Disease: Pneumonia
Patient developed a left lower lobe pneumonia and required
intubation. She was treated with Levaquin and Clindamycin and
was able to be extubated on [**2112-12-3**].
3. Hematology: Anemia
Patient was anemic with hematocrit that trended down to 23.6.
She received 2 units of packed red blood cells and hematocrit
was 34.6 upon discharge. Patient was guiac negative. Iron
studies were done and showed low TIBC and normal iron levels,
suggestive of anemia of chronic disease.
4. FEN: Aspiration Risk
Patient had several swallow studies done during the course of
her stay and was found to have slow/delayed swallowing. She was
NPO with NG tube feeds for some time and then advanced to ground
foods. She was discharged with NGT in place for tube feeds and
was able to tolerate ground foods. She was instructed not to
use straws.
5. Gynecology: Vaginal itching
On [**12-11**] she complained of vaginal itching. A gynecology consult
was called and said patient had no signs of of vaginitis. She
was started on vagisil prn.
Medications on Admission:
ADVAIR DISKUS 250-50 mcg/Dose--1 (one) puff inhaled twice a day
ALBUTEROL 90GM--2 puffs every 4 hours as needed for asthma
CLONAZEPAM 500 MCG--One by mouth twice a day
DIVALPROEX SODIUM 500 mg--2 (two) tablet(s) by mouth twice a day
ENSURE PLUS --1 (one) can by mouth twice a day has had
significant weight loss from 105 lbs. weight is hovering around
94 lbs for most visits. medically necessary due to weight loss
FLOVENT 44MCG--2 puff twice a day
LAMICTAL 25MG--Take half a tablet a day for one week, then one
tablet a day for a week, then one tablet in the morning and half
a tablet at night for one week, then one tablet in the morning
and one at night...
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO QPM
(once a day (in the evening)).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
3. Valproate Sodium 250 mg/5 mL Syrup Sig: 1500 (1500) mg PO Q8H
(every 8 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed for fever.
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
7. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed) as needed for prn vaginal itching.
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) SQ
Injection TID (3 times a day).
10. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane TID (3 times a day): Swish solution for 30
seconds in mouth and then spit out. DO NOT SWALLOW.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Ativan 2 mg/mL Solution Sig: One (1) mg IV Injection every
eight (8) hours: hold for RR< 10 or sedation.
Please decrease dose to 1 mg IV BID on [**2112-12-28**]. Please
decrease dose to 1 mg qd on [**2113-1-4**]. Please d/c ativan on
[**2113-1-11**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Epilepsy
2. Anemia
3. Hyponatremia
Discharge Condition:
Stable, seizure free with NG tube in place for tube feeds.
Patient was able to tolerate ground foods at discharge.
Discharge Instructions:
Your medications have been changed. Please take your new
medications as prescribed.
.
Please call your primary care doctor or return to the ER if you
have increasing frequency of seizures, loss of function in your
extremities, have chest pain, fevers or shortness of breath.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 3294**]
Date/Time:[**2113-1-13**] 8:00
2. Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Hospital1 7975**] FAMILY PRACTICE
Date/Time:[**2113-1-16**] 2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13790**] MD, [**MD Number(3) 13791**]
|
[
"51881",
"2761",
"5070",
"486",
"0389",
"99592"
] |
Admission Date: [**2200-4-7**] Discharge Date: [**2200-5-30**]
Date of Birth: [**2166-12-24**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Ceftriaxone
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
MS changes (tx'd from OSH)
Major Surgical or Invasive Procedure:
[**2200-4-11**]- R Hip washout secondary to infected hardward
[**2200-4-17**]- R Hip Hardware removed
[**2200-4-24**]- R Hip washed out and wound closed
[**2200-5-8**]- Removal of infected hematoma in R hip
[**2200-5-22**]- R hip Washout
History of Present Illness:
33 y/o male with PMH significant for AVR, NIDDM, h/o
polysubstance abuse, initially admitted to OSH on [**2200-3-25**] for s/p
tonic-clonic seizure resulting in a fall and broke right hip
requiring R hip ORIF on [**2200-3-31**]. It was felt that seizure was
secondary to benzo withdrawal as pt was taking 5 mg of Xanax tid
at home. He was then to d/c'd to transitional care rehab on
[**2200-4-2**] to be later admitted on [**2200-4-3**] for AMS/seizures.
In the ED at OSH, loaded with 1 gm dilantin, 2 mg ativan, and 2
mg dilaudid and admitted. Per records, pt not on benzos while at
rehab. EEG from [**4-4**] and [**4-5**] showed no localizing seizure
activity.
On [**2200-4-6**], pt became lethargic, tachypneic w/rr in 40's and
hypoxic. He was also reportedly febrile (unknown temp). He
received one dose of CTX which resulted in a skin rash. He was
then transferred to the ICU with concerns for NMS vs. sertonin
syndrome vs. benzo-withdrawal vs. infection/sepsis.
ICU course at OSH notable for start of ativan gtt and
psychotropic meds, including risperdal, seroquel, wellbutrin,
and xanaflex. WBC count at 11, Cr 4.4, LFTs wnl at that time.
Dilantin level 7.7 at that time. Daily head CT's from [**4-4**] to
[**4-6**] were all normal. During this time, pt became hyperkalemic
to 5.4 and acidotic with bicarb of 18. ABG on [**2200-4-6**] was
7.2/24/72/16. Pt was then started on a bicarb gtt. Lactate was
1.2, serum and urine tox unremarkable except for benzos. Pt was
ROMI with enzymes during his course. TTE today showed preserved
EF, moderate AS/AI, moderate MR, elevated RV pressures of 91.
Past Medical History:
1)AVR in [**2190**] for Enterococcus faecalis endocarditis
2)Cellulitis x 6
3) DM II, diagnose in [**4-21**], treated with glipizide
4)Polysubstance use (cocaine, opiates, benzos, anabolic
steroids)
5) H/O pancreatitis in [**2194**]
6) Cluster HA's
7) Neck and back pain - has been to musculoskeletal specialist
as well as PT
8) Anxiety
9) ADHD/ADD
10) Left pectoral and biceps tear, s/p surgery
Social History:
Recently divorced, currently lives with girlfriend. Moved to
[**Location (un) 86**] 6 months ago from [**State 5864**]. h/o IVDU. Unemployed.
Family History:
DM
Hyperlipidemia
Fibromyalgia (sister)
Multiple staph infections
DVT
Physical Exam:
VS - 99.6, 110/59, 112, 25-30 95%/3LNC
General - Somnolent, awakens with loud voice and tactile
stimulation
HEENT - NC/AT, PERRL, EOMI. MM dry
Neck - supple
Chest - CTA-B, no w/r/r
CV - RRR s1 s2 normal, + mechanical click
Abd - obese, NT/ND, pos BS
Ext - no c/c/e, pulses 2+ b/l
Neuro - Somnolent, awakens to loud voice, able to say he is in
[**Location (un) 86**]. Moves all four extremities. Nl muscle tone
Pertinent Results:
ADMISSION LABS:
[**2200-4-7**] 07:36PM TYPE-ART PO2-74* PCO2-35 PH-7.40 TOTAL CO2-22
BASE XS--1
[**2200-4-7**] 07:36PM GLUCOSE-237* LACTATE-1.2
[**2200-4-7**] 07:36PM HGB-10.4* calcHCT-31 O2 SAT-95
[**2200-4-7**] 07:36PM freeCa-1.12
[**2200-4-7**] 07:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2200-4-7**] 07:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2200-4-7**] 07:15PM URINE RBC-2 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0
[**2200-4-7**] 06:32PM GLUCOSE-247* UREA N-70* CREAT-5.8*#
SODIUM-131* POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-20* ANION GAP-17
[**2200-4-7**] 06:32PM ALT(SGPT)-22 AST(SGOT)-19 LD(LDH)-332*
CK(CPK)-157 ALK PHOS-110 AMYLASE-174* TOT BILI-0.5
[**2200-4-7**] 06:32PM LIPASE-228*
[**2200-4-7**] 06:32PM CALCIUM-8.4 PHOSPHATE-6.6*# MAGNESIUM-2.2
[**2200-4-7**] 06:32PM PHENYTOIN-<0.6*
[**2200-4-7**] 06:32PM WBC-11.2* RBC-3.25*# HGB-9.6*# HCT-27.4*#
MCV-84 MCH-29.7 MCHC-35.3* RDW-17.7*
[**2200-4-7**] 06:32PM NEUTS-76.6* BANDS-0 LYMPHS-13.1* MONOS-4.2
EOS-5.8* BASOS-0.3
[**2200-4-7**] 06:32PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL
POLYCHROM-OCCASIONAL
[**2200-4-7**] 06:32PM PLT SMR-NORMAL PLT COUNT-440
[**2200-4-7**] 06:32PM PT-31.0* PTT-31.8 INR(PT)-3.3*
[**2200-4-7**] 06:32PM FIBRINOGE-697*
[**2200-4-7**] 07:36PM BLOOD Type-ART pO2-74* pCO2-35 pH-7.40
calHCO3-22 Base XS--1
[**2200-4-7**] 07:15PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2200-4-7**] 07:15PM URINE RBC-2 WBC-0 Bacteri-FEW Yeast-NONE Epi-0
.
IMAGING:
[**4-7**] CXR on admission: No evidence of pneumonia or CHF.
.
[**4-8**] Renal U/S: 1. Left renal cortical scarring.
2. No evidence of mass, hydronephrosis or calculus within either
kidney.
3. Normal renal vascular flow.
.
[**4-9**] Hip Films: 1. No evidence of hardware fracture, or fracture
of the right pelvis or right femur.
2. Benign-appearing lucency of the left femoral neck as
described above.
.
[**4-9**] TTE: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The aortic root is mildly
dilated. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. A mechanical aortic valve prosthesis is
present. The transaortic gradient is probably mildly elevated
for this type of prosthesis (although some elevation is expected
in the presence of tachycardia). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. The mitral regurgitation jet
is eccentric. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2194-5-27**], the aortic valve gradient is similar.
Mitral regurgitation may now be slightly more prominent.
.
[**4-10**] Hip Films: There has been placement of a bipolar
hemiarthroplasty within the right hip. There are no signs for
hardware complications. No bony fractures are identified. There
is a lateral surgical skin staples seen.
.
[**4-10**] EEG: Mildly abnormal EEG in the waking and drowsy states
due to
the mild slowing of the background with occasional bursts of
generalized
slowing. This suggests a mild encephalopathy although some
background
frequencies were normal. Medications, metabolic disturbances,
and
infection are among the most common causes. There were no focal
abnormalities or epileptiform features. A tachycardia was noted.
.
[**4-14**] Difficult Crossmatch: DIAGNOSIS, ASSESSMENT AND
RECOMMENDATIONS: Mr. [**Known lastname **] has newly identified red cell
alloantibodies, anti-Cw and anti-Jkb, as well as a previously
identified, anti-E. All of these antibodies can cause hemolytic
transfusion reactions. E and Cw are members of the Rh blood
group system while Jkb is a member of the Kidd blood group
system. In the future he should receive red cells that are Jkb,
E, and Cw negative.
.
[**4-16**] Hip Films: A single frontal radiograph of the right hip
demonstrates the patient to be status post right hip
hemiarthroplasty. The stem of the femoral component projects
over the center of the medullary canal of the proximal femur.
Surgical staples project over the lateral right hip. No discrete
fracture is evident. Tubing overlying the right hip may
represent a surgical drain.
.
[**4-16**] TEE: The left atrium is normal in size. No mass or thrombus
is seen in the right atrium or right atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Overall left
ventricular systolic function is moderately depressed. The right
ventricular cavity is mildly dilated. There is moderate global
right ventricular free wall hypokinesis. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque. A bileaflet aortic valve
prosthesis is present. A mechanical aortic valve prosthesis is
present. The aortic prosthesis leaflets appear to move normally.
No masses or vegetations are seen on the aortic valve. No aortic
valve abscess is seen. Trace aortic regurgitation is seen. [Due
to acoustic shadowing, the severity of aortic regurgitation may
be significantly UNDERestimated.] There is a probable vegetation
on the mitral valve. Moderate (2+) mitral regurgitation is seen.
The mitral regurgitation jet is eccentric. There is no
pericardial effusion.
PERFOERATED ANTERIOR MITRAL LEAFLET (A2) scallop.
***Please note that this echo report was re-read, and it was
felt that there was NO vegetation.
.
CXR [**2200-4-25**]: SUPINE AP VIEW OF THE CHEST: Patient is status post
median sternotomy and aortic valve replacement. Cardiac and
mediastinal contours are normal. The right PICC has been
removed. The lungs are clear and the pulmonary vascularity is
normal. There are no effusions or pneumothorax. Osseous
structures are normal.
IMPRESSION: No pneumonia.
.
CXR [**2200-4-28**]: FINDINGS: There has been interval placement of a
right-sided PICC line with the tip malpositioned in the right
neck. The patient is again noted be status post aortic valve
replacement. The lungs remain clear. No effusion or
pneumothorax is seen.
IMPRESSION: Malpositioned right PICC line.
Results were discussed with the IV access team immediately
following
completion of the study.
.
CXR [**2200-4-30**]: COMMENTS: Portable supine AP radiograph of the
chest is reviewed, and compared to the previous study of [**4-28**], [**2199**].
The tip of the left-sided PICC line is identified at cavoatrial
junction.
The lungs are clear. The heart and mediastinum are within
normal limits. The patient has prior AVR and median sternotomy.
The right costophrenic angle is not included in the radiograph.
.
[**2200-5-19**]: AP pelvis: A right hip prosthesis is present, with
methyl methacrylate surrounding the metallic femoral head
component. This femoral head prosthesis is dislocated superiorly
from the acetabulum. The acetabulum is enlarged, of abnormal
morphology, with loss of the cortical rim superolaterally and
may be paretially resorbed. There is heterotopic ossification
about the dislocated proximal femur. The femoral prosthesis
remains seated within the shaft of the proximal femur. Allowing
for osteopenia, no definite loosening is identified. The
remainder of the pelvic girdle is within normal limits.
IMPRESSION: Dislocation of right femoral prosthesis from
acetabulum. ? acetabular debridement or resorption.
.
Micro:
[**2200-4-26**]: blood cx neg x2
[**2200-4-25**]: blood cx 1/4 bottles w/E. coli (anaerobic)
[**2200-4-25**]: urine cx neg
[**2200-4-24**]: blood cx neg x4
[**2200-4-22**]: blood cx neg x4
[**2200-4-22**]: urine cx neg
[**2200-4-20**]: blood cx neg x4
[**2200-4-20**]: urine cx neg
[**2200-4-18**]: blood cx neg x2
[**2200-4-17**]: blood cx neg x2
[**2200-4-17**]: urine cx neg
[**2200-4-15**]: blood cx neg x4
[**2200-4-13**]: blood cx neg x2
[**2200-4-12**]: urine cx neg
[**2200-4-12**]: blood cx neg x2
[**2200-4-11**]: blood cx neg x2
[**2200-4-11**]: wound swab: enterococcus ([**First Name9 (NamePattern2) **] [**Last Name (un) 36**]), coag neg staph,
corynebacterium
[**2200-4-11**]: blood cx neg x2
[**2200-4-10**]: catheter tip: coag neg staph
[**2200-4-10**]: urine cx: enterococcus, [**Month/Day/Year **] sensitive
[**2200-4-9**]: blood cx [**12-21**] coag neg staph
[**2200-4-7**]: blood cx neg x2
[**2200-4-7**]: urine cx neg
[**2200-5-8**] 11:30 am SWAB Site: HIP RIGHT HIP WOUND. R/O
MRSA.
INTRA-OPERATIVE .
GRAM STAIN (Final [**2200-5-9**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2200-5-14**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH SKIN FLORA.
FURTHER WORK-UP PER DR. [**First Name (STitle) **] [**2200-5-12**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ESCHERICHIA COLI. RARE GROWTH.
ESCHERICHIA COLI. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN----------<=0.25 S <=0.25 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- 32 I 32 I
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
ANAEROBIC CULTURE (Final [**2200-5-14**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum.
BACTEROIDES FRAGILIS GROUP. RARE GROWTH. BETA
LACTAMASE POSITIVE.
ACID FAST SMEAR (Final [**2200-5-9**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
[**2200-5-26**]- WOUND CULTURE (Final [**2200-5-28**]):
ESCHERICHIA COLI. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
# Altered mental status: Likely multifactorial on admission,
secondary to polypharmacy, benzodiazepine withdrawal, seizure,
uremia. There was no evidence of NMS during this hospital
course. The patient had been on an ativan gtt at the time of
transfer from the OSH, and was noted to be somnolent. When the
ativan gtt was discontinued his mental status gradually
improved. He was initially kept on a CIWA scale for
benzodiazepine withdrawal, but he required little valium and
this was discontinued after a few days. As noted in the HPI,
the patient had had seizures in the setting of benzodiazepine
withdrawal. He was initially treated with dilantin at the OSH,
but this was not continued as benzo withdrawal was considered to
be the cause of the seizures. Patient was insisted on being
treated with demerol for pain despite seizure risk. Several
discussions were had regarding this. He receieved up to 400 mg
IV demerol per days which he tolerated well and had no further
evidence of seizure activity.
.
# ARF: Cr 5.8 on admission from baseline 4. The etiology of the
patient's chronic renal insufficiency was not entirely clear.
On admission, the patient was felt to by hypovolemic, with
pre-renal etiology of his acute on chronic renal failure. Renal
ultrasound revealed no hydronephrosis. Creatinine improved
somewhat with hydration. There was no acute indication for
hemodialysis. At times the patient became somewhat hyperkalemic
to the mid-5's, which responded to kayexelate, but this was also
felt to be realted to . His creatinine remained stable at 2.6
by discharge but exhibited variation from day to day up to 3.5
for unclear reasons. Patient continued to make adequate amounts
of urine.
.
# Septic Arthritis of the Hip/infectious disease: The patient
had fever to 104F at the OSH, with no clear source initially.
He sustained a complex femoral neck fracture, which was managed
with a hemiarthroplasty at an outside hospital. He now presented
to the [**Hospital1 69**] with a large buttock
hematoma and evidence of bacteremia with continued hip pain. The
patient has been taken to operating room on [**2200-4-11**] for
debridement and wound cultures which revelaed enterococcus, coag
negatve staph and CORYNEBACTERIUM. He returned to the OR on [**4-16**]
for washout and hip spacer placement and a wound vac was placed.
He returned to OR on [**4-23**] for washout and wound closure. He was
noted to have serosanguinous drainage from the wound site, and a
hematoma at the site. He again returned to the OR on [**2200-5-8**],
where he was found to have an infected hematoma in the R hip
surgical site. The hip was washed out and cultures sent, which
grew e.coli, enterococcus and coag negative staph and a wound
vac was replaced and was changed Q3-4 days. The patient also
had enterococcus in a urine culture and coag negative staph from
2/4 bottles of a set of blood cultures and from the tip of a
PICC line which was removed early in the hospital course. An ID
consult was obtained and the patient was started on cipro,
vanco, flagyl. TTE and TEE were done to evaluate his valves in
the setting of bacteremia (see below). These studies were read
as having a question of mitral valve vegetation, as well as old
mitral valve perforation, but no involvement of the prosthetic
aortic valve was noted. AP of the pelvis was obtained on [**5-19**]
because his hip was internally rotated and films revleaed
dislocation so he was taken back to the OR for relocation on [**5-22**]
at which time his spacer was removed, washed and replaced and a
wound vac was left in place. Subsequent wound culture taken on
[**5-26**] grew sparse E.coli, interterminent sensitivity to Cipro.
ID felt that this was the same organism previously ([**5-8**])
cultured from his hip, now with resisence to cipro. Therefore
his abx regimen was changed from Cipro to Unasyn, but day one of
abx treatment will remain [**2200-5-8**], the day of removal of
infected hematoma. He should complete a 6 week course of ABX
from then-(Vancomycin 1gm IV Q24H, Ampicillin-Sulbactam 3 gm IV
Q8H, and Metronidazole 500 mg PO TID)needing 19 additional days
after discharge. After this course is completed, he will have a
one month waiting period without antibiotics to see if the
infection has actually cleared. Orthopedic Surgery will see him
at the end of this month, and will do a hip aspirate to eval for
infection. If his wound has closed, he is afebrile, and his
aspirate is clear of bacteria, he will have his hip hardware
replaced and should not require antibiotics afterwards. He will
need Q3-4 day wound vac dressing changes at rehab. He will
additionally follow up with infectious disease for antibiotic
management. He will need Q 3day labs including Chem10, and
PTT/INR and weekly LFTs while on antibiotics.
# Pain: The patient complained of continual severe hip pain
throughout his hospital course, and he made frequent and
repeated requests for increasing doses of pain medications. He
has a history of polysubstance abuse, making the management of
his pain more complicated. The pain management service was
consulted, and many different regimens were tried to control his
pain, including morphine and dilaudid PCA, increasing doses of
methadone, lidocaine patch, fentanyl patch, and the addition at
various times of neurontin, topamax, and muscle relaxants to his
regimen. At the time of discharge, his pain was controlled with
a regimen of Methadone 80mg PO four times a day, Dilaudid IV PCA
with 0.37mg given every 6 minutes with no basal rate, Morphine
Sulfate 15mg IV Q3-4 hours PRN, Diazepam 15mg PO Q8H, and
Meperidine 100 mg IV BID PRN for Wound Vac Changes. Many
discussions were had with the patient regarding pain control.
Limit setting was essential in allowing for pain control without
the patient being oversedated. Psychiatry was consulted to
manage his anxiety. They had no specific recommendations at this
time for longterm treatment, but he should follow up as an
outpatient.
.
# Polysubstance abuse: At the time of admission, the patient was
currently clean and on methadone. Pain was managed as noted
above.
.
# DM2: Oral hypoglycemics were held on admission. [**Last Name (un) **] was
consulted for help with management of his diabetes. His blood
sugars were initially difficult to control in the setting of
infection. Glargine insulin was started and was titrated up for
good glycemic control. Humalog insulin sliding scale was also
used.
.
# s/p AVR: The patient was on coumadin at home for
anticoagulation. When the need for operative management of his
hip arose, coumadin was discontinued and he was put on a heparin
gtt. TTE and TEE were done to evaluate his valves when blood
cultures grew coag negative staph. These studies were read as
having a question of mitral valve vegetation, as well as old
mitral valve perforation, but no involvement of the prosthetic
aortic valve was noted. This was re-read as having NO
vegetation on the mitral valve. The patient was treated for
endocarditis with vancomycin, with a plan for this to be
continued for 6 weeks. On [**2200-5-27**], Coumadin 5mg QHS was begun.
His Heparin ggt was continued, but can be d/c'd once his INR is
therapeutic with a goal of 2.5-3.5. Upon discharge, INR was 2.5,
PTT was 114; however will continue Heparin drip, given the fact
that INR cannot be interpreted with elevated PTT.
.
# Tachycardia: Sinus tachycardia on admission was felt to be
possibly [**12-19**] hypovolemia or benzo withdrawal and pain. He was
given IV hydration and was put on CIWA scale with valium which
he rarely required, as noted above.
.
# Pulmonary HTN: This was reported on TTE at OSH. The patient
had no signs or symptoms of RV strain. Mild pulmonary artery
hypertension was also noted on TTE done here.
.
# Pancreatitis: Patient was noted to have elevated amylase and
lipase on admission, but without abdominal pain. This was felt
to be related to medications, as the patient never developed any
symptoms of pancreatitis.
.
# Code: Full
Medications on Admission:
amlodipine 10 mg qd
tylenol prn
colace 100 mg [**Hospital1 **]
oxycodone 10 mg q4 prn
coumadin 3 mg qhs
hydroxyzine 50 mg q6 prn
ambien 10 mg qhs
ativan 1-2mg q 1hr prn
methadone 20 mg [**Hospital1 **]
NPH (unclear dose)
ativan gtt 1 mg/hr
propranolol 20 mg qid
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours).
Disp:*3600 ML(s)* Refills:*2*
6. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*qs * Refills:*2*
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed for constipation.
Disp:*qs ML(s)* Refills:*2*
8. Diazepam 5 mg Tablet Sig: Three (3) Tablet PO Q 8H (Every 8
Hours).
Disp:*qs Tablet(s)* Refills:*2*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 19 days.
Disp:*60 Tablet(s)* Refills:*0*
10. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble
PO QID (4 times a day).
Disp:*240 Tablet, Soluble(s)* Refills:*2*
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*1 Tablet(s)* Refills:*2*
12. Ampicillin-Sulbactam [**12-18**] g Recon Soln Sig: One (1) Recon
Soln Injection Q8H (every 8 hours) for 19 days.
Disp:*2 Recon Soln(s)* Refills:*0*
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Gram Intravenous Q 24H (Every 24 Hours) for 19 days.
Disp:*19 Gram* Refills:*0*
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Disp:*qs * Refills:*0*
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*2*
16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
17. Hydromorphone 4 mg/mL Solution Sig: 0.37mg Injection ASDIR
(AS DIRECTED): 0.37mg IV PCA every 6 minutes for pain. No basal
rate.
Disp:*qs * Refills:*2*
18. Morphine Sulfate 15 mg IV Q3-4H:PRN
19. Meperidine Sig: 100mg Intravenous (only) twice a day as
needed for pain: Only given for wound vac changes.
Disp:*qs * Refills:*1*
20. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed.
21. Insulin Glargine 100 unit/mL Solution Sig: Fifty Four (54)
units Subcutaneous at bedtime.
22. Humalog 100 unit/mL Solution Sig: Per sliding scale. units
Subcutaneous QACHS: See attached sliding scale.
23. 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.
24. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Per protocol Intravenous ASDIR (AS DIRECTED): Please give
per attached protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
1. Septic R artificial hip, s/p hardward removal & washout
2. Bacteremia
3. Seizure related to benzodiazepine withdrawl
4. Acute Renal Failure
Secondary:
1. Diabetes type II
2. Anemia secondary to blood loss
3. Hyperkalemia
4. Hypertension
Discharge Condition:
Hemodynamically stable, afebrile, glucose well controlled.
Discharge Instructions:
You were admitted to the hospital with a change in your mental
status and seizure, and found to have an infected R hip. You
were treated for this with surgery, antibiotics, and pain
medications. You should call your doctor or return to the
hospital if you have fever >101, chills, significantly increased
pain, or signs of infection.
Please take all of your medications as directed.
Please keep all of your follow up appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2200-7-1**] 8:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2200-7-1**] 8:40
You have the following appointment at infectious disease clinic.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2200-6-20**] 10:00
You should call to schedule a follow up appointment with a
primary doctor 1-2 weeks after you complete rehab. Please call
[**Telephone/Fax (1) 5867**] to set up an appointment with a new primary doctor.
Completed by:[**2200-5-30**]
|
[
"5849",
"5859",
"2767",
"40391",
"5990",
"42731",
"V5861",
"25000"
] |
Admission Date: [**2179-3-27**] Discharge Date: [**2179-4-1**]
Date of Birth: [**2095-1-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 84 yo M w/ h/o COPD on 2L home oxygen, cor
pulmonale with severe R sided diastolic dysfunction, dementia,
and R sided weakness s/p CVA who presents after recent admission
for syncope with altered mental status. Was admitted from rehab
recently on two occasions- from [**3-18**] to [**3-20**] for syncope in
setting of pseudomonal UTI and from [**2-22**] to [**2-25**] w/ hypotension
and bradycardia admitted to the ICU, ultimately diagnosed with
syncope of unclear etiology.
.
He was most recently discharged w/ a dx of vasovagal syncope
with a increase in his bowel regimen, decrease in his metoprolol
and plan for a two week course of ciprofloxacin for his
pan-sensitive pseudomonal UTI (he has h/o recurrent UTIs
including pseudomonal, proteus (R to cipro/bactrim/amp),
enterococcus (R to tetracycline), and klebsiella). His family
reports that he left the hospital in excellent shape but has
gradually deteriorated with weakness, lethargy and poor PO
intake. He has been continued on his 40 mg torsemide daily at
the rehab, anti-hypertensives, and supplemental potassium.
.
He was BIBA from the [**Hospital1 1501**] due to his altered state and due to
hypoxia- to the 80s on 2L, only improving the low 90s on
non-rebreather. He was also reportedly not behaving like
himself- sleeping more, needing additional help with feedings
and not oriented. Per records, torsemide was increased from 40
mg daily to 60 mg daily on [**3-26**]. Per family, baseline mental
status is oriented x2 with difficulties w/ memory for things
like phone number.
.
In the ED, initial VS were: 97.6 100 127/91 24 95%
Non-Rebreather. BS was 100. Initial ABG was: 68 48 7.41. He was
transitioned to 6L NC, but tired out so was put back on NRB then
CPAP was started [**3-11**] tachypnea. Labs were notable for a lactate
of 4.3, Na of 158 (was 141 on [**3-20**]), Cr 3.9 (1.8), Cl 110, HC03
37, hct 53.8 (47.7), plt 112, BNP 17,220 (was [**Numeric Identifier 11377**] on [**3-18**]). CXR
was notable for mild pulmonary edema, but no infiltrate. Lactate
trended down to 2.4 with 1 L NS. He was also given vancomycin,
CTX and levofloxacin. VS on transfer were: BP 120/77 HR 84, RR15
on CPAP (24 on NRB); 93% O2 sat.
.
On [**Month/Day (4) 11419**] to the MICU, the patient is somnolent but arousable.
He denies any pain, difficulty breathing, or palpitations. When
asked why he is in the hospital he reports, "to get better."
.
Review of systems: Obtained from patient and family.
(+) Per HPI; also w/ cough productive of dark colored sputum.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath or wheezing. Denies chest
pain, chest pressure, palpitations. 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:
- CAD s/p CABG
- Prostate cancer s/p XRT c/b residual incontinence, condom cath
qhs
- Severe Right Sided Systolic Failure
- Severe pHTN (on 2-3LNC)
- OSA on home BiPAP
- Multiple CVAs w residual R-sided weakness and R-facial droop
- Recurrent syncope of uncertain etiology
- HTN
- DVT
- Depression
- Mild Dementia
- s/p cataract surgery
- Internal hemorrhoids
Social History:
Home: lives with wife at [**Name (NI) 1501**]
Family: 5 kids a/w
Status: Hospice discussions documented since [**6-/2178**], FC at
present by pt request
Mob: wheelchair baseline, dependent for ADLs
Occ: retired [**Location (un) 669**] schoolbus driver
Origin: Grew up in [**Location (un) 4398**]
Tob: 20-40 pk-yr hx, quit x40 years
EtOH: denies
IVD: denies
Family History:
Mother had cancer, patient cannot recall diagnosis.
Physical Exam:
ON ADMISSION:
Vitals: T: 99.2 BP: 150/90 P: 86 R: 29 O2: 98% on CPAP
General: somnolent but arousable, oriented to person, breathing
rapidly, but no significant use of accessory muscles, able speak
full sentences
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: frequent ectopy, but no m/r/g
Lungs: rhonchorous anteriorly
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no organomegaly
GU: Foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: somnolent, but arousable; oriented to person and able to
state date is 19th by looking at calendar; residual R facial
droop, but otherwise CNII-XII intact; 4/5 strength throughout,
grossly normal sensation, tremulous legs b/l, gait deferred
ON DISCHARGE:
Vitals: T: 97.0 BP: 136/60 P: 61 R: 18 O2: 96 2L wt: 118.6 kg
General: Elderly African-American male in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at earlobe, no LAD
Lungs: Inspiratory and expiratory mild wheezes in all fields;
dry crackles in upper fields and bases
CV: Regular rate and rhythm, normal S1 + S2; systolic murmur
appreciated throughout, strongest at RUSB and apex
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm and well perfused; 1+ pulses, no clubbing or cyanosis;
1+ pitting edema to knees BLE
Neuro:
MSE: Alert; oriented to person (inc. birthday), "[**Hospital3 **]
Hospital", and "[**2179-3-10**]".
CN: CN II-VI, VIII, IX, XII intact. VII: Decreased strength
in R periorbitals; R facial droop (baseline). [**Doctor First Name 81**]: 4/5 strength
on shoulder shrug, head rotation.
Str: [**5-13**] in RUE, RLE.
[**Last Name (un) **]: Grossly intact bilaterally.
Coord: Pt noncompliant.
Derm: L arm and R shoulder burn scars noted.
Pertinent Results:
ADMISSION LABS:
[**2179-3-27**] 06:30PM GLUCOSE-105* UREA N-63* CREAT-3.9*#
SODIUM-158* POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-37* ANION
GAP-16
[**2179-3-27**] 06:30PM CALCIUM-9.0 PHOSPHATE-5.5*# MAGNESIUM-2.3
[**2179-3-27**] 06:30PM cTropnT-0.15*
[**2179-3-27**] 06:30PM proBNP-[**Numeric Identifier 11420**]*
[**2179-3-27**] 06:30PM LACTATE-4.3*
[**2179-3-27**] 06:30PM WBC-11.1* RBC-6.13 HGB-17.0 HCT-53.8* MCV-88
MCH-27.7 MCHC-31.6 RDW-17.2*
[**2179-3-27**] 06:30PM NEUTS-67.6 LYMPHS-26.1 MONOS-4.6 EOS-0.2
BASOS-1.6
[**2179-3-27**] 06:30PM PLT COUNT-112*
[**2179-3-27**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2179-3-27**] 07:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
[**2179-3-27**] 07:30PM URINE RBC-20* WBC-8* BACTERIA-FEW YEAST-NONE
EPI-1
[**2179-3-27**] 07:30PM URINE HYALINE-26*
OTHER NOTABLE LABS:
[**2179-3-27**] 06:30PM BLOOD cTropnT-0.15*
[**2179-3-28**] 01:09AM BLOOD CK-MB-2 cTropnT-0.15*
[**2179-3-30**] 02:53AM BLOOD CK-MB-4 cTropnT-0.10*
[**2179-3-28**] 01:09AM BLOOD VitB12-819
[**2179-3-28**] 01:09AM BLOOD TSH-0.95
[**2179-3-30**] 02:53AM BLOOD Cortsol-14.6
[**2179-3-29**] 11:41PM BLOOD Lactate-1.7
DISCHARGE LABS:
[**2179-4-1**] 08:05AM BLOOD WBC-7.1 RBC-4.78 Hgb-13.9* Hct-42.1
MCV-88 MCH-29.1 MCHC-33.0 RDW-16.9* Plt Ct-105*
[**2179-4-1**] 08:05AM BLOOD Glucose-86 UreaN-49* Creat-1.7* Na-137
K-3.7 Cl-101 HCO3-28 AnGap-12
[**2179-3-31**] 05:10AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.3
[**2179-3-29**] 11:26AM BLOOD HEPARIN DEPENDENT ANTIBODIES- equivocal
MICRO:
[**2179-3-28**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-
non-reactive
[**2179-3-28**] URINE CULTURE- No growth
[**2179-3-27**] BLOOD CULTURE- pending, no growth at time of
discharge
[**2179-3-27**] BLOOD CULTURE- pending, no growth at time of
discharge
STUDIES:
[**2179-3-27**] CXR: The patient's chin overlies the bilateral medial
upper lobes, obscuring the view. Given this, the cardiac
silhouette is persistently enlarged. There is again prominence
of the pulmonary arteries. Pulmonary vascular congestion appears
improved.
[**2179-3-27**] CT HEAD: 1. No evidence of intracranial hemorrhage or
definite CT evidence of major vascular territorial infarct. If
clinical suspicion is strong, MRI should be considered if not
contraindicated. 2. Small vessel ischemic disease and
age-related involution. 3. Unchanged basal ganglia lacunes. 4.
Limited view of right globe with suggestion of internal high
density material, to be correlated clinically. If of concern,
dedicated orbital imaging could be obtained.
[**2179-3-28**] RENAL U/S: 1. Multiple bilateral up to 11-cm cysts, some
of which with mural calcifications and septation. 2. Collapsed
thick-walled urinary bladder with internal debris. 3. No
hydronephrosis.
[**2179-3-29**] CXR: The heart remains markedly enlarged which may
reflect cardiomegaly, although a pericardial effusion should
also be considered. There is prominence of the perihilar
vasculature but no overt pulmonary edema on the current study.
Calcified diaphragmatic plaques are seen suggestive of prior
asbestos exposure. No focal airspace consolidation is seen to
suggest pneumonia. No pneumothorax. No pleural effusions.
Brief Hospital Course:
84 yo M w/ h/o COPD on 2L O2, cor pulmonale w/ severe RV
diastolic dysfunction, OSA, R hemiparesis s/p CVA, and dementia
who presented from [**Hospital1 1501**] w/ altered mental status in setting of
hypoxia and hypernatremia.
.
# Acute toxic/metabolic encephalopathy: Patient noted to have
increased lethargy and twitching in rehab in setting of poor PO
intake. Altered mental status was likely secondary to
hypernatremia (see below) and hypoxia. There were no
signs/symptoms of recurrent infection. Given a dirty UA and h/o
recurrent UTIs he was initially treated broadly (vanc/cefepime),
but was narrowed back to cipro when urine culture was negative.
Will continue on cipro through [**2179-4-3**] for treatment of
previously diagnosed UTI. CT head was negative for acute
process. TSH, B12 were normal and RPR was non-reactive. With
improvement in hypernatremia and hypoxia (patient back on
baseline oxygen requirement), mental status significantly
improved. On day of discharge patient was answering most
questions appropriately and could state his name, that he was at
[**Hospital1 18**], and that it was [**2179-3-10**].
.
# Hypernatremia: Likely occured in setting of poor access to
free water and poor thirst mechanism in an elderly, demented
patient. Further contributing to dehydration/hypovolemia were
increased diuretic doses at his [**Hospital1 1501**]. Using current dry wt
(104kg), initial free water deficit was appx 6.3 L. He was
volume resuscitated w/ NS, then corrected gradually w/ D5 1/2 NS
to a Na of 138 at transfer to floor (HD4). His sodium remained
within normal limits on the floor, and as above his mental
status improved. It is essential that he have access to free
water on discharge.
.
# Hypoxemia: Hypoxic in nursing home w/ sats in mid to high 80s
on 2L w/ minimal improvement on 3L oxygen and then
non-rebreather. Unclear etiology: volume overload appeared
improved on CXR w/o obvious infiltrates. Was possibly due to
mucous plugging given h/o thick secretions vs. aspiration in
setting of altered MS. [**First Name (Titles) **] [**Last Name (Titles) 11419**] in MICU patient was
transitioned from CPAP to non-rebreather with good tolerance. He
was then quickly transitioned to nasal cannula and by hospital
day 2 was on his home oxygen requirement. He was stable on this
oxygen requirement on the floor. Was on CPAP at night for OSA.
.
# Urinary tract infection: Pt w/ h/o recurrent UTIs including
pseudomonal, proteus (R to cipro/bactrim/amp), enterococcus (R
to tetracycline), and klebsiella. He had recently started a
course of cipro 500 [**Hospital1 **] for planned 14 days for pan sensitive
pseudomonas. UA this admission initially looked potentially
infected w/ 8 WBCs, + LE, and few bact so was switched from
cipro to broad coverage w/ vanc/cefepime. Urine culture
ultimately was negative so he was put back on his home cipro to
finish initial course of 14 days (will complete on [**4-3**]).
.
# Acute renal failure: Patient w/ baseline creatinine around 2.0
during last hospitalization, w/ elevation to 3.9 on admission.
Likely secondary to h/o poor po intake in setting of altered
mental status, lack of access to free water, and continued use
of diuretics and lisinopril. Held diuretics and lisinopril and
gave fluids as above with gradual improvement in creatinine.
Renal ultrasound was done which showed multiple bilateral up to
11-cm cysts, collapsed thick-walled urinary bladder with
internal debris, but no hydronephrosis. Creatinine returned to
baseline of 1.7 prior to discharge. Patient was restarted on
lisinopril. Will resume decreased dose of torsemide, 20 mg
daily.
.
# Hypotension: Patient was initially normotensive but during
admission dropped pressures to the 70s-90s systolically. No
signs of infection (see above) and was maintained on broad
spectrum abx. Was initially hypovolemic but was not hypotensive
at that time. Cortisol checked and wnl. Etiology was unclear,
but blood pressures trended up w/o further intervention. No
further hypotension was observed after HD4.
.
# Thrombocytopenia: Platelets below baseline (was in 200s last
month and trended down during hospitalization (as low as 73
during this admission). INR was also elevated so fibrinogen was
sent and returned wnl. Given recent exposure to heparin during
last admission there was concern for HIT. Heparin was stopped
and HIT antibody was sent; this returned as equivocal. He was
placed on pneumoboots for DVT ppx. Serotonin assay sent prior to
discharge, and will need to be followed-up. Until results
return, patient should not receive any heparin products. Also
considered possibility of dilutional effect leading to
thombocytopenia. Platelet count stable at time of discharge.
He had no sign of thrombosis, and thus
systemic anticoagulation was not given.
.
# Diastolic CHF: Has h/o severe RVD [**3-11**] cor pulmonale w/ intact
EF of 50-55% on recent echo on [**3-18**]. Was discharged on robust
regimen of torsemide after BNP came back at over 20K during last
hospitalization. BNP improved at 17K and per records torsemide
regimen was recently ramped up. Appeared extremely dry on
clinical exam so home torsemide held. Continued home metoprolol
w/ holding parameters. As pt appeared gradually more euvolemic
on HD5, lisinopril restarted. Torsemide will be restarted at
20mg daily, though patient will require ongoing assessment of
his volume status at his facility, and may need increase in
torsemide back to prior 40mg daily dose if weight increases or
he develops signs/symptoms of worsening heart failure.
.
# CAD/Troponin leak: No ischemic changes on EKG and no h/o chest
pain, though patient does have strong h/o CAD. Likely some
demand related leak and persistent levels in setting of [**Last Name (un) **].
Remained stable. Continued home aspirin and metoprolol.
Restarted ACE inhibitor once renal function improved.
.
# Dementia: Continued home donepezil. Held home ropinirole given
[**Last Name (un) **] until HD5, when Cr had returned to baseline, then restarted.
TRANSITIONAL ISSUES:
-Patient was FULL CODE this admission, though per his wife they
will likely continue discussion in outpatient setting about
possible transition to hospice care
-Patient should have repeat chem7 checked [**2179-4-3**] to ensure
renal function remains stable at baseline and to assess
electrolytes in setting of restarting torsemide
-Patient will need ongoing monitoring of weight and daily fluid
balance, and may need increase in torsemide dose to 40 mg daily
if weight increasing.
-Patient noted to have multiple bilateral (up tp 11cm) renal
cysts on renal ultrasound. Pending goals of care discussion,
these may be better evaluated with MRI.
-Blood cultures [**2179-3-27**] still pending at time of discharge
-Given some suspicion for HIT, serotonin assay was sent prior to
discharge. This will need to be followed up. Pending results,
would hold all heparin products.
-Imaging also revealed evidence of diaphragmatic/pleural
plaques, suggesting prior asbestos exposure.
-Would avoid volume depletion in this patient
Medications on Admission:
1. aspirin 325 mg PO DAILY
2. donepezil 5 mg PO HS
3. ropinirole 2 mg PO QPM
4. citalopram 20 mg PO DAILY
5. docusate sodium 100 mg PO BID
6. senna 8.6 mg Tablet PO BID
7. potassium chloride 10 mEq PO BID
8. brimonidine 0.15 % Drops 1 Drop [**Hospital1 **]
9. torsemide 40 mg PO DAILY (increased to 60 mg daily on [**3-26**])
10. metoprolol succinate 50 mg PO daily
11. ciprofloxacin 500 mg PO Q12H x 13 days (day 1 [**3-20**])
12. ranitidine HCl 150 mg PO DAILY
13. lisinopril 10 mg PO once daily
Discharge Medications:
1. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. ropinirole 2 mg Tablet Sig: One (1) Tablet PO qpm.
3. citalopram 20 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. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
8. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO twice a day.
9. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2
days: last day [**2179-4-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 6560**] Care & Rehab Center - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnoses:
Acute toxic/metabolic encephalopathy
Hypernatremia
Acute kidney injury
Thrombocytopenia
Secondary diagnoses:
Dementia
Obstructive sleep apnea
Urinary tract infection
COPD
Pulmonary hypertension
Chronic right heart failure
Coronary artery disease
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were hospitalized because you were confused and having
difficulty breathing. We gave you extra oxygen to help you
breathe. We scanned your head and found no evidence of a new
stroke or bleed. You had less water in your body than normal
(hypovolemia), your sodium level was high (hypernatremia), and
your kidney function was abnormal. We think the high sodium
caused you to become more confused. We believe this occurred
because you were drinking less water at the same time as an
increase in your water pills (diuretics). We gave you fluids to
correct your water and sodium levels; you felt better and your
breathing returned to [**Location 213**]. Your sodium level returned to
[**Location 213**] as well, and your kidneys returned to their previous
level of function. We checked your urine, and we found no
evidence of further infection.
Your platelet counts were low during this admission. We sent
several tests to determine why they are low. These results are
still pending, but we will communicate the results to you after
discharge.
We made the following changes to your medications:
-DECREASED torsemide to 20 mg daily
In addition:
-- Please weigh yourself every morning, [**Name8 (MD) 138**] MD if your weight
goes up more than 3 lbs.
-- Please follow up with your doctors as listed below.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2179-5-17**] at 11:30 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"5849",
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"496",
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"41401"
] |
Admission Date: [**2195-12-2**] Discharge Date: [**2195-12-5**]
Date of Birth: [**2121-4-27**] Sex: F
Service: MEDICINE
Allergies:
Clonidine
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
mental status changes, PE/DVT, RP bleed
Major Surgical or Invasive Procedure:
placement of left subclavian
History of Present Illness:
75yoW with h/o COPD, Alzheimer's dementia, diagnosed with DVT/PE
at Caritas [**Hospital6 5016**] and transferred to [**Hospital1 18**] ED with
RP bleed and hypotension.
.
The patient was initially transferred from her nursing home to
[**Hospital6 5016**] on [**2195-11-30**] with low grade fever, failure to
thrive, and altered mental status after staff found her
unresponsive for 40sec at breakfast. She had been discharged
from that hospitalization the week prior after admission for
urosepsis with hypotension, UTI, and dehydration. On admission
she was diagnosed with RLE DVT by U/S and bilateral PE by CT
angiogram. Heparin gtt was started, and she was sent for IVC
filter placement. Post-procedure she became hypotensive. She
was intubated and transfused 5units PRBC and 4units FFP after
Hct noted to be 20. Heparin gtt was discontinued. Abdominal CT
revealed a large left retroperitoneal hematoma. Prior to
transfer blood was also noted in the G-tube. She was
transferred to [**Hospital1 18**] on peripheral dopamine for continued BP
support.
Past Medical History:
1. Chronic obstructive pulmonary disease
2. Right tonsillar laryngeal carcinoma, status post XRT and
status
post resection in [**2186**].
3. Depression.
4. Arthritis
5. S/p cholecystectomy
6. Hypothyroidism
7. Hyperglycemia
8. Right upper lobe lung mass with negative biopsy in
[**2188-10-15**]
9. Alzheimer's dementia
10. osteoporosis
11. Peripheral vascular disease
12. Hypertension
13. prior stroke
Social History:
lives in nursing home. has 3 sons
[**Name (NI) **]: h/o 70pack yrs, quit [**2186**]
EtOH: none
Family History:
not elicited
Physical Exam:
T 100.4 HR 84 BP 139/89 RR 21
AC FiO2 50% PEEP 5.0 Tv 500 RR 20
GEN: somnolent, withdraws to pain
HEENT: PERRL, anicteric, MMM, ETT
Neck: supple, no LAD, JVP nondistended
CV: distant heart sounds, regular, no mrg
Resp: coarse B anteriorly R>L, no crackles
Abd: +BS, ttp, no guarding, ND, no masses
Ext: left groin echymoses, BLE edema R>L
Neuro: withdraws to pain, at baseline oriented x1
Pertinent Results:
[**2195-12-3**] 12:34AM BLOOD WBC-14.1* RBC-3.28* Hgb-10.3* Hct-28.2*
MCV-86 MCH-31.4 MCHC-36.5* RDW-16.1* Plt Ct-120*
[**2195-12-4**] 03:18AM BLOOD WBC-11.9* RBC-3.51*# Hgb-10.7* Hct-28.3*
MCV-81* MCH-30.4 MCHC-37.7* RDW-20.3* Plt Ct-76*
[**2195-12-3**] 12:34AM BLOOD Neuts-80* Bands-14* Lymphs-2* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-4*
[**2195-12-3**] 12:34AM BLOOD PT-20.9* PTT-34.0 INR(PT)-2.0*
[**2195-12-3**] 12:34AM BLOOD Plt Smr-LOW Plt Ct-120*
[**2195-12-4**] 11:18AM BLOOD Fibrino-420* D-Dimer-9033*
[**2195-12-4**] 11:18AM BLOOD FDP-80-160*
[**2195-12-3**] 12:34AM BLOOD Glucose-126* UreaN-36* Creat-1.9* Na-144
K-3.8 Cl-109* HCO3-20* AnGap-19
[**2195-12-3**] 12:34AM BLOOD ALT-2737* AST-6183* LD(LDH)-[**Numeric Identifier 7156**]*
CK(CPK)-548* AlkPhos-108 TotBili-0.6
[**2195-12-3**] 04:39AM BLOOD ALT-2511* AST-5932* AlkPhos-97
Amylase-587* TotBili-0.7
[**2195-12-4**] 03:18AM BLOOD ALT-1812* AST-3156* LD(LDH)-5992*
CK(CPK)-501* AlkPhos-119* TotBili-1.5
[**2195-12-3**] 12:34AM BLOOD CK-MB-21* MB Indx-3.8 cTropnT-0.34*
[**2195-12-3**] 12:34AM BLOOD Albumin-2.4* Calcium-6.7* Phos-6.5*
Mg-2.2
[**2195-12-3**] 04:00AM BLOOD Ammonia-39
[**2195-12-3**] 12:34AM BLOOD TSH-3.0
[**2195-12-3**] 12:34AM BLOOD Free T4-1.5
[**2195-12-3**] 12:42AM BLOOD Type-ART pO2-158* pCO2-24* pH-7.51*
calTCO2-20* Base XS--1
[**2195-12-4**] 03:32AM BLOOD Type-ART Temp-36.1 pO2-116* pCO2-29*
pH-7.42 calTCO2-19* Base XS--3 Intubat-INTUBATED
[**2195-12-3**] 10:51AM BLOOD Lactate-2.9*
[**2195-12-4**] 11:45AM BLOOD Lactate-2.0
[**2195-12-3**] 12:42AM BLOOD freeCa-0.93*
[**2195-12-4**] 11:45AM BLOOD freeCa-1.03*
.
Echo The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is no ventricular septal defect. The right
ventricular cavity is dilated. Right ventricular systolic
function is normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
CXR: Portable AP chest radiograph was reviewed. The ET tube
tip is 3.2 cm above the carina. The NG tube passes below the
diaphragm and terminates most likely in the stomach. The left
subclavian line tip terminates at the level of mid low SVC.
Minimal left apical pneumothorax cannot be excluded. There is
no apical hematoma. A small left pleural effusion as well as
right tiny effusion is identified. There is no congestive heart
failure or focal lung consolidation. The hila are bilaterally
enlarged, which may be related due to pulmonary emboli mentioned
in the patient's history.
Brief Hospital Course:
74yo woman with h/o COPD, Alzheimer's dementia, transferred from
OSH with RLE DVT, bilateral PE, RP bleed, and NSTEMI. During
her hospitalization the following issues were addressed. On
[**2195-12-4**], she was extubated and did not tolerate it with
persistant secretions and desaturation. Extensive discussion
was held with her son and health care proxy, [**Name (NI) **] [**Name (NI) 37080**],
and the decision was made to focus on comfort measures. She
expired [**2195-12-5**].
.
# RP bleed: This occurred following IVC filter placement while
on heparin. Serial hematocrits were followed. She did not
require further PRBC transfusion. Vitamin was given for INR
2.0.
# Hypotension: She was initially hypotensive requiring
dopamine for BP support. CVL was placed and CVP found to be
[**5-22**]. She was hypovolemic from bleeding and dehydration. She
was administered NS iv fluids. BP normalized and the dopamine
was stopped. She subsequently became hypertensive with BP
200s/100s, which was treated with propofol gtt sedation, iv
labetolol and hydralazine boluses.
.
# DVT/PE: filter in place for DVT. She was not anticoagulated
for the PE given her retroperitoneal bleed. Echo was performed.
.
# ARF: her renal function declined with rising BUN/Cr despite
fluid rehydration, and she became oliguric-anuric. This was
thought to be due to ATN although no casts were seen in urine
specimen.
.
# Resp failure: She presented with a respiratory alkalosis
which persisted with compensatory and concommittent metabolic
acidosis. She was weaned to pressure support ventilation and
extubated on the day prior to death.
.
# NSTEMI: She sufferred a leak of cardiac enzymes without ECG
changes during the episodes of hypovolemia/hypotension and
anemia. She received statin.
.
# Shock liver: she developed shock liver in setting of
hypotension and hypovolemia
.
# Dispo: She continued to decline with development of oliguric
renal failure, shock liver. Sedation was lifted but mental
status did not return. In discussion with her son and health
care proxy, decision was made to focus of comfort. She expired
[**2195-12-5**]. Communication is with her son [**Name (NI) **] [**Name (NI) 37080**]
[**Telephone/Fax (1) 71462**](h), [**Telephone/Fax (1) 71463**](c)
Medications on Admission:
Meds on Admission to OSH:
Depakote sprinkles 125mg 3caps [**Hospital1 **]
Folate 1mg daily
Plavix 75mg daily
Lasix 20mg daily
Cetrocal +D 1tab [**Hospital1 **]
Aclonel 35mg QThurs
Lipitor 10mg daily
Atenolol 50mg daily
ASA 325mg daily
KCl 30mEq daily
.
Meds on Transfer:
Folate 1mg daily
Depakote 125mg 3tabs [**Hospital1 **]
Zocor 20mg daily
Nexium 40mg iv daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
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] |
Admission Date: [**2183-10-27**] Discharge Date: [**2183-11-2**]
Date of Birth: [**2121-1-15**] Sex:
Service: Cardiothoracic. #58
DISCHARGE DIAGNOSES:
Coronary artery disease, status post coronary artery bypass
graft times four.
REASON FOR ADMISSION: The patient is a 62 year old female
who had a history of five months of chest pain with exertion.
The patient had positive ST changes in [**Month (only) 359**] on
electrocardiogram and presented earlier this month for heart
catheterization. The patient's catheterization showed an
ejection fraction of 50%, 80% left anterior descending lesion
and 80% circumflex.
PAST MEDICAL HISTORY: Significant for hypertension, insulin
dependent diabetes mellitus for 40+ weeks. She is status
post colon resection for cancer.
MEDICATIONS:
Lescol 20 mg q. day.
Loexepril 15 mg twice a day.
Enteric coated aspirin 81 mg q. day.
Prilosec 20 mg q. day.
Ambien 10 q. day.
Humilog 10 q. a.m. and sliding scale q. p.m.
Lente insulin 24 units q. a.m.
ALLERGIES: Lipitor and aspirin greater than 81 mg, causing
gastrointestinal upset.
REVIEW OF SYSTEMS: The patient denied cerebrovascular
accident or transient ischemic attack. No history of
claudication. No palpitations, no wheezing, no orthopnea.
Pulse in the 70's; blood pressure 156/63; respiratory rate of
17; room air oxygen saturation of 97%. The patient is awake,
alert, in no acute distress. Heart is regular rate and
rhythm without murmur. Lungs were clear to auscultation
bilaterally. Abdomen was soft, nontender, nondistended.
Bowel sounds were present. Neck was supple without masses.
Carotids had no bruits. Extremities showed palpable pulses in
the dorsalis pedis and posterior tibial bilaterally without
edema.
White count was 8.3; hematocrit was 37.3; platelets were 191.
Sodium of 136; potassium of 3.5; chloride 102; bicarbonate
26; BUN 13; creatinine .6 and glucose of 133. PT was 12.7;
PTT was 26.5 and INR was 1.1.
ASSESSMENT: 62 year old female with coronary artery disease.
The patient was admitted for planned coronary artery bypass
graft.
HOSPITAL COURSE: The patient was taken to the operating room
on the [**12-27**] and underwent coronary artery bypass
graft times four including left internal mammary artery to
the left anterior descending, saphenous vein graft to the
obtuse marginal times two with endarterectomy in saphenous
vein graft to posterior descending artery. There were no
complications. The patient was transferred to the CSRU
intubated in stable condition.
On postoperative day number one, the patient was stable on a
Neo drip of .3. Her chest tubes were continued. On
postoperative day number two, the patient had been extubated.
She was continued on Neo .75. Chest tubes were discontinued.
On postoperative day number three, the patient remained on
CSRU. Her Neo had been weaned off. Her chest tubes had been
pulled. She was begun on her diuresis and started on a beta
blocker.
The patient was seen by [**Last Name (un) 3208**] staff to manage her diabetes
on postoperative day number four. The patient was stable.
Her heart rate was 94 and sinus. Her Lopressor was increased
to 50 mg twice a day. Her Lasix was continued at 40 mg twice
a day. The patient remained stable throughout the rest of
her hospital stay, ambulating with physical therapy and
remained afebrile. She was discharged on [**2183-11-2**],
postoperative day number six in stable condition. She did
complain of palpitations. Heart rhythm showed sinus rhythm
with occasional premature ventricular contractions on
monitor. Her electrolytes were checked which were within
normal limits. The patient was voiding well and ambulating
with some pain. This was controlled with oral analgesics.
DISCHARGE DIAGNOSES:
Coronary artery disease.
Status post coronary artery bypass graft times four.
Insulin dependent diabetes mellitus.
Hypertension.
History of colon cancer, status post colectomy.
MEDICATIONS ON DISCHARGE:
Metoprolol 50 mg twice a day.
Insulin NPH 18 units q. a.m. and 14 units q. p.m.
Iron 150 mg q. day.
Protonic 40 mg q. day.
Plavix 75 mg q. day.
Fluvastatin 20 mg q. day.
Darvocet N 100 prn.
Aspirin 325 mg q. day.
Lasix 40 mg twice a day.
The patient was discharged and instructed to follow-up with
Dr. [**Last Name (STitle) **] in two weeks. To follow-up with her primary care
physician and cardiologist.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 23184**]
MEDQUIST36
D: [**2183-11-2**] 05:52
T: [**2183-11-3**] 18:39
JOB#: [**Job Number 23185**]
|
[
"41401",
"4019",
"53081"
] |
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